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Holmium laser enucleation of prostate for patients in urinary retention
ADULT UROLOGY
HOLMIUM LASER ENUCLEATION OF PROSTATE FOR PATIENTS IN URINARY RETENTION EHAB A. ELZAYAT, ENMAR I. HABIB,
AND
MOSTAFA M. ELHILALI
ABSTRACT Objectives. To evaluate holmium laser enucleation of the prostate in patients presenting in urinary retention secondary to benign prostatic hyperplasia. Methods. From May 2000 to May 2004, 169 patients, with a mean age of 74 years, who presented in urinary retention secondary to benign prostatic hyperplasia underwent holmium laser enucleation of the prostate. The mean urinary volume drained at catheterization was 670 mL (range 132 to 2000). All the patients were assessed preoperatively, 1, 3, 6, and 12 months postoperatively, and every year thereafter. All the patients were evaluated by physical examination, digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire, uroflowmetry (whenever possible), postvoid residual urine volume measurement, and prostate-specific antigen. The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351). Results. The mean catheter time and hospital stay was 1.6 and 1.7 days, respectively. The peak urinary flow rate, postvoid residual urine volume, and International Prostate Symptom Score and quality-of-life score were significantly improved by 1 month after surgery and continued to improve during subsequent follow-up. Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two used clean intermittent catheterization. Four patients (2.4%) were receiving anticoagulant therapy and required blood transfusion. Bladder neck contracture and urethral stricture developed in 1.7% and 1.2%, respectively. Conclusions. Holmium laser enucleation of the prostate represents a safe and effective treatment for patients with benign prostatic hyperplasia presenting in urinary retention. It has low morbidity and provides immediate symptom and voiding improvement. UROLOGY 66: 789–793, 2005. © 2005 Elsevier Inc.
I
n aging men, benign prostatic hyperplasia (BPH) and the related lower urinary tract symptoms are a common problem that has an impact on daily activity and quality of life and may lead to serious outcomes.1 The information from the Olmsted County study demonstrated that a 60-year-old man with moderate to severe lower urinary tract symptoms would have a 13.7% chance of developing acute urinary retention (AUR) within 10 years or an incidence rate of 0.7% per year.2 Taube and Gajraj3 reported that 72% of patients with AUR due M. M. Elhilali is a study investigator funded by Lumenis, Inc. From the Division of Urology, McGill University School of Medicine, Montreal, Quebec, Canada Reprint requests: Mostafa M. Elhilali, M.D., Ph.D., Division of Urology, Department of Surgery, Royal Victoria Hospital, McGill University Health Center, 687 Pine Avenue West, Room S6.95, Montreal, QC H3A 1A1, Canada. E-mail: mostafa.elhilali@ muhc.mcgill.ca Submitted: January 8, 2005, accepted (with revisions): April 21, 2005 © 2005 ELSEVIER INC. ALL RIGHTS RESERVED
to BPH have an unsuccessful voiding trial after catheter removal. It was reported that about 77% of patients with a first episode of AUR required prostate surgery within the next 2 years.4 Transurethral resection of the prostate (TURP) is still the reference standard for treatment of benign prostatic obstruction; however, TURP has a mortality rate of 0.2% and immediate postoperative morbidity develops in 18% of cases. This morbidity is more common in patients presenting with retention (24%).5 For patients with a high operative risk, as well as patients with a large prostate volume and urinary retention, an alternative treatment modality is required. Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive and effective surgical treatment of benign prostatic obstruction caused by prostate glands of all sizes and provides the modern alternative to TURP with low morbidity.6,7 The advantages of HoLEP compared with TURP are a lower amount of blood loss, particularly in patients 0090-4295/05/$30.00 doi:10.1016/j.urology.2005.04.049 789
receiving anticoagulation therapy, the lack of transurethral resection syndrome, use of normal saline as the irrigant, and a shorter convalescence. Several studies have reported the efficacy and safety of HoLEP in patients with symptomatic BPH. Some have included patients with urinary retention, but the number of patients has been small. Most data available on surgical management of AUR indicate a high complication rate.5 The aim of the present study was to evaluate HoLEP for patients with symptomatic BPH presenting in urinary retention, with an emphasis on efficacy and complications. MATERIAL AND METHODS This study included 169 patients with urinary retention secondary to BPH who required an indwelling catheter. Twenty-six men were able to void with minimal flow but had a large postvoid residual (PVR) urine volume requiring clean intermittent catheterization (CIC). Most patients had already tried medical therapy, which had failed. The preoperative evaluation included physical examination with a focused neurologic examination and digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire (IPSS) for the period before the episode of retention, a trial without a catheter during alpha-blocker therapy, measurement of PVR urine volume, uroflowmetry for patients who were able to void, prostate volume measurement using transrectal ultrasonography, and prostate-specific antigen determination, with transrectal ultrasound-guided biopsy when necessary. The exclusion criteria included neurogenic bladder, urethral stricture, and prostate cancer.
