Evaluation of minimally invasive surgical techniques in clinical BPH

Introduction and objectives: There are more and more men who suffer from lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Symptoms can be classified as storage symptoms or voiding symptoms, e.g. weak urinary flow and urgency-frequency. Several treatment options are possible. Transurethral resection of the prostate is the gold standard for surgical therapy. There is a correlation between prostatic obstruction and these symptoms. However, there is some evidence that patients who are not obstructed benefit from surgery. Two studies presented in this thesis compare obstructed with unobstructed patients who underwent TURP because of LUTS and associated BPH. TURP shows several complications like bleeding. New surgical modalities have been introduced to match the results of TURP, but with less complications. Several studies described in this thesis compare the results of TURP with contact laser prostatectomy (CLP) and electrovaporization (Evap). Costs of these treatments are nowadays of great importance and are analyzed in a separate chapter. A special group of patients with LUTS and BPH who suffer from bleeding disorders or use anticoagulants is treated with laser therapy. Materials and methods: 132 patients were urodynamically measured before and 6 months after TURP. They also completed validated questionnaires to quantify symptoms and subjective results. Urodynamic outcome was compared to subjective outcome. A subgroup af patients with a Schaefer grade of 1 or 2 (unobstructed or equivocal) were compared to patients who were obstructed according to Schaefer. A randomized, controlled study was conducted comparing TURP, CLP and Evap. Fifty, 45 and 46 patients were included respectively. Preoperatively and postoperatively up to 7 years tests were performed, including urodynamics, uroflowmetry, validated symptom questionnaires, morbidity and mortality. A separate cost analysis was performed. A prospective, controlled study of high risk patients was conducted, in which 30 patients with bleeding disorders or using anticoagulants were treated with laser therapy. They were compared to 45 normal risk patients undergoing laser therapy. Results and conclusions: Patients with a high obstruction grade benefited most from TURP, but those who were not obstructed showed also clinical relevant improvements in objective and subjective parameters. Urodynamic, uroflowmetric, symptomatic and subjective results, morbidity and mortality were very similar for all three groups at several times during the first year postoperatively and during long-term follow-up up to 7 years (mean follow-up 4.3 years). Costs were lowest for Evap and almost similar for CLP and TURP. Laser therapy is a safe and effective operation for high-risk patient