BENiGN PROSTAT HiPERPLAZisiNDE MiNiMAL invazif TED Avi SE(:ENEKLERi MINIMALLY INVASIVE TREATMENT OPTIONS OF BENIGN PROSTATIC HYPERPLASIA

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1 Kocatepe TlP Dergisi (2003), 1, 1-7 The Medical Journal of Kocatepe 2003, Afyon Kocatepe Universitesi BENiGN PROSTAT HiPERPLAZisiNDE MiNiMAL invazif TED Avi SE(:ENEKLERi MINIMALLY INVASIVE TREATMENT OPTIONS OF BENIGN PROSTATIC HYPERPLASIA Murat DEMiRBAS, Cetin DiN(:EL Afyon Kocatepe Universitesi, TIp Faktiltesi, Uroloji A.D., AFYON 6ZET: Benign prostat hiperplazisi cerrahi tedavisinde transuretral rezeksiyon [TUR(P)], altmis yildan beri en cok tercih edilen yontern olmustur. Buna karsin TUR(P) ile gorulcn 0/018 morbidite ve %0.2 mortalite nedeni ile TUR(P)' a alternatif cerrahi tedavi seceneklerinde son yillarda onemli gelismeler olrnustur. Bu derlemede, BPH'nde minimal invazif tedavi secenekleri son literatur esliginde gozden gecirilmistir. [Anahtar Kelimeler: benign prostat hiperplazisi, minimal invazif tedavi] ABSTRACT: Transurethral resection of the prostate is being the 1110St preferred treatment options of benign prostatic hyperplasia for the last sixty years. TUR(P) has 18% morbidity and 20/0 mortality rates and it caused an important developments in alternative surgical therapies to TUR(P) in BPH. In this article, minimally invasive treatment options of BPH were reviewed with current literature. [Key words: benign prostatic hyperplasia, minimally invasive treatment] GiRiS Benign prostat hiperplazisi cerrahi tedavisinde transuretral rezeksiyon [TUR(P)], altrrus yildan beri en cok tercih edilen yontem olrnustur. B una karsm TUR(P) ile gorulen %18 morbidite ve 0/00.2 mortalite nedeni ile TUR(P)' a alternatif cerrahi tedavi seceneklerinde son yillarda onemli gelismeler olmustur. Ote yandan, gunurnuzde cerrahide daha az invazif yonternlere, hatta gunluk coztimlere dogru bir egilim vardir. Bunun en onernli durtuleri de tedavinin mumkun olan en az travma ile saglanmasi, ekonomik faktorler, hasta yasammm daha az kesintiye ugraulrnasi ve isgucu kaybimn onlenmesidir (1). Sozu edilen gerckceler dogrultusunda gelistirilmis teknikler sunlardir; 1. Transuretral insizyon (TUIP) 2. Lazer Prostatektorni 3. Hiperterrni ve Termoterapi 4. TransUretral igne Ablasyonu (TLTNA) 5. Yuksek Siddetli Odaklanrrus Ultrason (HIFU) 6. Balon Dilatasyonu ve Stentler 7. Elektrovaporizasyon 8. Kriyoterapi 9. Robotik TransUretral Cerrahi 1. TRANSURETRAL insizyon (TUIP): ilk kez 1961 yilinda Keitzer tarafrndan tammlanrms, 1973 yilmda Orandi tarafindan yaygmlastmlnusnr (2,3). BugUn bircok arastirmaci, tahrnini aglrhgl 30 gramm altinda adenornu olan, median lobu bulunmayan TUR(P)'a uygun gene hastalann TUIP icinde uygun adaylar oldugunda hemfikirdir (1). TransUretral insizyonun temel prensibi mesane boynundan baslayarak verumontanum duzeyine kadar tek bir hat veya saat 5 ve 7 hizasmdan olmak uzere iki hat uzerinde prostatin cerrahi kapsulunu de icerecek