HOLEP EQUIPMENT AND TECHNIQUE The equipment we used was an 80 to 100 W holmium: yttrium-aluminum-garnet laser (Versapulse, Lumenis, Santa Clara, Calif), a 550-m end-firing fiber (SlimLine 550, Lumenis), a modified continuous-flow 26F resectoscope with a distal bridge, a 7F catheter with a proximal bridge to stabilize the laser fiber, continuous saline irrigation, a rigid indirect nephroscope, a tissue morcellator (Lumenis), and a video system. All laser surgeries were performed by a single surgeon (M.M.E.). HoLEP was performed as previously described by Gilling et al.,8 Fong and Elhilali,9 and Kuo et al.10 Intravenous furosemide was administered (20 mg/hr of enucleation) and almost always coincided with the end of enucleation to counteract any fluid absorption and enhance urine flow. Intermittent bladder irrigation was delivered through a Y-connector without changing the catheter. If the hematuria persisted despite intermittent irrigation, continuous irrigation was instituted using a three-way catheter. The catheter was routinely removed the next morning. When the patient was able to void adequately, he was discharged from the hospital. All patients were given prophylactic antibiotic before and during the procedure and for 1 week postoperatively. The operative time, total energy used, enucleation time, morcellation time, enucleated tissue weight, catheterization time, and hospital stay were recorded.
POSTOPERATIVE EVALUATION Follow-up evaluations after HoLEP were done for all patients during their visits at 1, 3, and 6 months and every year thereafter. The main values of peak urinary flow rate (Qmax), PVR urine volume, IPSS, and quality-of-life (QOL) score were 790
TABLE I. Mean operative data Variable
Mean (Range)
Enucleation time (min) Morcellation time (min) Enucleated tissue weight (g) Total energy used (Kj) Catheterization time (days) Hospital stay (days)
96.4 (15–255) 19.4 (2–120) 68.7 (5–340) 218.7 (22.8–602.4) 1.6 (1–21) 1.7 (1–34)
compared with the preoperative values using a paired Student t test, with P ⬍0.05 considered significant.
RESULTS From May 2000 to May 2004, 169 patients with a mean age of 74 years (range 50 to 93) presented with urinary retention requiring an indwelling catheter or CIC. Of the 169 patients, 23 (13.6%) voided with a minimal Qmax (mean 6.05 mL/s, range 1.9 to 10.7), but still had a high PVR urine volume (mean 601 mL, range 132 to 1800) requiring CIC. The remaining patients were unable to void and were considered to have a Qmax of 0 mL/s; the mean volume of urine drained at catheterization was 670 mL (range 132 to 2000). Thirteen patients (7.7%) had undergone TURP and two laser vaporization, and 39 patients (23%) were receiving anticoagulant therapy. Perioperative discontinuation and substitution of an oral anticoagulant was done on the basis of the cardiologic consultation findings. All patients who discontinued anticoagulant use started again the day after surgery. The mean enucleation time was 96.4 minutes, and the morcellation time was approximately 20% of the total operative time (mean 19.4 minutes). Morcellation efficiency was, on average, 3.5 g/min (weight of enucleated tissue/morcellation time). The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351), and the resected tissue weight was 68.7 g (range 5 to 340). The tissue weight could be misleading because a lot of the tissue is vaporized in the process. In 6 patients (3.5%), the adenoma was removed through a minicystostomy incision owing to the presence of multiple bladder stones in 1 case and the large size of the adenoma (range 146 to 351 g) in 5 patients (with inadequate morcellation progress in 2 of these patients). The main operative data are given in Table I. Continuous bladder irrigation was necessary in 8 patients (4.7%) for transient postoperative hematuria. Four patients (2.4%) were taking anticoagulant therapy and required blood transfusion. One patient had not stopped taking the anticoagulant before surgery and one had started anticoagulant therapy early in the postoperative period and developed clot retenUROLOGY 66 (4), 2005
TABLE II. Preoperative data and follow-up changes after HoLEP Follow-up (n)
Mean Qmax (mL/s)
Mean PVR (mL)
Mean IPSS
Mean QOL Score
Preoperative 1 mo (146) 3 mo (111) 6 mo (93) 1 yr (78) 2 yr (48) 3 yr (26)
0–6.05 21.8 (4.3–49) 22.9 (4.3–56) 23.5 (2.1–61) 23.3 (5.6–60) 21.5 (6.9–56) 19.9 (5.1–44)
670 (132–2000) 53 (0–442) 40 (0–442) 36.7 (0–823) 28.2 (0–160) 47.6 (0–511) 35.7 (0–156)
19.3 (8–35) 5.9 (0–20) 4.7 (0–20) 4.5 (0–21) 3.9 (0–21) 3.5 (1–21) 4.1 (0–26)
4 (1–6) 1.3 (0–5) 0.9 (0–5) 1.0 (0–6) 0.8 (0–6) 0.7 (0–6) 0.6 (0–4)
KEY: HoLEP ⫽ holmium laser enucleation of prostate; Qmax ⫽ peak urinary flow rate; PVR ⫽ postvoid residual (urine volume); IPSS ⫽ International Prostate Symptom Score; QOL ⫽ quality of life. Data in parentheses are ranges.
