Three-year follow-up of laser prostatectomy versus transurethral resection of the prostate in men with benign prostatic hyperplasia

Are adverse events during surgery for benign prostatic hyperplasia device related? A review of the MAUDE database

PURPOSE

The Manufacturer and User Facility Device Experience database contains anonymous, voluntary medical device reports. A review of device-related adverse events associated with Benign Prostatic Hyperplasia surgeries was completed. The objective was to evaluate the occurrence and contributing factors to clinically significant complications in a cohort of patients electing to undergo surgical intervention for Benign Prostatic Hyperplasia.

METHODS

The Manufacturer and User Facility Device Experience database was queried for "Aquablation, Greenlight Laser, Holmium Laser, Morcellator, Water Vapor Thermal Therapy, Loop Resection, and Prostatic Urethral Lift" from 2018 through 2021. A complication classification system (Level I-IV) based on the Clavien-Dindo system was used to categorize events. These events were then correlated with procedural technology malfunctions and classified as "device related" and "non-device related." Chi squared analysis was performed to identify associations between procedural technology and complication classification distribution.

RESULTS

A total of 873 adverse events were identified. The adverse events were classified into level I (minimal harm) versus levels II-IV (clinically significant). Aquablation (p < 0.017) and Water Vapor Thermal Therapy (p < 0.012) were associated with a higher proportion of reports with Level II-IV complications compared with other procedure types. Level II-IV complications were not associated with a reported device related malfunction.

CONCLUSIONS

Aquablation and water vapor thermal therapy demonstrated noteworthy clinically significant complications which were not driven by device-related malfunctions.

Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis

PURPOSE

Bladder neck stenosis (BNS) is a long-term complication of surgical procedures for benign prostatic hyperplasia (BPH). We performed a systematic literature review and a meta-analysis of the incidence of BNS after transurethral procedures for BPH.

METHODS

We performed a systemic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We accepted only randomized trials comparing transurethral resection of the prostate (TURP) vs. other transurethral surgery for BPH that were grouped in Ablation vs. Enucleation modalities. The incidences of BNS were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios, 95% Confidence Intervals, and p values. Study heterogeneity was assessed utilizing the I² value.

RESULTS

72 studies were identified for meta-analysis, 46 comparing TURP vs. Ablation and 26 TURP vs. Enucleation. The pooled incidence of BNS was 1.3% after TURP, 0.66% after enucleation and 1.2% after Ablation. The incidence of BNS was higher after TURP than after Enucleation but the difference was not statistically significant (RR 1.75 95% CI 0.81-3.79, p = 0.16). There was no significant heterogeneity among the studies (I² 0%, Chi² 4.11, p = 0.90). The incidence of BNS was higher after TURP than after Ablation, but the difference was not statistically significant (RR 1.31, 95% CI 0.82-2.11, p = 0.26) with no significant heterogeneity (I² 0%, Chi² 21.1, p = 0.51).

CONCLUSION

Our study showed no difference in the rate of BNS incidence among randomized trials comparing TURP vs. Ablation vs. Enucleation and can be used as a reference to counsel patients undergoing BPH surgery.

Benign Prostatic Hyperplasia Treatment by Transurethral Enucleation of the Prostate Using a 2-μm Laser

This study investigates the efficacy of benign prostatic hyperplasia (BPH) treatment by prostate transurethral enucleation using a 2-μm laser. A total of 107 patients with BPH were treated by prostate transurethral enucleation using a RevoLix 2-μm laser surgery system. Bleeding volume, operation time, catheterization time, voiding situation, maximum urinary flow rate, and hospital stay were observed. The mean operation time was 74 min ± 12 min (range 45 to 150 min), the mean follow-up period was 2 to 6 months, the mean catheter time was 5 days, and the mean peak urinary flow rate increased from 6.3 ± 0.6 to 17.5 ± 1.5 mL/s. The International Prostate Symptom Score and quality of life significantly declined (p < 0.01). No significant differences were observed in the hemoglobin and blood electrolytes before and after operation. Prostate transurethral enucleation using a 2-μm laser is safe and efficient for BPH treatment.

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction

BACKGROUND

In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP.

OBJECTIVE

To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data.

METHODS

The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis.

RESULTS

If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at -0.01 (95% confidence interval [CI] -0.05 to 0.01) instead of at -0.11 (95% CI -0.31 to -0.01) as in the 2008 analysis. The GOLIATH estimate of -0.01 (95% CI -0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21-£1286) in 2008 to £111 (-£315 to £595) for 2010 and to £109 (-£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom.

CONCLUSIONS

The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.

A prospective, randomized comparative study of monopolar transurethral resection of the prostate versus photoselective vaporization of the prostate with GreenLight 120-W laser, in prostates less than 80 cc

OBJECTIVE

In this study we aimed to compare photoselective vaporization (PVP) with the GreenLight 120-W Laser and monopolar transurethral resection as surgical treatments of prostates less than 80 cc in men with obstructive benign prostatic hyperplasia.

