Abstract
The introduction of laser energy for the treatments of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) has dramatically changed the surgical landscape of surgery for BPO. Several laser devices are available and they differ according to the used laser energy source. Each laser has unique properties resulting in a variety of possible techniques, ranging from vaporization to resection and enucleation.
Keywords
Benign prostatic obstruction, Laser
Introduction
The introduction of laser energy for the treatments of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) has dramatically changed the surgical landscape of surgery for BPO. Several laser devices are available and they differ according to the used laser energy source. Each laser has unique properties resulting in a variety of possible techniques, ranging from vaporization to resection and enucleation.
Although they are summarized using the acronym laser , available systems for the treatment of BPO diverge in the type of laser energy, radiation delivery, and interaction with the target tissue. The most important factors to differentiate lasers are wavelength, fiber type, and the surgical technique. The most important information is that deeper penetration depth leads to a higher rate of coagulation and to lower vaporization. Deep penetration of tissue may lead to excellent hemostasis but also to a deeper area of necrotic tissue which might lead to significant side effects. Shallow penetration means high-energy absorption in a very defined volume [ ].
In general, every reported approach of laser prostatectomy can be subdivided into three different principles, independent of the laser type used. These principles are vaporization (removal of the adenoma from the prostatic urethra to the surgical capsule), resection (excision of small tissue chips from the prostatic urethra to the surgical capsule), and enucleation (removal of the adenoma by cutting the layer of the surgical capsule and consecutive morcellation). By knowing the basic principles of laser generation, delivery, and laser-tissue interaction, the appropriate laser as well as the optimal fiber can be chosen. If the surgeon’s desire is to vaporize a prostate, a side-firing fiber may be advantageous because the energy can be easily delivered from the prostatic urethra to the adenoma. In contrast, in enucleation procedures the tip of the laser fiber mimics the index finger in open prostatectomy (OP). In that case a front-firing fiber allows the tissue to be cut into the layer of the surgical capsule, moving in a retrograde manner from the verumontanum to the bladder neck. Wavelength is another important factor. In enucleation procedures, the surgical site of action occurs at the pseudocapsule and thus close to the adjacent structures. A shallow penetration of laser radiation is necessary to control possible collateral damage. For example, in treating a patient with bleeding diathesis with a vaporizing technique, the coagulation performance of the laser system is of utmost interest. In this case a laser system with either deeper penetration into the adenoma or energy absorption in hemoglobin may be beneficial because the longer distance to the pseudocapsule reduces the risk of injury to adjacent structures. Table 13.1 shows the wavelength and penetration depth of laser systems for treatment of BPO [ , ].
| Laser Device | Wavelength (nm) | Optical Penetration Depth in Target Chromophore (mm) |
|---|---|---|
| KTP/LBO | 532 | 0.8 |
| Diode | 940, 980, 1318, 1470 | 0.5–5 |
| Nd:YAG | 1064 | 10 |
| Thulium | 1940/2013 | 0.2 |
| Holmium:YAG | 2100 | 0.4 |
| Eraser | 1318 | 3 |
The laser energies that can be used for the surgical treatment of LUTS due to BPE are the following:
- •
Holmium laser . The Ho:YAG laser operates at 2120 nm with tissue water as the chromophore. High energy concentration in a pulsed manner results in steam bubbles with resultant disruption of prostate tissue. The tissue penetration of this laser is only 0.4 mm, predominantly causing vaporization. Coagulation is achieved simultaneously via the dissipation of heat, with minimal coagulative necrosis or charring. The physical properties of this laser make it suitable for use in different tissues, including stones, due to the fact that water makes up a significant component of most calculi. Ablation (HoLAP), resection (HoLRP), and enucleation (HoLEP) are all possible, and dealing with bladder calculi at the same setting makes this the most versatile laser. Holmium technology for BPE evolved from HoLAP to HoLRP and finally HoLEP [ ].