tion. A third patient developed adult respiratory distress syndrome and bleeding and required intensive care unit admission for 1 week. He was discharged after complete recovery of his respiratory problem. The fourth patient developed clot retention 2 weeks postoperatively and required readmission for bladder irrigation and clot evacuation. The catheterization time for those patients was prolonged (range 5 to 18 days). No patients had any symptoms of dilutional hyponatremia or transurethral resection syndrome. Two patients developed cardiac events. One had non-Q myocardial infarction and required intensive care unit admission for 5 days, and one developed bradycardia for 20 minutes at the end of the procedure after which his condition improved. One patient developed capsular perforation toward the end of enucleation and was treated conservatively without discontinuation of surgery. The Qmax, PVR urine volume, IPSS, and QOL score were significantly improved by 1 month after surgery and continued to improve during the subsequent follow-up period (Table II). At 3 years postoperatively, the PVR urine volume had decreased from 670 mL (range 132 to 2000) to 35.7 mL (range 0 to 156; P ⬍0.0001). The IPSS had improved from 19.3 (range 8 to 35) to 4.1 (range 0 to 26; P ⬍0.0001), and the QOL score had improved from 4 (range 1 to 6) to 0.6 (range 0 to 4; P ⬍0.0001). In patients who were able to void, the improvement in Qmax at 3 years postoperatively was 159% (Qmax increased from 6.05 to 15.7 mL/s). Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two underwent CIC. These patients had chronic urinary retention with a catheterization volume between 850 and 2000 mL. The mean decrease in the prostate-specific antigen value was 87% (from 9.3 ng/mL [range 0.4 to 55] to 1.2 ng/mL [range 0.09 to 9.5] at 6 months postoperatively; P ⬍0.0001). Pathologic examination of the enucleated tissue revealed BPH in 163 patients, prostate adenocarcinoma in 5 patients (2.9%), and low-grade prostatic intraepithelial UROLOGY 66 (4), 2005
TABLE III. Summary of intraoperative and postoperative complications Complication
Patients (%)
Intraoperative Capsular perforation Cardiac events Myocardial infarction Bradycardia Postoperative Blood transfusion Irritative symptoms Stress incontinence Urinary tract infection Bladder neck contracture Urethral stricture Meatal stenosis
1 (0.6) 1 (0.6) 1 (0.6) 4 (2.4) 12 (7.1) 4 (2.4) 2 (1.2) 3 (1.7) 2 (1.2) 1 (0.6)
neoplasia in 1 patient. All patients were followed up with expectant management. The pathologic type in their prostates was focal in less than 5% of the specimens, with a low Gleason score. Four patients (2.4%) had stress urinary incontinence, which resolved in all four within 3 months. Two patients developed stones in the prostatic urethra at 1 week (possibly residual fragments) and 3 months postoperatively and were treated with endoscopic lithotripsy and extraction. Bladder neck contractures were noted in 3 patients (1.7%); at 5 months in 2 patients and at 2 years in 1 patient. All were treated successfully by laser incision of the bladder neck. Urethral strictures developed in 2 patients (1.2%) and were easily dilated under local anesthesia (Table III). COMMENT During the past decade, we have encountered a shift in the treatment of patients presenting with lower urinary tract symptoms secondary to BPH toward a more medical and less surgical approach. The results have been that patients wait longer before presenting for surgery, and, because most patients receive alpha-blockers as their medical 791
therapy, the prostate continues to grow during treatment. The net result has been that we are challenged with operating on older sicker patients, with more patients presenting in urinary retention with larger prostates. The additional combined factors such as anticoagulant therapy, increase in prosthetic heart valves, more patients with diabetes or urinary tract infection and calculi add further to the challenge. Conventional TURP remains the reference standard treatment of symptomatic BPH and is the treatment of choice for men with urinary retention. However, the morbidity after TURP is still high.11,12 Minimally invasive treatment alternatives to TURP are required, especially for high-risk patients. Among these minimally invasive treatments are insertion of urethral stents, thermotherapy, interstitial laser coagulation of the prostate, and visual laser ablation of the prostate (VLAP). However, prostatic stents were removed in 39% of patients after 1 year owing to complications such as stent migration, persistent urinary tract infection, and persistent hematuria.13,14 Transurethral microwave thermotherapy is a safe, welltolerated treatment for patients in urinary retention with a high surgical risk. However, the retreatment rate after transurethral microwave