Search

Aims To develop a nomogram predicting benign prostatic obstruction (BPO). Methods We included in this study 600 men with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) who underwent standardized pressure flow studies (PFS) between 1996 and 2000. Complete clinical and urodynamic data were available for all patients. Variables assessed in univariate and multivariate logistic regression models consisted of IPSS, PSA, prostate size, maximal urinary flow rate (Qmax) at free flow, residual urine (RU), and bladder wall thickness (BWT). These were used to predict significant BPO (defined as a Schäfer grade ≥ 3 in PFS). Results A preliminary multivariate model, including IPSS, Qmax at free flow and RU, suggested that only Qmax at free flow was a statistically significant predictor of BPO ( P = 0.00) with a predictive accuracy (PA) of 82%. Further development of the multivariate model showed how the inclusion of BWT did not increase PA. Only transitional zone volume (TZV) proved to be an additional statistically significant predictor for BPO ( P = 0.00). The combination of Qmax at free flow and TZV demonstrated a PA of 83.2% and were included in the final nomogram format. Conclusions We developed a clinical nomogram, which is both accurate and well calibrated, which can be helpful in the management of patients with LUTS and BPE. External validation is warranted to confirm our findings. Neurourol. Urodynam. 35:235-240, 2016. © 2014 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Context Lower urinary tract symptoms (LUTS) represent one of the most common clinical complaints in adult men and have multifactorial aetiology. Objective To develop European Association of Urology (EAU) guidelines on the assessment of men with non-neurogenic LUTS. Evidence acquisition A structured literature search on the assessment of non-neurogenic male LUTS was conducted. Articles with the highest available level of evidence were selected. The Delphi technique consensus approach was used to develop the recommendations. Evidence synthesis As a routine part of the initial assessment of male LUTS, a medical history must be taken, a validated symptom score questionnaire with quality-of-life question(s) should be completed, a physical examination including digital rectal examination should be performed, urinalysis must be ordered, post-void residual urine (PVR) should be measured, and uroflowmetry may be performed. Micturition frequency-volume charts or bladder diaries should be used to assess male LUTS with a prominent storage component or nocturia. Prostate-specific antigen (PSA) should be measured only if a diagnosis of prostate cancer will change the management or if PSA can assist in decision-making for patients at risk of symptom progression and complications. Renal function must be assessed if renal impairment is suspected from the history and clinical examination, if the patient has hydronephrosis, or when considering surgical treatment for male LUTS. Uroflowmetry should be performed before any treatment. Imaging of the upper urinary tract in men with LUTS should be performed in patients with large PVR, haematuria, or a history of urolithiasis. Imaging of the prostate should be performed if this assists in choosing the appropriate drug and when considering surgical treatment. Urethrocystoscopy should only be performed in men with LUTS to exclude suspected bladder or urethral pathology and/or before minimally invasive/surgical therapies if the findings may change treatment. Pressure-flow studies should be performed only in individual patients for specific indications before surgery or when evaluation of the pathophysiology underlying LUTS is warranted. Conclusions These guidelines provide evidence-based practical guidance for assessment of non-neurogenic male LUTS. An extended version is available online ( www.uroweb.org/guidelines ). Patient summary This article presents a short version of European Association of Urology guidelines for non-neurogenic male lower urinary tract symptoms (LUTS). The recommended tests should be able to distinguish between uncomplicated male LUTS and possible differential diagnoses and to evaluate baseline parameters for treatment. The guidelines also define the clinical profile of patients to provide the best evidence-based care. An algorithm was developed to guide physicians in using appropriate diagnostic tests. [ABSTRACT FROM AUTHOR]

