Histologic effects of holmium:YAG laser resection versus transurethral resection of the prostate

The Evolution of Endoscopic Prostate Enucleation: A historical perspective

Here, we review the evolution of prostate enucleation in chronological order based on energy technology starting first with holmium laser, then bipolar electrocautery, followed by thulium laser and finally greenlight and diode laser enucleation of the prostate.

Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: A prospective randomized study

AIM

Transurethral resection of prostate (TURP) is considered a gold standard surgical procedure. The management of benign prostatic hyperplasia (BPH) has undergone tremendous change in recent years and shifted from open to minimal invasive procedure. With the advancement in technology and skills of surgeons, lasers have been used more liberally, particularly holmium laser. Holmium laser enucleation of prostate (HoLEP) is seen as close rival of TURP. The objective if this study is to observe long- and short-term outcomes of transurethral resection and holmium laser enucleation in the prostate of more than 60 g.

MATERIALS AND METHODS

This prospective randomized study includes 164 patients. Inclusion criteria were age <75 years after failed or poor response to medical therapy, prostatic size >60 g, gross hematuria secondary to BPH, recurrent urinary tract infection, acute urinary retention, postvoid residual >150 ml, and Schafer Grade II or more. BPH associated with neurogenic bladder, stricture urethra, and carcinoma prostate were excluded from the study. Group 1 comprises patients who underwent TURP and Group 2 comprises who underwent HoLEP. Follow-up was done at 1, 3, 6, 12, and 24 months after the surgery.

RESULTS

Data of 144 patients were analyzed. The mean age of patients in TURP and HoLEP group was 66.78 ± 7.81 and 67.70 ± 7.44 years, respectively (P = 0.47), mean prostatic volume was 74.5 ± 12.56 and 75.6 ± 12.84 g, respectively (P = 0.60), operative time was 73.10 ± 10.49 and 89.56 ± 13.81 min, respectively (P = 0.0001). Mean resected tissue was 44.80 ± 9.87 and 48.49 ± 10.87, respectively (P = 0.03). The sexual function did not changed significantly in postoperative follow-up.

CONCLUSION

HoLEP is associated with less blood loss, lower transfusion rates, and a shorter hospital stay. The disadvantage of HoLEP is longer operative time and postoperative dysuria.

The evaluation of tissue mass loss in the incision line of prostate with benign hyperplasia performed using holmium laser and cutting electrode

INTRODUCTION

The aim of this study is to compare the changes in the incision line of prostatic adenoma using a monopolar cutting electrode and holmium laser, as well as the assessment of associated tissue mass and volume loss of benign prostatic hyperplasia (BPH).

MATERIAL AND METHODS

The material used in this study consisted of 74 preparations of prostatic adenoma obtained via open retropubic adenomectomy, with an average volume of 120.7 ml. The material obtained cut in vitro before fixation in formaldehyde. One lobe was cut using holmium laser, the other using a monopolar cutting electrode. After the incision was made, tissue mass and volume loss were evaluated. Thermocoagulation changes in the incision line were examinedunder light microscope.

RESULTS

In the case of the holmium laser incision, the average tissue mass loss was 1.73 g, tissue volume loss 3.57 ml and the depth of thermocoagulation was 1.17 mm. When the monopolar cutting electrode was used average tissue mass loss was 0.807 g, tissue volume loss 2.48 ml and the depth of thermocoagulation was 0.19 mm.

CONCLUSIONS

Where holmium laser was used, it was observed that the layer of tissue with thermocoagulation changes was deeper than in the case of the monopolar cutting electrode. Moreover, it was noticed that holmium laser caused bigger tissue mass and volume loss than the cutting electrode.

Enucleation techniques for benign prostate obstruction: which one and why?

PURPOSE OF REVIEW

Endoscopic enucleation of the prostate is the most advanced form of surgical management of benign prostate hyperplasia. The purpose of this review is to update the reader on various modalities currently in use, and in trial, for endoscopic enucleation.

