New techniques for laser prostatectomy: an update
Identifieur interne : 001D44 ( Istex/Corpus ); précédent : 001D43; suivant : 001D45New techniques for laser prostatectomy: an update
Auteurs : Doreen E. Chung ; Alexis E. TeSource :
- Therapeutic advances in urology [ 1756-2872 ] ; 2009-06.
English descriptors
- KwdEn :
- Anticoagulation, Benign prostatic hyperplasia, Bladder, Blood transfusion, Catheterization, Catheterization time, Chung, Coagulation, Enucleation, Gilling, High power, Holep, Holmium, Holmium laser enucleation, Ipss, Kuntzman, Large prostates, Laser, Laser prostatectomy, Laser system, Laser therapy, Laser vaporization, Malek, Morbidity, Open prostatectomy, Operative time, Orifice, Photoselective, Photoselective vaporization, Postoperative, Postoperatively, Prostate, Prostate tissue, Prostatectomy, Prostatic, Qmax, Randomized, Reoperation, Resection, Ruszat, Sandhu, Therapeutic advances, Thulium, Thulium laser, Transfusion, Transurethral, Transurethral resection, Turp, Urol, Urology, Vaporization.
- Teeft :
- Anticoagulation, Benign prostatic hyperplasia, Bladder, Blood transfusion, Catheterization, Catheterization time, Chung, Coagulation, Enucleation, Gilling, High power, Holep, Holmium, Holmium laser enucleation, Ipss, Kuntzman, Large prostates, Laser, Laser prostatectomy, Laser system, Laser therapy, Laser vaporization, Malek, Morbidity, Open prostatectomy, Operative time, Orifice, Photoselective, Photoselective vaporization, Postoperative, Postoperatively, Prostate, Prostate tissue, Prostatectomy, Prostatic, Qmax, Randomized, Reoperation, Resection, Ruszat, Sandhu, Therapeutic advances, Thulium, Thulium laser, Transfusion, Transurethral, Transurethral resection, Turp, Urol, Urology, Vaporization.
Abstract
Traditionally, the gold standard for treatment of BPH has been the electrocauterybased TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.
Url:
DOI: 10.1177/1756287209105436
Links to Exploration step
ISTEX:848F2367A20D0221B6E43B6CC3CBA0905AF91C27Le document en format XML
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Te</name><affiliation><mods:affiliation></mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: aet2005@med.cornell.edu</mods:affiliation></affiliation><affiliation><mods:affiliation>Associate Professor of Urology, Director of the Brady Prostate Center, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA, aet2005@med.cornell.edu</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:848F2367A20D0221B6E43B6CC3CBA0905AF91C27</idno><date when="2009" year="2009">2009</date><idno type="doi">10.1177/1756287209105436</idno><idno type="url">https://api.istex.fr/document/848F2367A20D0221B6E43B6CC3CBA0905AF91C27/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">001D44</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">001D44</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">New techniques for laser prostatectomy: an update</title><author><name sortKey="Chung, Doreen E" sort="Chung, Doreen E" uniqKey="Chung D" first="Doreen E." last="Chung">Doreen E. Chung</name><affiliation><mods:affiliation>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</mods:affiliation></affiliation><affiliation><mods:affiliation>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</mods:affiliation></affiliation></author><author><name sortKey="Te, Alexis E" sort="Te, Alexis E" uniqKey="Te A" first="Alexis E." last="Te">Alexis E. Te</name><affiliation><mods:affiliation></mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: aet2005@med.cornell.edu</mods:affiliation></affiliation><affiliation><mods:affiliation>Associate Professor of Urology, Director of the Brady Prostate Center, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA, aet2005@med.cornell.edu</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Therapeutic advances in urology</title><idno type="ISSN">1756-2872</idno><idno type="eISSN">1756-2880</idno><imprint><publisher>SAGE Publications</publisher><pubPlace>Sage UK: London, England</pubPlace><date type="published" when="2009-06">2009-06</date><biblScope unit="volume">1</biblScope><biblScope unit="issue">2</biblScope><biblScope unit="page" from="85">85</biblScope><biblScope unit="page" to="97">97</biblScope></imprint><idno type="ISSN">1756-2872</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1756-2872</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Anticoagulation</term><term>Benign prostatic hyperplasia</term><term>Bladder</term><term>Blood transfusion</term><term>Catheterization</term><term>Catheterization time</term><term>Chung</term><term>Coagulation</term><term>Enucleation</term><term>Gilling</term><term>High power</term><term>Holep</term><term>Holmium</term><term>Holmium laser enucleation</term><term>Ipss</term><term>Kuntzman</term><term>Large prostates</term><term>Laser</term><term>Laser prostatectomy</term><term>Laser system</term><term>Laser therapy</term><term>Laser vaporization</term><term>Malek</term><term>Morbidity</term><term>Open prostatectomy</term><term>Operative time</term><term>Orifice</term><term>Photoselective</term><term>Photoselective vaporization</term><term>Postoperative</term><term>Postoperatively</term><term>Prostate</term><term>Prostate tissue</term><term>Prostatectomy</term><term>Prostatic</term><term>Qmax</term><term>Randomized</term><term>Reoperation</term><term>Resection</term><term>Ruszat</term><term>Sandhu</term><term>Therapeutic advances</term><term>Thulium</term><term>Thulium laser</term><term>Transfusion</term><term>Transurethral</term><term>Transurethral resection</term><term>Turp</term><term>Urol</term><term>Urology</term><term>Vaporization</term></keywords><keywords scheme="Teeft" xml:lang="en"><term>Anticoagulation</term><term>Benign prostatic hyperplasia</term><term>Bladder</term><term>Blood transfusion</term><term>Catheterization</term><term>Catheterization time</term><term>Chung</term><term>Coagulation</term><term>Enucleation</term><term>Gilling</term><term>High power</term><term>Holep</term><term>Holmium</term><term>Holmium laser enucleation</term><term>Ipss</term><term>Kuntzman</term><term>Large prostates</term><term>Laser</term><term>Laser prostatectomy</term><term>Laser system</term><term>Laser therapy</term><term>Laser vaporization</term><term>Malek</term><term>Morbidity</term><term>Open prostatectomy</term><term>Operative time</term><term>Orifice</term><term>Photoselective</term><term>Photoselective vaporization</term><term>Postoperative</term><term>Postoperatively</term><term>Prostate</term><term>Prostate tissue</term><term>Prostatectomy</term><term>Prostatic</term><term>Qmax</term><term>Randomized</term><term>Reoperation</term><term>Resection</term><term>Ruszat</term><term>Sandhu</term><term>Therapeutic advances</term><term>Thulium</term><term>Thulium laser</term><term>Transfusion</term><term>Transurethral</term><term>Transurethral resection</term><term>Turp</term><term>Urol</term><term>Urology</term><term>Vaporization</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Traditionally, the gold standard for treatment of BPH has been the electrocauterybased TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>laser</json:string><json:string>prostatectomy</json:string><json:string>turp</json:string><json:string>holep</json:string><json:string>laser