Laser prostatectomy is a safer, better operation than electrovaporization of the prostate

Utilization of MOSES Modulated Pulse Mode Results in Improved Efficiency in Holmium:YAG Laser Ablation of the Prostate

OBJECTIVE

To determine if MOSES technology improves efficiency and short-term outcomes in holmium laser ablation of the prostate (HoLAP).

METHODS

A retrospective review of patients who underwent HoLAP between August 2016 and November 2019 was conducted. All procedures before and after the implementation of MOSES technology at our institution were evaluated. Preoperative patient characteristics and intraoperative data were collected. Postoperative International Prostate Symptom Score, quality of life, and postvoid residual measurements at 6 weeks and 3 months postoperatively were analyzed.

RESULTS

This cohort included 65 males who underwent HoLAP, 32 without and 33 with MOSES. Patients in the MOSES group were slightly older, but no other differences in baseline characteristics were observed between the two groups. Ablation time was similar at 49.6 ± 26.1 minutes without and 40.7 ± 41.2 minutes with MOSES (P = .38). However, HoLAP with MOSES had significantly higher ablation efficiency (0.59 ± 0.24 g/min without vs 0.86 0.5 g/min with MOSES, P = .01). On multivariable regression modeling, HoLAP without MOSES added 12 minutes to operating time (estimate 12.3, standard error 3.44, P < .01) after controlling for prostate size and laser energy usage. Duration of catheterization, urinary incontinence and need for reoperation within 3 months were similar. There were no differences between groups in International Prostate Symptom Score, quality of life, or postvoid residual at 3 months postoperatively.

CONCLUSION

Utilization of MOSES technology resulted in improved efficiency in HoLAP, translating into time savings in the operating room. Postoperative outcomes out to 3 months were similar among patients who underwent the procedure utilizing either laser pulse mode. Further studies are needed to investigate long-term outcomes as the use of MOSES is likely to become more commonly utilized.

EXPERIMENTAL COMPARISON OF HIGH POWER (80 W) POTASSIUM TITANYL PHOSPHATE LASER VAPORIZATION AND TRANSURETHRAL RESECTION OF THE PROSTATE

PURPOSE

Perioperative hemorrhage is still the major complication of standard transurethral prostate resection (TURP). Potassium titanyl phosphate (KTP) laser vaporization using 80 W is a novel technique that promises instant hemostatic tissue ablation. In this ex vivo investigation we compared the hemostatic properties of the 2 procedures.

MATERIALS AND METHODS

Ex vivo, blood perfused porcine kidneys were used to verify the hemostatic efficacy of KTP laser vaporization and TURP-like tissue resection. Bleeding could be exactly quantified in relation to tissue ablation for the 2 techniques. In addition, specimens were examined microscopically.

RESULTS

KTP laser vaporization demonstrated highly significantly decreased bleeding as compared to conventional tissue resection for a standardized ablation volume of 16 cm tissue (2.1 vs 23.3 ml per minute, p <0.0001). Tissue ablation was more rapid in the resection group (20 vs 100 seconds, p <0.001). Histological examinations revealed larger coagulation zones for the KTP group compared to conventional tissue resection (0.9 vs 0.6 mm, p <0.01).

CONCLUSIONS

Ex vivo, 80 W KTP laser vaporization is a virtually bloodless ablative procedure, giving rise to hemostasis that is highly superior to conventional TURP-like tissue resection. However, the novel procedure is considerably more time-consuming.

Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia

OBJECTIVE

To evaluate the safety and efficacy of holmium:YAG laser vaporization v transurethral electroresection (TURP) for benign prostatic hyperplasia.

PATIENTS AND METHODS

Thirty-six patients were randomized. Two laser procedures (60 to 80 W) were performed for one TURP. Symptom Score, peak flow rate, potency, and ejaculation status were measured at baseline and at 1, 3, 6, and 12 months.

RESULTS

The mean operative time was 75 minutes for laser and 56 minutes for TURP (P = 0.0407). With a mean laser energy delivered of 103.6 kJ, hemostasis was satisfactory during vaporization. The mean catheterization time was 1.7 and 2.1 days in the laser and TURP group, respectively. For the laser and TURP groups, the mean AUA Score improved from 20 preoperatively to 7 and from 24.1 to 5, respectively, at 12 months. The mean peak flow increased from 8.4 to 19.5 mL/sec and from 7.6 to 16.8 ml/sec, respectively, at 12 months. These results are not statistically different. No significant initial dysuria occurred. No significant difference between the groups appeared in potency or ejaculatory status during the follow-up. One patient in the laser group (Day 5) and two in the TURP group (2nd and 6th month) had to undergo a second procedure to relieve obstruction.