thermotherapy has been high (26% to 31%), with a long catheterization time (mean 21 days), high percentage of urinary tract infection (17.9%), and the presence of irritative symptoms, which developed in all patients after transurethral microwave thermotherapy.15 Interstitial laser coagulation of the prostate is a safe and effective treatment in patients with AUR, with a failure rate of 7.1%.16 Gilling et al.6,8 should be credited with the development of prostatic tissue morcellation, which allowed the development and use of the HoLEP technique for removal of obstructive prostatic tissue with adequate hemostasis. It has been described as an alternative to TURP in the treatment of patients with BPH. Several studies have confirmed the safety and efficacy of HoLEP in the treatment of men with symptomatic BPH, but with no detailed analysis of a urinary retention subset. In the current study, improvement was seen in the mean Qmax (up to 19.9 mL/s), with a 95% decrease in the PVR urine volume, 78% decrease in the IPSS, and 85% improvement in the QOL score at 3 years compared with the preoperative values. Of the 169 patients, 166 (98%) were able to void immediately postoperatively. Eight patients (4.7%) still had a low Qmax (range 6 to 13.7 mL/s) and a large PVR urine volume (range 144 to 511 mL). Choe and Sirls17 reported an 82% success rate in 17 patients with urinary retention treated with VLAP, with a 53% retrograde ejaculation rate. Fournier et al.18 reported the 6-month follow-up data of 18 pa792
tients, with an increase in the Qmax to 20.3 mL/s, a 90% decrease in the PVR urine volume, and an 86% decrease in the American Urological Association symptoms score. Gujral et al.11 compared VLAP and TURP and found a success rate of 91% for men who underwent TURP (n ⫽ 44) and 63% for those who underwent VLAP (n ⫽ 38), with more morbidity in the TURP group (septicemia in 3 cases, urinary infection in 2 cases, heavy bleeding in 6 cases, blood transfusion in 3 cases, and capsular perforation in 1 case). Kabalin et al.19 demonstrated the efficacy of holmium laser resection of the prostate in treatment of 36 patients with acute urinary retention. The procedure resulted in minimal morbidity, with recurrent urinary retention in 2 men and a treatment failure rate of 5.6% at 6 months of follow-up. In the current study, only 3 patients were unable to void. One had diabetes insipidus with a very large PVR urine volume (2000 mL), one had had a suprapubic catheter (chronic urinary retention 900 mL) for a long period preoperatively and could not void after removal of the catheter postoperatively, and the third had a large PVR urine volume and decompensated bladder (850 mL). The blood transfusion rate (2.4%) in our series was greater than that reported in previous studies. The greater rate was because of the large percentage of patients taking anticoagulant therapy included in our study, as well as that patients with retention and prolonged catheterization tend to be a greater surgical risk.5 Bladder neck contractures occurred in 1.7% and urethral strictures in 1.2% of patients observed in our study, less than the rates previously reported for HoLEP.7 Kuntz et al.20 reported a 3.2% rate of bladder neck contracture and 3.2% rate of urethral stricture in 100 patients undergoing HoLEP. The main limitation in our study was that it was a retrospective analysis of our data without randomization between HoLEP and TURP. CONCLUSIONS The results of the present study have demonstrated the safety and efficacy of HoLEP in the treatment of patients with BPH presenting in urinary retention. It has low morbidity and results in a short catheterization time and hospital stay. The postoperative improvement in symptoms and voiding outcomes was immediate and durable. REFERENCES 1. Jacobsen SJ, Girman CJ, and Lieber MM: Natural history of benign prostatic hyperplasia. Urology 58(suppl 1): 5–16, 2001. 2. Jacobsen SJ, Jacobson DJ, Girman CJ, et al: Natural history of prostatism: risk factors for acute urinary retention. J Urol 158: 481– 487, 1997. UROLOGY 66 (4), 2005
3. Taube M, and Gajraj H: Trial without catheter following acute retention of urine. Br J Urol 63: 180 –182, 1989. 4. McNeill SA: Does acute urinary retention respond to alpha-blockers alone? Eur Urol 39(suppl 6): 7–12, 2001. 5. Mebust WK, Holtgrewe HL, Cockett AT, et al, and the Writing Committee: Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 167: 5–9, 2002. 6. Gilling PJ, Kennett K, Das AK, et al: Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 12: 457– 459, 1998. 7. Kuo RL, Paterson RF, Siqueira TM Jr, et al: Holmium laser enucleation of the prostate: morbidity in a series of 206 patients. Urology 62: 59 – 63, 2003. 8. Gilling PJ, Cass CB, Cresswell MD, et al: The use of the holmium laser in the treatment of benign prostatic hyperplasia. J Endourol 10: 459 – 461, 1996. 9. Fong BC, and Elhilali MM: Video article. Ho:YAG laser enucleation of the prostate: technical details. BJU Int 90: 870 – 871, 2002. 10. Kuo RL, Paterson RF, Kim SC, et al: Holmium laser enucleation of the prostate (HoLEP): a technical update. World J Surg Oncol 1: 1–9, 2003. 11. Gujral S, Abrams P, Donovan JL, et al: A prospective randomized trial comparing transurethral resection of the prostate and laser therapy in men with chronic urinary retention: the CLasP study. J Urol 164: 59 – 64, 2000. 12. Chacko KN, Donovan JL, Abrams P, et al: Transurethral prostatic resection or laser therapy for men with acute
