Efficacy and safety of prostate vaporesection using a 120-W 2-μm continuous-wave Tm:YAG laser (RevoLix 2) in patients on continuous oral anticoagulant or antiplatelet therapy

Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis

Background

Thulium laser (Tm:YAG) prostate surgery is a safe and effective procedure with low morbidity and comparable clinical outcomes to those of transurethral resection of the prostate (TURP). However, the sexual function outcomes (erectile and ejaculatory function) have been scarcely studied.

Aim

We aimed to assess the impact of Tm:YAG prostate surgery on sexual outcomes (erectile and ejaculatory function) and compare them with those patients undergoing TURP.

Material and Methods

We searched digital databases like PUBMED, SCOPUS, CENTRAL and EMBASE using relevant keywords to identify comparative studies on TURP and non-comparative studies on Tm:YAG prostate surgery that assessed sexual outcomes. We performed qualitative and quantitative analyses with the extracted data. We carried out a meta-analysis to compare postoperative International Index of Erectile Function (IIEF-5) scores and incidences of retrograde ejaculation (RE) in patients undergoing either Tm:YAG or TURP. The pre-operative and post-operative IIEF-5 scores were pooled to estimate overall scores.

Results

We included 5 comparative and 8 non-comparative studies in this review. We found the postoperative IIEF-5 score improvements to be significantly higher in the Tm:YAG prostate surgery group than in the TURP group with a significant mean difference (MD) of 0.45 (95% CI, 0.18 to 0.72; P = .001). We found no significant associations between the procedures. The pooled OR for the association of RE was estimated at 0.90 (95% CI, 0.50 to 1.60; P = .71; I² = 0%).

Conclusion

Tm:YAG prostate surgery improves erectile function more than TURP, according to our findings. Tm:YAG prostate aided surgery also outperforms TURP in terms of preserving sexual function following surgery.However, We found similar or no difference in incidence of RE between Tm:YAG prostate surgery and TURP.

Bibo L, Hao L, Pang K, et al. Assessment of Sexual Outcomes in Patients Undergoing Thulium Laser Prostate Surgery for Management of Benign Prostate Hyperplasia: A Systematic Review and Meta-analysis. Sex Med 2022;10:100483.

Meta-analysis of the effect of antithrombotic drugs on perioperative bleeding in BPH surgery

Effects of antithrombotic agents on the bleeding risk after transurethral resection of the prostate (TURP) were assessed in patients with benign prostatic hyperplasia (BPH). Controlled clinical trials on the effects of perioperative anticoagulant therapy on postoperative bleeding in BPH patients published during January 1990 and February 2019 were searched in PubMed, Embase and the Cochrane Library. Two independent reviewers screened the studies according to the inclusion and exclusion criteria, extracted the data, evaluated the quality, and conducted a meta-analysis using the RevMan 5.3 software. A total of 20 studies were included. Analysis of these studies found that compared with interrupted use of antithrombotic agents, continuous use of antithrombotic drugs led to more frequent post-TURP bleeding (OR=4.34, 95% CI=2.29-8.23), and higher transfusion rate (2.96, 1.19-7.36). Compared with patients who never used antithrombotic agents, those who used antithrombotic agents continuously had higher bleeding risk (5.52, 1.64-18.66). Those who continued using antithrombotic agents during laser treatment had higher transfusion rate than those who stopped using them before the operation (5.39, 1.49-19.53), but it had no significant difference in clot retention, blood transfusion rate, intraoperative hemoglobin decrease and postoperative catheter-indwelling time compared with those who never used antithrombotic agents (P>0.05). Those who continued using antithrombotic agents during TURP showed less intraoperative hemoglobin decrease (-0.46, -0.58-0.35) than the patients who underwent low molecular weight heparin substitution. Interruption of antithrombotic agents during TURP can prevent the risk of postoperative bleeding; continuous use of antithrombotic agents is safe and feasible during laser treatment of BPH; whether low molecular weight heparin substitution is necessary during the discontinuation of antithrombotic agents is controversial.

Complications and functional outcomes of high-risk patient with cardiovascular disease on antithrombotic medication treated with the 532-nm-laser photo-vaporization Greenlight XPS-180 W for benign prostate hyperplasia

PURPOSE

To examine the complications and functional outcomes of high-risk patients on antithrombotic therapy (ATT) treated with photoselective vaporization of the prostate (PVP) using the Greenlight (GL) XPS-180 system.

