High power diode laser vaporization of the prostate: preliminary results in

ORIGINAL ARTICLE
High power diode laser vaporization
of the prostate: preliminary results in
benign prostatic hyperplasia treatment
Campos-Salcedo Jose Gadú, Martínez-Juárez Noé Esaul, Sedano-Lozano Antonio, Castro-Marín Melchor, FloresTerrazas Efraín, López-Silvestre Julio César, Zapata-Villalba Miguel Ángel, Mendoza-Álvarez Luis Alberto, EstradaCarrasco Carlos Emmanuel, Terrazas-Ríos Jose Luis.
•Abstract
•Resumen
Background: The criterion standard in benign prostatic
hyperplasia (BPH) treatment has been transurethral
resection of the prostate. However, in the last few years,
alternative treatments have been developed to remove
prostate tissue. One of these procedures is prostatectomy
with laser vaporization of the tissues that provides
instantaneous tissue reduction. The preliminary results
of photovaporization with the diode laser in obstructive
prostatic hyperplasia treatment are presented.
Introducción: El estándar de oro en el tratamiento de la
hiperplasia prostática benigna (HPB) ha sido la resección
transuretral de próstata, sin embargo, en los últimos años
se han desarrollado tratamientos alternativos para la
remoción del tejido prostático. Uno de estos procedimientos
es la prostatectomía con láser con vaporización de los
tejidos, cuyo resultado es una reducción instantánea
del tejido. Se presentan los resultados preliminares de
la fotovaporización con láser diodo, en el manejo de la
hiperplasia prostática obstructiva.
Aims: To prolectively evaluate the effectiveness of high
power vaporization with a 980 nm diode laser for the
treatment of urinary tract obstruction secondary to BPH,
affecting the exit of urine.
Objetivo: Evaluar prolectivamente la eficiencia de
vaporización de alto poder con láser diodo de 980 nm,
para el tratamiento de la obstrucción del tracto urinario de
salida, secundaria a HPB.
Material and methods: A total of 15 patients were
enrolled in the study. Inclusion criteria were a maximum
flow of 12 mL per second or less, an emptying volume
of 150 mL or more, a score of 12 or more using
the International Prostate Symptom Score, and a
Material y métodos: Se incluyeron un total de 15
pacientes en el estudio. Los criterios de inclusión fueron
un flujo máximo de 12 mL por segundo o menos, con un
volumen de vaciamiento de 150 mL o más, con calificación
en la escala internacional de síntomas prostáticos de 12 o
Department of Urology, Hospital Central Militar. Mexico City, Mexico.
Corresponding author: Dr. José Gadú Campos Salcedo. Hospital
Ángeles Lomas, Av. Vialidad de la barranca s/n 4° piso, Consultorio
455, Torre de consultorios, Colonia Valle de la Palmas, Huixquilucan,
C.P. 52763. Edo. de México. Telephones: (55) 5246 9545 y 5246
9537. E-mail:: [email protected]
Rev Mex Urol 2012;72(4):167-170
167
Campos-Salcedo JG, et al. High power diode laser vaporization of the prostate: preliminary results in benign prostatic hyperplasia treatment
score of 3 points or more for Quality of Life. Patients with
a history of neurogenic micturition dysfunction, chronic
prostatitis, or cancer of the prostate or bladder were
excluded. Preoperative maximum flow, residual urine
volume, the International Prostate Symptom Score, and
the Quality of Life index were compared with results
registered again after three months. Complications were
documented.
más y una calificación en la escala de calidad de vida de 3
puntos o más. Los pacientes con una historia de disfunción
miccional de origen neurogénico, prostatitis crónica,
o cáncer de próstata o vejiga fueron excluidos. El flujo
máximo preoperatorio, el volumen de orina residual, la
escala internacional de síntomas prostáticos, la calidad de
vida, fueron comparados con mediciones a los tres meses.
Se documentaron las complicaciones.