UROLOGY 66 (4), 2005
urinary retention: the ClasP randomized trial. J Urol 166: 166 –170, 2001. 13. Nissenkorn I, and Slutzker D: The intraurethral catheter: long-term follow-up in patients with urinary retention due to infravesical obstruction. Br J Urol 68: 277–279, 1991. 14. Sassine AM, and Schulman CC: Intraurethral catheter in high-risk patients with urinary retention: 3 years of experience. Eur Urol 25: 131–134, 1994. 15. Berger AP, Niescher M, Spranger R, et al: Transurethral microwave thermotherapy (TUMT) with the Targis System: a single-centre study on 78 patients with acute urinary retention and poor general health. Eur Urol 43: 176 –180, 2003. 16. Nishizawa K, Kobayashi T, Watanabe J, et al: Interstitial laser coagulation of the prostate for management of acute urinary retention. J Urol 170: 879 – 882, 2003. 17. Choe JM, and Sirls LT: High-energy visual laser ablation of the prostate in men with urinary retention: pressureflow analysis. Urology 48: 584 –588, 1996. 18. Fournier GR Jr, Tewari A, Induhara R, et al: Nd:YAG laser transurethral evaporation of the prostate (TUEP) for urinary retention. Lasers Surg Med 19: 480 – 486, 1996. 19. Kabalin JN, Mackey MJ, Cresswell MD, et al: Holmium: YAG laser resection of prostate (HoLRP) for patients in urinary retention. J Endourol 11: 291–293, 1997. 20. Kuntz RM, Ahyai S, Lehrich K, et al: Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 172: 1012–1016, 2004.
793
HOLMIUM LASER ENUCLEATION OF PROSTATE FOR PATIENTS IN URINARY RETENTION EHAB A. ELZAYAT, ENMAR I. HABIB,
AND
MOSTAFA M. ELHILALI
ABSTRACT Objectives. To evaluate holmium laser enucleation of the prostate in patients presenting in urinary retention secondary to benign prostatic hyperplasia. Methods. From May 2000 to May 2004, 169 patients, with a mean age of 74 years, who presented in urinary retention secondary to benign prostatic hyperplasia underwent holmium laser enucleation of the prostate. The mean urinary volume drained at catheterization was 670 mL (range 132 to 2000). All the patients were assessed preoperatively, 1, 3, 6, and 12 months postoperatively, and every year thereafter. All the patients were evaluated by physical examination, digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire, uroflowmetry (whenever possible), postvoid residual urine volume measurement, and prostate-specific antigen. The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351). Results. The mean catheter time and hospital stay was 1.6 and 1.7 days, respectively. The peak urinary flow rate, postvoid residual urine volume, and International Prostate Symptom Score and quality-of-life score were significantly improved by 1 month after surgery and continued to improve during subsequent follow-up. Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two used clean intermittent catheterization. Four patients (2.4%) were receiving anticoagulant therapy and required blood transfusion. Bladder neck contracture and urethral stricture developed in 1.7% and 1.2%, respectively. Conclusions. Holmium laser enucleation of the prostate represents a safe and effective treatment for patients with benign prostatic hyperplasia presenting in urinary retention. It has low morbidity and provides immediate symptom and voiding improvement. UROLOGY 66: 789–793, 2005. © 2005 Elsevier Inc.
I
n aging men, benign prostatic hyperplasia (BPH) and the related lower urinary tract symptoms are a common problem that has an impact on daily activity and quality of life and may lead to serious outcomes.1 The information from the Olmsted County study demonstrated that a 60-year-old man with moderate to severe lower urinary tract symptoms would have a 13.7% chance of developing acute urinary retention (AUR) within 10 years or an incidence rate of 0.7% per year.2 Taube and Gajraj3 reported that 72% of patients with AUR due M. M. Elhilali is a study investigator funded by Lumenis, Inc. From the Division of Urology, McGill University School of Medicine, Montreal, Quebec, Canada Reprint requests: Mostafa M. Elhilali, M.D., Ph.D., Division of Urology, Department of Surgery, Royal Victoria Hospital, McGill University Health Center, 687 Pine Avenue West, Room S6.95, Montreal, QC H3A 1A1, Canada. E-mail: mostafa.elhilali@ muhc.mcgill.ca Submitted: January 8, 2005, accepted (with revisions): April 21, 2005 © 2005 ELSEVIER INC. ALL RIGHTS RESERVED