Purpose We present the 1-year results of the GOLIATH prospective randomized controlled trial comparing transurethral resection of the prostate to GreenLight XPS for the treatment of men with nonneurogenic lower urinary tract symptoms due to prostate enlargement. The updated results at 1 year show that transurethral resection of the prostate and GreenLight XPS remain equivalent, and confirm the therapeutic durability of both procedures. We also report 1-year followup data from several functional questionnaires (OABq-SF, ICIQ-SF and IIEF-5) and objective assessments. Materials and Methods A total of 291 patients were enrolled at 29 sites in 9 European countries. Patients were randomized 1:1 to undergo GreenLight XPS or transurethral resection of the prostate. The trial was designed to evaluate the hypothesis that GreenLight XPS is noninferior to transurethral resection of the prostate on the International Prostate Symptom Score at 6 months. Several objective parameters were assessed, including maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen, in addition to functional questionnaires and adverse events at each followup. Results Of the 291 enrolled patients 281 were randomized and 269 received treatment. Noninferiority of GreenLight XPS was maintained at 12 months. Maximum urinary flow rate, post-void residual urine volume, prostate volume and prostate specific antigen were not statistically different between the treatment arms at 12 months. The complication-free rate at 1 year was 84.6% after GreenLight XPS vs 80.5% after transurethral resection of the prostate. At 12 months 4 patients treated with GreenLight XPS and 4 who underwent transurethral resection of the prostate had unresolved urinary incontinence. Conclusions Followup at 1 year demonstrated that photoselective vaporization of the prostate produced efficacy outcomes similar to those of transurethral resection of the prostate. The complication-free rates and overall reintervention rates were comparable between the treatment groups. [ABSTRACT FROM AUTHOR]

Abstract: Background: The comparative outcome with GreenLight (GL) photoselective vaporisation of the prostate and transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms due to benign prostatic obstruction (BPO) has been questioned. Objective: The primary objective of the GOLIATH study was to evaluate the noninferiority of 180-W GL XPS (XPS) to TURP for International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) at 6 mo and the proportion of patients who were complication free. Design, setting, and participants: Prospective randomised controlled trial at 29 centres in 9 European countries involving 281 patients with BPO. Intervention: 180-W GL XPS system or TURP. Outcome measurements and statistical analysis: Measurements used were IPSS, Qmax, prostate volume (PV), postvoid residual (PVR) and complications, perioperative parameters, and reintervention rates. Noninferiority was evaluated using one-sided tests at the 2.5% level of significance. The statistical significance of other comparisons was assessed at the (two-sided) 5% level. Results and limitations: The study demonstrated the noninferiority of XPS to TURP for IPSS, Qmax, and complication-free proportion. PV and PVR were comparable between groups. Time until stable health status, length of catheterisation, and length of hospital stay were superior with XPS (p <0.001). Early reintervention rate within 30 d was three times higher after TURP (p =0.025); however, the overall postoperative reintervention rates were not significantly different between treatment arms. A limitation was the short follow-up. Conclusions: XPS was shown to be noninferior (comparable) to TURP in terms of IPSS, Qmax, and proportion of patients free of complications. XPS results in a lower rate of early reinterventions but has a similar rate after 6 mo. Trial registration: ClinicalTrials.gov, identifier NCT01218672. [Copyright &y& Elsevier]

Abstract: Objective: To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS). Evidence acquisition: We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality. Evidence synthesis: Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment–resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30–80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental. Conclusions: These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf). [Copyright &y& Elsevier]

Abstract: Background: Photoselective vaporisation of the prostate has evolved from the GreenLight 80-W KTP powered laser to the latest 180-W XPS laser involving a MoXy fibre. Objective: Evaluate the prevalence of perioperative complications and short-term outcome for the first time with the XPS laser in men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE). Design, setting, and participants: Prospective data were collected from consecutive patients at seven centres worldwide during June 2010 and March 2011. Indication for surgery was based on the European Association of Urology and the American Urological Association guidelines. Patients receiving anticoagulants or those with retention were included and analysed separately. Intervention: 180-W XPS GreenLight laser prostatectomy using the MoXy fibre. Measurements: Standard parameters associated with transurethral prostate surgery and perioperative prevalence of surgery-associated problems or complications were documented. Results and limitations: A total of 201 patients were included in the study. Mean follow-up was 5.8 mo (standard deviation [SD]: 2.8; range: 1–12 mo). A quarter of the patients had a prostate volume ≥80ml. For prostates between 51 and 60ml, a mean of 300kJ (SD: 112) of energy was applied (lasing time: 35.0min; SD: 15). Statistically significant improvements were noted in all key parameters postoperatively. The prevalence of perioperative complications was low. Limitations of the study are short duration of follow-up and limited number of available patients for the functional follow-up. Conclusions: The 180-W GreenLight XPS laser is a new effective treatment option with a low prevalence of perioperative complications for patients suffering from LUTS due to BPE. [Copyright &y& Elsevier]

