Technique and Short-Term Outcome of Green Light Laser (KTP, 80 W) Vaporisation of the Prostate

european urology 52 (2007) 1632 1637 available at www.sciencedirect.com journal homepage: www.europeanurology.com Surgery in Motion Technique and Short-Term Outcome of Green Light Laser (KTP, 80 W) Vaporisation of the Prostate Elmar Heinrich *, Frank Schiefelbein, Georg Schoen Department of Urology, Missionsärztliche Klinik Würzburg, Würzburg, Germany Article info Article history: Accepted July 23, 2007 Published online ahead of print on July 31, 2007 Keywords: BPH KTP Laser surgery Prostate Prostatic hyperplasia Vaporisation Abstract Objective: Photoselective laser vaporisation prostatectomy with an 80-W potassium-titanyl-phosphate (KTP) laser is an effective procedure for men with symptomatic benign prostatic hyperplasia. The main advantages of the laser treatment are less blood loss and the short hospital stay. Methods: The DVD and photos show the main steps and difficulties of the procedure. All patients were evaluated preoperatively and postoperatively by using the International Prostate Symptom Score, volume of prostate, maximum flow rate, haemoglobin values, and postmicturition volume of residual urine. Days of bladder catheterisation, duration of the procedure, and prostate-specific antigen values were determined as well. Results: The results in 140 patients, who underwent KTP laser treatment, were evaluated. The mean age of the patients was 69 7.8 yr. Mean volume of prostates, mean operative time, and mean energy delivery were 43 22 ml, 53 16 min, and 181 58 kj, respectively. The bladder catheter was removed usually on the first postoperative day. Preoperative haemoglobin values were just slightly higher at 14.4 1.3 g/dl compared to the postoperative values of 13.9 1.4 g/dl. The most common complication, dysuria, was seen in 35 patients (25%), followed by mild haematuria in 21 patients (15%). Conclusions: Photoselective laser vaporisation of the prostate is a treatment option in men who are at high risk for clinically significant bleeding. The procedure provides a high level of intraoperative and postoperative safety and seems to be comparable to transurethral resection of the prostate in the relief of obstructive symptoms. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Missionsärztliche Klinik Würzburg, Department of Urology, Salvatorstraße 7, 97067 Würzburg, Germany. Tel. +49 931 791 2841; Fax: +49 931 791 2536. E-mail address: elmar.heinrich@gmx.de (E. Heinrich). 0302-2838/$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.07.033

european urology 52 (2007) 1632 1637 1633 1. Introduction Benign prostatic hyperplasia (BPH) affects >50% of men older than 60 yr [1]. Surgical treatment of patients suffering from lower urinary tract symptoms (LUTS) secondary to BPH remains the most effective treatment option to date. Electrosurgical transurethral resection of the prostate (TURP) is considered the gold standard treatment. Unfortunately, TURP is associated with a morbidity rate as high as 14%, the problem being primarily intraoperative or postoperative bleeding [2]. To minimise perioperative morbidity of TURP, various minimally invasive alternatives were introduced into clinical practice. Some of them are transurethral needle ablation (TUNA), transurethral microwave therapy (TUMT), interstitial laser coagulation (ILC), neodymium:yttrium-aluminumgarnet (Nd:YAG) laser, and holmium laser [3 6]. Visual laser ablation of the prostate with the Nd:YAG laser is haemostatic and has been successful in patients receiving anticoagulants [7]. The holmium laser has been used to treat upper tract calculi in anticoagulated patients [8]; its appropriateness for treating symptomatic BPH has been shown by different groups and seems to be favourable in the treatment of larger prostates and provides histologic samples [9,10]. Photoselective vaporisation of the prostate (PVP) using the high-power (80 W) potassium-titanyl-phosphate (KTP) laser has been applied for the treatment of symptomatic BPH, and its efficacy has been detailed in recent multicentre