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Treatment of urethral diseases with neodymium:Yag laser
TREATMENT OF URETHRAL DISEASES WITH NEODYMIUM:YAG GLENN BLOISO,
M.D.
ROGER WARNER, MARC COHEN,
LASER
M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT-Over a thirty-month period, a wide variety of common urethral problems were treated on an ambulatory basis, with the neodymium:yttrium-aluminum garnet (Nd:YAG) laser. When used discriminately, laser treatment appears to be an effective modality for the management of selected urethral strictures. Thus far, excellent results have been obtained in 30 of 31 cases of short strictures where laser urethrotomy was performed as the first stricture procedure (average follow-up 10 months). Furthermore, in a series of 36 cases of secondary bladder neck contractures, all of the evaluated patients responded well (average follow-up 7 months). Good results were obtained in only 11 of 48 complicated strictures (average follow-up 14 months). However, while most of these extensive strictures were not eradicated, laser therapy generally produced a documented clinical improvement, comparable to urethrotomy or dilatation, in 15 of these cases. A series of 24 condylomata involving the urethra were treated satisfactorily, with no recurrences (average followup 13 months). Laser treatment also has been used successfully for the management of several urethral caruncles, urethral polyps, two meatal hemangiomas, one urethral carcinoma, and a distal duplicated urethra. Recently, the Nd:YAG laser has been applied to the prostatic urethra with vaporization of obstructing median bar hyperplasia. Favorable results have been achieved in 5 of 6 cases treated with a newly developed technique that utilizes direct laser contact. Retrograde ejaculation has not been encountered in these patients (average follow-up 6 months). All of these procedures have been accomplished in the office, largely without urethral catheterization. Lidocaine iellu occasionallu sunvlemented with intravenous sedation provided satisfactory anesthesia.
Recent experience with neodymium:yttriumaluminum garnet (Nd:YAG) laser has supported its role as a valuable urosurgical modality with diverse applications. 1-3 With regard to urethral disorders, an evolution in technique has been achieved which now can permit satisfactory therapy for a wide range of problems. It appears the optimal management of urethral strictures requires an appreciation of the laser’s abilities and limitations. New contact probes and contact fiber techniques enable good results when the stricture is selected appropriately. These contact techniques can be used effectively to treat such common lesions as bladder
106
neck contractures, urethral condylomata, urethral caruncles, and urethral hemangiomas. Contact fiber vaporization as a treatment for obstructing median bar hyperplasia is currently being evaluated.4 While some of the benefits of urologic Nd:YAG laser surgery may appear to be subtle, one major advantage is the ability to accomplish a wide range of common urethral procedures in the office, under local anesthesia, without postoperative catheterization. Material and Methods Over the past thirty months, 177 urethral procedures were performed in our office. A
UROLOGY
/ AUGUST 1988
/
VOLUME
XxX11, NUMBER 2
large majority of these were accomplished using local anesthesia, although intravenous sedation/ analgesia was required for several cases (17). A variety of surgical techniques have been developed including conventional noncontact laser and contact vaporization, photocoagulation, coagulation, and cutting. Equipment used included the Medi-Las II Nd:YAG laser, the Cooper 4000 Nd:YAG laser, standard cystoscopy table, Storz 21-F cystoscope, adapted Albarrin bridge, standard light source, laser transmission fibers, hand-held laser delivery piece, safety glasses, safety filter, Surgical Laser Technologies contact laser probes.
FIGURE1.
Contact probes.
Contact probes Contact laser probes offer a new method of Nd:YAG laser delivery to tissue, which may overcome many of the limitations encountered with various conventional noncontact laser systems. Using less than 25 W of power and the appropriate contact tip, cutting, coagulation, vaporization, and interstitial irradiation are possible. Due to the optical properties and geometric design of each probe, contact laser probes can shape the power density to deliver a more precise laser energy intensity and distribution for various procedures. By selecting the appropriate probe and laser power, one can control the shape and volume of the thermal effect. Contact probes have been used successfully in gastrointestinal laser procedures and are now being evaluated in urologic laser surgery (Fig. 1, Table I).