CONCLUSION

Although taking slightly longer to accomplish, holmium:YAG laser vaporization of BPH provides early results very similar to those of TURP with a shorter catheterization time and no initial dysuria or pain.

Prostate cancer detection in candidates for open prostatectomy

PURPOSE

We determine the incidence of biopsy detectable prostate cancer in men with clinical benign prostatic hyperplasia (BPH) and prostate specific antigen (PSA) elevation who are candidates for open prostatectomy, and the histology of prostatic tissue of men who underwent surgery.

MATERIALS AND METHODS

Sextant peripheral zone prostate biopsies were performed in 128 consecutive men with obstructive voiding symptoms who had digital rectal examination not suspicious for cancer, PSA greater than 4.0 ng./ml. and prostate volume 75 ml. or greater. Of the patients 59 also underwent transition zone biopsy. Median PSA was 9.9 ng./ml. (range 4.1 to 80.0), median prostate volume was 92 ml. (range 75 to 220), median PSA density was 0.10 ng./ml./ml. (range 0.03 to 0.80) and median percent free PSA in 43 patients was 23.6 (range 8.8 to 41.3).

RESULTS

Of the 128 patients 16 (13%) had malignant biopsy including 1 who had cancer detected with transition zone biopsy only. Gleason score of tumors ranged from 4 to 8 (median 5). Of 57 patients who underwent prostatectomy 6 (11%) had stage T1a and 2 (4%) had stage T1b cancer. Among men without an indwelling urethral catheter due to acute urinary retention mean PSA, PSA density and percent free PSA were not significantly different in those with benign and malignant biopsies and/or prostatectomy specimens.

CONCLUSIONS

Greater than 10% of men with PSA elevation who are potential candidates for open prostatectomy will have biopsy detectable prostate cancer. This diagnostic yield, while lower than that reported for unselect men with normal digital rectal examination and PSA elevation, may justify preoperative peripheral zone biopsy to avoid surgical misadventure during open enucleation. Among patients with benign peripheral zone biopsy there is a less than 5% prevalence of large volume tumors that may complicate open enucleation.

Neodymium:yttrium-aluminum-garnet laser prostatectomy

Since 1986, benign prostatic hyperplasia has been treated with lasers, but clinical use was not practical until the right-angled fiber was developed in the early 1990s. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is one of four types available for treating the prostate. Laser energy levels can be adjusted to provide coagulation (at lower energy densities) or vaporization (at higher energy densities). In a randomized study of these two techniques, symptom scores were similar at 1-year follow-up, but the peak urinary flow rate was higher and the reoperation rate was lower in the patients who received vaporization treatment. In randomized investigations that have compared laser prostatectomy and transurethral resection of the prostate (TURP), symptom scores and urinary flow rates improved in both groups, but results were somewhat better after TURP. Cumulative data for 3-year follow-up after laser prostatectomy have shown that the improved symptom scores and urinary flow are durable. The major disadvantages with use of Nd:YAG prostatectomy are delayed time to voiding, posttreatment dysuria (which occurs in 15 to 30% of patients), and total cost. Overall, Nd:YAG prostatectomy has both pros and cons. In comparison with TURP, the laser procedure is shorter, has fewer complications, can be done on an outpatient basis, and provides quicker recovery and equivalent results.

A randomized prospective study of transurethral electrovaporization vs laser ablation of the prostate in men with benign prostatic hypertrophy

OBJECTIVE

A prospective randomized study comparing transurethral electrovaporization (TVP) vs laser ablation of the prostate was undertaken to compare the efficacy and safety of the procedures.

METHODS

A total of 31 patients underwent treatment, with 20 patients receiving electrovaporization surgery and 11 patients undergoing laser treatment. Patients underwent initial evaluation consisting of an American Urological Association (AUA) symptom score, prostate specific antigen (PSA), uroflowometry, pressure flow, and transrectal ultrasound for prostate volume. Patients were seen in follow-up at 1, 3 and 6 months.

RESULTS

A total of 31 patients with a 2:1 randomization of TVP to laser treatment were enrolled. The laser patients had a mean pre-operative AUA symptom score of 19.0 and scores of 9.0, 6.0 and 5.0 at 1-, 3- and 6-month follow-up. The TVP patients had a mean pre-operative symptom score of 22.0 and scores of 7.0, 8.0 and 5.0 at 1-, 3- and 6-month follow-up. Mean peak uroflow (PF) rate pre-operative was 10.7 for the laser group and 7.7 for the TVP group. At 1-, 3- and 6-month follow-up, mean PF rates of 13.3, 17.6 and 16.5 were present for the laser patients and 15.0, 17.5 and 14.2 for the TVP group. The differences were not statistically significant. There were 6 complications in the laser patients and 7 complications in the TVP group. Operative time was a mean of 27 min for the laser patients and 46 min for the TVP group, and the difference in operative time was statistically significant.