Abstract: The thermal effect is the most common effect of tissue–laser interaction in urology. With the widespread use of endoscopic instruments laser applications in urology have dramatically increased. Various urological conditions can nowadays be successfully treated with lasers. In the treatment of benign prostate hyperplasia (BPH), holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP) have proven as reliable, safe and effective treatment alternatives. Urethral strictures, bladder neck sclerosis and ureteropelvic junction (UPJ) obstruction have also been treated successfully with lasers; however their role is limited to selected cases and conditions. For the treatment of malignant diseases, lasers can be applied in early stage upper urinary tract transitional cell carcinoma (UUTTCC) and penile carcinoma. This review summarizes the potential and limitations of thermal lasers in urology. [Copyright &y& Elsevier]

OBJECTIVES To evaluate, ex vivo and in vivo, the tissue-removal capacity and coagulation properties of a diode laser emitting light at 940 nm, as in the search for potential therapeutic strategies for benign prostatic hyperplasia that cause less morbidity than transurethral resection of the prostate (TURP), various types of lasers have been tested. MATERIALS AND METHODS A diode laser system (prototype; wavelength 940 nm, Dornier MedTech, Wessling, Germany) was evaluated in an isolated, blood-perfused ex-vivo porcine kidney model at 10–60 W (five kidneys). An in-vivo beagle model was used to investigate the effects on six prostate lobes at a generator output power level of 200 W. After the laser treatment tissue were examined histologically to compare the depth of coagulation and vaporization. RESULTS With increasing generator output power levels there was an increasing vaporization and coagulation ability for the diode laser at 940 nm in the ex-vivo model. At 60 W the mean (sd) vaporization depth was 1.72 (0.47) mm with a coagulation zone of 9.56 (0.26) mm. In vivo, the diode laser caused rapid ablation with no intraoperative haemorrhage. Histologically, the zone of coagulation had a mean (sd) depth of 4.25 (0.15) mm at 200 W. The tissue removal capacity was estimated at 0.874–1.583 g/min in vivo. CONCLUSIONS Our findings indicate that diode-laser vaporization at 940 nm is feasible and might be effective for acutely relieving bladder outlet obstruction in an in-vivo setting. Due to its mean coagulation zone of 4.25 mm the diode laser seems to have effective haemostatic properties. [ABSTRACT FROM AUTHOR]

OBJECTIVES To evaluate the intermediate-term clinical efficacy and the rate of complications in 80 W photoselective vaporization of the prostate (PVP) with the potassium-titanyl-phosphate laser (GreenlightTM, (AMS, Minnetonka, MN, USA) compared with transurethral resection of the prostate (TURP) in a prospective non-randomised two-centre study. PATIENTS AND METHODS From December 2003 to August 2006, 396 patients (PVP 269, TURP 127) with lower urinary tract symptoms secondary to benign prostatic hyperplasia were included in the study. There was a significant difference in mean age (72 years for PVP vs 68 for TURP, P = 0.001). Patients were therefore stratified in age categories (<70, 70–80, >80 years) and compared for perioperative variables, functional outcome and complications, with a follow-up of up to 24 months. RESULTS The mean prostate size was greater (overall, 62 vs 48 mL, P < 0.001) and mean operative duration longer (overall 72 vs 53 min; P = 0.001) for PVP in all age categories. The rate of intraoperative bleeding (3% vs 11%), blood transfusions (0% vs 5.5%) and capsule perforations (0.4% vs 6.3%), and early postoperative clot retention (0.4% vs 3.9%) was significantly lower for PVP. Hospitalization time was significantly shorter in the PVP group for patients aged <70 years (3.0 vs 4.7 days) and 70–80 years (4.0 vs 5.0 days; P = 0.001). The improvement of peak urinary flow rate was higher after TURP for any age category. The International Prostate Symptom Score and postvoid residual volume during the follow-up showed no significant difference. After 12 months the overall prostate size reduction was 63% (−30 mL) after TURP and 44% (−27 mL) after PVP. The rate of repeat TURP/PVP was higher in the PVP group (6.7% vs 3.9%, not significant) within the follow-up of up to 2 years. The incidence of urethral and bladder neck strictures was comparable. CONCLUSIONS PVP was more favourable in terms of perioperative safety. Although patients assigned for PVP were older and had larger prostates, PVP resulted in a similar functional outcome. Further follow-up is needed to draw final conclusions about the long-term efficacy of PVP. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To compare the early follow-up and perioperative morbidity of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) in patients (pts.) suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Material and method: 101 pts. underwent PVP (n =64) and TURP (n =37) in a prospective, non-randomized bi-centre trial. Inclusion criteria were identical at both centres. Primary outcome parameters were maximum urinary flow rate (Q max), post-void residual volume (V res), International Prostate Symptom Score (IPSS). Secondary outcomes included intraoperative surgical parameters and perioperative and post-discharge morbidity. Results: Baseline characteristics of both groups were similar. Operating time was slightly shorter in the TURP group (p =0.047). During TURP significant more irrigation solution was used (p <0.001). Decrease of serum haemoglobin (p =0.027) and serum sodium (p =0.013) was larger after TURP. Catheter drainage was removed significant earlier after PVP than after TURP (p <0.001). Outcome of Q max, and IPSS were similar in both groups within 6 months. The sort of perioperative complications was different in both groups, however overall cumulative perioperative morbidity was comparable (PVP 39.1% versus TURP 43.2.1%; ns). Conclusion: PVP provides excellent intraoperative safety, instant tissue removal, and immediate relief from obstructive voiding symptoms, similar to TURP. Early outcomes 6-months after PVP and TURP are comparable. [Copyright &y& Elsevier]