studies [11,12]. The 80-W KTP laser is a recent invention, emitting light at a wavelength of 532 nm, which is strongly absorbed by haemoglobin. Our work, as shown in the animated DVD, demonstrates the surgical handling of PVP. Additionally we present the data from 140 patients treated from 2003 to 2006, including a 6-mo follow-up. Fig. 1 Continuous irrigation resectoscope 21 Ch with a working channel slanting to 5 o clock. were considered as high-risk patients. Anticoagulant medication was interrupted perioperatively. Exclusion criteria were the presence of prostatic malignancy or neurogenic bladder disease. IPSS was documented preoperatively on the day before treatment, postoperatively on the day after catheter removal, and 6 mo after treatment. Preoperative antibiotic prophylaxis was given to patients with increased risk of urinary tract infection. Laser vaporisation was performed with an 80-W KTP laser, using a GreenLight PVP system with 600 mm side-firing fibres and a StarPulse quasicontinuous wave laser (Laserscope, San Jose, CA), which emits green light with a wavelength of l = 532 nm. Although problems with resectoscopes smaller than 26 Ch in prostates > 30 ml have been reported [13],weare working with a continuous-irrigation resectoscope 21 Ch. The working channel is slanted to 5 o clock, which does not affect the video monitoring and minimises too much bending of the fibre and the risk of a possible breakage of the fibre (Fig. 1). The camera chip has to be protected from the laser light by a filter. The fibre emits the laser light onto the tissue at an angle of 1108 by means of a mirror system (Fig. 2). The near-contact 2. Methods In the following steps we describe the procedure of a KTP laser vaporisation of the prostate. Before treatment all patients provided a complete medical history and underwent physical examination, urine culture, prostate-specific antigen (PSA) measurement, digital rectal examination, blood chemistry studies, and transrectal ultrasound (TRUS) of the prostate. Postvoiding residual urine was measured by transabdominal ultrasonography. A total of 140 patients suffering from LUTS due to BPH and failed previous medical therapy were included in this study. Inclusion criteria were the presence of moderate or severe LUTS (International Prostate Symptom Score [IPSS] > 8) or intermittent postvoiding residual urine > 100 ml or both. Patients receiving anticoagulants, for example, acetylsalicylic acid (daily dose 100 mg), coumarin derivatives, or clopidogrel because of former thromboembolic diseases, Fig. 2 The laser light is emitted at an angle of 1108 by a mirror system.

1634 european urology 52 (2007) 1632 1637 Fig. 3 Control of the working beam. (a) Intraoperative red pilot beam as white spot at 4 o clock. The inserted window shows the fibre and the red pilot beam. (b) Intraoperative picture with blue arrow, which marks the contralateral side of the working beam. (c) Control handle (LaserscopeW) with a pin that indicates the direction of the working beam. procedure is used with an optimum fibre tissue distance of 1 mm; the diameter of the laser beam is 1.2 mm. After cystoscopic exclusion of a urinary bladder neoplasia and identification of the ureteral ostia, the fibre is inserted and Fig. 4 Scheme of systematic tissue ablation. the condition is checked visually. Isotonic sodium chloride solution is used for irrigation purposes. The three ways of controlling and checking the working beam are: (1) the pilot beam, (2) on the contralateral side of the fibre marked arrow, and (3) a control handle that can be used to control the fibre, with the pin that indicates the direction of application (Fig. 3). Similar to the conventional TURP a systematic procedure is advisable. In the case of a trilobular adenoma the middle lobe is vaporised before the lateral lobes and ventral parts are treated (Fig. 4). A three-dimensional sagittal, rotating, and lateral motion of the fibre is necessary, taking into account the optimum fibre tissue distance of 1 mm and avoiding any contact to prevent carbonisation of the fibre tip. To achieve sufficient distention of the bladder neck (Fig. 5), a special technique is used. At 4 o clock a roughly fibre-thick cavity is excised, then the fibre is turned 908 and the tissue is excised in layers with a sagittal motion of the fibre, and to avoid any injury in the region of the trigonum, in particular of the ureteral ostia, the bladder neck is distended in layers. The depth of penetration is only about 1 2 mm. The laser energy is released as a cytoplasmic explosion, which causes an immediate vaporisation of the tissue and coagulation of the

