Multicentricity and the Risk of Recurrence/Persistence After Laser Vaporization for High-Grade Vulvar and Vaginal Intraepithelial Neoplasia

Background

The aim of the study was to assess the effect of multicentricity on the recurrence/persistence of high-grade vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VAIN) after laser vaporization.

Methods

A retrospective cohort study was conducted on patients diagnosed with high-grade VIN/VAIN, who had undergone laser vaporization between 1997 and 2014. Recurrence/persistence rates and factors affecting recurrence/persistence were analyzed, and a life table analysis of recurrence-free intervals was conducted.

Results

Among the 65 patients, the recurrence/persistence rate following laser vaporization was 22.3 per 100 person-years, with a median time to recurrence/persistence of 31.2 months (95% confidence interval (CI): 0.0 - 71.9 months). Patients with multicentricity and unicentricity had a recurrence/persistence rate of 49.1 per 100 person-years, with a median time to recurrence/persistence of 11.4 months, and 7.4 per 100 person-years, with a median time to recurrence/persistence of 96.5 months, respectively (P = 0.0002). The difference in recurrence-free survival between the multicentricity and unicentricity groups was significant (P = 0.00035). Patients with multicentricity had a 4.7-fold higher risk of recurrence/persistence (hazard ratio (HR): 4.71, 95% CI: 1.87 - 11.88, P = 0.001). Multivariate analysis showed that multicentricity was an independent risk factor for recurrence/persistence (odds ratio (OR): 4.16, 95% CI: 1.56 - 11.06, P = 0.004).

Conclusions

Treatment of multicentric, high-grade VIN/VAIN with laser vaporization is strongly associated with treatment failure, with approximately half of patients experiencing recurrence/persistence.

Vocal Fold Granuloma: Updates and Advancements in Treatment

OBJECTIVE/HYPOTHESIS

Vocal fold granulomas (VFGs) are benign outgrowths from vocal folds with varying etiologies. If untreated, VFGs can result in mass effects on the surrounding larynx, leading to dysphagia, hoarseness of voice, and possibly dyspnea. With new advancements, novel treatment options and innovative collaborations of previous treatment modalities have started to surface.

STUDY DESIGN

This review aims to provide a world review of the current risks, etiologies, and complications surrounding VFGs, as well as discuss the current and future treatment modalities surrounding VFGs.

METHODS

Four databases (PubMed, Cochrane Library, Embase, and WoS) were searched from the earliest records until February 2023 using search terms related to VFGs. Relevant articles were assessed and analyzed to provide a broad scope of the current treatment options for VFGs.

RESULTS/CONCLUSIONS

The treatment options for VFGs run both wide and deep, ranging from conservative voice therapy to laser vaporization to surgical excision. Within each modality, variations to each technique and method of administration also play a role in maximizing the effectiveness of treatment. Overall, with more higher-powered studies, the complex interplay of treatment modalities can be further untangled to determine the ideal combination treatment for various VFGs.

Comparison of surgical procedures for benign prostatic hyperplasia of medium-volume prostates: evaluation of the causes of rehospitalization from the French National Hospital Database (PMSI-MCO)

PURPOSE

In France, transurethral resection of the prostate (TURP) is still the most commonly used surgical treatment for medium sized benign prostatic hyperplasia (BPH), but the Holmium Laser Enucleation of the Prostate (HoLEP) and laser vaporization procedures are becoming more common. For these three surgical procedures, we evaluate the initial complications, the short term (3 months) and the 4-12-month postoperative complications necessitating re-hospitalization.

METHODS

From the French national hospital data base (PMSI-MCO), all hospitalizations for BPH treatment in 2018 were extracted. We document the complications during the initial hospitalization and any subsequent rehospitalizations during the one-year postoperative period.

RESULTS

In 2018, 67,220 patients were treated for BPH: 46,242 TURP, 13,509 HoLEP and 7469 laser vaporization. Age and anticoagulation medications were similar for men treated by the three procedures, but TURP patients were more often hypertensive. Infections and hemorrhagic complications were the most common complications at the initial hospitalization: 17%, 10%, 13% for infections and 15%, 8.1%, 11% for hemorrhagic complications respectively, and TURP performed worse than the other two procedures at the initial hospitalization. During the first three months and then the subsequent nine months, there were fewer complications than initially, with little difference between the three procedures, all differences being less than 1%.