RECENT FINDINGS

A recent paradigm shift has occurred for the proponents of electrosurgery technology to utilizes the advantages offered by laser enucleation with interest in bipolar enucleation. Holmium laser enucleation still has the greatest randomized evidence with the longest follow-up among all the various lasers used to perform enucleation.

SUMMARY

Randomized trials with longer follow-up are required to demonstrate whether nonholmium types of energy really have advantages in enucleation (speed, ease of use and hemostasis) and durability (decade plus) as compared to the holmium laser.

Evolution and success of holmium laser enucleation of the prostate

Aims:

The purpose of this article is to review the development of instruments, current technique, and expected outcomes for holmium laser enucleation of the prostate (HoLEP).

Materials and Methods:

A review of published, peer-reviewed articles focusing on HoLEP was performed using the MEDLINE database.

Results:

Historically, the gold-standard management for symptomatic obstructing benign prostatic hyperplasia (BPH) has been transurethral resection of the prostate (TURP). With the development of new laser technology minimally invasive surgical procedures have been introduced in an attempt to decrease the morbidity experienced with standard TURP. Laser treatment of BPH has evolved from coagulation to complete adenoma enucleation. The holmium laser was initially utilized for prostate ablation and soon evolved into holmium laser tissue resection, but was limited by difficulties with extracting the prostate tissue from the bladder. With the development of a compatible tissue morcellator whole prostate lobes could be enucleated similar to an open prostate enucleation and the HoLEP procedure was developed. Currently HoLEP is the only procedure to demonstrate superior outcomes to TURP on urodynamic studies and long-term studies demonstrate its durability up to 7 years post procedure. Changes in enucleation technique have also increased the efficiency of the HoLEP procedure, such that any sized prostate can be treated.

Conclusions:

HoLEP is a safe and effective surgical treatment for symptomatic BPH, dependent on a high powered laser and morcellation system. The procedure continues to gain acceptance due to excellent short and long-term results, its wide application, and further simplification of technique.

Delayed diagnosis of prostate cancer with neuroendocrine differentiation after laser TURP

Laser transurethral resection of the prostate (TURP) is becoming widely used for surgical management of lower urinary tract symptoms from benign prostatic hyperplasia. Yet, one drawback to laser vaporization is the lack of a prostatic tissue sample for pathologic evaluation. We report the case of a 57-year-old man who presented with urinary obstruction, a normal digital rectal examination and a prostate-specific antigen level of 0.44 ng/mL. The patient then underwent transrectal ultrasonography to determine the size of his prostate (60 g). On the basis of these normal findings, laser TURP was performed. The patient's symptoms did not improve after the procedure, and cystoscopy confirmed continued prostatic obstruction. The patient subsequently underwent bipolar TURP, and the pathologic examination of the prostate chips revealed highly aggressive prostate adenocarcinoma with neuroendocrine differentiation. We discuss the potential drawbacks of laser TURP in the diagnosis of clinically undetectable prostate cancer.

RevoLix™ vaporesection of the prostate: initial results of 54 patients with a 1-year follow-up

Multiple laser systems for the treatment of benign prostatic hyperplasia (BPH) have been introduced. Current laser systems have limitations due to their laser physics. The RevoLix laser combines the advantages of the Holmium:YAG laser with the comfort of a continuous wave (cw) laser beam. This study reports the preliminary results of vaporesection (simultaneous vaporization and resection) of the prostate, using the 2 microm cw laser. A total of 54 consecutive patients were treated with the 70 W RevoLix laser for BPH. The mean age was 61 years. Mean prostate volume was 30.3 cc. A 550 microm RigiFib bare-ended fiber was used in combination with a 26 French laser resectoscope. Measured outcomes were resection time, decrease in hemoglobin and transfusion rate. Furthermore, the catheter time, improvement in the urinary flow rate (Q(max)), post-voiding residual urine (PVR), International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL) were recorded. Average resection time was 52 min. After crossing the learning curve, a tissue ablation of 1.5 g/min was possible. Transfusions were not necessary in any patient. Catheter time was 1.7 days. Q(max) significantly improved from 4.2 to 20.1 ml on average. PVR decreased from 86 to 12 ml. IPSS and QoL-Score improved from 19.8 to 6.9 and 4 to 1, respectively. No patient required re-hospitalization. These preliminary results indicate that RevoLix vaporesection of the prostate is safe and efficient. One-year follow-up data showed a significant improvement in voiding symptoms and patients' quality of life. A longer follow-up is needed to prove the durability of these promising results.