to BPH have an unsuccessful voiding trial after catheter removal. It was reported that about 77% of patients with a first episode of AUR required prostate surgery within the next 2 years.4 Transurethral resection of the prostate (TURP) is still the reference standard for treatment of benign prostatic obstruction; however, TURP has a mortality rate of 0.2% and immediate postoperative morbidity develops in 18% of cases. This morbidity is more common in patients presenting with retention (24%).5 For patients with a high operative risk, as well as patients with a large prostate volume and urinary retention, an alternative treatment modality is required. Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive and effective surgical treatment of benign prostatic obstruction caused by prostate glands of all sizes and provides the modern alternative to TURP with low morbidity.6,7 The advantages of HoLEP compared with TURP are a lower amount of blood loss, particularly in patients 0090-4295/05/$30.00 doi:10.1016/j.urology.2005.04.049 789
receiving anticoagulation therapy, the lack of transurethral resection syndrome, use of normal saline as the irrigant, and a shorter convalescence. Several studies have reported the efficacy and safety of HoLEP in patients with symptomatic BPH. Some have included patients with urinary retention, but the number of patients has been small. Most data available on surgical management of AUR indicate a high complication rate.5 The aim of the present study was to evaluate HoLEP for patients with symptomatic BPH presenting in urinary retention, with an emphasis on efficacy and complications. MATERIAL AND METHODS This study included 169 patients with urinary retention secondary to BPH who required an indwelling catheter. Twenty-six men were able to void with minimal flow but had a large postvoid residual (PVR) urine volume requiring clean intermittent catheterization (CIC). Most patients had already tried medical therapy, which had failed. The preoperative evaluation included physical examination with a focused neurologic examination and digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire (IPSS) for the period before the episode of retention, a trial without a catheter during alpha-blocker therapy, measurement of PVR urine volume, uroflowmetry for patients who were able to void, prostate volume measurement using transrectal ultrasonography, and prostate-specific antigen determination, with transrectal ultrasound-guided biopsy when necessary. The exclusion criteria included neurogenic bladder, urethral stricture, and prostate cancer.
HOLEP EQUIPMENT AND TECHNIQUE The equipment we used was an 80 to 100 W holmium: yttrium-aluminum-garnet laser (Versapulse, Lumenis, Santa Clara, Calif), a 550-m end-firing fiber (SlimLine 550, Lumenis), a modified continuous-flow 26F resectoscope with a distal bridge, a 7F catheter with a proximal bridge to stabilize the laser fiber, continuous saline irrigation, a rigid indirect nephroscope, a tissue morcellator (Lumenis), and a video system. All laser surgeries were performed by a single surgeon (M.M.E.). HoLEP was performed as previously described by Gilling et al.,8 Fong and Elhilali,9 and Kuo et al.10 Intravenous furosemide was administered (20 mg/hr of enucleation) and almost always coincided with the end of enucleation to counteract any fluid absorption and enhance urine flow. Intermittent bladder irrigation was delivered through a Y-connector without changing the catheter. If the hematuria persisted despite intermittent irrigation, continuous irrigation was instituted using a three-way catheter. The catheter was routinely removed the next morning. When the patient was able to void adequately, he was discharged from the hospital. All patients were given prophylactic antibiotic before and during the procedure and for 1 week postoperatively. The operative time, total energy used, enucleation time, morcellation time, enucleated tissue weight, catheterization time, and hospital stay were recorded.
POSTOPERATIVE EVALUATION Follow-up evaluations after HoLEP were done for all patients during their visits at 1, 3, and 6 months and every year thereafter. The main values of peak urinary flow rate (Qmax), PVR urine volume, IPSS, and quality-of-life (QOL) score were 790
TABLE I. Mean operative data Variable
Mean (Range)
Enucleation time (min) Morcellation time (min) Enucleated tissue weight (g) Total energy used (Kj) Catheterization time (days) Hospital stay (days)
96.4 (15–255) 19.4 (2–120) 68.7 (5–340) 218.7 (22.8–602.4) 1.6 (1–21) 1.7 (1–34)
compared with the preoperative values using a paired Student t test, with P ⬍0.05 considered significant.