Urethral strictures Seventy-nine patients were evaluated ranging in age from twenty-seven to eighty-three years (mean, 70). Etiologies included iatrogenic
TABLE I.
Guidelines for laser urethral surgery
Application
Wattage
Delivery
15
Urethral condylomata
20
External and meatal condylomata Prostatotomy
40
Bare contact fiber or conical tip contact probe Bare contact fiber or rounded tip contact probe Rounded tip contact probe Noncontact fiber
40-60
Bare contact fiber
Stricture
40-60
Bladder neck contracture
UROLOGY
!
AUGUST
1988 / VOLUME
(51 cases), inflammatory (17), congenital (l), and unknown (10). Several techniques of laser stricture treatment were evaluated. Initially, a simple 12o’clock band of photocoagulation was tried, with poor results; 360 Ononcontact photocoagulation of the entire area of the stricture, with 40 W was used next with much better results. We then compared 360” rounded contact probe photoirradiation to bare fiber contact photoirradiation, at 15 W. At present, it is unclear which method of 360” stricture photoirradiation produces superior results, although contact techniques are more accurate and less time-consuming. Figure 2 demonstrates contact photoirradiation of a short, band-like bulbar urethral stricture. Using this technique, the stricture can be vaporized without bleeding, and urethral catheterization is not necessary.
Bladder neck contractures The 36 patients in this group ranged from twenty-eight to eighty-six years of age (mean, 68). All of the contractures were secondary in nature; the etiologies included previous TURP (23 cases), suprapubic prostatectomy (3), implantation of iodine-125 (1)) radical retropubic prostatectomy (1)) suprapubic prostatectomy A-2 prostatic carcinoma, later treated with bilateral orchiectomy (I), external beam radiotherapy for A-2 prostatic carcinoma (l), urethral stricture requiring instrumentations (2)) chronic prostatitis requiring instrumentations (1)) pediatric urethral instrumentation (1)) and unclear causation (1). The techniques developed for the treatment of urethral strictures were successfully applied
XxX11, NUMBER 2
107
FIGURE 2. Urethral stricture. (A) Typical short bulbar urethral stricture. (B) Conical laser contact probe is being applied circumferentially to stricture. (C) Photoirradiation of remaining right aspect of this stricture. (0) Widely opened stricture on completion of photoirradiation. Over next several weeks, irregular white border will slough and urethral lumen will become smooth.
FIGURE 3. Bladder neck contracture. (A) Typical bladder neck contracture is viewed from prostatic fossa. (B) Midway through 360” contact photoirradiation. (C) Same area as viewed from prostatic urethra, after completion of photoirradiation.
FIGURE 4. Urethral condylomata. (A) Large field of pendulous urethral condylomata to left aspect of photograph. (B) Same area midway through procedure. (C) Urethral lumen after completion of photocoagula-
(A) Typical obstructive prostatic median lobe. (B) Vaporization of obstructing tissue has begun at midline. (C) Same area is viewed midway through laser vaporization procedure. (0) Open prostatic fossa obtained after completion of median lobe laser vaporization.
