A Comparative Study on the 160W Straight Light Beam Greenlight
Photoselective Vaporization of the Prostate and Transurethral
Electrovaporization Resection of Prostate for the Treatment of Benign Prostatic
Hyperplasia
Jin Wang1†, Li-na Xu2†, Hao Zhong2, Bo Li2, Chun-xiao Wei2, Xun-bo Jin2*
1
Department of Urology, Qianfoshan Hospital Affiliated to Shandong University,
Jinan, Shandong, 250014, China.
2
Minimally Invasive Urology Center, Provincial Hospital Affiliated to Shandong
University, Jinan, Shandong, 250014, China.
†These authors (Jin Wang and Li-na Xu) contributed equally to this work.
*To whom correspondence should be addressed.
*Correspondence author: Xun-bo Jin
9677 Jingshi Road, Minimally Invasive Urology Center, Provincial Hospital
Affiliated to Shandong University, Jinan, 250014, China.
E-mail: [email protected];
Phone Number: 086-18764015301
Disclosure of Potential Conflicts of Interest: No potential conflicts of interest were
disclosed.
Word count of abstract: 250;
Word count of text: 2411;
Number of references: 18;
The total number of tables: 4
Abstract
Objective To summarize the method, effect and safety of 160W straight light beam
greenlight photoselective vaporization of prostate in treatment of benign prostate
hyperplasia, and compare with transurethral resection of prostate for treatment of
benign prostatic hyperplasia.
Methods 100 cases of BPH were randomly treated with 160W straight light beam
greenlight PVP (n=50), or treated with transurethral resection of prostate (n=50). All
patients were followed up with RUV, IPSS, QOL, Qmax, operative time, blood loss,
catheter indwelling time, hospital stay time and operative complications.
Results All operations were successfully completed, and no severe complicaton
occures. The IPSS, QOL, Qmax and RUV were significantly improved in both groups
after operations (P<0.05), no significant differrence in the improvement of the
subjective symptom and objective signs were found between the 2 groups (P>0.05). A
significant difference in favor of straight light beam PVP was achieved for the
catheter indwelling time, hospital stay time and blood loss. A slight but not significant
difference was found in operating time [(60.4±23.1) min vs (57.5±21.2) min for
straight light beam PVP and TURP, respectively, P>0.05]. A 6-months followed-up
indicate postoperative complications between the 2 groups were similar.
Conclusions The results of our study shows that 160W straight light beam greenlight
PVP for the treatment of BPH has the advantage of few blood loss, safe surgical
procedures and short hospital stay time. It provide a ideal operation method for the
treatment of benign prostatic hyperplasia.
Key Words: Benign prostatic hyperplasia; 160W straight light beam greenlight
photoselective vaporization of prostate(PVP); Transurethral resection of prostate
(TURP); Minimally invasive.
INTRDUCTION
Benign prostate hyperplasia (BPH) is one of the most common diseases seen in
elder men, its incidence increased as the growth of the age, affecting 34.8% of those
over the age of 60 years [1]. The common goals of surgical treatment for lower urinary
tract symptoms (LUTS) related to BPH are to reduce subjective and objective
symptoms, improve quality of life, decrease the risk of postoperative complications,
and shorten hospitalization [2]. For decades, transurethral resection of the prostate
(TURP) is respected as the most effective surgical method for treatment of
symptomatic BPH. Because of its significant and durable improvement in LUTS,
TURP is a widely accepted reference standard in surgical treatment options, with
which any new surgical innovation should be compared [3]. However, despite various
technical and anesthetic improvements, certain significant morbidities such as severe
bleeding and transurethral resection syndrome (TURS) still occur. Intraoperative and
postoperative complications occur as high as 24.9% [4, 5]. Consequently, in an attempt
to minimize the morbidity of TURP, various alternative procedures including
photoselective vaporization of the prostate (PVP) have been developed. PVP by
GreenLight laser has been presented as a minimally invasive surgical alternative to
TURP, with several advantages such as reduced bleeding complications and short
hospital stay [4-6]. However, the traditional 160W side light beam greenlight
photoselective vaporization of prostate (side-PVP) has the disadvantages of long
operating time, high incidence of early acute urinary retention, difficult to control
postoperative infection, large volume of residual glands [6]. To a certain extent, it
limits the widely acceptance of the PVP. In order to further enhance the vaporization
efficiency of PVP, the 160W straight-light-PVP was developed for vaporization of the
prostate. In this study, 160W straight-light-PVP shows the advantage of shorter
operative time, lesser blood loss, intraoperative clear vision, rapid postoperative
recovery, shorter hospital stay, fewer complications compared with side-light-PVP, It
provides a safe and effective surgical treatment especially for elderly high-risk
patients. In this study, our primary goal was to compare the efficacy of 160W
straight-light-PVP with TURP in treatment of benign prostate hyperplasia through a 6
months follow-up. The secondary aims were to compare adverse events, sexual
outcomes, and quality of life after the two procedures.