prostatectomy</json:string><json:string>urol</json:string><json:string>resection</json:string><json:string>transurethral</json:string><json:string>prostate</json:string><json:string>urology</json:string><json:string>vaporization</json:string><json:string>postoperative</json:string><json:string>prostatic</json:string><json:string>holmium</json:string><json:string>randomized</json:string><json:string>qmax</json:string><json:string>thulium</json:string><json:string>enucleation</json:string><json:string>ipss</json:string><json:string>bladder</json:string><json:string>thulium laser</json:string><json:string>transfusion</json:string><json:string>ruszat</json:string><json:string>catheterization</json:string><json:string>transurethral resection</json:string><json:string>photoselective</json:string><json:string>malek</json:string><json:string>coagulation</json:string><json:string>large prostates</json:string><json:string>holmium laser enucleation</json:string><json:string>open prostatectomy</json:string><json:string>reoperation</json:string><json:string>operative time</json:string><json:string>laser vaporization</json:string><json:string>morbidity</json:string><json:string>therapeutic advances</json:string><json:string>sandhu</json:string><json:string>postoperatively</json:string><json:string>kuntzman</json:string><json:string>laser therapy</json:string><json:string>gilling</json:string><json:string>photoselective vaporization</json:string><json:string>orifice</json:string><json:string>benign prostatic hyperplasia</json:string><json:string>high power</json:string><json:string>catheterization time</json:string><json:string>prostate tissue</json:string><json:string>blood transfusion</json:string><json:string>laser system</json:string><json:string>anticoagulation</json:string><json:string>chung</json:string><json:string>laser energy</json:string><json:string>symptom score</json:string><json:string>transurethral laser enucleation</json:string><json:string>patients randomized</json:string><json:string>reoperation rate</json:string><json:string>laser group</json:string><json:string>hyperplasia</json:string><json:string>prospective study</json:string><json:string>laser systems</json:string><json:string>durable outcomes</json:string><json:string>blood loss</json:string><json:string>consecutive patients</json:string><json:string>durable improvements</json:string><json:string>prostate size</json:string><json:string>retrograde ejaculation</json:string><json:string>prostate volume</json:string><json:string>traditional turp</json:string><json:string>laser beam</json:string><json:string>postoperative catheterization</json:string><json:string>procedure time</json:string><json:string>turp group</json:string><json:string>clinical data</json:string><json:string>lobe</json:string></teeft></keywords><author><json:item><name>Doreen E. Chung</name><affiliations><json:string>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</json:string><json:string>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</json:string></affiliations></json:item><json:item><name>Alexis E. Te</name><affiliations><json:null></json:null><json:string>E-mail: aet2005@med.cornell.edu</json:string><json:string>Associate Professor of Urology, Director of the Brady Prostate Center, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA, aet2005@med.cornell.edu</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>surgical therapy and new technology</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>benign prostatic hyperplasia (BPH)</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>prostate cancer</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>medical and hormonal therapy</value></json:item></subject><articleId><json:string>10.1177_1756287209105436</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>review-article</json:string></originalGenre><abstract>Traditionally, the gold standard for treatment of BPH has been the electrocauterybased TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. 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However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.</p></abstract><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>surgical therapy and new technology</term></item><item><term>benign prostatic hyperplasia (BPH)</term></item><item><term>prostate cancer</term></item><item><term>medical and hormonal therapy</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2009-06">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/848F2367A20D0221B6E43B6CC3CBA0905AF91C27/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="review-article" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sptau</journal-id><journal-id journal-id-type="publisher-id">TAU</journal-id><journal-title>Therapeutic Advances in Urology</journal-title><issn pub-type="ppub">1756-2872</issn><publisher><publisher-name>SAGE Publications</publisher-name><publisher-loc>Sage UK: London, England</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/1756287209105436</article-id><article-id pub-id-type="publisher-id">10.1177_1756287209105436</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>New techniques for laser prostatectomy: an update</article-title></title-group><contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Chung</surname><given-names>Doreen E.</given-names></name><aff>Fellow In Voiding
Dysfunction, Department
of Urology, Weill Cornell
Medical College, 1300 York
Ave, Box 261, Suite F9
West, New York, NY 10065,
USA</aff></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Te</surname><given-names>Alexis E.</given-names></name><aff>Associate Professor of
Urology, Director of the
Brady Prostate Center,
Weill Cornell Medical
College, 1300 York Ave,
Box 261, Suite F9 West,
New York, NY 10065, USA, <email xlink:type="simple">aet2005@med.cornell.edu</email></aff></contrib></contrib-group><pub-date pub-type="ppub"><month>06</month><year>2009</year></pub-date><volume>1</volume><issue>2</issue><fpage>85</fpage><lpage>97</lpage><abstract><p>Traditionally, the gold standard for treatment of BPH has been the electrocauterybased TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.</p></abstract><kwd-group><kwd>surgical therapy and new technology</kwd>
<kwd>benign prostatic hyperplasia (BPH)</kwd>
<kwd>prostate cancer</kwd>
<kwd>medical and hormonal therapy</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Reviews</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>85
ReviewNew
techniques for laser prostatectomy: an update
SAGE Publications, Inc.200910.1177/1756287209105436
Doreen E.Chung
Brady Prostate Center, Weill Cornell Medical College,
1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA
Alexis E.Te
Department of Urology, Weill Cornell Medical College,
1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA, aet2005@med.cornell.edu
Traditionally, the gold standard for treatment of BPH has been the electrocauterybased
TransUrethral Resection of the Prostate (TURP). However, the number of laser
techniques being performed is rapidly increasing. Potential advantages of
laser therapy over traditional TURP include decreased morbidity and shorter
hospital stay. There are several techniques for laser prostatectomy that
continue to evolve. The main competing techniques are currently the Holmium
Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy.
