Safety of Safety of Green Light Green Light LaserLaser Vaporization of the Vaporization of the

Prostate Prostate in in

high risk patientshigh risk patientsAt the IMCAt the IMC

Anmar NassirAnmar Nassir, Mohamed El-Azab, , Mohamed El-Azab, Abdulmalik Tayib Abdulmalik Tayib

INTRODUCTIONINTRODUCTION

• BPH constitutes 20-40% of the whole BPH constitutes 20-40% of the whole urology work load in Saudi Arabia . urology work load in Saudi Arabia .

• TURP stayed for decades as the gold TURP stayed for decades as the gold standard procedure standard procedure – failure of medical treatment, failure of medical treatment, – severe symptoms severe symptoms – presence of complications. presence of complications.

INTRODUCTIONINTRODUCTION

• Many therapeutic modularities failed to Many therapeutic modularities failed to replace TURP wither : replace TURP wither : – Transurethral microwave thermotherapy (TUNA), Transurethral microwave thermotherapy (TUNA), – Interstitial laser coagulation of the prostate (ILC) Interstitial laser coagulation of the prostate (ILC)

• Holmium laser enucleation of the prostate Holmium laser enucleation of the prostate (HoLEP) proved to be safe and effective (HoLEP) proved to be safe and effective alternative for TURP and Open prostatectomy alternative for TURP and Open prostatectomy for treating men with symptomatic BPHfor treating men with symptomatic BPH

• The elevated demand on BPH The elevated demand on BPH management for better quality of life management for better quality of life and safety has determined and safety has determined continuous research into continuous research into development of less invasive development of less invasive therapies such as laser.therapies such as laser.

INTRODUCTIONINTRODUCTION

• Most new technologies Most new technologies failedfailed to to provide safe and effective provide safe and effective evaporation of the prostate until the evaporation of the prostate until the emerge of the powerful emerge of the powerful green light green light potassium titanyl-phosphate (KTP) potassium titanyl-phosphate (KTP) laserlaser..

INTRODUCTIONINTRODUCTION

• The laser energy is selectively The laser energy is selectively absorbed by absorbed by hemoglobinhemoglobin with the with the possibility of obtaining large cavity possibility of obtaining large cavity with minimal bleeding and negligible with minimal bleeding and negligible fluid absorption. fluid absorption.

ObjectiveObjective

• To evaluate the short term To evaluate the short term tolerability and outcome of high tolerability and outcome of high power green light (KTP) laser power green light (KTP) laser prostatectomy in high risk patient prostatectomy in high risk patient with symptomatic BPHwith symptomatic BPH

Material and Material and MethodsMethods

PATIENTSPATIENTS

• Between May 2007 and Feb 2009 Between May 2007 and Feb 2009

• High anesthesia risk patients were High anesthesia risk patients were included in this study at IMCincluded in this study at IMC

• The inclusion criteria in this study The inclusion criteria in this study were patients with: were patients with: – high anesthesia riskhigh anesthesia risk– multiple systemic diseasesmultiple systemic diseases– physically in satisfactory performance physically in satisfactory performance

status.status.• refractory urinary retention refractory urinary retention • severely symptomatic BPH severely symptomatic BPH

InterventionIntervention

• Patients enrolled in the study underwent Patients enrolled in the study underwent • preoperative and postoperative preoperative and postoperative

– cardiac, cardiac, – anesthesia evaluation, anesthesia evaluation,

• Ultrasound of urinary tract, Ultrasound of urinary tract, • preoperative laboratory investigation, preoperative laboratory investigation,

• Peri-operative were conducted as Peri-operative were conducted as out-patient prior to admission:out-patient prior to admission:– Systemic check upSystemic check up– Routine laboratory Routine laboratory – Radiological Radiological – UDS for all long standing DM patientsUDS for all long standing DM patients

High Risk PatientsHigh Risk Patients

• The American Association of The American Association of Anesthesia grading risk system has Anesthesia grading risk system has been used to categorize the patients been used to categorize the patients included in this study. included in this study.

• All anticoagulants stopped one week All anticoagulants stopped one week before admission. before admission.

InterventionIntervention

• All patients underwent high power All patients underwent high power green light laser prostatectomy green light laser prostatectomy using the using the green light photo green light photo vaporizationvaporization system with setting of system with setting of 120 watts. 120 watts.

• Performed by 2 surgeons Performed by 2 surgeons

Evaluation Evaluation Perioperative parameters: :

o Operation time, Operation time, o Delivered energy, Delivered energy, o CatheterizationCatheterizationo Hospitalization time Hospitalization time o Intraoperative and postoperative complications. Intraoperative and postoperative complications.

