Transurethral Cystolithotripsy With Holmium Laser Under Local Anesthesia in Selected Patients

Transurethral Cystolithotripsy With Holmium Laser Under Local Anesthesia in Selected Patients

Endourology and Stones Transurethral Cystolithotripsy With Holmium Laser Under Local Anesthesia in Selected Patients Cengiz Kara, Berkan Resorlu, Izze...

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Endourology and Stones Transurethral Cystolithotripsy With Holmium Laser Under Local Anesthesia in Selected Patients Cengiz Kara, Berkan Resorlu, Izzet Cicekbilek, and Ali Unsal OBJECTIVES METHODS

RESULTS

CONCLUSIONS

To evaluate the feasibility and effectiveness of transurethral holmium:yttrium-aluminum-garnet (YAG) laser cystolithotripsy under local anesthesia in selected patients. Thirteen consecutive male patients with large bladder calculi (3 cm or greater) caused by benign prostatic hyperplasia underwent transurethral cystolithotripsy using holmium:YAG laser under local anesthesia. The operation was performed with all the patients in the lithotomy position (except 3 with pelvic prosthesis). All patients underwent transurethral holmium laser cystolithotripsy (HLC) with a flexible cystoscope under local anesthesia by 1 surgeon. A urethral Foley catheter was placed postoperatively. Thirteen patients with a mean age of 58.2 years were managed with HLC. All patients were rendered stone-free, regardless of stone size. No patient underwent transurethral resection of the prostate at the completion of the procedure. The mean stone size was 3.6 cm (range 3-5) and the mean operative time was 51 minutes (range 45-65). The whole procedure was well tolerated and no significant differences were found in the mean pain score between the HLC group and a group of male patients who underwent flexible cystoscopy under local anesthesia (2.15 vs 1.86, respectively; P ⫽ .467). No major intraoperative complication occurred. The mean hospitalization was 2.3 days. After a mean follow-up of 16.6 months, no recurrent stone, urinary retention, or urethral stricture developed. Transurethral holmium:YAG laser lithotripsy under local anesthesia appears to be a safe and effective technique for the large bladder calculi. Thus, it may be used as an alternative treatment option in selected patients. UROLOGY 74: 1000 –1003, 2009. © 2009 Elsevier Inc.

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he management of bladder calculi has been developed in the recent decade, with the result that multiple management modalities are available. Commonly accepted modalities include transurethral or percutaneous cystolithotomy, open cystolithotomy, and extracorporeal shock wave lithotripsy (SWL).1 In adults, bladder calculi can be treated endoscopically by mechanical cystolithotripsy, litholapaxy, ultrasound and electrohydraulic lithotripsy, pneumatic lithotripsy, and holmium:yttrium-aluminum-garnet (YAG) laser.2 The usage of the holmium:YAG laser revolutionized the treatment of urinary lithiasis and this might be the intracorporeal modality of choice.3 Several studies have demonstrated the advantages the holmium:YAG laser lithotripsy for the treatment of bladder calculi, in comparison with other modalities.1-4

From the Department of Urology, Ministry of Health, Kecioren Training and Research Hospital, Kecioren, Ankara, Turkey Reprint requests: Cengiz Kara, M.D., Bahcelievler Mah, 71 Sok, Umutpark Sitesi, No: 18, 06830, Golbasi, Ankara, Turkey. E-mail: [email protected] Submitted: March 27, 2009, accepted (with revisions): May 20, 2009

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© 2009 Elsevier Inc. All Rights Reserved

Transurethral holmium laser cystolithotripsy (HLC) is usually performed under general or spinal anesthesia. We investigated to determine whether this technique can be performed with flexible cystoscope under local anesthesia in patients with bladder calculi. Furthermore, we used HLC in supine position as an alternative to patients who could not to be positioned for lithotomy. Thus far, local anesthesia has been used in varying endoscopic procedure for stone removal, but not in transurethral HLC. To our knowledge, this is the first study reporting a high success rate for HLC performed under local anesthesia.