The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results
similar to TURP and is suitable for patients on anticoagulation as well as
those with large prostates. Disadvantages of this technique are the high
learning curve and requirement of a morcellator. When used to treat BPH,
studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe
and effective in patients with large prostates and in those taking oral anticoagulation.
Several studies have compared these two techniques to TURP. Frequently reported
advantages of the HoLEP over the 80W laser prostatectomy are the availability
after the procedure of a pathology specimen and ability to remove a higher
percentage of prostate tissue during resection. However, the transurethral
laser enucleation of the prostate addresses these concerns and has shown
to have durable outcomes at 2-year follow-up. Two new laser systems and techniques,
the thulium laser and the 980nm laser, have emerged recently. However, clinical
data from these procedures are in their infancy and large long-term studies
are required.
surgical therapy and new technology
benign prostatic hyperplasia (BPH)
prostate cancer
medical and hormonal therapy
Introduction
Lasers have undergone an evolution from theory to practical application. One
application is the treatment of symptomatic benign prostatic hyperplasia,
or BPH, via laser prostatectomy. Traditionally, the gold standard for treatment
of BPH is the electrocautery-based TransUrethral Resection of the Prostate
(TURP). TURP, how- ever, is associated with complications and side effects,
including fluid absorption, electrolyte imbalance, intraoperative and postoperative
bleeding, and inadequate resection. Laser ther- apy has several advantages
over standard TURP, including technical simplicity and the absence or minimization
of complications such as intraoperative fluid absorption and bleeding. Laser
therapy may also result in a shorter hospital stay and shorter recovery. Less
bleeding and irrigant absorption theoretically allows laser
prostatectomy
to treat larger glands with less physiologic stress, suggesting a role for
laser therapy in patients with a high burden of coexist- ing medical disease.
Recent estimates suggest an increasing number of practicing urologists are
in fact already performing laser prosta- tectomies on patients with symptomatic
BPH, and this number is certain to keep increasing. Furthermore, the techniques
and lasers used for laser prostatectomy are constantly evolving. This review
is an update on current and new techni- ques for laser prostatectomy. Evolution
of laser therapy A variety of lasers have been developed to treat benign prostatic
hyperplasia (BPH). Each has its own unique optical characteristics that
86
have
resulted in significantly different clinical outcomes. Nd:YAG laser During
the early 1990s, the 1064 nm wavelength Neodymium Yttrium Aluminum Garnet
(Nd:YAG) laser was used for a technique known as Visual Laser Ablation of
the Prostate (VLAP). Close to the infrared portion of the electromagnetic
spectrum, the Nd:YAG wave- length is poorly absorbed by both water and hemoglobin
and is transmitted as a free beam through the liquid endoscopic environment
with little or no diminution of energy. Because it is poorly absorbed by tissue
water, it has a very long absorption length in tissue, penetrating more deeply
into tissue than other laser wave- lengths used in surgery. The predominant
laser- tissue interaction in surgical applications is absorption of laser
light energy and subsequent conversion to heat or thermal energy. The rela-
tively slow and nonselective absorption of Nd:YAG laser energy by melanin,
pigmented tissues, and proteins translates into a relatively gradual transfer
of thermal energy to tissues, pro- ducing slow tissue cooking or coagulation
as the predominant effect. The Nd:YAG laser was an excellent tissue coagulator.
VLAP became popular among urologists because it represented a low morbidity
procedure com- pared to electrocautery-based transurethral resection of the
prostate (TURP). Early data demonstrated good short-term subjective and objective
outcomes. Despite low initial morbid- ity, the VLAP procedure developed a
reputation for long-term dysuria and urinary retention requiring extended
postoperative catheterization. While the Nd:YAG laser was capable of reaching
power outputs as high as 120 W in continuous wave mode, its predominant coagulative
effect on tissue, leading to slough and resorption, resulted in prolonged
postoperative catheteriza- tion and dysuria. As a result, early during the
VLAP era, it became evident that this coagulative laser could not unseat the
gold standard of care, the electrocautery TURP (Te 2004). High power 980 nm
laser One new laser system with similar wavelength characteristics to the
Nd:YAG laser is the diode powered 980nm laser system. The current system has
power characteristics capable of up
to
150 W and the systems available (Biolitec, Inc, NJ) allow a continuous wave
mode to a flex- ible and customizable pulsing regime. This system allows either
a side- or endfire fiber to be utilized. The 980 nm wavelength is not in the
visible spectrum and has an aiming beam to allow visualization of target tissue.
While it is commercially available for application with laser prostatectomy
and data in animal studies suggest it may be useful, clinical data regarding
this tech- nology is scarce (Johnson et al. 1992). Holmium:YAG laser The next
step in the evolution of laser therapy, the 2140nm wavelength holmium:YAG
solid state laser, appeared poised to better achieve an electrocautery TURP-like
result (Kabalin 1995; Johnson et al. 1992a; 1992b). In contrast to the Nd:YAG
laser's deep tissue penetration, the hol- mium laser wavelength penetrates
less than 500mm into tissue. It is highly absorbed in water, and can be used
for tissue cutting and vaporization. The high absorption of the Ho:YAG laser
beam in the aqueous irrigant means that close contact between the optical
fiber and the tissue must be constantly main- tained for efficient tissue
vaporization. Gilling et al. first described the use of the Ho:YAG laser in
a side firing mode (Gilling et al. 1995). The first studies of Holmium Laser
Ablation of the Prostate (HoLAP) described suc- cessful early removal of catheters
and good clin- ical outcomes with this `vaporizing' wavelength, either alone
or combined with the Nd:YAG laser. While the laser was able to achieve vaporization,
removal of large tissue volumes was tedious and time-consuming since true
vaporization only occurred in thin layers with a relatively thin underlying
coagulation zone. Recently, a 100 W side firing holmium laser system has been
released and promoted as an ablative treatment for small glands. The Holmium
laser technique was further refined by directly incising and mobilizing the
prostatic lobes in a manner familiar to resection- ists, with clinical results
in fact rivaling those of electrocautery TURP (Mackey et al. 1998). The Holmium
Laser Enucleation of the Prostate (HoLEP) approach takes advantage of the
cut- ting capabilities of the Ho:YAG laser. The Ho:YAG laser is used to make
precise incisions in prostate tissue to separate lobes of adenoma
87
from
the prostatic capsule. Next the lobes are pushed into the bladder. The tissue
is then extracted by an evacuator or by pulling pieces out manually. To save
time, special morsellators cut and aspirate pieces of prostate tissue. Average
operative times typically range from 60 to 80 minutes in the hands of well-experienced
sur- geons and are comparable to TURP. Hemostasis is well controlled. The
major disadvantage of the HoLEP techni- que, however, lies with the associated
high learn- ing curve; a surgeon must perform an estimated 20 to 25 procedures
in a short period of time to gain proficiency. Prostatic perforations may
occur during the first few cases or even over an extended period of time if
infrequently per- formed. There is also a small but finite risk of bladder
perforation requiring open cystotomy closure due to the need for a morcellator.
