Tm:YAG laser vapoenucleation (ThuVEP) – One-year follow-up in elderly patients

Material and methods Laser prostatectomy was performed using a 70 W Tm:YAG 2 μm continuous wave laser (LISA laser, Katlenburg, Germany) in combination with a continuous-flow laser resectoscope and a mechanical tissue morcellator (R. Wolf, Knittlingen, Germany). The condition of patients was followed in terms of improvement of uroflow and post-void residual urine, intra- and postoperative course and the occurrence of complications. Results Eighty consecutive patients were included in this prospective observation. Patients were grouped according to age. Subgroup I included patients with an age ≥75 years, subgroup II included patients <75 years. The mean age was 80.2 years in subgroup I and 66.6 years in subgroup II. Preoperative data was comparable in both groups, as well as improvements in postoperative voiding function. Conclusion Transurethral ThuVEP is a safe and effective therapy method even in older patients. The patient's age does not influence the functional operative outcome. Zusammenfassung Einleitung Das zunehmende Alter der Bevölkerung in den industrialisierten Staaten, wie auch die höhere Effizienz der medikamentösen Therapie führen dazu, dass sich vermehrt ältere Patienten zur chirurgischen Therapie der benignen Prostataobstruktion (BPO) vorstellen. Fraglich ist, ob in dieser Patientengruppe die therapeutische Effektivität operativer Verfahren durch die oftmals verminderte Allgemeinkonstitution des Patienten und die längere Krankheitsdauer der BPO kompromittiert wird. Als eine mögliche Therapieoption der BPO wurde die Laserenukleation mit dem Thulium:YAG (Tm:YAG) 2 μm Dauerstrichlaser (ThuVEP) mit vielversprechenden Ergebnissen in die Klinik eingeführt. Ziel dieser Anwendungsbeobachtung ist es, die Effektivität der ThuVEP bei Patienten älter als 75 Jahre im 12-Monats-Follow-up zu überprüfen. Die Ergebnisse wurden mit einer Gruppe von Patienten jünger als 75 Jahre verglichen. Patienten und Methoden Die ThuVEP wurde mit einem 70 Watt Tm:YAG 2 μm Dauerstrichlaser (Lisa Laser, Katlenburg-Lindau) in Kombination mit einem Laserresektoskop und mechanischem Gewebemorcellator (R. Wolf, Knittlingen) durchgeführt. Die Patienten wurden in Bezug auf die Verbesserung der Miktionsparameter, dem intra- und postoperativem Verlauf sowie dem Auftreten von Komplikationen nachgesorgt. Ergebnisse 80 konsekutive Patienten konnten in diese prospektive Beobachtung eingeschlossen werden. Die Patienten wurden anhand ihres Alters unterteilt in Gruppe I (≥75 Jahre) und Gruppe II (<75 Jahre). Das mittlere Alter betrug 80,2 Jahre in Gruppe I und 66,6 Jahre in Gruppe II. Die präoperativen Daten sowie die postoperativen Ergebnisse, insbesondere die Verbesserung der Miktionsparameter waren zwischen den Gruppen vergleichbar. Zusammenfassung Die transurethrale ThuVEP ist ein sicheres und effektives Verfahren auch bei älteren Patienten. Das Patientenalter hat keinen Einfluss auf das funktionelle Ergebnis. Keywords Laser prostatectomy Benign prostatic obstruction Thulium:YAG ThuVEP High-risk patients Schlüsselwörter Laserenukleation Benigne Prostataobstruktion Thulium:YAG ThuVEP Hochrisikopatienten Introduction Transurethral resection of benign prostatic obstruction (BPO) is one of the most frequent procedures in daily urological practice. With increasing age and a consequently rising number of co-morbidities in the population, the potential risk of surgery may exclude this subgroup of men from surgical therapy. Laser prostatectomy has the potential of decreasing surgical morbidity and therefore may offer a treatment option for these patients. Various laser systems have been tested in the treatment of BPO in order to achieve safe and efficient treatment in this group of high-risk patients [1–3] . Thulium:YAG (Tm:YAG) laser prostatectomy has recently been introduced for the treatment of BPO with good results and multiple treatment options, e.g. pure Tm:YAG vaporization (ThuVAP), Tm:YAG vaporesection (ThuVARP) and Tm:YAG vapoenucleation (ThuVEP) [4] . However, new surgical devices also need to prove their safety and efficacy for this subgroup of older patients, in order to be considered as a valuable treatment option for every patient. Therefore we evaluated the safety and efficacy of the recently introduced ThuVEP in patients of higher age (≥75 years). The outcome and complication rates were analyzed within a follow-up period of 12 months, and compared to a group of younger patients (<75 years of age). Material and methods A total of 80 consecutive patients underwent ThuVEP of the prostate using a 70 W Tm:YAG 2 μm continuous wave (cw)-laser (RevoLix™; LISA laser products, Katlenburg, Germany) in combination with a continuous-flow laser resectoscope and mechanical tissue morcellator (Piranha Laser TUR-P-Set™; Richard Wolf GmbH, Knittlingen, Germany). The patients were divided in two subgroups according to their age. Patients aged ≥75 years were included in subgroup I and those aged <75 years in subgroup II. After thorough urological examination, including transrectal ultrasound (TRUS), assessment of the international prostate symptom