Laser treatment of symptomatic benign prostatic hyperplasia

The treatment of lower urinary symptoms secondary to benign prostatic hyperplasia (BPH) after failure of medical therapies remains controversial for most urologic surgeons. The complications of traditional surgery are the driving force behind the development of several minimally invasive treatments of symptomatic BPH. Laser prostatectomy is one of the most investigated such modalities. In this article we reviewed the results of the most common types of lasers used in prostatic surgery.

HOLMIUM LASER RESECTION OF THE PROSTATE VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: RESULTS OF A RANDOMIZED TRIAL WITH 4-YEAR MINIMUM LONG-TERM FOLLOWUP

PURPOSE

It has previously been shown that holmium laser resection of the prostate (HoLRP) is superior to transurethral resection of the prostate (TURP) with regard to perioperative morbidity and is equivalent to TURP in the short term. We present the long-term results of a randomized, prospective trial comparing HoLRP to TURP since information regarding the durability of holmium prostatectomy is lacking in the literature to date.

MATERIALS AND METHODS

A total of 120 patients with urodynamic obstruction were randomized (April 1996 to August 1997) into 2 comparable groups and assigned to HoLRP or TURP. All patients were assessed preoperatively and followed prospectively at 3 weeks, 3, 6, 12, 24 and 48 months postoperatively with an American Urological Association symptom score, quality of life score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow studies, ultrasound prostatic volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All adverse events were noted.

RESULTS

Of 120 patients 73 completed the 48-month assessment. HoLRP and TURP resulted in significant improvements in all parameters. There was no difference between the 2 techniques in terms of urodynamic parameters, potency, continence and symptom scores at the 48-month assessment. HoLRP took significantly longer to perform but perioperative morbidity, catheter time, nursing contact time and hospital stay were significantly less for HoLRP compared to TURP.

CONCLUSIONS

HoLRP and TURP give equivalent and satisfactory long-term results, with no differences noted in major morbidity. This confirms the durability of these 2 treatments. Peri-operative morbidity is less with HoLRP.

A Systematic Review of Holmium Laser Prostatectomy for Benign Prostatic Hyperplasia

PURPOSE

We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate.

MATERIALS AND METHODS

We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison.

RESULTS

Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia.

CONCLUSIONS

Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.

Free-beam and contact laser soft-tissue ablation in urology

The ablation of tissue by laser has several applications in urology. Most of the published research has been concerned with the treatment of benign prostatic hyperplasia (BPH). Other applications studied include superficial upper- and lower-tract transitional-cell carcinoma, urethral and ureteral strictures, ureteropelvic junction stenosis, and posterior urethral valves. The attraction of laser ablation for the treatment of BPH lies with the decreased morbidity in comparison with standard transurethral electrocautery resection of the prostate and the ability to remove tissue immediately and therefore allow a more rapid progression to catheter removal and early voiding. The three main laser wavelengths used in urology for tissue ablation are the neodymium:yttrium-aluminum-garnet when used with contact tips or high-density power settings, the potassium-titanyl-phosphate, and the holmium:YAG. This article reviews the published literature on the use of these laser wavelengths in soft-tissue ablation, focusing on the treatment of BPH.

Holmium Laser Enucleation Versus Transurethral Resection of the Prostate. Are Histological Findings Comparable?

