Usporedba učinaka transuretralne resekcije prostate i endoskopske laserske ablacije prostate na postoperativni imunološki status bolesnika s adenomom prostate [ Comparison between TURP and ELAP on postoperative immunological status in patients with BPH ]

Bedalov, Goran (2003) Usporedba učinaka transuretralne resekcije prostate i endoskopske laserske ablacije prostate na postoperativni imunološki status bolesnika s adenomom prostate [ Comparison between TURP and ELAP on postoperative immunological status in patients with BPH ]. PhD thesis, Sveučilište u Zagrebu.

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Abstract

In this investigation systemic effects of transurethral resection of the prostate (TURP) were compared to effects of endoscopic laser ablation of the prostate (ELAP) which represents one of the new methods in treatment of benign prostatic hyperplasia. The aim of the study was to investigate the influence of high-energy laser on acute-phase responses and on systemic immunological exhibitions as well as on analysis of laser effects relating to intensification of energy applied during the procedure. It was of great importance for the clinical praxis to find out which procedure would be more acceptable for patients concerning to their age and immunological parameters. We investigated 48 patients (aged 60-70 years) who were divided in two groups: first group of patients underwent transurethral resection of the prostate (TURP) and the second group underwent endoscopic laser ablation of the prostate (ELAP). Laboratory consisted of haematology (SE rate, hematocrit, haemoglobin, erythrocyte count, thrombocite count, the percent and the count of leukocyte, neutrophiles, monocytes and lymphocytes), biochemical parameters (urea, creatinine, glucose, AST, ALT, GGT, ALP, CK, total protein and the protein fractions), endocrinologic parameters (T3, T4, TSH, cortisol, ACTH), and immunologic parameters. Relative and absolute count of CD19+ B-lymphocytes and the levels of IgA, IgG and IgM were analysed among a lot of components of peripheral blood humoral immune system while CRP and complement fractions (C3, C4) were analysed among components of the humoral non-specific immunity. Relative and absolute number of T-lymphocytes subpopulations and NK-cells were investigated related to cellular immunity as well as "in vitro" timidine functional test of peripheral blood monocytes proliferation related to mytogenics PHA, ConA and PWM. Blood samples were collected on day 0 (immediately before and after surgical procedure) and 1, 6 and 21 day postoperative day respectively. Our investigation found both procedures to cause local tissue damage and systemic reaction of organism referred to the injury. This was presented by changing some values of inflammatory, biochemical, endocrinological, hematological and immunological parameters in peripheral blood samples. Comparing postoperative parameters we found TURP to provoke more intensive acute-phase responses than ELAP during first 24 hours following surgery. These findings were especially related to increased C-reactive protein serum levels and to increasing of leukocyte, neutrophile and monocyte absolute number in peripheral blood. An increase of CK serum levels was found significant. It was similar in both procedures pointing at similarity in local tissue damage. At the same time significantly lower postoperative values of haemoglobine and hematocrite suggested TURP as a more aggressive procedure causing more local damage of tissue and blood vessels. According to immunological parameters both procedure were found to provoke almost equally decreasing of total serum protein level, C3 and C4 components of complement and IgG serum fractions. There were no changes in number of preoperative and postoperative lymphocyte-B. In opposite, the cell immunity demonstrated decreasing of lymphocyte number, lymphocyte-T number and especially in number of cytotoxic lymphocyte-T and NK in both procedures finally resulting in significant increase of CD4/CD8 relation especially in the ELAP group of patients. The consistent trend in reaction of lymphocytes on mytogenics was not found postoperatively in both group of patients by reason of relatively small number of patients and a wide dispersion of results. In general, postoperative PHA and PWM reactivity (in absolute numbers) did not show significant discrepancy in both groups while ConA postoperative reactivity showed an increasing trend. There were not found statistically significant differences between TURP and ELAP in most of biochemical, endocrinological, immunochemical and immunological parameters except in acute-phase responses reaction. That pointed in conclusion that high-energy laser treatment probably has neither pre-mature nor postponed significant immunomodulative effect on human organism characterizing itself as the minimal invasive treatment method. Moreover, there is no significant influence of magnified laser energy to haematological, endocrinologic and immunologic parameters postoperatively in patients who underwent ELAP.

