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Photoselective vaporization of the prostate in the therapy of benign prostatic hyperplasia
Original article
Photoselective vaporization of the prostate in the therapy of benign prostatic hyperplasia Keywords Benign prostatic hyperplasia Photoselective vaporization Prostate
A.A. Kamalov, MD, PhD Russian Scientific Institute of Urology, 3rd Parkovaya St. 51, 105425 Moscow, Russia B.E. Osmolovskiy, MD Russian Scientific Institute of Urology, 3rd Parkovaya St. 51, 105425 Moscow, Russia E-mail: [email protected]
Online 14 May 2008
148
A.A. Kamalov and B.E. Osmolovskiy Abstract Background: The recent progress in the area of laser technology has permitted the development of a highly effective method of laser adenomectomy called transurethral vaporization of the prostate (TUVP). This method utilizes a high power potassium-titanyl-phosphate (KTP) laser. Methods: Forty patients with benign prostatic hyperplasia (BPH) were operated on by means of TUVP with an 80-watt high power KTP laser (GreenLight PVTM, Laserscope1, San Jose, CA) at the National Research Center for Urology during the period August 2005 to August 2007. Results: The duration of the surgical intervention averaged 52.4 min, while the mean time for the indwelling urethral catheter was 14 h. Complications were mild and included short-term dysuria (12%) and short-term hematuria (8%). The results of the repeated evaluations performed in all of the patients at 1, 3, 6, and 12 months after TUVP were as follows: by 12 months, the International Prostate Symptom Score (IPSS) value dropped by 78% to 5 points, the Quality-of-Life (QoL) index improved by 50% to equal 2.6 points. The Qmax value rose by 112% to average 18.3 ml/s, whereas the post-void residual urine volume decreased by 74% to average 22.1 ml. Conclusion: TUVP is a minimally invasive procedure that is not accompanied by the absorption of the lavage fluid or blood loss, allowing the hospitalization period to be considerably reduced, and in some cases allowing the intervention to be performed in an out-patient department or day hospital. Thus, the laser vaporization of the prostate is a worthy alternative to the conventional transurethral resection of the prostate (TUR). Further research into the long-term results of this surgical intervention would be of great help in the comprehensive assessment of its clinical efficacy. ß 2008 WPMH GmbH. Published by Elsevier Ireland Ltd.
Introduction Benign prostatic hyperplasia (BPH) is one of the most common urological diseases in elderly and senile men. The condition is found in 11.3% of men aged 40–49 years, whereas by the age of 80 years its prevalence rises to as high as 81.4% [1]. It is estimated that by the year 2020 the number of people aged over 60 years (many of whom will suffer from prostatic diseases) will increase threefold. The repair of
Vol. 5, No. 2, pp. 148–152, June 2008
infravesical obstruction is both a therapeutic and a prophylactic measure that prevents the patient from developing inflammation in the urinary tract, acute urinary retention, chronic renal failure, and urolithiasis [2]. The above data suggest that the therapy of BPH represents not only a serious medical problem, but also a big social issue. Currently, an endoscopic technique has been actively introduced into clinical practice for the laser energy-assisted removal of the
ß 2008 WPMH GmbH. Published by Elsevier Ireland Ltd.
Original article prostate, or laser adenomectomy (LA), which has evolved to the newer technology of transurethral photoselective vaporization of the prostate (TUVP). This article will give an account of the clinical experience acquired in the application of this new technique.