As a result, the HoLEP procedure has had lower acceptance in the urology community
than other systems. However, it is a new technology that will still require
scrutiny and long-term assessment. The largest series to date was repo- rted
by Vavassori et al. who described 3-year data on 330 consecutive patients
(Vavassori et al. 2008). They found the procedure to be safe, effective, and
durable at 3 years. Gilling et al. published the series with the longest follow-up
to date (Gilling et al. 2008). Thirty-eight patients were evaluated with a
mean follow-up time of 6 years. One patient required reoperation and over-
all 92% of patients were still satisfied or extre- mely satisfied with their
outcome. One advantage of HoLEP is that the procedure can be performed safely
on patients on anticoa- gulant therapy or with bleeding disorders. Elzayat
et al. performed the procedure on 83 patients with bleeding disorders or on
oral anticoagulant therapy and found the procedure to be safe and effective
(Elzayat et al. 2006). However, one patient required intraoperative platelet
transfu- sion and seven required blood transfusion early in the postoperative
period due to hematuria coinciding with restarting oral anticoagulant therapy.
Overall, however there were no major operative or postoperative complications
or thromboembolic events. As mentioned previously, for surgical treatment
of BPH, TURP remains the gold standard. Comparative studies have been done
to compare the outcomes of HoLEP to those of TURP.
Montorsi
et al. looked at outcomes of 100 patients randomized to HoLEP and TURP (Montorsi
et al. 2008). HoLEP and TURP were equally effective for relieving obstruction
and lower urinary tract symptoms. HoLEP was associated with shorter catheterization
time and hospital stay. At 1 year of follow-up complica- tions were similar
in the 2 groups. Ahyai et al. randomized 200 patients with prostate size less
than 100 cc to either HoLEP or TURP. After 2 and 3 years of follow-up, AUA
symptom score and post-void residual were similar in the two groups and late
complications were equally low. The authors concluded that at 3 years of follow-
up, outcomes were similar (Ahyai et al. 2007). One advantage of HoLEP over
TURP is that the procedure is suitable for large prostates. Outcomes after
treatment may rival those of open prostatectomy, the gold standard treatment
for BPH in large prostates. HoLEP has been compared in several studies to
open prostatect- omy. Naspro et al. evaluated 80 patients random- ized to
HoLEP or open prostatectomy 2 years following treatment (Naspro et al. 2006).
Hospital stay, blood loss, and blood transfusion rate were lower in the HoLEP
group but opera- tive time was shorter in the open prostatectomy group. Improvements
in urodynamic and uro- flowmetry were similar at 24 months. Kuntz et al. randomized
120 patients with prostates greater than 100 g to either HoLEP or open pros-
tatectomy (Kuntz et al. 2008). At 5 years, improve- ments in micturition were
equivalent and reoperation rates were similarly low. Elzayat et al. published
a series of 225 patients with pro- state size greater than 80g who underwent
HoLEP. The authors found the procedure to be safe and effective (Elzayat and
Elhilali 2006). The HoLEP is a safe and effective procedure for treatment
of BPH with durable outcomes. The procedure is also safer than and just effective
as effective as TURP and open prostatectomy in patients on anticoagulation
and in those with large prostates. Unfortunately the HoLEP is also limited
by learning curve and the need for using a morsellator. One may argue that
the thu- lium laser represents the next phase in evolution of the HoLEP procedure.
Thulium laser The thulium laser is the newest laser to be intro- duced for
treatment of BPH. It is a continuous
88
wave
laser device that emits a wavelength of 2013 nm, close to the peak absorption
of water (Bach et al. 2007; Fried and Murray, 2005). Because the laser energy
is quickly absorbed by interstitial water, which is present in all tissues,
the laser effect is not affected by tissue color or vascularization. As the
wavelength of the thulium laser is closer to the peak of the absorption spec-
trum of water than that of the holmium laser, absorption by tissue is theoretically
even more pronounced. Compared to the Ho:YAG laser, there should be increased
tissue vaporization per unit time (Wendt-Nordahl et al. 2008). Hemostasis
achieved is comparable to that of the Ho:YAG laser. The technique used with
this laser is a combination of vaporization and resection is achieved. Small
tissue chips are cre- ated then evacuated, without requirement of a morsellator.
Wendt-Nordahl et al. conducted a systematic ex vivo evaluation of the thulium
laser in order to compare the procedure to transurethral resec- tion of the
prostate (TURP) and the potassium- titanyl-phosphate (KTP) laser as reference
standard methods (Wendt-Nordahl et al. 2008). The group found that the 2 mm
continuous wave thulium laser offered a higher tissue ablation capacity and
similar hemostatic properties as those of the KTP laser. In comparison to
TURP both tissue ablation and the bleeding rate were significantly reduced.
Bach et al. demonstrated safety and efficacy of the thulium laser by performing
the procedure on 54 patients with BPH (Bach et al. 2007). Tissue ablation
was 1.5 g per minute. Catheterization time was 1.7 days. Qmax signifi- cantly
improved from 4.2 to 20.1 ml on average. PVR decreased from 86 to 12 ml. International
Prostate Symptom Score (IPSS) and QoL-Score improved from 19.8 to 6.9 and
4 to 1, respec- tively. No patient required blood transfusion or re-hospitalization.
Xia et al. conducted a comparison study to deter- mine safety and efficacy
of the thulium laser where 100 patients were randomized to TURP or thulium
laser resection of the prostate- tangerine technique (TmLRP-TT) (Xia et al.
