holmium laser ablation of the prostate webinar slides
DESCRIPTION
Presentation on an effective laser technique used to treat enlarged prostate glandsTRANSCRIPT
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Live Web Conference with Panel of HoLAP Experts
On the Cutting Edge: Holmium Laser Ablation for BPH
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Ramsay L. Kuo, MD
Web Conference Presenters
DirectorSt. Peter’s Hospital Kidney Stone
CenterAlbany, NY
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Glenn M. Preminger, MD
Web Conference Presenters
Professor of Urologic SurgeryDirector, Comprehensive Kidney Stone Center
Duke University Medical CenterDurham, NC
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Surendra M. Kumar, MD
Web Conference Presenters
Staff Urologist Department of Urology
Oakwood Annapolis HospitalSt. Joseph Mercy Hospital
Ann Arbor, MI
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Steven R. Previte, MD
Web Conference Presenters
Clinical Associate Professor Boston University School of Medicine
Assistant Clinical ProfessorTufts University School of Medicine
Boston, MA
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• Holmium laser physics– Holmium vs. KTP (GreenLight PVP)
• HoLAP indications and pre-operative patient evaluation
• HoLAP equipment
• HoLAP techniques and tips
• HoLAP outcomes– Long-term results– Comparison with TURP and GreenLight PVP
Agenda
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Holmium Laser Physics
• 2140 nm wavelength
• Acts via thermal vaporization
• Tissue penetration only 0.5 mm in water (tissue)
• Can vaporize, cut, or coagulate tissue and fragment stones of any composition
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Penetration Depth (mm)
0 1 2 3 4 5 6
Holmium Laser PhysicsHolmium Laser Physics
Nd:YAG Yellow KTP Red Holmium Blue
• Holmium energy has shallowest penetration depth of laser wavelengths utilized for tissue ablation
• No significant coagulation necrosis (i.e. Nd:YAG for VLAP) causing dysuria, urinary retention
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Holmium Laser PhysicsHolmium Laser Physics
> 5 mm away
Coagulation
Cutting and ablating
No tissue effect
Near contact or defocused
Contact
• The holmium laser enables focused control of treatment with minimal collateral effect
• Hemostasis easily achieved with defocused beam
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Comparison of Ablation Modalities
Holmium KTP (GreenLight)
Wavelength 2140 nm 532 nm
Absorption medium Water Hemoglobin
Penetration depth 0.5 mm 1-2 mm
Power requirements 120V 50 amp, 220V
Laser cooling system Contained water to air exchange External water
Laser fiber 550µ DuoTome 600µ ADDStat
Stone fragmentation Yes No
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• Energy absorption– Holmium preferentially absorbed by water, KTP
by hemoglobin
– As ablation progresses deeper into gland, KTP slow because of less vascularized tissue near capsule
– Holmium has better safety profile as energy is dissipated by water (i.e. if fiber tip held few mm away from tissue, no effect)
HoLAP vs. GreenLight PVP (KTP) Key Differences
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HoLAP vs. GreenLight PVP (KTP) Key Differences
• Ease of use
– GreenLight PVP unit requires dedicated water cooling and special plumbing modifications
– GreenLight PVP unit utilizes 50 Amp, 220 V circuit which is not standard OR power source
– KTP wavelength requires orange safety glasses, making bleeding points more difficult to visualize
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HoLAP vs. GreenLight PVP (KTP) Key Differences
• Versatility
– KTP has no effect on stones, unable to cleanly incise tissue
– Holmium has multiple applications such as stricture incision and stone fragmentation (important if concurrent bladder stones)
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HoLAP Indications
• Identical to those for TURP
– Can treat a wide variety of gland sizes
– Can simultaneously treat bladder calculi
– Hemostatic action of holmium wavelength enables treatment of coumadinized patients
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Essential tests:• Patient history and physical (including DRE)
• Total PSA – Patients with > 10 year life expectancy
• AUA symptom score– ≥ 8 considered moderate severity, should be
treated
• Urinalysis
Pre-operative Evaluation
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Optional tests:• Uroflowmetry
• TRUS volume estimation of prostate
• Post-void residual
• Cystoscopy– Assess for large median lobe and bladder calculi,
localize ureteral orifices
• Urodynamics– If history of urinary retention or suspicion of bladder
hypocontractility
Pre-operative Evaluation
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HoLAP Equipment
VersaPulse PowerSuite 100 watt unit
DuoTome 550µ side-firing fiber
• 70° incident angle• 7.2F outer diameter
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HoLAP Equipment
• Continuous flow resectoscope
– In conjunction with camera, light source, monitor
– 22-28F outer sheath (Storz, Olympus, Circon)
– Laser bridge stabilizes fiber tip and facilitates rotational motion over prostate surface
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HoLAP Equipment
• Irrigant
– Normal saline
– Water
• Both allow clear visualization; normal saline completely eliminates any risk of dilutional hyponatremia (TUR syndrome)
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HoLAP Technique
• Aperture of DuoTome fiber points toward prostate surface (red arrow)
• Always keep circumferential marker (blue arrow) within endoscopic view to prevent scope damage
• Do not extend fiber past cap anchor (black arrow)
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HoLAP Technique
• Endoscopic view of DuoTome fiber with aiming beam and aperture of fiber tip directed at prostate surface
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HoLAP Technique
100-watt laser:• Aiming beam on full• Ablation
– 2.0 J and 50 Hz – 3.2 J and 25 Hz
