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LOWER URINARY TRACT SYMPTOMS
Recent developments in laser therapy for BPH ROGER KIRBY
A new generation of lasers for photoselective vaporisation of the prostate operating at 180 watts of power has been introduced for the treatment of benign prostatic hyperplasia. The product was designed to speed up the lasering process and improve fibre durability, while maintaining the safety profile of previous generations. Roger Kirby reviews the history of laser therapy, and discusses whether the treatment can be considered a viable alternative to transurethral resection of the prostate.
reatment options for lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH) include surgery, minimally invasive thermal therapies or one of a number of medical therapies, eg alpha-blockers (tamsulosin, doxazosin, alfuzosin, terazosin) and 5-alpha-reductase inhibitors (finasteride, dutasteride).
Within surgical therapies, transurethral resection of the prostate (TURP) is the most common procedure utilised. TURP provides instant relief of the symptoms of BPH but can be associated with a number of complications, such as bleeding, incontinence and retrograde ejaculation.1 Most men tend to opt for medical therapy as a first-line therapy, often taking the medication for several years. laser diode
In the past decade, minimally invasive surgical options involving laser therapy have been developed. The wavelength of a laser results in different penetration depths into tissue, which range from 0.02mm to 10mm (Figure 1). Historically, laser prostatectomy involved coagulation, vaporisation or enucleation of the prostate tissue. Coagulation results in debulking of the prostate through sloughing of necrotic tissue and it can be a number of weeks before the benefits of treatment are realised. In contrast, vaporisation or enucleation of the prostate results in instant debulking of the gland. Laser therapy for BPH patients has evolved over time, from visual laser ablation (VLAP) of the prostate with the neodymium:yttrium-aluminium-garnet
Absorbtion coefficient (1/cm)
1000 100 10 1 0.1
0.001 0.0001 300
Roger Kirby, Director, The Prostate Centre, London
TRENDS IN UROLOGY & MEN’S HEALTH
1200 1500 Wavelength (nm)
Figure 1. Absorption characteristics of various wavelengths in three absorption media of different lasers including: potassium-titanyl phosphate (KTP); holmium:yttrium-aluminiumgarnet (Ho:YAG); and the neodymium:YAG (Nd:YAG) www.trendsinurology.com
LOWER URINARY TRACT SYMPTOMS
(Nd:YAG) laser to the current standards for laser therapy involving holmium:yttriumaluminium-garnet (Ho:YAG) laser for either ablation or enucleation of the prostate (HoLAP/HoLEP) and photoselective vaporisation of the prostate (PVP) using a 532nm wavelength laser (potassium-titanyl phosphate [KTP] or lithium triborate [LBO]). OUTCOME WITH LASER THERAPY HoLAP/HoLEP The HoLAP/HoLEP laser method involves precise enucleation of the prostate followed by removal of the excised tissue by morcellation. It has been reported that prostate volume can be reduced by 542 to 77 per cent3 with HoLEP, but the process is considered more complex than the other laser treatments, with a longer learning curve. In terms of outcome, multiple studies have been conducted and outcome to six years shows that the International Prostate Symptom Score (IPSS) was reduced from a mean (SD) of 25.7 (5.9) at baseline to 8.5 (6.3) and maximum flow rate (Qmax) from 8.1 (2.7) ml/s to 19 (11.2) ml/s.2 Comparative studies of HoLEP and TURP show a similar outcome with respect to improvement in symptom score and Qmax.4 HoLAP is much less common but has also been shown to result in immediate symptomatic and functional improvements.5 PVP: GreenLight 120-W HPS laser The 532nm KTP (GreenLight) laser was initially used for PVP using 80 watts delivered through a side-firing fibre. Following the 80-W laser, a more powerful GreenLight 120-W HPS laser involving an LBO laser was introduced. Ruszat and co-workers reported six-month outcomes with the 120-W HPS laser (n=62) compared with a new 980nm highintensity diode (HiDi) laser (n=55) in men with symptomatic BPH.6 The operative time was similar for the two techniques, but significantly more energy was applied with the HiDi laser. In terms of outcome, similar www.trendsinurology.com
improvements were reported in IPSS, postvoid residual urine (PVR) and Qmax for the two lasers. Complication rates differed between the two lasers. For patients treated with the GreenLight 120-W HPS laser, the rate of visual impairment from bleeding was significantly higher (0 versus 12.9 per cent; p<0.01), as was prostate capsule perforation (0 versus 4.8 per cent; p<0.05). However, the rates of dysuria (23.6 versus 17.7 per cent; p<0.05) and transient urge incontinence (7.3 versus 0 per cent; p<0.05) were significantly higher for the HiDi laser. During follow-up, significantly higher rates of bladder neck stricture (14.5 versus 1.6 per cent; p<0.01), retreatment (18.2 versus 1.6 per cent; p<0.01) and stress urinary incontinence (9.1 versus 0 per cent; p<0.05) were reported in the HiDi laser group.
to 22.5 (10.2) ml/s and 59 (87) ml, respectively. With regard to safety, few adverse events were noted and only 5.3 per cent of patients required recatheterisation.