2 derinl ikte bir insizyon yapmakur. Bu sekilde mesane boynu buyuyen ade norn dokusunun yaratug : sikisrkhktan kurtulacak, boylece mesanenin onundek i engel ort adan kalkacag i icin hasta tekrar normal iserne duzenine donecekti r (1). Genel veya spinal anestezi ile uygulanan TUIP, uygun hastalarda lokal anestezi ile de uygulanab ilmektedir.tuip icin bircok aiet ve yontem onerilrnis, sog uk ve sicak kesiler yapilrmsur. Collings bl<;agl, Sachse blr,:agl, Orandi bicagi, standart reze ktosko p Iupu, elektrokoterler. lazer sikca tercih ed ilen aygitlardrr. Secim tamarnen olanaklaru ve cerrahm deneyimine kalnus ur, birbirl erine belirgin ustiinlukleri yoktur (4). BPH nedeni ile arne liyat ediien hastalann % aras indaki bir grubunda histoloji k incelemede prostat kanserine ras tlanma ktad ir (I ). TUIp 'in en co k elestirilen yam ameliyat sirasmda histolojik inceleme icin doku elde edilernemesidir. Gerci pre-operatif donernde yapilacak oze nli bir inceleme ile bu durum ortadan kalkabilir ancak yine de ban aras unc rlar kesi oncesinde rezektoskopla biyopsi almaktadirlar (5). TUIP, yayg ll1 olarak uygulanan bir yontern olrnas ma ragmen literatur bilgilerinde standart bir degerlendirrn e yaprlmadrgi gorulmektedir. Tkocz ve Praisner, 30 grarrun alunda adenomu olan 100 hastayi TUIP ve TUR(P) icin randomize ederek gerceklestirdikleri cahsmada, yirmidort ayhk izlern sonucunda idrar akismd aki iyilesmenin, rnaksimurn idra r akmu ndaki arus m iki grupta istatistiksel olarak farkh bulunmadrgi gosterilrnistir (6), Soonaw alla ve Pardan ant 220 hastalik seriie rinde, T UR(P) sendro rn u, kanarna ve perforasyon oranlarnu n TUIP uygularnasmda TUR(P)'a gore cok daha az goruldugunu bild irmislerdir, Operasyon onces inde cinsel aktivitesi normal olan hasialarda retrograd eje kulasyon oranlan TUIP gr ubunda anlarnh derecede dusuk bulunmu s, ere ksiyon kaybma da rustlanmarmsur (7). TUIP, benign prostat hiperplazisi cerrahi teduv i sece nekleri arasmda, yillar icinde etkinligi kanul annu s, eko norni k, guvenli bir yon ternd ir. 2. LAZER PROSTATEKTOMi Lazer ism enerj isi bir terrnal enerj idir ve prostatta doku ablasyo nu yap maktadir. Bu arnacla neodyrnium.yur ium-alurninium garnet (Nd:YAG) lazerler tercih edilmektedir. Prostatta doku ablasyo nu icin cok sayidu lazer probu ve teknigi kullarnlmakta ve her gecen gun bu gelismelere yenileri kaulmaktadir (8). TULIP (Transurethral Ultrasound- Guided Laser Induced Prostatectomy): Bu sistemde, uretral insersiyon probu ve kolu, 90 transuretral ultrason sektor rarayrct si ve Nd:YAG lazer kaynagi olmak ilzere U<; komponent vardir, TULIP probu plastik ve ici su dolu bir kihf icersindeki paslanrnaz celik yapismdadir, ucund a 36 veya 48 F balon vardir. Bu balon yaklasik 2 atrnosfer bas inca Kad ar sisirilir ve boylece cihaz fikse edilir, kan akirm komprese edilerek daha etkili ve emniyetli bir lazer penetr asyonu sag lanrrus olur. Tedaviye genellikle mesane boynund an baslarnr ve 1mm/s'l ik bir luzla prob ger iye dogru cekilir. Post-operatif adem nedeni ile 1-2 haftah k donemde hastanm uretral veya suprapubik kateterli kalmasi onerilrnektedir (9,10). TULIP konu sund a yapi lan calisma sonuclan, yonternin TUR(P) Kadar basanh ve guvenilir oldugunu gosterrnistir (10). VLAP-ELAP (Visual-Endoscopic Laser Ablation of Prostate) : Gunumuzde en yaygm olara k kullarulan yontemdir. Sistoskop esliginde gorerek yapildrgi icin endos kopik lazer prastatektomi de denir (11,12). Kullarulan lazer probla nna gore ; non-kontakt ve kontakt olarak uygulamr, Non-kontakt uygulamad a terrnal yikirn, koag ulasyon veya evaporasyondur. Birkac haftadan birkac aya Kadar gecen surede koag ulurn likefiye olur ve dokulur. Kontakt uygularn a da gercek anlamda bir doku ablasyonu ve islern sonrasinda acik bir prostatik fossa saglamr (13). Yapilan cahs rnalurda, VLAP' li1 semptornlar ve uroflovmetrik parametreler Uzerindeki duzelrne oranlan TUR( P)'a yak 111 bulunrnu s, kanamanm minimal olrnas i ozellikle 2