Patients and methods The essence of LA consists of the shrinkage of the prostate as a result of the thermal impact delivered to the gland by a special light guided through an instrumental endoscopic canal. The speed and the achievement of the required temperature varies with the laser wave-length and power, the density of the target tissue and the time of exposure [3]. TUVP was carried out using a potassiumtitanyl-phosphate (KTP) laser with a power of 80 Wt, namely the Green Light PVTM produced by Laserscope1 San Jose, CA. The wave-length of the KTP laser is 532 nm, which is both within the region of the theoretical maximum of the oxyhemoglobin absorption curve and within the region of the theoretical minimum against the energy absorption curve for water (which accounts for the laser’s photoselectivity) that, on the one hand, yields effective vaporization of the prostatic tissue, while on the other hand yields acceptable hemostasis [4] The high power of the pulse KTP laser, along with the small optical depth of penetration of the green beam, destroys cellular membranes and leads to the evaporation of the cellular contents as small vesicles. The rapid heating of the cytoplasm to the evaporation temperature results in the bulk of the laser energy being liberated as ‘cytoplasmatic explosive energy’, while the thermal diffusion and coagulation of the tissue’s deeper layers is confined to the creation of a thin coagulation layer which provides acceptable hemostatic properties; therefore the intervention is virtually bloodless [5]. Compared to other types of lasers, the KTPlaser penetration depth of 0.8 mm is neither too small nor too great [6,7]. TUVP gives rise to vibration and rotation of the laser light-guide with the lateral luminescence that passes through the working channel of a small-size cystoscope (22–24 F) under the permanent irrigation with normal saline. The light-guide turns up- and downwards
along a 30–408 arc, its end being at a very small working distance (0.5–1.0 mm) from the tissue [7]. Such a close location of the light-guide permits the uniform impact of the KTP-laser energy. The effective evaporation of the tissue results in the formation of the vapor vesicles, which are washed away with the irrigational saline. To prevent hemorrhage, the laser coagulation requires either an increase in the working distance to the tissue of 3–4 mm or a reduction in the laser power to 30–40 Wt, without any change in the light-guide’s position. The vaporization of the prostate begins with the bladder cervix, proceeds to the lateral lobes at the level of the seminal colliculus and ends at the external sphincter. Our clinical experience involves 40 patients who underwent TUVP. Preoperatively, a comprehensive urological examination was carried out in all of the patients. This included an assessment of the patients’ complaints based on the International Prostate Symptom Score (IPSS), their quality-of-life (QoL) index, routine clinical measurements, a digital rectal examination, prostatic transrectal ultrasonography (TRUS) and transabdominal ultrasonic scan including measurement of the prostatic volume, measurement of the postvoid residual urine value, urodynamic investigations and evaluation of the serum prostate specific antigen levels (PSA). TUVP was not made available to patients with increased PSA levels. The following evaluations were performed before the patient’s discharge from the hospital and at 1, 3, 6, and 12 months following the intervention: assessment of patients’ complaints, the QoL index estimation, maximal urine flow rate (Qmax) assessment, and prostatic TRUS. The mean values for patients’ baseline characteristics are displayed in Table 1.
Results Forty patients with BPH underwent TUVP by means of an 80 Wt high-power potassium-titanyl-phosphate laser. The specifics for this technique had been determined previously, with the result that the clinicians could remove the prostatic tissue quickly and effectively during the surgery. It should be noted that in virtually all cases the intra-operative bleeding was minimal and did not prevent endoscopic
Vol. 5, No. 2, pp. 148–152, June 2008
149
Original article Table 1 Patients’ baseline characteristics (mean values) Age Transurethral photoselective vaporization (n = 40)
Prostatic 3
IPSS/QoL
Qmax
Vres
(years)
volume (cm )
(points)
(ml/s)
(cm3)
69
57
22.5/4.8
8.6
86
IPSS, International Prostate Symptom Score; QoL, quality-of-life; Qmax, maximal urine flow rate; Vres, residual volume of the prostate.
visualization of the operative field. The operating time required, from the moment of introduction of the light-guide into the urethra prior to the installation of the urethral catheter, averaged 52.4 min in patients with a mean preoperative prostatic volume of less than 57 cm3. The mean volume of the intra-operative blood loss was less than 52 ml. During the operation and in the early postoperative period, in the majority of patients, neither the lavage fluid nor the urine in the urethral catheter was seen, macroscopically, to contain blood. The duration of urethral catheter placement varied with the baseline functional parameters of the bladder. The mean time for in-dwelling of the urethral catheter was 14 h. Following removal of the urethral catheter, submissive urination resumed in all patients and dysuria, according to the patients’ reports, was only minimal. The dynamics of the IPSS
150
and QoL parameters after TUVP are given in Figures 1 and 2. The results of repeated TRUS scans suggest a significant decrease in the prostatic volume, similar to that commonly found in patients who undergo ‘conventional’ transurethral resection of the prostate (TUR). By month 6 postoperatively, the prostatic volume had decreased by, on average, 68.6% to a volume of 19.1 cm3. The changes in this parameter over time are presented in Figure 3. It should also be pointed out that analysis of the objective parameters describing the quality of urination showed a pronounced clinical effect (Figure 4). A significant increase in Qmax was already obvious in patients within the first 3 months after surgery, whereas by month 6 this parameter had peaked. Noteworthy also is a moderate decrease in Qmax later on in the follow-up. By the end of the follow-up, the Qmax
Figure 1
Mean International Prostate Symptom Score (IPSS) before and various periods after the intervention.