2007). TmLRP-TT is a procedure that uses thu- lium laser fiber to dissect
whole prostatic lobes off the surgical capsule, similar to peeling a tanger-
ine. In comparison to TURP, TmLRP-TT had decreased catheterization time (45.6
versus
87.4
hours), decreased hospital stay (115.1 versus 161.1 hours), and caused less
of a drop in hemoglobin (0.92 versus 1.46 g/dL). Procedure time, improvement
in subjective symptom scores, improvement in flow rate, and improve- ment
in PVR were equivalent between the groups. So far the results using the thulium
laser are promising. However, more large-scale studies are required to confirm
safety and efficacy. KTP or 532 nm wavelength laser Another laser undergoing
continuous evolution is the potassium-titanyl-phosphate (KTP) laser. Doubling
the frequency of pulsed Nd:YAG laser energy with a KTP crystal led to the
crea- tion of a 532 nm wavelength laser with substan- tially different tissue
interaction properties compared to its parent (Kuntzman et al. 1996). Unlike
the Nd:YAG wavelength, the KTP wave- length is selectively absorbed by hemoglobin
which acts as an intracellular chromophore. KTP laser energy is transparently
delivered through a fluid medium, such as water, into the cell where it is
absorbed by hemoglobin, then rapidly heated, leading to rapid vaporization
of tissue. This in addition to the wavelength's short optical penetration
into tissue confines high power laser energy to a superficial layer of prostatic
tissue that is vaporized rapidly and hemostatically with only a 1–2
mm rim of coagu- lation. The thin coagulation zone arises as a result of the
quasi-continuous emission charac- teristics of the KTP laser: typically, continual
irradiation of a single point causes heat to diffuse into deeper tissue layers,
creating coagulation wherever there is enough convection thermal energy for
protein denaturation but insufficient energy for vaporization. These selective
charac- teristics led to the use of the KTP laser in prostatectomy being coined
as `Photoselective Vaporization of the Prostate' (PVP). Historically, the
initial trials involved the compar- ison of the KTP laser against the Nd:YAG
laser in 41 canines (Kuntzman et al. 1996). Both techniques were hemostatic
in nature, with no irrigant absorption detected. KTP laser vaporiza- tion
produced a prostatic defect with a mean dia- meter of 3.0 and 2.4 cm at 2
days and 8 weeks postoperatively, respectively. Statistically smaller defects
were produced by Nd:YAG laser vaporization (2.0 and 1.4 cm, respectively)
and coagulation (0.5 and 0.9 cm, respectively). No dog treated with KTP laser
vaporization was
89
incontinent
or developed urinary retention post- operatively. The use of the KTP laser
thus appeared safe and effective in small-scale animal series. Nd:YAG/KTP
laser hybrid Low power KTP lasers were initially used in con- junction with
older Nd:YAG lasers. The former provided ancillary cutting, sculpting, or
incising capabilities while the latter induced tissue loss through coagulative
necrosis. Studies showed that durable improvements in Qmax, PVR, and AUA symptom
score could be achieved (Carter et al. 1999; Shingleton et al. 1999; Kollmorgen
et al. 1996). However, a longer period of time was required following surgery
to achieve maximum improvement compared to traditional TURP, a reflection
of the lack of tissue debulking of the laser. In addition the lower power
of the KTP laser limited its utility. 60 W KTP laser Experiments with a higher
power 60 W KTP laser began with both in vivo canine studies as well as cadaveric
canine and human trials (Kuntzman et al. 1997). These studies proved the ability
of the KTP laser to vaporize tissue while minimizing accompanying coagulation
effects. The first human trials with the 60 W KTP laser came in a series of
ten patients described by Malek et al. (1998). No patients suffered postoperative
TUR syndrome or urinary retention; in fact, all patients were catheter-free
in less than 24 hours after the procedure. Patients experienced a significant
improvement in Qmax (142%) by 24 hours postoperatively. Though the follow-up
described was preliminary in nature, initial results have suggested enduring
results in terms of Qmax, mean AUA symptom score, and mean PVR at the 3 month
follow-up period. Mean operative time was recorded at 29 minutes. The first
human trials with the 60 W KTP laser were followed by a larger series of 55
patients in 2000 (Malek et al. 2000). The 2 year experience with the higher
powered KTP laser again corro- borated initial findings. Patients experienced
statistically significant, enduring improvements in postoperative AUA symptom
score (mean = 14.82% improvement), Qmax (mean = 29.1 ml/ sec – 278%
improvement), and PVR (27 ml, 75% improvement) at 2 year follow-up, com- paring
favorably with published results for
conventional
transurethral resection of the pros- tate. Mean operative time was 44 minutes.
All patients in the series were catheter free 24 hours after the procedure; none required recathe- terization and none experienced TUR syndrome. Hematuria
was negligible despite the use of anti- platelet agents by many patients.
A 9% incidence of retrograde ejaculation at 2 year follow-up was noted, an
expected side effect given the authors' deliberate attempt to widely resect
the bladder neck. These results demonstrated that prostatect- omy with the
60 W KTP laser was as effective as conventional TURP and in fact demonstrated
postoperative complications comparable to TURP and even to other laser therapies,
such as Ho:YAG. 80 W KTP laser Despite the effectiveness of the 60 W KTP laser
in prostatectomy, its speed of vaporization, which is less than ideal, inherently
limited the size of prostate which could be resected given time con- straints.
The next logical improvement therefore lay in increasing laser power to speed
tissue abla- tion. It is interesting to note that to preserve a thin coagulation
zone while still maintaining high vaporization efficiency, a unique laser
pul- sing technology was incorporated into the 80W high power KTP laser system.
A high frequency modulation of laser light generates a continuous stream of
short micro-pulses with a duration of 4.5 ms and a peak power of 280 W, that
is, 3.5 times the average laser power of regular 80 W laser. The short duration
of the micro-pulses does not allow time for heat to diffuse from the superficial
layer, thus confining energy to a small volume of tissue, in a situation referred
to as ther- mal confinement. As each micro-pulse generates a very fast temperature
increase inside tissue, the tissue water is not only rapidly vaporized but
the surrounding tissue matrix is torn apart, allowing for efficient removal
of prostatic tissue. Continuous bladder irrigation is thus required to cool
the tissue as well as to provide a clear aqu- eous medium for laser light
to transmit to target tissue without energy loss. Optimal outcome of these
effects are technique dependent as well as target tissue composition dependent.