european urology 52 (2007) 1632 1637 1635 3. Results Fig. 5 Treatment of the bladder neck (schematically) with incision at 4 o clock in the left section of the picture and an intraoperative picture following strict sagittal motion of the fibre in the right section. well-perfused BPH tissue. The vaporisation results in vapor bubbles, which are carried away by the continuous flow setup with gravity inflow and outflow. By the end of the operation the ureteral ostia are checked and the ablated tissue particles (Fig. 6) are flushed out. After the resectoscope is removed, the uroflow is checked. The catheter is removed the following day. Irrigation is used only in patients with ongoing anticoagulation. Perioperative antibiosis and treatment with nonsteroidal antiphlogistics (eg, diclofenac) are optional. The patients are discharged on the second day after surgery. Data are expressed as means standard deviation. Microsoft Excel1 software was used for the statistical analysis of data. Differences between mean values were evaluated by the Student t test (two-sided, type 2). A two-sided p < 0.05 was considered significant. The results of 140 patients, who underwent 80-W KTP laser treatment, were evaluated. Sixty-seven patients (47.8%) were receiving anticoagulation medication. Detailed preoperative and intraoperative parameters are shown in Table 1. Seven prostates (5%) had a volume > 70 ml. The Foley bladder catheter was removed usually on the first postoperative day. Patients receiving coumarin derivatives required postoperative irrigation for 24 h. Preoperative haemoglobin values were just slightly higher compared to the postoperative values. Changes of preoperative to postoperative parameters (PVR, IPSS, maximum flow rate, haemoglobin) are shown in Table 2. Measurement of the postoperative maximum flow rate was short before patients were discharged and showed a significant increase ( p < 0.01). The postoperative evaluated IPSS values of 11.65 5.7 (range: 3 25) were significantly lower ( p < 0.0001) compared to the preoperative values 19.7 6.3 (range: 4 32). In the follow-up after 6 mo the IPSS value improved again to 8.8 6.5 (range: 1 31; p < 0.0001). The postoperative residual urine was significantly lower compared to preoperative volumes ( p < 0.0001). During PVP no intraoperative complication, such as severe bleeding or capsule perforation, was seen. Twice we had to convert to the conventional procedure because of technical problems. Electrolyte imbalance did not occur in any patient during the perioperative period. Mild haematuria occurred in 21 patients (15%), of whom 17 (81%) were receiving coumarin derivative or clopidogrel therapy. In five men (3.5%) recatheterisation was necessary due to clot retention or high residual urine. The most common complication, dysuria (urethral and perineal pain during micturition), was seen in 35 patients (25%) during the first 4 wk after the procedure. Urinary tract infection occurred in 10 patients (7.1%). One patient (0.7%) developed symptoms of urosepsis Table 1 Perioperative and intraoperative parameters Age, yr 69 7.8 (50 86) ASA 2.1 0.5 (1 4) PSA, ng/ml 4.26 4.5 (0.1 24) Prostate volume, ml 43 22 (15 130) Operation time, min 53 16 (15 97) Applied energy, kj 181 58 (1.3 407) Catheter removal, postoperative d 1.4 0.9 (1 6) Hospitalisation, d 3.6 1.5 (1 9) Fig. 6 Tissue particles cotton wool fibres after treatment. Data are presented as mean standard deviation, range, and median. ASA = American Society of Anesthesiologists; PSA = prostatespecific antigen.