The article reports on the use of GreenLight™ photoselective vaporization (PVP) as an alternative to transurethral resection of the prostate (TRUP). It says that the GreenLight PVP, which has a 532 nanometer (nm) wavelength laser energy, allows good hemostasis with no energy loss. It discusses the results of a trial on the PVP's safety and efficacy, that involved men with benign prostatic obstruction (BPO).

Laser technology has been applied to treat LUTS secondary to BPH for >15 years. Some of the early approaches failed to fulfil our expectations and have been abandoned, but technological advancements and growing clinical experience have produced more refined techniques and devices with clinical outcomes that seem to challenge transurethral resection of the prostate. Using an evidence-based approach, this review explains the basic principles of lasers and updates our knowledge on the progress of laser technology and the role of different laser techniques and types in the treatment of LUTS due to BPH in both the general population and specific groups of patients. The study also documents the need for better quality data to increase the level of evidence for each laser treatment. [ABSTRACT FROM AUTHOR]

Abstract: Context: Photoselective vaporisation (PVP) of the prostate is being used increasingly to treat symptomatic benign prostatic hyperplasia, due to the associated lower morbidity. Holmium laser enucleation of the prostate was considered to be the treatment with the highest evidence; however, evidence for PVP has dramatically increased recently. Objective: To conduct a systematic review and meta-analysis of level 1 evidence studies to determine the effectiveness of PVP versus transurethral resection of the prostate (TURP) for surgical treatment of benign prostatic hyperplasia. Outcomes reviewed included perioperative data, complications, and functional outcomes. Evidence acquisition: Biomedical databases from 2002 to 2012 and American Urological Association and European Association of Urology conference proceedings from 2007 to 2011 were searched. Trials were included if they were randomised controlled trials, had PVP as the intervention, and TURP as control. Meta-analysis was performed using a random effects model. Evidence synthesis: Nine trials were identified with 448 patients undergoing PVP (80W in five trials and 120W in four trials) and 441 undergoing TURP. Catheterisation time and length of stay were shorter in the PVP group by 1.91 d (95% confidence interval [CI], 1.47–2.35; p <0.00001) and 2.13 d (95% CI, 1.78–2.48; p <0.00001), respectively. Operation time was shorter in the TURP group by 19.64min (95% CI, 9.05–30.23; p =0.0003). Blood transfusion was significantly less likely in the PVP group (risk ratio: 0.16; 95% CI, 0.05–0.53; p =0.003). There were no significant differences between PVP and TURP when comparing other complications. Regarding functional outcomes, six studies found no difference between PVP and TURP, two favoured TURP, and one favoured PVP. Conclusions: Perioperative outcomes of catheterisation time and length of hospital stay were shorter with PVP, whereas operative time was longer with PVP. Postoperative complications of blood transfusion and clot retention were significantly less likely with PVP; no difference was noted in other complications. Overall, no difference was noted in intermediate-term functional outcomes. [Copyright &y& Elsevier]