Figure 2
Mean Quality-of-Life (QoL) scores before and various periods after the intervention.
Vol. 5, No. 2, pp. 148–152, June 2008
Original article
Figure 3
Mean prostatic volume before and various periods after the intervention.
Figure 4
Mean values of maximal urine flow rate (Qmax) before and various periods after the photoselective vaporization.
Figure 5
Mean values for the postvoid residual urine volume in patients before and various periods after the photoselective vaporization.
values in the control group, on average, implied that urination was non-obstructive and did not fall below the values typical of those at month 3 after TUPV. In those patients who underwent the intervention, the maximal decrease in the volume of the postvoid residual urine was evident in the first 6 months post-surgery. The value dropped from 86 ml at baseline to a minimum of 21.9 ml, on average, at month 6 of the follow-up. The dynamics of the postvoid residual urine volume in the postoperative period are shown in Figure 5. Thus, as evidenced by the data obtained during the 1-year follow-up, therapy of 40 patients with BPH using TUVP resulted in a significant improvement in the subjective and
objective symptoms and signs of lower urinary tract dysfunction.
Discussion The use of laser adenomectomy means that patients can avoid the complications that can accompany monopolar electroresection, which uses an electric current running through patients’ bodies and can result in burns to the gluteal area and urethra. Laser adenomectomy also enables clinicians to operate on patients with artificial pacemakers, heart pacemakers or steel artificial limbs. The photoselectivity of the KTP laser provides, on the one hand, effective vaporization
Vol. 5, No. 2, pp. 148–152, June 2008
151
Original article of the prostatic tissue, and on the other hand, acceptable hemostasis, which permits an operative intervention in patients on life-time anticoagulant and/or antiaggregant therapy. Since TUVP utilizes a light-guide of a considerably smaller diameter (22–23 F) than does conventional TUR, the risk of injury to the urinary tract during the intervention is substantially lower. The unique physical characteristics of the powerful KTP laser, when compared with other laser types, provide an optimal vaporization effect and a small zone of coagulation necrosis. This allows surgeons to reduce the risk of intraoperative bleeding, to substantially shorten the bladder drainage period, and to avoid the prolonged dysuria in the postoperative period that commonly occurs when other types of lasers are used. The analysis of sexual dysfunctions found in the postoperative period suggests the absence of erectile dysfunction and a significant decrease in the risk of retrograde ejaculation following TUVP, compared with conventional prostatic TUR, which is particularly important for younger patients interested in the preservation of their reproductive function. Perhaps the most serious disadvantage of this method is the absence of any material for histological investigation after the surgery, which invariably requires that prostatic malignancy be ruled out at the preoperative stage, while blood PSA screening then has to be carried out postoperatively, at a high cost of equipment and expendable materials.
Conclusion From our experience we can say that photoselective laser vaporization of the prostate by means of an 80-Wt high power KTP laser (GreenLight PVTM Laserscope1, San Jose, CA) is a minimally invasive procedure that enables surgeons to quickly acquire experience of the intervention, i.e. four to five procedures are sufficient for a TUR-experienced surgeon to feel confident enough doing TUVP. The efficacy of the method is comparable with conventional TUR. Furthermore, the surgery is performed under conditions of excellent hemostasis, it is not accompanied by the absorption of lavage fluid nor does it cause blood loss. The technique can be easily used in day hospitals, is applicable both to younger patients who wish to preserve their sexual function and escape antegrade ejaculation, and to elderly patients with concurrent conditions requiring the life-time intake of anticoagulants. This type of operation is primarily indicated and effective for the removal of the prostate of smaller or average size (up to 40–50 cm3). Overall, combining the effective vaporizing removal of the prostate with minimal intraoperative blood loss, prostatic laser vaporization may be considered a useful alternative to conventional TUR. Further research is needed on the long-term results of the surgical intervention and these would be of great help in the comprehensive assessment of its clinical efficacy.