METHODS

From February 2009 to March 2012 we allocated 101 patients with a prostate glands of less than 80 cc; patients were randomly assigned for surgical treatment with monopolar transurethral resection of the prostate (TURP) (n = 62) or PVP (n = 39). Serum prostate specific antigen (PSA), International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), maximum flow rate (Qmax) postmicturition residual (PMR), transrectal ultrasound volumes (TRUS), postvoid urine residual (PVR), complications, re-operations and hospitalization time were collected. The patients were seen in the follow up at 6, 12 and 24 months.

RESULTS

Median age was 69 (56-87) years old in the TURP group and 67 (51-87) years old in the PVP group. Mean preoperative prostate volume was 55 cc (40-72) and 60 cc (41-75) cc in the TURP group versus the PVP group. There was no statistically difference in subjectively (IPSS, SHIM) and objectively (Qmax-PMR) parameters and postoperatively complication rates between the two groups (p > 0.05). A significant difference was observed in the PVP group with a 2 (1-4) days hospital stay compared with 5 (3-9) days for the TURP group (p  < 0.001).

CONCLUSION

Prostate PVP and TURP are effective surgical treatments for benign prostatic hyperplasia. Postoperative functional improvements were durable and equivalent in the two groups. The two techniques have a similar complication rate.

Photoselective green-light laser vaporisation vs. TURP for BPH: meta-analysis

This study sought to evaluate the efficacy and safety of photoselective vaporisation (PVP) vs. transurethral resection of the prostate (TURP) for patients with benign prostatic hyperplasia (BPH). Eligible studies were identified from electronic databases (Cochrane Library, PubMed and EMBASE). The database search, quality assessment and data extraction were performed independently by two reviewers. Efficacy (primary outcomes: maximum urinary flow rate (Q(max)), international prostate symptom score (IPSS), postvoid residual urine (PVR) and quality of life (QoL); secondary outcomes: operative time, hospital time and catheter removal time) and safety (complications, such as transfusion and capsular perforation) were explored by using Review Manager 5.0. Six randomized controlled trials (RCTs) and five case-controlled studies of 1398 patients met the inclusion criteria. A meta-analysis of the extractable data showed that there were no differences in IPSS, Q(max), QoL or PVR between PVP and TURP (mean difference (MD): prostate sizes <70 ml, Q(max) at 24 months, MD=0.01, P=0.97; IPSS at 12 months, MD=0.18, P=0.64; QoL at 12 months, MD=-0.00, P=0.96; PVR at 12 months, MD=0.52, P=0.43; prostate sizes >70 ml, Q(max) at 6 months, MD=-3.46, P=0.33; IPSS at 6 months, MD=3.11, P=0.36; PVR at 6 months, MD=25.50, P=0.39). PVP was associated with a shorter hospital time and catheter removal time than TURP, whereas PVP resulted in a longer operative time than TURP. For prostate sizes <70 ml, there were fewer transfusions, capsular perforations, incidences of TUR syndrome and clot retentions following PVP compared with TURP. These results indicate that PVP is as effective and safe as TURP for BPH at the mid-term patient follow-up, in particular for prostate sizes <70 ml. Due to the different energy settings available for green-light laser sources and the higher efficiency and performance of higher-quality lasers, large-sample, long-term RCTs are required to verify whether different energy settings affect outcomes.

National trends in surgical therapy for benign prostatic hyperplasia in the United States (2000-2008)

OBJECTIVE

To report an update of the change in usage trends for different surgical treatments of benign prostatic hyperplasia (BPH) among the United States Medicare population data from 2000-2008. The rate of usage of thermotherapy and laser therapy in the surgical treatment of BPH has been changing over the past decade in conjunction with a steady decrease of transurethral resection of the prostate (TURP).

METHODS

Using the 100% Medicare carrier file for the years 2000-2008, we calculated counts and population-adjusted rates of BPH surgery. Rates of TURP, thermotherapy, and laser-using modalities were calculated and compared in relation to age, race, clinical setting, and reimbursement.

RESULTS

After years of a steady rise, the total rate of all BPH procedures peaked in 2005 at 1078/100,000 and then declined by 15.4% to 912/100,000 in 2008. TURP rates continued to decline from 670 in 2000 to 351/100,000 in 2008. Rates of microwave thermoablation peaked in 2006 at 266/100,000 and then declined 26% in 2008. Laser vaporization almost completely replaced laser coagulation and in 2008 was the most commonly performed procedure second to TURP, with the majority performed as outpatient procedures (70%) and an increasing percentage in the office (12%). Men between ages 70 and 75 had the highest rate of procedures. Reimbursement rates correlate using some but not all procedures. Racial disparities reported previously appear to have resolved.

CONCLUSION

Surgical treatment of BPH continues to change rapidly. TURP continues to decline and laser vaporization is the fastest growing modality. There is a big shift toward outpatient/office procedures. Reimbursement rates do not appear to have a consistent effect on usage.