Abstract: The most common surgical procedure for symptomatic benign prostatic hyperplasia is transurethral resection of the prostate. However, this procedure has complications, including bleeding, erectile dysfunction, and retrograde ejaculation. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures. Recently, photoselective vaporization of the prostate (PVP) was introduced using the GreenLight 60-W laser (American Medical Systems, Minnetonka, Minnesota, USA) and later the 80-W laser, which is the predominant device used in PVP trials. The latest evolution is the GreenLight HPS 120-W laser (532nm), which produces not only rapid vaporization of prostate tissue but also an acceptable rate of complications. Here we present a review of complications associated with surgical therapies for benign prostatic hyperplasia including data on the initial use of the GreenLight HPS 120-W system. Recommendations are provided on how the low complication rates achieved with PVP can be reduced even further through modification of the operating procedure. [Copyright &y& Elsevier]

Abstract: A total of 305 consecutive patients who were treated with the GreenLight HPS laser (American Medical Systems, Minnetonka, Minnesota, USA) at eight international centres since July 2006 were included. This subgroup analysis involved 63 patients in urinary retention, 70 patients on anticoagulants, and 52 patients with prostate volume ≥ 80ml. Observation period was a maximum of 11 mo, and mean follow-up was 4.2 mo (SD: 4.5). For all patients, the changes in maximum flow rate (Qmax), postvoid residual urine, International Prostate Symptom Score, and prostate volume from baseline to follow-up were significant (p <0.001). For those patients in retention prior to therapy, the only significant difference between groups with regard to change from baseline was for Qmax (p <0.001). The use of anticoagulants had no significant effect on changes from baseline values. For those patients with glands ≥ 80ml, the only significant difference in change from baseline was for prostate volume reduction (p <0.001). The rate of complications reported was low in all groups. This study shows that the GreenLight HPS 120-W laser can be used effectively and safely in patients in retention, on anticoagulant therapy, and with large prostates. [Copyright &y& Elsevier]

Abstract: We report the technical recommendations of the International GreenLight User Group on photoselective vaporization of the prostate in men with benign prostatic hyperplasia using the GreenLight HPS system (American Medical Systems, Minnetonka, Minnesota, USA). This high-power system employs a 120-W laser, which is a modification of the previous 80-W potassium-titanyl-phosphate (KTP) laser. The objective of this report is to optimize the efficacy and safety of the procedure by drawing on the experience of this multicentre international group. In this regard, recommendations for training are made, which relate to existing users of the 80-W KTP laser as well as to new laser users. [Copyright &y& Elsevier]

Abstract: The gold standard treatment of benign prostatic hyperplasia (BPH) has been the transurethral resection of the prostate (TURP). However, this procedure is associated with a number of complications, and other surgical therapies, including laser prostatectomy, have been developed to overcome these issues. Laser prostatectomy involves tissue coagulation or vaporization. Coagulation of the tissue results in debulking of the gland through sloughing of necrotic tissue, while vaporization results in an instantaneous debulking of prostatic tissue. The laser procedures developed over the past decade include visual laser ablation of the prostate using the neodymium:yttrium-aluminium-garnet laser. Clinical outcome with this procedure shows good results up to 3 yr. The same laser can be applied through direct insertion of the laser fibres into the prostate in a procedure termed interstitial laser coagulation. Holmium laser enucleation of the prostate is one of the most investigated of the laser procedures and is associated with a good outcome over a long follow-up period. One drawback is the high degree of training required to master the technicalities of the procedure. The latest addition to laser therapy for BPH is photoselective vaporization of the prostate. This procedure results in rapid vaporization of prostate tissue with good outcome up to 5 yr reported. The procedure can be applied to large glands, patients in retention, and those on anticoagulants. Clinical evidence now exists on the effectiveness of both the holmium and potassium-titanyl phosphate lasers, and these therapies now represent a valid clinical alternative to TURP. [Copyright &y& Elsevier]