• Coagulation– 2.5 J and 40 Hz
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HoLAP Technique
• Key point:
– DEFINE THE LEVEL OF THE CAPSULE INITIALLY
Two methods:
1. Proximal lobe ablation
2. Creation of floor grooves
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HoLAP TechniqueProximal Lobe Ablation
• Initial ablation of proximal median lobe near bladder neck
• Can also be done at proximal lateral lobe if no significant median lobe
• Ablation deepened to capsular level (circumferential fibers)
• Median lobe ablation proceeds distally to verumontanum, matching initial depth defined proximally
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HoLAP TechniqueProximal Lobe Ablation
• Proceed with lateral lobe ablation working proximal to distal
• Do not aggressively ablate tissue at apex of lateral lobes
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HoLAP TechniqueCreation of Grooves
• Initial grooves created along sulci lateral to median lobe (7 and 5 o’clock)
• Grooves progress from bladder neck to verumontanum
• Deepen both grooves to level of surgical capsule
• Ablate median lobe between grooves
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HoLAP TechniqueCreation of Grooves
• Proceed with lateral lobe ablation working proximal to distal
• Do not aggressively ablate tissue at apex of lateral lobes
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HoLAP Technique
• When starting treatment of each lobe, hold tip over surface of prostate and rotate tip of fiber back and forth
• As ablation deepens toward capsular level then approach nodules or tags of tissue at their bases to free them
• Never bury the fiber tip into the tissue
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HoLAP Troubleshooting
• Avoid burying fiber tip into tissue (speeds cap degradation)
• Increase energy settings and reduce frequency (i.e. try 3.2 J and 25 Hz)
• Check appearance of fiber cap (may need to replace fiber in long cases)
• Do not focus on superficial tags of adenoma
Treatment rate is slowing:
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HoLAP Troubleshooting
Control of bleeding points:
• “Defocus” beam by holding tip of fiber 1-2 mm from bleeding point
• Vaporize tissue surrounding bleeding point to define it
• Utilize settings of 2.5 J and 40 Hz
• May use SlimLine (end-firing) 550µ fiber to provide more focused coagulation
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HoLAP Post-op
3 Months Post-op
Immediate Post-op
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Long-term HoLAP Results
Tan, et al: BJU Int 92:707-9, 2003
• 79 patients (mean age 67 years, mean TRUS volume 40.5 g) underwent HoLAP from 9/94 to 5/95
• 34 patients completed follow-up assessment (median 7.4 years of follow-up)
Long-term results of high-power holmium laser vaporization (ablation) of the prostate
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Long-term HoLAP Results
Tan, et al: BJU Int 92:707-9, 2003
34797979N
15.2
9.4
1 month
14.5
8.3
3 months
10.018.8Mean
AUA SS
Mean Qmax
(ml/sec)16.89.2
7 yearsBaseline
• 5/34 pts (15%) required reoperation (1 BNI, 1 TURP, 2 HoLEP, 1 bladder stone removal)
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Long-term HoLAP Results Summary
HoLAP resulted in:
• 83% improvement in Qmax
• 47% decrease in AUA symptom score
• Durable outcomes over 7 years
• 15% reoperation rate comparable to TURP
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HoLAP vs. TURP Experience
• No clinically significant bleeding during or after procedure– Better visualization
– Clear field of view
– No transfusions
• No risk of fluid absorption or hyponatremia– Superior safety profile
– Can treat high risk patients
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HoLAP vs. TURP Experience• No post-op pain
– Narcotics not needed
• HoLAP is outpatient procedure
– Longer hospital stay with TURP (usually overnight)
• HoLAP has short learning curve
• Continuous bladder irrigation often not needed
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HoLAP vs. PVP Experience
• Efficiency and hemostasis seem equivalent with smaller glands
• HoLAP more uniform vaporization rate regardless of prostate size
• PVP may start faster but end slower
– More efficient when surface is vascular
– Less efficient as you move deeper into tissue
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HoLAP vs. PVP Experience• PVP post-op irritative symptoms more pronounced
– Especially when capsule not reached
– When treating larger glands (> 40-50 cc)
– The bigger the gland, the greater the symptoms
– Symptoms may be present for extended periods
– Some patients need re-treatment for relief
• HoLAP better tolerated post-op
– Superficial penetration
– Less coagulative necrosis
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HoLAP vs. PVP Experience
• Delayed bleeding has occurred after PVP of larger glands
– None after HoLAP
• Orange glasses used for PVP are more difficult to work with
– Especially in presence of bleeding
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HoLAP vs. PVP Additional Benefits
• Holmium laser is mobile, PVP is not- Does not require water cooling - Does not require special electrical hookup
• Holmium laser is multipurpose, PVP is not- Stones, tumors, strictures
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Getting Started with HoLAP• Observe at least 2 to 3 cases
• Optimally, have 2 cases mentored
• Starting on your own
– 30 to 40 cc prostate glands
– Keep tip of DuoTome fiber in endoscopic view during treatment
– Rotate scope and fiber to gain access to tissue; avoid extending fiber too far beyond scope tip
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Panel Conclusion• The holmium laser has proven to be a
versatile tool, with HoLAP providing advantages that make the procedure our preferred choice for treating BPH
• HoLAP is safe and effective with little risk of complications even with larger glands, making it preferable to standard TURP and GreenLight PVP.
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Thank You
Questions?