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Photoselective prostatic vaporization for bladder outlet obstruction: 12-month evaluation of storage and voiding symptoms

Photoselective Prostatic Vaporization for Bladder Outlet
Obstruction: 12-Month Evaluation of Storage and
Voiding Symptoms

Cosimo De Nunzio,* Roberto Miano, Alberto Trucchi, Lucio Miano, Giorgio Franco,Stefano Squillacciotti and Andrea Tubaro From the Departments of Urology, Sant’Andrea Hospital, University “La Sapienza” and Policlinico Tor Vergata, University “Tor Vergata”(RM), Rome, Italy Abbreviations
Purpose: We evaluated voiding and storage symptom evolution in patients
and Acronyms
treated with prostate photoselective vaporization by a KTP laser.
Materials and Methods: Enrolled in the study were 150 consecutive patients
with lower urinary tract symptoms due to benign prostatic hyperplasia and a diagnosis of bladder outlet obstruction. Patients underwent prostate photoselec- tive vaporization with the 80 W KTP laser. Baseline parameters included pros- tate volume, International Prostate Symptom Score with voiding and storage symptom subscores, uroflowmetry, pressure flow study and serum prostate spe- cific antigen. Patients were followed 1, 3, 6 and 12 months after surgery.
Results: Mean Ϯ SD patient age was 69.6 Ϯ 10 years. Mean prostate volume
was 52 Ϯ 18 ml. Mean International Prostate Symptom Score was 22.3 Ϯ 4, mean maximum urine flow was 9 Ϯ 2.9 ml per second and mean Schäfer obstruction class was 3.6 Ϯ 1. An average of 190 Ϯ 44 kJ were delivered in a mean of 68 Ϯ 24 minutes with an average of 3.6 kJ/ml prostate. The mean number of fibers was 1.2 Ϯ 0.4. Mean catheterization time was 20 Ϯ 8 hours.
Retrograde ejaculation was reported in 67% of patients. Prostate specific antigen was significantly decreased at 12 months (2.6 Ϯ 2.3 vs 0.9 Ϯ 0.7 ng/ml, p ϭ 0.001). Storage symptoms decreased by 54.5%, 63.6%, 72.7% and 81.8% at 1, 3, 6 and 12 months, respectively (p Ͻ0.001). Voiding symptoms decreased 63.6%, 72.7%, 81.8% and 90.9% at 1, 3, 6 and 12 months, respectively(p Ͻ0.001).
Submitted for publication July 21, 2009.
Conclusions: As shown by a prostate specific antigen significant decrease, proper
Study received local independent ethics com- prostate debulking may be achieved by prostate photoselective vaporization.
Significant continuous improvement in storage and voiding symptoms was ob- * Correspondence: Department of Urology, Osped- ale Sant’Andrea, II Faculty of Medicine, University “La Sapienza,” Roma, Italy (telephone: ϩ39-06-33775760;FAX: ϩ39-0633775428; e-mail: Key Words: prostate, urinary bladder neck obstruction, prostatic hyperplasia,
2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
PHOTOSELECTIVE PROSTATIC VAPORIZATION AND BLADDER OUTLET OBSTRUCTION reports show that PVP is efficient, safe, easy to learn urine culture and uroflowmetry at each visit. PSA analy- and bloodless. These characteristics make PVP a com- sis was reevaluated only at 12 months.
petitor with TURP for LUTS related to How- Statistical analysis was done with SPSS® 12.0. Data ever, although persistent storage urinary symptoms distribution was normal and the parametric Student t test are less common than after laser procedures, they are was used. We statistically analyzed the change in I-PSSscore, I-PSS voiding and storage subscores, PSA and uro- not uncommon after PVP and represent a major limi- dynamic parameters with statistical significance consid- tation. They seem to be related to surgeon experience, ered at ␣ Յ5%. Data are shown as the mean Ϯ SD.
