Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence

Effect of urinary retention on the surgical outcome of holmium laser enucleation of the benign prostatic hyperplasia

PURPOSE

To evaluate the effect of urinary retention (UR) on holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms.

MATERIALS AND METHODS

A retrospective analysis of a prospective cohort of patients who underwent HoLEP between January 2010 and December 2016 was performed. The perioperative factors, including the International Prostate Symptom Score, Overactive Bladder Symptom Score, prostate-specific antigen, urodynamic study results, uroflowmetry results, transrectal ultrasound prostate volume, operative time, morcellation time, enucleation weight, and complications, were evaluated. Postoperative evaluation was performed at 2, 3, and 6 months.

RESULTS

Overall, 903 patients were identified. The mean age and follow-up were 68.3 years and 6 months, respectively. Among the patients, 135 (15.0%) patients had a history of acute UR (AUR), and 36 patients (4.0%) had chronic UR (CUR). The mean detrusor pressures at maximum flow were 64.4, 74.3, and 77.7 cmH₂O (p<0.001). The mean maximum flow rates (Qmax) were 7.6, 6.6, and 4.8 mL/s (p<0.001). Additionally, the mean bladder outlet obstruction indices were 49.5, 61.1, and 69.4 (p<0.001). The postoperative Qmax improved in all three groups. The mean postvoid residual volumes (PVRs) were 55, 75, and 333 mL preoperatively; 20, 29, and 66 mL at 2 weeks; 16, 23, and 45 mL at 3 months; and 15, 22, and 52 mL at 6 months (p<0.001).

CONCLUSIONS

Voiding symptoms, PVR, and Qmax of BPH patients with preoperative AUR and CUR significantly improved after Ho-LEP, similar to those without preoperative UR.

1470 nm Diode Laser Enucleation vs Plasmakinetic Resection of the Prostate for Benign Prostatic Hyperplasia: A Randomized Study

Objective: The purpose of the current work was to comparatively assess 1470 nm diode laser enucleation of the prostate (DiLEP) and plasmakinetic resection of the prostate (PKRP) for treating benign prostatic hyperplasia (BPH).

Patients and Methods: From January 2016 to March 2017, 157 individuals with bladder outflow obstruction caused by BPH were randomized to DiLEP and PKRP groups, for prospective analysis. Of these, 152 cases were evaluated before operation and at 3, 6, and 12 months postsurgery. Patient baseline properties, presurgery data, and postsurgical outcomes were comparatively assessed, as well as complications.

Results: There were no significant preoperative differences between surgical groups. DiLEP-treated cases showed remarkable reduced operative time, postsurgical bladder irrigation time, catheterization duration, and hospital stay compared with the PKRP group (P < 0.001). Hemoglobin amount decrease was markedly less pronounced after DiLEP (P = 0.004). However, no patients needed blood transfusion in either group. The decrease in sodium level showed no marked differences between the DiLEP and PKRP groups (P = 0.380). In addition, complications were comparable and no significant differences in both groups. At 3, 6, and 12 months, International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR) were similar in both groups (P > 0.05).

Conclusions: DiLEP and PKRP are similar in efficacy and safety for relieving obstruction and low urinary tract symptoms. Compared with PKRP, DiLEP has decreased risk of hemorrhage, operative time, bladder irrigation time, catheterization duration, and hospital stay. However, IPSS, QoL, Qmax, and PVR were similar for both procedures within 12 postoperative months.

Efficacy of bipolar ‘button’ plasma vaporisation of the prostate compared to green laser vaporisation for benign prostatic obstruction

Objective:

Our objectives were to evaluate the efficiency of transurethral bipolar plasma vaporisation of the prostate (BPVP) using the button electrode and compare it to green laser vaporisation of the prostate (GLVP).

Patients and methods:

During the period March 2012 to January 2017, 155 patients with benign prostatic obstruction (BPO) were enrolled in our study. Overall, 80 patients underwent BPVP and 75 GLVP. All International Prostate Symptom Scores (IPSS), quality of life (QOL), uroflow Qmax, Qave and post-void residual (PVR) urine samples were evaluated 24 hours preoperatively and at three months postoperatively. Operative time, hospital stay, catheterisation time, and complications were reported. Mean serum haemoglobin, haematocrit and serum sodium changes were reported preoperatively and within 24 hours postoperatively in both groups. Statistical analysis was performed using the SPSS program version 20 for Windows.