PURPOSE

We investigated if an adequate histological diagnosis can be made from tissue after holmium laser enucleation of the prostate (HoLEP) and whether it is comparable to transurethral prostate resection (TURP) tissue findings in patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

We analyzed 40 HoLEP and 40 age matched TURP tissue specimens from patients who underwent 1 of the 2 procedures between January 2001 and August 2002. Each histological specimen was reviewed by a single pathologist. Preoperative prostate ultrasound volume, total serum prostatic specific antigen and postoperative tissue weight were evaluated. Microscopic histological diagnosis was assessed by standard histological techniques and immunohistochemical evaluation.

RESULTS

Patients were comparable in terms of age and preoperative total serum prostate specific antigen. Tissue remaining following the procedure was estimated to be 36.3% of preoperative ultrasound volume after HoLEP and 52.8% after TURP (p <0.001). Incidental adenocarcinoma and high grade PIN of the prostate were diagnosed in a comparable percent of specimens in the 2 groups. Tissue thermal artifacts induced by the laser were mostly due to coagulation. Thus, the alterations were similar to those after TURP.

CONCLUSIONS

Tissue quality is altered after HoLEP and TURP. General prostatic architecture was maintained in the majority of HoLEP histological specimens. A moderately higher percent of prostatic tissue obtained by the Ho laser is lost by vaporization and coagulation. Nevertheless, these differences do not seem to alter pathologist ability to detect incidental prostate cancer and PIN.

Holmium laser enucleation of the prostate can be taught: the first learning experience

OBJECTIVE

To present the initial experience of a senior urology resident with holmium laser enucleation of the prostate (HoLEP) and to address the difficulties encountered while learning this technique, describing the detailed operative technique and pitfalls.

PATIENTS AND METHODS

Between July and August 2001, 27 patients were treated using HoLEP administered by one senior urology resident (A.H.) under the supervision of an experienced urologist (M.M.E.). Patients were assessed before and 1 month after HoLEP by the International Prostate Symptom Score (IPSS), the associated quality-of-life (QoL) score, and measurements of maximum urinary flow rate (Qmax) and postvoid residual urine (PVR) volume. The prostate volume was measured before HoLEP using transrectal ultrasonography. The 27 patients were compared retrospectively with 118 who underwent HoLEP by the supervising urologist. Each of the 27 procedures was taped and reviewed.

RESULTS

The mean (range) prostate size was 54.8 (21-122) mL (A.H.) and 61.7 (20.5-172) mL (M.M.E.). The mean operative duration was 98 (50-175) min and the mean enucleation time 68 (29-108) min. The improvements in IPSS, QoL score, Qmax and PVR were highly significant (P < 0.001), with mean values before and after HoLEP of 16.8 and 8.2, 3.1 and 1.4, 7.7 and 20.8 mL/s, and 232 and 41.3 mL, respectively. Of the 27 patients, 23 (85%) were catheter-free on the first day after HoLEP; the mean hospital stay was 1.8 days. All these results were comparable with the results of 118 patients treated by M.M.E. The two most difficult technical steps identified were the initial apical enucleation and the incision of the remaining antero-apical mucosal attachment of the lateral lobes. The operator became adept with the HoLEP technique after a mean of 20 patients.

CONCLUSION

HoLEP can be learnt but requires longer training than standard transurethral resection. Extensive experience with transurethral surgery and the supervision of an experienced urologist are prerequisites for success.

Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm.:: a randomized prospective trial of 120 patients

PURPOSE

Prostate adenomas greater than 100 gm. have traditionally been treated with open prostatectomy. This procedure may involve considerable blood loss, morbidity, prolonged hospital stay and recovery time. The high powered holmium:YAG laser can be used endoscopically to enucleate obstructing prostatic tissue in a relatively bloodless manner. The technique of transurethral holmium laser enucleation of the prostate is compared to open prostatectomy for the surgical management of large prostate adenomas in a prospective randomized study.

MATERIALS AND METHODS

A total of 120 urodynamically obstructed patients with a prostate larger than 100 gm. on transrectal ultrasound were randomized to undergo holmium laser enucleation of the prostate or open prostatectomy. All patients were assessed preoperatively and 1, 3 and 6 months postoperatively. Patient baseline characteristics, perioperative data and postoperative outcome were compared. All complications were noted.

