Long-term results of high-power holmium laser vaporization (ablation) of the prostate.

OBJECTIVE: To present the 7-year follow-up data from the initial series of patients treated by holmium laser ablation of the prostate (HoLAP) for symptoms of benign prostatic hyperplasia at our institution. PATIENTS AND METHODS: In all, 79 patients underwent HoLAP in the initial series between September 1994 and May 1995. All patients were contacted by telephone and mail; those available for follow-up had their peak urinary flow rate, American Urological Association (AUA) symptom score, single-question quality-of-life (QoL) score and adverse events assessed. Patients were also assessed using the International Continence Society 'male short-form' (ICSmaleSF) questionnaire on lower urinary tract symptoms (LUTS). RESULTS: At a median follow-up of 89 months (7.4 years), 17 patients had died (21%), 28 could not be contacted or refused follow-up (35%), leaving 34 patients (43%) available for assessment. The mean (range) AUA score of the remainder was 10.0 (0-26), the maximum urinary flow rate 16.8 (5-35) mL/s and QoL score 2.1 (0-5). The mean ICSmaleSF voiding score was 5.8 and the mean incontinence score 3.2. The impact score of their current LUTS (QoL) was 0.68, implying a minimal effect. No patient required pads for incontinence. The reoperation rate was 15%, with one patient each undergoing transurethral resection or bladder neck incision, two undergoing holmium laser enucleation of the prostate and one having a bladder stone removed endoscopically. CONCLUSIONS: The long-term results of HoLAP were satisfactory in those patients who were available for the follow-up.

A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams).

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is a surgical treatment for bladder outlet obstruction secondary to benign prostatic hyperplasia. HoLEP is a transurethral procedure that uses the holmium laser fiber (wavelength 2,140 nm) to dissect whole prostatic lobes off of the surgical capsule in retrograde fashion, while maintaining excellent hemostasis. The lobes are removed from the bladder by a purpose built transurethral morcellator, which means that large volume prostates can be enucleated endoscopically. We compared this procedure with transurethral prostate resection (TURP) in a randomized trial by evaluating outcomes in patients with a prostate volume of 40 to 200 ml on transrectal ultrasound. MATERIALS AND METHODS: A total of 61 patients with urodynamically proved bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized to TURP or HoLEP. Perioperative parameters recorded included resectoscope, laser, electrocautery, morcellation and catheter time, hospital stay, bladder irrigation, volume blood transfusion the rate and resected tissue weight. Patients were followed 1, 3, 6 and 12 months postoperatively with peak urinary flow rate measurement and quality of life and American Urological Association symptom scores. Patients also underwent urodynamic assessment at 6 months with measurement of peak detrusor pressure at maximal flow, post-void residual volume and prostate volume by transrectal ultrasound. Continence, potency and all adverse events were recorded at each visit. RESULTS: HoLEP was superior to TURP in terms of mean catheter time (17.7 +/- 0.7 vs 44.9 +/- 10 hours) and hospital stay (27.6 +/- 2.7 vs 49.9 +/- 5.6 hours) but it required more time to perform (62.1 +/- 5.9 vs 33.1 +/- 3.7 minutes). More prostate tissue was removed in the HoLEP group (40.4 +/- 5.7 vs 24.7 +/- 3.4 gm). HoLEP was also superior to TURP in terms of relieving urodynamic obstruction at 6 months of followup (postoperative detrusor pressure at maximum flow 20.8 +/- 2.8 vs 40.7 +/- 2.7 cm H2O). HoLEP and TURP led to significant improvements in peak flow rates, symptom scores and quality of life scores compared with baseline and there was no significant difference between the 2 procedures with respect to these parameters at 12 months. Fewer adverse events were recorded in the HoLEP group. CONCLUSIONS: HoLEP is superior to TURP for relieving bladder outlet obstruction in men with benign prostatic hyperplasia. It allows more rapid catheter removal and hospital discharge. It requires more time to perform than TURP but more prostate tissue is removed, resulting in similar efficiency in tissue retrieval. HoLEP is equivalent to TURP in relieving men of lower urinary tract symptoms and in improving peak urinary flow rates at 12 months of followup.

Holmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomized prospective study.

