Ryan Alfonso, M.P.H.
Staff WriterBenign prostatic hyperplasia (BPH) afflicts up to 43% of men over the age of 60, and is a leading cause of voiding difficulties. Over half of all men over 50 have BPH symptoms, with the percentage growing to 80% of men over 80. Due to the overall aging of society, an increase in the proportion of elderly males is expected to grow from 5-7% of the total population in the US and other European countries to 9-12% by 2025. Although symptoms can often be handled adequately with medical therapy, patients who continue to suffer significant voiding problems will eventually require surgical intervention to avoid or treat long-term sequelae such as urinary retention, urinary tract infections, and bladder calculi.
When surgical treatment is considered, transurethral resection of the prostate (TURP) remains the standard to which all other surgical options are measured. Although the morbidity associated with TURP are low when performed by experienced surgeons, complications such as TUR syndrome and bleeding can still occur. For this reason, many alternative therapies have been developed in an attempt to not only provide an effective surgical treatment for BPH, but also to minimize the risk of post-operative complications and the length of hospital stays.
One such technological advance involves the holmium:YAG laser. This laser has found widespread urologic applications, especially in the treatment of urolithiasis. The holmium laser is ideal for precisely and cleanly ablating without charring or overheating tissue. Since the holmium absorption depth is only .5 mm or less, tissue is ablated faster than heat is conducted into surrounding tissue. Holmium energy is delivered in a pulsed mode with each pulse containing enough energy to vaporize the tissue. The vaporized tissue is removed before it can conduct heat, which minimizes thermal damage.
Holmium laser ablation of the prostate (HoLAP) and Holmium laser enucleation of the prostate (HoLEP) are two options that effectively treat obstructive prostates with little blood loss. Use of the holmium:YAG laser in the treatment of BPH has changed significantly over the past five years. As techniques have been refined and equipment improved, the spectrum of treatment has progressed from simple vaporization of tissue to the complete removal, or enucleation, of intact lobes of prostatic mass. Holmium laser enucleation of the prostate (HoLEP) with mechanical morcellation represents the latest refinement of the resection technique. The decision whether to use HoLAP or HoLEP (holmium enucleation of the prostate) is based primarily on the size of the prostate. Ablation usually is performed when the prostate is smaller than 60 cc (cubic centimeters). Enucleation, even extremely large glands (approx 300 cc), can be done with only an overnight stay for the patient.
One competing technology is PVP (Photo-Selective Vaporization of the Prostate). The PVP procedure is performed in an outpatient setting, typically a hospital or surgical center, with average operative times normally less then 60 minutes. The PV surgical laser system delivers laser light pulses through a specially designed fiber optic delivery device that is inserted through a standard cystoscope. The light pulses are directed towards the prostate tissue. The laser quickly and vaporizes and removes the prostatic obstruction without significant bleeding.
The HoLAP procedure has proven to be effective in offering relief for a period of more than 7 years after treatment. For larger prostate glands, HoLEP has been directly compared to traditional treatments such as transurethral resection of the prostate (TURP) and open simple prostatectomy. In these comparative studies, HoLEP produced equivalent improvements in patient urinary symptoms with significant reductions in hospital stays, catheterization times, and complications. HoLAP and HoLEP have minimal re-treatment rates. |