METHODS

A retrospective analysis of prospectively maintained institutional database was performed. Men with symptomatic LUTS related to BPH were treated with 523-nm GL PVP using the XPS-180 W system. They were stratified according to ATT status: group 1 (control group), group 2 (acetylsalicylic acid), group 3 (antiplatelet agents other than acetylsalicylic acid) and group 4 (anticoagulation agents). Postoperative adverse events at 30- and 90-days were prospectively recorded. Complications were stratified according to the Clavien-Dindo classification. Additionally, functional outcomes (IPSS, Qmax and PVR) were analyzed up to 48 months of follow-up after surgery. Multivariable logistic regression analyses were used to predict the effect of ATT on serious bleeding-associated complications that was defined as the sum of patients with hematuria Clavien grade ≥ 2, patients requiring transfusions and patient with postoperative hemoglobin drop ≥ 15 g/dl.

RESULTS

274 (63%), 87 (21%), 24 (6%) and 37 (9%) patients were included in groups 1, 2, 3 and 4, respectively. Patients on antiplatelet (group 3) and anticoagulant medication (group 4) were older (median age 60 vs. 68 vs. 77 vs. 76 years, p < 0.001) and had more comorbidities (ASA 3-4: 9.5 vs. 27.6 vs. 66.7 vs. 64.9%; p < 0.001) than their counterparts. The overall 30-day complications rates were 31, 28.7, 45.8 and 45.9% of patients included in groups 1, 2, 3 and 4, respectively (p = 0.4). Hematuria Clavien 1 events (p < 0.001), readmissions rates (p = 0.02), length of post-operative hospital stay (p < 0.001) and catheterization time (p < 0.001) were significantly higher in patients on antiplatelet and anticoagulation medication. In multivariable analyses, ATT status was not a predictor of serious bleeding events after surgery (p > 0.5). Finally, functional outcomes were significantly improved accross the four groups.

CONCLUSION

GL PVP is safe and effective in treating high-risk patients on ATT. Although serious bleeding complications are rare and equivalent with non-high-risk patients, patients on antiplatelet and anticoagulation medication should be counseled on the increased risk of minor bleeding events and readmissions rates at 30 days after surgery.

Thulium laser vaporesection of the prostate: Can we operate without interrupting oral antiplatelet/anticoagulant therapy?

Purpose

Thulium vaporesection of the prostate (ThuVARP) is a new and safe approach for patients receiving anticoagulant therapy in whom transurethral resection of the prostate (TURP) may possess a high bleeding risk. We aimed to demonstrate the efficacy and safety of ThuVARP in patients receiving oral antiplatelet/anticoagulant (OAP/OAC) therapy.

Materials and Methods

A total of 103 patients who underwent ThuVARP between 2011 and 2013 were enrolled in the study. Patients were divided into 2 groups. Group A consisted of 47 patients who underwent low molecular weight heparin (LMWH) bridging and group B consisted of 56 patients who were operated on while receiving OAP/OAC therapy.

Results

The drop in hemoglobin levels in the pre- and postoperative periods was significantly higher in group A than in group B. When subgroups were analyzed, the mean drop in hemoglobin was significantly lower in the warfarin and ticlopidine subgroups of group B than in group A. International Prostate Symptom Scores were significantly lower 3, 12, 18, and 24 months after surgery in group A than in group B. Quality of life scores, maximal flow rate values, and postmicturition residual urine volumes (mL) were similar between the 2 groups. A total of 38 and 41 patients in groups A and B, respectively, had no complications.

Conclusions

Our study showed the safety profile of continuing different OAP/OAC therapies in terms of bleeding problems in patients undergoing ThuVARP. We strongly recommend abandoning LMWH bridging and maintaining the OAP/OAC regimen patients are already receiving.

Long-term outcome following thulium vaporesection of the prostate

BACKGROUND

The continuous wave 2-μm Thulium Laser has been introduced as potential technology with both high efficiency and safe practice; although little data have been shown regarding the long-term outcomes.

OBJECTIVE

To analyze the long-term outcomes after thulium vaporesection of the prostate (ThuVaRP).

METHODS

ThuVaRP was performed using the continuous wave, 2-μm Thulium: YAG laser at 70 W. The perioperative and post-operative follow-up data were analyzed.

RESULTS

The average age at surgery was 71.5 (range 55-94 years). The median prostate size was 60.1 g (range 36.3-109.8 g). A median operation time was noted at 44.8 ± 6.5 minutes, while the median catheterization time was 3.5 ± 0.5 days. In regards to hospital stay, most patients had an average duration of 5.5 ± 1.5 days. Minor complications requiring non-interventional treatment happened in 237 (36.24%) of 654 patients, while major complications requiring re-interventions occurred in one patient (0.15%). During a 60-month follow-up, bladder neck fibrosis occurred in 1.22% of the patients. A BPH recurrence happened in 17 (2.60%) patients, of which 14 patients (2.14%) received a second surgery. In comparison to the pre-operative baseline, the patients Qmax, PVR volume, IPSS, and Qol scores all improved significantly (P < 0.01) at time of discharge. This continued into the post-operative follow-up visits (3-6-12-18-14-26-48-60 months).