108
UROLOGY
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to the bladder neck. Similar results were produced with 360” noncontact and contact photoirradiation. Contact fiber photoirradiation with 40 W to 60 W was rapid, essentially bloodless, and effective. Noncontact photocoagulation was less accurate and more time consuming. Figure 3 shows a typical bladder neck contracture treated with 360” contact fiber photoirradiation. Postoperative urethral catheterization is not employed. Condylomata Twenty-four patients ranging in age from twenty to twenty-nine years (mean, 28) were treated for urethral condylomata. Pendulous and fossa navicularis condylomata were treated with either noncontact (40 W) or rounded contact probe (20 W) techniques. Results were uniformly good; there were no recurrences over an average follow-up of thirteen months. Meatal condylomata were treated with the noncontact hand-held laser. Figure 4 demonstrates treatment of an area of condylomata in the pendulous urethra. Prostatotomy Six patients ranging in age from forty-six to eighty years (mean, 63) were treated. A previous TURP was performed on an eighty-yearold patient; the other patients were considerably younger (mean, 57) and were reluctant to undergo a conventional TURI? Vaporization of obstructing median bar hyperplasia was accomplished using either contact probe (20 W) or bare fiber contact (40 to 60 W) photoirradiation. The bare contact fiber technique appeared to be slightly more hemostatic (1 patient experienced mild bleeding after contact probe treatment, which responded to Bovie coagulation). Lidocaine jelly with intravenous sedation/analgesia provided adequate anesthesia. Contact laser photoirradiation of obstructive median bar hyperplasia is illustrated in Figure 5. Results In evaluating the results of laser urethrotomy, patients were relegated to one of two groups. Group 1 was composed of 31 virginal short strictures. Of these, 27 demonstrated an excellent result, 1 patient required a subsequent dilatation, and 3 patients had inadequate followup. The average follow-up interval was ten
UROLOGY
/ AUGUST 1988
/
VOLUME
XxX11, NUMBER
months. Group 2 was composed of 48 complicated strictures. These included extensive constrictions, multiple constrictions, and constrictions that have failed prior urethrotomies and dilatations. Criteria for a good result included improved uroflow and urethrogram, and no further stricture-releasing or dilating procedures. A fair result was considered any significant improvement in the pattern of restricture formation (i.e., a markedly improved interval between dilatations or urethrotomies) , Poor results were cases that quickly restrictured. Eleven good results, 15 fair results, and 9 poor results were noted. Nine patients had inadequate follow-up. The average follow-up interval was fourteen months. No patient required hospitalization after laser stricture surgery, and urethral catheterization was used in a single case. Widely opened bladder necks were achieved in 29 of 36 bladder neck contractures treated with laser photoirradiation. The remaining 7 patients were not evaluated postoperatively because of poor follow-up (1 case) or an inadequate follow-up interval for meaningful interpretation (less than 5 months) in 6 cases. The average follow-up was seven months. Two patients required Bovie coagulation for mild bleeding. Urethral catheterization was used in only 1 case. One patient with infected urine required a brief hospitalization for febrile urinary tract infection. The 24 cases of urethral condylomata responded well to laser therapy. No recurrences were seen over an average follow-up interval of thirteen months. The rounded contact probe technique is preferred due to its accuracy. One patient required a meatotomy after laser photocoagulation of extensive, recurrent meatal warts. In 6 cases of obstructive median bar prostatic hyperplasia, contact laser vaporization was possible with negligible bleeding, minimal discomfort, and no need for urethral catheterization. One patient required Bovie coagulation for mild bleeding. Postoperative retrograde ejaculation was not encountered in any of these patients. Results were good in 5 patients and fair in 1 as based on uroflow, follow-up cystoscopy, and symptomatic improvement, although the average follow-up interval of six months is too brief to draw definite conclusions. Satisfactory results were achieved with laser treatment, in the smaller series of caruncles, polyps, and hemangiomas.
2
109
Conclusions The Nd:YAG laser can be applied successfully to a wide variety of common urethral disorders. The results with selected urethral strictures, bladder neck contractures, condylomata, and other lesions are encouraging. The introduction of contact photoirradiation has expanded the surgical abilities of the laser and produced a more accurate and efficient treatment approach. It would appear the Nd:YAG laser is an excellent office modality for a wide range of genitourinary problems. The data presented suggest several advantages to office laser surgery of the urethra, and further surgical ex-
110
perience with contact and noncontact urethral surgery is warranted.
laser
Susquehanna Midtown Urologic Associates, Ltd. 120 Grampian Boulevard Williamsport, Pennsylvania 17701 (DR. BLOISO) References 1. Shanberg AM, Chaflin SA, and Tansey LA: NeodymiumYAG laser: new treatment for urethral stricture disease. Urolow-. 24: 15 (1984). 2. Staehler G, Chaussy C, Jocham D, and Schmiedt E: The use of neodvmium-YAG lasers in urolonv. I Urol 134: 1155 (1985). 3. Smith JA Jr (Ed): Lasers in U6lo& Surgery, Chicago, Yearbook Medical Publishers, 1985. 4. IDEM: Unpublished data, personal communication, 1985.