Results: The evaluation at three months revealed
a significant reduction in the mean score of the
International Prostate Symptom Score and the average
maximum flow rate increased significantly. The Quality
of Life index changed considerably in relation to the
baseline value. All values showed a slight improvement
at the third month. The most frequent postoperative
complications were retrograde ejaculation and
irritative symptoms.
Resultados: La evaluación a tres meses reveló que la
media de la escala internacional de síntomas prostáticos se
redujo significativamente. La tasa media de flujo máximo
se incrementó significativamente. La puntuación de calidad
de vida cambió considerablemente respecto al valor
basal. Todos estos valores mostraron una ligera mejora
en el tercer mes. Las complicaciones posoperatorias
más frecuentes fueron la eyaculación retrógrada y los
síntomas irritativos.
Conclusions: High power diode laser provided significant
improvement in the International Prostate Symptom
Score and in maximum flow and produced less morbidity.
Conclusiones: El láser diodo de alto poder ofreció
mejoría significativa en la escala internacional de síntomas
prostáticos y en el flujo máximo con menor morbilidad.
Keywords: Treatment, benign prostatic hyperplasia,
photovaporization, diodo laser, Mexico.
Palabras clave: Tratamiento, hiperplasia prostática
benigna, fotovaporización, diodo láser, México.
•Introduction
improving the not-so-insignificant secondary effects of
TURP, such as blood loss, retrograde ejaculation, and
urinary incontinence.3,4 One of these procedures is laser
prostatectomy with tissue vaporization that results
in instantaneous tissue reduction. Depending on the
longitude of the wavelength, the power, and the action
mode (continuous or in pulses), the effects of prostate
tissue coagulation can possibly be avoided. These effects
are thought to be responsible for the irritative symptoms
experienced after laser intervention. The neodymium
yttrium aluminum garnet (Nd-YAG) laser emits a 1 064
nm ray and can penetrate up to a depth of 10 mm.5
More recently, the potassium-titanium-phosphate (KTP)
laser, that operates with a 532 nm wavelength, has
been used for prostate vaporization,6 and is absorbed
by hemoglobin but not by water, and penetrates to a
depth of 0.8 mm. The diode laser functions with a 980
nm wavelength and penetrates to a depth of 0.5 mm,
is highly absorbed by both water and hemoglobin, and
has been proposed for high power tissue ablation with
good hemostasis.7
Clinically, the term benign prostatic hyperplasia (BPH)
can refer to any of the following conditions: microscopic
hyperplasia
detection
(stroma
and
epithelium
proliferation), prostate enlargement detected through
ultrasound or digital rectal examination (DRE), and
the group of clinical symptoms associated with BPH
and defined as “lower urinary tract symptoms”. The
prevalence of BPH increases lineally with age in all ethnic
groups. Surgical management of prostatic hyperplasia
is indicated in those patients that present with urinary
tract complications or in patients with moderate to
severe urinary symptoms that do not respond to medical
treatment.1 In the United States surgery for prostatic
hyperplasia holds second place in patients over 65 years
of age and in Mexico it represents 53% of the surgeries
performed on men.2
The criterion standard for the surgical treatment
of BPH has been transurethral resection of the
prostate (TURP). However, in the last few years,
alternative treatments have been developed for prostate
tissue removal. The focus of these techniques has been on
168
Rev Mex Urol 2012;72(4):167-170
These characteristics also provide the possibility of
working in pulse mode, allowing for the development
Campos-Salcedo JG, et al. High power diode laser vaporization of the prostate: preliminary results in benign prostatic hyperplasia treatment
of the lifting and rolling technique. The laser has been
studied at energy operational levels of 30 to 120 W in ex
vivo studies.