1 Object and methods
1.1 Clinical data
This prospective nonrandomized bicenter study was performed from March 2012
to August 2012. 50 patients with lower urinary tract symptoms （LUTS） due to BPH
underwent 160W straight-light-PVP, and 50 patients presenting with the same
condition underwent TURP, both the two groups were performed in our department.
Criteria for patient exclusion from the study were use of an indwelling urinary
catheter, patients with documented or suspected prostate cancer, neurogenic bladder
disorder, urethral strictures, any previous prostatic, bladder neck, or urethral surgery.
Anticoagulant medication in the TURP group was discontinued a week before surgery,
while in the PVP group anticoagulant therapy was not discontinued.
The preoperative evaluation included determination of serum prostate-specific
antigen (PSA) level, Qmax and PVR volume measurement. Patients were also asked
to complete the IPSS questionnaire. The prostate size was measured by transrectal
ultrasonography. All preoperative indexes are showed in Table 1, and the differences
between the two group patients in preoperative general information were not
statistically significant (all P> 0.05).
Table 1 Preoperative general information of TURP group and the straight light beam
PVP group
Disease
duration
(years)
Serum
PSA
(ng/L)
Group
n
Age
(years)
TURP group
50
71.3±4.6
8.4±2.3
2.4±0.4
Straight-firing
laser group
50
69.2±5.8
10.5±3.5
2.6±0.2
Prostate
volume
(ml)
56.65±
20.5
55.42±
23.7
Qmax
(mL/s)
RUV
6.4±1.2
154.5±20.1
6.7±1.6
151.2±16.3
(ml)
(Significant Difference: No significant differences were found between the two
groups, P>0.05.)
1.2 Surgical methods
The operation was completed by the same experienced surgeon, Professer Jin.
The 160W straight-light-PVP group: The Realton company’s Non-contact
Greenlight laser treatment system was used, whose rated vaporization power was set
at 160W and the rated coagulation power was at 60~80W. We used Olympus plasma
resectoscope (26F, 12°) and remove ADD side optical fiber front side-firing laser
device. Optical fiber was placed from resectoscope cutting ring hole into disposal.
0.9% saline solution was used as the perfusion fluid. The specific order of the
operation is as follows: firstly, place urethral cystoscope under direct vision to
observe the urethra, prostate hyperplasia, bladder neck, each wall of bladder and the
bilateral ureteral orifice, then be back again to see the location of seminal colliculus
and the distance between seminal colliculus and the bladder neck. Mucous membrane
of urethra was vaporized first from urethral neck to seminal colliculus. Then
hyperplastic prostate tissues were vaporized from tip of the prostate to the neck of
bladder, deep enough to surgical capsule. At the neck of bladder, we cut the
hyperplastic prostate tissue circularly.