OBJECTIVES: A cost-effectiveness analysis was carried out comparing electrosurgical transurethral resection of the prostate (TURP) with holmium:yttrium-aluminum-garnet laser resection of the prostate (HoLRP). METHODS: One hundred twenty patients with benign prostatic hyperplasia and urodynamically proved obstruction were randomized to undergo either TURP or HoLRP. Economic and clinical outcome data were recorded prospectively out to 1 year postoperatively. RESULTS: The HoLRP group experienced fewer complications and had a shorter hospital stay and catheterization time than the TURP group, with equivalent clinical outcomes at 12 months. HoLRP cost 24.5% less (New Zealand dollars $651) than TURP during the first year. CONCLUSIONS: Because the clinical outcomes out to 1 year were equivalent, HoLRP was more cost-effective than TURP. On the basis of these savings, a minimum of 93 cases per year are required to recover the capital and service costs of the holmium:yttrium-aluminum-garnet laser.

Holmium laser resection v transurethral resection of the prostate: results of a randomized trial with 2 years of follow-up.

BACKGROUND AND PURPOSE: The holmium laser (2140 nm) can be used to ablate, resect, and enucleate the enlarged prostate. The 2-year results of a randomized trial comparing holmium laser resection of the prostate (HoLRP) and transurethral resection (TURP) are presented. PATIENTS AND METHODS: The 120 patients were randomized to either TURP (N = 59) or HoLRP (N = 61). The patients were reviewed at 1, 3, 6, 12, 18, and 24 months postoperatively. Eighty six (72%) of the patients were available for review at the 2-year mark. RESULTS: At 2 years, there was no significant difference between the two groups in AUA Symptom Score, peak flow rate (Qmax) value, or quality of life score. Adverse events, including reoperations, incontinence, and loss of erectile potency, were also similar. CONCLUSIONS: The HoLRP and TURP procedures result in similar clinical outcomes at 2 years.

Holmium laser enucleation of the prostate for glands larger than 100 g: an endourologic alternative to open prostatectomy.

BACKGROUND AND PURPOSE: Treatment of the large (>100 g) prostatic adenoma often involves open prostatectomy, with its attendant risks and morbidity. Enucleation of the entire adenoma endoscopically is possible with the holmium:YAG laser and tissue removal from within the bladder by a transurethral tissue morcellator. These patients can usually be discharged from the hospital the following day without a catheter. PATIENTS AND METHODS: A series of 43 patients with prostates 100 g was followed for 6 months after laser resection. RESULTS: The mean morcellation time was 16.1 minutes. The mean catheter time was 19.7 hours, and the mean hospital time was 28.4 hours. One patient required readmission for evacuation of tissue fragments. The average AUA Symptom Score declined from 23.5 preoperatively to 2.8 at 6 months postoperatively, and the mean Qmax increased from 9.0 mL/sec to 24.8 mL/sec. CONCLUSION: The holmium:YAG laser can be used to enucleate the adenoma in a large prostate in much the way the surgeon's finger does during open prostatectomy.

Histologic effects of holmium:YAG laser resection versus transurethral resection of the prostate.

BACKGROUND AND PURPOSE: Holmium laser resection (HoLRP) is an effective surgical alternative to transurethral resection of the prostate (TURP). We investigated whether an adequate histologic diagnosis could be made from HoLRP tissue specimens. PATIENTS AND METHODS: A series of 120 patients were randomized to TURP (N = 59) or HoLRP (N = 61). Each histologic specimen was reviewed by a single pathologist, who was blinded to the treatment. Weight of tissue, histologic diagnosis, and degree of thermal artifact were assessed. Thermal damage was graded as follows: 1 = no significant thermal injury; 2 = <25% of the tissue damaged (minimal); 3 = 25% to 80% of the tissue damaged (moderate); and 4 = >80% of the tissue damaged, with loss of prostatic architecture (extensive). RESULTS: The mean weight of the TURP and HoLRP specimens was 15.6 g and 9.6 g, respectively. The mean grade of thermal artifact for the TURP group was 1.8 and for the HoLRP group 2.6. Of the HoLRP specimens, 56 (92%) were grade < or = 3. Of the entire series of 120 specimens, 5 contained malignant tissue, all of which were from the TURP group. Four of these specimens were adenocarcinoma of the prostate, whereas the other was a transitional-cell carcinoma. Of the four specimens that contained prostate cancer, two were stage pTla tumors. CONCLUSIONS: Although identifiable prostatic architecture was maintained in the majority of histologic specimens from the HoLRP group, the tissue quality was inferior to that of TURP. There was significantly more vaporization and subsequent tissue loss with HoLRP, and the thermal damage to tissue was greater.

Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year followup.

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.

Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience.

The preliminary experience with 64 patients who have undergone HoLEP combined with intravesical morcellation is presented. The mean preoperative prostate volume was 75.3 cc. The mean laser time was 46.9 minutes and the morcellator time a further 10.5 minutes. A mean total of 35.5 g of tissue was obtained, and 93% of the patients were discharged the day after their surgery without a catheter. The American Urological Association Symptom Score at 1 month was 8.6 and the peak flow rate 23.4 mL/sec. This combination of procedures allows prostate glands of virtually any size to be safely treated transurethrally, and a complete anatomic enucleation of the prostatic adenoma is achieved.

Application of the holmium:YAG laser for prostatectomy.

OBJECTIVE: The authors review the current knowledge regarding the application of the Holmium: YAG laser for prostatectomy. SUMMARY BACKGROUND DATA: Conventional surgical therapies for benign prostatic hyperplasia (BPH) are effective but associated with relatively high morbidity. Laser prostatectomy, using either Neodymium:YAG or potassium-titanyl-phosphate lasers, has emerged as a new and much safer operative approach to relieve symptoms of benign prostatic hyperplasia. However, these laser wavelengths possess key disadvantages that have limited their acceptability and dissemination in everyday urologic practice. METHODS: THE authors review their own extensive experience in the development of clinical application of Holmium: YAG laser technology for prostatectomy, as well as the published reports in the current medical literature now dealing with this subject. RESULTS: In multiple clinical trials, Holmium:YAG laser resection of the prostate has proven efficacious in relieving symptomatic BPH. Both objective urodynamic measures of voiding outcomes and symptomatic improvement have been shown to be equivalent to standard electrocautery resection of the prostate. At the same time, these studies have demonstrated the superior safety and hemostasis of Holmium:YAG laser prostatectomy compared to electrocautery resection, similar to prior laser prostatectomy procedure. Unlike prior forms of laser prostatectomy, Holmium:YAG laser resection of the prostate acutely removes all obstructing prostate tissue, so that the postoperative catheterization requirement is typically only overnight and improvement in voiding is immediate. Current operative techniques and the latest technological developments to facilitate Holmium:YAG laser prostatectomy are described. CONCLUSIONS: Holmium: YAG laser prostatectomy combines the best features of prior laser prostatectomy technologies, including minimal complications and morbidity, with the efficacy and immediacy of voiding outcomes associated with conventional electrocautery resection of the prostate.

Holmium:yttrium-aluminum-garnet laser prostatectomy.

As alternatives to transurethral resection of the prostate for treatment of benign prostatic hyperplasia, various types of laser prostatectomy-most notably, neodymium:yttrium-aluminum-garnet (YAG) and potassium titanyl phosphate laser procedures-have proved to be associated with considerably less morbidity (for example, bleeding, need for transfusion, intraoperative fluid absorption, and postoperative incontinence). Despite these advantages, certain disadvantages (need for prolonged postoperative catheterization and delayed symptomatic improvement) prompted investigation of the holmium:YAG laser for performance of prostatectomy. The holmium:YAG laser is highly absorbed by tissue water and causes rapid vaporization of exposed soft tissue. After initial studies in canine prostates and human prostatectomy specimens, clinical studies with the holmium:YAG laser showed no fluid absorption, appreciable blood loss, or complications, and voiding outcomes were improved immediately, similar to the result with transurethral resection of the prostate. In addition, the holmium:YAG laser has been used to perform transurethral incision of the prostate rapidly and hemostatically. Holmium laser resection of the prostate is a safe and efficacious procedure for relief of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia.

Cystic embryonal sarcoma of kidney: a case report.

BACKGROUND: Morphologic analysis of malignant renal tumors of childhood and adolescence has resulted in the identification of a variety of tumor types with characteristic histology and clinical behavior. The authors report a case of renal sarcoma in a 19-year-old male that differs in morphology from the various established categories of primitive renal tumors. METHODS: Sections taken from the nephrectomy specimen were stained by routine methods and by immunohistochemistry for stromal and epithelial markers, and for proliferation markers. In addition, ultrastructural studies were undertaken. RESULTS: The tumor, which the authors termed cystic embryonal sarcoma, was comprised of poorly differentiated malignant mesenchyme in a myxoid stroma. Numerous epithelial-lined cysts were present. The distribution of the cysts and proliferation kinetics of cyst-lining epithelial cells suggested that they were derived from entrapped renal tubules. The tumor showed early recurrence postoperatively and after aggressive chemotherapy. The pathologic features and clinical behavior of the tumor resemble those of 2 previously reported cases and an additional 25 cases from the files of the National Wilms' Tumor Study Pathology Center. CONCLUSIONS: The clinical and histologic features of cystic embryonal sarcoma differ from those of other renal tumors of childhood and adolescence, and the tumor appears to be a novel form of renal malignancy.

