A Randomized Trial Of Photoselective Vaporization Of The Prostate Using The 80-W Potassium-titanyl-phosphate Laser Vs. Transurethral Prostatectomy

Main Category: Urology / Nephrology
Also Included In: Prostate / Prostate Cancer
Article Date: 16 Mar 2010 - 5:00 PDT


UroToday.com - The treatment of lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction (BOO) makes up a significant amount of the workload of most urologists. The traditional approach of trans urethral resection of the prostate (TURP) has been the mainstay of surgery for this condition for over half a century, and would probably be considered to be the quintessential urological operation. However, as robust as TURP has been, it is an operation that is not bereft of complications and challenges, and these are often underestimated by urologists in practice as they are considered to be standard sequelae of an excellent operation. These would include hospital stays of 2 to 3 days, use of continuous irrigation post operatively, catheter blockages with clot and need for bladder washouts, not insignificant blood loss, difficulties with operating on patients who are anticoagulated or who are on platelet inhibitors, and the occasional but significant TUR syndrome. Allied to this is generally recognised that there is a significant number of cases needed to be performed before a performance plateau can be reached in performing TURP and that this is probably in the region of 50 cases.

Our study undertook to address whether photoselective vaporisation of the prostate (PVP) using the 80 W KTP Greenlight® laser would provide equivalent results in terms of improvement of flow and decrease of patients symptoms as TURP. The patient group was randomised to one of the two procedures and at all time points in the one-year follow-up there was no difference in maximal flow rate, International Prostate Symptom Score, AUA bother scores or quality of life scores between the two groups. However the study did show up some significant benefits for the use of PVP using this laser technology. The length of time in hospital and duration of catheterisation was 66% less in the PVP group. Blood loss was significantly less, and both minor and major complications were much less common in the PVP group. Allied to this, an ad hoc analysis of finances showed that due to the savings incurred on inpatient costs, that overall PVP was cheaper than TURP, despite the relatively high capital and disposable costs.

It is not uncommon in studies such as these for there to be an inherent bias for the new technology. Often an expert in the field of the new technology (in this case laser prostatectomy) will undertake the surgery for the majority, if not all, of the patients being treated with the new technology. This means that the results may not translate to standard urological practice. In this study, no practitioner performing PVP had done more than five laser prostatectomies of any type prior to operating on people in the trial. Added to this, the operating surgeons were all either urologists in training or fellows in the department. This was done in order to remove the expert bias that can skew the results in a more positive manner towards PVP, and try and replicate the experience of a urologist who is learning this procedure de novo. It is obvious that if urologists in training with little exposure to this technology are able to produce results which give levels of efficacy that are equivalent to TURP, and for it to be a safe procedure in their hands, then the transfer of skills to the general urological community can be anticipated to occur relatively seamlessly.

In conclusion, having undertaken this extensive study, the pervading feeling that PVP using the KTP Greenlight® system is an efficacious method of treating bladder outlet obstruction is, to my mind, proven. The procedure provides for a safe and efficient operation with much less impact on the patient than traditional TURP, and it would be anticipated that it could be learned very easily by most, if not all, practising urologists. It is questionable whether a randomised trial will be performed using the more updated Greenlight HPS® system which produces 120 W of power compared to the 80 Ws that this system uses. It does appear that the benefit of this increase in power is purely that it markedly increases the time that vaporisation takes. Initial results do indicate that the significant advantages that the 80 W system brings are carried over in the 120 W system and may in fact be improved.

Written by David M. Bouchier-Hayes, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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