3 yuksek risk tasiyan hastal arda VLAP 'nin onernli bir avantaj i olarak izlenmistir ancak post-operatif kateterli kalrna ve dizuri acismdan VLAP anlamli sekilde basan siz bunrnu stur (14,15). TUBAL-T ttransurethral Ballooll Laser Thermotherapy): Lazer irradyasyonu, prostatik uretraya transuretral olarak yerlestirilen bir lazer balon kateter iie 360 dere ce ve prostatik Uretra boyunca yapilabilrnektedir. Topikal anestezi ile de uygulanabilir. Prostatik doku derinc e koagule ve nekro ze edilirken, sogutrna neden i ile uretral mukoza intakt kalmaktadir (16). interstisyel LAZER: Bu youternde kuartz fiberoptik aplikatorler prostat dokusuna, transuretral, transrektal veya transp erineal yoldan uygularur. 5-7 Watt'hk devaml i lazer akuru uygularur, her yerlestirrnede prob yaklasik 10 dakika tutulur ve prostat buyuklugune gore 3 12 arasi uygul arna yapihr. Oretra intakt kaldrgi icin doku dokulrn esi olmaz, Nekrotik koagula syon zonu fibro zis ve atrofi ile dejen ere olrnakta ve geride minor skar dokulu gevsek prostat dokusu kalmaktadir. Etkin ve buyuk prostatlara uygulanabilecek en ernniyetli lazer teknigidir (17). HOLMiYUM LAZER (HOLEP): Holrniyum lazerin, prostatektomide kullururm nispeten yenidir. Prostat ik adenornun komplet enukleasyo nu saglarnr, histopatolojik incelerneye imkan saglar. Post-op er atif dizuri acismdan Nd:YAG lazere belirgin ustunlugu vardir. Morb idite, yan etkiler ve kornplikasyonlan, TUR(P) dan azken, sonuclan hemen hernen T UR(P) kadar bas anlidir. En onern li dezavantajlari, islern suresinin uzun olmasi ve yonternin pahah olmasidrr. (18,19). Sonuc olarak Lazer Prostatektorni; I. TUR(P)' a en iyi tedavi alternatiflerinden biridir. 2. Islem suresi ktsadir, lokal anestezi ile uygulanabilir,'kornplikasyonlan azdir. 3. Antikoagulan alanlarda, kardiy ovaskule r sistern hastahgi olanlarda, hernatol ojik hastalikl an ve kanama defektleri olanlard a emniyetlidir. 4. TUR(P) kadar efektif degildir, doku orne gi ahn amaz (HoLEP haric ), olusan kavite duzensizdir, 5. Pahalrdir ( 19). 3. HiPERTERMi VE TERMOTERAPi: HiPERTERMi ilk kez 1866 yilmda Bush, yilksek ates li bir hastada mevcut sarkorn un geriledigini: izlernesiyle, oze llikle malignitelerin sica khk ile tedavi edil ebilmesiyle ilgili cahsmalar baslarnisur (20). 1985'te ise ilk kez Yerushalrni ve arkadaslan yiiksek sicaklrgi BPH 'de uygulanu sur (2 1). Diinya Saglrk Orgutu, 42 ile 45 C arasi sicakhk uygulamalanm hip erternii, 45 ile 60 arasmdaki sicakhk uygularnalanm ise termot erapi olarak tammlarm sur (22). Prost atherrner, Primus gibi cihazlarla prostata, transrektal yolla 45 C'ye varan srcakliklar uygulanabilmektedir, sernptom skorlan nda ve idrar akrm hi zmda yiikselrne gorulrn usse de calismalarm nonrandomi ze ve kontrolsuz cahsmalar olrnasi nedeni ile, hiperterminin klinikt e kullanabilmesi icin uzun sureli randomize, kontrollu cah srnalara ihtiyac oldugu gorulrnektedir (23). TERMOTERAPi: Prostat dokusuna transrektal yolla yuksek sicakhk uygulanmasi, lokal rektal yaralanmalara ve rektovezikal fistul olusumuna neden olabildigi icin, transuretral mikrodal ga terrnoterapisi (TUM T) gundeme g e l m i~ t i r(2 4). T UMT tedavisinde, hiperterrniden Iarkh olarak prostat doku su sicak hk ile tahrip edilirken uretra mukozasi, mesane boynu ve sfinkter bolge si sogutularak bu etkid en uzak tutulrnaktadir, aynca terrnoterapi de prostat dokusuna uygulanan sicaklik derecesi de 3