•Methods
A total of 15 consecutive patients that underwent
prostate photovaporization with the 980 nm diode
laser within the time frame of January 2011 and
June 2011 were included in the study. Preoperative
evaluation included the patient’s past medical history,
physical examination emphasizing neurologic status,
and digital rectal examination (DRE). Inclusion criteria
were a maximum flow of 12 mL per second or less, a
micturition volume of 150 mL or more, a score of 12
or more on the International Prostate Symptom Score
(I-PSS), and a score of three or more in reference to
Quality of Life. Patients with a past medical history of
neurogenic bladder dysfunction, chronic prostatitis,
prostate cancer and/or bladder cancer were excluded
from the study. Preoperative maximum flow and quality
of life were compared three months after the surgery.
Complications associated with the procedure were
recorded. All surgical procedures were performed by the
same surgeon, with the patient under peridural block or
general anesthesia. All patients received prophylactic
antibiotics before the surgery and continued taking
them for four weeks. The suspension of anticoagulation
medication is recommended one week before surgery
unless there is a contraindication. A 23 F continuous
flow laser cystoscope with saline solution irrigation was
used. A 980 nm diode laser generator was employed,
with an energy configuration between 80 and 132 W
in continuous mode during the entire vaporization
procedure and a fiber optic with a 70° deviation angle
for light transmission. Vaporization was begun at the
bladder neck level with the bladder full of saline solution.
Then the lateral lobes in the zone between the one and
the 11 radii were vaporized. The energy was reduced to
80 W at the level of the bladder neck and the sphincter
zone. A urethral catheter was placed and then removed
the day after surgery. All of the patients except two were
released from the hospital on the third day. Statistical
analysis was carried out using the Student’s t test and
there was statistical significance when p<0.05.
•Results
The mean age of the patients was 65 years (60-75 year
range). The procedure was carried out on all patients
with no intraoperative complications.
No blood
transfusions were necessary. The mean surgery duration
was 60 minutes and the mean energy employed was 242
J. One fiber was used for each procedure. The mean days
of urethral catheter use was one day. Table 1 shows
Table 1. Follow-up at three months for patients that underwent
diode laser vaporization of the prostate
Preoperative
mean
Mean at three
months
I-PSS
21
11
Quality of life index
4
2
8 mL/sec
17 mL/sec
Maximum flow
I-PSS: International Prostate Symptom Score
the parameters measured at three months after the
procedure and their comparison with the preoperative
values. The I-PSS had a statistically significant decrease
from a mean preoperative score of 21 to a score of 11 at
the third postoperative month. Similarly, maximum flow
increased from a preoperative value of 8 mL/sec to 17
mL/sec at three months after the procedure. The quality
of life evaluation improved from a preoperative score of
4 to a score of 2 at the third postoperative month.
•Discussion
The search for other management alternatives to TURP,
the criterion standard in BPH treatment, is stimulated
after analyzing the results related to its morbidity and
mortality. TURP-related morbidity has been reported
in up to 18% of patients, mortality in up to 0.2%, and
transfusion requirements in 3%. Likewise, there is a 10
to 15% probability of a repeat intervention in 10 years.
These data justify the search for the most minimally
invasive procedures possible in the surgical treatment
of hyperplasia. In the 1990s the use of Nd-YAG was a
good alternative, however its use was discouraged due
to postoperative irritative symptoms.
High power diode laser vaporization of the prostate
has risen in importance in the last few years because, not
only does it offer an excellent means of prostate tissue
vaporization, it also provides adequate hemostasis and
there are fewer postoperative irritative symptoms. The
results of the present study in relation to quality of life,
the I-PSS, and uroflowmetry maximum urinary flow
were similar to those reported in the medical literature.
•Conclusions
High power diode laser offered significant improvement
in the International Prostate Symptom Score and in
maximum flow and had lower morbidity and these
results represent the first clinical study of high power
diode laser vaporization of the prostate to be reported in
the Mexican medical literature.
Rev Mex Urol 2012;72(4):167-170
169
Campos-Salcedo JG, et al. High power diode laser vaporization of the prostate: preliminary results in benign prostatic hyperplasia treatment
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