UROLOGY
! AUGUST
1988
i
VOLUME
XxX11, NUMBER
2
M.D.
ROGER WARNER, MARC COHEN,
LASER
M.D.
M.D.
From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT-Over a thirty-month period, a wide variety of common urethral problems were treated on an ambulatory basis, with the neodymium:yttrium-aluminum garnet (Nd:YAG) laser. When used discriminately, laser treatment appears to be an effective modality for the management of selected urethral strictures. Thus far, excellent results have been obtained in 30 of 31 cases of short strictures where laser urethrotomy was performed as the first stricture procedure (average follow-up 10 months). Furthermore, in a series of 36 cases of secondary bladder neck contractures, all of the evaluated patients responded well (average follow-up 7 months). Good results were obtained in only 11 of 48 complicated strictures (average follow-up 14 months). However, while most of these extensive strictures were not eradicated, laser therapy generally produced a documented clinical improvement, comparable to urethrotomy or dilatation, in 15 of these cases. A series of 24 condylomata involving the urethra were treated satisfactorily, with no recurrences (average followup 13 months). Laser treatment also has been used successfully for the management of several urethral caruncles, urethral polyps, two meatal hemangiomas, one urethral carcinoma, and a distal duplicated urethra. Recently, the Nd:YAG laser has been applied to the prostatic urethra with vaporization of obstructing median bar hyperplasia. Favorable results have been achieved in 5 of 6 cases treated with a newly developed technique that utilizes direct laser contact. Retrograde ejaculation has not been encountered in these patients (average follow-up 6 months). All of these procedures have been accomplished in the office, largely without urethral catheterization. Lidocaine iellu occasionallu sunvlemented with intravenous sedation provided satisfactory anesthesia.
Recent experience with neodymium:yttriumaluminum garnet (Nd:YAG) laser has supported its role as a valuable urosurgical modality with diverse applications. 1-3 With regard to urethral disorders, an evolution in technique has been achieved which now can permit satisfactory therapy for a wide range of problems. It appears the optimal management of urethral strictures requires an appreciation of the laser’s abilities and limitations. New contact probes and contact fiber techniques enable good results when the stricture is selected appropriately. These contact techniques can be used effectively to treat such common lesions as bladder
106
neck contractures, urethral condylomata, urethral caruncles, and urethral hemangiomas. Contact fiber vaporization as a treatment for obstructing median bar hyperplasia is currently being evaluated.4 While some of the benefits of urologic Nd:YAG laser surgery may appear to be subtle, one major advantage is the ability to accomplish a wide range of common urethral procedures in the office, under local anesthesia, without postoperative catheterization. Material and Methods Over the past thirty months, 177 urethral procedures were performed in our office. A
UROLOGY
/ AUGUST 1988
/
VOLUME
XxX11, NUMBER 2
large majority of these were accomplished using local anesthesia, although intravenous sedation/ analgesia was required for several cases (17). A variety of surgical techniques have been developed including conventional noncontact laser and contact vaporization, photocoagulation, coagulation, and cutting. Equipment used included the Medi-Las II Nd:YAG laser, the Cooper 4000 Nd:YAG laser, standard cystoscopy table, Storz 21-F cystoscope, adapted Albarrin bridge, standard light source, laser transmission fibers, hand-held laser delivery piece, safety glasses, safety filter, Surgical Laser Technologies contact laser probes.
FIGURE1.
Contact probes.
Contact probes Contact laser probes offer a new method of Nd:YAG laser delivery to tissue, which may overcome many of the limitations encountered with various conventional noncontact laser systems. Using less than 25 W of power and the appropriate contact tip, cutting, coagulation, vaporization, and interstitial irradiation are possible. Due to the optical properties and geometric design of each probe, contact laser probes can shape the power density to deliver a more precise laser energy intensity and distribution for various procedures. By selecting the appropriate probe and laser power, one can control the shape and volume of the thermal effect. Contact probes have been used successfully in gastrointestinal laser procedures and are now being evaluated in urologic laser surgery (Fig. 1, Table I).
Urethral strictures Seventy-nine patients were evaluated ranging in age from twenty-seven to eighty-three years (mean, 70). Etiologies included iatrogenic
TABLE I.