4 hipertermiden yuksektir. T UMT sea nsi siras inda, trans izyonel zo ndaki sicakhk 47 C'nin Uzerin e cikarak doku tahribau yapmaktadir. Bu arada uretra dokusu iletkenli sog uuna ile korunrnaktadrr (20). TUMT, bir saat suren ve minimal analjezi ile poliklinik duzeyinde uyguianabilen ve semptornatik iyilesme sag layan, guvenilir bir ted avi yontemidir. Sonuclan kahcrdrr ve seksue l fonk siyonlar korunm aktadrr, sag ladlgl Urollovmetrik du zelme kabul edilebilir duzeylerdedir. Bu ozellikleri ile TUMT, BPH tedavisinde etkin bir secenek haline gelmisiir (25). WIT (Water indu ced therm oth erapy): Oretral Foley kateterin icinde dol astmlan suyun sicakhgi kont rollu olarak artunlarak loka! sicakhk tedavisi uygulanmasidrr (20). 4.TRANSURETRALicNE ABLASYONU (T UNA) Ozel kateterler yardinu yla.interstisyel radyofrekans (RF) euerji sinin, ayarlanabilir igneter vas nas iyla prostata uygulanm asi ve koagulasyon nekr ozu olu sturuimasr yonternidir (26). Prostattaki sicakhk 100 C'nin Uzerine cikabilrne ktedir. lgne izola syon krhf ile kaplr oldugu icin uretrada doku harabiyeti olmamaktadrr. Poliklinik sartlan nda, lokal anestezi ile uygulanabilen yontemin, Urollovmetrik parametreler ve semptom skorlan acrsmdan so nuclan yuz gulduruc UdUr (27). 5. YUKSEK ~iddetli ODAKLANMI~ ULTRASON (H IF U) Yuksek yog unlukta ultrason dalgalan bircok piezoelektrik elementin senkronize olarak aktive edilmesi ile olusturulup, ern. uzaklrkta oda klanabilmekte, ve bu oda k noktasinda c C sica khk olusturarak dokud a nekr oz olusturabilrnektedir, odak ve lezyon keskin suu rh dir, komsu dokular tumuyle intakt kahr (28). Madersbacher ve arkaduslari tarafindan yapilan cahsma sonucunda hastalar HlFU sonrasi 1 yil sureyle izlenmis, semptorn skorlan ve uroflovmetrik parametreler acrsmda n %50 'ye varan iyilesme izlenmi stir (29). Bu heyecan verici yeni tedavi yonterninin en onernli avant aji, Uretral bir giris im yapmadan prostaua ablasyo n meydana getirmesid ir. Gerek BPH tedavisinde, gere kse bobrek, kara ciger gibi orga n turnorlerin in tedavisinde sonuclar urnut vericidir (30). 6. BALON DiLATASYONU VE STENTLER Prostaun balon dilaiasyonun a ait ilk cahsrna 1984 yilmda Burh enne ve arkadas lan tarafmdan yaymlannus ur, arasunc i once erkek kaclavracla daha soma kendi uretrasmda 24 F anjiyoplasti balonunu prostatik Uretracla 30 sn. ~ i~ iri l m i~ halde tutrnustur (3 1). Prostaun transu retral balon dilatasyonu icin cesitli balonlar ve degisik yontemler uygulan rnakta, girisirn f1oroskopik, endos kopik veya dijital kont rol alunda yapilabilmektedir. Prostatta basi doku nekrozuna, anterior ve/veya poster ior komi ssurlerin yirulmasma, a. adrenerjik resepiorlerin etkilenmesine ve cluz kas tonusunun kaybolmasina neden olmaktadir. Diger minimal invazif tedavi yontern leri ile karsrlasurildr gmda etkinl igi ve kullaruhrhgr smirhdrr (32). intraprostatik STENTLER Prostatik uretra ya uretral kateterizasyon gereks inimini ortadan kaldiracak metalik bir tel yumak yerlestirilrnesi ilk defa 1980 yilmda Fabian tarafrndan tarumlanrrusu r (33). Pro staiik stentler gecic i (epitelize olmayan), kaltct (epitelize olan) olm ak Uzere iki grupta ele almm aktadir. Gerici Prostatik Steutler: Urospiral; enfeksiyon, enkrustasyo n, rnigrasyon, gec ici hematliri gibi komplikasyonlar ge lisebilmektedir. Cerrahi girisim icin riskli veya diger teda vi yorue rnleri icin bekleme nedeni olan obstruktif BPH' li hastalarda uygun yaklasimlardan bir i oldugu kabul edilmektedir. Prostakath; enkrustasyon riskini en aza indirmek amaci ile altmla kaplannu sur, 4