score (IPSS), the quality of life score (QoL) as well as post-void residual urine (PVR) and peak urinary flow rate (Qmax), surgery was performed under either spinal or general anesthesia, according to the patient's preference. Oral anticoagulation or platelet inhibition was stopped prior to surgery and low molecular weight heparin bridging was used if applicable. The technique of ThuVEP has been described before and includes complete removal of the adenoma at the plane of the surgical capsule and subsequent morcellation of the enucleated lobes in the bladder lumen [5] . The assessed outcomes were an improvement of Qmax and PVR, as well as a positive change in the IPSS and QoL scores. Furthermore the intra- and postoperative course of the patients, together with the occurrence of complications, were recorded. Patients with a follow-up interval of 12 months were included in the evaluation. Statistical analysis was performed using analytical software (Statistical package for Social Sciences (SPSS) for Windows, version 8.0; SPSS Inc., Chicago, IL, USA). Statistical significance was calculated using independent and paired samples t -test and chi-squared ( χ 2 )-test as appropriate. A p -value of p < 0.05 was considered statistically significant. Results In total, 80 consecutive patients were included in this observation. Patients were grouped according to age. Subgroup I included 31 patients aged ≥75 years (mean: 80.2 ± 3.8 years, range: 76–91 years); subgroup II included 49 patients <75 years (mean: 66.6 ± 5.8 years, range: 46–74 years). The pre- and intraoperative characteristics are shown in Table 1 . Older patients in subgroup I had significantly higher American Society of Anesthesiologists (ASA) status as compared to those younger than 75 years of age. No significant differences could be found between subgroups I and II in any of the recorded pre- and intraoperative parameters ( Table 1 ). The postoperative course and complications during follow-up are summarized in Table 2 . Recorded complications included urinary tract infection in six patients as well as prolonged catheter time in three patients with indwelling catheter prior to surgery (Clavien-Dindo classification grade I). Two patients required transfusion of red blood cells, with a total of two units per patient (Clavien-Dindo classification grade II). Second-look procedure was necessary in two patients (Clavien-Dindo classification grade IIIa). One patient required early second-look vaporesection of the prostate due to insufficient de-obstruction during the initial surgery, a second patient required bladder neck incision using the Tm:YAG laser device. Increasing age did not lead to higher transfusion rate, but there may be a trend indicating that older patients had a higher risk of undergoing a second-look procedure, due to insufficient de-obstruction at initial surgery or the development of bladder neck sclerosis during follow-up. In total, 62 patients were available for 12-month follow-up. During this 1-year follow-up, the recorded parameters TRUS volume, IPSS, QoL, PVR and Qmax improved significantly in both groups ( Table 3 and Fig. 1 ). When comparing the inter-group correlation (≥75 years vs. <75 years) in terms of postoperative improvements, it could be shown, that no significant difference were found in functional parameters as measured by TRUS volume, decrease in PVR and improvement in Qmax. However, younger patients (<75 years) had a significant better improvement in IPSS ( p = 0.04) and QoL score ( p = 0.031), as compared to older patients ( Fig. 1 ). Discussion In recent years an increase in the population age in industrialized countries has occurred. As a consequence more and more older patients are seeking surgical treatment for BPO. The therapeutic effectiveness may be impaired in this subgroups of patients, due to the patient's overall condition as well as the prolonged time spent suffering from the progressive disease BPO [6] . Although transurethral electroresection of the prostate (TUR-P) is still considered the gold standard in the treatment of BPO, it is associated with a significant morbidity [7,8] . This has led to multiple laser systems being introduced for the treatment of BPO both to reduce this morbidity and to offer effective treatment, even to patients with a poor medical condition [1–3] . In 2007, ThuVEP was introduced for the treatment of BPO with good functional results and low morbidity in patients with smaller prostates [4] . These promising results have been confirmed by other groups [9,10] . Xia et al. [9] could even show superiority of ThuVARP compared to TUR-P in a prospectively randomized study. Lately, it could be demonstrated, that ThuVEP as consecutive development following ThuVARP and a pendant to open, simple prostatectomy and Holmium:YAG laser enucleation of the prostate (HoLEP), offers safe and effective treatment to patients with large volume prostates [11] . In addition, a learning curve – with one possible limitation namely HoLEP – seems to be acceptable in Tm:YAG laser enucleation [12] . However, new surgical devices need to prove their safety and efficacy in the previously