Guidelines for laser urethral surgery
Application
Wattage
Delivery
15
Urethral condylomata
20
External and meatal condylomata Prostatotomy
40
Bare contact fiber or conical tip contact probe Bare contact fiber or rounded tip contact probe Rounded tip contact probe Noncontact fiber
40-60
Bare contact fiber
Stricture
40-60
Bladder neck contracture
UROLOGY
!
AUGUST
1988 / VOLUME
(51 cases), inflammatory (17), congenital (l), and unknown (10). Several techniques of laser stricture treatment were evaluated. Initially, a simple 12o’clock band of photocoagulation was tried, with poor results; 360 Ononcontact photocoagulation of the entire area of the stricture, with 40 W was used next with much better results. We then compared 360” rounded contact probe photoirradiation to bare fiber contact photoirradiation, at 15 W. At present, it is unclear which method of 360” stricture photoirradiation produces superior results, although contact techniques are more accurate and less time-consuming. Figure 2 demonstrates contact photoirradiation of a short, band-like bulbar urethral stricture. Using this technique, the stricture can be vaporized without bleeding, and urethral catheterization is not necessary.
Bladder neck contractures The 36 patients in this group ranged from twenty-eight to eighty-six years of age (mean, 68). All of the contractures were secondary in nature; the etiologies included previous TURP (23 cases), suprapubic prostatectomy (3), implantation of iodine-125 (1)) radical retropubic prostatectomy (1)) suprapubic prostatectomy A-2 prostatic carcinoma, later treated with bilateral orchiectomy (I), external beam radiotherapy for A-2 prostatic carcinoma (l), urethral stricture requiring instrumentations (2)) chronic prostatitis requiring instrumentations (1)) pediatric urethral instrumentation (1)) and unclear causation (1). The techniques developed for the treatment of urethral strictures were successfully applied
XxX11, NUMBER 2
107
FIGURE 2. Urethral stricture. (A) Typical short bulbar urethral stricture. (B) Conical laser contact probe is being applied circumferentially to stricture. (C) Photoirradiation of remaining right aspect of this stricture. (0) Widely opened stricture on completion of photoirradiation. Over next several weeks, irregular white border will slough and urethral lumen will become smooth.
FIGURE 3. Bladder neck contracture. (A) Typical bladder neck contracture is viewed from prostatic fossa. (B) Midway through 360” contact photoirradiation. (C) Same area as viewed from prostatic urethra, after completion of photoirradiation.
FIGURE 4. Urethral condylomata. (A) Large field of pendulous urethral condylomata to left aspect of photograph. (B) Same area midway through procedure. (C) Urethral lumen after completion of photocoagula-
(A) Typical obstructive prostatic median lobe. (B) Vaporization of obstructing tissue has begun at midline. (C) Same area is viewed midway through laser vaporization procedure. (0) Open prostatic fossa obtained after completion of median lobe laser vaporization.