RESULTS From May 2000 to May 2004, 169 patients with a mean age of 74 years (range 50 to 93) presented with urinary retention requiring an indwelling catheter or CIC. Of the 169 patients, 23 (13.6%) voided with a minimal Qmax (mean 6.05 mL/s, range 1.9 to 10.7), but still had a high PVR urine volume (mean 601 mL, range 132 to 1800) requiring CIC. The remaining patients were unable to void and were considered to have a Qmax of 0 mL/s; the mean volume of urine drained at catheterization was 670 mL (range 132 to 2000). Thirteen patients (7.7%) had undergone TURP and two laser vaporization, and 39 patients (23%) were receiving anticoagulant therapy. Perioperative discontinuation and substitution of an oral anticoagulant was done on the basis of the cardiologic consultation findings. All patients who discontinued anticoagulant use started again the day after surgery. The mean enucleation time was 96.4 minutes, and the morcellation time was approximately 20% of the total operative time (mean 19.4 minutes). Morcellation efficiency was, on average, 3.5 g/min (weight of enucleated tissue/morcellation time). The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351), and the resected tissue weight was 68.7 g (range 5 to 340). The tissue weight could be misleading because a lot of the tissue is vaporized in the process. In 6 patients (3.5%), the adenoma was removed through a minicystostomy incision owing to the presence of multiple bladder stones in 1 case and the large size of the adenoma (range 146 to 351 g) in 5 patients (with inadequate morcellation progress in 2 of these patients). The main operative data are given in Table I. Continuous bladder irrigation was necessary in 8 patients (4.7%) for transient postoperative hematuria. Four patients (2.4%) were taking anticoagulant therapy and required blood transfusion. One patient had not stopped taking the anticoagulant before surgery and one had started anticoagulant therapy early in the postoperative period and developed clot retenUROLOGY 66 (4), 2005
TABLE II. Preoperative data and follow-up changes after HoLEP Follow-up (n)
Mean Qmax (mL/s)
Mean PVR (mL)
Mean IPSS
Mean QOL Score
Preoperative 1 mo (146) 3 mo (111) 6 mo (93) 1 yr (78) 2 yr (48) 3 yr (26)
0–6.05 21.8 (4.3–49) 22.9 (4.3–56) 23.5 (2.1–61) 23.3 (5.6–60) 21.5 (6.9–56) 19.9 (5.1–44)
670 (132–2000) 53 (0–442) 40 (0–442) 36.7 (0–823) 28.2 (0–160) 47.6 (0–511) 35.7 (0–156)
19.3 (8–35) 5.9 (0–20) 4.7 (0–20) 4.5 (0–21) 3.9 (0–21) 3.5 (1–21) 4.1 (0–26)
4 (1–6) 1.3 (0–5) 0.9 (0–5) 1.0 (0–6) 0.8 (0–6) 0.7 (0–6) 0.6 (0–4)
KEY: HoLEP ⫽ holmium laser enucleation of prostate; Qmax ⫽ peak urinary flow rate; PVR ⫽ postvoid residual (urine volume); IPSS ⫽ International Prostate Symptom Score; QOL ⫽ quality of life. Data in parentheses are ranges.
tion. A third patient developed adult respiratory distress syndrome and bleeding and required intensive care unit admission for 1 week. He was discharged after complete recovery of his respiratory problem. The fourth patient developed clot retention 2 weeks postoperatively and required readmission for bladder irrigation and clot evacuation. The catheterization time for those patients was prolonged (range 5 to 18 days). No patients had any symptoms of dilutional hyponatremia or transurethral resection syndrome. Two patients developed cardiac events. One had non-Q myocardial infarction and required intensive care unit admission for 5 days, and one developed bradycardia for 20 minutes at the end of the procedure after which his condition improved. One patient developed capsular perforation toward the end of enucleation and was treated conservatively without discontinuation of surgery. The Qmax, PVR urine volume, IPSS, and QOL score were significantly improved by 1 month after surgery and continued to improve during the subsequent follow-up period (Table II). At 3 years postoperatively, the PVR urine volume had decreased from 670 mL (range 132 to 2000) to 35.7 mL (range 0 to 156; P ⬍0.0001). The IPSS had improved from 19.3 (range 8 to 35) to 4.1 (range 0 to 26; P ⬍0.0001), and the QOL score had improved from 4 (range 1 to 6) to 0.6 (range 0 to 4; P ⬍0.0001). In patients who were able to void, the improvement in Qmax at 3 years postoperatively was 159% (Qmax increased from 6.05 to 15.7 mL/s). Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two underwent CIC. These patients had chronic urinary retention with a catheterization volume between 850 and 2000 mL. The mean decrease in the prostate-specific antigen value was 87% (from 9.3 ng/mL [range 0.4 to 55] to 1.2 ng/mL [range 0.09 to 9.5] at 6 months postoperatively; P ⬍0.0001). Pathologic examination of the enucleated tissue revealed BPH in 163 patients, prostate adenocarcinoma in 5 patients (2.9%), and low-grade prostatic intraepithelial UROLOGY 66 (4), 2005
TABLE III. Summary of intraoperative and postoperative complications Complication
Patients (%)
Intraoperative Capsular perforation Cardiac events Myocardial infarction Bradycardia Postoperative Blood transfusion Irritative symptoms Stress incontinence Urinary tract infection Bladder neck contracture Urethral stricture Meatal stenosis
1 (0.6) 1 (0.6) 1 (0.6) 4 (2.4) 12 (7.1) 4 (2.4) 2 (1.2) 3 (1.7) 2 (1.2) 1 (0.6)
neoplasia in 1 patient. All patients were followed up with expectant management. The pathologic type in their prostates was focal in less than 5% of the specimens, with a low Gleason score. Four patients (2.4%) had stress urinary incontinence, which resolved in all four within 3 months. Two patients developed stones in the prostatic urethra at 1 week (possibly residual fragments) and 3 months postoperatively and were treated with endoscopic lithotripsy and extraction. Bladder neck contractures were noted in 3 patients (1.7%); at 5 months in 2 patients and at 2 years in 1 patient. All were treated successfully by laser incision of the bladder neck. Urethral strictures developed in 2 patients (1.2%) and were easily dilated under local anesthesia (Table III). COMMENT During the past decade, we have encountered a shift in the treatment of patients presenting with lower urinary tract symptoms secondary to BPH toward a more medical and less surgical approach. The results have been that patients wait longer before presenting for surgery, and, because most patients receive alpha-blockers as their medical 791