Long-term followup after electrocautery transurethral resection of the prostate for benign prostatic hyperplasia

Introduction. For decades, transurethral resection of the prostate (TURP) has been the "gold standard" operation for benign prostatic hyperplasia (BPH) but is based mainly on historic data. The historic data lacks use of validated measures and current TURP differs significantly from that performed 30 years ago. Methods. Men who had undergone TURP between 2001 and 2005 were reviewed. International prostate symptom score (IPSS), quality of life (QOL) and peak urinary flow rate (Q(max⁡)), and postvoid residual (PVR) were recorded. Operative details and postoperative complications were documented. Patients were then invited to attend for repeat assessment. Results. 91 patients participated. Mean follow-up time was 70 months. Mean follow-up results were IPSS-7; QoL-1.5; Q(max⁡)-23 mL/s; PVR-45 mL. These were an improvement from baseline of 67%, 63%, 187%, and 80%, respectively. Early complication rates were low, with no blood transfusions, TUR syndrome, or deaths occurring. Urethral stricture rate was higher than anticipated at 14%. Conclusion. This study shows modern TURP still produces durable improvement in voiding symptoms which remains comparable with historic studies. This study, however, found a marked drop in early complications but, conversely, a higher than expected incidence of urethral strictures.

Effectiveness and Safety of Photoselective Vaporization of the Prostate with the 120 W HPS Greenlight Laser in Benign Prostatic Hyperplasia Patients Taking Oral Anticoagulants

Purpose

To examine the effectiveness and safety of photoselective vaporization of the prostate (PVP) with the 120 W high-performance system (HPS) Greenlight laser procedure in benign prostatic hyperplasia (BPH) patients taking oral anticoagulant medications.

Materials and Methods

This study was conducted on BPH patients taking oral anticoagulant medications form March 2009 to December 2010. Group I consisted of patients who stopped oral anticoagulant medications before surgery (n=30), and group II consisted of patients who continued oral anticoagulant medications before surgery (n=30). PVP applying the 120 W HPS Greenlight laser was done, and followed up for 12 weeks. Follow-up variables were International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR), and hemoglobin level change.

Results

At 12 weeks after surgery, we confirmed the improvement in the IPSS score of Group I compared with preoperative scores. The quality of life (QoL) score, Qmax and PVR were also improved. respectively, both of which were significantly improved. In Group II, similarly, the total IPSS score, the voiding symptom score, and the storage symptom score were improved in comparison with the preoperative scores. The QoL score, Qmax and the PVR were improved in comparison with the preoperative scores. During the 12-week follow-up period, no major postsurgical complications requiring transfusion, rehospitalization, etc. were observed.

Conclusions

The 120 W HPS Greenlight laser PVP procedure can be performed effectively and safely in BPH patients, even those who cannot stop oral anticoagulant medications despite requiring surgery.

The impact of minimally invasive surgeries for the treatment of symptomatic benign prostatic hyperplasia on male sexual function: a systematic review

A systematic review of randomized controlled trials and cohort studies was conducted to evaluate data for the effects of minimally invasive procedures for treatment of symptomatic benign prostatic hyperplasia (BPH) on male sexual function. The studies searched were trials that enrolled men with symptomatic BPH who were treated with laser surgeries, transurethral microwave therapy (TUMT), transurethral needle ablation of the prostate (TUNA), transurethral ethanol ablation of the prostate (TEAP) and high-intensity frequency ultrasound (HIFU), in comparison with traditional transurethral resection of the prostate (TURP) or sham operations. A total of 72 studies were identified, of which 33 met the inclusion criteria. Of the 33 studies, 21 were concerned with laser surgeries, six with TUMT, four with TUNA and two with TEAP containing information regarding male sexual function. No study is available regarding the effect of HIFU for BPH on male sexual function. Our analysis shows that minimally invasive surgeries for BPH have comparable effects to those of TURP on male erectile function. Collectively, less than 15.4% or 15.2% of patients will have either decrease or increase, respectively, of erectile function after laser procedures, TUMT and TUNA. As observed with TURP, a high incidence of ejaculatory dysfunction (EjD) is common after treatment of BPH with holmium, potassium-titanyl-phosphate and thulium laser therapies (> 33.6%). TUMT, TUNA and neodymium:yttrium aluminum garnet visual laser ablation or interstitial laser coagulation for BPH has less incidence of EjD, but these procedures are considered less effective for BPH treatment when compared with TURP.

Photoselective laser vaporization prostatectomy for acute urinary retention in China

PURPOSE

To assess the clinical efficacy and safety of photoselective laser vaporization of the prostate (PVP) in the treatment of patients with acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Forty-two patients (mean age 72 +/- 5 years, range 65-89) with AUR because of BPH were treated with a prospective trial of PVP with the potassium-titanyl-phosphate (KTP) laser. The treatment outcome was evaluated with subjective and objective tests at 1, 3, 6, and 12 months after PVP using the International Prostate Symptom Score (IPSS), disease-specific quality of life (QoL) score, postvoid residual (PVR) urine volume, and maximum urinary flow rate (Qmax). The International Index of Erectile Function questionnaire and a self-designed ejaculatory questionnaire were completed at different follow-up times to determine patient satisfaction and changes in sexual function.

