High-energy visual laser ablation of the prostate in men with urinary retention: pressure-flow analysis

[S2e guideline of the German urologists: Instrumental treatment of benign prostatic hyperplasia]

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the instrumental treatment of the lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding open and transurethral procedures (TUR-P, bipolar TUR-P, TUI-P, HE-TUMT, TUNA, and the different Laser techniques). Recommendations are also given concerning intraprostatic stents and injection therapies. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

Holmium laser enucleation of prostate for patients in urinary retention

OBJECTIVES

To evaluate holmium laser enucleation of the prostate in patients presenting in urinary retention secondary to benign prostatic hyperplasia.

METHODS

From May 2000 to May 2004, 169 patients, with a mean age of 74 years, who presented in urinary retention secondary to benign prostatic hyperplasia underwent holmium laser enucleation of the prostate. The mean urinary volume drained at catheterization was 670 mL (range 132 to 2000). All the patients were assessed preoperatively, 1, 3, 6, and 12 months postoperatively, and every year thereafter. All the patients were evaluated by physical examination, digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire, uroflowmetry (whenever possible), postvoid residual urine volume measurement, and prostate-specific antigen. The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351).

RESULTS

The mean catheter time and hospital stay was 1.6 and 1.7 days, respectively. The peak urinary flow rate, postvoid residual urine volume, and International Prostate Symptom Score and quality-of-life score were significantly improved by 1 month after surgery and continued to improve during subsequent follow-up. Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two used clean intermittent catheterization. Four patients (2.4%) were receiving anticoagulant therapy and required blood transfusion. Bladder neck contracture and urethral stricture developed in 1.7% and 1.2%, respectively.

CONCLUSIONS

Holmium laser enucleation of the prostate represents a safe and effective treatment for patients with benign prostatic hyperplasia presenting in urinary retention. It has low morbidity and provides immediate symptom and voiding improvement.

Interstitial laser coagulation of the prostate for management of acute urinary retention

PURPOSE

We evaluated the clinical efficacy and benefit of interstitial laser coagulation of the prostate (ILCP) in patients with benign prostatic hyperplasia (BPH) presenting with acute urinary retention.

MATERIALS AND METHODS

Patients presenting with acute urinary retention were prospectively evaluated. Patients underwent ILCP and outcomes were evaluated by post-void residual urine, maximum flow rate, International Prostate Symptom Score, and disease specific quality of life score at baseline, 1, 3, 6 and 12 months.

RESULTS

A total of 85 patients were enrolled in the study and 53 were diagnosed with acute urinary retention secondary to BPH. A total of 33 were not catheter-free after a week and 28 of them agreed to undergo ILCP. Mean preoperative prostate volume was 54.6 ml (range 23.0 to 130.0) and mean residual volume presenting with retention was 602 ml (range 200 to 1,150). There were no intraoperative or postoperative adverse events except urinary infection in 2 patients. Mean catheterization duration was 6.3 days (range 3 to 18) and all patients became catheter-free postoperatively. Mean followup was 16.9 months (range 7 to 31). Mean maximum flow rate (+/-SD) was 11.2 ml per second (+/-5.7) 3 months after treatment. Mean International Prostate Symptom Score and quality of life scores decreased from 23.1 (+/-6.4) at baseline to 8.0 (+/-5.3) at 3 months (p <0.001), and 5.0 (+/-1.2) to 1.9 (+/-1.6, p <0.001), respectively. Mean estimated prostate volume decreased by 19.4% (54.6 to 44.0 ml) 6 months postoperatively (p <0.001). Only 2 patients had recurrent urinary retention during followup.

CONCLUSIONS

Our study suggested that ILCP is a safe and effective therapy for patients with BPH presenting with acute urinary retention.

Interstitial radiofrequency therapy of the prostate in the management of acute urinary retention

OBJECTIVE

To evaluate in a prospective study the efficacy of interstitial radiofrequency therapy (IRFT) of the prostate in relieving acute urinary retention in patients with benign prostatic hyperplasia.

PATIENTS AND METHODS

Twenty-seven patients presenting in acute urinary retention who failed at least one trial of voiding one week after presentation were treated with IRFT of the prostate. During the 6-month follow-up, the International Prostate Symptom Score (IPSS), urinary flow rate, post-void residual volume (PVR) and serum creatinine were determined and changes in erectile and ejaculatory functions recorded. The treatment was considered successful if the patient resumed normal voiding, without compromising renal function and without troublesome lower urinary tract symptoms necessitating further treatment.

RESULTS

Of the 26 evaluable patients, 77% resumed normal voiding. At 6 months after treatment, the mean (SD) IPSS had decreased from 15.0 (8.3) to 8 (5.4), the PVR from 950 (203) to 88 (60) mL and the maximum flow rate was 10.5 (4.36) mL/s.

CONCLUSION

IRFT of the prostate is a safe and effective treatment, at least in the short-term, for relieving acute urinary retention in patients with benign prostatic hyperplasia. The longer term follow-up is continuing.

Holmium: YAG laser resection of prostate (HoLRP) for patients in urinary retention

We examined the holmium:YAG (Ho:YAG) laser as a tool to perform acute resection of obstructing prostatic tissue in the subgroup of men with benign prostatic hyperplasia (BPH) who present in urinary retention. A total of 36 men presented in acute urinary retention requiring catheterization before undergoing Ho:YAG laser resection of the prostate (HoLRP). Their mean age was 67 years. The mean laser energy delivery was 102 kJ (range 42-315 kJ). The mean postoperative catheterization time was 1.5 days (range 1-8 days), and only 3 men required a catheter for more than 48 hours. There were no acute perioperative complications. Improvement in voiding was immediate and sustained through 6 months of follow-up. At 6 months, the mean peak urinary flow rate was 22.5 mL/sec, and the AUA Symptom Index Score was 5.7. A meatal stricture requiring dilation in one man represents the sole late complication observed in this series. Late recurrence of urinary retention has occurred in two men who had contributing medical problems, for an overall treatment failure rate of 5.6%. Thus, HoLRP represents an effective surgical therapy for patients with bladder outlet obstruction presenting in urinary retention. Morbidity is minimal compared with electrocautery resection, while the efficacy and immediacy of voiding improvement appear similar.

Neodymium:YAG laser coagulation prostatectomy for patients in urinary retention

Urinary retention necessitating catheterization is the presenting complaint for a significant minority of men requiring surgical therapy for bladder outlet obstruction. A total of 67 men presented in acute or chronic urinary retention and underwent Nd:YAG laser prostatectomy. Their mean age was 71 years, the mean estimated excess transition zone tissue was 40 g, and the mean laser energy delivery was 48 kJ. The median postoperative catheterization time was 10 days. Five men required catheterization for > or = 6 weeks, and in five men, the catheter was removed within 48 hours. In four men (6%), a successful postoperative voiding trial was never achieved. Postoperatively, mean voiding measures for the remaining 63 men were a peak flow rate of 16.1 mL/sec, a post void residual volume of 113 mL, and an AUA Symptom Index score of 7.7. Complications included urinary tract infection in two, urethral stricture in one, and bladder neck contracture in 3 men. Four men have subsequently elected additional treatment for bladder outlet obstruction (two transurethral resections, one repeat laser, and one terazosin), for an overall treatment failure rate of 6 of 67 (9%), including the two men who remain catheterized. Laser coagulation prostatectomy produces little or no acute morbidity with a successful long-term voiding outcome in the majority of men requiring treatment for acute or chronic urinary retention.