1636 european urology 52 (2007) 1632 1637 Table 2 Preoperative versus postoperative parameters Preoperative Postoperative PVR, ml 88 103 (0 500) 23 70 (0 600) (after catheter removal) IPSS 19.7 6.3 (4 32) 11.65 5.7 (3 25) (after catheter removal) 8.8 6.5 (1 31) (after 6 mo) Maximum flow rate, ml/s 13.0 10.3 (3 66) 18.6 11.8 (4 63) Haemoglobin, g/dl 14.4 1.3 (9.9 16.6) 13.9 1.4 (9.6 17.7) (day of discharge) Data presented as mean standard deviation. PVR = postvoid residual; IPSS = International Prostate Symptom Score. due to urinary infection. Twenty-four patients (17.1%) stated that they had combined stress and urge incontinence preoperatively. At the 6-mo followup, 9 men (6.4%) were still suffering from urge incontinence. Endoscopic re-examination of these patients revealed fibrinoid material, especially in larger prostates but no morphologic lesions of the external sphincter. Four patients (2.6%) developed a bladder-neck stricture during the follow-up period and underwent conventional resection. 4. Discussion The gold standard surgical BPH therapy, TURP, is still associated with a blood transfusion rate of 2.0 7.1% and an early revision rate of 3.0 5.0% [14]. The growing life expectancy and general ageing population leads to a treatment group for TURP with more comorbidity, necessitating surgical treatments causing fewer perioperative complications. As a result of this development various lasers have been introduced as alternatives to TURP. Historically, application of the KTP laser energy in urology began in the late 1980s when the early KTP laser systems with power outputs of initially 20 W and later 38 W became available. The KTP laser at these lower power outputs was used mainly for transurethral incision of small prostates, bladder-neck contractures, and urethral strictures [15]. Kuntzman et al established the scientific foundation of PVP by studying the functional outcomes and tissue effects of low-power (38 W) and prototype high-power (60 W) KTP lasers in living canines at the Mayo Clinic [16,17]. The next step was the development and introduction of the 80-W laser generator by Malek and Hai [18]. Outcomes of the first multicentre study in the United States of 139 patients with prostate volumes as large as 174 ml who underwent PVP with the 80-W KTP laser system and followed for 1yr[11] confirmed the earlier remarkably favourable results achieved with the 60-W power setting [19]. The major advantage of PVP is seen in the haemostatic property. Short catheterisation and hospitalisation times due to the unnecessary postoperative irrigation are further advantages. Direct comparison of PVP- versus TURP-treated patients published by Bouchier-Hayes et al [20] showed a similar functional outcome of both groups but with significant shorter times of catheterisation and hospitalisation in the PVP group. Ruszat et al [21] revealed the effectiveness and safety of PVP treatment, comparing PVP-treated patients with and without ongoing anticoagulation. Nevertheless, bladder irrigation for 24 h after surgery seems to be necessary for patients treated with PVP with ongoing anticoagulation to avoid acute clot retention due to slight haematuria. The shallow penetration depth of 0.8 mm allows the confinement of high-power laser energy to a superficial layer of prostatic tissue, which is vaporised rapidly and haemostatically with only a 1 2-mm rim of coagulated tissue. Tissue removal is caused by the rapid vaporisation of heated cellular water from within the cell [13]. Efficacy appears equivalent or almost equivalent to that of standard TURP because an open channel can be created with low blood loss and without absorption of hypotonic fluid. PVP can be performed with regional or general anaesthesia. Holmium laser enucleation of the prostate is reported as an equally blood less laser technique as the PVP treatment of the prostate [22]. Major drawbacks of this technique are higher intraoperative complications such as capsular perforation, superficial bladder mucosal injury, and ureteral ostia injury [23]. The high learning curve and essentially needed endoscopic skills are limiting this technique [22]. PVP treatment of the prostate seems to be best suited for patients with symptomatic BPH receiving anticoagulants, due to low perioperative bleeding. Major complications are bladder-neck stricture and urethral stricture [21]. Temporary complications are mild dysuria and haematuria [13,24]. The highly significant decrease of IPSS results reveals the excellent postoperative outcomes and patient satisfaction.

