What Will Become of the Scalpel?
Jody A. Charnow
Two articles in this issue report on outcomes in patients who underwent holmium laser enucleation for enlarged prostates, called HoLEP for short.
A front-page piece describes a study showing that the laser procedure, even when performed on an outpatient basis, is safe and feasible and associated with good outcomes. In the other article, researchers present evidence that HoLEP is associated with two-year urinary outcomes equivalent to that of the gold standard procedure, transurethral resection of the prostate (TURP).
Both reports got me wondering about the various minimally invasive alternatives to conventional surgery with knives, and whether they could eventually make such surgery a relatively uncommon event in the treatment of urologic diseases such as BPH and prostate and renal cancer. Much depends, I suppose, on whether the outcomes of these new technologies have a long-term durability as least comparable to that of surgical resection.
At the last annual meeting of the American Urological Association, investigators reported that photoselective vaporization of the prostate with the potassium-titanyl-phosphate laser improves urinary outcomes as well as TURP at 12 months.
Researchers also reported promising results with other potential minimally invasive alternatives to open surgery. These include microwave therapy for enlarged prostates, cryotherapy for prostate tumors, and radiofrequency ablation and cryotherapy for renal tumors. At least in the short term in selected patients, these treatments have been shown to reduce operative complications and hospital stays compared with open surgery, and to have outcomes considered good enough for researchers to conclude that they may offer alternatives to surgical resection.
Continued development of minimally invasive procedures is only one trend that may reduce the number of open surgeries. For example, new approaches such as gene therapy and antibody-guided treatments could tilt the management of some urinary diseases toward medical rather than surgical treatment.
Additionally, growing evidence suggests that low-risk prostate cancer and even some kidney cancers are being overtreated, and that expectant management may be appropriate for many men with selected low-risk malignancies. If urologists embrace this approach, they may be performing a lot fewer operations in general.
Like technologies of all sorts, minimally invasive surgical approaches will evolve and become safer and easier to use, and perhaps achieve better and better outcomes. Consequently, urologists may be more likely to be wielding fiber optics and probes than scalpels in the not-too-distant future.