RESULTS

After preliminary urine drainage and adequate preoperative preparation, PVP was performed and bladder outlet obstruction was effectively relieved. The mean prostate volume was 62.5 +/- 11.7 cc, and the mean residual volume with retention was 650 mL (range 240-1200 mL). Mean operative time was 28.6 +/- 5.7 minutes. Mean catheterization duration was 5.6 days (range 3-14 d). There was significant subjective improvement of symptoms and objective improvement in urinary flow rates at 12 months. The mean IPSS and QoL score decreased significantly (P < 0.05). Mean PVR volume also decreased. The mean Qmax was 16.2 +/- 4.6 mL/sec after treatment. Only two patients had recurrent urinary retention during follow-up. There were no intraoperative or postoperative adverse events.

CONCLUSIONS

The early clinical results suggest that the PVP is a promising safe, effective, and less-invasive treatment with minimal morbidity for patients with urine retention secondary to BPH.

Practice patterns in benign prostatic hyperplasia surgical therapy: the dramatic increase in minimally invasive technologies

PURPOSE

We describe the trends in transurethral prostatectomy and minimally invasive surgical treatments for benign prostate hyperplasia from 1999 through 2005 among elderly male Medicare beneficiaries.

MATERIALS AND METHODS

Benign prostatic hyperplasia surgeries were identified using the annual 100% Medicare carrier files which contain physician claims for services reimbursed under Medicare Part B. The annual age group specific procedure rates as well as the age adjusted rates by race and percent of each procedure performed in different clinical settings were calculated.

RESULTS

The total number of benign prostatic hyperplasia procedures increased 44% from 88,868 in 1999 to 127,786 in 2005. The minimally invasive surgical treatment procedure counts increased 529% from 11,582 to 72,887 and the rates increased 439% from 136 to 678 per 100,000 males during that period. The transurethral prostate resection rate decreased approximately 5% per year. By 2005 minimally invasive surgical treatment procedures accounted for 57% of total benign prostatic hyperplasia surgeries, while transurethral prostate resection accounted for only 39%. Almost all transurethral microwave thermotherapy, 86% of transurethral needle ablation and 54% of laser coagulation procedures were performed in office clinics, and 78% of laser vaporization procedures were performed in hospital outpatient clinics. Black beneficiaries were 17% less likely to receive minimally invasive surgical treatment than whites in 2005.

CONCLUSIONS

The increase of total benign prostatic hyperplasia procedure rate was driven by a marked increase in minimally invasive surgical treatment and a continuing decrease of transurethral prostate resection. Differences in the use of minimally invasive surgical treatment across age and racial groups persisted. This dramatic change in the pattern of benign prostatic hyperplasia surgical treatment may have a profound impact on health care expenditures and outcomes, and requires further investigation.

The evolution of KTP laser vaporization of the prostate

The search for a minimally invasive approach to the treatment of Lower Urinary Tract Symptoms (LUTS) suggestive of Benign Prostatic Hyperplasia (BPH) is probably as old as Transurethral Resection of the Prostate (TURP). In an effort to overcome the limitations and morbidities of TURP, and in light of evidence suggesting that medical treatment for BPH has a limited life-span, laser-based treatments have emerged during the last decade. Photoselective Vaporization of the Prostate (PVP) by the "GreenLight" KTP laser is considered one of the most promising options, one that is constantly evolving new technologies in prostate surgery. In this overview of KTP laser usage in BPH treatment, we will briefly discuss the evolution of this modality since it was first introduced and focus on the available evidence regarding safety, efficacy and cost parameters of its application.

[Lasers in urology]

The objective of this article is to quote under the form of a document the opinions expressed by the participants of the round table "Lasers in Urology Today" (january 2006). The material and method used is the compilation of critical and updated notions on the usefulness of lasers in urology, supplemented by bibliographic references, a limited iconography. The results achieved by lasers today enable us to state that: Holmium laser is the choice treatment for in situ lithotripsy; however, it has not significantly improved previous results when treating urologic tumours and stenoses. Nowadays we have two types of lasers: KTP and HoL, which obtain results similar to surgery regarding BPH, but with reduced morbidity. The usefulness of laser in laparoscopic surgery is still under development.

CONCLUSION

Lasers in Urology Today play an active role in in situ lithotripsy (HoL), and a competitive one in BPH surgery (KTP and HoL). Regarding the rest of indications, i.e. tumours, stenoses, laparoscopic surgery, etc., further studies and enough follow-up times are still needed.

Five-Year Follow-up of Feedback Microwave Thermotherapy Versus TURP for Clinical BPH: A Prospective Randomized Multicenter Study

OBJECTIVES

To compare the efficacy and safety of transurethral microwave thermotherapy (TUMT) with ProstaLund Feedback Treatment, using the CoreTherm device, with transurethral resection of the prostate (TURP) 5 years after treatment.

METHODS

This prospective, randomized, multicenter study was conducted at 10 centers in the United States and Scandinavia. A total of 154 patients with benign prostatic hyperplasia were randomized to TUMT or TURP in a 2:1 ratio. Patients were followed up at 3, 6, 12, 24, 36, 48, and 60 months after treatment. The intermediate results at 12 and 36 months have been previously reported. The treatment outcome at 5 years was evaluated with the International Prostate Symptom Score (IPSS), quality of life question (QOL), peak urinary flow rate (Qmax), postvoid residual urine volume, and prostate volume. The CoreTherm device differs from other microwave devices in that the intraprostatic temperature is constantly measured during the procedure to guide the treatment.

