735Day case holmium laser enucleation of prostate: An early experience

PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE P R O S P E C T I V E E V A L U A T I O N IN 88 H I G H RISK PATIENTS

733

734

(PVP):

PHOTOSELECTIVE LASER VAPORIZATION OF THE PROSTATE (PVP): P E R I O P E R A T I V E DATA AND C O M P L I C A T I O N RATE O F H1 G HR I S K PATIENTS W I T H I N T R A O P E R A T I V E A N T I C O A G U L A T I O N (A K) AND I N H I B I T O R S O F P L A T E L E T A G G R E G A T I O N (IPA)

Reich O.1, Bachmann A.% Zaak D. t, Gratzke C / , Ruszat R. 2, Seitz M ? , Sulser T?, St±el C.1 ~Klinikum der Universit/it Mtinchen - Groghadern, Dept. of Urology, M~nchen, Germany, 2Klinikum der Universidit Basel, Dept. of Urology, Basel, Switzerland I N T R O D U C T I O N & O B J E C T I V E S : High power (80W) Photoselective Vaporization of the Prostate (PVP) is a novel technique, in which instant hemostatic tissue ablation is achieved. The objective of this study was to evaluate this procedure in patients with lower urinary tract symptoms (LUTS) at high risk and/or long-term ant±coagulation, which are commonly denied surgical treatment.

Bachmann A.I, Reich O. ~, Ruszat R. 2, Wyler S.2, Seifert H.H. 2, Sulser T.2 iLudwig Maximilian University, Urology, Munich, Germany, 2University Hospital Base[, Urology, Basel, Switzerland INTRODUCTION & OBJECTIVES: To evaluate the feasibility of PVP in high-risk patients with long-term ant±coagulation. MATERIAL & METHODS: In a consecutive series of 160 patients (pts.) with symptomatic benign prostate hyperplasia (BPH) a total of 23 pts. (AK-group) and 46 pts. (IPA-group) were treated with ongoing ant±coagulation and inhibitors of platelet aggregation, respectively. Both groups are compared to the control group (controls) in terms of per±operative data and early complication rate. RESULTS:

M A T E R I A L & METHODS: Between September 2002 and August 2004, 88 patients at high cardiopulmonary risk (presenting with an American Society of Anesthesiology (ASA) - Score _> 3) with LUTS were enrolled in a prospective multicenter trial and underwent PVP Potassium-Titanyl-Phosphate (KTP) - laser vaporization of the prostate. In addition, 41 patients received ongoing oral anticoagulant therapy (n=37) or suffered from severe bleeding disorders (n=4). Mean follow-up was 12.6 months. RESULTS: In all 88 patients the procedure could be performed without major complication intra- and postoperatively; no blood transfusion was required. Mean operating time was 54+20 min, mean preoperative prostate volume was 55=~38 ml. Three patients had to be re-operated due to recurrent urinary retention (2 TURP, 1 PVP). Catheterization time averaged 1.9±2 days. At 1, 3, 6 and 12 months the IPSS decreased from 20.2±7 to 11.9~:7, 8.3±7, 7.9±6 and 7.1±7, respectively. The urinary peak flow increased from 7.1±5 ml/s preoperative to 17.7J:8 ml/s, 18.1±9 ml/s, 18.4±7 ml/s and 19.1±9 ml/s, respectively.

Number of patients Total prostate volume (ml) Age (years) Operating time (rain) Applied energy (kJ) Change hemoglobin (24h) Change sodium (24h) Time of catheter removal (days) Transfusion rate Clot retention0 Transient hematuria

I

Controlls 91 53

AK-Group 23 55

IPA-Group I P 46 54 Ns

69 53 179 -8.6%

73 46 182 -7.4%

84 58 164 -9.4%

<0.00 l ns ns ns

- 1.1% 1.7

- 1.8% 2.0

- 0.8% 1.7

ns ns

0 0 0

0 0 2 (9%)

0 I (2%)

Data presented in the table (means). C O N C L U S I O N S : Based on our experience, we believe that photoselective vaporization of the prostate (PVP) is a hemostatic, therefore safe but efficient option for critically ill patients and patients on oral ant±coagulation.

CONCLUSIONS: PVP is characterized by excellent hemostatic properties in combination with very low intraoperative complication rate. Therefore, PVP is feasible even in high-risk patients with ongoing ant±coagulation.

735

736

DAY CASE HOLMIUM L A S E R E N U C L E A T I O N O F PROSTATE: AN EARLY EXPERIENCE

H O L M I U M LASER ENUCLEATION OF THE PROSTATE (HOLEP) VERSUS OPEN PROSTATECTOMY FOR PROSTATES >70 GR: 1 Y E A R FOLLOW-UP

Lee G?, Tsiriopoalos ][.2, Marathe S. 2, Crisp j.2 ~Institute of Urology and Nephrology, Urology, London, United Kingdom, 2Watford General Hospital, Urology, Watford, United Kingdom

Naspro R., Suardi N., Salonia A., Mazzoccoli B., Di Girolamo V., Colombo R., Guazzoni G., Rigatti E, Montorsi F. University Vita-Salute San Raffaele, Urology, Milan, Italy

INTRODUCTION & OBJECTIVES: Transurethral resection of prostate is associated with blood loss, TUR syndrome and requires overnight hospital stays. Holmium laser enueleation of prostate is equally efficacious and has less complication. We examine the safety, effectiveness and patient satisfaction of holmium laser enucleation of prostate carried out as a day case procedure.