- •
Thulium laser . The two thulium lasers, Tm:YAG laser at 2013 nm, and Tm-fiber laser [Vela XL] at 1940 nm, target water and emit energy in a continuous mode. Due to the shallow penetrance of 0.2 mm, tissue is rapidly vaporized, and hence the techniques of vaporization (ThuVAP), vaporesection (ThuVARP), vapoenucleation (ThuVEP), and enucleation (ThuLEP) employed with these lasers [ , ]. The largest case series is for enucleation (ThuVEP), with variation in power setting between 70-W and 120-W. ThuVEP appears to be better at the higher power setting in terms of resected weight efficiency [ ]; however, there appears to be no further advantage at a 200-W setting [ ].
- •
Potassium-titanylphosphate (KTP) and lithium tri-borate lasers (LBO) . KTP laser is a crystal laser developed from the Nd:YAG laser and lithium borate lasers (LBO). The principal use of these lasers is vaporization carried out by side-firing laser fibers at 532 nm wavelength [ , ]. The light of the photoselective vaporization of the prostate (PVP) technology is generated by passing a neodymium:yttrium aluminum garnet (Nd:YAG) laser with 1064-nm laser light through a frequency-doubling crystal, reducing the wavelength by half, to 532 nm. Frequency-doubling crystals consist of KTP or LBO. The older 80-W laser device used the KTP crystal, and the latest generation uses the LBO crystal with a 120–180-W power setting. This passes through the tissue fluid medium and is absorbed by hemoglobin, leading to coagulation and vaporization. A potential advantage of PVP over TURP is the ability to undergo surgery despite anticoagulation or antiplatelet agents, due to the coagulative properties of the 532 nm laser. One of the drawbacks of laser vaporization is the relatively long operative time and the lack of specimen for pathologic assessment [ , , ].
- •
Diode lasers . Diodes are semiconductors that are electronically pumped in order to emit laser light. Diode lasers present a heterogenous group of lasers with varied wavelengths. 980 nm, 1318 nm, side firing 940 nm and 1470 nm wavelengths [ , ]. Power settings are usually set at 80–200 W. Vaporization is achieved without direct tissue contact using a side-firing fiber [ ].
- •
Neodymium-yttrium-aluminum-garnet (Nd-YAG) laser . Nd-YAG laser is a crystal laser with water and hemoglobin as the absorbing chromophore, a wavelength of 1064 nm, and a penetration depth of 10 mm. Tissue ablation occurs via pulsed or continuous coagulation—the basis of initial contact laser prostatectomy procedures. However, due to its low absorption coefficient and tissue penetration depth, Nd-YAG has a greater risk of thermal injury, particularly deep coagulative necrosis which can take up to 3 months to heal completely but form the basis of its effect [ ].
- •
Eraser laser . Eraser is a 1318-nm diode laser. It represents a useful device for cutting, coagulating, and sealing during resection of lung metastases and of small kidney tumors. This type of laser creates three zones of tissue necrosis: a central crater of vaporized tissue, a broad and light zone of coagulation, and a third zone of hyperemia [ ].
Laser treatment of BPH encompasses a variety of techniques using the different laser wavelengths and surgical techniques. Lasers may be used for vaporization and/or enucleation techniques according to their physical characteristics [ , ].
Lasers Typically Used for Vaporization
GreenLight Laser
The GreenLight laser emits laser radiation at a wavelength of 532 nm. The tissue target chromophore is the hemoglobin molecule, which has a very high absorption coefficient at this wavelength. Laser radiation into the tissue is delivered using a side-firing fiber. In general, this laser is used with good results in pure vaporization techniques, although enucleation procedures were reported recently [ , , , ].
Diode Lasers
There is not a unique diode laser. The term diode laser defines a group of lasers using a semiconductor bar to generate laser radiation. By using different semiconductor elements and layer structures, the generation of various wavelengths is possible, thus providing laser systems emitting at 940, 980, 1318, and 1470 nm. The target chromophore differs depending on wavelength. Compared with the GreenLight LBO laser, different diode laser systems showed comparable or superior tissue ablation rates and lower bleeding rates. However, tissue necrosis and penetration depth were significantly higher [ ].
