Two-micrometer thulium laser resection of the prostate-tangerine technique for patients with acute urinary retention

Rezūm water vapor therapy for the treatment of patients with urinary retention and permanent catheter dependence secondary to benign prostate hyperplasia: a systematic review of the literature

PURPOSE

Recurrent urinary retention due to benign prostate hyperplasia (BPH), requiring permanent catheterization, represents one of the most challenging issues geriatric patients can face. Rezūm, as a minimal invasive treatment for BPH, takes the advantage of sterile water vapor injections directly into the prostate. The purpose of this Systematic Review is to report the safety and the efficacy of Rezūm regarding urinary retention relief and permanent catheter withdrawal.

METHODS

PubMed, Scopus and Cochrane databases were meticulously screened using the keywords "Rezum", "retention" and "permanent catheter". Only human studies and articles in English were included. Rezūm should be the only intervention employed in patients. Patients of included studies should not have been submitted to any prior interventions, such as transurethral prostatectomy (TURP) for the relief of their symptoms. Patients' baseline characteristics along with intraoperative and postoperative parameters were collected and analysed. Catheter relief was the primary outcome.

RESULTS

Five studies fulfilled all the criteria and were included in the final qualitative synthesis. Four studies were retrospective and one was prospective. All studies were non-comparative. The success rate ranged from 70.3 to 100%, while no grade ≥ III Clavien-Dindo complications were reported in any of the studies.

CONCLUSION

Rezūm Water Vapor Therapy Treatment seems to be a feasible, safe and efficient minimally-invasive procedure for catheterized patients with urinary retention secondary to BPH, especially for frail ones with comorbidities who cannot undergo general anesthesia.

ROS-NLRP3 signaling pathway induces sterile inflammation after thulium laser resection of the prostate

The sterile inflammation (SI) of the urinary tract is a common problem requiring serious consideration after prostatectomy. This study mainly focuses on the role of the reactive oxygen species-NLR family, pyrin domain-containing 3 (ROS-NLRP3) signaling pathway in SI after thulium laser resection of the prostate (TmLRP). Urinary cytokines were determined in patients who received TmLRP, and heat shock protein 70 (HSP70) was detected in the resected tissues. The involvement of ROS signaling in HSP70-induced inflammation was explored in THP-1 cells with or without N-acetyl- l-cysteine (NAC) pretreatment. The function of NLRP3 and Caspase-1 was determined by Western blot analysis, enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction. These phenomena and mechanisms were verified by the beagle models that received TmLRP. Clinical urine samples after TmLRP showed high expression of inflammatory factors and peaked 3-5 days after surgery. The high expression of HSP70 in the resected tissues was observed. After HSP70 stimulation, the expression of ROS, NLRP3, Caspase-1, and interleukin-18 (IL-18) increased significantly and could be reduced by ROS inhibitor NAC. The expression of IL-1β and IL-18 could be inhibited by NLRP3 or Caspase-1 inhibitors. In beagle models that received TmLRP, HSP70, NLRP3, Caspase-1, IL-1β, and IL-18 were highly expressed in the wound tissue or urine, and could also be reduced by NAC pretreatment. Activation of the ROS-NLRP3 signaling pathway induces SI in the wound after prostatectomy. Inhibition of this pathway may be effective for clinical prevention and treatment of SI and related complications after prostatectomy.

Nomenclature in thulium laser treatment of benign prostatic hyperplasia: it's time to pull the rabbit out of the hat

We performed a narrative review with the focus on laser settings and surgical procedure with thulium laser. Our primary goal was to define the most valid settings of each surgical procedure to overcome the inconsistency about nomenclature of thulium surgery and to ensure comparability of future publications. A literature search of articles on thulium laser treatment of benign prostatic hyperplasia (BPH) was conducted between 2009 and 2019. We proposed a new classification standard for laser settings and associated surgical procedure. Each article was analyzed and categorized as concordant or discordant referring to the new classification. In total, 74 papers were included in this narrative review. Overall, 43% and 42% of included studies reported discordant laser parameters and surgical description, respectively. Most of the studies on vaporization were categorized as discordant because they reported a medium/low laser setting instead of high power. Conversely, 93.3% of studies on enucleation were deemed as discordant for laser setting because they reported high power parameters instead of medium-low power setting. Most of the studies on laser enucleation and vapo/enucleation were considered discordant for surgical procedure since authors did not mention the use of mechanical vs. laser method for enucleation. The current literature lacks a uniform definition and standardization of the terminology of thulium laser settings and surgical techniques to guarantee comparability between different approaches. We found a huge heterogeneity in 10 years of surgery with thulium laser. We proposed a new classification of laser setting and procedural description for categorization of thulium laser surgery for BPH.

Comparison of vaporization using 120-W GreenLight laser versus 2-micrometer continuous laser for treating benign prostatic hyperplasia: A 24-month follow-up study of a single center

OBJECTIVE

To evaluate safety, efficacy, and long-term outcomes of photoselective vaporization of prostate using 120-W HPS GreenLight KTP laser and compare the results with those obtained with 2-micrometer continuous-wave (2 um CW) laser for treatment of patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

One group of 216 patients diagnosed with BPH underwent 120-W KTP laser vaporization of the prostate, while another group of 198 BPH patients underwent 2 um CW laser vaporization. The relevant pre-, peri-, and post-operative parameters were compared between the two therapy groups. Functional results in terms of improvement of International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) urine were assessed at 3, 6, 12, and 24 months.