Abstract in Croatian

U ovom radu uspoređeni su sustavni učinci kirurškog zahvata na prostati (TURP) s učincima endoskopske laserske ablacije prostate (ELAP), zahvata koji predstavlja jednu od novijih metoda liječenja dobroćudnog uvećanja prostate. Težište istraživanje bilo je na istraživanju učinaka lasera visoke energije na odgovor akutne faze i na sustavne imunološke pokazatelje, te na usporedbi učinaka lasera u odnosu na povećanje primijenjene energije. S praktičnog stajališta važno je utvrditi koji je zahvat za liječenje adenoma prostate prihvatljiviji za bolesnika, posebice uzimajući u obzir starost bolesnika i imunološke parametre. U istraživanju je bilo 48 bolesnika u dobi između 60 i 70 godina koji su bili podijeljeni u dvije skupine: prva skupina bolesnika liječena je transuretralnom resekcijom adenoma prostate (TURP), a druga endoskopskom laserskom ablacijom prostate (ELAP). Laboratorijsko istraživanje bolesnika prije i nakon zahvata ELAP i TURP uključivalo je hematološke pokazatelje (sedimentaciju eritrocita, broj eritrocita, hematokrit i hemoglobin, broj trombocita, udio i broj leukocita, neutrofilnih leukocita, monocita i limfocita), biokemijske pokazatelje krvi (urea, kreatinin, GUK, AST, ALT, GGT, ALP, CPK, ukupne proteine i proteinske frakcije), endokrinološke pokazatelje (T3, T4, TSH, kortizol i ACTH), te imunološke pokazatelje. Od sastavnica humoralnog imunosnog sustava periferne krvi istražen je relativni i apsolutni broj CD19+ limfocita B i razina imunologulina IgA, IgG i IgM, dok su od sastavnica humoralne nesepcifične imunosti istražene komponente komplementa C3 i C4, kao i C-reaktivni protein. Od sastavnica celularne ili stanične imunosti istražen je relativni i apsolutni broj T-limfocitnih subpopulacija i NK-stanica, a od funkcijskih testova proliferacija mononukleara periferne krvi na mitogenike PHA, ConA i PWM s pomoću timidinskog testa in vitro. Uzorci krvi vađeni su neposredno prije i nakon zahvata, te 1., 6. i 21. postoperativnog dana. Dobiveni rezultati pokazuju da oba zahvata dovode do lokalnog oštećenja tkiva i sustavnog odgovora organizma na ozljedu, a to se očitovalo promjenom nalaza upalnih, biokemijskih, endokrinoloških, hematoloških i imunoloških pokazatelja u perifernoj krvi bolesnika. Usporedba postoperativnih pokazatelja između skupina ELAP i TURP pokazuje da zahvat TURP uzrokuje jači odgovor akutne faze od zahvata ELAP unutar prvih 24 sati nakon zahvata. To se posebice odnosi na povećanu razinu serumskog CRP te porast apsolutnog broja leukocita, neutrofila i monocita u perifernoj krvi. Oba zahvata dovela su do značajnog, ali podjednakog povećanja razine CPK u serumu, što govori da je stupanj lokalnog oštećenja tkiva u oba zahvata podjednak. Nasuprot, TURP uzrokuje značajniji pad vrijednosti hemoglobina i hematokrita nakon zahvata, što govori u prilog da on ipak predstavlja agresivniju metodu s većim stupnjem lokalnog oštećenja tkiva i krvnih žila. Glede imunoloških parametara, oba zahvata dovode podjednako do pada razine ukupnih proteina seruma, serumskih frakcija, IgG i komponenti komplementa C3 i C4, dok se broj limfocita B nije mijenjao u odnosu na vrijednosti prije zahvata. Nasuprot tome, stanična imunost nakon obaju zahvata pokazala je promjene u smislu pada broja limfocita, pada broja limfocita T, a posebice pada broja citotoksičnih limfocita T i NK-stanica. Shodno tome postoji značajno povećanje omjera CD4/CD8, posebice u skupini ELAP. Zbog relativno malog broja ispitanika i velikog rasapa podataka, u ovom radu nije nađen konzistentan trend u reakciji limfocita na mitogenike nakon zahvata TURP i ELAP. Općenito, reaktivnost na PHA i PWM (u apsolutnim vrijednostima) ne pokazuje značajnija odstupanja nakon obaju zahvata, dok reaktivnost na ConA pokazuje trend povećanja. Izuzev reakcije akutne faze, između zahvata ELAP i TURP nisu uočene statistički značajne razlike u većini biokemijskih, endokrinoloških, imunokemijskih i imunoloških pokazatelja. Taj podatak upozorava na to da lasersko zračenje visoke energije nema izražen ni rani niti odgođeni (kasni) imunumodulacijski učinak na ljudski organizami te da predstavlja minimalno invazivnu metodu liječenja. Štoviše, povećanje energije laserskog zračenja nema značajnog utjecaja na postoperativne hematološke, biokemijske, endokrinološke i imunološke pokazatelje u bolesnika podvrgnutih elektivnoj laserskoj ablaciji prostate.

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