2005

Outpatient Laser Surgery of the Prostate for Bladder Outlet Obstruction Due to Benign Prostatic Hyperplasia

Points to Remember

• Benign prostatic hyperplasia (BPH) is common and causes obstructive symptoms in 40% of men in their 50s and 90% of men in their 80s.
• Photoselective vaporization of the prostate (PVP) is outpatient laser surgery that is emerging as a desirable alternative to traditional surgical treatments for BPH.
• PVP offers long-term benefits. After 5 years, patients who undergo PVP have persistent improvement in urinary flow rates and decreased symptoms of urinary obstruction.

Scope of Problem

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that often leads to bladder outlet obstruction and restriction of urine flow. Symptoms may include frequent urination (especially at night), urgency, burning or pain during urination, leakage of urine, and diminished stream.

BPH is a natural consequence of aging. Each year, approximately 2 million men in the United States seek treatment for it. An estimated 40% of men in their 50s and 90% of men in their 80s experience symptoms of BPH. The prevalence of BPH is expected to increase in the United States as more men live longer.

Limitations of Standard Treatments

First-line medical approaches include watchful waiting and long-term therapy with medication. a-Blockers relax the bladder outlet muscles and make urination easier. However, their adverse effects include orthostatic hypotension and failure to ejaculate. Finasteride may improve symptoms because it reduces prostate size. a-Blockers and finasteride may be prescribed individually or in combination. Unfortunately, these medications often fail to provide lasting benefits.

Minimally invasive procedures include transurethral needle ablation, transurethral microwave therapy, and interstitial laser coagulation. These procedures often require several weeks for patients to become comfortable with urination and may require the use of indwelling catheters for days to weeks afterwards.

When medical or minimally invasive treatments are not adequate, surgical intervention may be necessary. Transurethral resection of the prostate (TURP) has been the gold standard surgical treatment for decades. However, up to 25% of patients may experience complications after TURP, including excessive bleeding, urinary incontinence, retrograde ejaculation, and sexual impotence. TURP also subjects patients to risks inherent in any surgical procedure, as well as a hospital stay of 1 to 4 days and recovery time of 4 to 6 weeks.

A New Approach: PVP Laser Technique

Photoselective vaporization of the prostate (PVP) is transurethral resection of the prostate that uses a high-energy potassium-titanyl-phosphate (KTP) laser to vaporize the obstructive tissue and provide relief of symptoms. This form of laser energy is uniquely powerful enough to eradicate the obstructive portion of BPH while minimizing damage to healthy tissue. Mayo Clinic urologists began using the technique of PVP laser therapy in 1997. Overall, patients are highly satisfied with the outcome of PVP, which is now a frequently used surgical treatment of obstructive BPH at Mayo Clinic in Rochester (Figure).

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Advantages

• A Mayo Clinic study published in the Journal of Urology in 2000 showed that complications with PVP were mild and infrequent in 55 patients followed up for 2 years. There were no intraoperative or immediate postoperative problems.
• The period during which the patient is fully catheterized is shorter, generally less than 24 hours with PVP vs days and occasionally weeks after other procedures. Up to 30% of PVP patients may not need any catheterization postoperatively.
• Patients are generally treated in an outpatient setting.
• Patients resume light activity (such as office work) within 2 to 3 days and vigorous activity within 4 to 6 weeks.
• No incidence of postoperative impotence has been seen, and the incidence of retrograde ejaculation has been greatly reduced.
• The reoperation rate is low. None was required in Mayo's 5-year study.

Limitations

• Investment in PVP laser equipment is required.
• Effective use of PVP has a learning curve, and the procedure should be performed only by urologists with adequate training in the technique. Mayo Clinic and several other medical centers offer courses in PVP for interested urologists.

Candidates for PVP

Any patient with bladder outlet obstruction due to an enlarged prostate who is a candidate for minimally invasive procedures or TURP may have PVP. Patients with obstructive prostate glands larger than 250 cm3 generally are not suitable candidates for PVP or other transurethral surgical procedures. They require open surgical procedures (eg, enucleation). Patients with neurogenic bladder disorders are more likely to experience urinary control problems after PVP, just as they would after TURP, and are not good candidates for either procedure.