Short-term report on transurethral diode laser vaporization of the prostate at Ahmadu Bello University Teaching Hospital, Zaria-Nigeria

Muhammed Ahmed; Ahmad Tijjani Lawal; Ahmad Bello; Hussaini Yusuf Maitama

doi:10.4103/2278-9596.187196

ORIGINAL ARTICLE

Year : 2016 | Volume : 6 | Issue : 1 | Page : 32-35

Short-term report on transurethral diode laser vaporization of the prostate at Ahmadu Bello University Teaching Hospital, Zaria-Nigeria

Muhammed Ahmed, Ahmad Tijjani Lawal, Ahmad Bello, Hussaini Yusuf Maitama
Division of Urology, Department of Surgery, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication

28-Jul-2016

Correspondence Address:
Dr. Ahmad Tijjani Lawal
Division of Urology, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2278-9596.187196

Abstract

Background: Laser vaporization of the prostate is an evolving addition to the armamentarium for prostate surgery. This is despite the availability of cheaper treatment modalities such as open prostatectomy and transurethral resection of the prostate (TURP). However, diode laser vaporization in this regard has the advantages of a shorter learning curve and minimal complications. This paper was aimed at assessing the effectiveness of this mode of therapy and to share our initial experience with this procedure.
Patients and Methods: This was a prospective study carried out over a period of 18 months. All men requiring surgery for bothersome prostatic obstruction with benign prostate size ≤100 g were included. Those with malignant prostatic obstruction irrespective of size were also included. The exclusion criteria were benign prostate of size >100 g, and indication for open prostatectomy/channelization or medical therapy. Clearance was obtained from the Health Research Ethics Committee of the institution and informed consent was obtained from all the patients. Each patient's demographics and pre-, intra-, and post-operative details were entered into a pro forma. Results were analyzed using descriptive statistics.
Results: Eleven men were included in this study, aged 59-81 years with a mean of 67 years. 63.6% had benign prostatic hyperplasia (BPH) while the remaining 36.4% had carcinoma of the prostate. The mean prostate size was 88 g with a range of 54-182 g. Main symptoms were severe or bothersome lower urinary tract symptoms (LUTS). The mean operating time (lasing time) was 65 min. There were no intraoperative complications and none required blood transfusion. Most had irrigation for only 24 h, one didn't require irrigation while two others required irrigation for 48 h and 72 h, respectively. Out of all the patients, 90.9% had catheter removed at ≤48 h, while one had catheter removed on the fifth postoperative day. All except one were discharged at 72 h or less postoperatively. All the patients had satisfactory subjective outcome at a mean follow-up of 9 months with a range of 1 to 18 months.
Conclusion: We found transurethral laser vaporization of the prostate to be effective and safe in the treatment of prostatic obstruction. However, a study involving larger number of patients and longer follow-up will establish its true place in the management of prostatic obstruction in our environment.

Keywords: Diode, laser, LUTS, vaporization, prostate, short term

How to cite this article:
Ahmed M, Lawal AT, Bello A, Maitama HY. Short-term report on transurethral diode laser vaporization of the prostate at Ahmadu Bello University Teaching Hospital, Zaria-Nigeria. Arch Int Surg 2016;6:32-5

How to cite this URL:
Ahmed M, Lawal AT, Bello A, Maitama HY. Short-term report on transurethral diode laser vaporization of the prostate at Ahmadu Bello University Teaching Hospital, Zaria-Nigeria. Arch Int Surg [serial online] 2016 [cited 2023 Mar 29];6:32-5. Available from: https://www.archintsurg.org/text.asp?2016/6/1/32/187196

Introduction

Transurethral resection of the prostate (TURP) remains the gold standard surgical therapy for severely symptomatic and bothersome benign prostatic obstruction.^[1],[2],[3] Established comorbid risk factors in some of these patients and documented intra- and post-operative complications have given a push for the development of newer, equally effective, and safer minimally invasive methods of treatment that will negate these problems.^[4]

Laser therapy for the prostate is gaining popularity in this regard, despite the high cost of the treatment and limited access to the same.^[4],[5] There exist two basic principles of laser therapy for the enlarged prostate, viz. laser vaporization and laser coagulation.^[6] Laser vaporization uses high energy, as opposed to the lower energy requirement for the laser coagulation of the prostate.^[6] The main advantage of vaporization over coagulation is the provision of an immediate TUR-like defect in the prostatic urethra.^[6],[7] The major drawback of laser therapy for the obstructing prostate is the prolonged operating time and in most instances the lack of tissue retrieval for histology.^[2],[7] Laser types used for the prostate therapy have evolved from the visual laser ablation of the prostate (VLAP) to neodymium yttrium aluminum garnet (Nd: YAG) to the potassium titanyl phosphate (KTP) laser, and subsequently to Holmium YAG.^[8] More recently, the high power Diode Laser, 980 nm, has been introduced. It has a high ablative rate and superb hemostatic properties.^{[9],[10],[11]} Thus, a shorter lasing time for the same volume of prostate and less bleeding, when compared to the earlier lasers.^[12] It also has a short learning curve, a more compact and easily movable generator, and lower energy requirements.^[10],[12]

The objective of this paper is to assess the efficacy and safety of this mode of therapy, and to share our initial experience with this procedure.