CONCLUSION

Laser vaporization techniques led to fewer complications. However, the PMSI-MCO only registers complications during hospitalizations. This study should be extended to non-hospitalized, more minor complications.

Laser vaporization compared with other surgical techniques in women with ovarian endometrioma: a systematic review and meta-analysis

OBJECTIVE

To compare outcomes after laparoscopic cystectomy versus laser vaporization in women of reproductive age with ovarian endometrioma.

EVIDENCE REVIEW

Our systematic review and meta-analysis was registered in PROSPERO (CRD42021281781) and was done according to the PRISMA 2020 checklist. Studies (published until October 2021) were identified by searching PubMed, Cochrane Library, Google Scholar, and ClinicalTrials.gov databases (key words "cystectomy", "laser vaporization", and "endometrioma"). The search was conducted independently by two investigators (L.P. and S.I.). Inclusion criteria were: women of reproductive age undergoing surgery for symptomatic endometriomas larger than 30 mm. The exclusion criteria were: women who undergo conservative treatment. Outcomes were: risk ratio for recurrence, ovarian reserve and pregnancy rates. The studies included were randomized clinical trials (RCTs) and nonrandomized clinical trials (prospective controlled, prospective cohort, retrospective studies, and other types of studies) that included a minimum of 10 patients and written in English. Tools recommended by the Cochrane Society achieved risk-of-bias assessment.

RESULTS

Totally, 874 studies were found, 9 studies were included in qualitative synthesis (822 patients). All the authors compared the efficacy and safety of cystectomy or laser vaporization in reproductive-aged women with ovarian endometrioma. The overall risk of bias for the randomized trials was 80% 'some concerns' and 20% 'low', and for the cohort studies, 50% 'some concerns' and 50% 'low'. The primary meta-analysis focused on recurrence rates (4 studies included) with no statistically significant differences found between these two interventions (RR = 0.53, 95% CI 0.24 to 1.21, P = 0.13). The next meta-analysis estimated antral follicle count (3 studies) which was significantly lower in cystectomy group (RR = - 2.56, 95% CI - 3.71 to - 1.42, P < 0.0001). Pregnancy rates were analyzed in 3 studies with no statistically significant difference (RR = 0.96, 95% CI 0.81 to 1.14, P = 0.64).

CONCLUSIONS

There was no statistical difference in the recurrence rate and pregnancy rates, but the antral follicle count was higher in the laser vaporization group. However, we need more clinical trials to make stronger recommendations.

Combining Sclerotherapy with CO2 Laser Ablation for the Laparoscopic Management of Large Endometrioma: Advantages and Pitfalls

STUDY OBJECTIVE

To demonstrate the feasibility of management of large endometrioma laparoscopically.

DESIGN

Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO₂ laser ablation and 6-month follow-up.

SETTING

The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size.^2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve.^1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future.

INTERVENTION

The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow.^5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO₂ laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1).

CONCLUSION

Laparoscopy sclerotherapy combined to CO₂ laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis.

Simulation training in transurethral resection/laser vaporization of the prostate; evidence from a systematic review by the European Section of Uro-Technology

PURPOSE

Transurethral resection (TURP) and photoselective vaporization of the prostate (PVP) constitute established surgical options to treat benign prostate hyperplasia. We investigated the current literature for simulators that could be used as a tool for teaching urologists alone or within the boundaries of a course or a curriculum.

METHODS

A literature search was performed using PubMed, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials-CENTRAL. Search terms included: Simulat*, train*, curricull*, transurethral, TUR*, vaporesect*, laser. The efficacy of different simulators and the impact of different devices, curricula and courses in training and trainee learning curves were the primary endpoints.

RESULTS

Thirty-one studies are selected and presented. Validated virtual reality TURP simulators are the UW VR, PelvicVision, Uro-Trainer, and TURPsim™. Validated synthetic TURP models are Dr. K. Forke's TURP trainer, Bristol TURP trainer, different tissue prostate models, and 3D-printed phantoms. The Myo Sim PVP and the GreenLightTM are sufficiently validated PVP simulators. Several TURP and PVP training curricula have been developed and judged as applicable. Finally, the TURP modules of the European Urology Residents Education Programme (EUREP) Hands-on Training course and the Urology Simulation Bootcamp Course (USBC) are the most basic annual TURP courses identified in the international literature.

