145 Ahmed M. Elshal1 & Mostafa M. Elhilali2 1 Urology and Nephrology Center, Mansoura University, Egypt 2 Division of Urology, McGill University, Montreal, QC, Canada Transurethral resection of the prostate (TURP) has been the reference standard for the treatment of benign prostatic hyperplasia (BPH) for decades. It was reported that TURP was associated with significant perioperative morbidity (13–24%) [1], but with significant technical advancements over years its perioperative morbidity has been significantly reduced (11.1%) [2]. However, it still has limitations that increase the perioperative morbidity, particularly when treating large prostates and patients with coagulopathy. Reich et al. showed that with resected prostate weight more than 60 g, blood transfusion rate was 9.5%, transurethral resection syndrome was 3%, surgical revision rate was 9.8%, and perioperative mortality was 0.71% [2]. Furthermore, data showed that coagulopathy independently impacted TURP outcome in terms of more bleeding complications [3]. Laser prostatectomy was introduced as a less invasive modality for treatment of BPH, because it overcomes the disadvantages and limitations of the standard TURP and open prostatectomy. It is much less invasive than the open procedure [4], and, because it uses physiological saline as an irrigant, the incidence of transurethral resection syndrome is reduced and a higher safety profile is achieved in patients with comorbidity who are on anticoagulants or antiplatelets during surgery [5]. Laser prostatectomy also can be used to tackle large prostate glands beyond the limits of TURP. It is often done as day surgery with a shortened catheterization time. These considerations result in it being more cost effective [6]. The holmium (Ho) laser has been associated with strong clinical evidence for its effectiveness in many applications in urology, such as incision of ureteral stricture [7], lithotripsy of urinary calculi [8], ablating superficial urothelial tumors [9], bladder neck incision (BNI) [10], and surgical management of BPH. The combination of the Nd:YAG laser with the Ho:YAG laser was used early on to vaporize and coagulate tissue using a technique known as combination endoscopic laser ablation of the prostate (CELAP). The initial experience of this technique was first reported by Gilling et al., who found the use of the Nd:YAG laser led to a longer catheterization time, delayed symptom improvement, and high recatheterization rate (26%) [11]. These side‐effects limit the usefulness of this technique, and CELAP has been replaced by the holmium‐only technique. Since its first use in 1994, various techniques using the holmium laser wavelength have been used in the surgical management of BPH: holmium laser ablation (HoLAP), resection (HoLRP), and enucleation of the prostate (HoLEP) [12]. Every new laser technology has specific advantages; however, its physics may result in significantly different outcomes. The holmium:yttrium–aluminum–garnet (Ho:YAG) laser emits a pulsed, invisible infrared beam with a wavelength of 2140 nm, which is absorbed strongly by water (which constitutes 60–70% of the prostate). The depth of penetration is 0.4 mm, which predominantly causes vaporization without a deep coagulation zone when used with a side‐firing fiber. It provides a precise incision and enucleation while maintaining hemostasis when used with an end‐firing fiber. Energy absorption by the irrigant forms a vapor bubble around the laser fiber tip and this result in a microexplosion, causing a jackhammer effect that can cut tissues or disintegrate stones when in close contact to the target tissue. If direct contact is not adequately maintained, laser efficiency will be reduced due to consumption of energy in the formation of vapor bubbles [12, 13]. Figure 145.1 Endoscopy set. (a) Laser guide probe with retracting beaks. (b) Laser guide probe with retracting beaks. (c) Continuous flow 26 Fr resectoscope with inner and outer sheaths and an obturator system. (d) Connecting piece/adaptor for the outer sheath to fit indirect nephroscope for morcellation. Holmium laser transurethral incision of the prostate (HoL‐TUIP) is performed using a 100 W Ho:YAG laser and a 550 µm end‐firing fiber. The bladder neck is deeply incised at 5 and/or 7 o’clock, just distal to each ureteral orifice, using laser energy to create a trough down to the true capsule to either side of the verumontanum (laser energy of 2 kJ and rate of 50 Hz). Usually a single incision is sufficient as the bladder neck splits open wide. Rarely a second incision is necessary on the other side. A two‐way 22 Fr Foley catheter is inserted and connected to straight drainage [10] to be removed before discharge the same day if the urine is clear. HoL‐TUIP can be performed safely as a catheter‐free outpatient procedure [15]. Cornford et al. confirmed the efficacy of this technique at 2‐year follow‐up. The mean maximum urinary flow rate (Qmax) increased from 9.7 to 18.2 ml/s [15]. The long‐term outcome could be improved and the reoperation rate minimized with appropriate selection of cases. Elkoushy et al. reported on 82 patients who underwent HoL‐TUIP; 9 (11%) patients were reoperated for recurrent symptoms of bladder outlet obstruction. Only prostate size independently predicted reoperation after HoL‐TUIP (adjusted odds ratio [aOR] 7.12, 95% confidence interval [CI] 2.92–9.14, P = 0.01) with cut‐off value of prostate volume of 29 ml to characterize long‐term reoperation, with area under the curve (AUC) of 0.96, sensitivity of 89.7, and specificity of 88.9 [16]. Comparing cost efficacy for HoL‐TUIP and GreenLight (532 nm) laser photoselective vaporization of the prostate (PVP) for treatment of small prostates including high‐risk patients, the mean estimated cost per HoL‐TUIP procedure was significantly lower than that per PVP procedure. The higher cost of PVP was mainly due to the cost of a single‐use laser fiber and a significant difference in hospital admission time [10]. Using a 550 µm side‐firing laser fiber with laser settings ranging from 2 J and 50 Hz to 3.2 J and 30 Hz, without the need for any tissue retrieval instruments. HoLAP is performed with the patient under general or regional anesthesia and normal saline is used as the irrigant. Vaporization of the prostate usually starts at the bladder neck using the side‐firing laser fiber to make a bladder neck incision at 5 and 7 o’clock; then the laser fiber is gently moved over the surface of the obstructed lobe toward the apex of the prostate proximal to the verumontanum. The end‐point of the laser procedure is a TURP‐like cavity lined by capsular fibers [17]. A controversial issue related to HoLAP when compared to TURP is the lack of tissue for histopathologic examination, which could lead to diagnoses of prostatic carcinoma being missed. Therefore, it is mandatory to perform a thorough evaluation of patients with an elevated prostate specific antigen (PSA) level or abnormal digital rectal examination (DRE), with transrectal ultrasound (TRUS)‐guided biopsies prior to the intervention. Recently, with the increased popularity of using multiparametric MRI we can probably reduce the chance of missing significant cancer. It is also mandatory to continue postoperative PSA and DRE surveillance. In a randomized trial comparing HoLAP and TURP in men with prostates smaller than 60 ml, the subjective and objective improvements in both groups were similar at 1 year follow‐up. However, the advantages of HoLAP over TURP included less dysuria and bleeding, and shorter hospital stay and catheter time, without need for any postoperative irrigation [17]. Elshal et al. reported after a median of 71.3 months in a randomized trial comparing HoLAP versus GreenLight (532 nm) laser PVP. Retreatment for recurrent infravesical obstruction was 19.2% in HoLAP and 25% in PVP (P > 0.05). Smaller prostate volume was significantly associated with bladder neck contracture (BNC) after laser ablation, regardless of the type of laser used. BNC and de novo urethral stricture seem to be the main causes for an early (first‐year) reintervention. Redo treatment for recurring prostate adenoma was associated with less postoperative PSA reduction (less than 20%) suggesting inadequate tissue ablation. At 7 years follow‐up of 34 patients who underwent HoLAP, there was an 83% improvement in Qmax, a 47% decrease in symptom score, reoperation rate of 15%, and recatheterization rate of 9% [18, 19]. Looking for cost efficacy of both HoLAP and GreenLight (532 nm) laser PVP for treatment of small to moderate size prostate (less than 60 ml), accounting for all clinic visits and readmissions for reoperations, total costs were 200.45 Canadian dollars lower in the HoLAP group [19]. Xpeeda™ D/S/L fiber is a single‐use, side‐firing fiber that can deliver more energy to the tissue while in direct contact with it, as proposed by the manufacturer for use with 120 W laser system. Laser ablation with the new fiber might revive the use of holmium laser in prostate ablation for further clinical studies [20]. Before the development of the morcellator for tissue retrieval, Gilling et al. developed a technique that aimed to resect prostatic tissue by the holmium laser, similar to TURP. The resected pieces were small enough to be retrieved by a modified resectoscope loop or Ellik evacuator. HoLRP starts with bilateral incision to define the depth and amount of tissue to be removed. The next step is to join the two incisions just in front of the verumontanum to undermine the median lobe and deposit it into the bladder. Incisions at 1 and 11 o’clock position over the entire length of the prostate are