A critical analysis of laser prostatectomy in the management of benign prostatic hyperplasia

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.

Potassium titanyl phosphate laser prostatectomy: a review

PURPOSE OF REVIEW

High-powered potassium titanyl phosphate laser (GreenLight PV) has gained attention as a minimal access alternative for the treatment of prostate obstruction. This article reviews the recent data and technical refinements of potassium titanyl phosphate laser prostatectomy.

RECENT FINDINGS

The technique is similar to transurethral resection of the prostate in improving symptoms and urinary flow but with minimal morbidity. Striking advantages of this technique include minimal catheter times, true day-case surgery and the virtual abolition of blood transfusions. The absence of intraoperative irrigant absorption (transurethral resection syndrome) in this technique allows high-risk patients, or those with massive prostates, to be safely treated with minimal hospitalization.

SUMMARY

The availability of a safe and effective technique to overcome the considerable drawbacks of open prostatectomy and transurethral resection of the prostate is a major advance. Although randomized studies are limited, multicentre prospective data from a variety of clinical settings show similar benefits and promising durability over 3-5 years.

Instrumental treatments for benign prostatic obstruction

PURPOSE OF REVIEW

The need to treat increasing numbers of patients with symptomatic benign prostatic obstruction has led to the continuous development of various novel or modified instrumental procedures with minimal invasiveness. The aim of the following review is to provide an overview of the current research focused on the complications and morbidity of instrumental treatment options for symptomatic benign prostatic obstruction.

RECENT FINDINGS

A systematic Medline database search, over the past 12 months of the literature with a focus on articles about surgical treatment for benign prostatic obstruction or benign prostatic hyperplasia, provided some interesting new data concerning laser prostatectomy (holmium laser enucleation of the prostate and photoselective vaporization of the prostate) and transurethral resection of the prostate using bipolar electrocautery systems available for the review.

SUMMARY

The data of this review period confirmed a favorable safety profile of holmium laser enucleation of the prostate for treating patients with comorbidities. Photoselective vaporization of the prostate seems to be an efficient technique with a favorable safety profile. Its long-term potential, however, has to be confirmed by randomized controlled studies. Transurethral resection of the prostate using bipolar electrocautery systems appears to offer the advantages of improved hemostasis and the ability to avoid transurethral resection syndrome. More randomized comparisons, however, need to be undertaken before an accurate general picture is available.

Clinical Approach to the Prostate: An Update

Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.

Current role of lasers in the treatment of benign prostatic hyperplasia (BPH)

OBJECTIVE

Evaluate the current role of lasers in the treatment of benign prostatic hyperplasia (BPH).

METHODS

The results of a MEDLINE search for randomised trials and case series of the last 5 yr and published review articles were analysed for the safety and efficacy of neodymium:yttrium aluminum garnet (Nd:YAG), potassium-titanyl-phosphate (KTP), and holmium (Ho):YAG laser prostatectomy. The analysis includes 12 reports on randomised clinical trials, 2 comparative studies, 10 review articles, and a total of >5000 patients.

RESULTS

Laser treatment of BPH has evolved from coagulation to enucleation. Blood loss is significantly reduced compared with transurethral resection and open prostatectomy. Visual laser ablation of the prostate and interstitial laser coagulation cause coagulative necrosis with secondary ablation. Long postoperative catheterisation, unpredictable outcomes, and high reoperation rates have restricted the use of these techniques. Ablative/vaporising techniques have become popular again with the marketing of new high-powered 80-W KTP and 100-W Ho lasers. Vaporisation immediately removes obstructing tissue. Short-term results are promising, but large series, long-term results, and randomised trials are lacking. Holmium laser enucleation (HoLEP) allows whole lobes of the prostate to be removed, mimicking the action of the index finger in open prostatectomy. Prostates of all sizes can be operated on. It is at least as safe and effective as transurethral resection of the prostate and open prostatectomy, with significantly lower morbidity. It is the only laser procedure that provides a specimen for histologic evaluation.

CONCLUSIONS

HoLEP appears to be a size-independent new "gold standard" in the surgical treatment of BPH.