CONCLUSIONS

Simulators and courses or curricula are valuable learning and training TURP/PVP tools. The existent models seem efficient, are not always adequately evaluated and accepted. As part of training curricula and training courses, the use of training simulators can significantly improve quality for young urologists' education and clinical practice.

Are all procedures for benign prostatic hyperplasia created equal? A systematic review on post-procedural PSA dynamics and its correlation with relief of bladder outlet obstruction

PURPOSE

To evaluate and provide a comprehensive literature review of Prostate specific antigen (PSA) dynamics after various surgical procedures for benign prostatic hyperplasia (BPH).

METHODS

A thorough PubMed database search was performed over last 30 years including terms "PSA" and various surgical procedures for BPH. PSA nadir after various procedure was evaluated. The post-operative improvement in International Prostate Symptom Score, maximum void rates and post-void residue after surgeries were recorded. An indirect correlation was made between PSA nadir and outcome of various BPH surgical procedures.

RESULTS

Enucleation procedures like simple prostatectomy and endoscopic enucleation of prostate (EEP) produced maximum drop in PSA level after surgery and were associated with the highest improvement in post-operative parameters. The PSA nadir following resection techniques like transurethral resection of prostate and Holmium laser resection of prostate and vaporization technique was variable and less robust when compared to EEP. Newer techniques like Aquablation, Rezum, Urolift, Prostate artery embolization and Temporary implantable nitinol devices (iTIND) produce relatively less reduction in PSA and lesser percentile improvement in post-operative parameters.

CONCLUSIONS

Various surgical procedures for BPH result in varying PSA nadirs level. Enucleation procedures and simple prostatectomy produce the most drastic and sustained decrease in PSA. There is a possible indirect evidence suggesting that the level of PSA nadir corresponds closely with the degree of post-operative improvement and durability of the procedure. Establishing the new PSA nadir at 3-6 months after the procedure is recommended as a part of routine surveillance for prostate cancer in eligible patients.

Prognostic outcomes and risk factors for recurrence after laser vaporization for cervical intraepithelial neoplasia: a single-center retrospective study

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is a precancerous lesion that may progress to invasive cervical cancer without intervention. We aim to examine the prognostic outcomes and risk factors for recurrence after laser vaporization for CIN 3, CIN 2 with high-risk human papillomavirus (HPV) infection, and CIN 1 persisting for more than 2 years.

METHODS

Between 2008 and 2016, a total of 1070 patients underwent cervical laser vaporization using a carbon dioxide laser. We performed a retrospective review of their medical records to assess their clinical characteristics, pathologic factors, and prognostic outcomes.

RESULTS

The mean patient age was 34 years (range 18-64 years). The preoperative diagnosis was CIN 1 in 27 patients, CIN 2 in 485 patients, and CIN 3 in 558 patients. Over a median follow-up period of 15 months, the 2-year recurrence rate was 18.9%, and the 5-year recurrence rate was 46.5%. The 2-year retreatment rate was 12.6%, and the 5-year retreatment rate was 30.5%. We diagnosed 9 patients with invasive cancer after treatment; all patients underwent combined multidisciplinary treatment, and there were no deaths during follow-up. The recurrence-free interval was correlated with patient age (hazard ratio [HR], 1.028; 95% CI 1.005-1.051; P = 0.0167), body mass index (HR, 1.052; 95% CI 1.008-1.098; P = 0.0191), and glandular involvement (HR, 1.962; 95% CI 1.353-2.846; P = 0.0004).

CONCLUSIONS

Cervical laser vaporization is effective and useful for patients with CIN who wish to preserve fertility. However, patients with glandular involvement, older age, and higher body weight require close follow-up for recurrence.

[Greenlight laser vaporization: Past, present and future?]

Greenlight laser prostate vaporization is considered a valid alternative to transurethral prostate resection (TURP) for patient with LUTS due to BPH. The current review highlights the current evidence on greenlight technique and current state of-the-art. We will review clinically relevant concerns such as size limitation, economic issues and same-day surgery options. We will also describe technological improvements overtime and its relationship with current vaporization practices.CURRENT SITUATION: Based on clinical trial Goliath, Greenlight 180W vaporization showed non-inferiority to TURP and similar mid-term functional outcomes. A benefit towards length of hospital stay, similar complication rate (below 80% at 2 years). The current laser generators (higher potency) are able to provide an ablative effect on tissue that is associated to a shorter operative time. The major advantage of greenlight laser is the same day discharge, with a low readmission rates. Greenlightlaser is more cost-effective than TURP. CONCLUSIONS: Green light laser remains as an alternativevalid option despite the technological improvementsin the field.