Results:

Mean age at surgery was 62.8 ± 4 (53–82) years and 63 ± 6.6 (54–86) years for the BPVP and GLVP groups respectively. Mean prostatic volume was 45 ± 10 (36–90) and 43 ± 9 (32–85) in each group, respectively. Patients from both series had similar preoperative characteristics. The mean operative duration was 58 ± 21 (range: 20–70) minutes and 57 ± 13 (range: 24–75) minutes, hospital stay was 12.2 ± 6.4 (12–60) hours vs 7 ± 3.3 (6–48) hours ( p = 0.01), and catheterisation period was 48 ± 1.28 (24–72) hours vs 6 ± 6.2 (6–7) hours ( p = 0.001).

Conclusions:

Both BPVP and GLVP offer good options for management of BPO with less bleeding, one-day surgery, less catheterisation time with significant improvement of IPSS, QOL score and uroflow postoperatively. However, more studies comparing the cost of both techniques are needed for a solid conclusion.

Level of evidence:

Not applicable for this multicentre audit.

Efficacy of bipolar ‘button’ plasma vaporisation of the prostate compared to green laser vaporisation for benign prostatic obstruction

Objective:

Our objectives were to evaluate the efficiency of transurethral bipolar plasma vaporisation of the prostate (BPVP) using the button electrode and compare it to green laser vaporisation of the prostate (GLVP).

Patients and methods:

During the period March 2012 to January 2017, 155 patients with benign prostatic obstruction (BPO) were enrolled in our study. Overall, 80 patients underwent BPVP and 75 GLVP. All International Prostate Symptom Scores (IPSS), quality of life (QOL), uroflow Qmax, Qave and post-void residual (PVR) urine samples were evaluated 24 hours preoperatively and at three months postoperatively. Operative time, hospital stay, catheterisation time, and complications were reported. Mean serum haemoglobin, haematocrit and serum sodium changes were reported preoperatively and within 24 hours postoperatively in both groups. Statistical analysis was performed using the SPSS program version 20 for Windows.

Results:

Mean age at surgery was 62.8 ± 4 (53–82) years and 63 ± 6.6 (54–86) years for the BPVP and GLVP groups respectively. Mean prostatic volume was 45 ± 10 (36–90) and 43 ± 9 (32–85) in each group, respectively. Patients from both series had similar preoperative characteristics. The mean operative duration was 58 ± 21 (range: 20–70) minutes and 57 ± 13 (range: 24–75) minutes, hospital stay was 12.2 ± 6.4 (12–60) hours vs 7 ± 3.3 (6–48) hours ( p = 0.01), and catheterisation period was 48 ± 1.28 (24–72) hours vs 6 ± 6.2 (6–7) hours ( p = 0.001).

Conclusions:

Both BPVP and GLVP offer good options for management of BPO with less bleeding, one-day surgery, less catheterisation time with significant improvement of IPSS, QOL score and uroflow postoperatively. However, more studies comparing the cost of both techniques are needed for a solid conclusion.

Level of evidence:

Not applicable for this multicentre audit.

Randomized, controlled trial of laser vs. bipolar plasma vaporization treatment of benign prostatic hyperplasia

INTRODUCTION

Prostate vaporization technology is becoming a standard of care for treatment of moderate, symptomatic benign prostatic hyperplasia (BPH). We compared two transurethral prostate vaporization technologies with respect to cost, efficiency, efficacy, safety, and surgical team satisfaction.

METHODS

Fifty-five patients meeting standardized symptom criteria for BPH were randomized to either Olympus Plasma Button^TM or Biolitec EVOLVE^® diode laser vaporization. Primary outcome of cost with secondary outcomes of clinical efficacy, resection time, surgical team satisfaction, and safety were analyzed. Followup was carried out at six and 12 weeks. Patient factors included baseline, as well as six- and 12-week International Prostate Symptom Score (IPSS) with quality of life (QoL) scores. We recorded surgical team satisfaction with a Likert-style survey investigating ease of set-up, reliability, efficiency, and ability to reach desired endpoint. All complications or side effects detected within three months and the resulting management were included in the cost analysis.

RESULTS

Mean cost per patient was $3418 for the Olympus group and $4564 for Biolitec (p<0.05). Surgical vaporization time was significantly less for the Olympus group, 24.3 vs. 33.5 minutes (p<0.05). Surgical and nursing staff preferred the Olympus device (p<0.05). IPPS symptom improvement and complication rates were similar between groups. Patients in the Biolitec arm had more intraoperative bleeding episodes requiring conversion to monopolar transurethral resection of the prostate (TURP) (three vs. none).