Lasers Typically Used for Resection/Enucleation
Thulium Lasers
Two types of thulium lasers have been introduced in the treatment of BPO. Both use a wavelength around 2000 nm (Tm:YAG laser [Revolix], 2013 nm, and Tm-fiber laser [Vela XL], 1940 nm) for laser radiation [ , ]. The target chromophore is water, with radiation emission in a continuous wave mode. Due to the shallow optical penetration of approximately 0.2 mm, radiated tissue is rapidly vaporized. The side-fire technique is available, but published applications of the thulium:YAG laser are mainly resection and enucleation procedures using front-firing fibers. Due to the high proportion of vaporization during these procedures, the terms vaporesection and vapoenucleation have been introduced [ , , ].
Holmium:YAG Lasers
The Ho:YAG laser operates at 2100 nm, using water as the chromophore. As the laser that has the longest postlaunch time, multiple surgical techniques have been introduced, including ablation, resection, and enucleation. Enucleation (HoLEP) is the main field of application today for the Ho:YAG laser in BPO. Using the pulsed energy release, the laser can be used like a chisel to enucleate enlarged prostatic tissue at the layer of the surgical pseudocapsule. In general, HoLEP is mimicked by all recently introduced enucleation procedures and modified according to the properties of the particular laser. Ho:YAG laser enucleation has proven to be efficacious and safe in multiple trials and represents the reference method for all newly introduced laser-based enucleation procedures [ , , ].
Enucleation for BPO: Techniques and Results
Before the introduction of transurethral surgery for BPE, patients underwent open surgery with the removal of the adenoma along the prostatic capsule through the surgeon’s finger. After the introduction of transurethral resection of the prostate (TURP), open surgery was kept only for patients with large adenomas. In the last 15 years, with the introduction of laser devices, it was proven that the adenoma could be removed endoscopically repeating the surgical maneuver that used to be performed with open surgery, resulting in transurethral enucleation of the prostate. Several lasers are nowadays available for prostate enucleation [ ].
Holmium Laser Enucleation of the Prostate
Principles of Surgical Technique
The holmium laser is delivered through small flexible low-water content quartz fibers and releases energy in short pulses. The absorbing chromophore for holmium laser energy is water, and with a wavelength of 2140 nm and penetration depth in prostate tissue of 0.5 mm means that beyond this distance, energy is dissipated in cellular and extracellular water and has no deep thermal effect on tissue [ ]. Due to the high water content of prostatic tissue, which leads to excellent thermal conductance, the holmium laser allows the operating surgeon to either coagulate or ablate. The pulsed nature of the wavelength also contributes to its ability to vaporize tissue and aids in the dissection necessary for enucleation. Furthermore, hemostasis is independent of the patient’s coagulative state making it ideal for use in patients on anticoagulant therapy [ , ].
Holmium energy was first used in the prostate in conjunction with Nd:YAG in 1994. Following coagulation with the Nd:YAG wavelength (1064 nm), holmium was used to create a channel using vaporization and incision. The procedure was termed combination endoscopic laser ablation of the prostate (CELAP). The neodymium component was omitted in favor of a holmium-only approach using a side-firing fiber in the technique named Holmium Laser Ablation of the Prostate (HoLAP) [ ]. This was subsequently modified to enable direct resection of adenomatous tissue using an endfire fiber resulting in the procedure known as Holmium Laser Resection of the Prostate (HoLRP). With the introduction of a mechanical soft-tissue morcellator, Holmium Laser Enucleation of the Prostate (HoLEP) evolved from the resection experience. HoLEP has continued to grow in popularity as different holmium lasers and morcellators have been produced but also due to its continued favorable outcomes from a range of authors [ , ]. During HoLEP, the laser fiber is stabilized in the end of the endoscope using a modified inner sheath and a ureteric catheter which enables the surgeon to control both the laser and endoscope at the same time.
