Holmium Laser Ablation of the Prostate webinar slides

Live Web Conference with Panel of HoLAP Experts On the Cutting Edge: Holmium Laser Ablation for BPH

Ramsay L. Kuo, MD
Web Conference Presenters Director St. Peter’s Hospital Kidney Stone Center Albany, NY

Glenn M. Preminger, MD
Web Conference Presenters Professor of Urologic Surgery Director, Comprehensive Kidney Stone Center Duke University Medical Center Durham, NC

Surendra M. Kumar, MD
Web Conference Presenters Staff Urologist Department of Urology Oakwood Annapolis Hospital St. Joseph Mercy Hospital Ann Arbor, MI

Steven R. Previte, MD
Web Conference Presenters Clinical Associate Professor Boston University School of Medicine Assistant Clinical Professor Tufts 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

Holmium 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 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 50 amp, 220V 120V Power requirements 600µ ADDStat 550µ DuoTome Laser fiber Stone fragmentation Laser cooling system Penetration depth Absorption medium Wavelength No Yes External water Contained water to air exchange 1-2 mm 0.5 mm Hemoglobin Water 532 nm 2140 nm KTP (GreenLight) Holmium

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

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

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 550 µ 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 Technique Proximal 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 Technique Proximal Lobe Ablation
Proceed with lateral lobe ablation working proximal to distal
Do not aggressively ablate tissue at apex of lateral lobes

HoLAP Technique Creation 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 Technique Creation 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) 550 µ 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
5/34 pts (15%) required reoperation (1 BNI, 1 TURP, 2 HoLEP, 1 bladder stone removal)
34 79 79 79 N 15.2 9.4 1 month 14.5 8.3 3 months 10.0 18.8 Mean AUA SS Mean Qmax (ml/sec) 16.8 9.2 7 years Baseline

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

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

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.

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Holmium Laser Ablation of the Prostate webinar slides

by Ramsay Kuo on Oct 03, 2009

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Holmium Laser Ablation of the Prostate webinar slides — Presentation Transcript