therapy, the prostate continues to grow during treatment. The net result has been that we are challenged with operating on older sicker patients, with more patients presenting in urinary retention with larger prostates. The additional combined factors such as anticoagulant therapy, increase in prosthetic heart valves, more patients with diabetes or urinary tract infection and calculi add further to the challenge. Conventional TURP remains the reference standard treatment of symptomatic BPH and is the treatment of choice for men with urinary retention. However, the morbidity after TURP is still high.11,12 Minimally invasive treatment alternatives to TURP are required, especially for high-risk patients. Among these minimally invasive treatments are insertion of urethral stents, thermotherapy, interstitial laser coagulation of the prostate, and visual laser ablation of the prostate (VLAP). However, prostatic stents were removed in 39% of patients after 1 year owing to complications such as stent migration, persistent urinary tract infection, and persistent hematuria.13,14 Transurethral microwave thermotherapy is a safe, welltolerated treatment for patients in urinary retention with a high surgical risk. However, the retreatment rate after transurethral microwave thermotherapy has been high (26% to 31%), with a long catheterization time (mean 21 days), high percentage of urinary tract infection (17.9%), and the presence of irritative symptoms, which developed in all patients after transurethral microwave thermotherapy.15 Interstitial laser coagulation of the prostate is a safe and effective treatment in patients with AUR, with a failure rate of 7.1%.16 Gilling et al.6,8 should be credited with the development of prostatic tissue morcellation, which allowed the development and use of the HoLEP technique for removal of obstructive prostatic tissue with adequate hemostasis. It has been described as an alternative to TURP in the treatment of patients with BPH. Several studies have confirmed the safety and efficacy of HoLEP in the treatment of men with symptomatic BPH, but with no detailed analysis of a urinary retention subset. In the current study, improvement was seen in the mean Qmax (up to 19.9 mL/s), with a 95% decrease in the PVR urine volume, 78% decrease in the IPSS, and 85% improvement in the QOL score at 3 years compared with the preoperative values. Of the 169 patients, 166 (98%) were able to void immediately postoperatively. Eight patients (4.7%) still had a low Qmax (range 6 to 13.7 mL/s) and a large PVR urine volume (range 144 to 511 mL). Choe and Sirls17 reported an 82% success rate in 17 patients with urinary retention treated with VLAP, with a 53% retrograde ejaculation rate. Fournier et al.18 reported the 6-month follow-up data of 18 pa792
tients, with an increase in the Qmax to 20.3 mL/s, a 90% decrease in the PVR urine volume, and an 86% decrease in the American Urological Association symptoms score. Gujral et al.11 compared VLAP and TURP and found a success rate of 91% for men who underwent TURP (n ⫽ 44) and 63% for those who underwent VLAP (n ⫽ 38), with more morbidity in the TURP group (septicemia in 3 cases, urinary infection in 2 cases, heavy bleeding in 6 cases, blood transfusion in 3 cases, and capsular perforation in 1 case). Kabalin et al.19 demonstrated the efficacy of holmium laser resection of the prostate in treatment of 36 patients with acute urinary retention. The procedure resulted in minimal morbidity, with recurrent urinary retention in 2 men and a treatment failure rate of 5.6% at 6 months of follow-up. In the current study, only 3 patients were unable to void. One had diabetes insipidus with a very large PVR urine volume (2000 mL), one had had a suprapubic catheter (chronic urinary retention 900 mL) for a long period preoperatively and could not void after removal of the catheter postoperatively, and the third had a large PVR urine volume and decompensated bladder (850 mL). The blood transfusion rate (2.4%) in our series was greater than that reported in previous studies. The greater rate was because of the large percentage of patients taking anticoagulant therapy included in our study, as well as that patients with retention and prolonged catheterization tend to be a greater surgical risk.5 Bladder neck contractures occurred in 1.7% and urethral strictures in 1.2% of patients observed in our study, less than the rates previously reported for HoLEP.7 Kuntz et al.20 reported a 3.2% rate of bladder neck contracture and 3.2% rate of urethral stricture in 100 patients undergoing HoLEP. The main limitation in our study was that it was a retrospective analysis of our data without randomization between HoLEP and TURP. CONCLUSIONS The results of the present study have demonstrated the safety and efficacy of HoLEP in the treatment of patients with BPH presenting in urinary retention. It has low morbidity and results in a short catheterization time and hospital stay. The postoperative improvement in symptoms and voiding outcomes was immediate and durable. REFERENCES 1. Jacobsen SJ, Girman CJ, and Lieber MM: Natural history of benign prostatic hyperplasia. Urology 58(suppl 1): 5–16, 2001. 2. Jacobsen SJ, Jacobson DJ, Girman CJ, et al: Natural history of prostatism: risk factors for acute urinary retention. J Urol 158: 481– 487, 1997. UROLOGY 66 (4), 2005
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