High-Powered 120 W Holmium Laser Vaporization for BPH - Beyond the Abstract

Benign prostatic hyperplasia (BPH), commonly called enlarged prostate, is a highly prevalent problem, affecting 50-60% of men ages 60-69 and 80-90% aged 70-89.1 Current treatment options for symptomatic BPH include alpha-adrenergic blockers, monopolar or bipolar transurethral resection of the prostate (TURP), Greenlight laser vaporization (Nd:Yag) and holmium vaporization.2-7

The 120 W high-powered holmium laser (Lumenis Pulse 120H, Lumenis Ltd) was approved in January 2015 for treatment of symptomatic prostatic obstruction. The Pulse 120H differs from older holmium lasers in that its higher power permits shorter operative times,7 and the unit’s foot pedal allows surgeons to alternate between laser vaporization and hemostasis.

My colleagues and I are reporting our early experience using the Lumenis Pulse 120H system and a unique side-firing fiber called XpeedaTM to perform holmium vaporization, a minimally invasive procedure for treatment of lower urinary tract symptoms (LUTS) secondary to BPH. We enrolled nearly 100 patients in an ongoing prospective study and now have complete data on 70 patients. Outcomes measures included a comparison of pre- and post-procedure prostatic configuration, uroflow patterns, post-void residual (PVR) bladder ultrasound, and subjective American Urological Association (AUA) symptom score measurements.

We began enrolling patients in the prospective study in April 2015, offering a range of treatments, including medications and surgical options. Patients who chose surgery had baseline cytoscopy, uroflowmetry, PVR bladder ultrasound, AUA symptom score questionnaires, and PSA testing when indicated. Candidates for holmium vaporization with the Pulse 120H laser showed prostatic hyperplasia on cytoscopy, evidence of obstruction on uroflowmetry and maximum flow rate, >100 cc on PVR ultrasound, and AUA symptom scores in the moderate to severe range. Patients were not excluded for large prostate volumes, median lobe tissue, urinary retention, high-risk comorbidities, or the need to pause anticoagulation therapy.

Surgeons used a standard technique for holmium vaporization: Patients had spinal or general anesthesia, followed by irrigation with normal saline using a continuous flow cystoscope and evaluation of the prostate’s size and configuration. The Lumenis Pulse 120H was coupled with a side-firing Xpeeda laser fiber, providing 120 W in available energy.

Using the fiber in as close contact with the tissue as possible, we made incisions in the prostate and used a sweeping motion to vaporize the tissue and create a TURP-like defect. (Table 1) The Lumenis Pulse 120H’s dual pedal system allowed us to quickly switch between vaporization settings (2.0 J and 60 Hz) and coagulation, or hemostasis settings (wide pulse option at 1.0 J and 10 Hz). Electrocautery was not required.
BeaghlerTab1
After holmium vaporization treatment with the holmium laser, patients were discharged the same day with a two-way catheter in place. Patients came back in 1-3 days for a voiding trial, and most had their catheters removed. We repeated preoperative parameters three months after surgery.

At three months, AUA symptom scores averaged 9.4, compared to 24.1 before surgery. PVR decreased an average 142 cc. Peak flow rates jumped an average 7.1 cc (from 8.2 cc to 15.3 cc). (Figure 1) All thirteen men who were in retention before surgery voided successfully after holmium vaporization. Most patients could discontinue alpha-blockers and/or 5-alpha reductase inhibitors.
Beaghler Fig1
Adverse events were minor and self-limiting, such as urinary frequency and urgency. We saw three cases of urinary retention, two episodes of clot retention, and one patient with urinary retention who required standard TURP retreatment after 13 months. There were no serious complications.

Holmium vaporization with the Lumenis Pulse 120H holmium laser resulted in clear subjective and objective improvements comparable to standard TURP.7 Vaporization with the holmium laser resulted in a larger decrease in PVR than the Greenlight laser in our practice (142 vs 71 cc). My colleagues and I also think that the laser’s high power and advanced fiber technology improve hemostasis and cut surgery time. (The procedure took an average 27 minutes to perform and used 126 kJ of energy.) Importantly, this platform enabled us to treat patients with holmium vaporization who were previously outside the parameters for this or other surgeries, such as those with large glands or median lobe tissue, in urinary retention, using chronic anticoagulation therapy, or not considered candidates for major surgery, thus opening a broader population to surgical treatment.2

In performing over 100 procedures, we noted a slight learning curve and excellent intraoperative visualization and surgeon satisfaction. The Lumenis Pulse 120H was also notably quieter than our previous holmium laser. We look forward to continuing this study, as well as using the laser for other applications, including lithotripsy for urinary calculi.10

Read the Abstract

Written by: Marc Beaghler, MD, San Buenaventura Urology Center in Ventura, Calif 

Beaghler M, Leo M, Gass J, March J, Sandoval S, et al. (2017) Initial Experience with New High Powered 120 W Holmium for Vaporization of the Prostate. Urol Nephrol Open Access J 4(2): 00119. DOI:10.15406/unoaj.2017.04.00119

References:

  1. Claus G Roehrborn CG. Benign Prostatic Hyperplasia: An Overview. Rev Urol. 2005; 7(Suppl 9): S3–S14.
  2. Tan AH, Gilling PJ, Kennett KM, Fletcher H, Fraundorfer MR (2003) Long term results of high-power holmium laser vaporization (ablation) of the Prostate. BJU Int 92(7):707-709.
  3. Moody JA, Lingeman JE (2001) Holmium laser enucleation for prostate adenemoa greater than 100 gm: comparison to open prostatectomy. J Urolo 165(2):459-462.
  4. Lee SW, Choi JB, Lee KS, Kim TH, Son H, et al. (2013) Transurethral procedures for lower urinary tract symptoms from benign prostatic enlargement: a quality and meta-analysis. Int Neruouol J 17(2):59- 66.
  5. Bouchier-Hayes DM, Van Appledorn S, Bugeja P, Crowe H, Challacombe B, et al. (2010) A randomized trial of photoselective vaporization of the prostate using the 80-W potassium-titanyl- phosphate laser vs transurethral prostatectomy, with one year follow-up. BJU Int 105(7) 964-969.
  6. Teng J, Zhang D, Li Y, Yin L, Wang K, et al. (2013) Photoselective vaporization with the green light vs transurethral resection of the prostate for treating benign prostate hyperplasia: a systemic review and meta-analysis. BJU Int 111(2):312-323.
  7. Mottet N, Anidjar M, Bourdon O, Louis JF, Teillac P, et al. (1999) A randomized Comparision of transurethral electroresection and holmium: Yag laser vaporization for symptomatic benign prostatic hyperplasia. J Endourol 13(2):227-230.
  8. Grasso M (1996) Experience with the holmium laser as an endoscopic litotrite. Urology 48(2):199-206.
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