needed to define the upper margin of the excision of the lateral lobes. Dissection occurs precisely in the plane between the adenoma and capsule in a retrograde fashion until only a bridge of tissue remains at the bladder neck [21]. The technique of HoLRP produces a cavity identical in appearance to TURP, but with a relatively bloodless procedure that results in a short catheter time, immediate functional improvement, and minimal postoperative irritative symptoms. HoLRP offers significant improvements over TURP in terms of catheterization time, length of hospital stay, risk of bleeding, and incidence of untoward events [22]. Fraundorfer et al. reported in their randomized trial comparing HoLRP to TURP that HoLRP offers equivalent outcomes to TURP in terms of rapid relief of symptoms and improved urodynamic parameters [22]. The long‐term data have shown sustained improvement of flow rate and symptom score for a minimum of 4 years [23]. HoLRP offers a 24.5% cost savings over TURP when in‐hospital and postdischarge events were analyzed. Furthermore, 93 procedures annually for 5 years would achieve total machine payback, including fiber and service costs [22]. HoLEP reproduces the removal of the obstructing prostatic tissue with a true anatomic surgical enucleation of the adenoma, identical to using the index finger in open prostatectomy. The advantages of this technique include an almost bloodless field, allowing better vision with simultaneous coagulation of all bleeding vessels. Moreover, the dissection can be sharp or blunt. Three‐dimensional awareness and hand–eye coordination are mandatory in this technique. The visibility in HoLEP, compared with standard TURP, is much better because of the bloodless field and the greater image magnification. Inspection of the prostate anatomy looking for presence or absence of grossly enlarged median lobe and the depth of the grooves at the bladder neck determines the location of the first incision and plan of enucleation. Enucleation is done using a combination of blunt and sharp dissection in a retrograde fashion. The blunt enucleation is achieved by using the tip of the scope, just like using a finger, to separate the adenoma from the surgical capsule in a technique similar to traditional retropubic prostatectomy but in a retrograde manner. Eventually, the adenoma is attached at the bladder neck, apical mucosal strip at the level of the urinary sphincter, and the anterior commissure to the contralateral adenoma.
Holmium Laser Therapy of the Prostate
Introduction
History and evolution
Physics
Equipment and instruments required for holmium laser management of BPH
Holmium laser transurethral incision of the prostate
Technique (see Video 145.1)
Safety
Efficacy
Durability
Cost efficacy
Holmium laser ablation of the prostate
Technique
Safety
Efficacy
Durability
Cost efficacy
Future perspectives
Holmium laser resection of the prostate
Technique
Safety
Efficacy
Durability
Cost efficacy
Holmium laser enucleation of the prostate
Technique
Inspection
Enucleation
Three‐lobes technique is used for grossly enlarged median lobe and deep grooves at the bladder neck (see Video 145.2.a)
Following median lobe enucleation (in case of three‐lobes technique) or creation of the initial incision at the deepest groove at the bladder neck (in case of two‐lobes technique) (see Video 145.2.b.i), lateral lobe enucleation is achieved.
The operator should always use a rotating movement to follow the contour of the prostate and care must be taken to avoid using excessive force so as not to unnecessarily stretch the external urinary sphincter or go through the surgical capsule. Blunt enucleation should be avoided if the tissues do not separate easily. Instead, the laser should be used to cut any attachments. The proper plane can be identified from its appearance, as well as from the ease with which the tissues separate (see Video 145.2.b.ii). The dissection of the adenoma continues, progressing toward the bladder neck. When the adenoma is separated laterally and the anterior aspect of the prostate is reached, the dissection is extended across the midline in order to facilitate the later separation of the two lobes in the midline anteriorly when the 12 o’clock incision is performed, eliminating any guesswork about the depth needed.
The adenoma is sharply dissected from the bladder neck completely then the apical mucosal strip is carefully incised using short energy bursts at settings of 1.5 J at 30 Hz for an energy level of 45 W, to minimize the risk of thermal damage to the sphincter (see Video 145.2.b.iii). The incision is extended through the anterior commissure, separating the two adenomas without the need for guesswork on the depth of incision. The lateral lobes are gently pushed into the bladder.
Hemostasis
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