Holmium laser core-through urethrotomy for traumatic obliterative strictures of urethra: Initial experience

Experience of 138 Transurethral Urethrotomy With Holmium:YAG Laser

Introduction: Many valid option modalities are available for the management of urethral stricture disease (USD), such as internal urethrotomy which has the success rates of 33%-60%. The aim of this study was to assess the outcome of holmium: YAG (Ho: YAG) laser urethrotomy (HLU). Methods: One hundred thirty-eight patients with urethral stricture with the mean age of 48±3.03 years old treated by HLU from March 2011 to August 2017. The main purpose of this investigation was to evaluate mean operation time, stricture recurrence rate and post-operation Qmax and complications of transurethral HLU. Results: The most common cause of USD was trauma in 82 (59.4%) patients. Mean laser operation time, mean hospital stay and mean postoperative duration of catheterization were 23.08 ± 9.1 minutes, 19.02 ± 10.7 hours and 10.3 ± 1.05 days respectively. The mean Qmax was 8.3 ± 2.07 mL/s before surgery and 16 ±3.1 mL/s afterward. At the end of 12 months follow-up, a total of 37 (26.8%) patients developed recurrence of the stricture. Patients with posterior, longer urethral strictures and previous history of interventions have more recurrence rate of the stricture. Conclusion: HLU is minimally invasive and seems to be an effective and safe management option for primary, short, urethral strictures. The hospital stay is remarkably short and complications are negligible.

The role of lasers in modern urology

INTRODUCTION

The functioning of modern urological departments and the high level of service they provide is possible through, among other things, the use of modern laser techniques.

MATERIAL AND METHODS

Open operations have been replaced by minimally invasive procedures, and classical surgical tools by advanced lasers. The search for new applications with lasers began as technology developed. Among many devices available, holmium, diode and thulium lasers are currently the most popular.

RESULTS

Depending on the wavelength, the absorption by water and hemoglobin and the depth of penetration, lasers can be used for coagulation, vaporization and enucleation. In many centres, after all the possibilities of pharmacological treatment have been exhausted, lasers are used as the primary treatment for patients with benign prostatic hyperplasia, with therapeutic results that are better than those obtained through open or endoscopic operations. The use of lasers in the treatment of urolithiasis, urinary strictures and bladder tumours has made treatment of older patients with multiple comorbidities safe, without further necessity to modify the anticoagulant drug treatment. Laser procedures are additionally less invasive, reduce hospitalization time and enable a shorter bladder catheterization time, sometimes even eliminating the need for bladder catherterization completely. Such procedures are also characterized by more stable outcomes and a lower number of reoperations.

CONCLUSIONS

There are also indications that with the increased competition among laser manufacturers, decreased purchase and maintenance costs, and increased operational safety, laser equipment will become mandatory and indispensable asset in all urology wards.

Direct vision internal urethrotomy by using endoscopic scissors

PURPOSE

To evaluate the effectiveness and safety of direct vision internal urethrotomy (DVIU) by using endoscopic scissors for incision of short (<1 cm) urethral strictures in adult men.

PATIENTS AND METHODS

Twenty-one patients who had short bulbar urethral strictures were evaluated in this study. Endoscopic scissors was used for incision of urethral strictures in all patients. Retrograde urethrography (RGU) and maximum flow rate(Qmax) <15.0 ml/s by uroflowmetry were used for the definition of recurrences.

RESULTS

The procedure was found successful in all patients. The mean size of stricture was 0.73 cm. The mean pre-procedure Qmax was 7.9 ml/s. The mean procedure time was 10.2 min. The mean Qmax was 19.4 ml/s at the third month postoperatively. RGU was normal in all patients at the third month postoperatively. The mean follow-up was 8.1 months. Three (14.2 %) patients underwent second DVIU due to recurrence. No complication was observed during the follow-up except urinary tract infection in two (9.5 %) patients.

CONCLUSIONS

DVIU using endoscopic scissors appears to be an effective and safe treatment modality for incision of short urethral strictures in adult men.

Review of the current management of lower urinary tract injuries by the EAU Trauma Guidelines Panel

CONTEXT

The most recent European Association of Urology (EAU) guidelines on urologic trauma were published in 2014.