One-year follow-up with the GreenLight 120-W HPS laser has been reported by Woo et al.7 The study, involving 76 men, showed that mean (SD) IPSS improved by eight points from 20.0 (7) at baseline to 8.1 (6.1) at 12 months. Qmax and PVR at baseline were 7.6 (3.5) ml/s and 155 (155) ml, respectively, and clinically meaningful improvements were reported at 12 months
PVP: GreenLight 180-W XPS laser Following on from the 120-W HPS laser, a new GreenLight 180-W XPS laser system has been developed along with a novel fibre design. The system is aimed at improving efficacy in patients with larger prostate glands so that the procedure time does not increase substantially and only a single fibre is required.
Three-year outcome with the GreenLight 120-W HPS laser has been shown to be comparable to TURP in a study by AlAnsari and co-workers.8 A total of 120 patients were randomly assigned to TURP or 120-W HPS laser treatment. Improvements in IPSS, Qmax and PVR were similar between the two groups; only change in prostate size was greater with TURP. Complications reported in the intraoperative, early and late postoperative periods are shown in Table 1. Hospital stay and catheterisation times were significantly shorter with the GreenLight 120-W HPS laser than TURP (p=0.0001).
GreenLight 120-W HPS laser
Intraoperative • Blood transfusion • Capsular perforation • TUR syndrome
12 (20%) 10 (16.7%) 3 (5%)
0 0 0
0.0001 0.0001 0.079
Early (<30 days) postoperative • Clot retention • Dysuria/urge
Table 1. Number of patients experiencing intraoperative and early and late postoperative complications and treated with transurethral resection of the prostate (TURP) or GreenLight 120-W HPS laser. Three-year follow-up is reported for 55 and 54 patients treated with TURP or 120-W HPS laser, respectively.8 TRENDS IN UROLOGY & MEN’S HEALTH
LOWER URINARY TRACT SYMPTOMS
Data from perfused porcine kidney studies show that tissue removal is twice as fast with the GreenLight 180-W XPS laser compared with the 120-W HPS laser (Figure 2); however, these ex vivo observations have yet to be confirmed using human clinical data.10 Malek et al. reported comparative results with the GreenLight 120-W HPS and 180-W XPS lasers in living dog prostates.9 PVP with the higher-powered laser created a 76 per cent larger cavity (mean 11.8 versus 6.7cm3; p=0.014), vaporised tissue at a 77 per cent higher rate (mean 2.3 versus 1.3cm/min; p=0.03) and did so in 37 per cent less time per volume vaporised (0.5 versus 0.8min/cm3; p=0.003). The first report of the GreenLight180-W XPS laser in men with BPH involved 60 consecutive patients treated at six centres internationally since June 2010.11 Before surgery, 14 patients (23 per cent) were in retention. Mean (SD) prostate volume was 67.8 (42.1) ml and active laser time was 39.8 (21.2) min. No severe complications (bleeding, transfusion, absorption syndrome) were observed intraoperatively. Urosepsis was reported in one patient and three patients required recatheterisation. At three months, mean (SD) Qmax increased from 8.7 (5.3) to 17.9 (10.1) ml/s, IPSS declined from 22.1 (6.4) to 6.5 (7) and PVR from 141 (213) TRENDS IN UROLOGY & MEN’S HEALTH
160 In 40 min, 180-W XPS removes ~95g of tissue (2 x HPS)
120 Tissue removed
To improve the rate of vaporisation, the power of the system was increased by 50 per cent while simultaneously increasing the area of the laser beam by 50 per cent to avoid overly deep vaporisation. Based on bench and animal data, the actual depth of vaporisation and coagulation in the tissue are the same as those of the 120-W system.9 The result is that faster vaporisation is achieved through a wider tissue vaporisation defect. A new fibre design has increased its durability. The fibre technology utilises dedicated saline flow over the fibre to minimise fibre-tip degradation, which was the primary limitation of the previous fibre technology.