CONCLUSIONS

In a head-to-head randomized trial, Olympus Plasma Button transurethral vaporization was more cost-effective, faster, and preferred by surgical staff when compared to Biolitetec Diode Laser vaporization. Both devices showed similar safety and efficacy.

Trends in the surgical treatment of benign prostatic hyperplasia in a tertiary hospital

BACKGROUND

To assess current treatment trends and perioperative outcomes of transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) in a tertiary institution.

METHODS

We prospectively collected a database of all patients undergoing TURP and PVP for benign prostatic hyperplasia (BPH) at a tertiary hospital between January 2011 and December 2013. Patient characteristics such as length of stay, readmission, anticoagulation status, American Society of Anesthesiologists (ASA) score and need for blood transfusion were recorded and analysed.

RESULTS

In total, 560 cases were included: 204 (36.4%) underwent TURP and 356 (63.6%) PVP. Patients undergoing PVP had higher ASA scores (P < 0.001) and were more frequently on continuing anticoagulant therapy (P < 0.001). With regards to non-aspirin/asasantin coagulation therapy, 61 (17.1%) patients underwent PVP with their anticoagulants continued while no patients who received TURP continued anticoagulation. Blood transfusion percentages were similar at 1.0% for TURP and 1.7% for PVP but readmission proportions were higher after PVP (32 patients, 9.0%) compared to TURP (10 patients, 4.9%). These differences were attenuated when excluding patients continuing anticoagulation during the procedure.

CONCLUSION

At our institution, the use of PVP has been increasing on a year-by-year basis. The results of the current study demonstrated that PVP is safe in patients with increased anaesthetic risk or on active anticoagulation when compared to traditional TURP. While this makes PVP an attractive alternative to TURP in high-risk anticoagulated patients, these patients may have complex post-discharge issues that should be addressed during the informed consent process.

Comparison of Holmium Laser Prostate Enucleation Outcomes in Patients with or without Preoperative Urinary Retention

PURPOSE

We determine whether outcomes of holmium laser enucleation of the prostate are similar in patients with and those without preoperative urinary retention.

MATERIALS AND METHODS

From May 2008 to July 2014, 231 patients underwent holmium laser prostate enucleation for symptomatic benign prostatic hyperplasia. Retrospective analysis was performed to evaluate for differences in postoperative outcomes for patients with and those without preoperative urinary retention.

RESULTS

Overall 95 patients (41%) had urinary retention before holmium laser prostate enucleation while 136 (59%) did not. Mean followup for all patients was 15.3 months. Patients with retention tended to be older, have larger prostates, and have higher scores on the AUA SS and bother questionnaires (all p <0.05). Postoperatively there was no difference in rates of complications, including urinary retention. Both groups showed significant improvement in AUA SS and bother score after the procedure at all postoperative points. Median post-void residual was less than 60 ml and median maximum flow rate on uninstrumented uroflow was greater than 18 ml per second at all postoperative points for all patients regardless of preoperative retention status. No patients required long-term catheterization and rates of postoperative complications did not differ significantly during the followup period.

CONCLUSIONS

This study represents the first direct comparison to our knowledge of holmium laser prostate enucleation outcomes in patients with or without urinary retention. There was no increased risk of postoperative urinary retention in patients with preoperative retention, and both groups demonstrated significant postoperative improvement in subjective and objective voiding measures.

One day surgery in the treatment of benign prostatic enlargement with thulium laser: A single institution experience

PURPOSE

Various articles have previously addressed the introduction of new surgical laser therapies for an enlarged prostate gland causing obstructive symptoms. The objective of this study was to report the feasibility of performing the thulium laser vapo-enucleation of the prostate (ThuVEP) procedure for benign prostatic obstruction in a 1-day surgery.

MATERIALS AND METHODS

From September 2011 to September 2013, we conducted a prospective study on patients who underwent ThuVEP in a 1-day surgery. The primary outcomes measured perioperatively included operative time, resected tissue weight, hemoglobin decrease, transfusion rate, postoperative irrigation and catheterization time, and postoperative hospital stay. Also, the preoperative and postoperative International Prostate Symptom Score (IPSS) and results of uroflowmetry performed on the 7th and 30th postoperative days were recorded. All perioperative and postoperative complications were monitored.