OBJECTIVE

To present a summary of the 2014 version of the EAU guidelines on urologic trauma of the lower urinary tract with an emphasis on diagnosis and treatment.

EVIDENCE ACQUISITION

The EAU Trauma Panel reviewed the English-language literature via a Medline search for lower urinary tract injury (LUTI) up to November 2013. The focus was on newer publications and reviews, although older key references could be included.

EVIDENCE SYNTHESIS

A full version of the guidelines is available in print (EAU Guidelines 2014 edition, ISBN/EAN 978-90-79754-65-6) and online (www.uroweb.org). Blunt trauma is the main cause of LUTI. The preferred diagnostic modality for bladder and urethral injury is cystography and urethrography, respectively. In the treatment of bladder injuries, it is important to distinguish between extra- and intraperitoneal ruptures. Treatment of male anterior urethral injuries depends on the cause (blunt vs penetrating vs penile-fracture-related injury). Blunt posterior urethral injuries can be corrected by immediate/early endoscopic realignment. If this is not possible, such injuries are managed by suprapubic urinary diversion and deferred (>3 mo) urethroplasty. Treatment of female urethral injuries depends on the location of the injury and is usually surgical.

CONCLUSIONS

Correct treatment of LUTIs is important to minimise long-term urinary symptoms and sexual dysfunction. This review performed by the EAU trauma panel summarises the current management of LUTIs.

PATIENT SUMMARY

Patients with trauma to the lower urinary tract benefit from accurate diagnosis and appropriate treatment according to the nature and severity of their injury.

Therapeutic applications of lasers in urology: an update

There has been renewed interest in the use of lasers for minimally invasive treatment of urologic diseases in recent years. The introduction of more compact, higher power, less expensive and more user-friendly solid-state lasers, such as the holmium:yttrium-aluminum-garnet (YAG), frequency-doubled neodymium:YAG and diode lasers has made the technology more attractive for clinical use. The availability of small, flexible, biocompatible, inexpensive and disposable silica optical fiber delivery systems for use in flexible endoscopes has also promoted the development of new laser procedures. The holmium:YAG laser is currently the workhorse laser in urology since it can be used for multiple soft- and hard-tissue applications, including laser lithotripsy, benign prostate hyperplasia, bladder tumors and strictures. More recently, higher power potassium-titanyl-phosphate lasers have been introduced and show promise for the treatment of benign prostatic hyperplasia. On the horizon, newer and more effective photosensitizing drugs are being tested for potential use in photodynamic therapy of bladder and prostate cancer. Additionally, new experimental lasers such as the erbium:YAG, Thulium and Thulium fiber lasers, may provide more precise incision of soft tissues, more efficient laser lithotripsy and more rapid prostate ablation. This review provides an update on the most important new clinical and experimental therapeutic applications of lasers in urology over the past 5 years.

Treatment of urethral/bladder neck stricture after high-intensity focused ultrasound for prostate cancer with holmium: yttrium-aluminium-garnet laser

Purpose

To evaluate the efficacy and safety of the Holmium: yttrium-aluminium-garnet (YAG) laser for the treatment of urethral/bladder neck strictures after high-intensity focused ultrasound for prostate cancer.

Methods

Between February 2007 and July 2010, Holmium: YAG laser urethrotomies were performed in eleven patients for bladder neck strictures or prostatic urethral strictures. The laser was used with a 550-µm fiber at 2 J and frequency 30 to 50 Hz. The medical records were retrospectively reviewed for medical history, perioperative and postoperative data, uroflowmetry, International Prostate Symptoms Score/quality of life, and stricture recurrence.

Results

At a median follow-up of 12.0 months (range, 4 to 35 months), the mean postoperative maximal flow rate and residual volume were improved significantly (P<0.05). The mean postoperative total, voiding and quality of life of international prostate symptom score were improved significantly (P<0.05). Of the 11 patients, 7 patients required one treatment, 4 patients two treatment, and 1 patients three treatment. 2 patients who had a documented urinary incontinence prior to the laser treatment subsequently required artificial urinary sphincter implantation and reported satisfaction without developing any recurrent strictures or artificial urinary sphincter erosion. All patients exhibited well-healed strictures and could void without difficulty.

