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Rapid superpulse carbon dioxide laser treatment of urethral condylomata
RAPID SUPERPULSE CARBON DIOXIDE LASER TREATMENT OF URETHRAL CONDYLOMATA SAMUEL K . ROSEMBERG, M .D . TERRY FULLER, Pn .D . HOWARD JACOBS, M .D . From the Departments of Urology and Laser Surgery, Sinai Hospital of Detroit, Michigan
ABSTRACT - Complete eradication of urethral condylonutta was accomplished by rapid superpulsed carbon dioxide laser in 4 patients . Minimal postoperative discomfort and lack of stricture formation indicate that this new modality is an advantageous, fast, and secure method of manageinent of intraurethral eondylumata, and substantiated by our previous experimental reports .
Urethral condylomata have been considered by many as innocuous lesions of minor importance affecting people with poor general hygiene . They are commonly associated with urethral irritation and infection, urinary obstruction, bleeding, and fistula formation .' They have been considered preinalignant lesions that could assume major proportions, causing extensive urethral and bladder involvement, requiring radical operative procedures such as total penectomy 2 and cvstectomy. Treatment of these lesions has been extensive and variable, consisting of surgical excision, electrodesiccation, and topical application of cytotoxic agents such a podophyllin . Other agents used have included sulfa cream, chloroquine, and ammoniated mercury, and have not been effective . The latest described method has been 5% fluorouracil cream with an acceptable cure rate ;` nevertheless, it requires prolonged treatment, producing meatal inflammation, adherence of adjacent denuded meatal nmcosa . spraying of the urinary stream, severe dysuria, and urethral irritation . Laser energy is an effective, safe, and fast method of eradication of urethral condvlomata that has the ability to vaporize mueosal pathology completely with minimal adjacent tissue
UROLOGY
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FEBRUARY 1961 / VOLUME XVII . NUMBER 2
damage, as evidenced by lack of stricture formation and minimal postoperative discomfort . 4-6 Material and Methods Since July, 1979, 4 hale patients with urethral condyloinata, localized to the distal meatal region, were treated by fulguration with rapid superpulsed carbon dioxide laser using a repetition rate of 100 pulses per second and an average power varying from 3 .0 to 6 .8 watts (Fig. IA) . All 4 patients presented with urethral irritative symptoms, 2 of them with urethral bloody discharge . Cases 1 and 2 had been treated previously by surgical excision and electrofulguration, with inadequate results as evidenced by recurrent lesions . Follow-up and Results Average follow-up ranged from eight to thirty-six weeks . All four patients had complete eradication of the urethral condylomata (Fig . 1B), complaining of initial dysuria for a period of twenty-four to forty-eight hours, not requiring analgesic administration . Postoperative urethral meatal calibration with Otis bulbs to 22 F failed to reveal any stricture formation (Fig . 1C) . None experienced meatal adherence or spraying of the urinary stream .
149
FicoaE 1 . (A) Distal urethral condylomata protruding through meatus (representative (ases) ; (B) immediate postoperative results; and (C) sixteen weeks post-laser fulguration there is no evidence of recurrence and/or stricture of meatus .
1 .50
UROLOGY ;
FEBRUARY 1951
;
A OLC' .ME RFII, N UMBER 2
Comment Successful treatment of urethral condylomata requires accurate determination of the location and extent of involvement, so an adequate treatment plan can be chosen . Topical application of 5% 5-fluorouracil is required for prolonged periods of time, and often will cause severe irritative symptoms . On the other hand, electrofulguration could result in urethral stricture formation . The recent addition of laser energy in urologic practice has provided excellent clinical results with minimal postoperative disability . The laser radiation absorbed by a biological tissue is converted directly into heat energy, causing vaporization of the water cell component and denaturation of tissue protein . The precise control of the incident beam minimizes injury to adjacent tissues to an area not exceeding 2 .0 mm ., facilitating healing with minimal fibrosis . Furtherlnore, rapid superpulse laser, as reported by us in 1979,' creates a lesion to a predetermined depth with a lower average power density than the continuous wave mode . By using comparable power densities in both modes, the rapid superpulse laser
UROLOGY
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FEBRUARY 19}11
!
VOLUME XVII, NUMBER 2
results in less edema and tissue necrosis, resulting in faster healing with less scarring as clinically demonstrated in this selected group of patients . In conclusion, carbon dioxide laser therapy is a safe, fast and painless method for ablation of urethral condylomata that can be used as a first choice treatment modality or in cases in which 5% 5-fluorouracil topical application or electrolulguration has failed . Detroit, Michigan 48235 (DR . ROSEMRERG) References 1 . Morrow RP, Jr, McDonald JR, and Emmett J : Condvioniata accnninata of the urethra . J . Urol . 68 : 209 (1952) . 2, Iindner HJ, and Pasquier CM . Jr : Condylomata acuminata of the urethra, ibid . 72 : 875 (1961) . 3 . Dretler SP, and Klein LA : The eradication of intraurethral coadyloma acanninata with 5 per cent 5-fluorouracil cream, ibid. 11 :3 : 195 (1975) . 4 . Willsehcr M . et al : Development of carbon dioxide laser cystoscope .ibid . 119: 202 (1978) . 5 . Rattner WH . and Rosemherg SK : Differences between continnons wave and superpulse carbon dioxide laser in bladder surgery, Urology 13 : 264 (1979) . 6 . Fuselier HA, Jr, et al : Treatment of condylomata acvminata with carbon dioxide laser, ibid . 15: 265 (1980) .