mentioned subgroup of high-age patients, in order to be considered a valuable treatment option for every patient. Recorded complications have mostly been minor ones, scoring Grade I or II on the Clavien-Dindo classification [13] , affecting only two patients who required endoscopic intervention under spinal anesthesia, and were comparable to those published in the literature for other minimally invasive laser devices [14,15] . The presented results support the assumption that ThuVEP is safe and effective in a larger series of high-age patients. Despite significant improvements in functional parameters as well as in QoL and IPSS in all groups, the improvement in QoL and IPSS is significantly greater in the group of younger patients (<75 years). However, it seems reasonable, that older patients (≥75 years) tend to have a higher baseline IPSS, and higher QoL values [16] . Compared to other laser systems, Tm:YAG laser prostatectomy may offer superiority, as virtually every surgical approach can be carried out with this laser system. Besides proven efficacy in ThuVARP [9] and ThuVEP [11] , first evidence supports the efficacy of pure vaporization techniques [17–19] with the Tm:YAG laser device. Conclusion Transurethral ThuVEP is a safe and effective procedure in all patients. Age does not influence the functional operative outcome; however improvement in QoL and IPSS seems to be higher in the subgroup of patients younger than 75 years. References [1] M. Gürdal A. Tekin E. Yücebaş F. Sengör Nd:YAG laser ablation plus transurethral resection for large prostates in high-risk patients Urology 62 5 2003 914 917 [2] O. Reich A. Bachmann M. Siebels A. Hofstetter C.G. Stief T. Sulser High power (80 W) potassium-titanyl-phosphate laser vaporization of the prostate in 66 high risk patients J Urol 173 1 2005 158 160 [3] E. Elzayat E. Habib M. Elhilali Holmium laser enucleation of the prostate in patients on anticoagulant therapy or with bleeding disorders J Urol 175 4 2006 1428 1432 [4] T. Bach T.R. Herrmann R. Ganzer M. Burchardt A.J. Gross RevoLix vaporesection of the prostate: initial results of 54 patients with a 1-year follow-up World J Urol 25 3 2007 257 262 [5] T. Bach G. Wendt-Nordahl M.S. Michel T.R. Herrmann A.J. Gross Feasibility and efficacy of Thulium:YAG laser enucleation (VapoEnucleation) of the prostate World J Urol 27 4 2009 541 545 [6] R. Berges Epidemiology of benign prostatic syndrome. Associated risks and management data in German men over age 50 Urologe A 47 2 2008 141 148 [7] J.O. Littlejohn Jr. M.A. Ghafar Y.M. Kang S.A. Kaplan Transurethral resection of the prostate: the new old standard Curr Opin Urol 12 1 2002 19 23 [8] G. Schatzl S. Madersbacher B. Djavan T. Lang M. Marberger Two-year results of transurethral resection of the prostate versus four ‘less invasive’ treatment options Eur Urol 37 6 2000 695 701 [9] S.J. Xia J. Zhuo X.W. Sun B.M. Han Y. Shao Y.N. Zhang Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial Eur Urol 53 2 2008 382 389 [10] R. Szlauer R. Götschl A. Razmaria L. Paras N.T. Schmeller Endoscopic vaporesection of the prostate using the continuous-wave 2-μm thulium laser: outcome and demonstration of the surgical technique Eur Urol 55 2 2009 368 375 [11] T. Bach C. Netsch A. Haecker M.S. Michel T.R. Herrmann A.J. Gross Thulium: YAG laser enucleation (VapoEnucleation) of the prostate: safety and durability during intermediate-term follow-up World J Urol 28 1 2010 39 43 [12] C. Netsch K. Oberhagemann A.J. Gross Enucleation of the prostate with the 2 μm continuous wave thulium laser in different experienced surgeons J Endourol 23 Suppl. 1 2009 P15 P80 10.1089/end2009.2002.supp [13] D. Dindo N. Demartines P.A. Clavien Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey Ann Surg 240 2 2004 205 213 [14] R. Naspro A. Bachmann P. Gilling R. Kuntz S. Madersbacher F. Montorsi A review of the recent evidence (2006–2008) for 532 nm photoselective laser vaporisation and holmium laser enucleation of the prostate Eur Urol 55 6 2009 1345 1357 [15] M. Rieken N. Ebinger Mundorff G. Bonkat S. Wyler A. Bachmann Complications of laser prostatectomy: a review of recent data World J Urol 28 1 2010 53 62 [16] C.G. Roehrborn P. Siami J. Barkin R. Damião E. Becher B. Miñana The influence of baseline parameters on changes in international prostate symptom score with dutasteride, tamsulosin, and combination therapy among men with symptomatic benign prostatic hyperplasia and an enlarged prostate: 2-year data from the CombAT study Eur Urol 55 2 2009 461 471 [17] S. Mattioli R. Muñoz R. Recasens C. Berbegal J. Cortada J.M. Urmeneta Treatment of benign prostatic hyperplasia with the Revolix laser Arch Esp Urol 61 9 2008 1037 1043 [18] G. Wendt-Nordahl S. Huckele P. Honeck P. Alken T. Knoll M.S. Michel Systematic evaluation of a recently introduced 2-μm continuous-wave thulium laser for vaporesection of the prostate J Endourol 22 5 2008 1041 1045 [19] T. Bach N. Huck F. Wezel A. Häcker A.J. Gross M.S. Michel 70 vs 120 W thulium:yttrium-aluminium-garnet 2 μm continuous-wave laser for the treatment of benign prostatic hyperplasia: a systematic ex-vivo evaluation BJU Int 106 3 2010 368 372