[Prostate laser photovaporisation in patients at high risk of bleeding]

Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants

Objective

Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity.

Methods

A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification.

Results

There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77±6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94±56 mL, 301±211 kJ, and 35±21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2±2.4 days and 2.4±2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions.

Conclusions

This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

A Study of the Role of 180W XPS Lithium Triborate Laser in the Treatment of Patients With Lower Urinary Tracts Symptoms Due to Benign Prostatic Hyperplasia

Introduction: Benign prostatic hyperplasia (BPH) is a disease of the prostate commonly seen in elderly males known to cause lower urinary tract symptoms (LUTS) that may require surgery as a part of treatment. Transurethral resection of the prostate (TURP) is considered the gold standard of surgical treatment, but it is not without complications. Laser photoselective vaporisation of the prostate (PVP), introduced in 1998 as an 80 W Nd:YAG laser which passed through a KTP (potassium-titanylphosphate) crystal, emerged as a safe alternative to TURP in selected cases. A recent upgrade to the Greenlight XPS 180 W powered with an LBO (lithium triborate) crystal has been available for use since 2012. Data on the use of this new upgrade is still being collected and analysed, especially in patients with large prostates or high risk cases. We analysed cases done at Jaslok Hospital over a 2-year period. Methods: A total of 34 patients who underwent Laser PVP using XPS 180W for LUTS due to BPH at Jaslok Hospital were part of this study. We analysed the pre- and postoperative variables and the intraoperative parameters of all patients. Results: The XPS 180W was found to be safe and efficacious. Eighteen patients were high-risk cases, classified as ASA (American Society of Anesthesiologists) Classes 3 and 4. Average postoperative catheter duration was 40.18 hours. In prostates of size <80 mL, an average of 229 kJ of energy was used. In large prostates (>80 mL), an average of 390 kJ of energy was used. No major complications were seen in any of the high-risk patients, classified as Clavien Dindo Class 3 and 4. The postoperative drop in IPSS (International Prostate Symptom Score) was 8.7. Conclusion: We found that Green Light Laser XPS 180W may be used for large (>80 g) prostates, hitherto an indication for open surgery, and that it may be used in high-risk patients, who were otherwise unfit for TURP. It is safe and efficacious. Further, multicenter trials are required to confirm the findings.