151
ABSTRACT - Complete eradication of urethral condylonutta was accomplished by rapid superpulsed carbon dioxide laser in 4 patients . Minimal postoperative discomfort and lack of stricture formation indicate that this new modality is an advantageous, fast, and secure method of manageinent of intraurethral eondylumata, and substantiated by our previous experimental reports .
Urethral condylomata have been considered by many as innocuous lesions of minor importance affecting people with poor general hygiene . They are commonly associated with urethral irritation and infection, urinary obstruction, bleeding, and fistula formation .' They have been considered preinalignant lesions that could assume major proportions, causing extensive urethral and bladder involvement, requiring radical operative procedures such as total penectomy 2 and cvstectomy. Treatment of these lesions has been extensive and variable, consisting of surgical excision, electrodesiccation, and topical application of cytotoxic agents such a podophyllin . Other agents used have included sulfa cream, chloroquine, and ammoniated mercury, and have not been effective . The latest described method has been 5% fluorouracil cream with an acceptable cure rate ;` nevertheless, it requires prolonged treatment, producing meatal inflammation, adherence of adjacent denuded meatal nmcosa . spraying of the urinary stream, severe dysuria, and urethral irritation . Laser energy is an effective, safe, and fast method of eradication of urethral condvlomata that has the ability to vaporize mueosal pathology completely with minimal adjacent tissue
UROLOGY
/
FEBRUARY 1961 / VOLUME XVII . NUMBER 2
damage, as evidenced by lack of stricture formation and minimal postoperative discomfort . 4-6 Material and Methods Since July, 1979, 4 hale patients with urethral condyloinata, localized to the distal meatal region, were treated by fulguration with rapid superpulsed carbon dioxide laser using a repetition rate of 100 pulses per second and an average power varying from 3 .0 to 6 .8 watts (Fig. IA) . All 4 patients presented with urethral irritative symptoms, 2 of them with urethral bloody discharge . Cases 1 and 2 had been treated previously by surgical excision and electrofulguration, with inadequate results as evidenced by recurrent lesions . Follow-up and Results Average follow-up ranged from eight to thirty-six weeks . All four patients had complete eradication of the urethral condylomata (Fig . 1B), complaining of initial dysuria for a period of twenty-four to forty-eight hours, not requiring analgesic administration . Postoperative urethral meatal calibration with Otis bulbs to 22 F failed to reveal any stricture formation (Fig . 1C) . None experienced meatal adherence or spraying of the urinary stream .
149
FicoaE 1 . (A) Distal urethral condylomata protruding through meatus (representative (ases) ; (B) immediate postoperative results; and (C) sixteen weeks post-laser fulguration there is no evidence of recurrence and/or stricture of meatus .
1 .50
UROLOGY ;
FEBRUARY 1951
;
A OLC' .ME RFII, N UMBER 2
Comment Successful treatment of urethral condylomata requires accurate determination of the location and extent of involvement, so an adequate treatment plan can be chosen . Topical application of 5% 5-fluorouracil is required for prolonged periods of time, and often will cause severe irritative symptoms . On the other hand, electrofulguration could result in urethral stricture formation . The recent addition of laser energy in urologic practice has provided excellent clinical results with minimal postoperative disability . The laser radiation absorbed by a biological tissue is converted directly into heat energy, causing vaporization of the water cell component and denaturation of tissue protein . The precise control of the incident beam minimizes injury to adjacent tissues to an area not exceeding 2 .0 mm ., facilitating healing with minimal fibrosis . Furtherlnore, rapid superpulse laser, as reported by us in 1979,' creates a lesion to a predetermined depth with a lower average power density than the continuous wave mode . By using comparable power densities in both modes, the rapid superpulse laser
UROLOGY
/
FEBRUARY 19}11
!
VOLUME XVII, NUMBER 2
results in less edema and tissue necrosis, resulting in faster healing with less scarring as clinically demonstrated in this selected group of patients . In conclusion, carbon dioxide laser therapy is a safe, fast and painless method for ablation of urethral condylomata that can be used as a first choice treatment modality or in cases in which 5% 5-fluorouracil topical application or electrolulguration has failed . Detroit, Michigan 48235 (DR . ROSEMRERG) References 1 . Morrow RP, Jr, McDonald JR, and Emmett J : Condvioniata accnninata of the urethra . J . Urol . 68 : 209 (1952) . 2, Iindner HJ, and Pasquier CM . Jr : Condylomata acuminata of the urethra, ibid . 72 : 875 (1961) . 3 . Dretler SP, and Klein LA : The eradication of intraurethral coadyloma acanninata with 5 per cent 5-fluorouracil cream, ibid. 11 :3 : 195 (1975) . 4 . Willsehcr M . et al : Development of carbon dioxide laser cystoscope .ibid . 119: 202 (1978) . 5 . Rattner WH . and Rosemherg SK : Differences between continnons wave and superpulse carbon dioxide laser in bladder surgery, Urology 13 : 264 (1979) . 6 . Fuselier HA, Jr, et al : Treatment of condylomata acvminata with carbon dioxide laser, ibid . 15: 265 (1980) .
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