Thulium Laser Enucleation of the Prostate: Tecnique and Results
To evaluate the safety and efficacy of 200 W Thulium Laser vapo-enucleation of the prostate (THUVEP) for patients with symptomatic benign prostatic obstruction. The authors report the experience about tecnique laser vapo-enucleation of the prostate during a period between March 2012 and Dicember 2013: they analyze clinical and immediate outcames of this procedure and stressed THUVEP as an easier institutional learning curve. THUVEP procedure lead to a significant improvement in symptoms, quality of life, urinary flow and post-void residual urine. Surgery-related morbidity, especially bleeding complications is significantly reduced with laser vapo-enucleation. Its advantages include also short catheterization time and a brief hospital stay.
Methods and results
From March 2012 to Dicember 2013, we enrolled 121 patients with symptomatic BPO. The patients' age was between 56 and 82 and the evaluation included a complete medical history: physical examination, digital rectal examination, urinalysis and urine culture, ultrasound of the upper urinary tract with measurement of postvoid residual volume and transrectal ultrasound including measurement prostate volume, uroflowmetry, IPSS, QoL score and measurement of PSA. Patients taking oral anticoagulants were also included in the study.
Patients were placed in lithotomy position. We used a Wolf laser resectoscope 26 Ch with a 550 or 800 micron end-firing fiber. The energy produced by the Thulium laser was in continuos impulses at a range of 120 – 180 watt.
For tissue morcellation a Wolf system called "Piranha"was used. Localizated and fixed the fiber-tip at the tip of endoscope, incisions were performed at the 5 and 7 o'clock positions. The connected incision was directed to visualizate the prostatic capsule. As soon as the capsule was visualizated, the incision was directed about 2-3 mm over the capsule and the median lobe was dissected off the capsule. The lateral lobes were enucleated one at the time. Dissection of the left lobe was started by performing an incision at the 12-13 o' clock position. The incision at the 12-13 o' clock was connected distally to that at the 5 o'clock position at the level of verumontanum. This incision is very important to set an edge between the apex and the sphincter and must therefore be performed before starting enucleation of the lateral lobe. The left lateral lobe was enucleated keeping the incision always 2-3 mm over the capsule. The right lateral lobe was enucleated by similar procedure. Haemostasis can be achieved with a defocused laser energy (about 20 – 30 W) and at a distance of 4 – 5 mm from the surface. The morcellator (Piranha) was used to evacuate prostatic lobes. A 20 F three-way Dufour catheter was inserted and bladder irrigation started for about 6-8 hours.
Perioperative results were: operative time (40 – 70 m), weight prostate (45 g – 95 g), 2 blood trasfusion, catheter time (24 h – 48 h), hospital time (36 h – 96 h).
Medium follow-up was 18 months, initial parameters were: Qmax=(4.4-11.6), IPSS=(16-36), QoL (2-6), post-void residual=(75-450). 6 months parameters were: Qmax= (13-22), IPSS=(5-10), QoL=(2-3), post-void residual=(45-60).
25 patients had stranguria and 9 had small stress-incontinence. No urethral or bladder neck stricture were presented. In 22 patient was present small haemathuria for about 20 days post treatment. 5 cases of symptomatic urinary tract infection treated with antibiotic therapy.
Alternative tecniques have been promising in term of reducing peri e post operative morbidity for the treatment of BPO. THUVEP is a laser easy mini-invasive tecnique with demonstrated good results (2-4). Open adenomectomy and TURP remain nowadays the gold standard for treatment of BPO. Both of these procedures are associated with perioperative and post-operative morbidity. Other tecnique, as HOLEP, has not been adopted by many urologists, because of its steep learning curve, long operating time, pulsed-wave laser and higher percentage of post-treatment stress-incontinence (1-3-11).
An important aspect of our tecnique is to develop the plane between the adenoma and the prostatic capsule about 2-3 mm over the same capsule. The tissue ablation is improved by concurrent vaporitazion and this vaporization is not trasmitted to the prostatic capsule. In this way the irritative symptoms post-operative are decreased (5). The other peri and post-operative data are very similar to those reported in HOLEP studies (10-11). Recently a chineese author has presented his experience using a same vapoenucleation tecnique (called DiLEP) but with a Diode-laser with a wavelength of 980 nm (5). The author reports problems finding the right amount of laser energy to clearly identify the prostatic capsule when starting the procedure because of too intense and deep coagulation. Besides in Europe, nowadays there are some problems about the periodical servicing of these laser built in China.
In view of good haemostatic properties, easy procedure with a sample learning curve, short catheter time, short hospital time and good post-operative results (6-7-8), we can concluded that our tecnique is similar to HOLEP and is sure and efficacy in the treatment of BPO (11-9).
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