GreenLight laser prostatectomy
Lasers for the treatment of LUTS/BPH were introduced in part to decrease surgical morbidity. The 532 nm wavelength is selectively absorbed by hemoglobin, which acts as an intracellular chromophore and is fully transmitted through aqueous irrigants.
The short optical penetration associated with this wavelength confines its high power laser energy to a superficial layer of prostatic tissue that is vaporized rapidly and hemostatically with only a 1-2 mm rim of coagulation.24 The GreenLight laser system has gone through several evolutions from the original 60-watt laser to the most recent 180-watt system with a larger water cooled fiber.
A recent multicenter prospective study similarly demonstrated the performance of the 180-watt system. Bachman et al examined 201 patients with LUTS who had a mean follow-up of 5.8 ± 2.8 months.23 Improvements in Qmax, IPSS, PVR, QoL, and PSA from baseline measures were significant in all patients after surgery (p<0.001).
The researchers reported that the 180-watt laser system applied three times the energy (324.4 ± 187.5 kJ) of the 80-watt laser in the same lasing time (38.2 ± 20.4 min) without additional complications, including in patients with urinary retention and on anticoagulants.
The prevalence of perioperative complications was low, and included impaired visibility due to bleeding (10%), capsule perforation (3.5%), and urinary retention during the hospital stay (5%). They also reported mild to moderate dysuria (8.0%), urethral stricture (1.0%), temporary urinary incontinence (8.0%), urinary tract infection (UTI, 2.5%), and retention (2.5%).
Transurethral resection of the prostate
Geavlete et al completed a prospective three-armed study with 510 randomized patients comparing monopolar TURP, bipolar TURP, and bipolar transurethral vaporization of the prostate (TUVP). Patients undergoing bipolar TUVP demonstrated significantly better improvements in IPSS and Qmax compared with both monopolar and bipolar TURP at 18 months (by 3.3 and 2.9, and 3.5 mL and 3.1 mL respectively, p<0.05), although QoL, PVR, and PSA for each group were similar.24 Seckiner et al performed a prospective randomized study of 21 patients undergoing monopolar TURP and 23 with bipolar TUVP with one year follow-up.
The investigators observed comparable improvements in IPSS, QoL, and Qmax, (by 14.9 and 15.4, 2.7 and 2.6, and 7.4 and 10.3 mL/sec, respectively), but these differences were not reported to be statistically significant.25
In separate prospective randomized trials comparing monopolar TURP and bipolar TUVP, Hon et al reported similar improvements in IPSS, QoL, Qmax, and PVR (by 13.7 and 13.6, 2.8 and 2.5, 11.6 and 13.6 mL/sec, and 113 and 83 mL, respectively), and Patankar et al reported similar improvements in IPSS and Qmax (by 16.01 and 17.19, and 14.27 and 13.26 mL/sec), although with shorter or uncertain durations of follow-up.26, 27
However, patients who had undergone bipolar TUVP were significantly less frequently affected by hyponatremia (p<0.005) and had significantly shorter catheter retention times (73.2±13.4h vs. 54.3±11.8h, p<0.005).28
In the longest reported study comparing monopolar TURP and bipolar TUVP, Xie et al reported that patients treated with bipolar TUVP demonstrated a 15.55 point decrease in IPSS, a 2.66 point decrease in QoL, a 1.09 ng/mL decrease in serum PSA, a 16.55 mL/sec increase in Qmax, and an 82.79 mL decrease in PVR after five years. Improvements in these parameters were similar to those seen for patients undergoing monopolar TURP.29
Complications for TURP can include retention, UTI, incontinence, capsule perforation, TUR syndrome, blood transfusion, and urethral stricture.30 Other studies have reported mixed results with TUVP in regards to complications. Geavlete et al, for example, found that bipolar TUVP produced fewer complications than monopolar TURP (1.2% vs. 9.4% capsular perforation, p = 0.004; 23.5 vs. 72.8 hour catheterization period, p=0.0001; and 0.5 vs. 1.6 g/dL hemoglobin drop, p = 0.0001, respectively),24 whereas others observed statistically similar rates of complication between bipolar TUVP and monopolar TURP. For example, Xie et al reported similar rates of urinary retention, UTI, TUR syndrome, and blood transfusion between monopolar TURP and bipolar TUVP.29
Open surgery is typically reserved for those with prostate glands larger than 80 grams. The envelope for this has been pushed, especially in the hands of those very experienced with transurethral techniques. Open techniques lead to an improvement of AUA-SS by 11-20 points. Early complication rates are 17.3% and are associated with prolonged hospitalization and recovery.31
Treatment of BPH-related LUTS has evolved from surgical therapy to medical monotherapy to combination therapy. The combination of 5-alpha-reductase inhibitors with alpha-adrenergic antagonists is effective in men with LUTS secondary to BPH. At present, only combination therapy with alpha-adrenergic antagonists and 5-ARIs is recommended in clinical practice guidelines. Further studies are required to elucidate which specific population of patient benefits most from other combination therapies.
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