Several approaches have been proposed, but the original HoLEP approach starts from incisions at 5 o’clock and 7 o’clock. These incisions will serve as the standard for the depth of dissection during the rest of the procedure. The capsule is defined by white tissue fibers running in a circular direction in contrast with the yellow charring findings when cutting prostate adenoma tissue. A 12 o’clock incision is often performed to separate the right and left lateral lobes. Subsequently, a transverse incision is made just proximal to the verumontanum, which connects the previous longitudinal incisions until the capsule planes are identified. If the baseline capsule of the median lobe is identified, the beak of the scope is pushed to sweep the median lobe below the distal part of the median lobe. Enucleation of a large median lobe may result in the creation of a deep prostatic fossa and high bladder neck because the bladder neck becomes relatively narrow in comparison to the distal wide fossa area where both lateral lobes were previously located. Complete enucleation of one lobe at a time is recommended. After enucleation of the median lobe, the endoscope is retracted distally to identify the verumontanum and the external urethral sphincter, which is generally attached distal to the verumontanum. The appropriate apical capsule plane dissection is very important for lateral lobe enucleation. Then, the dissection plane is extended to the 3 (left) and 9 (right) o’clock directions. The last step of lateral lobe enucleation is conjoining the two planes from the upper and lower incisions. The incision line that is made from the bladder neck to the 12 o’clock direction terminal point of dissection is extended transversely to meet the upward border of the mucosal incision made two steps previously. In most cases, connection of the plane is made anteriorly (at the 2 or 10 o’clock position). To avoid damage to the sphincter, the incision should be made closer to the adenoma side. After hemostasis is achieved, a transurethral morcellator is used to extract the tissue [ ].
Results
The efficacy of HoLEP is well established with consistent, statistically significant results across a range of studies, including multiple randomized controlled trials. Promising early outcomes were first reported by Gilling et al in 1998, in a prospective study of 64 patients with a mean prostate size of 75.3 cm 3 , with statistically significant improvements in Q max (8.9–23.4 mL/s at 1 month) and AUASA (23–8.6) [ ]. This has subsequently been reproduced in both prospective and retrospective studies, the largest of which is a retrospective study with a sample size of 1065 patients [ ]. Q max improvements range from increases of 157%–470%, while PVR is reduced by at least 80% [ , ]. More importantly, HoLEP has shown efficacy using validated symptom scores such as IPSS and AUASA, with reductions of greater than 70%, as well as more than 60% improvement in QoL or HRQL scores [ , ]. These improvements have been sustained in long-term studies, including an RCT by Gilling et al. with a 7-year follow-up period, as well as the large retrospective analysis from Elmansy et al which had a 10-year follow-up [ , ].
Many studies comparing the outcome of HoLEP and TURP have been published [ ]. In a randomized study of 120 patients, Westenberg et al. demonstrated that the 2-year follow-up results in patients undergoing HoLEP and TURP are comparable in terms of urodynamic parameters, potency, continence, and symptom scores [ ]. Compared with TURP, HoLEP takes longer to perform, but perioperative morbidity, catheter time, and hospital stay are significantly lower in the HoLEP group. Kuntz et al. performed a similar study in 200 patients with a 1-year follow-up [ ]. The authors found a significantly longer operative time in the HoLEP group, but a significantly shorter catheterization time and hospital stay. Interestingly, at 6-month and 12-month evaluation, the postvoid residual urine volume was significantly lower in the HoLEP group, whereas all other urodynamic parameters were statistically comparable [ ]. Tan et al. compared the outcome of HoLEP and TURP in 61 patients with BPE and prostate volume between 40 and 200 mL [ ]. The urodynamic assessment at 6-month follow-up indicated better relief of urodynamic obstruction in HoLEP patients, with significantly lower detrusor pressure at maximum flow [ ]. Montorsi et al. performed a two-center prospective and randomized study comparing HoLEP and TURP in 100 consecutive patients [ ]. The authors’ results confirmed the conclusions of the previously described studies. Recently, Ahyai et al. [ ] reported their 3-year follow-up results of the Kuntz et al. study [ ], which demonstrated the durability of the outcome of both HoLEP and TURP; Ahyai et al. substantially confirmed the good long-term outcome of HoLEP compared with TURP [ ]. Finally, Wilson et al. [ ] analyzed the 2-year results of a randomized study on 61 patients subjected to HoLEP and TURP with prostates more than 40 g. In this particular population of patients, the authors found better urodynamic results and greater volume reduction in patients undergoing HoLEP. In conclusion, four different prospective randomized and well-designed studies have demonstrated that HoLEP is at least as effective as TURP in relieving LUTS due to BPE. Moreover, some advantages related to postoperative parameters and better urodynamic findings in some patients have been demonstrated for patients undergoing HoLEP [ ].