MATERIAL AND METHODS A total of 13 consecutive male patients were enrolled in this prospective study for 24 months. All had been diagnosed with large bladder calculi (3 cm or greater) as a result of benign prostatic hyperplasia (BPH). Patients with a prostate volume ⬎ 50 cm3 (according to transrectal ultrasonography), urethral stricture, hydronephrosis, renal insufficiency, or urinary retention history were excluded from the study. Patients with sufficient medical comorbidities to present an unacceptable risk for anesthesia were also excluded from study. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.05.095

The preoperative evaluation included history, clinical examination, routine laboratory tests (serum creatinine, complete blood count, coagulation profile, liver function, and serum prostate-specific antigen), urinalysis, and urine culture. Urinary tract infections that were detected preoperatively were managed vigorously considering antibiotics sensitivity, and the operation were postponed until the urine became sterile. Radiologic investigations included kidney, ureter, bladder (KUB) film and urinary ultrasonography. Cystoscopy and intravenous urography were done when necessary. The calculus size was determined by preoperative KUB film. In the patients with BPH, the International Prostate Symptom Score (IPSS) was calculated before and after the operation. Postvoid residual urine volume was also measured. Pain was evaluated with a 10-cm (0: no pain, 10: worst possible pain) visual analog scale (VAS) at the beginning of the procedure. The VAS score was compared with the groups (15 men) who underwent flexible cystoscopy as a result of hematuria evaluation under local anesthesia. After receiving a detailed explanation of the operative procedure, the compliant patients signed an informed consent form. Pethidine HCl (50 mg intramuscularly) was used for premedication, and 1 dose of a first-generation cephalosporin was administered as antibiotics prophylaxis. The surgery was performed with all the patients in the lithotomy position (except 3 with pelvic prosthesis) under local anesthesia. The irrigation fluid was warmed to 36 C. In all the patients, 10 mL of 2% lidocaine gel (Cathagel, Farco-Pharma, GmbH, Cologne, Germany) was instilled and a penile clamp was placed for 10 minutes. All operations were performed by 1 urologist (A. U.). During the surgery, the operator kept the patient informed about the steps of the procedure being performed, including gel instillation, endoscope insertion, and intravesical examination. Initially, cystoscopic evaluation of bladder and prostate was performed with 13.8/16.5F cystoscope (Olympus, CYF-5A flexible cystoscope, Japan). The flexible cystoscope was connected to an aspirator needed to reduce the tension in bladder during the surgery. For HLC, a 365 or 550 nm end-firing laser fiber was used for the lithotripsy. The laser energy was set at 0.5-1 J per between 5 and 20 Hz. The calculus fragments were evacuated by using the aspirator. At the end of the surgery, 20F urethral Foley catheter was placed. The heart rate, ventilatory frequency, arterial pressure, and peripheral oxygen saturation were recorded during the surgery. Transurethral resection of prostate (TURP) was not performed in any patient. Calculus clearance was assessed on the first day after the surgery with KUB film. Complete clearance was defined as absence of any fragments on the KUB film. When they could urinate without difficulty, patients were discharged and reassessed clinically at 1 month. Patients were followed up with KUB film and ultrasonography every 6 months thereafter. The data of the operations and the VAS scores were analyzed with the Mann-Whitney U test, with P ⬍.05 value considered statistically significant.

RESULTS The demographics and operative characteristics of the patients are shown in Table 1. The HLC for bladder calculi was technically feasible under local anesthesia in all patients, and all were rendered stone-free. The mean patient age was 58.2 ⫾ 6.4 years (range 52-75). The mean stone size was 3.6 ⫾ 0.61 cm (range 3-5 in the single largest dimension). The mean operative time for UROLOGY 74 (5), 2009

Table 1. Patients and treatment characteristics (all values are mean and range) No. Patients Age (y) Stone size (cm) Operative time (min) Stone free rate VAS score IPSS before surgery IPSS after surgery Prostate vol (mL) Hospital stay (d) Complications (n) Fever

13 58.2 ⫾ 6.4 (52-75) 3.6 ⫾ 0.61 (3-5) 51 ⫾ 5.9 (45-65) 100% 2.15 ⫾ 0.89 (1-4) 17.92 ⫾ 1.97 (16-23) 8.69 ⫾ 1.18 (7-11) 44.15 ⫾ 5.69 (32-50) 2.38 ⫾ 1.32 (1-5) 1

Figure 1. Holmium laser cystolithotripsy in supine position under local anesthesia.