RESULTS

A total of 53 patients underwent the surgical treatment in a 1-day surgery. Seven patients continued antiaggregant therapy with aspirin. Mean preoperative prostatic adenoma volume was 56.6 mL. Mean operative time was 71 minutes. The average catheter time was 14.8 hours. The peak urinary flow rate on day 7 improved from 9.3 to 17.42 mL/s (p<0.001) and the IPSS improved from 18 to 10.2 (p<0.01). Patients were routinely discharged on the day of catheter removal. No complications were recorded.

CONCLUSIONS

ThuVEP can be safely conducted as a 1-day surgical procedure. This strategy results in cost savings. ThuVEP shows good standardized outcomes with respect to improvement in flow parameters and length of bladder catheterization.

Does prostate size impact upon perioperative outcomes associated with photoselective vaporization of the prostate using the 180W lithium triborate laser?

Introduction:

Photoselective vaporization of the prostate (PVP) has been widely adopted as a surgical treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). Recently, a high-powered 180 W lithium triborate (LBO) laser has become commercially available and there is relatively little information on the impact of this very high-powered laser on perioperative outcomes. Even more so is the impact of the laser on outcomes according to prostate size.

Objectives:

The objective of this study was to evaluate perioperative outcomes after PVP with the 180W laser, relative to prostate size.

Patients and Methods:

A prospectively maintained institutional ethics approved database was retrospectively reviewed. Subjects were analyzed according to transrectal ultrasound and categorized into groups namely 0-39 mL, 40-79 mL, 80-120 mL and >120 mL. Perioperative measures included energy utilized, length of operation, duration catheterization, post operative length of stay (POLOS), Clavien-Dindo adverse events and number discharged home within 24 hours catheter free.

Results:

With increasing prostate size, there was a statistically significant increase in energy utilization and operation time (P < 0.01 between groups). Duration of catheterization, POLOS, incidence of Grade 3 and above Clavien-Dindo adverse events and discharge home catheter free within 24 hours was not statistically significant across groups.

Conclusions:

Prostate volume impacts upon energy utilized with PVP surgery. Prostate volume does not influence duration of catheterization or POLOS. Clavien-Dindo Grade 3 or greater adverse events were low and do not appear to be influenced by prostate size. The ability to be discharged home catheter free within 24 hours likewise does not appear to be influenced by prostate size.

Vaporization techniques for benign prostatic obstruction: GreenLight all the way?

PURPOSE OF REVIEW

To give an overview and discuss the recent literature of different vaporization techniques of the prostate using laser energy or high-frequency current.

RECENT FINDINGS

Ten studies covering GreenLight vaporization of the prostate with its evolution from 80 W KTP to 120 W HPS to 180 W XPS system were identified. Only one study had a randomized design comparing HPS to transurethral resection of the prostate. The diode laser is discussed with its results after recent modification with quartz head fiber. Although complication rates are low, the comparison to transurethral resection of the prostate is lacking. Current data on established vapoenucleation and promising vaporesection of thulium:YAG lasers are presented. Further, recent studies on plasmakinetic vaporization are discussed.

SUMMARY

At present, high evidence data on vaporization techniques of the prostate are lacking. The data on GreenLight vaporization of the prostate are the most convincing.

Update on the use of diode laser in the management of benign prostate obstruction in 2014

AIM

To determine the status quo in respect of various diode lasers and present the techniques in use, their results and complications. We assess how these compare with transurethral resection of the prostate and other types of laser in randomized controlled trials (RCTs). When adequate RCTs were not available, case studies and reports were evaluated.

MATERIALS AND METHODS

Laser for the treatment of benign prostatic hyperplasia (BPH) has aroused the interest and curiosity of urologists as well as patients. The patient associates the term laser with a successful and modern procedure. The journey that started with coagulative necrosis of prostatic adenoma based on neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has culminated in endoscopic "enucleation" with holmium laser. Diode laser is being used in urology for about 10 years now. Various techniques have been employed to relieve bladder outlet obstruction due to BPH.

RESULTS

The diode laser scenario is marked by a diversity of surgical techniques and wavelengths. We summarize the current published literature in respect of functional results and complications.

CONCLUSION

More randomized controlled studies are needed to determine the position and the ideal technique of diode laser treatment for BPH.

Effects of low-frequency ultrasound combined with microbubbles on benign prostate hyperplasia

INTRODUCTION

Our objective is to assess the effects of low-frequency ultrasound combined with microbubbles on benign prostate hyperplasia (BPH).

