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Live Web Conference with Panel of HoLAP Experts On the Cutting Edge:  Holmium Laser Ablation for BPH
<ul><li>Ramsay L. Kuo, MD </li></ul>Web Conference Presenters Director St. Peter’s Hospital Kidney Stone Center Albany, NY
<ul><li>Glenn M. Preminger, MD </li></ul>Web Conference Presenters Professor of Urologic Surgery Director, Comprehensive K...
<ul><li>Surendra M. Kumar, MD </li></ul>Web Conference Presenters Staff Urologist Department of Urology Oakwood Annapolis ...
<ul><li>Steven R. Previte, MD </li></ul>Web Conference Presenters Clinical Associate Professor Boston University School of...
<ul><li>Holmium laser physics </li></ul><ul><ul><li>Holmium vs. KTP (GreenLight PVP) </li></ul></ul><ul><li>HoLAP indicati...
Holmium Laser Physics <ul><li>2140 nm wavelength </li></ul><ul><li>Acts via thermal vaporization </li></ul><ul><li>Tissue ...
Holmium Laser Physics Nd:YAG Yellow  KTP Red  Holmium Blue <ul><li>Holmium energy has shallowest penetration depth of lase...
Holmium Laser Physics > 5 mm away Coagulation Cutting and ablating No tissue effect Near contact or defocused Contact <ul>...
Comparison of Ablation Modalities 50 amp, 220V 120V Power requirements 600µ ADDStat 550µ DuoTome Laser fiber Stone fragmen...
<ul><li>Energy absorption </li></ul><ul><ul><li>Holmium preferentially absorbed by  water , KTP by  hemoglobin </li></ul><...
HoLAP vs. GreenLight PVP (KTP)  Key Differences <ul><li>Ease of use </li></ul><ul><ul><li>GreenLight PVP unit requires ded...
HoLAP vs. GreenLight PVP (KTP) Key Differences <ul><li>Versatility </li></ul><ul><ul><li>KTP has no effect on stones, unab...
HoLAP Indications <ul><li>Identical to those for TURP </li></ul><ul><ul><li>Can treat a wide variety of gland sizes </li><...
<ul><li>Essential tests: </li></ul><ul><li>Patient history and physical (including DRE) </li></ul><ul><li>Total PSA  </li>...
<ul><li>Optional tests: </li></ul><ul><li>Uroflowmetry </li></ul><ul><li>TRUS volume estimation of prostate </li></ul><ul>...
HoLAP Equipment VersaPulse PowerSuite 100 watt unit DuoTome 550 µ side-firing fiber   <ul><li>70° incident angle </li></ul...
HoLAP Equipment <ul><li>Continuous flow resectoscope </li></ul><ul><ul><li>In conjunction with camera, light source, monit...
HoLAP Equipment <ul><li>Irrigant </li></ul><ul><ul><li>Normal saline  </li></ul></ul><ul><ul><li>Water </li></ul></ul><ul>...
HoLAP Technique <ul><li>Aperture of  DuoTome fiber points toward prostate surface (red arrow) </li></ul><ul><li>Always kee...
HoLAP Technique <ul><li>Endoscopic view of DuoTome fiber with aiming beam and aperture of fiber tip directed at prostate s...
HoLAP Technique <ul><li>100-watt laser: </li></ul><ul><li>Aiming beam on full </li></ul><ul><li>Ablation </li></ul><ul><ul...
HoLAP Technique <ul><li>Key point: </li></ul><ul><ul><li>DEFINE THE LEVEL OF THE CAPSULE INITIALLY </li></ul></ul><ul><ul>...
HoLAP Technique Proximal Lobe Ablation <ul><li>Initial ablation of proximal median lobe near bladder neck </li></ul><ul><l...
HoLAP Technique Proximal Lobe Ablation <ul><li>Proceed with lateral lobe ablation working proximal to distal </li></ul><ul...
HoLAP Technique Creation of Grooves <ul><li>Initial grooves created along sulci lateral to median lobe (7 and 5 o’clock) <...
HoLAP Technique Creation of Grooves <ul><li>Proceed with lateral lobe ablation working proximal to distal </li></ul><ul><l...
HoLAP Technique <ul><li>When starting treatment of each lobe, hold tip over surface of prostate and rotate tip of fiber ba...
HoLAP Troubleshooting <ul><li>Avoid burying fiber tip into tissue (speeds cap degradation) </li></ul><ul><li>Increase ener...
HoLAP Troubleshooting Control of bleeding points: <ul><li>“ Defocus” beam by holding tip of fiber 1-2 mm from bleeding poi...
HoLAP Post-op <ul><li>3 Months Post-op </li></ul>Immediate Post-op
Long-term HoLAP Results <ul><li>Tan, et al: BJU Int  92:707-9, 2003 </li></ul><ul><ul><li>79 patients (mean age 67 years, ...
Long-term HoLAP Results Tan, et al: BJU Int  92:707-9, 2003 <ul><li>5/34 pts (15%) required reoperation (1 BNI, 1 TURP, 2 ...
Long-term HoLAP Results Summary <ul><li>HoLAP resulted in: </li></ul><ul><ul><li>83% improvement in Qmax </li></ul></ul><u...
HoLAP vs. TURP Experience <ul><li>No clinically significant bleeding during or after procedure </li></ul><ul><ul><li>Bette...
HoLAP vs. TURP Experience <ul><li>No post-op pain </li></ul><ul><ul><li>Narcotics not needed </li></ul></ul><ul><li>HoLAP ...
HoLAP vs. PVP Experience <ul><li>Efficiency and hemostasis seem equivalent with smaller glands </li></ul><ul><li>HoLAP mor...
HoLAP vs. PVP Experience <ul><li>PVP post-op irritative symptoms more pronounced </li></ul><ul><ul><li>Especially when cap...
HoLAP vs. PVP Experience <ul><li>Delayed bleeding has occurred after PVP of larger glands </li></ul><ul><ul><li>None after...
HoLAP vs. PVP Additional Benefits <ul><li>Holmium laser is mobile, PVP is not -  Does not require water cooling  - Does no...
Getting Started with HoLAP <ul><li>Observe at least 2 to 3 cases </li></ul><ul><li>Optimally, have 2 cases mentored </li><...
Panel Conclusion <ul><li>The holmium laser has proven to be a versatile tool, with HoLAP providing advantages that make th...
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Holmium Laser Ablation of the Prostate webinar slides

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Presentation on an effective laser technique used to treat enlarged prostate glands

Holmium Laser Ablation of the Prostate webinar slides

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

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