lithotripsy was 51 ⫾ 5.9 minutes (range 45-65). Of the 13 patients, 11 had a single stone and 2 had multiple stones. Two patients (% 15.3) had failed SWL for bladder calculus previously. One of the patients (7.6%) had undergone open cystolithotomy before. Complete calculus clearance was achieved in all patients (100%). There were no major complications during surgery. In addition, no significant changes in the heart rate, blood pressure, ventilatory frequency, or oxygen saturation were detected. Mild hematuria due to small mucosal lesion was common but no patients required a blood transfusion or developed clot retention. Transient fever was seen in one patient, which resolved with conservative treatment. In 3 patients with pelvic prosthesis, HLC was performed in supine position (Fig. 1). The procedure was well tolerated in all patients and no significant difference was found in the mean VAS score between the HLC and flexible cystoscopy groups (2.15 ⫾ 0.89 vs 1.86 ⫾ 0.74, respectively, P ⫽ .467). Additional analgesic requirement did not occur intraoperatively in any patient. 1001

A flexible 13.8/16.5cystoscope (Olympus, CYF-5A, Japan) was used in all procedures and it was connected to aspirator for removing the stone fragments and reducing the tension of bladder during surgery. Holmium laser was used to produce small (⬍ 1 mm) or powdered fragments, and these fragments were evacuated by using an aspirator. Furthermore, after completion of the procedure 20F Foley urethral catheter was inserted in all patients and bladder irrigation was performed through the catheter for removing residual small fragments. Five days before the procedure, all patients with BPH began taking ␣-blockers. This treatment resulted in improvement of the IPSS (mean preoperative 17.92 ⫾ 1.97 vs mean postoperative 8.69 ⫾ 1.18). The mean hospitalization time was 2.38 ⫾ 1.32 days (range 1-5). Eleven of 13 patients voided by postoperative day 1. The patients not voiding by the postoperative first day were re-catheterized and these patients voided by postoperative day 5. A mean follow-up of 16.6 months (range 12-24) showed no recurrent of stones, urinary retention, or urethral stricture.

COMMENT Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction (BOO), neurogenic bladder, infection, and foreign bodies.5 There is no agreement about the preferred method of treating bladder calculi in patients with associated BOO caused by BPH. Various methods attempted for the management of bladder calculi include SWL, transurethral cystolithotripsy, percutaneous cystolithotripsy, or open surgery. SWL for bladder calculi appears to be simple, well tolerated, and effective. However, SWL does not address etiology nor does it usually remove all fragments, while its efficacy is influenced by calculus size.6 Furthermore, the clearance of large bladder calculi, however, will often necessitate multiple treatments and ancillary endoscopic procedures. Open cystolithotomy has been used for a long time for the bladder calculi, with a high success rate. Today, it is a rarely used method. It can be applied, however, to patients having a larger stone burden, with hard stones that are refractory to the endoscopic procedures, or who are undergoing open prostatectomy and diverticulectomy.7 Percutaneous suprapubic lithotripsy was introduced, which uses the principles of percutaneous access and tract dilatation that were developed for renal endourologic surgery. Salah et al8 performed percutaneous cystolithotomy in 155 children with endemic bladder lithiasis and concluded that this procedure is safe and effective. Sofer et al1 presented a combined technique of percutaneous suprapubic and transurethral route in 12 consecutive patients with bladder calculi ⬎ 4 cm in diameter. The median operative time was 56 minutes, morbidity was minimal, and median hospitalization time was 2.7 days. They found it useful to immobilize rolling stones through one route, for effective fragmentation through another 1002

