Volume 49, Issue 6, Pages 939-941 (June 2006)

The change was not dictated by a better clinical outcome but was rather based on convenience, including therapeutic burden and economic considerations. Open surgery offers the highest probability of symptomatic improvement and the lowest failure rate, but it also has the highest rate of surgical complications and the highest costs [1]. It is difficult to define a date at which transurethral resection of the prostate (TURP) became the gold standard treatment of BPH, but it gradually happened in most countries under the pressure of decreasing number of beds for inpatients and shortening hospital stay.

Notwithstanding a worldwide consensus on the new gold standard, alternative treatments have been actively developed during the last 15 yr to overcome some of the limitations of TURP. The technique is, in fact, difficult to master and complications directly relate to prostate volume. Although the role of the medical industry in proposing and promoting new treatment of BPH is indisputable, equally undeniable is the demand of the urologic community. A number of different factors played a role in the development of alternative treatments: the need to move BPH treatment outside surgical theatres to reduce costs and to allow office urologists (a category existing only in some countries) to treat patients, the need to manage patients at high risk for surgery, the need to reduce blood loss in a population that often takes antiaggregant and anticoagulant medications, the need to ease the management of large prostates, and the need to manage BPH as a day case.

In 1990s, the concept of minimally invasive treatment was introduced and rapidly spread in the urologic world and every new treatment was considered minimally invasive. Some minimally invasive treatments proved to be also minimally effective, and others provided a clinical improvement better than drugs but lower than surgery. No consensus has ever been reached as to the minimum improvement required to define a treatment effective and retreatment rate remains the single most important outcome parameter to define the clinical benefit of a new treatment and to allow an economic evalution of a new treatment.

Looking at surgical alternatives to standard TURP, two different approaches prevailed: reducing bleeding by improving delivery units and current generators. Numerous modifications of the standard loops were proposed including rolling electrodes, thick loops, bipolar loops, and intermittent current and bipolar generators. All new devices proved to be effective in reducing blood loss while maintaining the good clinical outcome of a standard TURP. Some of them did not stand the test of time, others remained, but none of them really challenged the gold standard.

Lasers were first introduced in 1991 when transurethral laser incision of the prostate (TULIP) was developed. The thermal energy of a neodymium:yttrium aluminum garnet (Nd:YAG) laser light was used to induce coagulative necrosis of the adenomatous tissue; the procedure was certainly bloodless but the necrotic tissue that gradually sloughed in the early postoperative weeks was thought to be responsible for the high prevalence of storage symptoms. The techniques evolved into the so-called side-firing laser (visual laser ablation of the prostate [VLAP] and all its modifications) and interstitial laser coagulation (ILC) techniques. Other laser technologies were developed to produce vaporisation of prostate tissue that achieved the immediate creation of a prostate cavity with significant debulking of the gland and minimised the postoperative discomfort. The change of state from solid to vapour requires a significant amount of thermal energy and temperatures in excess of 300°C; lower temperatures result in simple evaporation of water and coagulation of tissue proteins. Most technologies failed to provide efficient vaporisation of the prostate until recently when a powerful potassium-titanyl-phosphate (KTP) laser, also known as green light laser, was made available. The laser energy is selectively absorbed by haemoglobin but not by water. Vaporisation of large prostate volume requires enormous amount of energy and the current KTP lasers release up to 280W of energy during a single pulse of energy; this is about 1000-fold the energy used in ophthalmology. Data from the Mayo Clinic and other centres show the possibility of obtaining a large cavity with minimal bleeding so that the catheter can be removed within hours from the operation and the patient discharged immediately afterwards [2–4]. Evaluation of the prostate-specific antigen (PSA) level at 1 yr suggests an average decrease down to 1.5ng/mL, which is higher than seen in patients undergoing TURP, who reach levels <1.0ng/mL.

Holmium laser, a different light source, is highly absorbed by water. It can also be used to vaporise tissue although the efficiency is relatively low but it proved to be ideal to cut through tissue and to seal small vessels provided the energy density is high enough. The pioneer work of Gilling and coworkers proved that laser enucleation of the adenoma through a transurethral approach was feasible using high-power holmium laser [5]. The operation was technically challenging and the learning curve significant but the outcome outstanding. Holmium laser enucleation of the prostate (HoLEP) was proposed an ideal alternative to TURP and open prostatectomy for managing prostates >100g with minimal blood loss and short hospital stay. The technique proved to work miracles and not just for a short time. The paper from Kuntz, published in this issue of the journal, reviews the role of lasers in the treatment of BPH and the author proposes HoLEP as a “size-independent new gold standard in the surgical treatment of BPH.” The conclusion is certainly provoking and worthwhile discussing [6].

