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Laser Surgery


Benign prostatic hyperplasia (BPH) is a non cancerous condition characterised by a gradual increase of glandular and fibromuscular tissue in the central area of the prostate.  Approximately 50% of men older than 60 years have significant symptoms of bladder outflow obstruction affecting their quality of life.  Lower urinary tract symptoms that occur secondary to BPH are either obstructive or irritative in nature.  The obstructive symptoms include hesitancy, reduced stream, a feeling of incomplete emptying and a post micturition dribble.  The irritative symptoms include nocturia, frequency, urgency and urge incontinence.  Investigations used for assessment include urinalysis or MSU, serum creatinine, ultrasound of the urinary tract and PSA.  Other investigations which may be required include a urinary flow rate, urodynamic evaluation or cystoscopy.  Treatment is tailored according to the degree of bother, severity of urinary symptoms and the wishes of the patient with a full discussion of the options available.  These options of management include pharmacological management in the form of alpha adrenergic blocking agents.  The commonly used agents are Prasozin (Minipress) and Tamsulosin (Flomax).  Five alpha reductase inhibitors (Proscar) can also be used in selective patients to decrease the size of the prostate.

The traditional surgical option used is a trans-urethral resection of the prostate.  A recent advance has been the use of a Holmium laser to resect the prostate.  This Holmium laser has been used by Dr Kooner in over 500 cases.  The Holmium laser achieves the same cavity as a TURP (transurethral resection of prostate) in a relatively bloodless manner.  Its advantages are a significantly decreased catheterisation time, reduced bleeding, decreased hospitalization, sustained effects and patients ability to go back to unrestricted activities sooner than following a TURP.  The disadvantage of the Holmium laser is the cost of the initial capital outlay.  St Vincent's Hospital committed to this technology in 2002 with the purchase of a 100 watt Holmium laser machine.  It has been used extensively by the principal user, Dr Kooner, over this time period with excellent results.  The results of the use of this machine have been presented at the New South Wales State Urology Meeting and the Australasian Annual Urology Scientific Meeting.  The author believes the use of the Holmium laser provides significant advantages over a standard TURP.  It is particularly useful for patients who are anticoagulated or patients who need to stay on Aspirin for their surgery due to cardiac conditions etcetera.  The results as regards improvement in flow rates and relief of symptoms are equivalent to a TURP.  The author hence believes that this technique has all the advantages of the traditional gold standard of a TURP with fewer side effects and hence is an option that should be discussed with patients when considering surgical treatment for BPH.  Multiple randomized trials performed throughout the world have shown this to be superior to a standard TURP.

The Holmium laser is also used to treat stones in the kidney with a flexible ureteroscope.  The usual indication for this are stones that have failed treatment with lithotripsy or radiolucent stones (unable to be seen on x-ray).  This has the advantages of offering a patient a relatively non invasive method of treatment rather than open surgery or a percutaneous approach.  The Holmium laser has been used on over 300 patients with complex stones in the upper ureter and kidney.  These results have been presented at the New South Wales Urology State Meeting and the Annual Australasian Urology Scientific Meeting by Dr Kooner.

Other current new technologies that are used by Dr Kooner at St Vincent's Hospital include laparoscopic surgery for kidney and adrenal tumours resulting in decreased hospitalization and earlier recovery and advances in the operation of radical prostatectomy which is now performed with robot assistance by Dr Kooner.  These advances include using a nerve stimulator to preserve the neurovascular bundle or resecting the nerves widely in aggressive prostate tumours and performing a sural nerve graft.  These new techniques are aimed at improving erectile function post-operatively.

In conclusion, many significant recent advances in urology are now available at the St Vincent's Hospital campus.  Dr Kooner believes the Holmium laser offers significant advances over traditional methods of treatment for BPH.  He has performed the greatest number of laser prostate surgeries in New South Wales (both Greenlight and Holmium) and is in a unique position as can offer patients a variety of prostatic treatments for benign prostatic hyperplasia including TURP, laser surgery (Greenlight and Holmium), transurethral vaporization of the prostate (TUVP: presented in an international urology meeting) and transurethral needle ablation of the prostate (TUNA).  Patients’ treatments can hence be individualized thus providing optimal ‘state of art’ care with scientifically validated treatments backed up by personal results.