The TURP group: We used WOLF produced continuous infusion resectoscope
(26F, 12°), whose rated cut power was set at 130W and the rated coagulation power
was at 80W. 5% mannitol solution was used as the perfusion fluid. The specific order
of the operation is as follows: firstly, place resectoscope under direct vision to observe
the urethra and bladder and make the position of seminal colliculus clear. From the
6:00 of seminal colliculus, we started to excise the hyperplastic prostate tissues
circularly on the counterclockwise direction, deep enough to surgical capsule. We
relocated the resectoscope outward gradually and repeated the above process to excise
the bi-sided grand of seminal colliculus. At last, we retreated the resectoscope outside
of seminal colliculus and observed the urethra open as a round-shaped at water-filled
state.
After opetations, a 22Fr three-cavity catheter needed to be stayed conventionally.
It was pulled and fixed on the thigh. Continuous bladder irrigation was needed
postoperation.
1.3 Observable index and item
By observing two groups of patients in operative time, bleeding volume, bladder
irrigating time, catheter indwelling time and hospitalization time, and comparing the
IPSS, QOL, Qmax and RUV changes and the recent various complications in the two
groups in the 6-months follow-up.
1.4 Statistics processing
With SPSS 17.0 statistical software, measurement data are expressed as mean ±
standard deviation. T test is used for group comparison and count data are analyzed by
chi-square test. P<0.05 means it has significant difference
2 Results
2.1 Comparison of two group patients’ general conditions during and after operation
Both operations were successfully completed, and no serious complications
occurred. There was no blood transfusion, transurethral resection syndrome or
capsular perforation in the operation. Operative time, bleeding volume, postoperative
bladder irrigation, catheter indwelling time and hospitalization time of the TURP
group and straight-firing laser PVP group are shown in Table 2. The bleeding volume,
postoperative bladder irrigation, catheter indwelling time and hospitalization time of
straight-firing laser PVP group are significantly less than that of TURP group (P
<0.05). The operative time of TURP group is shorter than that of the straight-firing
laser PVP group, but there is no statistical significance.
Table 2 Comparison of General Condition of TURP group and straight-firing laser
PVP group in intraopration and postoperation
intraoperative
bleeding
volume
(ml)
postoperative
bladder irrigation
time
(d)
catheter
indwelling
time
(d)
hospitalization
time
(d)
Group
n
Operative
time
(min)
TURP group
Straight-firing
laser group
50
57.5±21.2
85.7±23.8
2.0±1.3
7.5±3.1
12.5±1.7
50
60.4±23.1
25.2±10.6
1.0±0.4
2.4±1.5
7.1±2.0
(Compared with the TURP group, operative time was P>0.05, bleeding volume and
the remainder are P<0.05.)
2.2 Comparison with the improvement of preoperative and postoperative symptoms
between two group patients
It was measured preoperatively and at 6 months postoperatively in IPSS, QOL,
Qmax and RUV of TURP group and straight-firing laser PVP group of patients. The
comparisons of them are shown in Table 3. No significant differences are found from
the preoperative and postoperative data between the two groups (P>0.05), while all
the indexes are markedly improved in each group and better than the preoperative
index (P<0.05). It indicates that two groups have similar therapeutic index。
Table 3 Comparison with the improvement of preoperative and postoperative
symptoms between two group patients
IPSS
QOL（min）
Qmax（ml/s）
RUV（ml）
Group
Pre
Post
Pre
Post
Pre
Post
Pre
Post
TURP group
25.5±4.6 9.2±3.7 7.5±1.4
2.4±0.5 6.4±1.2 20.8±5.2 154.5±20.1 31.6±14.1
straight-firing group 22.9±4.8 8.5±2.3 8.2±2.2
1.9±0.5 6.7±1.6 22.8±1.3 151.2±16.3 32.6±10.2
[In the intra-group comparison, all indexes had significant difference in both groups
before and after operation (P<0.05). In the inter-group comparison, each index had no
significant difference between the two groups (P>0.05).]
