Holmium laser

1. Presentant : Anugerah Afrianto (GRY)
JOURNAL READING
Holmium laser versus cold knife
visual internal urethrotomy for
management of short segment
urethral stricture:
a prospective randomized clinical trial

2. THE JOURNAL

3. ABSTRACT
Objectives
To report the safety and efficacy of holmium laser and compare its results with cold knife visual internal urethrotomy
(VIU) in the management of short segment urethral stricture.
Methods
This prospective randomized study included 66 male patients aged more than 18 years, with short segment bulbar
urethral strictures < 2 cm from March 2020 to March 2022. The patients were randomized into two groups each
containing 33 patients. In group A (Cold knife group), Sachse cold knife was used for stricture treatment. In group B
(Holmium group), internal urethrotomy was done with Ho:YAG laser. Patients were evaluated before the operation and
followed up after the operation at 1, 3, 6 and 12 months by physical examination, IPSS, PVR, Qmax and retrograde
urethrography.
Results
There was significant improvement in the mean values of IPSS, PVR and Qmax in both groups. There was no
significant difference between both groups in the mean values of IPSS, PVR and Qmax during follow-up visits.
However, at the end of follow-up at one year there was statistically significant difference between both groups in the
mean values of IPSS, PVR and Qmax due to higher recurrence rate in cold knife group than laser group. The overall
complication rate is significantly lower in laser group (p = 0.014).
Conclusion
Holmium laser VIU is an effective and safe treatment option for short segment urethral stricture with shorter operative
time, less complication rate and less recurrence than cold knife VIU.

4. PATIENT’S
SUMMARY
In this report :
We performed a prospective comparative study that report the safety and
efficacy of holmium laser and compare its results with cold knife visual
internal urethrotomy (VIU) in the management of short segment urethral
stricture. . The patients were randomized into two groups each containing 33
patients. In group A (Cold knife group), Sachse cold knife was used for
stricture treatment. In group B (Holmium group), internal urethrotomy was
done with Ho:YAG laser.

5. INTRODUCTION
Urethral stricture  Treatment challenges and patient
satisfaction issues  Various treatment modalities
Treatment Modalities:
 Dilatation
 Blind or direct vision urethrotomy
 Stent placement
 Urethroplasty with or without flaps or grafts
 Salvage perineal urethrostomy
 Sachse's urethrotome  80% success rate

6. INTRODUCTION
Laser Usage in Urethral Strictures 
 Types of lasers used  carbon dioxide, argon, diode, excimer,
Nd:YAG, KTP, and Ho:YAG
 Ho:YAG laser  newly introduced
Objective of the Study 
 Compare the efficacy and safety of Ho:YAG laser vs. cold knife in
managing short segment bulbar urethral strictures.

7. PATIENTS
AND
METHODS

8. MATERIALS & METHOD
 Prospective comparative study.
Study design
 Pediatric age group
 Patients with previous urethral
surgery or dilatation
 Patients with multiple strictures
 Patients with skeletal deformity
hindering lithotomy position
 Unfit for surgery and/or anesthesia
 Patients with bleeding tendency
and/or coagulopathy
Exclusion criteria:
 March 2020 to March 2022.
Study Duration
 80 male patients with bulbar
urethral strictures < 2 cm.
Participants:
 Institutional Review Board (IRB)
Aprroval

9. PATIENTS AND METHODS
 Group A: Cold knife urethrotomy
 Group B: Ho:YAG laser urethrotomy
Randomized  Closed envelop method
Groups
 Comparison of outcomes between
the two groups.
Data Analysis
 Pelvi-abdominal ultrasound  post-voiding residual (PVR) urine
estimation.
 Sono-urethrogram (7.5 MHz transducer)  degree of spongio-fibrosis.
Imaging Studies

10. POSTOPERATIVE
ASSESSMENT
 All Group  intra- and postoperative complications.
 Complications evaluation  bleeding, fever, and postoperative pain.
 Visual Analog Scale (VAS)  postoperative pain.

11. FOLLOW-UP AND OUTCOME
MEASUREMENTS
 Patients' follow-up
schedule:
 After catheter removal.
 At 1, 3, 6, and 12 months after
OP.
 Evaluation methods in each
follow-up visit:
 IPSS assessment, Ultrasound
examination, Uroflowmetry
 Retrograde urethrogram
 6 and 12 months of follow-up
period.
Successful treatment
• Spontaneous voiding without persistent
symptoms
• Significant Post-Void Residual (PVR) with
Qmax > 15 mL/s without auxiliary
maneuver.
Treatment failure:
• Obstructive lower urinary tract
symptoms.
• Qmax < 10 mL/s.
• Recurrent stricture by retrograde
urethrogram.
• Requirement for any auxiliary procedure

12. STATISTICAL ANALYSIS
 SPSS version 20.0
Software
 Categorical data  number and
percentage.
 Quantitative data  mean±SD.
Representation of Data
 normal distribution  Shapiro-Walk test.
Distribution
 Independent t-test  normally distributed data.
 Mann–Whitney U test  non-normally
distributed data.
Quantitative Independent Groups
 Chi-square test  comparison.
Qualitative Independent Multiple
Groups
 Repeated-measures ANOVA test
 Post hoc analysis  Bonferroni test  significant
differences
Preoperative and Postoperative
Results
•p value set at<0.05 for significant results.
•p value set at<0.001 for highly significant results.
Significance Levels

13. RESULTS
Patients flowchart in the
study

14. RESULTS
Patient demographics and clinical data
 mean age of patients in both
groups was (44.23±12.04 and
42.58±9.32 years)
 No significant difference between
groups in patient and stricture
characteristics.