RESULTS

BPH was successfully treated with 120-W HPS KTP laser and 2 um CW laser in all patients. There were no significant difference between two patient groups in the baseline characteristics (such as PSA, IPSS, QoL, and Qmax). No major complications occurred intraoperatively (capsule perforation and TUR syndrome) or postoperatively (electric unbalance), and no blood transfusions were required in both groups. Average catheterization time was 1.9±1.3 days for the 120-W PVP and 2.2±1.9 days for the 2 um CW laser treatment. In addition, the hospitalization times were 3.8±1.2days (120-W PVP) and 4.8±1.5 days (2 um CW laser), respectively. The incidence of dysuria and urge incontinence was higher in the 2 um CW laser group (35/198, 24/198) than in the 120 W PVP group (15/216, 10/216). Dramatic improvement was observed in Qmax, IPSS, Qol, and PVR as compared with the respective pre-operative values. The degree of improvement during the follow-up period was comparable in both groups. No significant differences were observed in terms of re-operation rates, bladder neck stricture, and urethral stricture.

CONCLUSIONS

Both 120-W HPS laser and 2 um CW laser vaporization present effective treatment options in patients with BPH, but 120-W PVP provides safer therapy with less post-operative complications within the 2-year follow-up period.

Transurethral thulium laser enucleation versus resection of the prostate for treating benign prostatic hyperplasia: a retrospective study

This study aimed to compare the clinical outcomes between transurethral thulium laser enucleation of the prostate (ThuLEP) and transurethral thulium laser resection of the prostate (ThuLRP) for treating benign prostatic hyperplasia (BPH). From May 2014 to August 2015, 212 patients underwent ThuLRP and 188 patients underwent ThuLEP. The ThuLEP group was further divided into two subgroups according to the ways the prostate was taken out. The perioperative parameters were recorded and analyzed. The international prostate symptom score (IPSS), quality-of-life (QoL) score, maximum flow rate (Qmax), and postvoid residual urine volume (PVR) in both groups were estimated and compared 3, 6, and 12 months after surgery. No significant difference was observed between the groups in terms of irrigated time, irrigated volume, catheterization time, and hospital stay. However, the significantly lower hemoglobin drop was observed in the ThuLRP group compared with the ThuLEP group. The ThuLEP group with a morcellator required a shorter operation time for patients with large prostate volume (> 60 mL) compared with the ThuLRP and ThuLEP groups without a morcellator. During 12 months of follow-up, IPSS, Qmax, QoL, and PVR improved significantly without significant differences between the groups. No severe complications were reported; however, the occurrence of transient urge incontinence was higher after ThuLEP compared with ThuLRP, and the proportion of urinary tract infection after surgery was higher in ThuLRP than in ThuLEP. ThuLRP and ThuLEP are safe and efficient for treating patients with symptomatic BPH. ThuLRP offers advantages in terms of minimal blood loss.

Macrophages are targets of retinoic acid signaling during the wound-healing process after thulium laser resection of the prostate

BACKGROUND

The wound-healing process is very important for reducing complications after thulium laser resection of the prostate (TmLRP). The retinoic acid (RA) signaling pathway has been well studied in the wound-healing process of the skin and other organs. The goals of this study were to identify the role of RA signaling in the repair of the prostate after TmLRP and to investigate the molecular mechanism of this process.

RESULTS

Retinoic acid receptors (RARs) were present in the prostate, and their expression was increased after TmLRP. RARβ was expressed in the macrophages and may be related to the role of stromal cells in the wound-healing process. In vitro, RA enhanced the function of anti-inflammatory macrophages and promoted stromal cell activation and angiogenesis. Arg1 was also increased via RARβ after treatment with RA.

MATERIALS AND METHODS

The expression of RARs was analyzed in vivo by immunohistochemistry (IHC), real time qPCR, and western blot analysis. THP-1 cells were co-treated with or without RA and stimulating factor and then assessed by ELISA and qPCR. The supernatants from these cells were cultured with stromal cells and vascular endothelial cells, and the effects on these cells were analyzed.

CONCLUSIONS

We found that RA signaling was involved in the wound-healing process of the prostate after TmLRP. RA treated macrophages activated stromal cells and promoted angiogenesis. RARβ was the key isoform in this process.

