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Endoscopic laser ablation of the prostate: A prospective study and 4-year follow-up in 170 patients
Abstract
Introduction: The aim of the study was to evaluate the longterm efficacy of laser ablation of the prostate (using a freebeam technique) and its associated morbidity. Patients and methods: Between November 1992 and November 1995. a prospective study of 170 patients with symptomatic BPH (mean age 64.9 years, range 51-87) was conducted. Before starting therapy, a sextant prostatic biopsy was taken in all patients. NdiYAG laser energy was delivered using a side-firing 1 mm quartz fibre (Prolase II & I). Energy was delivered at 60 W for 60 s to various sectors, achieving deep coagulation necrosis. The patients were catheterized after treatment for 7 days. The mean prostatic volume was 34.4 g (range 22-64) and the mean laser energy delivered was 36.1 kj. The variables assessed comprised the IPSS. quality-of-life score (QoL), urinary flow rate (Qmax) and post-void residual volume (PVR). Results: The values of the variables assessed before treatment and during follow-up were; Mean Follow-up (years) (SD) Before 2 4 Number 170 119 37 IPSS 19.7(7) 6.4(5) 4.9(7) QoL 4.0(1) 1.6(1) 1.1(1) Qmax(mL/s) 9.0(4) 19.8(7) 15.3(4) PVR (mL) 121(110) 37(35) 22(30) For all values at 2 and 4 years, V < 0.001 vs. before treatment Early complications at 3 months were irritative symptoms in 24 (14%). haematuria in eight (5%), retention in seven (4%), stress incontinence in two (1%) and perineal pain in two (1%). Late complications at 6 months were bladder neck sclerosis in one (0.6%) and urethral stricture in one (0.6%). Of the 67% of patients who reported being sexually active before treatment. 34% reported retrograde ejaculation afterward. The mean hospital stay was 1.6 days (range 1-3). The re-operation rate was 4.7% in the first year (60% > 50 g prostate). 1% in the second and third year and none in the fourth year. Conclusions: The only significant morbidity was irritative symptoms. The 4-year follow-up results were satisfactory, with a low re-operation rate and short hospital stay. This laser application is most suitable for patients with BPH of < 50 g.
The long-term results of different laser technologies in the management of lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO) are not well known. We studied the durability of the effect of laser prostatectomy and tried to identify the factors predictive of treatment outcome.
Between December 1992 and November 1996, 190 patients underwent laser prostatectomy because of LUTS suggestive of BOO. One hundred seven patients received visual laser ablation of the prostate (VLAP), 30 received contact laser vaporization (CLV), and 53 received interstitial laser coagulation (ILC). The baseline evaluation included the International Prostate Symptom Score (IPSS), uroflowmetry (maximum urinary flow rate), postvoid residual urine (PVR), prostate volume measurement, and urodynamic investigation. Patients were followed up until April 1999. Kaplan-Meier plots were constructed to calculate the risk of retreatment, and the log-rank test was used to evaluate the predictive value of clinical parameters for treatment failure.
The median follow-up in the VLAP group was 53 months; the retreatment rate was 14% (95% confidence interval [CI] 6% to 22%). The corresponding numbers for the CLV and ILC groups were 47 months and 14% (95% CI 1% to 26%) and 34 months and 41% (95% CI 23% to 60%), respectively. A high PVR and a high grade of obstruction in the VLAP group, and a younger age in the ILC group, were associated with increased retreatment risk.
VLAP and CLV have a durable effect, as demonstrated by their low retreatment rate. ILC is a less aggressive procedure, at the expense of a high retreatment rate. Patient selection for VLAP can be based on the grade of obstruction and PVR.
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