The outcome of patients submitted to HoLEP compared with that of patients submitted to OP has been also addressed in randomized studies [ , ]. The main advantages found in the HoLEP patients were related to the lower hemoglobin loss and transfusion rate, catheterization time, and postoperative hospital stay. The functional results were comparable in both studies, whereas a longer operative time was needed in the HoLEP groups. Moreover, the outcome of patients presenting with very large prostates was reported in different studies [ ]. All of these studies confirmed the feasibility and the satisfactory results of HoLEP in these patients, thus providing similar results with a less invasive procedure. Table 13.2 shows some of the reported functional results of patients undergoing HoLEP for BPO [ , , , ].
| Kuntz et al. [ ] | Kuntz et al. [ ] | Briganti et al. [ ] | Gupta et al. [ ] | Naspro et al. [ ] | Wilson et al. [ ] | Montorsi et al. [ ] | Gilling et al. [ ] | Kuntz et al. [ ] | |
|---|---|---|---|---|---|---|---|---|---|
| Follow-up (mo) | 18 | 12 | 24 | 12 | 24 | 24 | 12 | 72 | 60 |
| Patients (n) | 60 | 100 | 60 | 18 | 41 | 31 | 52 | 71 | 60 |
| Mean prostate size (mL) | 114.6 | 53.5 | 73.3 | 57.9 | 113.27 | 77.8 | 70.3 | 58.5 | 114.6 |
| PSA reduction (%) | NA | NA | NA | NA | NA | NA | NA | NA | NA |
| Change in symptoms (%) | − 90 | − 92 | − 83 | − 78 | − 61 | − 77 | − 81 | − 67 | − 86 |
| Change in Q max (mL/s) (%) | 23.60 (721) | 23 (569) | NA | 19.20 (527) | 11.36 (245) | 12.6 (250) | 16.9 (306) | 10.9 (235) | 20.5 (639) |
| PVR change (%) | − 97 | − 98 | NA | − 83 | NA | NA | NA | NA | − 96 |
| LE | 1b | 1b | 1b | 1b | 1b | 1b | 1b | 3a | 1b |
Complications
One of the most interesting characteristics of the HoLEP procedure is represented by the low rates of intraoperative and perioperative complications. From the outset of use of HoLEP, the lower rates of blood transfusions and the shorter catheterization time encouraged urologists to accept HoLEP as a minimally invasive procedure for the treatment of BPH. To date, a large number of patients in many different institutions have been treated, and the rate of complications can be safely listed as almost definitive [ ]. Table 13.3 lists the rate of intraoperative, perioperative and postoperative complications reported by some of the largest published studies [ , , , ]. It is of note that the rates of transfusion, reintervention for bleeding, and retention of clots are extremely low. Moreover, the rates of reintervention during follow-up for residual prostate adenoma are very low and can be compared with those seen in patients subjected to OP. Some studies have analyzed the rate of complications with regard to advances in the learning curve. As expected, the incidence of complications such as recatheterization and transient and permanent urinary incontinence decreased as experience with the procedure increased [ ]. Moreover, an analysis of the complication rate according to prostate size was performed by Vavassori et al. [ ]. The authors found a significantly higher rate of bladder mucosal injury, urethral stenosis, and bladder-neck stenosis in patients with prostate volume more than 50 g.