Patients and Methods

This is a prospective study carried out in our institution over a period of 18 months (April 2013 to September 2014). All men requiring surgery for bothersome prostatic obstruction with benign prostate volume ≤100 g were included. Those with malignant prostatic obstruction irrespective of size were also included. The exclusion criteria were benign prostate of volume >100 g and indication for open prostatectomy or medical therapy. Clearance was obtained from the Health Research Ethics Committee of the institution. Eleven patients met the criteria. Informed consent was routinely obtained from the patients. All patients had preoperative evaluation including digital rectal examination (DRE), prostate specific antigen (PSA), and transrectal ultrasound (TRUS). Prostate size was determined by using ultrasonic calipers via the employment of a transrectal probe. Prostate biopsy was done when indicated. All the patients had transurethral laser vaporization of the prostate using a high power diode laser, 980 nm, with a side-firing free beam contact, twister laser fibre. The power setting was between 80 W and 100 W. All the surgeries were done under spinal anesthesia with the patient in Lloyd-Davies position. Normal saline was used as an irrigant. Perioperative antibiotics was administered and continued until the indwelling catheter was removed. Cystoscopy was done and intraoperative findings were noted. With sweeping back and forth movements of the laser fiber, vaporization was commenced starting with the lateral lobes, and extending from the bladder neck to the verumontanum. The median lobe was vaporized last. The vaporization was continued until an adequate TUR-like defect was created. A size 24 Fr three way silicone catheter was passed and the irrigation was commenced.

Results

Eleven men were included in the study, aged 59-81 years with a mean age of 67 years. Out of these patients, 63.6% had BPH while the remaining 36.4% had carcinoma of the prostate. The mean prostate size was 88 g with a range of 54-182 g. Main symptoms were severe or bothersome LUTS. The mean operating time (lasing time) was 65 min. There were no intraoperative complications and none required blood transfusion. Most had irrigation for only 24 h, one didn't require irrigation while two others required irrigation for 48 h and 72 h, respectively. Out of all the patients, 90.9% of the patients had catheter removed at 48 h, while one had urethral catheter removed on the fifth postoperative day. All except one patient were discharged at 72 h or less postoperatively. Early postoperative complications were noted in two of the patients. One had acute urinary retention (AUR) while the other had urinary tract infection (UTI). All the patients had satisfactory subjective outcome at a mean follow-up of 9 months with a range of 1-18 months. [Table 1] shows the Distribution of pre-, intra-, and postoperative parameters of the patients.

Table 1: Distribution of pre-operative and post-operative paramaters of the 11 patients treated with diode laser vaporization of the prostate

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Discussion

Laser therapy for the treatment of obstructing prostate glands has over the last two decades constituted itself as a challenge to the traditional role of TURP as the gold standard operative therapy.^{[1],[7],[8],[12]} This challenge is driven by the fact that TURP is associated with hemorrhage and TUR syndrome, complications that may be seen in up to 20% of cases and which have become increasingly unacceptable to both the patient and the urologist.^{[9],[13],[14],[15],[16]} Also, compared to TURP it is associated with a higher quality of life outcome due to the lower incidence of erectile dysfunction.^[17] Transurethral diode laser vaporization of the prostate reduces the morbidity associated with these complications. Furthermore, the instant TUR-like effect on the prostate is associated with the reduction in the duration of urethral catheterization and hospital stay while maintaining satisfactory outcome.^[11] Diode lasers come in wavelengths of 940 nm, 980 nm, 1318 nm, and 1470 nm.^[11] In this study, the 980 nm diode laser was used in all patients at a power setting of 80-100 W.

All the patients except one had prostate size of <100 g. One had prostate size of 182 g and actually had the procedure for channelization for malignant prostatic obstruction. None of the patients had intraoperative complications such as hemorrhage and TUR syndrome. None of them required blood transfusion in the perioperative period. However, two patients (18.2%) developed early postoperative complications, viz. urinary tract infection (UTI) and acute urinary retention (AUR). These necessitated continued urethral catheterization along with extension of the antibiotic regimen; and urethral recatheterization for another 72 h respectively. The patient with UTI had his catheter removed on the fifth postoperative day and discharged home on the seventh postsurgery day. The patient that had AUR was the same patient that did not have irrigation. His urethral catheter was removed 24 h postoperatively. Following the recatheterization, he was discharged home and catheter was removed at the OPD 72 h later.

Three patients in this series (27.3%), had persistent irritative LUTS after the removal of urethral catheter. This may be attributable to the greater depth of the coagulation zone of 7 mm as against 1-2 mm and 0.4 mm with KTP and Holmium lasers, respectively.^[10],[11] The resultant tissue necrosis and sloughing may cause a self-limiting persistence of irritative LUTS.^{[14],[15],[16]} Secondary vesical changes following lower urinary tract obstruction (LUTO) may however be contributory. This resolved spontaneously over a period of 10-12 days.

Most of the patients in this series (72.7%) had bladder irrigation for only 24 h. One patient (9.1%) did not require irrigation while two patients (18.2%) required irrigation for 48 h and 72 h, respectively. Out of all the patients, 72.7% of the patients (N = 8) had their urethral catheter removed 48 h postoperatively. Two patients (18.2%) had their catheters removed at 24 h, while one patient had his catheter removed 5 days postoperatively. The latter patient had UTI and thus required prolonged urethral catheterization. Miodrag et al. reported duration of urethral catheterization of 24 h.^[11]

Ten of the patients (90.9%) were discharged ≤72 h postoperatively. The one patient who developed UTI was discharged a week after the surgery.

All the patients had satisfactory subjective outcome (absence of LUTS and improved QoL) at a mean follow-up of 9 (1-18) months. This is similar to previous studies on diode laser vaporization of the prostate.^{[9],[10],[11]}

Conclusion

This short-term report found transurethral laser vaporization of the prostate to be effective and safe in the treatment of LUTS due to prostatic obstruction. However, further studies with larger number of patients randomized to have either diode laser vaporization of the prostate or TURP and longer follow-up will establish the true place of transurethral diode laser vaporization in the management of LUTS due to prostatic obstruction in our environment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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