Conclusions

Holmium: YAG laser therapy represents a safe, effective and minimally invasive treatment for urethral/bladder neck strictures occurring secondary to high-intensity focused ultrasound for prostate cancer.

[European Association of Urology guidelines on laser technologies]

CONTEXT

The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.

OBJECTIVE

Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.

EVIDENCE ACQUISITION

Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.

EVIDENCE SYNTHESIS

Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.

CONCLUSIONS

In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

Endoscopic holmium:YAG laser ablation of early gastrointestinal intramucosal cancer

Various endoscopic techniques are being increasingly used in early gastrointestinal (GI) cancer. The holmium: yttrium-aluminum-garnet (Ho:YAG) laser has precise tissue cutting ability and good hemostatic properties and has been widely applicated to soft tissue, but the use of endoscopic Ho:YAG laser ablation for early gastrointestinal cancer has not been reported. Twenty patients with biopsy-proven early GI cancer who had a high surgical risk or refused surgery were treated by endoscopic Ho:YAG laser ablation. The tumors of all patients were confined to the mucosal layer without ulceration and without lymph node metastasis. The tumor diameter was not more than 2.5 cm. Endoscopy, endoscopic ultrasound, and computed tomography scan were performed 1-3 months after the treatment, and a biopsy was performed to evaluate the effects of the therapy. Long-term endoscopic follow-up was maintained. Complete eradication was achieved in all the 20 patients, including four patients with high-grade dysplasia associated with focal canceration, seven patients with well-differentiated squamous cell cancer, and nine patients with well-differentiated adenocarcinoma, resulting in a complete response rate of 100% at 1-3 months after treatment. No recurrence was found during 36-73 months of follow-up in all 20 patients. No operative or delayed complications were observed in any of the 20 patients. Preliminary study shows that endoscopic Ho:YAG laser ablation may be an effective, safe, and minimally invasive method for selected patients with early GI intramucosal cancer. Further research is required to confirm the safety and efficacy of this technique compared to its alternative techniques in a multicenter randomized controlled trial.

Comparison of treatment results between holmium laser endourethrotomy and optical internal urethrotomy for urethral stricture

PURPOSE

We comparatively evaluated urethral stricture (US) treatment outcomes, efficacy and complications, using either holmium laser endourethrotomy (HLU) or optical internal urethrotomy (OIU) since studies such as this are scarce in literature.

METHODS

During 2003-2008, 50 men aged 17-78 years were operated on for primary or refractory US, 32 (64%) and 18 (36%) patients, respectively. The average stricture length was 1.86 cm. Strictures were single or multiple, forty-one (82%) and nine (18%) patients, respectively, and were located in the anterior or posterior urethra in 27 (54%) and 32 (64%) patients, respectively. US were iatrogenic in 32 (64%) and idiopathic in 18 (36%). Patients were divided into two groups, grpA and grpB, each containing 25 patients who were treated using either HLU or OIU, respectively. An evaluation scale of 1-3 was adopted and took maximum flow rate (Q(max)), postvoid residual (PVR), and quality of life (QL) into consideration. A score of '1 was very good, '2 was good, and '3 was poor.

RESULTS

Treatment results were evaluated after 3, 6, and 12 months, respectively. Evaluation of grpA was as follows: five (20%), nine (36%), and seven (28%) patients scored a '1; thirteen (52%), nine (20%), and four (16%) patients scored a '2; and seven (28%), eleven (44%), and fourteen (56%) patients scored a '3. Evaluation of grpB: seven (28%), ten (40%), and five (20%) patients scored a '1; eleven (44%), seven (28%), and ten (40%) patients scored a '2; and seven (28%), eight (32%), and ten (40%) patients scored a '3.

CONCLUSIONS

Neither complication rate nor degree of efficacy between HLU and OIU for US revealed a significant difference. We found both laser and conventional urethrotomies to be safe and effective modes of treatment.

EAU guidelines on laser technologies

CONTEXT

The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.