5 intraiiretral kateter; c ift malek ot seklinde ve 16F kalinhgmda poli Uretan bir kateterdir, di stal ucunda absorbe olmayan nayl on bir sutur vardir ve istendigi an cekilebilme ozelligine sahiptir. Komplikasyon ge lis me riskinin e n aza indirilmesi amaciyla 6-12 ayda bir degi stirilmesi gerek me ktedir. Mcmokat h; Nikel-titanyum alasrmdan ya pilnusu r. Sicakhkla ge nisle rnekte, sogutuldu gunda ise gevseye bilmekted ir. D I~ c,:ap l 22F, ic c,:apl 18F ve icersinden 16 F sistos kop gece bilme kted ir. Prostacoil; birbirine heliks seklinde bir tel ile baglanan iki kisimdan olusrna kta, prostat ik Uretraya yerlesen uzun seg rn-nt ve intrabulbar kis a segmentten olu sm aktadi r (32). Kabel Prostatik Stelltler: UroLumc Endoiirctral Protez; manyetik olmayan alasirndan yaprlrms, tubuler ag seklind e orulrnus, inert ve doku uyumlu bir stenttir. Bukul ebi lrne ve kendiliginden ge nisleyebilme ozelligine sahiptir, kendi haline birakildrgmda ic capt 42 F'ye kadar ulasabilrnektedir. Endosko pik olarak ozel bir yerl esti rrne aygiu ile yerlestirilir (3 2). ilk kez Milro y ve arkad aslan, inatci bulb oz Uretra da rhklannda dah a so ma da BPH ted avi sind e kullanrmslardrr (34). Literaturdeki, ge re k ce rrahi icin yuksek riskli, ge re kse saghkli o bs truktif olgularda UroLume endo pro tez uygularnalanrun sonuclan cesaret verici duzeyd cdi r. Bu yontern, T UR(P )'a basit ve etkili bir alternatiftir (35). Titanyum intraprostatik Stcnt; doku uyumu, toksisite az ligi, asinmay a diren cli olmasi gibi ozelliklerind en dolayt titan yumdan yapilrms bu stentlerle yaprlan calisma sonuclan ba sanlidir (36). Gianturco-Z Stent; paslanmaz celik tellerin zikz ak seklinde di ziler ek si lindir olusturdugu bir perkutan bili er stenttir. M or gantaler ve De Wolfun calismas mda retan si yondaki olgulan n %95'inde spo ntan iserne saglanrmsu r (3 7). Mcmotherm Stent, -icakhga du yarh ve yuk sek doku uyumlu Nitino l' den yapilmisur. T am ep ite lizasyon alun cr ay so nunda %6 0 hastad a, onikinc i ay sonunda ise % 80 hastad a ge lisrnektedir (38). 7. ELEKTROVAPORiZASYON Ozel gelistirilmis donen bir bar (Vaportrode) ile prostaun va po rize ed ilrne esasina dayarnr, kucuk prostatlarda TUR(P )' a gore daha kisa za rnanda yapihr ve daha az kanamaya ned en o lur. Post-operatif a de m ned eni ile uretral kat eter daha uzun kalabilmekte ve tedaviden yaklasik bir haft a sonra sekonder kanamal ar gorulebilmektedir (39). Son zamanla rda bipol ar elektrot ile uygulanan, per-operatif izotonik so lus yo nlarla yapilabi len ve bu nedenle TUR sendromu riskini ortada n kald iran vaporiza syo n teknikleri ile so n derece basanli so nuc lar bildirilmektedir (4 0). 8. KRiYOTERAPi Kri yop roblarla int rap rost atik sicakligm -215 C ' ye kad ar dusurulrnesi esasina dayamr. Erektil disfonksiyon, prostorekt al fistul ge lisme riski nedeni ile uygulanrnamaktadir (4 1). 