RESULTS

Of the 154 patients, 66% completed the 60 months of follow-up. Statistically significant improvements in the TUMT and TURP groups were observed for IPSS, QOL, and Qmax at 60 months. The average values for the TUMT group were an IPSS of 7.4, QOL score of 1.1, and Qmax of 11.4 mL/s. The values for the TURP group were IPSS of 6.0, QOL score of 1.1, and Qmax of 13.6 mL/s. No statistically significant differences were found in any of these variables between the two treatment groups. In the TUMT group, 10% needed additional treatment versus 4.3% in the TURP group.

CONCLUSIONS

The clinical outcome 5 years after TUMT using the CoreTherm device was comparable to the results seen after TURP. The safety of TUMT using the CoreTherm device compared favorably with that of TURP.

Evaluation of greenlight photoselective vaporization of the prostate for the treatment of high-risk patients with benign prostatic hyperplasia

AIM

To explore the feasibility and safety of greenlight photoselective vaporization of the prostate (PVP) on high-risk patients presenting with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) and to evaluate their clinical and voiding outcome.

METHODS

A total of 85 high-risk patients with obstructive BPH underwent PVP with an 80 W potassium-titanyl-phosphate laser, which was delivered through a side-deflecting fiber with a 23 Fr continuous flow cystoscope. Operative time, blood loss, indwelling catheterzation, international prostate symptom score (IPSS), quality of life score (QoL), uroflowmetry, postvoid residual urine volume and short-term complication rates were evaluated for all patients.

RESULTS

All patients got through the perioperative period safely. The chief advantages of PVP were: short operative time (25.6 +/- 7.6 min), little bleeding loss (56.8 +/- 14.3 mL) and short indwelling catheterization (1.6 +/- 0.8 d). The IPSS and QoL decreased from (29.6 +/- 5.4) and (5.4 +/- 0.6) to (9.5 +/- 2.6) and (1.3 +/- 0.6), respectively. The vast majority of patients were satisfied with voiding outcome. The mean maximal urinary flow rate increased to 17.8 mL/s and postvoid residual urine volume decreased to 55.6 mL. These results are significantly different from preoperative data (P < 0.05). No patient required blood transfusion or fluid absorption. There were few complications and very high patient satisfaction after operation.

CONCLUSION

PVP has a short operative time and high tolerance, and is safe, effective and minimally invasive for high-risk patients, therefore it might be considered as a good alternative treatment for high-risk patients with obstructive urinary symptoms as a result of BPH.

Photoselective Vaporization of the Enlarged Prostate with KTP Laser: Long-Term Results in 240 Patients

PURPOSE

To report the 1-year efficacy and safety of photoselective vaporization of the prostate (PVP) by KTP laser for symptomatic and obstructive benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between January 2004 and March 2005, 240 patients aged 49 to 80 years (mean 65.3 years) with a referring complaint of infravesical obstruction were treated with laser prostatectomy using KTP/532 laser energy at 80 W. The prostatic lobes were readily vaporized to the capsular fibers. All patients underwent standard urologic evaluation with the International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), ultrasound measurement of prostate volume and residual urine volume, assay of prostate specific antigen, and digital rectal examination. The mean prostatic volume was 52.1 cc (range 28-120 cc). The patients were reassessed at 6 and 12 months postoperatively for changes in these measures. The Mann- Whitney U test was used to determine statistical significance.

RESULTS

The operating time ranged from 25 to 90 minutes with an average of 45 minutes. The maximum postoperative hospital stay was 24 hours, and the Foley catheters were removed in less than 24 hours with a mean catheterization time of 12.2+/-6.8 hours (range 6-24 hours). Following the laser prostatectomy, mean IPSS values decreased from 22.6+/-6.4 to 5.3+/-2.9 (76.6%) at 6 months and to 3.7+/-2.5 at 12 months (84%) (P<0.001). The mean peak urinary flow rate increased from 7.9+/-2.7 mL/sec to 26.1+/-10.1 mL/sec at 6 months and to 27.9+/-10.3 mL/sec at 12 months. The mean quality of life score improved from 4.7+/-0.8 to 0.6+/-0.6 (87.3%) (P<0.001), and the mean postvoiding residual volume decreased from 145.6+/-122.2 mL to 52.6+/-38.6 mL at 6-month follow-up and to 16.2+/-8.9 mL at 12 months (P<0.001) (82.3%). The mean prostate volume had decreased by 53% after 12 months.

CONCLUSIONS

High-power photoselective KTP laser vaporization prostatectomy is feasible and appears to be safe and effective for immediate relief of the bladder-outlet obstruction secondary to benign hyperplasia. The system is a promising alternative in all, but especially in high-risk patients receiving anticoagulant therapy.

Functional anatomy of the prostate: implications for treatment planning

PURPOSE

To summarize the functional anatomy relevant to prostate cancer treatment planning.

METHODS AND MATERIALS

Coronal, axial, and sagittal T2 magnetic resonance imaging (MRI) and MRI angiography were fused by mutual information and registered with computed tomography (CT) scan data sets to improve definition of zonal anatomy of the prostate and critical adjacent structures.

