682 THE LONG-TERM DURABILITY OF HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP)

681



682

Comparison of treatment outcomes between photoselective vaporization and transurethral resection of the prostate depending on experiences of surgery

The Long-Term Durability of Holmium Laser Enucleation of the Prostate (HoLEP)

Park J., You C.H., Hong B., Choo M.S., Kim C.S., Ahn H., Ahn T.Y.

Tauranga Hospital, Urology, Tauranga, New Zealand

Asan Medical Center, Urology, Seoul, South Korea Introduction & Objectives: Since the advent of photoselective vaporization of the prostate (PVP), it has been questionable if effectiveness of PVP is equivalent to that of the standard transurethral resection of the prostate (TURP). Taking into consideration learning curve of PVP, we prospectively compared treatment outcomes of PVP with those of TURP. Material & Methods: A prospective clinical trial was performed from October 2004 through June 2006, with 131 patients treated by PVP and 41 patients treated by TURP. PVP was performed by one operator who started the operation and TURP was performed by another operator who had previously experienced over 800 surgeries. Efficacy parameters were International Prostate Symptom Score, quality of life score, peak urinary flow rate, postvoid residual volume, and prostatic volume reduction estimated by transrectal ultrasonography. In addition, perioperative parameters and complications were compared at 1, 3, 6 and 12 months following surgery, taking into consideration the operative period of PVP (the first half and second half). Results: Baseline characteristics of both groups were similar. Operating time, catheter indwelling time, and hospital stays were significantly shorter in the PVP group. All efficacy parameters of the PVP group significantly improved compared to preoperative parameters irrespective of operative period; the degree of improvement of efficacy parameters was similar in both groups within 12 months. Prostatic volume reduction in the second half of PVP was larger than that of first half, however, was less than that of TURP. Prostatic volumes at pre- and post-operative 6 months were 41.7±15.6 and 33.1±12.4ml during the first half, 42.7±13.0 and 30.9±10.7ml during the second half, 47.4±17.1 and 25.4±9.5ml for TURP, respectively. In the PVP group, mean operating times for the first half and second half were 49.9±22.0 and 52.9±16.9 min (p>0.05); applied energies were 95.0±44.5 and 143.2±40.7 kJ, respectively (p<0.001). There were no differences in overall complications between PVP and TURP groups although more transfusions were required and capsule perforations occurred in the TURP group. In the PVP group, urethral stricture was more common in the first half and urinary retension requiring re-catheterization was more common in the second half. Incidence of complications such as gross hamaturia, frequency, urgency, and retrograde ejaculation was not different according to PVP operative period. Conclusions: PVP provides excellent intraoperative safety and helps immediate relief from obstructive voiding symptoms, similar to TURP, although operators don’t have enough experiences. The degree of prostatic volume reduction of PVP increases with the operator’s experience but is less than that of TURP. Long-term follow-up is necessary to assess the durability of PVP.



683

Prostate injection of Botulinum Toxin A treatment of BPH patients with an indwelling catheter due to urinary retention and unfit for surgery Silva J., Dinis P., Silva C., Saraiva L., Silva A., Pinto R., Cruz F. Hospital de S. João, Urology, Porto, Portugal Introduction & Objectives: To evaluate the effect of intraprostatic injection of Botulinum Toxin A (BTX-A, Botox) in BPH patients with indwelling catheter due to urinary retention and unfit for surgery. Primary objective was to determine the number of patients that could resume voiding. As secondary objectives Qmax, post-void residual urine, prostate volume and total serum PSA were determined Material & Methods: Thirteen men with BPH on chronic indwelling catheter for at least 3 months, who were not candidates for surgery because of poor general condition, received 200U BTX-A injection in the transition zone under transrectal ultrasound guidance. Fifteen days later a first attempt to remove the urethral catheter was done. Patients were re-evaluated at 1 and 2 months after treatment. Results: Patients had a mean age of 80,2 years. Injection was done without anaesthesia as an outpatient procedure. No significant local effects occurred. One patient referred a very mild asthenia during the first 3 days after injection. At 1 month, 10 patients (77%) were voiding spontaneously with a mean Qmax of 11,4 ± 5 ml/sec. At 2 months 11 patients (85%) had spontaneous voiding with a mean Qmax of 10,3 ± 4 ml/sec. Residual urine was 73±88 ml at 1 month and 88±109 ml at 2 months. Prostate volume was significantly reduced, from 70,5 ± 53 ml at baseline to 59,9 ± 53 ml at 1 month (p<0.004). At 2 months a further reduction to 46,4 ± 34 ml (p<0.04) was found. Mean total PSA was not significantly altered (5,7±3.8 ng/ml at baseline, 5.1±3.6 ng/ml at 1 month and 5.4±3.6 ng/ml at 2 months). Conclusions: BTX-A injection into the prostate seems to be a promising treatment for BPH patients in urinary retention who are unfit for surgery. The procedure has rare side effects and seems to act by reducing prostate volume. Future studies will determine the duration of BTX-A effect.