The first experiments with a higher powered (80 W) KTP laser began with ex
vivo animal models (Reich et al. 2004). Twenty perfused por- cine kidneys
were used as a model for human prostatic tissue. High power KTP laser resection
90
was
compared to high frequency current, i.e. TURP-like, resection. The 80 W KTP
laser tech- nique showed a statistically significant decrease in hemorrhage
(p50.0001) compared to tradi- tional TURP-like resection, demonstrating that
essentially bloodless ablation of tissue could occur. Hai and Malek presented
the first human experi- ence with 80 W KTP laser prostatectomy (Hai and Malek
2003). Ten patients were followed for one year after their prostatectomy in
a pilot study. Patients experienced statistically signifi- cant improvements
in AUA symptom score (23.2–2.6), quality of life (QOL) scores (4.3– 0.5), Qmax (10.3–30.7 ml/sec), and PVR (137.6–3 ml). No patient
experienced postopera- tive urinary retention, infection, incontinence, or
erectile dysfunction; none subsequently devel- oped bladder neck contractures
or urethral stricture. Two patients in fact did not require postoperative
catheterization at all. Only one patient, on active anticoagulation, experienced
mild transient postoperative hematuria requiring recatheterization for 24
hours. The mean opera- tive time was 19.8 minutes. Te et al. have presented
the first large, multicenter series on the use of 80 W KTP in laser prostatect-
omy for 145 patients with long-term follow-up (Te et al. 2004). Of note, this
experience repre- sented the initial laser experience of this techno- logy
with these centers, testing ease of use. Significant and durable improvements
in AUA Symptom Index (AUA SI) scores, QOL scores, Qmax, and PVR were demonstrated
up to 12 months postoperatively. Mean AUA symptom scores declined from 24
to 1.8 at 12 months; mean QOL scores improved from 4.3 to 0.4, Qmax from 7.7
to 22.8 ml/sec, PVR volume from 114.2 to 7.2 ml. Mean prostate volume, as
determined by ultrasound, decreased from 54.6 to 34.4 ml. Mean operative time
was 36 minutes, and no patient required a blood transfusion. More than 30%
of patients were sent home with- out a catheter; those with postoperative
catheters had them removed in a mean of 14 hours. Reported morbidities were
generally minor. Eight per cent of patients experienced mild- to-moderate
dysuria lasting more than 10 days. Eight per cent had transient hematuria,
and 3% had post-operative retention. Among the 56 men who were potent prior
to the procedure, 27% experienced retrograde ejaculation but none of them
experienced impotence.
As
a novel procedure, there are growing numbers of reports of long-term outcomes
of 80 W KTP laser prostatectomy. Ruszat et al. published the largest series
of 80 W KTP laser prostatectomies. At a single center, 500 patients underwent
PVP, including 45% taking oral anticoagulation (Ruszat et al. 2008a). After
3 years, 26.2% of patients had follow-up and mean AUS SI, PVR, and QOL were
significantly improved compared to baseline. At 60 months, retreatment rate
was 6.8% and reoperation rate was 14.8%. Urethral and bladder neck strictures
were observed in 4.4% and 3.6% of patients, comparable to the rate in TURP
(Ruszat et al. 2008a). Te et al. reported 3-year multi-center long-term follow-
up in 139 patients who underwent 80 W PVP. At 3 years, 33.8% of patients had
follow-up and improvements in symptom relief and urinary flow rate were durable
(Te et al. 2006). Retreatment rate was 4.3%. One of the advantages of the
80 W KTP/532 nm laser is the ability to perform laser prostatectomy on larger
glands with good outcomes and an excellent safety profile. Sandhu et al. detailed
large prostate volume resection with the 80 W KTP laser (Sandhu et al. 2004).
Sixty-four men with BPH possessing prostates with volumes of at least 60 ml
who had failed medical therapy were taken for vaporization with the 80 W KTP
laser. The mean preoperative prostate volume was 101 ml with a mean operative
time of 123 min- utes. IPSS decreased from 18.4 to 6.7 at 12 months; Qmax
increased from 7.9ml/sec to 18.9 ml/sec while PVR decreased from 189 ml to
109 ml. No transfusions were required nor was there evidence of postoperative
hyponatre- mia. All 62 patients were discharged within 23 hours. This was
the first evidence that the 80 W KTP laser could be used as a safe and effective
means for with durable results for large volume prostatectomy. Of note, since
the procedure was very hemostatic and performed under normal saline unlike
TURP and open prostatectomy, higher risk patients could be treated due to
improved hemodynamic stable safety profile pro- vided by this laser tehcnique.
Large prostates, as a result, could be treated safely despite the longer operative
times. Of note, hospital stay is short compared to TURP and open prostatectomy.
Pfitzenmaier et al. conducted a comparative study between vaporization of
prostates greater than or equal to 80 ml and those smaller than 80 ml. Thirty-nine
of 173 patients had prostates
91
≥80
ml. The authors found that PVP was safe and effective in prostates ≥80
ml but the reopera- tion rate was higher (Pfitzenmaier et al. 2008). In another
study, Rajbabu et al. assessed 54 con- secutive patients with prostates 4100
ml who underwent 80 W KTP laser prostatectomy. Consistent with other published
series, the pro- cedure was found to be safe, effective, and pro- duced durable
improvements in IPSS and QOL at 24 months (Rajbabu et al. 2007). The safety
of the 80 W KTP laser prostatectomy has been studied in patients at high cardiopul-
monary risk, and demonstated to be excellent due to the excellent hemostatic
profile and perioperative hemodynamic stability of the pro- cedure. Reich
et al. performed 80 W laser prosta- tectomy on 66 patients with an American
Anaesthesiology Score of 3 or greater (Reich et al. 2005). Of these patients,
29 were being treated with ongoing oral anticoagulation or had a severe bleeding
disorder. No major compli- cations occurred during or following the proce-
dure and no blood transfusions were required. Two patients required reoperation
within 12 months due to recurrent urinary retention. Mean improvements in
IPSS (20.2–6.5) and peak flow (6.7 ml/s to 21.6 ml/s) were durable
at 12 months. The final safety aspect of the 80 W KTP laser to be studied
in detail was its use in anti- coagulated patients at high risk for clinically
sig- nificant bleeding. A series of 24 anticoagulated patients with BPH treated
with laser prostatect- omy using the 80 W KTP laser was studied (Sandhu et
al. 2005). Of these, eight were on warfarin; two on clopidogrel; and 14 on
aspirin. Eight (33%) of these patients had a previous myocardial infarction; seven (29%) cereberovas- cular disease, and seven (29%) peripheral vascu-
lar disease. No patients developed clinically significant hematuria postoperatively
and none developed clot retention. No transfusions were required and there
were no thromboembolic events. One patient had transient postoperative urinary
retention requiring discharge with a catheter, two patients developed retrograde
eja- culation, and two patients had urinary tract infec- tions postoperatively.
Mean operative time was 101 minutes. Follow-up revealed a decrease in IPSS
from 18.7 to 9.5 as well as an increase in Qmax from 9.0 to 20.1 ml/sec at
12 months. PVR decreased from 134 to 69 ml at 1 month but were not statistically
significant beyond that timepoint.