References [1] Lopatkin NA, Martov AG, Kozlov SA. Vserossiiskoe nauchnoe obshchestvo urologov. Plenum: Materialy - Kursk; 1993, S.-112–113. [Lopatkin NA, Martov AG, Kozlov SA. All-Russian Research Society for urologists. Plenary Session: Abstracts - Kursk; 1993, p. 112–113]. [2] Gorilovskiy LM. Ocherki geriartricheskoi urologii.– M., 1993. [Gorilovskiy L.M. Essays on geriatric urology – Moscow, 1993]. [3] Bachmann A, Wyler S, Ruszat R, Gasser T, Sulser T. Photoselective KTP laser vaporization of the prostate. First experiences after 50
152
Vol. 5, No. 2, pp. 148–152, June 2008
procedures. J Endourol 2003;(Suppl 1): A188. [4] Hai MA, Malek RS. Photoselective vaporization of the prostate: initial experience with a new 80 W KTP laser for the treatment of benign prostatic hyperplasia. J Endourol 2003;17:93–6. [5] Kuntzman RS, Malek RS, Barrett DM, Botwick DG. Potassium-titanyl-phosphate laser vaporization of the prostate: a comparative functional and pathologic study in canines. Urology 1996;48:575–83.
[6] Langley SE, Gallegos CR, Moisey CU. A prospective randomized trial evaluating endoscopic Nd:YAG laser prostate ablation with or without potassium titanyl phosphate (KTP) laser bladder neck incision. BJU Int 1997;80: 880–4. [7] Malek RS, Kuntzman RS, Barrett DM. High power potassium-titanyl-phosphate laser vaporization prostatectomy. J Urol 2000; 163:1730–3.
Photoselective vaporization of the prostate in the therapy of benign prostatic hyperplasia Keywords Benign prostatic hyperplasia Photoselective vaporization Prostate
A.A. Kamalov, MD, PhD Russian Scientific Institute of Urology, 3rd Parkovaya St. 51, 105425 Moscow, Russia B.E. Osmolovskiy, MD Russian Scientific Institute of Urology, 3rd Parkovaya St. 51, 105425 Moscow, Russia E-mail: [email protected]
Online 14 May 2008
148
A.A. Kamalov and B.E. Osmolovskiy Abstract Background: The recent progress in the area of laser technology has permitted the development of a highly effective method of laser adenomectomy called transurethral vaporization of the prostate (TUVP). This method utilizes a high power potassium-titanyl-phosphate (KTP) laser. Methods: Forty patients with benign prostatic hyperplasia (BPH) were operated on by means of TUVP with an 80-watt high power KTP laser (GreenLight PVTM, Laserscope1, San Jose, CA) at the National Research Center for Urology during the period August 2005 to August 2007. Results: The duration of the surgical intervention averaged 52.4 min, while the mean time for the indwelling urethral catheter was 14 h. Complications were mild and included short-term dysuria (12%) and short-term hematuria (8%). The results of the repeated evaluations performed in all of the patients at 1, 3, 6, and 12 months after TUVP were as follows: by 12 months, the International Prostate Symptom Score (IPSS) value dropped by 78% to 5 points, the Quality-of-Life (QoL) index improved by 50% to equal 2.6 points. The Qmax value rose by 112% to average 18.3 ml/s, whereas the post-void residual urine volume decreased by 74% to average 22.1 ml. Conclusion: TUVP is a minimally invasive procedure that is not accompanied by the absorption of the lavage fluid or blood loss, allowing the hospitalization period to be considerably reduced, and in some cases allowing the intervention to be performed in an out-patient department or day hospital. Thus, the laser vaporization of the prostate is a worthy alternative to the conventional transurethral resection of the prostate (TUR). Further research into the long-term results of this surgical intervention would be of great help in the comprehensive assessment of its clinical efficacy. ß 2008 WPMH GmbH. Published by Elsevier Ireland Ltd.