european urology 52 (2007) 1632 1637 1637 5. Conclusion KTP laser vaporisation of the prostate is a good validated treatment for symptomatic BPH. This technique enables the surgical treatment of patients with ongoing anticoagulation, due to its haemostatic properties and low intraoperative complication rate. In the relief of LUTS due to BPH the available results are almost equivalent to the gold standard therapy TURP. Conflicts of interest The authors have nothing to disclose. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.eururo.2007.07.033 and via www.europeanurology. com. Subscribers to the printed journal will find the supplementary data attached (DVD). References [1] Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984;132:474 9. [2] AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia (2003). Diagnosis and treatment recommendations. J Urol 2003;170: 530 47. [3] Schulman CC, Zlotta AR, Rasor JS, Hourriez L, Noel JC, Edwards SD. Transurethral needle ablation (TUNA): safety, feasibility, and tolerance of a new office procedure for treatment of benign prostatic hyperplasia. Eur Urol 1993;24:415 23. [4] Kabalin JN, Bite G, Doll S. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients. J Urol 1996;155:181 5. [5] Blute ML, Tomera KM, Hellerstein DK, et al. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. J Urol 1993;150:1591 6. [6] Muschter R, Hofstetter A. Interstitial laser therapy outcomes in benign prostatic hyperplasia. J Endourol 1995; 9:129 35. [7] van Melick HH, van Venrooij GE, Boon TA. Laser prostatectomy in patients on anticoagulant therapy or with bleeding disorders. J Urol 2003;170:1851 5. [8] Watterson JD, Girvan AR, Cook AJ, et al. Safety and efficacy of holmium:yag laser lithotripsy in patients with bleeding diatheses. J Urol 2002;168:442 5. [9] Kuntz RM. Laser treatment of benign prostatic hyperplasia. World J Urol 2007;25:241 7. [10] Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve. Eur Urol 2007;52: 1465 72. [11] Te AE, Malloy TR, Stein BS, et al. Photoselective vaporization of the prostate for the treatment of benign prostatic hyperplasia: 12-month results from the first United States multicenter prospective trial. J Urol 2004;172:1404 8. [12] Bachmann A, Reich O, Wyler S, et al. The 80 W potassiumtitanium-phosphate (KTP) laser vaporization of the prostate. Technique and 6 month follow-up after 70 procedures. Urologe A 2004;43:1262 70. [13] Kumar SM. Photoselective vaporization of the prostate: a volume reduction analysis in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia and carcinoma of the prostate. J Urol 2005; 173:511 3. [14] Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) incidence, management, and prevention. Eur Urol 2006;50: 969 80 (discussion 980). [15] Malek RS, Nahen K. Photoselective vaporization of the prostate: KTP laser therapy of obstructive benign prostatic hyperplasia. AUA Update Service 2004;2004:153 9. [16] Kuntzman RS, Malek RS, Barrett DM, Bostwick DG. Highpower (60-watt) potassium-titanyl-phosphate laser vaporization prostatectomy in living canines and in human and canine cadavers. Urology 1997;49:703 8. [17] Kuntzman RS, Malek RS, Barrett DM, Bostwick DG. Potassium-titanyl-phosphate laser vaporization of the prostate: a comparative functional and pathologic study in canines. Urology 1996;48:575 83. [18] Hai MA, Malek RS. Photoselective vaporization of the prostate: initial experience with a new 80 W KTP laser for the treatment of benign prostatic hyperplasia. J Endourol 2003;17:93 6. [19] Malek RS, Kuntzman RS, Barrett DM. High power potassium-titanyl-phosphate laser vaporization prostatectomy. J Urol 2000;163:1730 3. [20] Bouchier-Hayes DM, Anderson P, Van Appledorn S, Bugeja P, Costello AJ. KTP laser versus transurethral resection: early results of a randomized trial. J Endourol 2006;20:580 5. [21] Ruszat R, Wyler S, Forster T, et al. Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation. Eur Urol 2007; 51:1031 41 (discussion 1038 41). [22] Ahyai SA, Lehrich K, Kuntz RM. Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol 2007;52:1456 64. [23] Shah HN, Mahajan AP, Hegde SS, Bansal MB. Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature. BJU Int 2007;100:94 101. [24] Volkan T, Ihsan TA, Yilmaz O, et al. Short term outcomes of high power (80 W) potassium-titanyl-phosphate laser vaporization of the prostate. Eur Urol 2005;48:608 13.