Holmium laser resection of the prostate versus neodymium:yttrium-aluminum-garnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy.

OBJECTIVES: To directly compare holmium laser resection of the prostate (HoLRP) with neodymium:yttrium-aluminum-garnet visual laser ablation of the prostate (VLAP), which represent two fundamentally different methods of laser prostatectomy. METHODS: In a randomized, prospective comparison, a total of 44 men with symptomatic benign prostatic hyperplasia (BPH) were treated with either HoLRP or VLAP. Standard preoperative assessment included American Urological Association (AUA) symptom score, peak urinary flow rates (Qmax), ultrasound prostate volume, and residual urine measurements. Pressure-flow urodynamics were performed preoperatively and at 3 months postoperatively. Intraoperative and perioperative factors were assessed. The patients were followed at 1, 3, 6, and 12 months following the procedure. RESULTS: There were no significant differences between the patient groups for any preoperative parameter. The mean total operating time was longer in the HoLRP group (52 minutes) compared with the VLAP group (41 minutes) (P <0.01). The mean catheter times were 1.4 days (HoLRP) and 11.6 days (VLAP) (P <0.001). These times included the 9% of patients undergoing HoLRP and 36% of patients undergoing VLAP who required recatheterization. Immediate postoperative dysuria scores were higher in the VLAP group compared with the HoLRP group. There were no significant differences in AUA scores between the two treatment groups at any postoperative interval. The Qmax values were greater at follow-up in the HoLRP group, but statistical significance was not achieved at 12 months. However, both PdetQmax and Schäfer grade measurements taken at 3 months postoperatively were significantly lower in the patients undergoing HoLRP. Three patients (14%) required reoperation in the VLAP treatment arm but no patient who underwent HoLRP has required reoperation to date. CONCLUSIONS: HoLRP results in significantly improved patient outcomes compared to VLAP.

Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results.

OBJECTIVES: To determine the feasibility of holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation to surgically treat bladder outflow obstruction due to the larger prostate. METHODS: The first 14 patients treated with this new combination technique are described. Standard preoperative investigations were performed and all patients were assessed at 1 month postoperatively with an AUA symptom score and peak urinary flow rate (Qmax). Both transurethral (8 patients) and suprapubic (6 patients) morcellation was utilised. RESULTS: The mean ultrasound volume of the prostate was 98.6 ml (55-200). The mean total operating room time was 98 min (64-190). No patient required blood transfusion but 2 patients required postoperative bladder irrigation. Twelve of the patients were discharged catheter-free the following day. The only significant complication was extraperitoneal extravasation from the suprapubic site in 2 patients. At 1 month the mean Qmax was 25.2 ml/s and the mean AUA score was 7.2. CONCLUSIONS: This combination of techniques offers a minimally morbid method of treating the larger prostate gland.

Holmium laser prostatectomy: a technique in evolution.

This review documents the evolution of the current techniques of Holmium:yttrium-aluminium-garnet (Ho:YAG) laser prostatectomy. An increasing number of centres are accumulating experience with this wavelength in the surgical treatment of Benign Prostatic Hyperplasia. Newer techniques, including prostatic enucleation combined with intracavitary morcellation, are discussed.

Holmium: YAG laser resection of prostate (HoLRP) for patients in urinary retention.

We examined the holmium:YAG (Ho:YAG) laser as a tool to perform acute resection of obstructing prostatic tissue in the subgroup of men with benign prostatic hyperplasia (BPH) who present in urinary retention. A total of 36 men presented in acute urinary retention requiring catheterization before undergoing Ho:YAG laser resection of the prostate (HoLRP). Their mean age was 67 years. The mean laser energy delivery was 102 kJ (range 42-315 kJ). The mean postoperative catheterization time was 1.5 days (range 1-8 days), and only 3 men required a catheter for more than 48 hours. There were no acute perioperative complications. Improvement in voiding was immediate and sustained through 6 months of follow-up. At 6 months, the mean peak urinary flow rate was 22.5 mL/sec, and the AUA Symptom Index Score was 5.7. A meatal stricture requiring dilation in one man represents the sole late complication observed in this series. Late recurrence of urinary retention has occurred in two men who had contributing medical problems, for an overall treatment failure rate of 5.6%. Thus, HoLRP represents an effective surgical therapy for patients with bladder outlet obstruction presenting in urinary retention. Morbidity is minimal compared with electrocautery resection, while the efficacy and immediacy of voiding improvement appear similar.