In
this study, all patients underwent PVP safely without any adverse thromboembolic
or bleeding events. Significantly, more energy and time was used for lasing
per gland size in these patients. Since that time, multiple reports have confirmed
this experience (Ruszat et al. 2007). The gold standard comparator of minimally-
invasive procedures for BPH is the TURP. For a novel procedure, there is a
quickly growing literature comparing 80 W KTP laser prosta- tectomy to TURP.
Currently Ruszat et al. is con- ducting a study with 396 patients randomized
to either 80 W laser prostatectomy or TURP (Ruszat et al. 2008). Interim 24-month
follow- up data of this study was recently published. The rate of intraoperative
bleeding (3 versus 11%), blood transfusion (0 versus 5.5%), capsule perforations
(0.4 versus 6.3%), and early post- operative clot retention (0.4 versus 3.9%)
was sig- nificantly lower in the laser group. There was no significant difference
in IPSS and PVR. After 12 months, size reduction was greater in the TURP group
(66 versus 44%) and the rate of repeat pro- cedure was greater in the PVP
group (6.9 versus 3.9%, not significant). Bouchier-Hayes et al. reported data
on 120 patients randomized to undergo TURP or 80 W laser PVP (Bouchier- Hayes
et al. 2006). At 12 months equivalent improvements in IPSS and flow rates
were demonstrated. Length of hospitalization, length of catheterization, and
adverse events were lower in the laser group. In a non-randomized study Bachmann
et al. studied 101 patients who underwent either TURP or laser prosta- tectomy.
Perioperative morbidity and symptom improvement was equivalent in the groups
at 6 months (Bachmann et al. 2005). Another rando- mized study has yielded
divergent results. In this study, 76 patients with prostate size 470 ml were
randomized to TURP and 80 W laser prostatect- omy (Horasanli et al. 2008).
Procedure time was shorter for the TURP group. Hospitalization stay and catheterization
time were significantly shorter in the laser group. There was a significant
difference in favor of TURP in terms of improve- ment in IPSS, PVR, and Qmax
as well as volume reduction in the TURP group. In addition, reo- peration
rate was higher in the laser group. Clinically the 80 W KTP laser prostatectomy
possesses many advantages. Its efficacy appears to be equivalent or nearly
equivalent to that of standard transurethral resection of the prostate as
an instant tissue defect can be created with
92
Table
1. PVP and large prostates.
Table
3. PVP in comparison to TURP.
*statistically
significant
excellent
hemostasis, without absorption of hypo- tonic fluid. The ability to use normal
saline solu- tion as irrigation also removes the risk of dilutional hyponatremia.
The procedure can be performed with a range of anesthesia from a pros- tate
block with IV sedation to regional anesthetic
to general anesthesia. It can be used in high-risk patients such as those
anticoagulated with heparin, coumadin, nonsteroidal anti-inflammatory drugs
and aspirin. Often, no postoperative irriga- tion is required, and catheter
time is relatively short. Many patients do not even require
93
postoperative
catheters. However, one criticism is the length of operative time with larger
gland prostates and the desire to increase vaporization efficiency. 120 W
532 nm laser system The 80 W KTP laser system has evolved to a higher power
system capable of 80 W to one of 120 W. This new laser emits the same 532
nm wavelength, with the same hemostastic properties as the 80 W KTP (Te 2008).
The 532 nm 80W KTP laser is created by passing a 1064nm Nd:YAG laser beam
through a KTP crystal. In contrast, the 120 W HPS 532 nm wavelength is created
by passing a Nd:YAG laser beam through a lithium triborate (LBO) crystal.
The 532 nm LBO beam is better-collimated than the KTP beam. Several animal
studies have been performed with the 120 W 532nm laser. Lee et al. investigated
the use of the 120 W laser in five male beagles (Lee et al. 2008). Photoselective
vaporization of the prostate was performed in antegrade fashion through a
suprapubic cystotomy at 40, 80 and 120 W settings for three distinct firing
periods (5, 10 and 20 seconds) at unique locations in the prostate. One hundred
and twenty watts HPS consistently vaporized more tissue per unit time while
the depth of coagulation (1.2– 2.5 mm) was decreased compared to the
lower powered systems. Kang et al. compared the use of the 120 W HPS laser
to the 80 W HPS laser and the 80 W KTP laser from 96 specimens of bovine prostate
tissue (Kang et al. 2008). The 120 W HPS laser vaporized bovine prostate tissue
more efficiently than the 80 W KTP laser and coagulation was equivalent. Few
studies have been published on the safety and efficacy of the 120 W 532 nm
laser prosta- tectomy in humans (Woo et al. 2008). In a multi-center prospective
study, 305 patients with BPH underwent laser prostatectomy with the 120 W
HPS laser. Changes in maximum flow rate (Qmax), postvoid residual urine, IPSS,
and prostate volume from baseline to follow-up were significant (p50.001)
in all patients. A subgroup analysis was done in 3 groups of patients: those
in retention (n = 63), on anticoagulation (n = 67), and with prostates ≥80
ml (n = 52). Complications were compara- tively low in all groups.
Transurethral
laser enucleation/vaporization techniques with 532 nm laser systems Frequently
reported advantages of the HoLEP over the 80 W laser prostatectomy are the
avail- ability after the procedure of a pathology speci- men and ability to
remove a higher percentage of prostate tissue during resection. This advantage,
however, is not unique to HoLEP. We have devel- oped and now routinely apply
a new technique of laser prostatectomy with the 532 nm laser. This technique
is a variation of enucleation/vapori- zation/resection that we call transurethral
laser enucleation of the prostate (TLEP) and is demonstrated in Figures 1a–e.
The procedure allows pathology to be collected and analyzed, provides more
improved surgical debulking of obstructive prostate tissue, and increased
tissue removal efficiency to shorten operative times. This new advance technique
is essentially a hybrid between a HoLEP, a TURP, and laser vaporization techniques
utilizing the 532nm laser. In contrast to the HoLEP, the technique can be
quickly learned by those with prior trans- urethral resection skills. Like
the HoLEP, patho- logy is provided and resection/enucleation is very complete.