9.ROBOTiK TRANSURETRAL PROSTAT CERRAHisi ilk kez 1991 yilmda, Timoney tarafmdan ge listirilen yonternde, daha onceden belirlenen ka vite ile, bil gi sa yar ro bo tu kontrol eder ek rezeksiyon sag larnaktadir, so n yillarda ye nide n popularize olmustur (42). KAYNAKLAR I. Sirnsek F. Transu retral insizyon T UIP: Beni gn Pro stat Hiperpl azisi. Hekimler Yaym Birl igi, p , Keit zer W A, Ch ervant es L, Dem acul ang A. Tran surethral inci sion of bladder neck for co ntrac ture. J U ro l, 86: 242-5, Grandi A. Transurethral incision of the Prostate. J Uro l, 110 : , Drago JR. Transurethral inci sion o f the Prostate. Uro log y, 36 : ,

6 5. Sirnsek F, TUrkeri L, Ilker Y, et al. of beni gn prostatic hyp erplasia. Urol ogy, T ransure thral groo ving o f the pro state in 46: , the treatm ent o f pati ent s with beni gn 15. A nso n A, Nawrock i J, Bu ckl ey J, et al. A pro static hyperplasia. A n alterna tive to multi cent er, randomi sed, prospecti ve study T ran surethral incision. Br J Urol, 72 : 84 of E ndoscopic La ser Abl ati on vers us 87, Transureth ral Resecti on o f the Prostate. 6. Tkocz M, Praj sn er A. Co mparison o f long Urol ogy, 46 : , term resu lts of tran sur ethral incision o f the 16. Furuya S, Ogu ra K, Ts ukamato T, et al: prostate with tran surethral resection o f the T ransur ethral balloon laser therm oth erapy prostate, in pati ents with beni gn prostatic for symptom atic beni gn prostatic hypert rophy. Neuro urol Urodyn, 21: 112 hyperplasia: Preliminary clinical res ults. J 116, Endo uro l, 9: , So onawalla PF, Pard anani DS. 17. Mu scht er R, Hofsteter A: Interstiti al Laser Transur ethral incision versus transurethral therap y outcomed in beni gn prostatic resection of the pro state. A subjective and hyperplasia. J End ou rol, 9 : , objective analysis. Br J Urol, 70: , 18. Kabalin IN, G illin g PJ, Frau ndorfer MR Applicat ion of the Holmium: YAG Laser 8. BedUk Y. Laser prostatektomi: Beni gn for prostate ctomy. J Clin Laser Med Surg, Prostat Hiperpl azisi. Hekimler Yayin 16: 21-27, Birl igi, p , McNi cholas TA, Singh S. Th e use of 9. Babayan RK. Transurethral ultr asound laser s in beni gn prostatic enlarge ment. guide d Laser indu ced pro statectomy C url' Uro l Rep, 1: , (TULIP) : Past, present, and future. J 20. Saglarn R, Adsan 6. Hip ert ermi ve Endo uro l, 9: , Terrnoterapi. Beni gn Pro stat Hiperpl azisi. 10. Pup po P, Perachino M, Ricciotti G, et al : Hekimler Yaym Birligi, p , Transurethral ultrasound-guid ed Laser 2 1. Yeru shalmi A, Fishelov itz Y, Singer D, et indu ced prostatectom y. Eur Uro l, 25 : 220 al : Locali zed deep microvawe hyp ert ermi a 225, in the trea tme nt of poor ope rative risk 11. Norri s JP, No rris DM, Lee RD, et patient s with beni gn prostatic hyperpl asia.. al:v isua l laser ablation of the prostate: J Uro l, 133 : , C linical expe rience in 108 patients. J Urol, 22. Smith P, Chanssy C, Con ort P, et al: 150: , Intern ational Con sultation on BPH by 12. Boon TA, Lepor H, M usthe r R, et al: World Health Or ganisation : Report of the Laser treatment of ben ign prostatic co mmittee on other non-medi cal hyp erpl asia (BPH) Workshop. Benign treatm ent. Par is, WHO:22 3, Prostatic Hyperpl asia: Recent Progress in 23. Boyd S, Baert L, Petrovich Z: M icro vawe Clinical Resea rch and Pr act ice (Kurth K, heating in the managem