route. Aron et al9 found percutaneous suprapubic cystolithotripsy and TURP more advantageous than transurethral cystolithotripsy/lapaxy and TURP in terms of operating time and morbidity in their series of 14 patients with BPH and large bladder calculi. However, the percutaneous approach requires an incision, a suprapubic tube, and carries a risk of bowel perforation and inadvertent vascular injury.10 Transurethral cystolithotripsy is probably the most common way to manage cystolithiasis. This approach permits the use of diverse tools for stone fragmentation, including a mechanical stone crusher, and instruments providing electrohydraulic, ultrasonic, pneumatic, and laser energy. Mechanical cystolithotripsy is associated with hematuria, bladder perforations, and mucosal injuries. When combined with TURP, it has a 21% complication rate with a mean hospital stay of 8 day.11 Pneumatic lithotripsy can fragment almost all varieties of stones, but fragments sometimes have to be pursued within the bladder. Pneumatic lithotripsy is also associated with hematuria, making endoscopic vision difficult. Razvi et al12 confirmed the effectiveness of ultrasonic lithotripsy in 17 patients with bladder calculi. The success rate was 88%. The advantages of this method are safety, lower cost, and its ability to remove larger stones, together with the chance to avoid repeated urethral instrumentation. It has the disadvantage, however, of a lower success rate with harder stones as well. The holmium laser has now become the device of choice for intracorporeal lithotripsy. It can successfully fragment large stones with minimal trauma to the bladder mucosa and minimal hematuria. Teichman et al13 demonstrated that holmium:YAG laser produced smaller stone fragments than other lithotriptors. This laser appears to exert its effect by way of a photothermal means. The depth of thermal injury to the tissue in contact on laser activation is 0.5-1 mm, which limits the possibility of deep thermal injury to tissue. The holmium:YAG laser has an aiming beam that helps operators ensure that the stone is focused accurately, thus decreasing the chance of mucosal injury. The same investigators reported that there is negligible stone vibration or movement in their patients as long as energy levels were kept to ⬍ 1.2 J.2 In a comparative study between the holmium:YAG laser and the Swiss LithoClast (EMS, Nyon, Switzerland), the authors concluded that the holmium: YAG laser is preferable for larger bladder calculi.14 We performed HLC with flexible cystoscope in 13 consecutive male patients with large bladder calculi under local anesthesia. The success rate was 100%. The overall stone-free rate proved similar to that reported in other series, in which the technique was performed under general or regional anesthesia. No intraoperative major complication was seen in our patients, and the procedure was well tolerated. Transient fever was observed in 1 patient (7.6%), which was treated by conservatively. The pain was minimal in all patients and this was proved by UROLOGY 74 (5), 2009

the comparison of pain felt during the surgery with that reported by a group of male patients undergoing flexible cystoscopy under local anesthesia. The mean VAS scores did not differ significantly in the 2 groups. In 3 patients who could not to be positioned in lithotomy position, HLC was performed in supine position. These patients had pelvic prosthesis and tolerated the procedure well. Thus far, local anesthesia has been used in varying endoscopic procedure for stone removal but not in transurethral HLC.15-17 To our knowledge, this is the first study reporting a high success rate for HLC performed under local anesthesia. Application of this procedure under local anesthesia reduced not only the anesthesiarelated risks but also the cost per anesthesia. We did not perform TURP in any patient in this series, and all patients voided postoperatively. No recurrent stones, urinary retention, and urethral stricture developed during a mean follow-up of 16.6 months. Although the European University Association guideline18 on BPH still considers bladder calculi as a complication of BPH and recommends surgical treatment of BOO, the American Urological Association practice guidelines committee has not considered bladder calculi as a complication of BPH.19 Tzortzis et al15 treated 16 patients with BOO and associated with bladder calculi using percutaneous suprapubic cystolithotripsy under local anesthesia and medical management of BOO. No patients needed surgery for BOO or developed recurrence of bladder calculi. It was noted that if a patients refuses surgery or if they had sufficient medical comorbidities to present, an unacceptable risk for surgery alternative therapy might be considered. Therefore, patients presenting with BPH and associated with bladder calculi can be managed with medical treatment of BPH and minimally invasive treatment of their stones.20,21 Millan-Rodriguez et al21 achieved a 93% success rate using SWL to fragment bladder calculi ⬍ 4 cm in size. They also reported a significant reduce in the mean IPSS after the treatment. In our study, all patients were successfully treated with ␣-blockers after the procedure with a significant reduction in the IPSS. No patients required prostatectomy at the follow-up period.

CONCLUSIONS HLC with flexible cystoscope under local anesthesia is a safe and an effective minimal invasive technique for the treatment of large bladder calculi. It is well tolerated by the patients and may be used as an alternative treatment option in selected patients such as those with a high anesthetic risk to undergo surgery under general or regional anesthesia. Furthermore, this procedure may also be used in patients who could not to be positioned for lithotomy.

UROLOGY 74 (5), 2009

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