Five-year data from the Oxford Laser Prostatectomy Trial

Long-term followup after electrocautery transurethral resection of the prostate for benign prostatic hyperplasia

Introduction. For decades, transurethral resection of the prostate (TURP) has been the "gold standard" operation for benign prostatic hyperplasia (BPH) but is based mainly on historic data. The historic data lacks use of validated measures and current TURP differs significantly from that performed 30 years ago. Methods. Men who had undergone TURP between 2001 and 2005 were reviewed. International prostate symptom score (IPSS), quality of life (QOL) and peak urinary flow rate (Q(max⁡)), and postvoid residual (PVR) were recorded. Operative details and postoperative complications were documented. Patients were then invited to attend for repeat assessment. Results. 91 patients participated. Mean follow-up time was 70 months. Mean follow-up results were IPSS-7; QoL-1.5; Q(max⁡)-23 mL/s; PVR-45 mL. These were an improvement from baseline of 67%, 63%, 187%, and 80%, respectively. Early complication rates were low, with no blood transfusions, TUR syndrome, or deaths occurring. Urethral stricture rate was higher than anticipated at 14%. Conclusion. This study shows modern TURP still produces durable improvement in voiding symptoms which remains comparable with historic studies. This study, however, found a marked drop in early complications but, conversely, a higher than expected incidence of urethral strictures.

Five-Year Follow-up of Feedback Microwave Thermotherapy Versus TURP for Clinical BPH: A Prospective Randomized Multicenter Study

OBJECTIVES

To compare the efficacy and safety of transurethral microwave thermotherapy (TUMT) with ProstaLund Feedback Treatment, using the CoreTherm device, with transurethral resection of the prostate (TURP) 5 years after treatment.

METHODS

This prospective, randomized, multicenter study was conducted at 10 centers in the United States and Scandinavia. A total of 154 patients with benign prostatic hyperplasia were randomized to TUMT or TURP in a 2:1 ratio. Patients were followed up at 3, 6, 12, 24, 36, 48, and 60 months after treatment. The intermediate results at 12 and 36 months have been previously reported. The treatment outcome at 5 years was evaluated with the International Prostate Symptom Score (IPSS), quality of life question (QOL), peak urinary flow rate (Qmax), postvoid residual urine volume, and prostate volume. The CoreTherm device differs from other microwave devices in that the intraprostatic temperature is constantly measured during the procedure to guide the treatment.

RESULTS

Of the 154 patients, 66% completed the 60 months of follow-up. Statistically significant improvements in the TUMT and TURP groups were observed for IPSS, QOL, and Qmax at 60 months. The average values for the TUMT group were an IPSS of 7.4, QOL score of 1.1, and Qmax of 11.4 mL/s. The values for the TURP group were IPSS of 6.0, QOL score of 1.1, and Qmax of 13.6 mL/s. No statistically significant differences were found in any of these variables between the two treatment groups. In the TUMT group, 10% needed additional treatment versus 4.3% in the TURP group.

CONCLUSIONS

The clinical outcome 5 years after TUMT using the CoreTherm device was comparable to the results seen after TURP. The safety of TUMT using the CoreTherm device compared favorably with that of TURP.

Laser treatment of symptomatic benign prostatic hyperplasia

The treatment of lower urinary symptoms secondary to benign prostatic hyperplasia (BPH) after failure of medical therapies remains controversial for most urologic surgeons. The complications of traditional surgery are the driving force behind the development of several minimally invasive treatments of symptomatic BPH. Laser prostatectomy is one of the most investigated such modalities. In this article we reviewed the results of the most common types of lasers used in prostatic surgery.

Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention

OBJECTIVES

To update the complications of transurethral resection of the prostate (TURP), including management and prevention based on technological evolution.

METHODS

Based on a MEDLINE search from 1989 to 2005, the 2003 results of quality management of Baden-Württemberg, and long-term personal experience at three German centers, the incidence of complications after TURP was analyzed for three subsequent periods: early (1979-1994); intermediate (1994-1999); and recent (2000-2005) with recommendations for management and prevention.

RESULTS

Technological improvements such as microprocessor-controlled units, better armamentarium such as video TUR, and training helped to reduce perioperative complications (recent vs. early) such as transfusion rate (0.4% vs. 7.1%), TUR syndrome (0.0% vs. 1.1%), clot retention (2% vs. 5%), and urinary tract infection (1.7% vs. 8.2%). Urinary retention (3% vs. 9%) is generally attributed to primary detrusor failure rather than to incomplete resection. Early urge incontinence occurs in up to 30-40% of patients; however, late iatrogenic stress incontinence is rare (<0.5%). Despite an increasing age (55% of patients are older than 70), the associated morbidity of TURP maintained at a low level (<1%) with a mortality rate of 0-0.25%. The major late complications are urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%). The retreatment rate range is 3-14.5% after five years.

CONCLUSIONS

TURP still represents the gold standard for managing benign prostatic hyperplasia with decreasing complication rates. Technological alternatives such as bipolar and laser treatments may further minimize the risks of this technically difficult procedure.

