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Holmium Laser Ablation Versus Photoselective Vaporization ofProstate Less Than 60 cc: Long-Term Results of aRanomize Trial

Hazem M. Elmansy, Ehab Elzayat and Mostafa M. Elhilali*,

From the Division of Urology, Department of Surgery,Faculty of Medicine,McGill University, Montreal, Quebec,Canada

Purpose: We evaluated the long-term results and durability of photoselective

vaporization and holmium laser ablation as surgical treatment of small to me-

dium prostates in a prospective, randomized study in men ith obstructive

benignprostatic hyperplasia.

!aterials an !ethos: !rom March "##$ to %pril "##& e randomly allocated'#( patients ith a prostate gland of less than )# cc to prostate photoselectivevaporization $"+ or holmium laser ablation $&+ and evaluated them ', " and

years postoperatively. !unctional folloup included measurement of maimum

urinary flo rate, post-void residual urine, nternational /rostate 0ymptom

0core, 1uality of life, nternational nde of Erectile !unction and prostate

specific antigen.

Results: Mean 02preoperativeprostatevolumeas.' '3.$and&.

'.) in the laser ablation and vaporization groups, respectively. %ll functional

parameters improved significantly compared to baseline values in each group.

4here as no difference in nternational /rostate 0ymptom 0core, 1uality of life,

maimum urinary flo rate, post-void residual urine or percent of prostate

specific antigen decrease beteen the " groups ', " and years postoperatively.%t -year folloup nternational /rostate 0ymptom 0core had improved by

.$5, 1uality of life had improved by )(.35, maimum urinary flo rate had

increased by ')35 and post-void residual urine had decreased by 6'5 in the

holmium laser ablation group. n the photoselective vaporization group nterna-

tional /rostate 0ymptom 0core improved by )3.'5, 1uality of life improved by

)$.$5, maimum urinary flo rate increased by '6(5 and post-void residual

urine decreasedby &(.$5. 4he overall re-treatment rate as '$.65 for holmium

laser ablation vs '(.5 for photoselective vaporization.

"onclusions: /rostate photoselective vaporization and holmium laser ablation

are effective surgical treatments for benign prostatic hyperplasia. /ostoperativefunctional improvements ere significant and durable, and e1uivalent in the "

groups. 4he " techni1ues have a similar complication rate.

Abbreviations

an Acron#ms

7/H benign

prostatic hyperplasia

Ho8%/ holmium laser ablation

of prostate

Ho8E/ holmium

laser enucleation of

prostate

E! nternational nde of

Erectile !unction

-/00 nternational /rostate

0ymptom 0core

8940 loer urinary

tract symptoms

/0% prostatic specific antigen

/:/ photoselective

vaporization of prostate

/:; post-void residual

urine volume

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2=?'#.'#')DK.Kuro."#'#.#).'#&

www!urologycom &0&'

http://www.jurology.com/http://www.jurology.com/

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&0&( H=8M9M 8%0E; %78%4=F :E;090 /H=4=0E8E>4:E :%/=;L%4=F =! /;=04%4E

Hoever, the most concerning aspect about minimally

invasive techni1ues is the possible high recurrence

rate and the need for re-treatment due to treatment

failure ith time.$

;ecently ongoing advances in laser technology

have resulted in ne technical refinements and de-

vices, and their effective application for surgical

treatment of symptomatic 7/H.)

9se of the 4/

laser ith a avelength of $" nm to vaporize pros-

tatic adenoma is referred to as /:/. 2oubling the

fre1uency of pulsed Fd?%@ laser energy ith a

4/ crystal led to the production of a $" nm ave-

length laser, hich is selectively absorbed by hemo-

globin, leading to rapid tissue vaporization ith only

a ' to " mm rim of coagulation using optimal tech-

ni1ue.&

/:/ leads to immediate, sustained improvement

in subKective and obKective voiding parameters. 4helate complication rate is comparable to that of

49;/.6,(

/:/ provides durable results ith

durable improvements in functional outcome

parameters.

Hoever, the clinical functional outcome in smaller

or larger prostates treated ith /:/ may be dispro-

portionate.6

8ong-term data on the durability of /:/

for 8940 secondary to 7/H are still sparse.(

4he most

favorable aspect of /:/ is safe, effective applicationin

patients on anticoagulation, eg arfarin, and anti-platelet agents, eg aspirin and clopidogrel, hile con-

tinuing medication mostly in an outpatientsetting.'#

4he Ho?%@ laser is a pulsed solid-state laser

ith a ",'3# nm avelength. 4his produces vapor-

ization ithout deep coagulation hen used ith aside firing fiber, and provides the striNing surgical

effect of a precise incision and enucleation hile

maintaining hemostasis hen used ith an end

firing fiber.''

Ho8%/ as the first procedure using

the holmium avelength alone for laser prostatec-

tomy.'"

Ho8%/ and /:/ are easy to learn but Ho8%/

re1uires longer operative time.'

/:/ and Ho8%/

are best suited to small or medium prostates sinceotherise they re1uire much longer operative time

and more than ' fiber ith reoperation needed inmore patients. 4his may raise concern about theeconomic aspect of these procedures compared

ith standard 49;/.'3,'$

% controversial aspect concerning /:/ and

Ho8%/ compared to 49;/ is the lacN of tissue for

histopathological eamination ith the risN of miss-

ing the diagnosis ofprostatic carcinoma. 4hus, it is

mandatory to thoroughly evaluate patients ith in-

creased /0% or abnormal digital rectal eamination

necessitating transrectal ultrasound guided biopsybefore the intervention, hen indicated. t is also

mandatory to continue postoperative /0% and digi-

tal rectal eamination surveillance.6,(,'),'&

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!AT)R*AL+ A, !)TH.+

!rom March "##$ to %pril "##& e randomly allocated

'#( patients ith loer urinary tract symptoms second-

ary to 7/H ith a prostate gland of lessthan)# cc to /:/

$"+ or Ho8%/ $&+. 4he hospital ethics committee ap-

proved the protocol. %ll patients ere treated or super-

vised by ' surgeon MME+ at the 2ivision of 9rology,

2epartment of 0urgery, Mc@ill 9niversity Health>enter.

