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Some clinical applications of carbon dioxide laser in urologic surgery
SOME CLINICAL APPLICATIONS OF CARBON DIOXIDE LASER IN UROLOGIC SURGERY SAMUEL K. ROSEMBERG, M.D. SHERWIN J. LUTZ, M.D.
From the Department of Urology, Harper-Grace Hospitals, Detroit, Michigan
A B S T R A C T - - F o u r clinical cases are presented in which the carbon dioxide laser was used as an adjunct to control massive post-prostatectomy bleeding, minimize parenchymal damage in a patient with bilateral renal tumors and impaired renal function, and in bivalving the kidney in 2 patients with staghorn calculus in order to shorten operative time and reduce blood loss.
In all surgical applications the laser serves as a source of radiant power directly focused onto tissue, causing a localized temperature increase to a desired level. The rise in temperature depends on the energy absorbed and on the thermal parameters of the tissue itself (density, specific heat, and thermal conduction) which determines the rate of temperature increase. When tissue is heated at about 60 °C no changes occur; temperatures above 60°C will result in coagulation and denaturation of protein. Darkening of the tissue is observed at 80 °C, and between 90 ° and 100°C vaporization of tissue water takes place, preceding carbonization that occurs after a few hundred degrees. Heat-induced spontaneous contraction of blood vessels, as observed during the application of surgical lasers by beam defocusing, offers, in theory, a sound advantage during urologic surgery. Being encouraged by this enormous potential and reports by others, 1 the carbon dioxide (CO2) laser beam was used to facilitate hemostasis during anatrophic nephrolithotomy, partial nephrectomy, and uncontrollable postoperative hemorrhage secondary to a suprapubic prostateetomy. Case Reports
not amenable to a transurethral resection. A suprapubic prostatectomy was performed necessitating packing of the prostatic fossa due to persistent bleeding. Serum prothrombin time, partial thromboplastin time, thrombin time, fibrinogen level, split products, platelet count, all were found to be within normal limits. On the second postoperative day, the prostatic packing was removed with immediate occurrence of uncontrollable hemorrhage, requiring operative intervention and plication of the posterior capsule which provided adequate bleeding control immediately after being extubated, life-threatening hemorrhage recurred followed by re-exploration. Generalized oozing from the prostatic fossa with no particular arterial bleeding continued in spite of hemostatic sutures placed at the five and seven-o'clock positions. A Sharplan 733 CO2 laser unit was brought in and hemostasis achieved by using an unfocused beam, average power 10 watts, CW mode. The prostatic fossa was packed again, and the suprapubic tube as well as the Foley catheter drainage were left indwelling for irrigation. Postoperatively, a right epididymitis developed that responded to antibiotic administration, and the patient was discharged at which time he was voiding with adequate control.
Case 1
A seventy-year-old man was admitted for evaluation of lower urinary tract obstruction. Cystoscopic examination had revealed a trilobar prostate with severe bladder trabeculation,
240
Case 2
A fifty-two-year-old white woman was admitted for an elective right anatrophic nephrolithotomy because of persistent urinary tract
UROLOGY
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M A R C H 1984
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V O L U M E XXIII, N U M B E R 3
FIGURE 1. Flat plate of abdomen showing right staghorn calculus.
FIGURE 2. Bight renal arteriogram reveals hypovascular lower pole mass.
infection and metabolically active stone disease (Fig. 1). The posterior division of the renal artery was isolated and occluded, after indigo carmine and mannitol had been given intravenously. A Sharplan 733 CO2 laser unit with a maximum out-power of 28 watts, and focused beam to a spot size of 2.0 mm, CW mode, was used to incise the kidney parenchyma along the Brodel line. Sharp and clean incision followed with minimal bleeding; nevertheless, a prolonged time to cut with the CO2 laser beam, even when focused perfectly, was noted (15 minutes). No postoperative complications occurred, and the patient was discharged in satisfactory clinical condition.
733 COn laser unit, with an average power of 10 watts, CW mode, was used and easily controlled the bleeding by beam defoeusing. No postoperative complications oecurred, and the patient was discharged on the ninth postoperative day with stable renal function and with similar surgery contemplated in the near future for the opposite left renal unit.