Introduction Benign prostatic hyperplasia (BPH) is one of the most common urological diseases in elderly and senile men. The condition is found in 11.3% of men aged 40–49 years, whereas by the age of 80 years its prevalence rises to as high as 81.4% [1]. It is estimated that by the year 2020 the number of people aged over 60 years (many of whom will suffer from prostatic diseases) will increase threefold. The repair of
Vol. 5, No. 2, pp. 148–152, June 2008
infravesical obstruction is both a therapeutic and a prophylactic measure that prevents the patient from developing inflammation in the urinary tract, acute urinary retention, chronic renal failure, and urolithiasis [2]. The above data suggest that the therapy of BPH represents not only a serious medical problem, but also a big social issue. Currently, an endoscopic technique has been actively introduced into clinical practice for the laser energy-assisted removal of the
ß 2008 WPMH GmbH. Published by Elsevier Ireland Ltd.
Original article prostate, or laser adenomectomy (LA), which has evolved to the newer technology of transurethral photoselective vaporization of the prostate (TUVP). This article will give an account of the clinical experience acquired in the application of this new technique.
Patients and methods The essence of LA consists of the shrinkage of the prostate as a result of the thermal impact delivered to the gland by a special light guided through an instrumental endoscopic canal. The speed and the achievement of the required temperature varies with the laser wave-length and power, the density of the target tissue and the time of exposure [3]. TUVP was carried out using a potassiumtitanyl-phosphate (KTP) laser with a power of 80 Wt, namely the Green Light PVTM produced by Laserscope1 San Jose, CA. The wave-length of the KTP laser is 532 nm, which is both within the region of the theoretical maximum of the oxyhemoglobin absorption curve and within the region of the theoretical minimum against the energy absorption curve for water (which accounts for the laser’s photoselectivity) that, on the one hand, yields effective vaporization of the prostatic tissue, while on the other hand yields acceptable hemostasis [4] The high power of the pulse KTP laser, along with the small optical depth of penetration of the green beam, destroys cellular membranes and leads to the evaporation of the cellular contents as small vesicles. The rapid heating of the cytoplasm to the evaporation temperature results in the bulk of the laser energy being liberated as ‘cytoplasmatic explosive energy’, while the thermal diffusion and coagulation of the tissue’s deeper layers is confined to the creation of a thin coagulation layer which provides acceptable hemostatic properties; therefore the intervention is virtually bloodless [5]. Compared to other types of lasers, the KTPlaser penetration depth of 0.8 mm is neither too small nor too great [6,7]. TUVP gives rise to vibration and rotation of the laser light-guide with the lateral luminescence that passes through the working channel of a small-size cystoscope (22–24 F) under the permanent irrigation with normal saline. The light-guide turns up- and downwards
along a 30–408 arc, its end being at a very small working distance (0.5–1.0 mm) from the tissue [7]. Such a close location of the light-guide permits the uniform impact of the KTP-laser energy. The effective evaporation of the tissue results in the formation of the vapor vesicles, which are washed away with the irrigational saline. To prevent hemorrhage, the laser coagulation requires either an increase in the working distance to the tissue of 3–4 mm or a reduction in the laser power to 30–40 Wt, without any change in the light-guide’s position. The vaporization of the prostate begins with the bladder cervix, proceeds to the lateral lobes at the level of the seminal colliculus and ends at the external sphincter. Our clinical experience involves 40 patients who underwent TUVP. Preoperatively, a comprehensive urological examination was carried out in all of the patients. This included an assessment of the patients’ complaints based on the International Prostate Symptom Score (IPSS), their quality-of-life (QoL) index, routine clinical measurements, a digital rectal examination, prostatic transrectal ultrasonography (TRUS) and transabdominal ultrasonic scan including measurement of the prostatic volume, measurement of the postvoid residual urine value, urodynamic investigations and evaluation of the serum prostate specific antigen levels (PSA). TUVP was not made available to patients with increased PSA levels. The following evaluations were performed before the patient’s discharge from the hospital and at 1, 3, 6, and 12 months following the intervention: assessment of patients’ complaints, the QoL index estimation, maximal urine flow rate (Qmax) assessment, and prostatic TRUS. The mean values for patients’ baseline characteristics are displayed in Table 1.