Two-micrometer thulium laser resection of the prostate-tangerine technique in benign prostatic hyperplasia patients with previously negative transrectal prostate biopsy

The 2-μm thulium laser resection of the prostate-tangerine technique (TmLRP-TT) has been introduced as a minimally invasive treatment for benign prostatic hyperplasia (BPH). This study was undertaken to assess the clinical efficacy and safety of TmLRP-TT for the treatment of BPH patients with previously negative transrectal prostate biopsy. A prospective analysis of 51 patients with previously negative transrectal prostate biopsy who underwent surgical treatment using TmLRP-TT was performed from December 2011 to December 2013. Preoperative status, surgical details, and perioperative complications were recorded. The follow-up outcome was evaluated with subjective and objective tests at 1 and 6 months. TmLRP-TT was successfully completed in all patients. Mean prostate volume, operative duration, and catheterization time were 93.3 ± 37.9 ml, 69.5 ± 39.5 min, and 6.5 ± 1.3 days, respectively. The mean International Prostate Symptom Score, quality of life score, maximum urinary flow rate, and post-void residual urine volume changed notably at 6-month follow-up (22.5 ± 6.9 vs 6.1 ± 3.2, 4.8 ± 1.3 vs 1.1 ± 0.9, 7.3 ± 4.5 vs 18.9 ± 7.1 ml s⁻¹, and 148.7 ± 168.7 vs 28.4 ± 17.9 ml). Two (3.9%) patients required blood transfusion perioperatively, while 3 (5.9%) patients experienced transient hematuria postoperatively, and 2 (3.9%) patients received 3 days recatheterization due to clot retention. TmLRP-TT is a safe and effective minimally invasive technique for patients with previously negative transrectal prostate biopsy during the 6-month follow-up. This promising technology may be a feasible surgical method for previously negative transrectal prostate biopsy in the future.

The efficacy and safety of 2-μm continuous laser in the treatment of high-risk patients with benign prostatic hyperplasia

Two-micrometer laser resection of prostate-tangerine technique dissects whole prostatic lobes off the surgical capsular, similar to peeling a tangerine. The present study aimed to evaluate the safety and efficacy of 2-μm continuous laser vaporization in the treatment of high-risk patients with benign prostatic hyperplasia (BPH) during the 24-month follow-up. The study included 248 patients with moderate to severe lower urinary tract symptoms who underwent 2-μm continuous laser vaporization of the prostate. All patients were accompanied with different degree comorbidities and 94 patients were taking oral anticoagulants. BPH was successfully treated with 2-μm continuous laser vaporization in all patients. Mean pre-operative prostate volume was 76 ± 25.3 ml and mean operative time was 49.8 ± 16.5 min. There were no major complications intra-operatively or postoperatively, and no blood transfusions were needed. About 20 patients (8.1%) needed bladder irrigation postoperatively. Average catheterization time was 2.0 ± 1.8 days (range 1-5 days). Four patients required reoperation due to enlarged prostates from residual adenoma. At 3-, 6-, 12-, and 24-month follow-ups, maximum urinary flow rates (Qmax) increased from 6.9 ± 1.7 to 19.1 ± 4.2, 19.5 ± 4.6, 19.4 ± 4.6, and 19.5 ± 4.1 ml/s, respectively. Mean International Prostate Symptom Scores (IPSS) decreased from 27.6 ± 5.1 (pre-operation) to 9.2 ± 2.6, 7.12 ± 1.42, 6.18 ± 1.32, and 6.25 ± 1.30 at 3-, 6-, 12-, and 24-month post-operation, respectively. Two-micrometer continuous laser vaporization is a safe and effective surgical endoscopic technique associated with low complication rate in BPH patients at high risk and those on anticoagulation therapy who have severe LUTS caused by BPH.

Thulium laser versus standard transurethral resection of the prostate for benign prostatic obstruction: a systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of thulium laser versus standard transurethral resection of the prostate (TURP) for treating patients with benign prostatic obstruction.

METHODS

A systematic search of the electronic databases, including Medline, Embase, Web of Science, and The Cochrane Library, was performed up to February 1, 2014. The pooled estimates of demographic and clinical baseline characteristics, perioperative variables, complications, and postoperative efficacy including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and postvoid residual (PVR) were calculated.

RESULTS

Seven trials assessing thulium laser versus standard TURP were considered suitable for meta-analysis including four randomized controlled trials (RCTs) and three non-RCTs. Compared with TURP, although thulium laser prostatectomy (TmLRP) needed a longer operative time [weighted mean difference (WMD) 8.18 min; 95 % confidence interval (CI) 1.60-14.75; P = 0.01], patients having TmLRP might benefit from significantly less serum sodium decreased (-3.73 mmol/L; 95 % CI -4.41 to -3.05; P < 0.001), shorter time of catheterization (WMD -1.29 days; 95 % CI -1.95 to -0.63; P < 0.001), shorter length of hospital stay (WMD -1.83 days; 95 % CI -3.10 to -0.57; P = 0.005), and less transfusion (odds ratio 0.09; 95 % CI 0.02-0.41; P = 0.002). During the 1, 3, and, 12 months of postoperative follow-up, the procedures did not demonstrate a significant difference in IPSS, QoL, Qmax, and PVR.

CONCLUSIONS

TmLRP had a similar efficacy to standard TURP in terms of IPSS, QoL, Qmax, and PVR, and offered several advantages over TURP in terms of blood transfusion, serum sodium decreased, catheterization time, and hospital stay, while TURP was superior in terms of operation duration. Well-designed multicentric/international RCTs with long-term follow-up are still needed.