0hort-term results, instruments and surgical techni1ues

ere previously described.',

8ong-term folloup as done ', " and yearspostop-

eratively. /atients presenting for folloupere re1uested

to complete the -/00hanges in preoperative

and postoperative outcomeparameters ere compared

using the paired 0tu- dent t test. =utcome parameters in

each group erecom- pared using the unpaired 0tudent t

test. 4hecomplication rate in the groups as compared

ith the "-tailed chi- s1uare or !isher eact test.

R)+/LT+

We noted no statistical difference in baseline char-

acteristics beteen the " groups *table '+. Mean

preoperative prostate volume as .' '3.$ and

&. '.) in the Ho8%/ and /:/ groups, and

mean folloup as 3#.#& 6.33 and 3". &.&

months, respectively.

-ata

Operative. 4able ' lists the main operative data.

Ho8%/ re1uired '3 minutes more operative time than

/:/, hich as significantly different p #.##6+.

Outcome and followup. :oiding parameters sig-

nificantly improved immediately after surgery and

continued to do so during folloup in each group

table "+. %t ', " and -year folloup e had data on

$ and $', $" and $', and $' and $# patients in the

Ho8%/ and /:/ groups, respectively. %t 3-year fol-

loup '& patients #5+ ith Ho8%/ and " 335+

ith /:/ ere available for evaluation. %t -year

folloup in the Ho8%/ vs the /:/ group mean

-/00 had improved from "# to $.( .$5+ vs from

'6.3 to ).) )3.'5+, mean

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>hronic atrial fibrillation "

/rosthetic heart valves ' #

Myocardial infarction " 3

2eep venous thrombosis # '

%ortic aneurysm ' #

Hemophilia # '

H=8M9M 8%0E; %78%4=F :E;090 /H=4=0E8E>4:E :%/=;L%4=F =! /;=04%4E &0&

Table 12 "aseline preoperative characteristics and operative data on patients with #o$%& and &'&

:ariable Ho8%/ /:/ p :alue

Mean 02 age range+ &".& '#. $'('+ &'.) '#. $'66+ #.$)Fo. indication *5+?

8940 failed medical treatment 3) *6#.&+ 3" *6#.&+ #.36

9rinary retention '' *'(.+ 6 *'$.+ #.""

Hematuria # " 3+ #."#Fo. anticoagulant *5+ & *'"."+ 6 *'$.+ #."#

Fo. anticoagulant indication *5+?

Mean 02 cc transrectal ultrasound volrange+ .' '3.$ '#)#+ &. '.) '$)#+ #.'"Mean 02 ngDml /0% range+ ".6 "." #.366.(+ ".' '.6 #."$(.$+ #.''Mean 02 -/00 range+ "# ).6 6$+ '6.3 ).) 6+ #.)Mean 02

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groups.

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Ho8%/ &.$ ". &.& '.& &.$ '.6 &.' '.6/:/ ).6 ".6 ).& ".$ ).) ".) ).) '.(

p :alue #.' #.#6 #.' #.')esire function? Fot significant

Ho8%/ &.' '.6 )." '.( ).3 '.) ).3 '.3

/:/ ). ".# ).$ '.( ).6 '.& ).6 '.3

p :alue #.'" #.) #.$ #.""

ntercourse satisfaction? Fot significant

Ho8%/ (.6 .& 6.& ".) 6.& ".( 6. ".3

/:/ 6.( .) 6.) .) 6.' ". &.( ".)

p :alue #.' #.( #.3" #.3

verall satisfaction? Fot significant

Ho8%/ &.' ".$ &.3 ".# &. '.6 &.# '.&/:/ ). .# ).$ ".& ).3 ".' ).) '.(

p :alue #."$ #.'3 #.' #."&

9rge incontinence ' '.65+ " .65+ #.$#

9rethral stricture " .$5+ $.65+ #.$&7ladder necN contracture $.5+ 3 &.&5+ #.)#

;eoperation 3 *&5+ $.65+ #.6#

/rostate >a ' '.65+ " .65+ #.$#

&0&6 H=8M9M 8%0E; %78%4=F :E;090 /H=4=0E8E>4:E :%/=;L%4=F =! /;=04%4E

Table &2 &retreatment and posttreatment sub!ective and ob!ective voiding parameters, and (()F domainchanges in #o$%& and

&'& groups

Mean 02 /reop range+ Mean 02 ' r range+ Mean 02" rs range+ Mean 02 rs range+ p :alue

'oidingparameters

-/00? #.###'Ho8%/

"# ).6 6$+ &.' 3.& #"#+ ).# $.) #"6+ $.( $.' *#"#+/:/ '6.3 ).) 6+ 6.' ).# #")+ &. $." #"$+ ).) $." *#"3+

p :alue #.) #. #." #.33

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/:/ leads to immediate, sustained improvement insub-

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H=8M9M 8%0E; %78%4=F :E;090 /H=4=0E8E>4:E :%/=;L%4=F =! /;=04%4E &0&3

Kective and obKective voiding parameters that lasts

up to $ years. n different prostate size subgroups

less than 3# and 3# to 6# ml+ -/00 improved by

)35 and $&5, and

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&0&4 H=8M9M 8%0E; %78%4=F :E;090 /H=4=0E8E>4:E :%/=;L%4=F =! /;=04%4E

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