Objective: To characterize the safety and efficacy of the 180-W XPS-Greenlight laser in patients on systemic anticoagulation.Materials and Methods: A retrospective analysis of 384 patients who underwent photoselective vaporization of the prostate with the 180-W XPS-laser between 2010 and 2013 at two centers in the United States and Switzerland was performed. The primary outcome was the intraoperative and postoperative complication rates for those on anticoagulation undergoing photoselective vaporization of the prostate. The secondary outcome was International Prostate Symptom Scores, postvoid residual, maximum flow rate, and prostate-specific antigen levels.Results: Of 384 patients, aspirin, clopidogrel, and warfarin were used in 146 (38%), 34 (8.9%), and 57 (14.8%) patients, respectively. Single-drug, two-drug, and three-drug combinations were used in 142 (35.5%), 37 (9.3%), and 7 (1.7%) of the cases. Median lasing time (39 min vs 36 min; P = .99) and number of fibers used (1.0 vs 1.0; P = .63) were comparable between patients on vs off systemic anticoagulation. Postoperatively, urinary symptoms (International Prostate Symptom Score, quality of life) and objective voiding parameters (maximum flow rate, postvoid residual) improved in both groups of patients. During a maximum follow-up of 2 years, patients on vs off systemic anticoagulation did not show any significant differences in the rate of postoperative urinary tract infection (3.8% vs 5.1%; P = .71), retention (5.1% vs 5.9%; P = .71), urethral stricture (1.5% vs none, P = .05), and reoperation (2.2% vs 1.5%; P = .49). The primary limitation is the retrospective nature of the study.Conclusion: Photovaporization of the prostate with the 180-W XPS-laser is a safe and effective minimal-invasive treatment option for patients on systemic anticoagulation. [ABSTRACT FROM AUTHOR]

Background In 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP. Objective To reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data. Methods The same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis. Results If the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at −0.01 (95% confidence interval [CI] −0.05 to 0.01) instead of at −0.11 (95% CI −0.31 to −0.01) as in the 2008 analysis. The GOLIATH estimate of −0.01 (95% CI −0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21−£1286) in 2008 to £111 (−£315 to £595) for 2010 and to £109 (−£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom. Conclusions The available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients. [ABSTRACT FROM AUTHOR]

Abstract: Context: Laser treatment of benign prostatic obstruction (BPO) has become more prevalent in recent years. Although multiple surgical approaches exist, there is confusion about laser–tissue interaction, especially in terms of physical aspects and with respect to the optimal treatment modality. Objective: To compare available laser systems with respect to physical fundamentals and to discuss the similarities and differences among introduced laser devices. Evidence acquisition: The paper is based on the second expert meeting on the laser treatment of BPO organised by the European Association of Urology Section of Uro-Technology. A systematic literature search was also carried out to cover the topic of laser treatment of BPO extensively. Evidence synthesis: The principles of generation of laser radiation, laser fibre construction, the types of energy emission, and laser–tissue interaction are discussed in detail for the laser systems used in the treatment of BPO. The most relevant laser systems are compared and their physical properties discussed in depth. Conclusions: Laser treatment of BPO is gaining widespread acceptance. Detailed knowledge of the physical principles allows the surgeon to discriminate between available laser systems and their possible pitfalls to guarantee high safety levels for the patient. [Copyright &y& Elsevier]

Abstract: Background: Laser vaporisation of the prostate has had a considerable impact in recent years. In an attempt to achieve tissue vaporisation with bipolar high-frequency generators, plasma vaporisation was recently introduced. Objective: To provide the first clinical information on bipolar plasma vaporisation of the prostate for patients with lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO). Design, setting, and participants: Thirty patients were included in this prospective bicentre study. Intervention: All patients underwent bipolar plasma vaporisation with a novel electrode (Olympus Winter & Ibe GmbH, Hamburg, Germany). Measurements: International Prostate Symptom Score (IPSS), bother score, maximum flow rate (Qmax), and postvoid residual were evaluated at baseline and at the time of discharge as well as at 1, 3, and 6 mo after the intervention. Results and limitations: Mean preoperative prostate volume was 59±32ml (range: 30–170), and mean operating time was 61±26min (range: 20–140). Besides one reoperation (conventional transurethral prostatectomy) due to persistent obstruction, no major complication occurred intra- or postoperatively and no blood transfusion was required. Catheterisation time averaged 41±35h (range: 18–192). Transient mild to moderate dysuria was noted in four patients (13%). At 1, 3, and 6 mo, Qmax increased from 6.6±2.7ml/s preoperative to 17.3±4.7ml/s (p <0.01), 18.5±4.6ml/s (p <0.01), and 18.1±5.0ml/s (p <0.01), respectively. The IPSS decreased from 20.8±3.6 to 10.4±3.5 (p <0.01), 8.2±2.9 (p <0.01), and 8.1±3.1 (p <0.01), respectively. These data represent a small nonrandomised study cohort with limited follow-up. Conclusions: Our initial experience indicates that bipolar plasma vaporisation might be a safe and effective treatment option for patients with LUTS due to BOO. To define the potential role of this novel technique, randomised trials with longer follow-up are mandatory. [Copyright &y& Elsevier]