| Kuo et al. [ ] | Montorsi et al. [ ] | Westenberg et al. [ ] | Kuntz et al. [ , ] | Elzayat et al. [ ] | Naspro et al. [ ] | Wilson et al. [ ] | Kuntz et al. [ ] | Vavassori et al. [ ] | Shah et al. [ ] | |
|---|---|---|---|---|---|---|---|---|---|---|
| No. of patients | 206 | 52 | 61 | 100 | 552 | 41 | 31 | 120 | 330 | 280 |
| Mean prostate volume (mL) | NA | 70.3 | 44.3 | 53.5 | 83.7 | 113.2 | 77.8 | 114.6 | 62 | 29.8 |
| Mean prostate weight (g) | 68.2 | 36.1 | NA | 32.6 | 52.1 | 59.3 | NA | 83.9 | 40 | 54.6 |
| Intraoperative | ||||||||||
| Capsular perforation | 1.5% | 0% | NA | NA | 0.3% | NA | NA | NA | NA | 9.6% |
| Bladder injury | 1.9% | 18.2% | NA | NA | 0.7% | 7.3% | NA | NA | 5.7% | 0% |
| Ureteral orifice damage | 0% | 0% | NA | NA | 0% | 0% | NA | NA | 0.3% | 2.1% |
| Postoperative | ||||||||||
| Blood transfusions | 1.0% | 0% | 0% | 0% | 1.4% | 4% | 0% | 0% | 0% | 1.8% |
| Transient irritative symptoms | NA | 58.9% | NA | NA | 9.4% | 10.8% (12 mo.) | NA | NA | 28% | |
| Transient stress incontinence | NA | 44.0% | 3.2% | 5.0% | 4.2% | 34.1% | 3.2% | 8.3% | 7.3% | 10.7% |
| Permanent incontinence | NA | 1.7% | ? | 1.1% | 0.5% | 2.4% | 0% | 1.6% | 0.6% | 0.7% |
| Urinary tract infection | NA | NA | 4.9% | NA | 1.1% | 0% | NA | NA | 3.2% | |
| Recatheterization | 7.8% | 5.3% | 8.1% | 0% | 1.4% | 12.1% | 16.1% | 5.0% | 5.1% | 3.9% |
| Clot retention/bleeding | 2.4% | 1.7% | NA | 1.0% | 0.7% | 2.4% | NA | 5.0% | 0.7% | |
| Follow-up | ||||||||||
| Bladder-neck contracture | 3.9% | 0% | 4.9% | 3.1% | 1.3% | 5.4% | 0% | 1.7% | 0.6% | 0.4% |
| Urethral stricture | 2.4% | 1.7% | 3.2% | 4.1% | 1.3% | 0% | 0% | 3.3% | 3% | 2.1% |
| Meatal stenosis | NA | 0% | 6.5% | 0% | 0.5% | 0% | 3.2% | 0% | 0% | 2.5% |
| Reintervention for residual adenoma | NA | 0% | 1.6% | 1.0% | 0.3% | 0% | 0% | 3.3% | 2.7% | 0% |
The impact on sexual function of HoLEP was investigated by Briganti et al. in 2006 [ ]. The authors compared the 2-year postoperative International Index of Erectile Function (IIEF) questionnaire in 60 patients subjected to TURP and in 60 patients subjected to HoLEP. They demonstrated that both TURP and HoLEP significantly lower the orgasmic function domain of the IIEF because of retrograde ejaculation. No difference in the overall erectile function, however, was noted between the patients undergoing the two procedures.