METHODS

Sixteen Beagle dogs with BPH were randomly assigned into 4 groups (n = 4): control group (without treatment), G1 group (injection with 2 mL of microbubble contrast agent); G2 group (21 kHz ultrasound); and G3 group (injection with 2 mL of micro-bubble contrast agent +21 kHz ultrasound). The histopathological damage to prostate cells was assessed via transmission electron microscopy and optical microscopy. The protein expressions of prostate-specific antigen (PSA), inducible nitric oxide synthase (iNOS), superoxide dismutase (SOD) of vessels were detected by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Histopathologically, the prostate cells exhibited nuclear chromatin contraction, mitochondrial swelling, degranulation of rough endoplasmic reticulum, basement membrane rupture and cell apoptosis in the G2 and G3 groups; it was especially obvious in the G3 group, while no changes were observed in the control and G1 groups. Although prostate volume using imaging was not significantly changed in all groups after treatment, PSA was significantly reduced in the G2 and G3 groups, and especially obvious in the G3 group (p < 0.05). The iNOS and SOD, which are important oxidative stress factors, significantly increased after treatment in the G2 and G3 groups, but not in the control and G1 groups (p < 0.05).

CONCLUSIONS

Low-frequency ultrasound is effective in treating BPH; low-frequency ultrasound combined with microbubbles improves the treatment efficacy.

Tissue effects resulting from eraser laser enucleation of the prostate: in vivo investigation

BACKGROUND/AIMS/OBJECTIVES: To describe the depth of the laser coagulation zone in vivo based on histological examinations and the functional outcome of a 1,318-nm diode laser for enucleation in benign prostatic enlargement (BPE).

METHODS

A total of 20 patients with BPE were treated by laser Eraser® enucleation of the prostate (ELEP). Prostatic tissue wedges were evaluated to assess the depth of the ELEP coagulation zones. Additionally, patients were assessed preoperatively and 12 months postoperatively.

RESULTS

The coagulation zones were 0.36 ± 0.17 mm in epithelial tissue, 0.28 ± 0.15 mm in stromal tissue, and 0.25 ± 0.12 mm in mixed tissue. The coagulation area at the cutting edge completely sealed capillary vessels, reaching a depth of 0.35 ± 0.15 mm. The diameter of the coagulated vessels measured 1.75 ± 0.83 mm. Mean blood loss was 115.54 ± 93.12 ml, catheter time 1.35 ± 0.33 days, and hospital stay 1.89 ± 0.52 days. The International Prostate Symptom Score, maximal flow rate, and quality of life significantly improved 12 months after the procedure.

CONCLUSIONS

ELEP is safe and effective for BPE treatment and yields good results at a follow-up of 1 year. Because of the limited penetration depth, damage to the urinary sphincter is not expected.

Review of current laser therapies for the treatment of benign prostatic hyperplasia

The gold standard for symptomatic relief of bladder outlet obstruction secondary to benign prostatic hyperplasia has traditionally been a transurethral resection of the prostate (TURP). Over the past decade, however, novel laser technologies that rival the conventional TURP have multiplied. As part of the ongoing quest to minimize complications, shorten hospitalization, improve resection time, and most importantly reduce mortality, laser prostatectomy has continually evolved. Today, there are more variations of laser prostatectomy, each with several differing surgical techniques. Although abundant data are available confirming the safety and feasibility of the various laser systems, future randomized-controlled trials will be necessary to verify which technique is superior. In this review, we describe the most common modalities used to perform a laser prostatectomy, mainly, the holmium laser and the potassium-titanyl-phosphate lasers. We also highlight the physical and clinical characteristics of each technology with a review of the most current and highest-quality literature.

[Laservaporization of the prostate: current status of the greenlight and diode laser]

In the last decade laser vaporization of the prostate has emerged as a safe and effective alternative to transurethral resection of the prostate (TURP). This was facilitated in particular by the introduction of photoselective vaporization of the prostate (PVP) with a 532 nm 80 W KTP laser in 2002. Prospective randomized trials comparing PVP and TURP with a maximum follow-up of 3 years mostly demonstrated comparable functional results. Cohort studies showed a safe application of PVP in patients under oral anticoagulation and with large prostates. Systems from various manufacturers with different maximum power output and wavelengths are now available for diode laser vaporization of the prostate. Prospective randomized trials comparing diode lasers and TURP are not yet available. In cohort studies and comparative studies PVP diode lasers are characterized by excellent hemostatic properties but functional results vary greatly with some studies reporting high reoperation rates.