previous finasteride treatment, laser fiber deteriora-tion and the energy delivered per Weevaluated the safety and clinical outcome of 80 W KTP laser treatment in symptomatic patients with a uro-dynamic diagnosis of BOO, focusing on some postop- Available for analysis were 150 patients. erative functional aspects and particularly on voiding lists baseline characteristics. An average of 190 Ϯ 44 and storage symptom evolution after treatment.
kJ (range 90 to 410) was delivered in 68 Ϯ 24 min-utes (range 30 180, average 3.65/ml prostate). Anaverage of 1.2 Ϯ 0.4 fibers was used per patient. Of MATERIALS AND METHODS
the 150 patients 130 received a 2-way Foley catheterafter treatment, 20 required CBI at the end of the A total of 300 consecutive patients with LUTS observed procedure and none required blood transfusion. The from 2005 to 2007 completed I-PSS and underwent digitalrectal examination, prostatic TRUS and a full urodynamic mean postoperative Hb decrease at 24-hour followup investigation with PFS. The local independent ethics com- was 0.7 gm/dl (range 0.4 to 1.5). No Na changes were mittee approved the study protocol and dedicated in- recorded. Mean catheterization time was 20 Ϯ 8 formed consent was obtained for all patients before study hours (range 12 to 144). The catheter was routinely enrollment. Of the cases 179 (60%) were considered ob- removed at least 12 hours postoperatively but none structed by the Schäfer nomogram (obstruction classes was removed after 6 p.m. Patients were discharged 3–5) and 121 (40%) were unobstructed. Of the 179 patients home at least 6 hours after catheter removal and 150 underwent PVP. Patients with neurological disorder, clear urine voiding but none was routinely dis- renal insufficiency, bladder stone, prostate cancer or ure- charged after 6 p.m. Hematuria 7 to 10 days after thral stricture and those on 5␣-reductase inhibitors were hospital discharge was noted in 2 cases (1.3%) and acute urinary retention within 24 hours after cath- All patients were evaluated at baseline by medical his- tory, I-PSS, physical examination, serum total PSA, urinal- eter removal was noted in 6 (4%). One patient pre- ysis and culture, TRUS and PFS. TRUS was done with a sented with bladder neck stricture approximately 4 biplanar linear plus convex transrectal probe and PVR was months after the procedure, 4 presented with bulbar assessed by bladder scan. Urodynamic equipment was a urethral stenosis and in 2 temporary urinary inconti- multichannel system. Urodynamics were done according to nence spontaneously resolved after 1 month. the International Continence and International lists all intraoperative and postoperative complica- tions. Retrograde ejaculation was reported by 67% of pressure at maximum flow and minimal urethral opening the patients at a clinical interview. shows pressure were plotted on the 1993 Schäfer nomogram to clinical and urodynamic parameters evaluated at 1, 3, determine the Schäfer obstruction class. The urethral resis- 6 and 12 months. At 1, 3, 6 and 12 months storage tance algorithm and the Abrams-Griffith’s number were alsocalculated.
symptoms decreased by 54.5%, 63.6%, 72.7% and PVP was done using a GreenLight™ PV 80 W KTP 81.8%, and voiding symptoms decreased by 63.6%, laser generator via a 23Fr continuous flow dedicated en- 72.7%, 81.8% and 90.9%, respectively (each p Ͻ0.001, doscope. The technique of Hai and was used to achieve complete debulking of adenomatous tissues, as inTURP. All patients received regional anesthesia and 1 gmcefotaxime 1 hour preoperatively. More than 1 laser fiber Table 1. Baseline patient characteristics
was used as needed. The fiber was changed when the aiming beam emerged straight from the fiber rather thanat a right angle. NaCl saline solution (0.9%) served as irrigation fluid. At the end of the procedure a 2-way Foley catheter was routinely inserted. CBI was done in hema- turia cases. The catheter was removed after urine was clear at least 6 hours after surgery. A single expert en- dourological surgeon (AT) performed all procedures after a limited initial experience of 10 cases. Followups were scheduled at 1, 3, 6 and 12 months. Patients were evalu- ated by I-PSS, digital rectal examination, urinalysis, PHOTOSELECTIVE PROSTATIC VAPORIZATION AND BLADDER OUTLET OBSTRUCTION Table 2. Intraoperative and postoperative complications in 150
patients with PVP at 1 and 12-month followup Baseline
12 months
* No patient had intraoperative bleeding or capsular penetration with bleeding, postoperative bleeding with clot retention or blood transfusion, or urinary tract DISCUSSION
Baseline
12 months
PVP using a high power 80 W KTP laser is a safe,reproducible technique providing rapid, bloodless va- Voiding and storage symptom evolution after PVP in 150 pa- porization of prostatic adenomatous tissue in BPH tients. Asterisk indicates p Ͻ0.001 vs previous control.