2.3 The comparison of short-term postoperative complications in two groups
The comparison of postoperative symptoms of bladder irritation, incontinence,
urethral stricture, hematuria, sexual dysfunction and dysuria in TURP group and
straight-firing laser PVP group is shown in Table 4. The amount of patients with
hematuria of TURP is significantly more than that of the straight-firing laser PVP
group (P<0.01). There is no significant difference in the remainder (P>0.05).
Group
Table 4 Comparison of postoperative short-term complications in TURP group and
straight-firing laser PVP group
symptoms
urethral
sexual
n of bladder incontinence
hematuria
dysuria
stricture
dysfunction
irritation
TURP group 50 20(40%)
0
1(2%)
8(16%)
3(6%)
5(10%)
straight-firing
50 18(36%)
0
0
0
2(4%)
4(8%)
group
(Compared with TURP group, hematuria was P<0.05, the remainder are P>0.05.)
3 Discussion
Benign prostate hyperplasia (BPH) is one of the most common diseases seen in
elder men. Patients with moderate to severe lower urinary tract symptoms choose
surgery because it significantly affects their quality of life. For decades, transurethral
resection of the prostate (TURP) is respected as the most effective surgical method for
treatment of symptomatic BPH [2,3]. However, various serious postoperative
complications of TURP are up to 24.9%, and its mortality rate is from 0.2% to 0.8%.
Besides, the reoperation rate in 10-year is 10% to 15% [7,8]. Especially, in the
treatment of large volume hyperplastic prostate, the longer operative time and the
significantly increased risk of complications [9] limit its clinical application.
With the application of new technologies, the surgical treatment of benign
prostatic hyperplasia has undergone tremendous change in the last 15 years.
Compared with TURP, transurethral greenlight photoselective vaporization of the
prostate (PVP) has advantages of less intraoperative bleeding, shorter hospital stay,
etc. Meanwhile, its therapeutic effect and rate of postoperative complications were no
significant difference with TURP. Its application in the treatment of BPH is gradually
increased.
Green laser, whose wavelength is 532 nm, is also known as KTP laser. The
characteristics of green laser are that it can be selectively absorbed by hemoglobin,
has very effective organization vaporizing effect, closes blood vessels, forms 1~2 mm
solidification belt, improves hemostatic effect, and almost has no intraoperative
bleeding so that the visual field is clear[10]. The 60W green laser was first applied by
Malek etc [11] for the treatment of benign prostatic hyperplasia in 1997. In 2005,
Malek etc [12] had published a report again to indicate that PVP is safe and reliable
after 5 years of follow-up. Thangasamy IA ect [13] had analyzed 889 cases of BPH
patients (448 cases underwent PVP and 441 cases underwent TURP) retrospectively
from 2002 to 2012, and showed that compared to TURP, 80W/120W PVP had
advantages of less bleeding, lower surgical risk, shorter hospital stay, etc., but it had
longer operative time (19.64 minutes longer than the TURP). As the laser power
increased (80W laser year in 2001 and 120W laser in 2006), the vaporization
efficiency had improved gradually, and the operative time had been shorter. We coule
minimize the risk of unstable hemodynamics caused by surgery in elderly patients, so
the perioperative safety was significantly higher than TURP. The higher safety is
mainly showed in the following factors: ①Using physiological saline in the operation
as perfusion fluid has clear effect of hemostasis and little effect on the patient's
internal environment, and there is no TURP syndrome. ②The depth of tissue thermal
lesion is shallow, only 0.8mm, and the possibility of peripheral tissue damage is small.
③There is almost no intraoperative bleeding, which makes the surgical visual field
clear and ensures that the surgery is safe and fast. It does not need to disable
anticoagulant drugs in PVP, so PVP is safe for the patients who underwent heart
stenting or prosthetic valve implantation. ④The laser energy can be selectively and
highly absorbed by the prostate tissue rich in oxyhemoglobin, which makes the
wound vascular of vaporizing tissue instantly closed, so that perfusiing fluid is
absorbed rarely. Because of its safety and effectiveness, PVP in the treatment of
benign prostatic hyperplasia is widely recognized, and some scholars believe that PVP
will gradually replace TURP and become the gold standard for treatment of BPH [14].