Results Forty patients with BPH underwent TUVP by means of an 80 Wt high-power potassium-titanyl-phosphate laser. The specifics for this technique had been determined previously, with the result that the clinicians could remove the prostatic tissue quickly and effectively during the surgery. It should be noted that in virtually all cases the intra-operative bleeding was minimal and did not prevent endoscopic
Vol. 5, No. 2, pp. 148–152, June 2008
149
Original article Table 1 Patients’ baseline characteristics (mean values) Age Transurethral photoselective vaporization (n = 40)
Prostatic 3
IPSS/QoL
Qmax
Vres
(years)
volume (cm )
(points)
(ml/s)
(cm3)
69
57
22.5/4.8
8.6
86
IPSS, International Prostate Symptom Score; QoL, quality-of-life; Qmax, maximal urine flow rate; Vres, residual volume of the prostate.
visualization of the operative field. The operating time required, from the moment of introduction of the light-guide into the urethra prior to the installation of the urethral catheter, averaged 52.4 min in patients with a mean preoperative prostatic volume of less than 57 cm3. The mean volume of the intra-operative blood loss was less than 52 ml. During the operation and in the early postoperative period, in the majority of patients, neither the lavage fluid nor the urine in the urethral catheter was seen, macroscopically, to contain blood. The duration of urethral catheter placement varied with the baseline functional parameters of the bladder. The mean time for in-dwelling of the urethral catheter was 14 h. Following removal of the urethral catheter, submissive urination resumed in all patients and dysuria, according to the patients’ reports, was only minimal. The dynamics of the IPSS
150
and QoL parameters after TUVP are given in Figures 1 and 2. The results of repeated TRUS scans suggest a significant decrease in the prostatic volume, similar to that commonly found in patients who undergo ‘conventional’ transurethral resection of the prostate (TUR). By month 6 postoperatively, the prostatic volume had decreased by, on average, 68.6% to a volume of 19.1 cm3. The changes in this parameter over time are presented in Figure 3. It should also be pointed out that analysis of the objective parameters describing the quality of urination showed a pronounced clinical effect (Figure 4). A significant increase in Qmax was already obvious in patients within the first 3 months after surgery, whereas by month 6 this parameter had peaked. Noteworthy also is a moderate decrease in Qmax later on in the follow-up. By the end of the follow-up, the Qmax
Figure 1
Mean International Prostate Symptom Score (IPSS) before and various periods after the intervention.
Figure 2
Mean Quality-of-Life (QoL) scores before and various periods after the intervention.
Vol. 5, No. 2, pp. 148–152, June 2008
Original article
Figure 3
Mean prostatic volume before and various periods after the intervention.
Figure 4
Mean values of maximal urine flow rate (Qmax) before and various periods after the photoselective vaporization.
Figure 5
Mean values for the postvoid residual urine volume in patients before and various periods after the photoselective vaporization.
values in the control group, on average, implied that urination was non-obstructive and did not fall below the values typical of those at month 3 after TUPV. In those patients who underwent the intervention, the maximal decrease in the volume of the postvoid residual urine was evident in the first 6 months post-surgery. The value dropped from 86 ml at baseline to a minimum of 21.9 ml, on average, at month 6 of the follow-up. The dynamics of the postvoid residual urine volume in the postoperative period are shown in Figure 5. Thus, as evidenced by the data obtained during the 1-year follow-up, therapy of 40 patients with BPH using TUVP resulted in a significant improvement in the subjective and
objective symptoms and signs of lower urinary tract dysfunction.