INTRODUCTION & OBJECTIVES: A prospective, randomised study comparing outcomes and 1 year follow-up between holmium laser enucleation (HoLEP) and standard open prostatectomy for the treatment of benign prostatic hyperplasia (BPH) of prostates >70 gr.

MATERIAL & METHODS: Patients with no significant co-morbid±ties were prospectively recruited for day case holmium laser enucleation of prostate over a sixmonth period. After undergoing the procedure, patients were monitored on the ward and discharged home with indwelling urethral catheters. Trials of void were carried out on the following day, when the haemoglobin levels were also recorded. Patients were assessed six and twelve weeks after the procedure for the IPSS, flow rates, post void residuals and complications.

MATERIAL & METHODS: From March to August 2003, 40 consecutive patients with symptomatic BPH were randomised to be treated surgically either with HoLEP (group l, n 20) or standard open prostatectomy (group 2, n 20). Patients of both groups were pre-operatively assessed by scoring of subjective symptoms with International Prostate Symptom Score (I-PSS) and Quality of life (QoL) questionnaires. Physical exam including digital rectal examination, total serum PSA level, kidney-bladder and taans-rectal prostatic ultrasonography. Total time in the operative room, time of morcellation, total grams of tissue removed, pre~operative and post-operative serum hemoglobin levels, time of catheterization, of hospital stay and histologic diagnosis were also assessed. Patients were evaluated at 1 and 3 and 12 month follow-up with the same tests.

RESULTS: Twenty patients were recruited and 2 were excluded due to overnight admission after prolonged procedures. The patients have mean age of 68.1 years (55-81 years), pre-op IPSS of 24 (18-30), Q max of 8.4 ml/s (3.0-13.8 ml/s) and post void residual of 138 ml (80-192ml). The mean resection time was 40 minutes (11-92 minutes), mean hospital stay was 7.5 hours (6.5-10 hours) and mean catheter time was 30.9 hours (18-96 hours).The post-op haemoglobin remained unchanged. Two patients failed trial of void the following day but all patients were catheter free by 4 days. Three post-operative complications were recorded including paraphimosis, catheter obstruction and perineal pain. The six-week follow-up revealed mean IPSS of l 1.5(1-30), Q max of 19.9 ml/s(9.5-29.4 ml/s) and post void residual of 56 ml (0-92ml). The mean weight resected was 15.7g (2-46g) and one was positive for adenocarcinoma. The second follow-up demonstrated sustained improvement in IPSS, Q max and post void residual. The self-administered questionnaire revealed 3 patients worried about early discharge and catheter care, but 83% thought it was a good idea and 94% were assured by the post-operative instructions. CONCLUSIONS: Day case holmium laser enucleation of prostate is safe, effective and economical. It is not associated with fluid absorption, blood loss or major complication. Our series demonstrate a sustained improvement in IPSS, flow rates and post-void residuals. Most patients arc also satisfied with the management. Despite 10% of patients failed the day care procedure, the procedure still generates economic advantage since it does not require overnight stay and has mean hospital stay of only 7.5 hours.

European Urology Supplements 4 (2005) No. 3, pp. 186

RESULTS: The mean pre-operative trans-reetal ultrasound volume of the prostates was (mean+SE) 108.15±30.5 gr and 116.7±24.02 gr (p=0.33) and volume of the adenoma was (mean±SE) 75.8±34.5 gr and 82.5±4.5 gr (p=.0.41), in the HoLEP and open prostatectomy groups respectively. Pre-operative total PSA values (mean+SE) were 5.8±3.0I ng/dl and 6.9~2.89 ng/dl (p-0.29) and the mean weight of the specimens was 28.3±3.3 gr and 12.6±2.04 gr (p=0.005), in the HoLEP and open prostatectomy groups respectively. Time of the operation was overall longer in the HoLEP group (62.9±18.3 mins vs. 53.5±11.5 mins, p=0.06), whilst catheter removal (1.5±1.07 days and 4.1±0.5 days) and hospital stay (2.7±1.07 days vs. 5.4±1.05 days, p<0.00l) were significantly shorter in the HoLEP group compared to open prostatectomy. Day 1 post-operative hemoglobin levels were 12.3±1.8 g/dl vs. 11.1±1.64 g/dl (p 0.04) in the HoLEP and open prostatectomy groups respectively. Twelve patients from the open prostatectomy group required blood transfusion compared to four from the HoLEP group (p<0.07). At 1, 3 and 12 month follow-up no statistical difference was seen between the two groups at uroflowmetry, at IPSS and QoL. At 3 months follow-up, 3 patients still cmnplained of mild stress incontinence in the HoLEP group and 2 from the open prostatectomy group, all resolved at the 12 month follow-up, incidence of uretral strictures and overall reintervention was similar in both groups at the 1 year follow-up. CONCLUSIONS: HoLEP for treatment of BPH with prostates >70 gr is a feasible technique guaranteeing similar results to open prostatectomy after 1 year follow-up. Furthermore, the reduction in catheterization, hospital stay and blood loss make HoLEP an attractive endourologie option for the treatment of larger prostates.