Currently, the power of LBO/532nm green laser system has been increased to
160W. Since the power is increased, it can vaporize tissue more quickly while it
retains the same advantage of the hemostasis with the 80/120W PVP system. Studies
have shown that the operative time of 160W PVP is shorter than 80/120W PVP, but
compared with TURP, it is still longer [15-17].
The traditional side-firing laser PVP has some limitations which are mainly
showed in the following aspects: ① It used the American ACMI (23F, 30 °)
continuous perfusion urethral cystoscopy, whose sheath is finer, circulating water
flushing is poorer than TURP and the visual field is affected by minor bleeding which
extends the operative time and increases the surgical risk. ②Currently, at home and
abroad, We still use 80W-120W PVP mainly which has limitations of longer operation
time, less vaporization efficiency and larger postoperative residual gland, so the
application of PVP alone is still controversial, especially for the high-risk elderly
patients with large volume hyperplastic prostate. ③The light can refract through the
side light device in the front of optical fiber, so the energy loss is large which make
the vaporization efficiency lower and the operation time longer. ④The side-firing
laser PVP is difficult to take prostate tissue intraoperation. Considering the
shortcomings of traditional side-firing laser PVP, Professor Xunbo Jin improved and
invented 160W straight-firing laser PVP. It has some advantages as follows: ①The
use of Olympus plasma resectoscope (26F,12 °) makes the visual field clear and open.
The effect of circulating water flushing is good, which makes arterial bleeding clearly
visible and can be accurate hemostasis and reduce the risk of capsular perforation
caused by prolonged exposure of fixed site of bleeding due to poor visibility. ②Laser
irradiates to the hyperplastic prostate tissue directly without surrounding radiation and
no energy dissipated, which speeding up the vaporization efficiency, shortening the
operation time and reducing the risk of surgery. ③Using green laser gasification
characteristics of cutting, retrograde propulsion of vaporization of prostate tissue can
achieve the effects of eradicating thin layer prostate tissue without complete
vaporization of the prostate tissue, which can greatly reduce the operative time [18]. ④
It can take prostate tissue for pathologic examination in intraoperation through
changing the angle of direct light and hyperplastic prostate tissue. ⑤The direction of
straight-firing laser laser is parallel to optical fibers, without reflection and divergence
and reduces the risk of laser injury in the mirror and mirror sheath.
This research shows: compared to TURP, the bleeding volume, postoperative
bladder irrigation, catheter indwelling time and hospitalization time of 160W straight
light beam greenlight PVP were significantly better. The operative time of 160W
straight light beam greenlight PVP was a little longer than TURP, but there was no
statistically significant difference. Besides, there was no significant difference in the
postoperative subjective symptoms, objective improved indexes and short-term
complications between the TURP and 160W straight light beam greenlight PVP. It
was a first domestic and foreign report by Professor Xunbo Jin that he innovated in
using Greenlight HPS straight-firing laser to vaporize hyperplasia of prostate tissue
the first reported. For 80-100g prostate, our operative time is about 45-90minutes, and
there are no obvious surgical contraindications. It provides a new operation choice for
the treatment of large prostate.
The short-term efficacy of 160W green laser straight-firing laser PVP is worth
affirming. Although a large sample and long-term follow-up data are lacking, there
are distinct advantages of less bleeding, shorter hospital stay, low surgical risk and
pathological tissue available intraoperation. Compared with the TURP, 160W
straight-firing laser PVP is a new and more ideal surgical approach for the treatment
of BPH, particularly large prostate.
Key of Definitions for Abbreviations: BPH, benign prostatic hyperplasia; TURP,
transurethral resection of the prostate; TURS, transurethral resection syndrome; PVP,
photoselective vaporization of the prostate; IPSS, international prognostic scoring
system; QoL, Quality of Life; Qmax, maximum urinary flow rate; RUV, residual
urine volume; DRE, digital rectal examination
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