CONCLUSIONS

ThuVaRP is both an effective and safe treatment procedure for symptomatic BPO (with a low occurrence of complications). Lasers Surg. Med. 48:505-510, 2016. © 2016 Wiley Periodicals, Inc.

Evidence of the efficacy and safety of the thulium laser in the treatment of men with benign prostatic obstruction

In 2005, the high power thulium laser was introduced for the surgical treatment of benign prostatic obstruction. It has several properties that confer theoretical advantages over other lasers used for the same indication, such as technical versatility and a relatively small zone of thermal damage. Studies using the 70-150 W thulium laser systems demonstrate good efficacy of these procedures with low morbidity and few complications even in higher risk patients. Different techniques have been employed to treat the prostate with this technology, including enucleation, vapoenucleation, vaporization and resection. Comparative studies have been published comparing thulium laser prostatectomy to monopolar transurethral resection of prostate (TURP), bipolar TURP and holmium laser enucleation of prostate (HoLEP). In this review we discuss the current literature on the safety and efficacy of various thulium techniques for the treatment of benign prostatic hyperplasia and examine comparative studies.

[Current Practice in the Transurethral Treatment of Benign Prostatic Obstruction under Oral Anticoagulants : A Nation-wide Survey]

BACKROUND

Only few studies have assessed the safety and efficacy of transurethral surgery (TS) for the treatment of benign prostatic obstruction (BPO) in patients on oral anticoagulants. The aim of our study was to evaluate current treatment strategies and complication rates of TS for the treatment of BPO in patients on OA using an online survey.

MATERIALS AND METHODS

A total of 300 German departments of urology received an e‑mail with a link for the online survey. The items of the questionnaire assessed the present practice of TS for BPO in patients on OA and the occurrence of complications.

RESULTS

Seventy-five (23.4 %) departments responded to the online questionnaire. Of the respondents, 94.7 % performed TS in patients with BPO on OA and 42.7 % answered that they perform more than 30 prostate surgeries per year under OA. The respondents indicated that surgeries were carried out under aspirin (96 %), clopidogrel (46.7 %) or phenprocoumon (26.7 %). Indications for surgeries under OA were made by cardiologist recommendation (82.7 %), the surgeon (37.3 %), a need for emergency surgery (52 %), or the patient's will (10.7 %). Sixty-two (82.7 %) of the respondents perform bipolar or monopolar transurethral resection of the prostate (TUR-P) in patients on OA. In addition, 69.3 % of the respondents indicated that they use laser prostatectomy in patients on OA (thulium 24 %, Greenlight 24 %, holmium 16 %, and diode laser 5.3 %). Cardiovascular complications occurred in 12 % of the respondents.

CONCLUSIONS

Despite the poor evidence for performing TS of BPO under OA, our survey showed surprising results: TS of BPO under OA is frequently performed, especially bipolar and monopolar TUR-P. Although our data were obtained using an online survey, the complication rates appear to be lower than previously thought.

High-power thulium laser vaporization of the prostate: short-term outcomes of safety and effectiveness

INTRODUCTION

The thulium laser was introduced in 2005 for the treatment of benign prostatic hyperplasia (BPH). Enucleation studies from outside North America show comparable efficacy and lower morbidity to transurethral resection of the prostate. A few studies exist describing outcomes of vaporization, the most commonly used technique for urologists. We present our 3-month outcomes of thulium laser vaporization of the prostate (ThuVP).

MATERIALS AND METHODS

From December 2010 to October 2013, 68 men underwent ThuVP using the 150 W CyberTM(®). Data were collected on demographics, comorbidities, intraoperative measures, complications, serum parameters, maximum flow rate (Qmax), postvoid residual (PVR), International Prostate Symptom Score (IPSS), quality-of-life (QoL) score, and prostate-specific antigen. Patients were evaluated at 1 week, 1 month, and 3 months postoperatively. Nine patients were excluded for known prostate cancer.

RESULTS

The mean age was 66±10 years, with a mean prostate size of 57±30 mL. At baseline, the mean IPSS was 19.9±8.0, QoL score was 4.5±1.1, Qmax was 5.2±4.5 mL/sec, and PVR was 220±397 mL. The mean laser time was 35±18 minutes, and energy used was 234±139 kJ. Forty-seven (78%) patients were discharged the day of surgery. No blood transfusions were administered with a mean drop in hemoglobin of 0.7±0.8 g/dL (p<0.05). There were no Clavien grade≥III complications within 30 days of surgery. Six (10%) patients were diagnosed with urinary tract infection. Significant improvements from baseline were seen in Qmax, PVR, IPSS, and QoL score. All 15 patients who were in retention were voiding at the last follow-up.

CONCLUSIONS

Thulium laser vaporization of the prostate appears to be a safe and effective outpatient technique for the treatment of BPH with durable outcomes at 3 months.