In 40 min, 120-W HPS removes ~47g of tissue
60 40 20 0 0
30 40 Lasing time (min)
Figure 2. Comparative tissue vaporisation with the GreenLight 120-W HPS and 180-W XPS laser systems. Perfused porcine kidney data.10
to 50.9 (64.8) ml. No patient required a reoperation in this time period. HEALTH ECONOMICS A comparative cost analysis of laser therapy using the GreenLight 120-W HPS system or TURP was conducted in the USA over a 12-month period (2007–2008).12 A total of 250 men underwent TURP and 220 men had laser therapy. The costs analysed included the procedural costs and perioperative hospital costs. The actual direct costs included the cost of equipment, disposables, medication, staff and hospital stay; laser fibre costs reflected the cost of only one fibre per procedure. Indirect costs comprised administration, human resources, medical records, operations and facility costs. The total costs calculated excluded physician professional fees. The analysis revealed that overall costs of laser vaporisation were significantly lower than those for TURP; mean (SD) costs were $4266 ($1182) versus $5097 ($5003) (p=0.01). Of note, significantly more men could be treated on an outpatient basis with laser therapy than those with TURP. A total of 209 out of 220 (95 per cent) laser-treated patients were discharged
within 23 hours of the treatment, compared with 194 of 250 (78 per cent) TURP-treated patients (p<0.01). Other reports on the economics of laser therapy have come from Armstrong et al., who found that initial therapy with diathermy vaporisation of the prostate followed by HoLEP in the cases of failure was cost-effective.13 Lourenco et al. also conducted a critical analysis of costs of laser therapy and found that HoLEP was estimated to be more cost-effective than a single TURP but less effective than a strategy involving a repeat TURP for treatment failures.14 CONCLUSIONS Laser therapy for BPH is becoming increasingly common and the outcome with the principal therapies can be considered equivalent to TURP. Enucleation with the holmium laser is safe and effective, but learning the technique can be difficult and protracted. PVP with the new GreenLight 180-W XPS laser, leveraging the existing experience with the 120-W HPS laser, has shown promising initial results. Further data from a larger patient cohort are expected later this year and should allow a more definite conclusion www.trendsinurology.com
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to be made regarding the benefits of the technological improvements.
Declaration of interests: none declared.
• Laser therapy is an accepted minimally invasive treatment option for men with benign prostatic hyperplasia
Madersbacher S, Marberger M. Is transurethral resection of the prostate still justified? BJU Int 1999;83:227–37. Gilling PJ, Aho TF, Frampton CM, et al. Holmium laser enucleation of the prostate: results at 6 years. Eur Urol 2008;53:744–9. Peterson MD, Matlaga BR, Kim SC, et al. Holmium laser enucleation of the prostate for men with urinary retention. J Urol 2005;174:998–1001. Wilson LC, Gilling PJ, Williams A, et al. A randomised trial comparing holmium laser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 2006;50:569–73. Elzayat EA, Al-Mandil MS, Khalaf I, Elhilali MM. Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results of a prospective randomized trial. J Urol 2009;182:133–8. Ruszat R, Seitz M, Wyler SF, et al. Prospective single-centre comparison of 120-W diode-pumped solid-state highintensity system laser vaporization of the prostate and 200-W high-intensive diodelaser ablation of the prostate for treating benign prostatic hyperplasia. BJU Int 2009;104:820–5. Woo HH, Hossack TA. Photoselective vaporization for prostatic obstruction with
• Outcomes with laser therapies, including the Greenlight photoselective vaporisation and holmium laser ablation/enucleation of the prostate (HoLAP/HoLEP), are comparable to those with transurethral resection of the prostate (TURP) in terms of improvement in International Prostate Symptom Score, maximum flow rate and postvoid residual urine, but with less bleeding • A preliminary health economic analysis suggests that the Greenlight 120-W HPS laser therapy is competitive with TURP, more so if patients are treated on an outpatient basis. • Positive cost benefits have also been reported with HoLEP compared with TURP • Further studies with the new generation of GreenLight laser operating at 180 watts power are needed to determine whether it does allow for a faster treatment while maintaining safety
the 120-W lithium triborate laser: 1-year clinical outcomes. Int J Urol 2011;18:162–5. 8 Al-Ansari A, Younes N, Sampige VP, et al. GreenLight HPS 120-W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. Eur Urol 2010;58:349–55. 9 Malek RS, Kang HW, Peng YS, et al. Photoselective vaporization prostatectomy: experience with a novel 180 W 532 nm lithium triborate laser and fiber delivery system in living dogs. J Urol 2011;185:712–8. 10 AMS. Data on file. 11 Woo H, Bachmann A, Gomez Sancha F, et al. An International Multicenter Experience with 180 W XPS photoselective vaporization of the prostate: first report on
perioperative data, adverse outcomes and early functional results. Poster presented at the American Urological Association Congress, Washington, USA, May 2011. 12 Goh AC, Gonzalez RR. Photoselective vaporization: prostatectomy versus transurethral resection of the prostate. J Urol 2010;183:1469–73. 13 Armstrong N, Vale L, Deverill M, Nabi G, et al. Surgical treatments for men with benign prostatic enlargement: cost effectiveness study. BMJ 2009;338:b1288. 14 Lourenco T, Armstrong N, N’Dow J, et al. Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement. Health Technol Assess 2008;12:169-515.