Patients presenting for follow-up … International Prostate Symptom Score International Prostate Symptom Score

(IPSS)(IPSS) Maximal flow rate (Qmax)Maximal flow rate (Qmax) Post-voiding residual volume (V) Post-voiding residual volume (V) Complications Complications

ResultResult

• 14 patients were recruited 14 patients were recruited

• Patients' age Patients' age

– varied between 65 and 87 years varied between 65 and 87 years – average age of 75.5 years. average age of 75.5 years.

High Risk PatientsHigh Risk Patients

• All of the patients had >2 co-morbid All of the patients had >2 co-morbid illnesses: illnesses: – DMDM– HTNHTN– atrial fibatrial fib– IVC filter,IVC filter,– vocal cord tumor vocal cord tumor – IHD IHD – mitral valve regurge mitral valve regurge

Co-morbiditiesCo-morbidities

High Risk PatientsHigh Risk Patients

• 9 patients were categorized as high 9 patients were categorized as high risk patients for anesthesia grade III risk patients for anesthesia grade III

• 5 patients as grade IV5 patients as grade IV • 10 patients were on Acetyl salicylic 10 patients were on Acetyl salicylic

acid or plavix (Clopidogrel bisulfate). acid or plavix (Clopidogrel bisulfate). • 6 patients were also on Warfarin6 patients were also on Warfarin

High Risk PatientsHigh Risk Patients

• Echocardiogram patients prior to surgery Echocardiogram patients prior to surgery showed EF showed EF – 13 pts between 35-60% 13 pts between 35-60% – 1 patient it was 20%.1 patient it was 20%.

• The size of the prostate by USThe size of the prostate by US– 55 -112 cc 55 -112 cc – average size of 60 ccaverage size of 60 cc

• One patient had two bladder stones One patient had two bladder stones 2.5 cm and 2.3 cm .2.5 cm and 2.3 cm .

• 1212 patients had patients had uneventfuluneventful intra intra and postoperative course without and postoperative course without any significant complications any significant complications

• 22 patient who required patient who required postoperative admission to the postoperative admission to the ICUICU. .

• Average blood loss was insignificantAverage blood loss was insignificant– only only 11 of the patients required of the patients required blood blood

transfusiontransfusion..

ComplicationComplication

DiscussionDiscussion

• TURP stood as the gold standard TURP stood as the gold standard procedure in management of BOO procedure in management of BOO secondary to BPH, secondary to BPH,

• It is not without its disadvantages It is not without its disadvantages and limitations especially in patient and limitations especially in patient who are at high risk of developing who are at high risk of developing fluid overload during the procedure fluid overload during the procedure

• It can be associated with a relatively It can be associated with a relatively high rate of high rate of complications (15%).complications (15%).

GLL P vs TURP

Prolonged resection time

No risk of dilutional hyponatremia

Risk of TURP syndrome

Catheterization time

1 - 0 ≥ 2-3 days

Hospital stay (day case -1) Longer

Retrograde ejaculation

(35 - 55%) (53 - 75%)

GLL P vs TURP

Procedure time Lengthier - slower vaporization speed

( ～ 0.5 gr/min)

Shorter - higher resection speed (up to 1 gr/min)

Histological evaluation

Absence of prostatic tissue

Ability to detect (incidental) prostate cancer

Re-operation rates

? Higher More durable

Complications (Complications (LUTS and and AUR))

Number % Number %

Dysuria 31 30 15 28

UTI* 12 11.8 8 16

Failed TWOC 4 4 6 11.3

Ureteric injury 2 2 0 0

Urethral stricture 4 4 1 1.8

Haematuria 7 6.9 2 3.7

Stress incontinence 1 1 2 3.7

Re-admission 12 11.8 6 11.3

Re-intervention** 6 5.9 3 5.6 *most probably post op related dysuria; no evidence of UTI. ** 1 AUS, 2 Nephrostomies, 3 OUs and 3 TURPs

CONCLUSION

Considering the lower Considering the lower morbiditymorbidity, shorter , shorter catheterisationcatheterisation and and hospitalizationhospitalization times, and the times, and the degree of degree of effectivenesseffectiveness that that was achieved even at the low-was achieved even at the low-power settings used in this power settings used in this study, GLL prostatectomy study, GLL prostatectomy appears to be a appears to be a viable and safe viable and safe alternative alternative to standard TURP. to standard TURP.