Recent series show that PVP is associ-ated with significant, durable improvement in LUTSand urinary flow with BOO relief comparable to that of The committee also recommended it in clinical practice before surgery, particularly in patients with cedures that challenge TURP as standard treatment Qmax greater than 10 ml per second. Almost 30% of for LUTS due to Our study confirms that PVP patients with Qmax between 10 and 14 ml per second is safe and bloodless since no patients underwent have no Data from other studies using the blood transfusion or had clot retention. We observed Qmax 15 ml per second inclusion criterion may be significant improvement in LUTS and urinary flow, affected by this bias. We used stricter study inclusion similar to that in the peer reviewed literature criteria and confirmed that PVP may significantly de- A particular characteristic of our population is that all crease LUTS by 81%, increase Qmax by 162% and patients were evaluated by PFS at baseline and only those with an urodynamic diagnosis of BOO were Our followup was relatively short but we believe studied. In previous series the inclusion criterion for that perioperative and postoperative morbidity surgery has usually been Qmax less than 15 ml per were safely assessed. We noted no TUR syndrome or extensive bleeding requiring intraoperative or assess LUTS related to BPH but the Urodynamic postoperative endoscopic fulguration, or blood Committee of the Fifth International Consultation on transfusion. Minor intraoperative bleeding was al- BPH stated that PFS remains the only means of diag- ways managed by the KTP laser by increasing the nosing BOO and it should be mandatory in clinical working distance and decreasing laser power.
Table 3. PVP Followup outcomes in 150 patients
Table 4. Perioperative results, postoperative outcome and complications of 80 W KTP laser vaporization
PHOTOSELECTIVE PROSTATIC VAPORIZATION AND BLADDER OUTLET OBSTRUCTION Postoperatively CBI was done during our learning quency vs laser). Adequate tissue debulking in our curve in 20 patients for modest/moderate bleed- series is supported by the significant decrease ing. CBI was initially used because of our limited Ϫ65% in PSA at 12 months, comparable to the experience with cases treated with PVP. We sig- nificantly decreased its use when we attained bet- studies lower 36% and 56.7% postoperative retro- ter confidence with the technique. Our mean cath- grade ejaculation rates were associated with a eterization time and hospital stay are longer than mean of 103.5 and 247 kJ total energy delivered, in available probably due to our clinical 1.89 and 2.8 kJ/gm mean energy delivered, and a organization. At our department for administra- 40% and 31.8% postoperative PSA decrease, re- tive reasons patients must spend at least 2 nights in the hospital and PVP cannot be performed as an outpatient procedure. Patients also cannot be dis- Persistent postoperative storage symptoms are charged home before 6 hours after catheter re- often reported after laser treatment. In the largest moval, they must pass clear urine and cannot be series they were noted in 0% to 25% of patients Parameters such as catheterization time and We evaluated voiding and storage symptom evo- hospital stay may depend on local organization lution at different times after PVP. Improvement and, thus, they may vary significantly in different in voiding symptoms was more rapid than in stor- series. We adopted this protocol to decrease the age symptoms, although a significant decrease in number of early postoperative complications and each was noted after 30 days (54.5% and 63.6%, access to the emergency department. Our 3.3% respectively). Continuous, significant improve- incidence of urethral and bladder neck strictures ment in storage and voiding symptoms was also thral strictures were in the bulbomembranous Superficial KTP laser penetration and efficient urethra and occurred within 3 to 6 months post- heat energy release from tissue by efficient vapor- operatively. Observed strictures may be related to ization may limit thermal damage and edema, as urethral mucosal injury from the endoscope. Al- proposed by Bachmann et However, fiber struc- most 50% of observed strictures were detected in tural deterioration may lead to scattering and im- the first 20 cases, suggesting that careful endo- paired laser energy deposition with increased coag- scope handling may decrease urethral damage.
