Viewpoint - Use of lasers in prostatectomy

Laser treatment has great advantages over traditional surgery, writes Mr Tim Larner.

Despite the advances in medical therapy for benign prostatic hyperplasia (BPH) with alpha-blockers and 5-alpha reductase inhibitors, around 35,000 UK men require surgical intervention each year.

Indications for surgery include failure of medical treatment, urinary tract infections, urinary retention, obstructive uropathy and bladder stones.

The commonest operation for urinary symptoms due to an obstructing prostate is trans - urethral resection of the prostate (TURP). This is an effective procedure and has been considered the 'gold-standard' operation with excellent long-term results.

Complications of TURP

Bleeding is a common post-TURP occurrence, resulting in a mean in-patient stay of four and a half days, and a mean transfusion rate of 5 per cent.

Strenuous activity should be avoided for up to four weeks.

Further complications may occur due to the use of the non-ionic solution glycine, which is necessary to avoid the dispersement of the electrical current, as an irrigation fluid.

Absorption of glycine either directly into open veins or due to leakage into periprostatic tissues can lead to the serious but rare TUR syndrome characterised by the triad of dilutational hyponatraemia, fluid overload and glycine toxicity.

Due to this, and other complications, there has been much interest in less invasive procedures that cause less blood loss, shorter in-patient stay and faster return to normal life.

The use of lasers for BPH is not new. Side-firing Nd YAG lasers result in prostate tissue coagulation, but the resultant sloughing of tissue led to unacceptable rates of dysuria and urodynamic results inferior to TURP.

Despite short in-patient stay and limited bleeding, after initial enthusiasm, these were largely dropped in the UK.

Laser prostatectomy

Currently, two lasers are used globally for laser prostatectomies, the Holmium laser enucleation of the prostate (HoLEP) and the photoselective vaporisation of the prostate (PVP) systems, but their uptake in the UK has been slow.

Both systems employ a laser fibre passed through a modified cystoscope and use normal saline to irrigate, avoiding the TUR syndrome. Both have short inpatient stay, reduced blood loss and more rapid return to normal activity.

The Holmium laser

The Holmium laser can be used as a 'light scalpel' with the light energy delivered at the tip of the fibre. The prostate tissue can be enucleated from the prostatic capsule and the lobes of prostate are dropped into the bladder. The resultant defect is similar to the old open prostatectomy and the operation removes more tissue than the TURP. The prostatic tissue needs to be removed from the bladder at the end of the procedure with a morcellator.

Care must be taken to avoid bladder injury, but the operation has excellent long-term outcomes equivalent to TURP with a shorter hospital stay and decreased blood loss.

The PVP laser

The PVP employs a side firing fibre with the KTP laser energy selectively being absorbed by the oxygenated haemoglobin in the prostatic tissue. This results in vaporisation of the tissue with a limited zone of coagulation leaving a TUR-like cavity and causing extremely limited blood loss.

This can be performed as a day case procedure. Dysuria is uncommon and return to normal activities is rapid.

Due to limited bleeding, the procedure may be used for anti- coagulated and high-risk patients. Reports suggest less incidence of retrograde ejaculation and effect on erectile function, but this has not yet been proven in a randomised control trial against TURP.

While some institutions have embraced the laser prostatectomy in the UK, these are still very much in the minority. Why is it that the vast majority of patients are still only offered the TURP as an operative choice?

Reasons for TURP

Having tried numerous minimally invasive procedures that have promised much but delivered little, urologists are sceptical about new technology.

These procedures are not that new. Both laser systems are NICE approved and there are large numbers of peer-reviewed published papers demonstrating their long-term efficacy.

Any good endoscopic urologist can master the techniques with appropriate training, but they cost more. The initial purchase of equipment may seem daunting, but the saving in bed days offsets any additional cost. With an average bed stay for TURP of 4.8 days and for Greenlight of 23 hours, the bed-stay saving for the past 250 patients is 950 bed days. Blood transfusion is expensive and rare after laser prostatectomy (>1 per cent in our institution).

TURP also takes longer but there is less postoperative nursing time involved with irrigation being a rarity and bladder washouts uncommon.

Summary

Laser prostatectomy provides an alternative to TURP with potential patient benefits. There has been a slow uptake in the UK despite a wealth of published series demonstrating efficacy and safety.

Most patients still will not be offered laser prostatectomy by their primary care organisations. With NICE approval and increasing patient awareness of technology, laser prostatectomy, PVP or HoLEP, is likely to become common.

- Mr Larner is a consultant urological surgeon at the Brighton and Sussex University Hospital Trust, East Sussex

KEY POINTS IN LASER PROSTATECTOMY

- Around 35,000 men in the UK each year require surgical intervention for benign prostatic hyperplasia (BPH).

- The current operation - trans-urethral resection of the prostate (TURP) - carries complications, including bleeding and TUR syndrome characterised by dilutational hyponatraemia and glycine toxicity.

- Despite laser prostatectomy being a less invasive alternative to traditional surgery, avoidance of the TUR syndrome and a faster return to normal life, treatment uptake in the UK has been slow.

- The two systems most widely used are the Holmium laser enucleation of the prostate (HoLEP) and the photoselective vaporisation of the prostate (PVP). Both systems employ a laser fibre passed through a modified cytoscope. Normal saline is used to irrigate.

- The HoLEP is used as a scalpel where prostate tissue is enucleated from the prostatic capsule and the lobes of prostate dropped into the bladder.

- The PVP system vaporises the prostatic tissue, causing extremely limited blood loss.

REFERENCES

- Montorsi F et al. HolEP versus TURP: results from a two-center, prospective, randomized trial in patients with obstructive BPH. J Urol 2004 Nov; 172 (5 Pt 1): 1,926-9.

- Tan A H et al. A randomized trial comparing HoLEP with TURP for the treatment of bladder outlet obstruction secondary to BPH in large glands (40 to 200 grams). J Urol 2003 Oct; 170 (4 Pt 1): 1,270-4.

- Kumar S M. PVP: a volume reduction analysis in patients with lower urinary tract symptoms secondary to BPH and carcinoma of the prostate. J Urol 2005 Feb; 173(2): 511-3.

- Reich O et al. High power (80W) potassium-titanyl-phosphate laser vaporization of the prostate in 66 high-risk patients. J Urol 2005 Jan; 173(1): 158-60.

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