15. RESULTS
Operative data and clinical outcomes
Cold knife group:
 Highly significant improvement in IPSS,
PVR, and Qmax at 1, 3, 6, and 12
months from preoperative measurements
(p<0.001)
Laser group:
 Highly significant improvement in IPSS,
PVR, and Qmax at 1, 3, 6, and 12
months from preoperative measurements
(p<0.001)

16. RESULTS
Post HOC analysis: comparison between serial measurement of IPSS, PVR and Qmax in each
group

17. RESULTS
Follow-Up Measurements:
 No significant difference  both groups in
follow-up mean values of IPSS, PVR, and Qmax at
1, 3, and 6 months.
Operative Time and Complications:
 Significantly shorter in Operative time (p<0.001) in laser group.
 Significantly lower in overall complication (p<0.001) in laser group.
Recurrence Rate:
 Significantly lower  at the end of
follow-up period in laser group
(p=0.021)
Cold knife group:
 Preoperative measurements  worst
 No significant difference  1, 3, 6, and 12
months.
Laser group:
 Preoperative measurements  worst
 No significant difference  1, 3, 6, and 12
months.
Post Hoc Analysis

18. DISCUSSION
Laser technology :
 Widely used in urology for various procedures:
 Endoscopic resection of benign prostatic hyperplasia or bladder
tumors
 Fragmenting renal or ureteric stones
 Treatment of urethral strictures
Advantages of Laser in Urethral Stricture Treatment:
 Less bleeding
 Shorter hospitalization time
 Lower complication rate

19. DISCUSSION
Minimizing Recurrence Risk  Removal of fibrotic tissues,
Avoidance of injury to healthy tissues
Holmium for Urethral Strictures :
 Holmium laser with wavelength of 2140 nm
 Short emission time of 0.25 mL/s
 Minimal thermal damage to normal tissues
Study Comparison :
 Laser urethrotomy  better, but no statistically significant difference
 Recent publications  laser urethrotomy is more effective and safer.

20. DISCUSSION

21. DISCUSSION
Yenice et al. :
 longer operative time
for laser group (21.9 ±
3.8 min)
This Study :
 laser group had shorter
operative time with
significant difference
Difference
 technical difficulty and lack
of experience with laser
treatment
Previous Study
 Consistent results
This Study :
 Dramatic improvement in mean values of
IPSS, PVR, and Qmax in both groups
 Significant difference  1 year follow-up
 Higher recurrence rate in cold knife group
Previous Study
 Consistent results
This Study :
 Lower in laser group  significant
difference

22. DISCUSSION
Urethroplasty  best treatment option for urethral stricture
removing all the scarred and fibrotic tissues  preventing recurrence.
VIU:
 Ease
 Simplicity
 Less invasiveness
 Short convalescence
 Suitability for short segment strictures
Main challenge  Inability to remove fibrotic tissues completely
Holmium Laser:
 vaporizes an impeachable part of the scarred tissues without affecting
healthy tissues

23. LIMITATION
Surgeon knows which arm the patient belongs to
 Bias is inevitable, unfortunately
Relatively small sample size and relatively short follow-up
period
Further studies
 Larger sample size and longer duration of follow-up.

24. CONCLUSION
HOLMIUM LASER VIU IS AN EFFECTIVE AND SAFE
TREATMENT OPTION FOR SHORT SEGMENT URETHRAL
STRICTURE WITH SHORTER OPERATIVE TIME, LESS
COMPLICATION RATE AND LESS RECURRENCE THAN COLD
KNIFE VIU.

25. CRITICAL APPRAISAL
1. Is the question posed by the author well defined? Yes
2. Are the methods appropriate and well described? Yes, Prospective
comparative study.
3. Are the data sound? Yes, the data were collected from 80 male
patients with bulbar urethral strictures < 2 cm.
4. Do the figures appear to be genuine, i.e. without evidence of
manipulation? Yes
5. Does the manuscript adhere to the relevant standards for
reporting and data deposition? Yes

26. CRITICAL APPRAISAL
6. Are the discussion and conclusion well balanced and adequately
supported by the data? Yes
7. Are limitation of the work clearly stated? Yes
8. Do the authors clearly acknowledge any work upon which they are
building, both published and unpublished? Yes
9. Do the title and abstract accurately convey what has been found?
Yes
10. Is the writing acceptable? Yes

27. Is this paper significant? YES___ NO___
New? YES___ NO___
Require statistical review? YES___ NO___

28. THANK YOU