Total Circulating Microparticle Levels After Laparoscopic Surgical Treatment for Endometrioma: A Pilot, Prospective, Randomized Study Comparing Stripping with CO2 Laser Vaporization

STUDY OBJECTIVE

To evaluate serial generation of microparticles (MPs) after laparoscopic stripping or CO₂ laser vaporization in the surgical treatment of patients with ovarian endometrioma (OE).

DESIGN

A prospective, randomized, blinded, pilot study (Canadian Task Force classification I).

SETTING

Tertiary care university hospital from December 2014 to July 2016.

PATIENTS

Thirty women with unilateral OE undergoing laparoscopic surgery.

INTERVENTION

Patients were randomly selected to undergo either CO₂ laser vaporization (L group) or laparoscopic stripping (S group) of OE.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected before surgery and at 2 hours, 24 hours, 1 month, and 3 months after surgery. An MP generation curve after OE surgery was created. MP generation was greater in the S group than in the L group at all time points evaluated. The MP generation curve showed a significantly higher area under the curve after excisional surgery (p <.05).

CONCLUSION

The higher MP levels in the S group suggest an increased inflammation and procoagulant response after this procedure.

Reconstructive Management Options of Delayed Complications Following Bladder Outlet Surgery

PURPOSE OF REVIEW

Technological advancements in urologic endoscopy within the last decades have improved outcomes following bladder outlet reduction surgery while minimizing risks of short- and intermediate-term complications. This review aims to examine late complications of endoscopic reduction of the prostate and the various treatment options available.

RECENT FINDINGS

Urinary incontinence, ejaculatory dysfunction, urethral strictures, bladder neck contractures, and fistula formations are the most common delayed complications following bladder outlet reduction surgery. Evaluation of these complications typically involves a combination of endoscopic examination, urodynamic findings, pelvic imaging, and review of pre-existing symptoms. Treatment options range from conservative measures such as pelvic floor muscle therapy to complex reconstructive procedures including anti-incontinence surgery, urethral reconstruction, and permanent urinary diversion. Although rare, late complications of bladder outlet reduction surgery are important to recognize in order to manage appropriately. Careful evaluation involving multiple diagnostic modalities with consideration for referral to a dedicated reconstructive urologist may be warranted in complex cases.

Electrical and Optical Properties of CeNi5 Nanoscale Films

Rare earth compounds are interesting from both a theoretical point of view and for their applications. That is the reason why determining their optical and electrical properties deserves special attention. In this article, we present the conditions we obtained homogenous CeNi5 thin films of nanometer thicknesses. To achieve this goal, our method of choice was laser-induced vaporization, using short and modulated impulses, with electro-optical tuning for the quality factor. The layers that were deposited at a single laser burst had thicknesses between 1.5 and 2.5 nm, depending on the geometry of the experimental setup.Structural and compositional studies of the nanoscale films were made using XRD. The temperature dependence of electrical conductivity was also determined. The following optical properties of the specimens were computed using the Kramers-Krönig framework and discussed: absolute reflection and transmission coefficients for a single wavelength and relative ones for the wide UV-VIS-IR spectra, spectral dependence of the refractive index, and extinction coefficient as real and imaginary parts of the complex refractive index. The valence band studies were made with X-ray photoelectron spectroscopy. All these determinations were well correlated and permitted the evaluation of the energy densities of states in the deeper bands, near the Fermi energy, and at the surface states.

Management of Benign Prostatic Hyperplasia Larger than 100 ml: Simple Open Enucleation Versus Transurethral Laser Prostatectomy

Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms (LUTS) in aging men. Over the age of 60, more than a half of men have BPH and/or bothersome LUTS. Contemporary guidelines advocate surgery as the standard of care for symptomatic BPH after failure of medical therapy, where the choice of the appropriate surgical procedure depends on the prostate size. Transurethral resection of the prostate (TURP) and simple open prostatectomy (OP) have been considered for decades the reference-standard techniques for men with prostate smaller and larger than 80 ml, respectively. However, both procedures are potentially associated with considerable perioperative morbidity which prompted the introduction of a variety of minimally invasive surgical techniques with comparable long-term outcomes compared to TURP and OP. Nevertheless, the management of prostates larger than 100 ml remains a clinical challenge. Transurethral anatomical enucleation of the prostate utilizing different laser energy represents an excellent alternative concept in transurethral BPH surgery. These procedures gained popularity and demonstrated similar outcomes to OP with the advantages of favorable morbidity profiles and shorter catheter time and hospital stay. Despite the fact that OP remains a viable treatment option for patients with bothersome LUTS secondary to very large prostates, this procedure has been to a large extent replaced by these emerging enucleation techniques. Given the advent of surgical alternatives, the current review presents an evidence-based comparison of the efficacy and safety profile of the currently available transurethral laser techniques with the standard OP for the management of BPH due to adenomas larger than 100 ml.

Ambient Molecular Analysis of Biological Tissue Using Low-Energy, Femtosecond Laser Vaporization and Nanospray Postionization Mass Spectrometry

Direct analysis of plant and animal tissue samples by laser electrospray mass spectrometry (LEMS) was investigated using low-energy, femtosecond duration laser vaporization at wavelengths of 800 and 1042 nm followed by nanospray postionization. Low-energy (<50 μJ), fiber-based 1042 nm LEMS (F-LEMS) allowed interrogation of the molecular species in fresh flower petal and leaf samples using 435 fs, 10 Hz bursts of 20 pulses from a Ytterbium-doped fiber laser and revealed comparable results to high energy (75-1120 μJ), 45 fs, 800 nm Ti:Sapphire-based LEMS (Ti:Sapphire-LEMS) measurements. Anthocyanins, sugars, and other metabolites were successfully detected and revealed the anticipated metabolite profile for the petal and leaf samples. Phospholipids, especially phosphatidylcholine, were identified from a fresh mouse brain section sample using Ti:Sapphire-LEMS without the application of matrix. These lipid features were suppressed in both the fiber-based and Ti:Sapphire-based LEMS measurements when the brain sample was prepared using the optimal cutting temperature compounds that are commonly used in animal tissue cryosections.

Photodynamic Therapy Combined with CO(2) Laser Vaporization on Disseminated Superficial Actinic Porokeratosis: A Report of 2 Cases on the Face

Disseminated superficial actinic porokeratosis (DSAP) is a skin condition that usually shows a poor response to different modalities of treatment. Herein we describe 2 patients with DSAP on the face, each treated with 3 to 4 sessions of photodynamic therapy combined with laser vaporization.

Long-Term Follow-Up Results of Photoselective Vaporization of the Prostate with the 120 W Greenlight HPS Laser for Treatment of Benign Prostatic Hyperplasia

Purpose

With the use of 12 months of follow-up data, this study was conducted to evaluate the efficacy of photoselective vaporization of the prostate (PVP) with the 120 W Greenlight high performance system (HPS) laser for the treatment of symptomatic benign prostatic hyperplasia.

Materials and Methods

Data were collected from 104 patients who were diagnosed with benign prostatic hyperplasia and who underwent PVP with the 120 W Greenlight HPS Laser. Postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum urinary flow rate (Qmax), and postvoid residual volume (PVR), were assessed and compared with preoperative baseline values.

Results

The mean age of the patients was 71.1±7.7. The baseline mean prostate-specific antigen level was 3.8±2.7 ng/ml, the mean prostate size was 43.9±20.6 g, the mean preoperative IPSS was 18.4±8.5, the mean QoL score was 4.1±1.0, the mean Qmax was 9.9±5.5 ml/sec, and the mean PVR was 89.6±207.1 ml. During surgery, the mean operation time was 21.8±11.3 minutes, the mean lasing time was 16.9±10.5 minutes, and the mean total applied energy was 170,068±63,181 J. At 1 month, significant improvements were observed in total IPSS (11.5±6.7, p<0.05), voiding symptom score (6.1±5.4, p<0.05), and QoL score (2.2±1.5, p<0.05); however, there were no significant improvements in storage symptom score (4.8±3.8, p=0.06), Qmax (12.6±10.2, p=0.06), and PVR (40.1±30.5, p=0.41). However, 3 months after surgery, all postoperative follow-up parameters showed significant improvements, and the 6- and 12-month data showed sustained improvement of postoperative follow-up parameters.

Conclusions

Significant improvements were observed in subjective and objective voiding parameters, which were evident at 3 months after PVP and were sustained throughout a period of 12 months after PVP.