RESULTS

Holmium laser enucleation of the prostate and open prostatectomy resulted in a similar and significant improvement in American Urological Association symptom scores, peak urinary flow rates and post-void residual urine volumes. Operating time was significantly longer in the holmium group but blood loss was significantly less, and catheterization time and hospital stay were significantly shorter. Effects on continence and potency were similar in both groups but adverse events were less frequent in the holmium group. None of the holmium group patients needed blood transfusions in contrast to 8 patients in the prostatectomy group.

CONCLUSIONS

Holmium laser enucleation of the prostate and open prostatectomy are equally effective procedures for removal of large prostatic adenomas. Holmium laser enucleation resulted in significantly less perioperative morbidity and may become the endourological alternative to open prostatectomy.

Holmium laser prostatectomy: current techniques

INTRODUCTION

During the past 7 years, holmium laser prostatectomy has evolved into an enucleation procedure, incorporating the use of established surgical planes. Holmium laser enucleation of the prostate (HoLEP) uses the excellent incisional and hemostatic properties of the holmium laser wavelength. Clinical outcomes with this may be superior to transurethral resection of prostate. HoLEP is also a minimally invasive therapy for larger glands that have traditionally been treated by open prostatectomy.

TECHNICAL CONSIDERATIONS

There are four steps to performing HoLEP: (a) creation of bladder neck incisions, (b) enucleation of the median lobe, (c) enucleation of the lateral lobes off the prostatic capsule, and (d) transurethral morcellation. In most cases, postoperative irrigation is not needed and the catheterization time is less than 24 hours.

CONCLUSIONS

HoLEP is an emerging technique in the surgical management of benign prostatic hyperplasia. There is a learning curve with this procedure, because the technique is very different from transurethral resection of prostate.

Holmium laser enucleation for large (greater than 100 mL) prostate glands

BACKGROUND

To evaluate the holmium laser enucleation of the prostate (HoLEP) using the transurethral soft tissue morcellator (TUSTM), as a primary surgical treatment for symptomatic benign prostatic hyperplasia (BPH) with prostate glands > 100 mL.

METHODS

Eighteen patients with preoperative prostate volumes > 100 mL underwent the HoLEP procedure. The criteria for surgery were determined by a preoperative International Prostate Symptom Score (IPSS), a prior failure of medical therapy, and urinary retention.

RESULTS

The mean preoperative IPSS and prostate gland size were 13.8 and 142.3 mL, respectively. The total energy used by the laser was 288.4 kJ. The mean catheter time was 23.8 h and, perioperatively, no patients had electrolyte abnormalities or required blood transfusions. The 3-week postoperative IPSS was 2.8, with minimum long-term complications.

CONCLUSIONS

Holmium laser enucleation of the prostate with TUSTM is a safe and effective alternative to open prostatic surgery for glands > 100 mL.

Holmium laser prostatectomy

Holmium laser prostatectomy has evolved in the last decade to reproduce the short- and long-term results of both transurethral and open prostatectomy. This article discusses our surgical approach at the Methodist Hospital of Indiana as well as offers a review of the literature of holmium prostatectomy.

Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years of follow-up

BACKGROUND AND PURPOSE

The holmium laser (2140 nm) can be used to ablate, resect, and enucleate the enlarged prostate. The 2-year results of a randomized trial comparing holmium laser resection of the prostate (HoLRP) and transurethral resection (TURP) are presented.

PATIENTS AND METHODS

The 120 patients were randomized to either TURP (N = 59) or HoLRP (N = 61). The patients were reviewed at 1, 3, 6, 12, 18, and 24 months postoperatively. Eighty six (72%) of the patients were available for review at the 2-year mark.

RESULTS

At 2 years, there was no significant difference between the two groups in AUA Symptom Score, peak flow rate (Qmax) value, or quality of life score. Adverse events, including reoperations, incontinence, and loss of erectile potency, were also similar.

CONCLUSIONS

The HoLRP and TURP procedures result in similar clinical outcomes at 2 years.