Abstract: Arginase 2, inducible- and endothelial-nitric-oxide synthase (iNOS and eNOS), indoleamine 2,3-dioxygenase (IDO) and TGF-β, might impair immune functions in prostate cancer (PCA) patients. However, their expression was not comparatively analysed in PCA and benign prostatic hyperplasia (BPH). We evaluated the expression of these genes in PCA and BPH tissues. Seventy-six patients (42 BPH, 34 PCA) were enrolled. Arginase 2, eNOS and iNOS gene expression was similar in BPH and PCA tissues. TGF-β1 gene expression was higher in BPH than in PCA tissues (p =0.035). IDO gene expression was more frequently detectable (p =0.00007) and quantitatively higher (p =0.00001) in PCA tissues than in BPH. IDO protein, expressed in endothelial cells from both BPH and PCA, was detectable in tumour cells in PCA showing evidence of high specific gene expression. In these patients, IDO gene expression correlated with kynurenine/tryptophan ratio in sera. Thus high expression of IDO gene is specifically detectable in PCA. [Copyright &y& Elsevier]

Abstract: Background: Long-term data of photoselective vaporization of the prostate (PVP) for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is scanty. Objective: Evaluate the long-term efficacy and the complication rate in 80-watt (W) PVP. Design, Setting, and Participants: 500 consecutive patients with LUTS secondary to BPH underwent PVP between September 2002 and April 2007. The mean follow-up was 30.6±16.6 (5.2–60.6) mo. Intervention: All patients underwent 80-W PVP performed by seven surgeons. Measurements: We evaluated perioperative parameters, including operation time, delivered energy, changes of hemoglobin and serum sodium, catheterization, and hospitalization time as well as intraoperative and postoperative complications. Patients presenting for follow-up had data assessed on the International Prostate Symptom Score and quality-of-life questionnaire (IPPS-QoL), maximal flow rate (Qmax), and post-voiding residual volume (Vres). Results and Limitations: Mean patient age was 71.4±9.6 (46–96) yr, with a mean preoperative prostate volume of 56.1±25.3 (10–180) ml. Mean operation time was 66.4±26.8 (10–160) min, and mean energy delivery was 206±94 (2.4–619.0) kJ. Despite ongoing oral anticoagulation in 45% of the patients (n =225), no severe intraoperative complications were observed. Mean catheterization and postoperative hospitalization time was 1.8±1.2 (0–10) and 3.7±2.9 (0–35) d, respectively. The mean IPSS after 3 yr was 8.0±6.2, the QoL score was 1.3±1.3, the Qmax was 18.4±8.0ml/s, and the Vres was 28±42ml. The retreatment rate was 6.8%. Urethral and bladder neck strictures were observed in 4.4% and 3.6% of the patients, respectively. Localized prostate cancer was diagnosed during follow-up in six patients. Conclusion: PVP is a safe and effective procedure for treatment of LUTS secondary to BPH. Patients on ongoing oral anticoagulation can be safely operated on. PVP leads to an immediate and sustained improvement of subjective and objective voiding parameters. The late complication rate is comparable to that of transurethral electroresection of the prostate. [Copyright &y& Elsevier]