RESULTS

The three major prostate zones (inner, outer, and anterior fibromuscular) are visible by T2 MRI imaging. The bladder, bladder neck, and internal (preprostatic) sphincter are a continuous muscular structure and clear definition of the preprostatic sphincter is difficult by MRI. Transition zone hypertrophy may efface the bladder neck and internal sphincter. The external "lower" sphincter is clearly visible by T2 MRI with wide variations in length. The critical erectile structures are the internal pudendal artery (defined by MRI angiogram or T2 MRI), corpus cavernosum, and neurovascular bundle. The neurovascular bundle is visible along the posterior lateral surface of the prostate on CT and MRI, but its terminal branches (cavernosal nerves) are not visible and must be defined by their relationship to the urethra within the genitourinary diaphragm. Visualization of the ejaculatory ducts within the prostate is possible on sagittal MRI. The anatomy of the prostate-rectum interface is clarified by MRI, as is the potentially important distinction of rectal muscle and rectal mucosa.

CONCLUSION

Improved understanding of functional anatomy and imaging of the prostate and critical adjacent structures will improve prostate radiation therapy by improvement of dose and toxicity correlation, limitation of dose to critical structures, and potential improvement in post therapy quality of life.

Short Term Outcomes of High Power (80 W) Potassium-titanyl-phosphate Laser Vaporization of the Prostate

PURPOSE

We have evaluated the safety and efficacy of 80 W potassium-titanyl-phosphate (KTP) laser in the treatment of patients with lower urinary system symptoms (LUTS) due to benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 186 patients with LUTS have been evaluated using the International Prostate Symptom Score (IPSS) and quality of life (QoL) scoring questionnaire. Volume of prostate, post-micturition volume of residual urine (PVR), maximum flow rate (Qmax) and serum prostate specific antigen (PSA) values were determined. Laser vaporization of the prostate with an 80 W KTP was applied to all the patients. IPSS and QoL scores were evaluated on postoperative days 30, 90 and 180. The below values were measured on the postoperative days mentioned respectively: Qmax-15, 30 and 90; PSA-1, 15, 30 and 60; PVR-90.

RESULTS

The results of 186 patients, who underwent KTP laser treatment, have been evaluated. Mean age of the patients was 66+/-8 (47-90). Mean volume of prostates, mean operative time and mean energy delivery were 48.1+/-13.2 ml (26-70), 57+/-17 minutes (10-120) and 105+/-37 kJ (20-350), respectively. Following the procedures, Foley catheters were removed after a mean time of 7.59+/-0.9 hours (6-13). Compared with the preoperative period, IPSS, QoL, PVR and Qmax values decreased significantly during the postoperative period (p<0.01). Mean preoperative PSA value was 2.59+/-0.9 ng/ml (0.28-4). There were statistically significant increases in PSA values on postoperative day 1 (p<0.001). However, on postoperative day 15, PSA values decreased as low as preoperative values. There was moderate dysuria in 55 (30%) patients with a mean duration of 2 months and mild hematuria in 10 (18%) patients with a mean duration of 1 month postoperatively. Urinary tract infection occurred in 12 (6%) patients. None of the patients had fever or required re-catheterization. We observed contracture of the bladder neck in 2 (1%) patients and clot retention in 2 (1%) patients. Urinary incontinence due to operation was not observed.

CONCLUSIONS

KTP laser vaporization of the prostate is a treatment method which can be used in patients at high risk of anesthesia. This procedure is safe and effective in that it quickly relieves bladder outlet obstruction symptoms and has a low rate of postoperative complications. However, long-term follow-up studies are called for in order to ascertain whether the results of this procedure are durable or not.

Lasers for lower urinary tract symptoms secondary to benign prostatic hyperplasia: when is the fuss worth it?

In the recent past, several endoscopic procedures using laser technology have evolved for the treatment of benign prostatic hyperplasia. The term "laser treatment of the prostate" comprises a variety of different application systems, different laser wavelengths, and different surgical techniques to eliminate bladder outlet obstruction. The aim of laser prostatectomy is to be less invasive than transurethral electroresection, but equally effective. Promising short-term results led to a booming laser decade in the 1990s, stimulating the development of several devices. However, the emergence of medium-term data has shown that some of these techniques did not stand the test of time due to the lack of long-term efficacy, unacceptable morbidity, and high retreatment rates. Nevertheless, the results of transurethral resection of the prostate are challenged by some of the newer laser devices, putting the so-called "gold standard" into question.

Three-year follow-up of feedback microwave thermotherapy versus TURP for clinical BPH: A prospective randomized multicenter study

OBJECTIVES

To compare, in a prospective randomized multicenter study, the efficacy and safety of transurethral microwave thermotherapy with ProstaLund Feedback Treatment (PLFT), using the CoreTherm device, with transurethral resection of the prostate (TURP) 36 months after treatment.

METHODS

The study was conducted at 10 centers in the United States and Scandinavia. A total of 154 patients with benign prostatic hyperplasia were randomized to PLFT or TURP in a 2:1 ratio. The treatment outcome was evaluated on the basis of the International Prostate Symptom Score (IPSS), the quality-of-life question (QOL) of the IPSS, peak urinary flow rate (Qmax), urodynamics, and adverse events. The microwave power and treatment time were adjusted according to each patient's response to the supplied energy (ie, the intraprostatic temperature guided the PLFT).