Thulium Laser Enucleation of the Prostate (ThuLEP)
Principles of Surgical Technique
The thulium (Tm) laser has a wavelength of 2013 nm and a penetration depth of 0.25 mm, using water as the absorbing chromophore [ ]. Unlike holmium, energy is released in a visible continuous wave [ ]. Two forms of thulium lasers are currently used in clinical practice—Tm-YAG (Revolix) and Tm-fiber (Vela XL) [ ]. Similar to holmium, the thulium laser can be used for vaporization, resection, or enucleation. First used for BPH in 2005 by Xia et al., a Tm:YAG laser was used for a procedure known as thulium laser resection of the prostate (TmLRP-TT) in which thulium laser is used to resect the prostate into small tissue chips [ ]. Another version is known as thulium vaporesection of the prostate (ThuVARP), referring to a combination of vaporization and resection [ , ]. In 2009, Bach et al. then adopted enucleation which became Thulium VapoEnucleation of the prostate (ThuVEP) initially, analogous to HoLEP. This has been further refined to become thulium laser enucleation of the prostate (ThuLEP), in which the incision is apical rather than the original three-lobe HoLEP/ThuVEP, and blunt enucleation is used more, for dissection to the surgical capsule [ , ].
Results
ThuLEP is extremely similar to ThuVEP except that enucleation of the adenoma is done mechanically without the use of energy. The initial cuts are still made with the laser [ ]. Due to the continuous pulse, vaporization occurs whenever the laser is employed. Indeed, in papers the description between the two techniques is often indistinguishable [ , ].
Iacono and colleagues described a series of 148 men who underwent ThuLEP with large prostate size (108 ± 24 mL) who underwent the procedure using the 120 W RevoLix laser with 12 months of follow-up. Significant improvements were seen in IPSS, QoL, and PVR [ ]. Complications included UTI in 19 patients (12.8%), postoperative urgency incontinence in 10 (6.7%), early recatheterization with residual tissue at prostatic apex in four patients (2.7%), blood transfusion in four patients (2.7%), and bladder injury during morcellation in 2 patients (1.3%). There was significant increase in IIEF but the absolute difference in score was very small (19.3 ± 8.2–20.3 ± 8.2, P < .05).
Rausch and colleagues performed ThuLEP between 2008 and 2012 in 234 patients with a mean prostate size of 84.8 ± 34.9 mL using the RevoLix (power not specified). Overall the 30-day complication rate was 19.7%. In the perioperative period, only 3% of patients experienced a UTI, 6.8% required catheter replacement and 0.9% required a blood transfusion. In the postoperative period, 3% experienced urgency incontinence and 2.1% experienced bladder neck stricture [ ]. Complications occurring after 30 days included stress incontinence in one patient (0.5%) and inability to void requiring chronic catheterization in 19 (8.1%) patients. Predictors of complications in univariate and multivariate analysis were age > 80 years and prostate size < 50 mL [ ].
Very few studies have addressed sexual outcomes in detail following any thulium laser prostatectomy. In 2015, Carmignani and colleagues evaluated sexual outcomes in 110 men undergoing ThuLEP with the Cyber 150™ W laser in a prospective study using validated instruments. Patients were evaluated before surgery and at 3 and 6 months after ThuLEP with IPSS, IIEF-5 and ICIQ-Male Sexual Matters associated with Lower Urinary Tract Symptoms (ICIQ-MLUTSsex) [ ]. While a significant and sustained improvement in the scores evaluating urinary symptoms was observed, there were no significant differences in erectile function before and after surgery. Table 13.4 shows some of the reported functional results of patients undergoing ThuLEP for BPO [ , , ].
Related posts:
Pathologic Triggers Related to LUTS and BPH
The Relationship Between Inflammation and LUTS/BPH
Medical Aspects of the Treatment of LUTS/BPH: Alpha-Blockers
Diagnostic Work-up of LUTS/BPH: From Standard to New Perspectives
Phytotherapy in Benign Prostatic Hyperplasia
Surgical Management of LUTS/BPH: New Mini-Invasive Techniques
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