Discussion The use of laser adenomectomy means that patients can avoid the complications that can accompany monopolar electroresection, which uses an electric current running through patients’ bodies and can result in burns to the gluteal area and urethra. Laser adenomectomy also enables clinicians to operate on patients with artificial pacemakers, heart pacemakers or steel artificial limbs. The photoselectivity of the KTP laser provides, on the one hand, effective vaporization
Vol. 5, No. 2, pp. 148–152, June 2008
151
Original article of the prostatic tissue, and on the other hand, acceptable hemostasis, which permits an operative intervention in patients on life-time anticoagulant and/or antiaggregant therapy. Since TUVP utilizes a light-guide of a considerably smaller diameter (22–23 F) than does conventional TUR, the risk of injury to the urinary tract during the intervention is substantially lower. The unique physical characteristics of the powerful KTP laser, when compared with other laser types, provide an optimal vaporization effect and a small zone of coagulation necrosis. This allows surgeons to reduce the risk of intraoperative bleeding, to substantially shorten the bladder drainage period, and to avoid the prolonged dysuria in the postoperative period that commonly occurs when other types of lasers are used. The analysis of sexual dysfunctions found in the postoperative period suggests the absence of erectile dysfunction and a significant decrease in the risk of retrograde ejaculation following TUVP, compared with conventional prostatic TUR, which is particularly important for younger patients interested in the preservation of their reproductive function. Perhaps the most serious disadvantage of this method is the absence of any material for histological investigation after the surgery, which invariably requires that prostatic malignancy be ruled out at the preoperative stage, while blood PSA screening then has to be carried out postoperatively, at a high cost of equipment and expendable materials.
Conclusion From our experience we can say that photoselective laser vaporization of the prostate by means of an 80-Wt high power KTP laser (GreenLight PVTM Laserscope1, San Jose, CA) is a minimally invasive procedure that enables surgeons to quickly acquire experience of the intervention, i.e. four to five procedures are sufficient for a TUR-experienced surgeon to feel confident enough doing TUVP. The efficacy of the method is comparable with conventional TUR. Furthermore, the surgery is performed under conditions of excellent hemostasis, it is not accompanied by the absorption of lavage fluid nor does it cause blood loss. The technique can be easily used in day hospitals, is applicable both to younger patients who wish to preserve their sexual function and escape antegrade ejaculation, and to elderly patients with concurrent conditions requiring the life-time intake of anticoagulants. This type of operation is primarily indicated and effective for the removal of the prostate of smaller or average size (up to 40–50 cm3). Overall, combining the effective vaporizing removal of the prostate with minimal intraoperative blood loss, prostatic laser vaporization may be considered a useful alternative to conventional TUR. Further research is needed on the long-term results of the surgical intervention and these would be of great help in the comprehensive assessment of its clinical efficacy.
References [1] Lopatkin NA, Martov AG, Kozlov SA. Vserossiiskoe nauchnoe obshchestvo urologov. Plenum: Materialy - Kursk; 1993, S.-112–113. [Lopatkin NA, Martov AG, Kozlov SA. All-Russian Research Society for urologists. Plenary Session: Abstracts - Kursk; 1993, p. 112–113]. [2] Gorilovskiy LM. Ocherki geriartricheskoi urologii.– M., 1993. [Gorilovskiy L.M. Essays on geriatric urology – Moscow, 1993]. [3] Bachmann A, Wyler S, Ruszat R, Gasser T, Sulser T. Photoselective KTP laser vaporization of the prostate. First experiences after 50
152
Vol. 5, No. 2, pp. 148–152, June 2008
procedures. J Endourol 2003;(Suppl 1): A188. [4] Hai MA, Malek RS. Photoselective vaporization of the prostate: initial experience with a new 80 W KTP laser for the treatment of benign prostatic hyperplasia. J Endourol 2003;17:93–6. [5] Kuntzman RS, Malek RS, Barrett DM, Botwick DG. Potassium-titanyl-phosphate laser vaporization of the prostate: a comparative functional and pathologic study in canines. Urology 1996;48:575–83.
[6] Langley SE, Gallegos CR, Moisey CU. A prospective randomized trial evaluating endoscopic Nd:YAG laser prostate ablation with or without potassium titanyl phosphate (KTP) laser bladder neck incision. BJU Int 1997;80: 880–4. [7] Malek RS, Kuntzman RS, Barrett DM. High power potassium-titanyl-phosphate laser vaporization prostatectomy. J Urol 2000; 163:1730–3.