CONCLUSION

At 6-month follow-up the improvement in symptoms score and peak flow rate are comparable in both treatment groups. The electrovaporization procedure required significantly longer to perform than the laser procedure. Long-term follow-up is required to see if these results remain sustainable for electrovaporization therapy.

Outcome of vaportrode transurethral vaporization of the prostate using pressure-flow urodynamic criteria

OBJECTIVES

To use pressure-flow urodynamic parameters to evaluate the outcome of patients with benign prostatic hyperplasia (BPH) who were treated with transurethral vaporization of the prostate (TUVP) using the Vaportrode.

METHODS

Forty consecutive patients (mean age 71.7 years) undergoing TUVP for treatment of symptomatic obstructive BPH or urinary retention were evaluated preoperatively and postoperatively with American Urological Association (AUA) Symptom Score, uroflowmetry, and pressure-flow multichannel urodynamic studies.

RESULTS

Twenty-nine patients were voiding preoperatively. Eleven patients presented with urinary retention and were analyzed separately. At 3-month mean follow-up, the AUA Symptom Score decreased from 20.7 to 7.2 (n = 26). Peak uroflow rate (Qmax) increased from 8.2 to 15.5 mL/s (n = 27), whereas detrusor pressure at maximal flow (Pdet) decreased from 95.0 to 44.7 cm H2O (n = 24), indicating relief of obstruction. Postvoid residual urine volume decreased from 181.8 to 37.3 mL (n = 27). At 1-year mean follow-up, the AUA Symptom Score was 5.6 (n = 15) and Qmax was 14.3 mL/s (n = 19). The overall complication rate was 17.5% and included meatal stenosis (n = 1), bulbar urethral stricture (n = 1), refractory detrusor hyperreflexia (n = 1), dystrophic bladder neck calcification (n = 1), prostatic synechial formation requiring revision (n = 2), and residual prostatic tissue requiring revision (n = 1).

CONCLUSIONS

This study provides objective evidence that TUVP is effective in providing prompt relief of bladder outlet obstruction with durable improvement in symptoms and flow rate with no acute morbidity. Accordingly, TUVP should continue to be considered as a minimally invasive surgical alternative to transurethral resection of the prostate.

Interstitial laser coagulation for management of benign prostatic hyperplasia: a Japanese experience

PURPOSE

The principle of interstitial laser coagulation is to shrink the prostate by generating intraprostatic necrosis without damaging the urethra or causing tissue sloughing. The clinical efficacy and durability of interstitial laser coagulation in the treatment of benign prostatic hyperplasia (BPH) were evaluated.

MATERIALS AND METHODS

From December 1993 to June 1996, 76 patients with symptomatic BPH were treated with interstitial laser coagulation. A neodymium:YAG laser was used in combination with a specially designed interstitial thermotherapy light guide. The tip of the light guide was inserted into each lobe of the prostate transurethrally under direct vision. All evaluations were made at baseline and then 1, 3, 6 and 12 months after therapy. Treatment outcome was evaluated by International Prostate Symptom Score (I-PSS), flow rate and post-void residual urine volume. Disease specific quality of life was assessed via a quality of life assessment score and a BPH impact index. Independent of symptom assessment, a self-reporting questionnaire was prepared at 3 months postoperatively regarding satisfaction with treatment and sexual function.

RESULTS

Among 44 patients followed to 12 months the mean I-PSS significantly decreased from 20.4 at baseline to 7.4, representing 64% improvement (p <0.001). Peak flow rate increased by 50% from a preoperative average of 7.4 to 11.1 ml. per second at 12 months in 42 patients (p <0.001). The post-void residual volume decreased by 57% from 102 to 44 ml. at 12 months in 40 cases (p <0.001). Steady and progressive improvement was observed on quality of life assessment and BPH impact index scores at 3, 6 and 12 months. No patients reported new onset of erectile dysfunction. No serious side effects were observed, except for loss of ejaculation in 3 cases and seminal vesicle abscess in 1. Only 6 patients (8%) required re-treatment for persisting obstructive symptoms during 12 months of followup. A recent change in methods towards more aggressive treatment plausibly influenced the outcomes to require less repeat treatment.

CONCLUSIONS

After the interstitial laser coagulation procedure satisfactory results were obtained and improvement lasted through 12 months. Although the optimal number of fiber placements for each prostate is not known, more aggressive treatment appears to provide better outcomes.