In our initial experience, 428 patients underwent TLEP utilizing both the
80 W and 120 W 532 nm systems, and the procedure has been shown to be safe
and effective. There were no life-threatening complications experienced by
any patients. A blood transfusion was required by only one patient for delayed
bleeding a few weeks postoperatively. At 24 months, improvements in AUA SI
(18.56 to 6.84), Qmax (9.46 to 12.54 ml/s), and PVR (161.61 ml to 85.03) are
durable (Chung et al. 2009). Conclusions Laser prostatectomy has become widely
accepted by urologists as an alternative to TURP for the treatment of BPH.
Laser technology is generally accessible to the practicing urologist and the
transurethral endoscopic approach and operative techniques are familiar to
practicing urologiest. Laser prostatectomy has proved to be a safe and efficacious
surgical intervention to relieve symp- tomatic bladder outlet obstruction.
Overall mor- bidity contrasts favorably with standard surgical approaches.
There are several techniques for laser prostatectomy that continue to evolve.
The main competing techniques are currently the HoLEP and the 80 W 532 nm
laser PVP. There are several advantages of these procedures over traditional
TURP. Both techniques can be
94
Figure
1. Transurethral laser enucleation/vaporization technique (TLEP). View of
the prostate through cystoscope; (a) First an incision is made through the
median lobe until the bladder neck fibers can be seen. Sweeping motions with
the side-fire laser fiber ensure that a wide channel is made that allows for
the strong flow of cooling irrigant. Second, incisions are made lateral to
the median lobe. It is important at this step to visualize the ureteric orifices; (b) The intervening tissue between the incisions, if large, is divided into
smaller chips. The chip is also vaporized to reduce bulk before it is incised
and pushed into the bladder; (c) The middle lobe is removed in this maner
on both sides to view the ureteral orifice well from behind the bladder neck; (d) An multiple vaporization-enucleation-incisions are made starting at the
11 o'clock position of the lateral lobe down to the fibres of the prostatic
capsule. This 11 o'clock incision is continued medial to join the median lobe
defect at the 7 o'clock position. Intervening tissue is vaporized, incised,
and pushed into the bladder. The same procedure is done to the other side
to remove the contralateral lateral lobe starting at the 1 o'Clock position
to the 5 o'clock position. Apical tissue proximal o the verumontanum is carefully
ablated with care to preserve the veru; (e) Anterior tissue at the 12 o'clock
position is then incised- vaporized-enucleated as needed to connect the 1
o'clock to the 11 o'clock position. The goal is to achieve a TURP like cavity
with removal of tissue to capsule and with view of the Ureteral orifice as
well as removal of any intravesical components.
used
on patients with high comorbidity and those taking anticoagulation. Furthermore
both techni- ques may be applied to patients with large pros- tates. The HoLEP
is limited by its high learning curve and need for a morselator. Some disadvan-
tages of 80 W 532 nm KTP based PVP technique include lack of tissue specimen
and lower
percentage of tissue resection. However, the transurethral laser enucleation
of the prostate addresses these concerns and has shown to have durable outcomes
at 2-year follow-up. Two new laser systems and techniques, the thulium laser
and the 980 nm laser, have emerged recently. However, clinical data from these
procedures
95
Figure
1. Continued. are in their infancy and large long-term studies are required.
Conflicts of interest statement None declared.
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<volume>53</volume>: <fpage>382</fpage>-<lpage>389</lpage>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>New techniques for laser prostatectomy: an update</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>New techniques for laser prostatectomy: an update</title></titleInfo><name type="personal"><namePart type="given">Doreen E.</namePart><namePart type="family">Chung</namePart><affiliation>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</affiliation><affiliation>Fellow In Voiding Dysfunction, Department of Urology, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Alexis E.</namePart><namePart type="family">Te</namePart><affiliation></affiliation><affiliation>E-mail: aet2005@med.cornell.edu</affiliation><affiliation>Associate Professor of Urology, Director of the Brady Prostate Center, Weill Cornell Medical College, 1300 York Ave, Box 261, Suite F9 West, New York, NY 10065, USA, aet2005@med.cornell.edu</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="review-article" displayLabel="review-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-L5L7X3NF-P">review-article</genre><originInfo><publisher>SAGE Publications</publisher><place><placeTerm type="text">Sage UK: London, England</placeTerm></place><dateIssued encoding="w3cdtf">2009-06</dateIssued><copyrightDate encoding="w3cdtf">2009</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">Traditionally, the gold standard for treatment of BPH has been the electrocauterybased TransUrethral Resection of the Prostate (TURP). However, the number of laser techniques being performed is rapidly increasing. Potential advantages of laser therapy over traditional TURP include decreased morbidity and shorter hospital stay. There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HoLEP) and the 80W 532nm laser prostatectomy. The HoLEP, using the Holmium:YAG laser, has been shown to have clinical results similar to TURP and is suitable for patients on anticoagulation as well as those with large prostates. Disadvantages of this technique are the high learning curve and requirement of a morcellator. When used to treat BPH, studies have demonstrated that, like the HoLEP, the 80W KTP laser is safe and effective in patients with large prostates and in those taking oral anticoagulation. Several studies have compared these two techniques to TURP. Frequently reported advantages of the HoLEP over the 80W laser prostatectomy are the availability after the procedure of a pathology specimen and ability to remove a higher percentage of prostate tissue during resection. However, the transurethral laser enucleation of the prostate addresses these concerns and has shown to have durable outcomes at 2-year follow-up. Two new laser systems and techniques, the thulium laser and the 980nm laser, have emerged recently. However, clinical data from these procedures are in their infancy and large long-term studies are required.</abstract><subject><genre>keywords</genre><topic>surgical therapy and new technology</topic><topic>benign prostatic hyperplasia (BPH)</topic><topic>prostate cancer</topic><topic>medical and hormonal therapy</topic></subject><relatedItem type="host"><titleInfo><title>Therapeutic advances in urology</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1756-2872</identifier><identifier type="eISSN">1756-2880</identifier><identifier type="PublisherID">TAU</identifier><identifier type="PublisherID-hwp">sptau</identifier><part><date>2009</date><detail type="volume"><caption>vol.</caption><number>1</number></detail><detail type="issue"><caption>no.</caption><number>2</number></detail><extent unit="pages"><start>85</start><end>97</end></extent></part></relatedItem><identifier type="istex">848F2367A20D0221B6E43B6CC3CBA0905AF91C27</identifier><identifier type="ark">ark:/67375/M70-8KNBHW8S-G</identifier><identifier type="DOI">10.1177/1756287209105436</identifier><identifier type="ArticleID">10.1177_1756287209105436</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/848F2367A20D0221B6E43B6CC3CBA0905AF91C27/metadata/json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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