108
UROLOGY
I AUGUST1988
I VOLUMEXXXII.NUMBER2
to the bladder neck. Similar results were produced with 360” noncontact and contact photoirradiation. Contact fiber photoirradiation with 40 W to 60 W was rapid, essentially bloodless, and effective. Noncontact photocoagulation was less accurate and more time consuming. Figure 3 shows a typical bladder neck contracture treated with 360” contact fiber photoirradiation. Postoperative urethral catheterization is not employed. Condylomata Twenty-four patients ranging in age from twenty to twenty-nine years (mean, 28) were treated for urethral condylomata. Pendulous and fossa navicularis condylomata were treated with either noncontact (40 W) or rounded contact probe (20 W) techniques. Results were uniformly good; there were no recurrences over an average follow-up of thirteen months. Meatal condylomata were treated with the noncontact hand-held laser. Figure 4 demonstrates treatment of an area of condylomata in the pendulous urethra. Prostatotomy Six patients ranging in age from forty-six to eighty years (mean, 63) were treated. A previous TURP was performed on an eighty-yearold patient; the other patients were considerably younger (mean, 57) and were reluctant to undergo a conventional TURI? Vaporization of obstructing median bar hyperplasia was accomplished using either contact probe (20 W) or bare fiber contact (40 to 60 W) photoirradiation. The bare contact fiber technique appeared to be slightly more hemostatic (1 patient experienced mild bleeding after contact probe treatment, which responded to Bovie coagulation). Lidocaine jelly with intravenous sedation/analgesia provided adequate anesthesia. Contact laser photoirradiation of obstructive median bar hyperplasia is illustrated in Figure 5. Results In evaluating the results of laser urethrotomy, patients were relegated to one of two groups. Group 1 was composed of 31 virginal short strictures. Of these, 27 demonstrated an excellent result, 1 patient required a subsequent dilatation, and 3 patients had inadequate followup. The average follow-up interval was ten
UROLOGY
/ AUGUST 1988
/
VOLUME
XxX11, NUMBER
months. Group 2 was composed of 48 complicated strictures. These included extensive constrictions, multiple constrictions, and constrictions that have failed prior urethrotomies and dilatations. Criteria for a good result included improved uroflow and urethrogram, and no further stricture-releasing or dilating procedures. A fair result was considered any significant improvement in the pattern of restricture formation (i.e., a markedly improved interval between dilatations or urethrotomies) , Poor results were cases that quickly restrictured. Eleven good results, 15 fair results, and 9 poor results were noted. Nine patients had inadequate follow-up. The average follow-up interval was fourteen months. No patient required hospitalization after laser stricture surgery, and urethral catheterization was used in a single case. Widely opened bladder necks were achieved in 29 of 36 bladder neck contractures treated with laser photoirradiation. The remaining 7 patients were not evaluated postoperatively because of poor follow-up (1 case) or an inadequate follow-up interval for meaningful interpretation (less than 5 months) in 6 cases. The average follow-up was seven months. Two patients required Bovie coagulation for mild bleeding. Urethral catheterization was used in only 1 case. One patient with infected urine required a brief hospitalization for febrile urinary tract infection. The 24 cases of urethral condylomata responded well to laser therapy. No recurrences were seen over an average follow-up interval of thirteen months. The rounded contact probe technique is preferred due to its accuracy. One patient required a meatotomy after laser photocoagulation of extensive, recurrent meatal warts. In 6 cases of obstructive median bar prostatic hyperplasia, contact laser vaporization was possible with negligible bleeding, minimal discomfort, and no need for urethral catheterization. One patient required Bovie coagulation for mild bleeding. Postoperative retrograde ejaculation was not encountered in any of these patients. Results were good in 5 patients and fair in 1 as based on uroflow, follow-up cystoscopy, and symptomatic improvement, although the average follow-up interval of six months is too brief to draw definite conclusions. Satisfactory results were achieved with laser treatment, in the smaller series of caruncles, polyps, and hemangiomas.
2
109
Conclusions The Nd:YAG laser can be applied successfully to a wide variety of common urethral disorders. The results with selected urethral strictures, bladder neck contractures, condylomata, and other lesions are encouraging. The introduction of contact photoirradiation has expanded the surgical abilities of the laser and produced a more accurate and efficient treatment approach. It would appear the Nd:YAG laser is an excellent office modality for a wide range of genitourinary problems. The data presented suggest several advantages to office laser surgery of the urethra, and further surgical ex-
110
perience with contact and noncontact urethral surgery is warranted.
laser
Susquehanna Midtown Urologic Associates, Ltd. 120 Grampian Boulevard Williamsport, Pennsylvania 17701 (DR. BLOISO) References 1. Shanberg AM, Chaflin SA, and Tansey LA: NeodymiumYAG laser: new treatment for urethral stricture disease. Urolow-. 24: 15 (1984). 2. Staehler G, Chaussy C, Jocham D, and Schmiedt E: The use of neodvmium-YAG lasers in urolonv. I Urol 134: 1155 (1985). 3. Smith JA Jr (Ed): Lasers in U6lo& Surgery, Chicago, Yearbook Medical Publishers, 1985. 4. IDEM: Unpublished data, personal communication, 1985.
UROLOGY
! AUGUST
1988
i
VOLUME
XxX11, NUMBER
2