Post on 21-Dec-2014
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Live Web Conference with Panel of HoLAP Experts
On the Cutting Edge: Holmium Laser Ablation for BPH
Ramsay L. Kuo, MD
Web Conference Presenters
DirectorSt. Peter’s Hospital Kidney Stone
CenterAlbany, NY
Glenn M. Preminger, MD
Web Conference Presenters
Professor of Urologic SurgeryDirector, Comprehensive Kidney Stone Center
Duke University Medical CenterDurham, NC
Surendra M. Kumar, MD
Web Conference Presenters
Staff Urologist Department of Urology
Oakwood Annapolis HospitalSt. Joseph Mercy Hospital
Ann Arbor, MI
Steven R. Previte, MD
Web Conference Presenters
Clinical Associate Professor Boston University School of Medicine
Assistant Clinical ProfessorTufts University School of Medicine
Boston, MA
• 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
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
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
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
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
• 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
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
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)
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
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
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
HoLAP Equipment
VersaPulse PowerSuite 100 watt unit
DuoTome 550µ side-firing fiber
• 70° incident angle• 7.2F outer diameter
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
HoLAP Equipment
• Irrigant
– Normal saline
– Water
• Both allow clear visualization; normal saline completely eliminates any risk of dilutional hyponatremia (TUR syndrome)
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)
HoLAP Technique
• Endoscopic view of DuoTome fiber with aiming beam and aperture of fiber tip directed at prostate surface
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
HoLAP Technique
• Key point:
– DEFINE THE LEVEL OF THE CAPSULE INITIALLY
Two methods:
1. Proximal lobe ablation
2. Creation of floor grooves
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
HoLAP TechniqueProximal Lobe Ablation
• Proceed with lateral lobe ablation working proximal to distal
• Do not aggressively ablate tissue at apex of lateral lobes
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
HoLAP TechniqueCreation of Grooves
• Proceed with lateral lobe ablation working proximal to distal
• Do not aggressively ablate tissue at apex of lateral lobes
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
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:
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
HoLAP Post-op
3 Months Post-op
Immediate Post-op
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
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)
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
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
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
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
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
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
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
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
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.
Thank You
Questions?