Further Information

Holmium Laser Enucleation of the Prostate is a relatively new technique to treat the prostate.  It allows an excellent clearance of the prostate with minimal blood loss and rapid recovery.  It is the only technology currently proven to be superior in randomised trials to a TURP.  There is a shorter catheterisation time and less bleeding.  As opposed to other laser treatments, tissue is retrieved for full histopathological analysis.  Five year results are now available with this technology proving its durability.  The Holmium laser uses a unique wavelength that provides both cutting and coagulation properties.  Normal saline is used for irrigation and hence there is no risk of developing a TURP Syndrome (over absorption of fluid). 

Dr Kooner has been performing this procedure at St Vincent’s Private Hospital for approximately eight years.  He has the largest experience in this area in NSW and has presented this data at the Australasian Urological Society Meeting in 2005.  The Holmium laser does take slightly longer to perform than a standard trans-urethral resection of the prostate and it is more capital intensive.  St Vincent’s Private Hospital have fortunately supported this technology introduced by Dr Kooner to the hospital and they have purchased the Holmium laser enabling patients to benefit from this new technology.  The catheterisation time is usually 24 hours and patients normally require two nights in hospital.  This can be reduced to an overnight stay in certain cases.  As opposed to other laser treatments it is applicable for use on all prostate sizes.  Holmium enucleation requires significant technical skill to obtain excellent results.  It is more demanding than other forms of laser treatment.  This, and the capital cost of the laser machine is the reason that it is not offered by many surgeons but it has been consistently shown to be superior to a TURP. 
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Greenlight Laser is a new side firing laser treatment which has recently been introduced to St Vincent’s Private Hospital.  It involves the laser being fired from the side of the laser fibre to vaporize prostate tissue.  Lasers such as these were initially used for prostate surgery approximately ten to fifteen years ago although the new Greenlight Laser has a different wavelength that allows more efficient vaporization of tissue.  There is minimal bleeding with this procedure and it is ideal for small prostates as a limited amount of tissue can be vaporized.  As tissue vaporizes no tissue is retrieved for histopathology.  As this is a relatively new technique long term data is not available although initial results are encouraging.   It is relatively easy to learn and perform unlike holmium enucleation. 
For further information

The Successful Application of the Holmium Laser for
Urological Procedures

Raji Kooner. St Vincent's Hospital, Darlinghurst, Sydney.

Introduction:  The Holmium laser, with its coagulative and cutting qualities, has uses in a variety of urological procedures.

Aim: To assess the use and success of the Holmium laser at a single institution by one surgeon.

Method: Data prospectively collected from Aug 1999 to Aug 2004. All laser cases were logged. The rate and energy were individualised to each case.

Results: 145 laser prostate treatments were performed. These required no transfusions, and incurred no secondary bleeds, TUR syndrome or incontinence. There were 2 bladder neck contractures and 2 cases of prolonged urgency. Anticoagulated patients were included.

The Holmium laser was also applied in 182 cases of ureteroscopy and pyeloscopy for the fragmentation and total removal of both ureteric and renal stones (in cases unsuitable for ESWL, cysteine stones, coagulopathy, solitary kidneys and large uric acid stones). There were no ureteric injuries or conversions to open operations in all 182 cases. Two failures were managed with laparoscopic removal of the stone and removal via partial nephrectomy respectively.

11 patients underwent vaporisation for large bladder stones.

13 cases of PUJ obstruction and 7 ureteric and anastomotic strictures( ureteric reimplantation-2, ileal conduit-2, neobladder-1, ureteric stricture-2) were performed. The Holmium laser was further applied in 2 bladder tumours (in frail patients utilizing flexible cystoscope), 3 anticoagulated patients with urethral strictures, 3 ureteric tumours, 1 case of penile warts, 1 partial nephrectomy and 1 encrusted urethral stent.

Conclusion: The Holmium laser can be used successfully in a variety of conditions. It is a precise and versatile urological tool that provides excellent haemostasis rendering it especially useful in anticoagulated patients. Patients with BPH, ureteric and renal stones should be offered this option. The Holmium laser is also ideal for ureteric anastomotic or congenital strictures and has new use in the treatment of large bladder stones.