RESULTS

Statistically significant improvements in both the TURP and the PLFT groups were observed for IPSS, QOL, and Qmax at 36 months. The average value for the PLFT group was 8.2, 1.2, and 11.9 mL/s for IPSS, QOL, and Qmax, respectively. The corresponding values for the TURP group were IPSS 5.0, QOL 1.0, and Qmax 13.5 mL/s. The difference in IPSS outcome was statistically significant; however, no statistically significant differences were found in QOL or Qmax between the two treatment groups. The degree of improvement was in the same range as that observed after 12 and 24 months for both groups. During the 12 to 36-month period, the most frequent adverse events in the TURP group were impotence (15%), micturition urgency (13%), and urethral disorder (8%); in the PLFT group, impotence (8%), prostate-specific antigen increase (5%), and hematuria (4%) were the most common.

CONCLUSIONS

The clinical outcome 3 years after microwave thermotherapy with PLFT was comparable to the results seen after TURP. The safety of PLFT compared favorably to that of TURP in this study.

Could the latest generation potassium titanyl phosphate lasers be the ones to make transurethral resection of the prostate an operation of historical interest only?

PURPOSE OF REVIEW

We have witnessed an explosion of interest in surgical alternatives to transurethral resection of the prostate over the past decade. These have predominantly involved the delivery of heat to the prostate to cause either coagulation or vaporization. The latest generation laser technique involves the delivery of the potassium titanyl phosphate wavelength at high powers to cause large volumes of prostatic vaporization. This short review assesses the limited present evidence base supporting its use and asks the question of whether it will relegate transurethral resection of the prostate to an operation of historical interest only.

RECENT FINDINGS

The 80 W delivery system clearly results in impressive tissue vaporization with minimal bleeding. There is a learning curve to the procedure with operative times varying between 30 and 120 min. The postoperative recovery appears rapid and generally uncomplicated with early catheter removals. The short-term results suggest equivalent efficacy to transurethral resection of the prostate with improved safety; the lack of phase III trials, however, means that the durability of the procedure cannot be assessed at this early stage.

SUMMARY

Like many of the surgical alternatives to transurethral resection of the prostate this procedure shows early promise and represents the latest evolutionary development in the laser prostatectomy story. Only randomized comparisons with transurethral resection will tell us if it is a worthy challenger or simply a young pretender to the throne.

Vaporization of the prostate

PURPOSE OF REVIEW

Transurethral resection of the prostate remains the treatment of choice for men with symptomatic benign prostatic enlargement. Concerns regarding the morbidity of this operation have led to the development of alternative surgical procedures. Vaporization of the prostate can be achieved using either laser energy or electrosurgery. The advantage of these approaches is that they allow tissue removal with reduced blood loss. Vaporization techniques have been around for almost a decade and more powerful lasers have recently become available. This has led to a minor resurgence in interest in laser vaporization. We reviewed articles on all forms of vaporization of the prostate published in the 12 months from August 2002.

RECENT FINDINGS

Electrovaporization of the prostate is an effective treatment for men who require surgery for benign prostatic enlargement. The results are well maintained at 5 years follow-up with low reoperation rates. Scanty data are available for the Gyrus (Gyrus Medical Ltd, Cardiff, Wales) bipolar electrovaporization system but preliminary results suggest there is no significant advantage over transurethral resection of the prostate. Early forms of laser vaporization of the prostate are not as effective as either transurethral resection of the prostate or transurethral electrovaporization of the prostate and have a higher retreatment rate. Newer, more powerful lasers have been recently introduced with encouraging initial results in small numbers of patients.

SUMMARY

Electrovaporization of the prostate is a safe, effective and durable alternative to transurethral resection. Early laser vaporization techniques have high retreatment rates, which limit their cost-effectiveness. Few data are yet available on high-powered lasers for bladder outflow obstruction. Whether any vaporization technique will stand the test of time is unclear.

Laser prostatectomy for benign prostatic obstruction

BACKGROUND

Symptomatic benign prostatic obstruction is a common problem for older men. The gold standard treatment, transurethral resection of the prostate (TURP), significantly improves urinary symptoms and urinary flow. However, TURP has up to a 20% morbidity. Currently, there are a number of minimally invasive procedures that may be safe, effective alternatives to TURP. One promising surgical technique is laser prostatectomy.

OBJECTIVES

To assess the therapeutic efficacy and safety of laser prostatectomy techniques for treating men with symptomatic benign prostatic obstruction.

SEARCH STRATEGY

Randomized controlled trials were identified from the Cochrane Collaboration Library, MEDLINE, EMBASE, bibliographies of retrieved articles and reviews, and contacting expert relevant trialists and laser manufacturers.

