Laser treatment in urology: our experience with neodymium:YAG and carbon dioxide lasers

Preclinical optimization of a diode laser-based clamp-free partial nephrectomy in a large animal model

Kidney cancer is a common urologic malignancy with either laparoscopic (LPN) or robotic partial nephrectomy as therapeutic options of choice for localized tumors. However, renal resection and suturing are challenging steps of the procedure that can lead to complications such as prolonged warm ischemia, bleeding, and urinary fistulas. LPN with a diode laser is an efficient technique due to its cutting and/or coagulation attributes. Surprisingly, key laser features such as wavelength and power remain undefined. Using a large porcine model, we evaluated the laser range of wavelength and power in a clamp-free LPN and compared it to the established gold-standard LPN technique (i.e., cold-cutting and suturing). By analyzing surgery duration, bleeding, presence of urine leak, tissue damage related to the resected renal fragment and the remaining organ, hemoglobin levels, and renal function, we show that an optimized experimental diode laser clamp-free LPN (wavelength, 980 nm; power, 15 W) had shorter surgery time with less bleeding, and better postoperative renal function recovery when compared to the well-established technique. Together, our data indicate that partial nephrectomy with a diode laser clamp-free LPN technique is an improved alternative to the gold-standard technique. Therefore, translational clinical trials towards human patient applications are readily feasible.

Dual laser circumcision: a novel technique to improve traditional surgery

Circumcision represents one of the oldest and routinely performed urological surgery. It implies the exeresis of the prepuce due to ethnic, religious and medical reasons. Different authors reported straightforward advantages of this procedure including increased penile hygiene, reduction of penile cancer risks and lower rates of urinary tract infections. Circumcision can be easily performed and reproduced according to different techniques. Nowadays, different types of lasers have been developed and this technology is gaining consensus in the urological community. Aim of this article is to describe our surgical technique for laser circumcision with the Lasemar Eufuton 1500, clarifying the surgical steps and the benefits of this technology.

A Systematic Review of the Efficacy and Safety of Outpatient Bladder Tumour Ablation

CONTEXT

Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent need for repeated transurethral resections under general/regional anaesthesia. Outpatient-based diathermy or laser ablation is another option, but evidence for its efficacy is mixed and its use is controversial.

OBJECTIVE

To systematically review evidence regarding the efficacy and safety of outpatient diathermy and laser ablation for the treatment of recurrent NMIBC.

EVIDENCE ACQUISITION

The EMBASE, MEDLINE/PubMed, and Cochrane Library were searched from inception to June 26, 2020. All studies evaluating the use of diathermy or laser ablation for bladder tumours (new or recurrent) in an outpatient setting under local anaesthetic were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools.

EVIDENCE SYNTHESIS

The search yielded 1328 studies. After excluding duplicates, 1319 titles and abstracts were screened and 17 studies (1584 patients) were eligible for inclusion in the final review. The majority of patients had small, low-grade tumours, but there was heterogeneity in the inclusion criteria. Overall, laser ablation and diathermy resulted in mean recurrence rates of 47% and 32% at follow-up of 22-38 mo, respectively, with a mean progression rate of 3-12% (low certainty of evidence). Both procedures were well tolerated, with low pain scores and low periprocedural complication rates (moderate certainty of evidence).

CONCLUSIONS

Outpatient diathermy and laser ablation have good short-term efficacy in patients with low-grade NMIBC and reduce the need for intervention under general/regional anaesthesia. The procedures are well tolerated with low complication rates. The overall certainty of evidence is low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for randomised trials with long-term follow-up using standardised risk classification and outcome measures. Despite these limitations, the findings will aid in patient counselling regarding this less invasive treatment option that avoids the morbidity of transurethral resection.

PATIENT SUMMARY

Outpatient diathermy and laser ablation have good success rates in treating recurrent low-grade bladder tumours in the short term, avoiding the need for more invasive procedures under general/regional anaesthesia, with low rates of side effects. Further studies are needed to determine whether these treatments remain safe and effective in the long term.

Audit of safety, efficacy, and cost-effectiveness of local anaesthetic cystodiathermy

INTRODUCTION

The aim of this study was to audit our experience of cystodiathermy under local anaesthetic (LA) at the time of flexible cystoscopy for recurrent superficial bladder transitional cell carcinoma (TCC).

PATIENTS AND METHODS

A total of 264 flexible cystoscopies were performed on patients with a past history of TCC. The number and site of recurrences were recorded and selected patients were offered cystodiathermy. Patient tolerability was noted. At follow-up, any recurrence was recorded.

RESULTS

Eighty patients (30%) had 91 procedures showing one or more recurrences. Fifty-one of the 80 patients (64%) were treated with cystodiathermy under LA. All completed treatment. Forty-five (88%) tolerated the procedure well. Forty-seven (92%) treatments were completed within 5 min. At a median follow-up of 15 weeks, 30 (59%) treated patients had no recurrence and three (6%) had recurrence at the site of treatment.