Case 3 A seventy-five-year-old white man was admitted for an elective right inguinal herniorrhaphy, and was found to have bilateral renal masses by intravenous pyelography. Ultrasonography was obtained, revealing a 4.0 em, solid, right lower pole renal lesion with multiple left renal cysts. A renal arteriogram confirmed these findings (Fig. 2) and the hypovascular nature of the lesion. A CAT scan was then obtained with the finding of a 3.0 cm, solid, left lower pole lesion, and a 1.0 cm, solid, left upper pole mass. Due to the fact that the patient's preoperative ereatinine was 2.3 mg, it was decided to perform a right lower pole partial nephreetomy. During surgery, a Sharplan
UROLOGY
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M A R C H 1984
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V O L U M E XXIII, N U M B E R 3
Case 4 A sixty-three-year-old white woman, previously treated for reeurrent urinary tract infections secondary to a left staghorn calculus, was admitted for anatrophic nephrolithotomy. Occlusion of the posterior division of the renal artery was accomplished prior to intravenous injeetion of indigo carmine. A carbon dioxide laser, CW mode, with an output power of 28 watts, focused to a spot size of 2.0 mm was used, producing a sharp clean incision of the kidney parenehyma, but individual ligation of several interlobular arteries was still required. Again, a prolonged time (over 15 minutes) was required to incise the renal tissue. Her postoperative course was uneventful. Comment One of the attributes of the CO2 laser is its ability to vaporize tissue. This requires a perfeetly focused beam to maximize the power density. W h e n the beam is defoeused, the power density (watts x em 2) will decrease and
241
FmURE 3. Right renal arteriogram substraction film showing abnormal vasculature. vaporization will no longer take place; instead, the tissues to which the laser is applied will be heated and coagulated because work will be done below the threshold of vaporization. To our knowledge, this is the first ease reported of post-prostatectomy hemorrhage requiring the use of CO2 laser as an adjunct for bleeding control. Vessels smaller than 0.5 m m in diameter can be sealed off with ease, 1 and the lack of tissue fibrosis 2 due to the limited heat transmission found surrounding a CO~ laser lesion makes this modality attractive since vesieal neck eontraeture and posterior urethral stricture, in theory, can be avoided. Hemostatie sutures at the five and seveno'clock positions, as well as plication of the posterior capsular wall as deseribed by O'Connor, 3 did not control the bleeding, and our last resort would have been a bilateral hypogastric artery ligation. Previous experimental and clinical reports 4 on the use of the carbon dioxide laser beam in renal surgery have corroborated its efficacy in reducing blood loss, shortening hemostasis time, and minimizing parenchymal damage. It is i m p o r t a n t to note that cutting with the laser beam through the avascular plane took approximately fifteen minutes. Bleeding arteries of more than 0.5 m m required individual ligature with 4-0 chromic catgut. Smaller vessels were coagulated by beam defocusing. It is possible that the prolonged incisional time could be shortened by the use of output powers in excess of 50 watts as previously suggested, 5 and that
242
this cannot be achieved with a 733 CO2 laser unit from which a m a x i m u m output of 28 to 30 watts can be obtained. Partial nephrectomy can be done in situ in most cases of bilateral renal cell carcinoma, and the operation can be performed under the protection of cold isehemia to minimize renal damage. The possibility of hereditary multifocal renal carcinoma ~ and yon Hippel-Lindau syndrome 7 should be kept in mind. Our patient did not have any of the clinical stigmata of von Hippel-Lindau disease nor a history of a previous family m e m b e r afflicted with a renal neoplasm. The advantages offered by the CO2 laser incision of the renal parenchyma, such as shortening operative time, facilitating hemostasis, and minimizing parenchymal damage, are to be considered in selected cases of bilateral renal neoplasm. It is important to note that powers in excess of 50 watts should be used for this particular type of surgery, and that the CO2 laser Sharplan 733 does not provide this high output power. Summary The carbon dioxide laser was useful as an adjunct to control life-threatening post-prostateetomy bleeding in combination with prostatic fossa packing. Although the exact nature of its contribution cannot be defined as yet, more similar clinical eases are necessary to verify or deny this fact. The carbon dioxide laser produees a clean and sharp parenehymal incision, and output powers in excess of 50 watts should possibly be used. The carbon dioxide laser, w h e n properly used, also provides useful adjunct therapy in eases where maximal renal tissue preservation is needed, such as in bilateral renal neoplasms. 18700 Meyers Road Detroit, Michigan 48235 (DR. ROSEMBERG) References 1. Hall RR, et ah Partial hepateetomy using CO2 laser, Br Urol Surg 60:141 (1973). 2. Wilsher MK, et ah Development of carbon dioxide laser eystoscope, J Urol 119" 202 (1978). 3. O'Connor, VJ, Jr: An aid for hemostasis in open prostatectomy: capsular plication, ibid 127:448 (1982). 4. Barzilav B, et ah Comparative experimental study on the use of the COs laser beam in partial nephreetomy, Laser Surg Med 2:73 (1982). 5. Barzilav B, et ah The clinical use of CO2 laser beam in the surgery of kidney parenehyma, ibid 2:81 (1982). 6. Berg S, et al: Surgical management of hereditary multifoeal renal carcinoima, J Urol 126:313 (1981). 7. Milman KL, and Rosin SW: Lindau's disease--review of the literature and study of a large kindred, Am J Med 36. 595 (1964).