Review papers are based on thorough reviews of the peer-reviewed literature and source data are undisputable. Interpretation of data is critical. This is an exciting time for BPH treatment. As always happens in medicine, the subject was “hot” in the early 1990s, but then many urologists lost confidence in the promises of emerging new technologies, and others continued to research during some dark years when sessions on surgical treatment of BPH were scanty in any international meeting. The subject is “hot” again because of the rapid diffusion of high-power KTP lasers. The TURP is dead! Long life to TURP! The debate continues. In the Kuntz paper, photoselective vaporisation of the prostate with the KTP laser is discharged as a novel technique providing tissue vaporisation similar to the holmium laser vaporisation but resulting in a lower decrease in prostate volume compared to HoLEP. Various randomised studies confirm the outstanding outcome of KTP laser also in large prostates but only one study provides evidence of the 5-yr results [2,7]. Only time will say whether the excellent results obtained by Malek can be confirmed in extramural studies. I certainly concur with Kuntz in saying that “The development of high-powered KTP and holmium lasers have excited a new interest in laser vaporisation/ablation of the prostate.” Which of the two technologies is going to prevail, which is going to be the new gold standard is not the subject for an editorial. But one issue deserves further discussion.

New surgical treatments are of importance when they are able to change the way we manage our patients. There is an inevitable trend to move surgical management of BPH into a day case and I believe that the technology that will allow us to achieve such goal will become the new gold standard. The reasons for such a strong trend are numerous. Patients are increasingly reluctant to be admitted to hospitals for the fear of contracting multiple resistant-strain infections, the number of beds for inpatients is decreasing in every country because of the increasing costs of modern medicine, and day-hospital units are booming in every country as the new standard of care. A number of papers were published on TURP as a day case but these remain as anecdotes because most urologists find it difficult to apply the procedure in standard patients, particularly because the average prostate volume in our surgical cases is increasing possibly as a consequence of the increase in medical treatment of BPH [8]. I have seen medical centres managing almost all their patients with BPH as day cases and many urologic units are working in this direction. My personal experience suggests this is a feasible and desirable approach. I do not think urologists care whether the holmium or the KTP laser is going to be the new gold standard surgical treatment of BPH but I believe that day surgery treatment is going to be the new standard and I suggest we all start to adapt to the concept and adopt one of the new techniques if we do not want to lose our patients to high-volume, high-tech, highly organised centres for the treatment of BPH.

References
1. Benign Prostatic Hyperplasia: Diagnosis and Treatment Clinical Practice Guideline No. 8. AHCPR Pub. No. 94-0582. 1994 (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.17571).

2. Sarica K, Alkan E, Luleci H, Tasci AI. Photoselective vaporization of the enlarged prostate with KTP laser: long-term results in 240 patients. J Endourol. 2005;19:1199–1202.

3. Bachmann A, Ruszat R, Wyler S, et al.. Photoselective vaporization of the prostate: the basal experience after 108 procedures. Eur Urol. 2005;47:798–804.

4. Malek RS, Barrett DM, Kuntzman RS. High-power potassium-titanyl-phosphate (KTP/532) laser vaporization prostatectomy: 24h later. Urology. 1998;51:254–256.

5. Tooher R, Sutherland P, Costello A, Gilling P, Rees G, Maddern G. A systematic review of holmium laser prostatectomy for benign prostatic hyperplasia. J Urol. 2004;171:1773–1781.

6. Kuntz R. Current role of lasers in the treatment of benign prostatic hyperplasia (BPH). Eur Urol. 2006;49:961–969.

7. Sandhu JS, Ng C, Vanderbrink BA, Egan C, Kaplan SA, Te AE. High-power potassium-titanyl-phosphate photoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates. Urology. 2004;64:1155–1159.

8.Vela-Navarrete R, Gonzalez-Enguita C, Garcia-Cardoso JV, Manzarbeitia F, Sarasa-Corral JL, Granizo JJ. The impact of medical therapy on surgery for benign prostatic hyperplasia: a study comparing changes in a decade. BJU Int. 2005;96:1045–1048.

Andrea Tubaro

Department of Urology, 2nd School of Medicine, “La Sapienza” University-Sant’Andrea Hospital, Via di Grottarossa, 1035, 00189 Rome, Italy

published online 10 April 2006.

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