Lasers for lower urinary tract symptoms secondary to benign prostatic hyperplasia: when is the fuss worth it?

In the recent past, several endoscopic procedures using laser technology have evolved for the treatment of benign prostatic hyperplasia. The term "laser treatment of the prostate" comprises a variety of different application systems, different laser wavelengths, and different surgical techniques to eliminate bladder outlet obstruction. The aim of laser prostatectomy is to be less invasive than transurethral electroresection, but equally effective. Promising short-term results led to a booming laser decade in the 1990s, stimulating the development of several devices. However, the emergence of medium-term data has shown that some of these techniques did not stand the test of time due to the lack of long-term efficacy, unacceptable morbidity, and high retreatment rates. Nevertheless, the results of transurethral resection of the prostate are challenged by some of the newer laser devices, putting the so-called "gold standard" into question.

Free-beam and contact laser soft-tissue ablation in urology

The ablation of tissue by laser has several applications in urology. Most of the published research has been concerned with the treatment of benign prostatic hyperplasia (BPH). Other applications studied include superficial upper- and lower-tract transitional-cell carcinoma, urethral and ureteral strictures, ureteropelvic junction stenosis, and posterior urethral valves. The attraction of laser ablation for the treatment of BPH lies with the decreased morbidity in comparison with standard transurethral electrocautery resection of the prostate and the ability to remove tissue immediately and therefore allow a more rapid progression to catheter removal and early voiding. The three main laser wavelengths used in urology for tissue ablation are the neodymium:yttrium-aluminum-garnet when used with contact tips or high-density power settings, the potassium-titanyl-phosphate, and the holmium:YAG. This article reviews the published literature on the use of these laser wavelengths in soft-tissue ablation, focusing on the treatment of BPH.

Long-term follow-up after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization

OBJECTIVES

To compare the long-term results of subjective changes, flowmetry, morbidity, and mortality after transurethral resection of the prostate, contact laser prostatectomy, and electrovaporization in men with lower urinary tract symptoms associated with benign prostatic hyperplasia.

METHODS

A prospective randomized controlled trial was conducted. Included in the study were men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on Benign Prostatic Hyperplasia, had a prostate volume between 20 and 65 cm(3), and a Schäfer obstruction grade of 2 or greater. The subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, quality-of-life question, and benign prostatic hyperplasia impact index. Morbidity was registered objectively and by patient questionnaire. Maximal flow was measured by free uroflowmetry. These parameters were measured at regular intervals for up to 1 year. At the end of 2002, all patients were invited for a long-term follow-up examination, including the aforementioned parameters.

RESULTS

Fifty men were randomized to undergo transurethral resection of the prostate, 45 laser treatment, and 46 electrovaporization. Of the 50 men, 70% were followed up for a maximum of 7 years. The values for the International Prostate Symptom Score, Symptom Problem Index, quality-of-life score, and benign prostatic hyperplasia impact index increased slightly after a mean follow-up of 4.3 years. The maximal uroflow decreased similarly in all treatment groups to about 150% of the preoperative values. Morbidity, reoperation rates, and mortality were also similar.

CONCLUSIONS

This study, with up to 7 years of follow-up, demonstrated durable subjective and objective results for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia after transurethral resection of the prostate, contact laser prostatectomy, or electrovaporization. No clinically relevant differences were found among these modalities.

Long-term results of high-power holmium laser vaporization (ablation) of the prostate

OBJECTIVE

To present the 7-year follow-up data from the initial series of patients treated by holmium laser ablation of the prostate (HoLAP) for symptoms of benign prostatic hyperplasia at our institution.

PATIENTS AND METHODS

In all, 79 patients underwent HoLAP in the initial series between September 1994 and May 1995. All patients were contacted by telephone and mail; those available for follow-up had their peak urinary flow rate, American Urological Association (AUA) symptom score, single-question quality-of-life (QoL) score and adverse events assessed. Patients were also assessed using the International Continence Society 'male short-form' (ICSmaleSF) questionnaire on lower urinary tract symptoms (LUTS).

RESULTS

At a median follow-up of 89 months (7.4 years), 17 patients had died (21%), 28 could not be contacted or refused follow-up (35%), leaving 34 patients (43%) available for assessment. The mean (range) AUA score of the remainder was 10.0 (0-26), the maximum urinary flow rate 16.8 (5-35) mL/s and QoL score 2.1 (0-5). The mean ICSmaleSF voiding score was 5.8 and the mean incontinence score 3.2. The impact score of their current LUTS (QoL) was 0.68, implying a minimal effect. No patient required pads for incontinence. The reoperation rate was 15%, with one patient each undergoing transurethral resection or bladder neck incision, two undergoing holmium laser enucleation of the prostate and one having a bladder stone removed endoscopically.

CONCLUSIONS

The long-term results of HoLAP were satisfactory in those patients who were available for the follow-up.