Recent developments in the surgical management of benign prostatic hyperplasia

A new era in the surgical management of benign prostatic hyperplasia (BPH) has emerged in the past decade. A variety of less invasive treatment modalities have been introduced and well-established surgical treatments are being reassessed. Although progress has been made in the management of BPH, the substantial economic burden to the healthcare system caused by BPH emphasizes the importance of cost-effective treatment. Open prostatectomy is the most efficient BPH treatment for relieving symptoms and improving uroflow, but it is also the most invasive and morbid. Transurethral resection of the prostate (TURP) is still the "gold standard" for treatment of BPH, but open prostatectomy has been reported to have a lower perioperative mortality than TURP, and low retreatment rates reduce the long-term cost. The morbidity associated with TURP, such as impotence or urinary incontinence, has been reduced in recent years while new features, such as performing TURP under local anesthesia and bipolar electrosurgical techniques, have been introduced. Transurethral electrovaporization of the prostate (TVP) is a recent modification of TURP that has rapidly gained popularity. TVP greatly reduces TURP syndrome, provides good hemostasis, and may reduce catheterization and hospitalization times. Transurethral incision of the prostate (TUIP) is another safe and inexpensive procedure that is well-documented and comparable to TURP in long-term efficacy. TUIP is an underused procedure with which the newer, less invasive treatments should be compared. Whereas the well-established surgical treatments primarily relieve obstruction by tissue ablation, some of the newer treatment modalities may ameliorate lower urinary tract symptoms (LUTS) with minimal urodynamic change. In some of the newer nonresection treatments, no major significant postoperative reduction in prostate volume can be demonstrated. Laser treatments are based on a broad variety of techniques, generators, and fibers, of which most have initially demonstrated promising results. Well-known techniques include visually laser-assisted prostatectomy (VLAP) and interstitial laser coagulation (ILC). The laser techniques are generally not as effective as TURP, but are safe under local anesthesia on an outpatient basis with low complication rates. Transurethral microwave thermotherapy of the prostate (TUMT) and radiofrequency transurethral needle ablation (TUNA) are minimally invasive, safe new therapies. There is some evidence that the procedures create long-term, alpha-adrenoceptor-like blockade. Complications, except for transient catheterization in up to 40% of patients, may be practically nonexistent. The cost is difficult to estimate and the long-term outcome is still to be assessed. If the newer, less invasive treatment modalities provide stable long-term results and competitive costs, they will be tempting alternatives to prostate resections and may also challenge medical therapy.

High-power potassium-titanyl-phosphate (KTP/532) laser vaporization prostatectomy: 24 hours later

OBJECTIVES

To study the feasibility and immediate postoperative outcome of vaporization prostatectomy by high-power potassium-titanyl-phosphate (KTP/532) laser in 10 men with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) and to evaluate their clinical and voiding outcome 24 hours postoperatively.

METHODS

The KTP/532 laser at 60 W was produced by a prototype Laserscope generator and delivered through a side-deflecting fiber with a 22F continuous-flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were readily vaporized to within capsular fibers. The mean lasing time was 29 +/- 8 minutes, during which a mean of 104.6 +/- 30 kJ of energy was delivered.

RESULTS

The prostate volumes ranged from 22 to 60 mL (mean 38.4 +/- 9.7). None of the 10 patients had any significant blood loss or any fluid absorption. Foley catheters were removed in less than 24 hours postoperatively. All patients were satisfied with their voiding outcome. The mean peak urine flow rate increased from 8 +/- 1.3 mL/s preoperatively to 19.4 +/- 8.4 mL/s (142%, P = 0.003266) 24 hours postoperatively. Postvoid residual volumes remained essentially unchanged from their preoperative levels, as expected (P = 0.767423). One patient had urgency, but none had dysuria, hematuria, or incontinence or required recatheterization. Three patients have returned for 3-month follow-up; all 3 patients have had excellent results and are very satisfied with the outcome.

CONCLUSIONS

Our very early and limited experience indicates that high-power KTP/532 laser vaporization prostatectomy is feasible and appears to be safe and effective for quickly relieving bladder outlet obstruction due to BPH. Larger randomized clinical trials to compare this technique with standard transurethral resection of the prostate and more follow-up data are needed to determine its long-term efficacy and durability.

Minimally invasive treatment for benign prostatic hyperplasia

The armamentarium of minimally invasive treatment modalities for patients with benign prostatic hyperplasia has constantly increased during the past decade. The energy sources used range from micro-/radiofrequency waves to high-intensity focused ultrasound, laser vaporization/coagulation/resection and electrosurgical techniques. Each of these devices has its particular advantages and disadvantages. At present, the most intensively studied techniques are interstitial laser coagulation, holmium laser resection and new approaches to transurethral electrosurgery.