Abstract: Objectives: Laser-assisted vaporization of prostate tissue by means of the KTP laser is in clinical use. Alternative laser sources are available but are lacking clinical experience. In this study, the capability, feasibility, and post-operative outcome of vaporization of prostate by means of a diode laser were investigated. Methods: The light (λ=1470nm, 50W) of a diode laser (Biolitec AG, Jena, Germany) was fed into a side-fire fiber introduced through a 24F continuous-flow cystoscope and thus transmitted to prostate tissue. Normal saline was used for irrigation with additive of 1% ethanol for observation of TUR syndrome. The study includes 10 men suffering from bladder outlet obstruction due to benign prostatic hyperplasia (BPH) (prostate volume range: 35–78ml). The prostatic lobes were vaporized within the prostatic capsule. Depending on the vaporized tissue the exposure time was in the range of 1220–4000s (mean: 2397±757s) during which a mean of 121±38kJ (range: 61–200kJ) of energy was delivered. Post-operative outcome and voiding were evaluated during a follow-up of 6 months. Results: During surgery no significant blood loss or any fluid absorption occurred. Catheters were removed in the mean after 50h (range: 18–168h). All patients excepted two, were satisfied with their voiding outcome. After removing the catheter the mean peak urine flow rate significantly (p=0.05) increased from 8.9±2.9ml/s pre-operatively to 15.7±5ml/s post-operatively. No evidence of urgency, dysuria, hematuria, or incontinence was observed. Two patients required re-catheterization and consecutive TURP. After 1 month as well as after 6-month follow-up, 8/10 patients are still satisfied with the outcome. Conclusion: This first and limited experience showed that 50W-1470nm-diode-laser vaporization prostatectomy is feasible and appears to be safe and effective for quickly relieving bladder outlet obstruction due to BPH. Long-term efficacy and durability should be evaluated in a randomized clinical trial with long-term follow-up. [Copyright &y& Elsevier]

Abstract: Objectives: A prototype diode laser was used to evaluate the feasibility and postoperative outcome of diode laser vaporisation of the prostate in patients with bladder outlet obstruction (BOO) necessitating interventional desobstruction. Methods: Ten patients were included in this pilot study. The prostate was vaporised via a side-fire laser fibre (diode laser at 1470nm, 50W; Biolitec-AG, Jena, Germany). IPSS, quality of life, Qmax, and PVR volume were measured pre- and postoperatively and 1 yr after the intervention. Results: Prostate volumes were 35–78ml. A mean 121kJ (61–200kJ) of energy was delivered. No patient had significant blood loss or fluid absorption. Three-way catheters were removed after a median of 33h. Qmax increased from 8.9ml/s (3.6–13.2ml/s) preoperatively to 15.7ml/s (10.5–22ml/s) (p <0.01) postoperatively. After the 12-mo follow-up, Qmax increased to 22.35ml/s (±4.32ml/s; p <0.001). PVR volume changed from a baseline of 243ml to 26.9ml (p <0.001) after 12 mo. Volume reduction was estimated by transrectal ultrasound postoperatively (15cc±6.39), and by PSA levels before surgery (3.8ng/ml±2.3) and after 6 mo (2.64ng/ml±1.51). No patient is incontinent. Two patients required recatheterisation postoperatively on days 1 and 2, respectively. Two patients required TURP within 2 mo. All patients without reintervention have presented for the 1-yr follow-up examination and are satisfied with the outcome. Conclusions: Our preliminary findings indicate that 50-W diode laser vaporisation prostatectomy at 1470nm is feasible and appears to be effective for acutely relieving BOO. [Copyright &y& Elsevier]

Abstract: Objectives: Ongoing oral anticoagulation (OA) contraindicates transurethral electroresection of the prostate. We evaluated the safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing OA with coumarin derivatives, aspirin, or clopidogrel, complaining of symptomatic benign prostatic hyperplasia (BPH). Methods: We evaluated perioperative parameters, functional outcome, and adverse events up to 24 mo postoperatively of patients on OA, and compared results with 92 men at normal risk without anticoagulant therapy undergoing PVP for the same indication (control). Results: Within 40 mo, 116 men on OA were included, with 31% (n =36) receiving coumarin derivatives; 61% (n =71), aspirin; and 8% (n =9), clopidogrel. Mean prostate volume (62±34ml vs. 57±25ml; p =0.289) and mean operation time (67±28min vs 63±29min; p =0.313) were comparable with control. We observed no bleeding complications necessitating blood transfusions. Average postoperative decrease of haemoglobin was 8.6% for patients on OA versus 8.8% for control. At 3, 6, 12, and 24 mo postoperatively, improvement of the International Prostate Symptom Score ranged from 60–70%; postvoid residual volume, 80–88%; and average maximum urinary flow rate, 116–140%, respectively. Postoperative complications were low and comparable with control. Conclusions: PVP is characterized by excellent haemostatic properties and very low intraoperative complication rate even in patients on OA. On the basis of our perioperative results, we recommend PVP as first-line procedure for patients with symptomatic BPH at high risk of bleeding. [Copyright &y& Elsevier]