Holmium:YAG laser resection of the prostate: preliminary experience with the first 400 cases.

AIM: To report the development of the technique of laser resection of the prostate using the holmium:YAG (Ho:YAG) laser and to present preliminary results. METHODS: Four hundred and eleven patients underwent Ho:YAG laser resection of the prostate (HoLRP). Preoperative and postoperative symptom scores, and flow rates were assessed. A description of the technique and its development is presented. RESULTS: The mean American Urological Association (AUA) symptom score reduced from 23.6 to 4.9, and the mean peak urinary flow rate improved from 7.7 ml/s to 22.6 ml/s at 6 months postoperatively. The mean hospital stay was 1.3 days and complication rates were lower than those generally associated with electrosurgical transurethral resection of the prostate (TURP). CONCLUSION: Transurethral resection of the prostate using Ho:YAG laser produces early results equivalent to or better than those usually associated with electrosurgical TURP, with a shorter hospital stay and a lower rate of complications.

The use of the holmium laser in the treatment of benign prostatic hyperplasia.

The holmium wavelength (2.1 microns) can be used for incision, ablation, and resection of prostate tissue. Four different techniques for the surgical management of benign prostate hyperplasia (BPH) have evolved using the holmium laser either alone or in combination with Nd:YAG energy. The results in 650 patients undergoing these procedures are presented. The holmium laser has been used most recently to perform a transurethral resection of the prostate in 381 patients to date. This procedure appears to be the most efficient way of using the holmium laser for the removal of obstructing prostatic tissue.

Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia.

OBJECTIVES: To assess the early efficacy and safety of holmium laser resection of the prostate (HoLRP) for the treatment of patients with symptomatic benign prostatic hyperplasia (BPH). METHODS: The initial 84 patients undergoing HoLRP at this institution are reported. All patients underwent standard urologic evaluation for BPH with American Urological Association (AUA) symptom score, peak urinary flow rate (Qmax), ultrasound prostate volume estimation, prostate-specific antigen and digital rectal examination. The patients were reassessed at 1 month (72 patients) and 3 months (48 patients) postoperatively. The resection time, total operating time, holmium energy used (kilojoules), catheter time, and hospital stay were all recorded. RESULTS: The mean patient age was 65.3 years (49 to 80). The mean AUA score improved from 21.3 preoperatively to 7.6 at 1 month and 4.1 at 3 months. The mean Qmax likewise increased from 7.5 mL/s preoperatively to 17.8 mL/s at 1 month and 19.3 mL/s at 3 months. Two patients (2%) required bladder irrigation for heavy hematuria perioperatively and 4 patients (5%) required recatheterization. Few patients experienced irritative urinary symptoms and to only a mild degree. CONCLUSIONS: The technique of HoLRP produces a cavity identical in appearance to transurethral resection of the prostate. It is a relatively bloodless procedure that results in a short catheter time, immediate symptomatic improvement, and minimal postoperative irritative symptoms. The short-term results are excellent but longer-term follow-up is necessary.

Combination holmium and Nd:YAG laser ablation of the prostate: initial clinical experience.

The holmium laser is a recent addition to the urologist's armamentarium, being used primarily for the destruction of urinary calculi. Its use as a tool for ablation of the prostate has not been previously described. Our initial experience with 110 patients who have undergone a combination procedure using the Nd:YAG laser for standard circumferential coagulation followed by holmium laser ablation is reported. A further 32 patients who have had a holmium-only technique are described. In the patients who had the combination technique, the AUA Symptom Score improved from a mean value of 19.8 preoperatively to 7.8 at 3 months. The peak urine flow rate likewise improved, from a mean of 8.9 mL/sec preoperatively to 15.1 mL/sec at 3 months. Only one patient who had the holmium-only technique required recatheterization, compared with nine patients who had the combination procedure. The combination Ho/Nd:YAG laser ablation technique is evolving. The early results of the holmium-only technique suggest an advantage over the combination with regard to catheterization time and degree of irritative symptoms. The longer-term results must be assessed to confirm this impression.