The clinical result of fiber deterioration Two patients reported temporary stress urinary is a higher incidence of postoperative storage incontinence and used a mean of 2 pads daily.
symptoms. Hermanns et al noted that laser fibers Continence was achieved within 2 months with no for PVP with less then 175 kJ applied resulted in intervention in either case. Retrospective analysis moderate damage and severe damage appeared of medical charts revealed that these 2 patients after 200 We applied an average of 160 kJ had abundant apical tissue at the 12 o’clock posi- per fiber to minimize the possible coagulation re- tion. Prolonged application of laser energy at this lated to fiber deterioration and achieved rapid, site may be responsible for limited thermal injury significant relief from storage and voiding symp- or edema of the external urinary sphincter mech- toms 30 days after treatment. Our policy is more expensive but better clinical results may be ob- The overall reoperation rate for residual adeno- tained by limiting use of a single laser fiber until matous tissue and persistent LUTS was 4.6%, in a maximum of 200 kJ. Further studies are neces- sary to better clarify this important aspect.
patients were re-treated with TURP. We considered The low postoperative storage symptom rate may 12 months as a limited period to provide any esti- also be related to our study inclusion criteria. Pa- mation of clinical outcome in terms of adenomatous tients on finasteride, which is associated with a tissue regrowth or the need for long-term re-treat- higher postoperative LUTS rate in those treated The highest retrograde ejaculation rate in our tant limitation of our data is the lack of followup series can be explained by our PVP technique of PFS, which we considered not mandatory due to its attempting complete removal of adenomatous tis- invasiveness, particularly in patients with a satis- sue, as in TURP. We delivered a mean of 190 kJ factory clinical outcome (mean I-PSS 4 and mean per patient (3.7/gm prostate), some of the highest Qmax 24 ml per second). In previous studies PVP energy delivered per gm prostate in the peer re- provided successful relief from BOO without affect- viewed literature (range 1.9 to Retrograde ing detrusor contractility in men with LUTS and a ejaculation may be more related to the extent of prostate debulking than to energy type (radio fre- knowledge we are the first to separately analyze PHOTOSELECTIVE PROSTATIC VAPORIZATION AND BLADDER OUTLET OBSTRUCTION storage and voiding symptom evolution after PVP in cant serum PSA decrease were achieved by PVP a large series of symptomatic, urodynamically ob- treatment with the 80 W KTP laser. More than 70% structed cases by specific I-PSS subscores.
of patients reported retrograde ejaculation after sur-gery.
CONCLUSIONS
In patients with BOO PVP resulted in significant
improvement in voiding and storage symptoms,
ACKNOWLEDGMENTS
which continued to decrease in the first 12 months of Prof. Anna Romagnuolo, University La Tuscia, Vit- followup. Proper prostate debulking and a signifi- erbo, Italy, reviewed the manuscript.
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EDITORIAL COMMENT
For more than 5 years PVP has been the most pop- phase II trials. Limited data on randomized trials vs ular laser prostatectomy in many industrialized TURP and initial long-term data with a followup of countries. Efficacy and safety were shown in several up to 5 years are now available. These authors add PHOTOSELECTIVE PROSTATIC VAPORIZATION AND BLADDER OUTLET OBSTRUCTION to our knowledge mainly for 2 reasons. 1) Their the role of PVP. The role of the 120 W high power study included only patients with urodynamically proven obstruction. 2) They report a detailed assess-ment of storage and voiding symptoms.
Anton Ponholzer
This study provides further evidence that PVP with the 80 W laser provides proper debulking with significant, continuous improvement in storage and Stephan Madersbacher
voiding symptoms for up to 12 months. However, only prospective, randomized trials vs TURP with greater than 5-year followup can ultimately define

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