Gilling P., King C., Williams A., Wilson L., Westenburg A., Fraundorfer M.

Introduction & Objectives: The issue of durability is an important concern when evaluating new surgical modalities. To date, only 24 month data from 3 RCT’s has been published concerning HoLEP despite its widespread use worldwide although 4 year data exists for the earlier technique of Holmium resection. This study addresses the issue of durability of HoLEP. Material & Methods: Patients who had undergone HoLEP and been evaluated in 3 prospective trials conducted at this institution between 1997 and 2002 were evaluated. All patients were urodynamically obstructed preop., had no previous surgery and had been extensively evaluated for the first two years postoperatively. At follow-up, those available had an IPSS, Qmax, QOL, ICS Male (SF), IIEF, BPH-Impact Index and continence questionnaire. Results: The mean age of the patients at follow-up was 75.7 (58-88) years. Of 70 HoLEP patients originally studied on protocol, 38 (54%) were available for analysis, 14 were deceased and 18 were lost to follow-up. The mean follow-up was 5.7(4.1 – 8.1) years. The mean IPSS was 8.5(0-24) and Qmax 18.8(6-28) ml/s. The QOL score was 1.7(0-5) and the BPH-II 2.0 (011). 1 (3%) patient had required re-operation. 7 patients were dissatisfied with there outcome the remainder (82%) were either satisfied or extremely satisfied. 13 patients (34%) still had erections sufficient for intercourse compared with 19 (50%) pre-operatively. At follow-up 7 patients had some degree of incontinence compared with 12 before their surgery Conclusions: HoLEP is durable and most patients remain satisfied or extremely satisfied in the long-term with the outcome overall.



684

Ex-vivo evaluation of new 980nm diode laser device for treatment of benign prostatic enlargement Wendt-Nordahl G., Huckele S., Honeck P., Alken P., Knoll T., Michel M.S., Häcker A. University Hospital Mannheim, Urology, Mannheim, Germany

Introduction & Objectives: Various laser techniques offer an alternative to transurethral resection of the prostate (TURP) in surgical treatment of benign prostatic enlargement. We evaluated a lately introduced diode laser system working on a wavelength of 980nm. As this wavelength offers a high absorption in water as well as in haemoglobin, the laser combines high tissue ablation with good haemostasis. Material & Methods: The well established ex-vivo model of the isolated blood-perfused porcine kidney was used to evaluate the Ceralas HPD150 Laser system (Biolitec AG, Jena, Germany) using different output power parameters (30, 50, 60, 80, 100, 120 Watt) in the continuous wave and pulsed mode. The results were compared to the reference standard 80 Watt potassium-titanyl-phosphate (KTP)-Laser (Laserscope, USA) and conventional TURP. N=5 experiments were carried out per parameter. Porcine kidneys were weighed before and after 10 minutes of laser ablation in an area of 3x3cm; the weight difference marked the amount of ablated tissue. Bleeding was determined by the weight difference of a swab before and after it was placed on bleeding surface for 60 seconds after ablating an area of 9cm2. Samples of the ablated area were taken and processed for histological determination of the coagulation zone. Results: The diode laser displayed increasing tissue ablation capacity at higher output powers. The tissue ablation at 100 Watt reached 6.06±1.54g after 10 minutes. The KTPLaser offered a significantly lower ablation of 3.99±0.48g after 10 minutes (p<0.05), whereas only 30 seconds were needed to resect the tissue in the same surface area using TURP, resulting in 8.28±0.38g of tissue ablation. The bleeding rate at 100 Watt was 0.09±0.03g/min for the diode laser compared to 0.21±0.07g/min for the KTP-Laser and 20.14±2.03g/min for TURP (p<0.05). The corresponding depths of the coagulation zones were 255.1±28.3µm for the diode laser, 666.9±64.0µm for the KTP-Laser (p<0.05) and 287.1±27.5µm for TURP. Using the pulsed mode (5 Hz), at 100 Watt tissue ablation was slightly reduced to 5.21±1.06g compared to 6.06±1.54g for the continuous-wave mode. In contrast bleeding was significantly higher in the pulsed mode (0.54±0.56g/min vs. 0.09±0.03g/min; p<0.05), whereas the depth of the coagulation zone was similar (208.8±30.8µm vs. 255.1±28.3µm). However, the coagulation zone using the continuous-wave mode appeared much denser. Conclusions: In our standardized ex-vivo investigation, the Ceralas HPD150 Laser offers a higher ablation capacity and similar haemostasis compared to the KTP-Laser. Compared to TURP both tissue ablation and bleeding rate are significantly lower. The promising ex-vivo results warrant further clinical investigation.

Eur Urol Suppl 2007;6(2):193