UROLOGY
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MARCH 1984
/
VOLUME XXIII, NUMBER 3
From the Department of Urology, Harper-Grace Hospitals, Detroit, Michigan
A B S T R A C T - - F o u r clinical cases are presented in which the carbon dioxide laser was used as an adjunct to control massive post-prostatectomy bleeding, minimize parenchymal damage in a patient with bilateral renal tumors and impaired renal function, and in bivalving the kidney in 2 patients with staghorn calculus in order to shorten operative time and reduce blood loss.
In all surgical applications the laser serves as a source of radiant power directly focused onto tissue, causing a localized temperature increase to a desired level. The rise in temperature depends on the energy absorbed and on the thermal parameters of the tissue itself (density, specific heat, and thermal conduction) which determines the rate of temperature increase. When tissue is heated at about 60 °C no changes occur; temperatures above 60°C will result in coagulation and denaturation of protein. Darkening of the tissue is observed at 80 °C, and between 90 ° and 100°C vaporization of tissue water takes place, preceding carbonization that occurs after a few hundred degrees. Heat-induced spontaneous contraction of blood vessels, as observed during the application of surgical lasers by beam defocusing, offers, in theory, a sound advantage during urologic surgery. Being encouraged by this enormous potential and reports by others, 1 the carbon dioxide (CO2) laser beam was used to facilitate hemostasis during anatrophic nephrolithotomy, partial nephrectomy, and uncontrollable postoperative hemorrhage secondary to a suprapubic prostateetomy. Case Reports
not amenable to a transurethral resection. A suprapubic prostatectomy was performed necessitating packing of the prostatic fossa due to persistent bleeding. Serum prothrombin time, partial thromboplastin time, thrombin time, fibrinogen level, split products, platelet count, all were found to be within normal limits. On the second postoperative day, the prostatic packing was removed with immediate occurrence of uncontrollable hemorrhage, requiring operative intervention and plication of the posterior capsule which provided adequate bleeding control immediately after being extubated, life-threatening hemorrhage recurred followed by re-exploration. Generalized oozing from the prostatic fossa with no particular arterial bleeding continued in spite of hemostatic sutures placed at the five and seven-o'clock positions. A Sharplan 733 CO2 laser unit was brought in and hemostasis achieved by using an unfocused beam, average power 10 watts, CW mode. The prostatic fossa was packed again, and the suprapubic tube as well as the Foley catheter drainage were left indwelling for irrigation. Postoperatively, a right epididymitis developed that responded to antibiotic administration, and the patient was discharged at which time he was voiding with adequate control.
Case 1
A seventy-year-old man was admitted for evaluation of lower urinary tract obstruction. Cystoscopic examination had revealed a trilobar prostate with severe bladder trabeculation,
240
Case 2
A fifty-two-year-old white woman was admitted for an elective right anatrophic nephrolithotomy because of persistent urinary tract
UROLOGY
/
M A R C H 1984
/
V O L U M E XXIII, N U M B E R 3
FIGURE 1. Flat plate of abdomen showing right staghorn calculus.
FIGURE 2. Bight renal arteriogram reveals hypovascular lower pole mass.
infection and metabolically active stone disease (Fig. 1). The posterior division of the renal artery was isolated and occluded, after indigo carmine and mannitol had been given intravenously. A Sharplan 733 CO2 laser unit with a maximum out-power of 28 watts, and focused beam to a spot size of 2.0 mm, CW mode, was used to incise the kidney parenchyma along the Brodel line. Sharp and clean incision followed with minimal bleeding; nevertheless, a prolonged time to cut with the CO2 laser beam, even when focused perfectly, was noted (15 minutes). No postoperative complications occurred, and the patient was discharged in satisfactory clinical condition.
733 COn laser unit, with an average power of 10 watts, CW mode, was used and easily controlled the bleeding by beam defoeusing. No postoperative complications oecurred, and the patient was discharged on the ninth postoperative day with stable renal function and with similar surgery contemplated in the near future for the opposite left renal unit.