A 4-year follow-up of a randomized prospective study comparing transurethral electrovaporization of the prostate with neodymium: YAG laser therapy for treating benign prostatic hyperplasia

OBJECTIVE

To compare the safety, efficacy and durability of neodymium (Nd):YAG laser prostatectomy with transurethral electrovaporization of the prostate (TUVP) for treating benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

From March 1995 to March 1997, 180 patients with bladder outlet obstruction secondary to BPH were randomized equally either to Nd:YAG laser therapy or TUVP. Laser therapy combined two different techniques, side-fire coagulation of the lateral lobes and contact vaporization of the median lobe. Before treatment the two groups had a comparable International Prostate Symptom Score (IPSS), quality-of-life score (QoL), maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR), and prostate and adenoma volume. In all, 62 and 78 patients completed the 1, 2, 3 and 4-year follow-up from the laser and TUVP groups, respectively.

RESULTS

At each follow-up, the IPSS, QoL, Qmax and PVR were significantly better and more durable in the TUVP than in the laser group. In the TUVP and laser groups respectively, at the 4-year follow-up the mean value of the IPSS was 3.7 vs 11.9, the QoL 1.3 vs 3.1, the Qmax 21.4 vs 13.6 mL/s and the PVR 25.1 vs 64.6 mL (all P < 0.001). The mean prostate and adenoma volume were significantly lower after TUVP than after laser therapy (P < 0.001) at the 1- and 4-year follow-up, with final values of 27.9 vs 35.9 and 11.7 vs 20 mL (both P < 0.001) for the TUVP and laser groups, respectively. Retrograde ejaculation was significantly more common after TUVP (63%) than after laser therapy (18%; P < 0.001). Impotence was reported in 8% of men after TUVP and in none after laser therapy (P = 0.040). The re-operation rate was 12% after TUVP and 38% after laser treatment (P < 0.001).

CONCLUSION

These 4-year follow-up results confirm that TUVP is significantly more effective and durable than the Nd:YAG laser for treating BPH. Residual obstructing adenoma was the main cause of failure in the laser group, which reflects the inadequacy of laser therapy for removing the adenoma.

Laser therapy for benign prostatic hyperplasia: a review of recent developments

PURPOSE OF REVIEW

Over the past 10-15 years a variety of endoscopic laser techniques have evolved for the treatment of benign prostatic hyperplasia. The laser is merely an energy source with the ability to coagulate, incise, vaporize, resect and dissect (enucleate), all fundamentally different procedures. Generalization regarding "laser prostatectomy" is therefore inappropriate. The potential for shorter hospital stays and decreased morbidity while maintaining the efficacy and durability of transurethral resection of the prostate has been the driving force behind the laser techniques that acutely remove tissue, whereas the ideal minimally invasive non-tissue removing laser technique is a well-tolerated office procedure, performed under local anaesthesia. We define the various laser techniques currently available for the treatment of benign prostatic hyperplasia, and review developments reported during the period July 2001 to July 2002.

RECENT FINDINGS

Although there are few long-term data available on laser techniques, more medium-term data is emerging. Issues such as cost-effectiveness and applicability to certain sub-groups of patients are being investigated as each laser technique aims to find its own niche in the ever-expanding treatment armamentarium for benign prostatic hyperplasia.

SUMMARY

Satisfactory moderate term results are now available for several minimally invasive laser techniques including interstitial laser coagulation and visual laser ablation of the prostate. There are promising early results for holmium laser enucleation of the prostate and potassium titanyl-phosphate, which have the potential to rival transurethral resection if proved durable in the long-term. Holmium laser enucleation is currently a serious contender for the "gold standard" for large prostates.

Minimally invasive therapies for benign prostatic hyperplasia in the new millennium: long-term data

Over the last decade, a number of minimally invasive therapies have been investigated for the treatment of symptomatic benign prostatic hyperplasia. Most of these therapies use thermal energy to ablate prostatic tissue. The major common problem with all these new minimally invasive therapies has been the lack of long-term data concerning efficacy, re-intervention rates and side-effects. We present here the available long-term data on these alternative minimally invasive therapies for benign prostatic hyperplasia and their current place in the urologist's armamentarium.

Lasers for median lobe hyperplasia

Laser treatment encompases a variety of techniques using different laser wavelengths, application systems, and surgical techniques to achieve contrasting tissue effects such as incision, resection, vaporization, or coagulation. Many studies have proven the clinical efficacy of the various laser techniques for the treatment of benign prostatiuc hyperplasia, including randomized studies versus transurethral prostatectomy (TURP). Recently, long-term follow-up of up to 5 years has demonstrated the durability of the results, although in some of the studies, retreatment rates were higher than after TURP. Median lobes were never seen as a contraindication for treatment in the laser based procedures. Technically, laser treatment techniques such as side-firing transurethral coagulation, contact- and free-beam laser vaporization, interstitial laser coagulation, and the holmium laser-based resection and enucleation are fully suitable for treatment of median lobes. Surprisingly, no studies focussing specifically on laser treatment of median lobes have been published.