SELECTION CRITERIA

All randomized controlled trials evaluating laser prostatectomy treatment for men with symptomatic BPH. Trials were eligible if they (1) were randomized comparisons of a laser technique with TURP, (2) included at least 10 men with BPO in each treatment arm, (3) provided at least 6-months follow-up, and (4) included clinical outcomes such as urologic symptom scales or urodynamic measurements.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of methodologic quality was performed independently by two reviewers. Information on study design, subject and treatment characteristics, adverse events, urinary symptoms, and urinary flow were extracted using a standard form.

MAIN RESULTS

20 studies involving 1898 subjects were evaluated, including studies 4 with multiple comparisons. We found 8 comparisons of TURP with contact lasers, 8 with non-contact lasers, 4 with hybrid techniques, and one with interstitial laser coagulation (ILC). Two studies compared transurethral electrovaporization (TUVP) with contact lasers, one study compared interstitial laser coagulation with transurethral microwave thermotherapy (TUMT), and one study compared holmium contact lasers (HoLRP) with open prostatectomy. Among the studies comparing laser prostatectomy with TURP, follow-up duration ranged from 6 to 36 months. Mean age (67.2 yrs), mean baseline symptom score (20.2), and mean baseline peak urinary flow (9.2 ml/s) did not differ by treatment group. The pooled percentage improvements for mean urinary symptoms ranged from 59% to 68% with lasers and 63% to 77% with TURP. The improvements for mean peak urinary flow ranged from 56% to 119% with lasers and 96% to 127% with TURP. Overall, laser subjects were less likely to receive transfusions or develop strictures and their hospitalizations were shorter. Non-contact laser subjects were more likely to have dysuria, urinary tract infection, and retention. Re-operation occurred more often following laser procedures.

REVIEWER'S CONCLUSIONS

Laser techniques are a useful alternative to TURP for treating BPO. Small sample sizes and differences in study design limit any definitive conclusions regarding the preferred type of laser technique. Data were insufficient to compare laser techniques with other minimally invasive procedures.

Laser therapy for benign prostatic hyperplasia: a review of recent developments

PURPOSE OF REVIEW

Over the past 10-15 years a variety of endoscopic laser techniques have evolved for the treatment of benign prostatic hyperplasia. The laser is merely an energy source with the ability to coagulate, incise, vaporize, resect and dissect (enucleate), all fundamentally different procedures. Generalization regarding "laser prostatectomy" is therefore inappropriate. The potential for shorter hospital stays and decreased morbidity while maintaining the efficacy and durability of transurethral resection of the prostate has been the driving force behind the laser techniques that acutely remove tissue, whereas the ideal minimally invasive non-tissue removing laser technique is a well-tolerated office procedure, performed under local anaesthesia. We define the various laser techniques currently available for the treatment of benign prostatic hyperplasia, and review developments reported during the period July 2001 to July 2002.

RECENT FINDINGS

Although there are few long-term data available on laser techniques, more medium-term data is emerging. Issues such as cost-effectiveness and applicability to certain sub-groups of patients are being investigated as each laser technique aims to find its own niche in the ever-expanding treatment armamentarium for benign prostatic hyperplasia.

SUMMARY

Satisfactory moderate term results are now available for several minimally invasive laser techniques including interstitial laser coagulation and visual laser ablation of the prostate. There are promising early results for holmium laser enucleation of the prostate and potassium titanyl-phosphate, which have the potential to rival transurethral resection if proved durable in the long-term. Holmium laser enucleation is currently a serious contender for the "gold standard" for large prostates.

New innovative therapies for benign prostatic hyperplasia: any advance?

PURPOSE OF REVIEW

Benign prostatic hyperplasia is the most common human neoplasm and it is the most frequent tumour requiring surgical treatment in men. Not surprisingly, interest centres on either understanding of prostatic growth during ageing or on various medical or interventional treatments.

RECENT FINDINGS

Recent publications describe the interaction of various 5alpha-reductase inhibitors on the two 5alpha-reductase isoforms type 1 and 2, giving a potential new insight into the pathogenesis of benign prostatic hyperplasia. Likewise, chronic inflammation increases growth patterns of fibromuscular tissue in benign prostatic hyperplasia similar to wound healing, and a paracrine loop for chronic inflammation with overexpression of interleukin could be identified. This could be of particular importance in the further understanding of prostatic enlargement. Herbal drug treatment for lower urinary tract symptoms seems to be more effective than previously thought. According to recent publications the effectiveness is well beyond placebo effects. Likewise, alpha-blockers play an important role in treatment of lower urinary tract symptoms with alpha-1 adrenoreceptor antagonists preventing cell proliferation and apoptotic imbalances in prostatic tissue. The effect of alpha-blockers, however, may be limited by severe bladder outlet obstruction with patients at increased risk of treatment failure. Laser prostatectomy and microwave thermotherapy are under consideration as alternative treatments of benign prostatic hyperplasia. The efficacy of urodynamically proven de-obstruction as compared with transurethral resection of the prostate needs to be evaluated. Newer alternative treatments like ethanol installation or bipolar plasma kinetic vaporization have been described, but long-term results and larger patients cohort are still lacking.

SUMMARY

New insights into prostatic growth and pathogenesis of benign prostatic hyperplasia are presented. Medical treatment and interventional therapies are evaluated for their safety and efficacy. Only a few new therapeutical options, however, have been published during this review period.