ent of BPH. AUA Newlin g DWW,ed ) New York, W iley Meet ing, San Antonio, Texas, 1C: 23-25, Liss , Go rnella LG,Lofti MA, Riv as DA, et al, 24. Kirby RS, Christmas JT: Beni gn prostatic Co ntac t Laser vaporization tecniques for hyperplasia. Mosby Int ern ational p.75, beni gn prostati c hyperplasia. J Endo uro l, : , Devon ec M, Fendler lb, Joubert P, et al. 14. Cowles RS, Kjab alin I N, Childs S, et al. A Responders versus non responders to prospective, ra ndo mised co mpa riso n of thermotherap y for the treatment of ben ign Transurethral Resecti on to Visual Laser prostatic hyperplasia. Eur Urol, 23: 282-6, Ablation of the Pro state for the treatment

7 26. Schulman CC, Zlotta AR, Rasor JS, et al.: 36. Kaplan SA, Merrill DJ, Mosely WG, et al : Transurethral needl e ablation (T UNA) : The titanium intraprostati c stent: The Safety, fea sibility, and tolerance of a Unit ed Stat es ex perience. J Urol,150: newoffice procedure for treatment of ,1993. beni gn pro static hyperpl asia. Eur.Urol, 24 : 37. Morgantaler A, De Wolf We. A self , expanding pro stati c stent for bladder outlet 27. Issa MM, Kabalin IN. Transurethral obstruction in high risk patients. J Urol, needle abl ation (T UNA) of the pro stat e: 150: ,1993. report of initial United Stat es clinica l trial. 38. Gottfried HW, Hautrnann RE, Sinterrnann J Urol, 153 : 533A, R, et al : Memotherm stent for BPH 28. Ter Haar G. Focused ultrasound therapy. treatment in high risk pati ents: experi enc e Curr Opin Uro l, 4 : 89, of more than 100 cases. J Urol, 15I: 29. Madersbach er S, Kratzik C, Marb erger M. 397A,1994. Prostatic tissue ablation by transrectal high 39. Kirb y RS, Christmas JT: Beni gn pro static inten sity focused ultr asound: histol ogical hyperplasia. Mosby International p.84, imp act and clini cal applicati on. Ultrason Sonochem,4: , Bott o H, Lebret T, Barre P, et al. 30. Saglam R, Safak M. Yuk sek siddetli Electrovapori zation of the Prostate with odakl anrrus ultrason HIFU. Beni gn Prostat the Gyrus device. J Endourol, 15: 3 13 Hiperplazisi Hek imler Yayin Birl igi. 316,2001. p , Kirb y RS, Chri stmas JT. Beni gn pro static 31. Burhenne HJ, Chi sholm RJ, Qu en ville NF : hyperplasi a. Mo sby Internation al p.70, Prostatic hyperplasia: radiological inter vent ion. Radi olo gy, 152: , 42. Timoney AG, Davi es BL, Hibberd RD et al: Th e use of robots in surgery: the 32. Yildi z S, Buyukalpelli R. Balon devel opment of a frame for pro statectomy. dil atasyonu ve stentler. Hekimler Yaym J End ourol, 5: ,1991. Birligi. p , Fabian KM. Der Intraprostatich e 'Partielle Yazarlar: Kath eter' (Urologische Spirale). Urologe M. DEMIRBA~, Yrd. Doc, Dr., Afy on A, 19: ,1980. Kocatepe Un iversitesi, Droloji A.D., Afyon 34. Milroy EJG, Coulage C, Pan sadoro V, et C;. DiNc;EL, D o ~. Dr., Afy on Kocatepe al : The UroLume permanent Prostate stent Universitesi, Uroloji A.D., Afyon as an alternative to TUR(P): long-term European results. J Urol,151 : 396A, Yazisma Adresi: Yrd.Doc.Dr.Murat 35. Guazzon i G, Bergarnaschi F, Montorsi F, DEMiRBA~, Afy on Koc atepe Universitesi et al: Prostatic UroLume W allstent for Droloji A.D., AFYON beni gn prostati c hyperplasia patients at mur atc poor operative risk: clin ical, uroflowmetric, Tel: and ultrasonographic patt ern s. J Urol, 150 : ,

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