CONCLUSIONS

LA cystodiathermy is an effective and well-tolerated alternative to general anaesthetic cystodiathermy that enables treatment at the time of detection and may, thereby, reduce patient anxiety.

The Use of Local Anesthesia with N-DO Injector (Physion) for Transurethral Resection (TUR) of Bladder Tumors and Bladder Mapping: Preliminary Results and Cost-Effectiveness Analysis

OBJECTIVE

We evaluated feasibility of TUR of Ta-T1 TCC of the bladder or bladder mapping under local anesthesia using a Physion endoinjector to see if correct tumor staging was possible, to check patient tolerability, and to analyze cost-effectiveness.

METHODS

Thirty patients with bladder tumors and 10 patients with hematuria and/or doubtful cytologies were treated in a day hospital setting. TUR or biopsies were performed after injecting lidocaine into the outer area of the lesion in the bladder at 2-3 sites under the mucosa. A single injection per biopsy site was necessary for bladder mapping. We evaluated tolerability using the VAS questionnaire. Cost analysis considered length of hospital stay, number of anesthesiological procedures, and complications.

RESULTS

The stage and grade after TUR were 19 TaG1-2, 10 T1G2, and 1 papillary hyperplasia. After bladder mapping, 5 patients had CIS and 5 had inflammation. Sixty percent of patients had no or mild pain, 30% moderate pain requiring light sedation or analgesia, and 10% severe pain requiring spinal or general anesthesia. The mean hospital stay was 9h. Four of 40 patients complained of macroscopic hematuria; one was readmitted to the ward. This procedure saved 1097.07 euros per case and 36 anesthesiological procedures were avoided.

CONCLUSIONS

This is a simple, safe, cost-effective technique, allowing TUR of bladder tumors and bladder mapping in 60% of patients and, with light sedation or analgesia, in 90% of patients, with a low complication rate. Tumor staging was correct in 90% of cases. The mean hospital stay was 9h.

Evaluation of carbon dioxide laser ablation combined with mitoxantrone and piroxicam treatment in dogs with transitional cell carcinoma

CASE DESCRIPTION

8 dogs that underwent carbon dioxide (CO2) laser ablation of transitional cell carcinoma in the bladder trigone and proximal portion of the urethra and were also treated with mitotranxone and piroxicam.

CLINICAL FINDINGS

Transitional cell carcinoma of the bladder frequently involves the trigone and urethra and can be difficult to manage surgically. Dogs underwent laser ablation of the primary tumor and were treated with mitoxantrone at a dosage of 5 mg/m2)every 3 weeks for 4 treatments. Piroxicam was given at a dosage of 0.3 mg/kg (0.14 mg/lb) once daily for the remaining life of the dog.

TREATMENT AND OUTCOME

Median and mean disease-free intervals were 200 and 280 days, respectively. Median and mean survival times were 299 and 411 days, respectively. Adverse treatment effects were observed in 2 dogs; signs included mild, self-limiting inappetance and lethargy. The procedure appeared to be well tolerated; all treated dogs had rapid resolution of clinical signs of disease of the lower portion of the urinary tract.

CLINICAL RELEVANCE

Although survival times achieved with CO2 laser ablation and treatment with mitoxantrone and piroxicam were similar to survival times associated with chemotherapy alone, resolution of clinical signs was better with the combined treatment.

Persistence, recurrence, and progression rates of superficial bladder tumours after resection using the differentiated technique

OBJECTIVE

To investigate whether the differentiated resection technique for excising superficial bladder cancer leads to higher recurrence and progression rates as compared with regular resection.

SUBJECTS AND METHODS

We evaluated 163 patients, 66 undergoing a differentiated and 97 a regular resection. All patients underwent a routine second resection within 6-10 weeks. Recurrence and progression rates as well as tumour persistence on second resection were analyzed.

RESULTS

Patients with differentiated resections of bladder tumours did not have higher tumour recurrence and progression rates. Also, these patients had a significantly higher percentage of tumour-free second resections (p = 0.03).

CONCLUSION

The differentiated resection technique for excising superficial bladder cancer has no negative influence on recurrence and progression rates, but it leads to a reduced tumour persistence.

[Nd-YAG laser photocoagulation of scrotal sebaceous cysts]

Scrotum's sebaceous cyst is an usual pathology, not life threatening, but susceptible of infection, producing abscess with their associated cosmetic and psychological disturbance. The classical management is the complete excision, under local anaesthesia, to prevent its recidive. Until today, the use of de Nd-YAG laser for the management of the scrotum's sebaceous cysts as not been reported. We report a case of a young man with several scrotum's sebaceous cysts, treated successfully with the use of a Nd-YAG laser.