OBJECTIVE

Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.

EVIDENCE ACQUISITION

Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.

EVIDENCE SYNTHESIS

Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.

CONCLUSIONS

In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

Comparison of neodymium-doped yttrium aluminum garnet laser treatment with cold knife endoscopic incision of urethral strictures in male patients

OBJECTIVE

To assess the effectiveness of visual laser ablation treatment with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in male patients with urethral strictures and to compare the effects with those obtained in patients treated with Sachse's optical urethrotomy.

MATERIALS AND METHODS

Fifty patients aged 22 to 83 (mean age 61.8) with primary (n = 26, 52%) and recurrent (n = 24, 48%) urethral strictures 0.3 to 2.4 cm long qualified for the study. The patients were randomized into two groups: 30 men treated using visual laser ablation of urethral strictures (VLASU) with Nd:YAGlaser and 20 men treated by correction of urethral strictures using Sachse's optical urethrotomy.

RESULTS

At 12-month follow-up, seven (35%) patients who underwent optical urethrotomy and 21 (70%) in the VLASU group did not require repetition of the procedure. The choice of VLASU as a method of treatment significantly decreased the probability of therapeutic failure and recurrence of urethral strictures (p = 0.02).

CONCLUSION

VLASU can be used as a method of treatment of this disorder. It is an effective, modern, low-invasive, and repeatable technique and is technically simple and easy to master. It can be used in cases in which introduction of a 22 Char optical urethrotome into the stricture site is impossible, as well as for treatment of multiple strictures during one procedure.

Application of endoscopic Ho:YAG laser incision technique treating urethral strictures and urethral atresias in pediatric patients

Endoscopic holmium:yttrium-aluminum-garnet (Ho:YAG) laser incision is a new method applied in pediatric urology recent years. To evaluate its therapeutic efficacy on treating the pediatric patients with urethral strictures and urethral atresias, a retrospective study was performed from June 2001 to July 2005 in a total of 28 pediatric patients who underwent endoscopic internal urethrotomy using Ho:YAG laser in our center. In these patients, 25 had urethral strictures and 3 urethral atresias. Follow-up was done ranging from 2 months to 4 years to assess the treatment. Of the 28 patients, 25 (89.3%) have achieved satisfied result without complications following initial incisions. Two patients with urethral atresias and another with long lesion of stricture (> 2 cm) have postoperative stenosis (10.7%). Among the three reoccurred patients, two were successfully reoperated by Ho:YAG laser and open end-to-end anastomosis, respectively. One patient failed to follow-up. With the advantages of safety, efficacy and minimal invasion, endoscopic Ho:YAG laser incision technique could be used as a primary treatment in urethral stricture patients and is worthy to be popularized further in pediatric surgery.

What is the place of internal urethrotomy in the treatment of urethral stricture disease?

As a treatment for male urethral stricture, internal urethrotomy (IU) has the advantages of ease, simplicity, speed and short convalescence. Various modifications of the single cold-knife incision in the 12 o'clock position have been proposed, but there are no prospective, randomized studies to prove their claims of greater efficacy. IU can be performed as an outpatient procedure using local anesthesia, with an indwelling silicone catheter for 3 days after the procedure. Complications of IU are usually minor, including infection and hemorrhage. The reported success rate of IU varies, mainly because of differences in the definition of success and the duration of follow-up. Strictures can recur, usually within 3-12 months of IU. There are several known risk factors for recurrence: a previous IU, penile and membranous strictures, long (>2 cm) and multiple strictures, untreated perioperative urinary infection and extensive periurethral spongiofibrosis. Repeated IU might be useful in patients who have a stricture recurrence more than 6 months after the initial procedure, but repeat IU offers no long-term cure after a third IU, or if a stricture recurs within 3 months of the first IU. Such patients should be offered urethroplasty. Repeated IU followed by long-term self-dilation is an alternative option for men with severe comorbidity and limited life expectancy, or those who have failed previous urethroplasty. Overall, IU has a lower success rate (+/-60%) than urethroplasty (+/-80-90%), but if used for selected strictures, the success rate of IU could approach that of urethroplasty.