Case 3 A seventy-five-year-old white man was admitted for an elective right inguinal herniorrhaphy, and was found to have bilateral renal masses by intravenous pyelography. Ultrasonography was obtained, revealing a 4.0 em, solid, right lower pole renal lesion with multiple left renal cysts. A renal arteriogram confirmed these findings (Fig. 2) and the hypovascular nature of the lesion. A CAT scan was then obtained with the finding of a 3.0 cm, solid, left lower pole lesion, and a 1.0 cm, solid, left upper pole mass. Due to the fact that the patient's preoperative ereatinine was 2.3 mg, it was decided to perform a right lower pole partial nephreetomy. During surgery, a Sharplan
UROLOGY
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M A R C H 1984
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V O L U M E XXIII, N U M B E R 3
Case 4 A sixty-three-year-old white woman, previously treated for reeurrent urinary tract infections secondary to a left staghorn calculus, was admitted for anatrophic nephrolithotomy. Occlusion of the posterior division of the renal artery was accomplished prior to intravenous injeetion of indigo carmine. A carbon dioxide laser, CW mode, with an output power of 28 watts, focused to a spot size of 2.0 mm was used, producing a sharp clean incision of the kidney parenehyma, but individual ligation of several interlobular arteries was still required. Again, a prolonged time (over 15 minutes) was required to incise the renal tissue. Her postoperative course was uneventful. Comment One of the attributes of the CO2 laser is its ability to vaporize tissue. This requires a perfeetly focused beam to maximize the power density. W h e n the beam is defoeused, the power density (watts x em 2) will decrease and
241
FmURE 3. Right renal arteriogram substraction film showing abnormal vasculature. vaporization will no longer take place; instead, the tissues to which the laser is applied will be heated and coagulated because work will be done below the threshold of vaporization. To our knowledge, this is the first ease reported of post-prostatectomy hemorrhage requiring the use of CO2 laser as an adjunct for bleeding control. Vessels smaller than 0.5 m m in diameter can be sealed off with ease, 1 and the lack of tissue fibrosis 2 due to the limited heat transmission found surrounding a CO~ laser lesion makes this modality attractive since vesieal neck eontraeture and posterior urethral stricture, in theory, can be avoided. Hemostatie sutures at the five and seveno'clock positions, as well as plication of the posterior capsular wall as deseribed by O'Connor, 3 did not control the bleeding, and our last resort would have been a bilateral hypogastric artery ligation. Previous experimental and clinical reports 4 on the use of the carbon dioxide laser beam in renal surgery have corroborated its efficacy in reducing blood loss, shortening hemostasis time, and minimizing parenchymal damage. It is i m p o r t a n t to note that cutting with the laser beam through the avascular plane took approximately fifteen minutes. Bleeding arteries of more than 0.5 m m required individual ligature with 4-0 chromic catgut. Smaller vessels were coagulated by beam defocusing. It is possible that the prolonged incisional time could be shortened by the use of output powers in excess of 50 watts as previously suggested, 5 and that
242
this cannot be achieved with a 733 CO2 laser unit from which a m a x i m u m output of 28 to 30 watts can be obtained. Partial nephrectomy can be done in situ in most cases of bilateral renal cell carcinoma, and the operation can be performed under the protection of cold isehemia to minimize renal damage. The possibility of hereditary multifocal renal carcinoma ~ and yon Hippel-Lindau syndrome 7 should be kept in mind. Our patient did not have any of the clinical stigmata of von Hippel-Lindau disease nor a history of a previous family m e m b e r afflicted with a renal neoplasm. The advantages offered by the CO2 laser incision of the renal parenchyma, such as shortening operative time, facilitating hemostasis, and minimizing parenchymal damage, are to be considered in selected cases of bilateral renal neoplasm. It is important to note that powers in excess of 50 watts should be used for this particular type of surgery, and that the CO2 laser Sharplan 733 does not provide this high output power. Summary The carbon dioxide laser was useful as an adjunct to control life-threatening post-prostateetomy bleeding in combination with prostatic fossa packing. Although the exact nature of its contribution cannot be defined as yet, more similar clinical eases are necessary to verify or deny this fact. The carbon dioxide laser produees a clean and sharp parenehymal incision, and output powers in excess of 50 watts should possibly be used. The carbon dioxide laser, w h e n properly used, also provides useful adjunct therapy in eases where maximal renal tissue preservation is needed, such as in bilateral renal neoplasms. 18700 Meyers Road Detroit, Michigan 48235 (DR. ROSEMBERG) References 1. Hall RR, et ah Partial hepateetomy using CO2 laser, Br Urol Surg 60:141 (1973). 2. Wilsher MK, et ah Development of carbon dioxide laser eystoscope, J Urol 119" 202 (1978). 3. O'Connor, VJ, Jr: An aid for hemostasis in open prostatectomy: capsular plication, ibid 127:448 (1982). 4. Barzilav B, et ah Comparative experimental study on the use of the COs laser beam in partial nephreetomy, Laser Surg Med 2:73 (1982). 5. Barzilav B, et ah The clinical use of CO2 laser beam in the surgery of kidney parenehyma, ibid 2:81 (1982). 6. Berg S, et al: Surgical management of hereditary multifoeal renal carcinoima, J Urol 126:313 (1981). 7. Milman KL, and Rosin SW: Lindau's disease--review of the literature and study of a large kindred, Am J Med 36. 595 (1964).
UROLOGY
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MARCH 1984
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VOLUME XXIII, NUMBER 3