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Benign Prostatic Hyperplasia
Figure 1: Absorption Coefficient and Wavelength of curve. It is suggested that at least 10–20 procedures on small
Different Lasers
prostates (20–40g) are needed.
51
10,000
KTP/532nm (Greenlight PV
TM
) Recently, a new 120W High Performance System (HPS) laser was
1,000
introduced. HPS delivers the same 532nm-wavelength light with the
Diode 830nm (ILC, Indigo
®
)
100
same inherent absorption characteristics, but uses a lithium
10 triborate (LBO) crystal
51–55
and delivers up to 120W of quasi-
1
continuous power. HPS could probably increase the speed of
ablation and treat larger prostates in a shorter time with the same
0.1
Ho:YAG, holmium
safety profile as standard PVP.
0.01
2,100nm (HoLEP and HoLAP)
Absorption coefficient (1/cm)
0.001
Nd:YAG 1,064nm (VLAP) Prostatic Stenting
0.0001
200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000
The use of an endoprosthesis to maintain luminal patency is a well-
established concept used in a variety of surgical settings, including
Wavelength (nm)
Water Oxyhaemoglobin
cardiovascular and gastrointestinal pathologies. However, the
usefulness of a self-retaining endoprosthesis in prostatic
HoLAP = holmium laser ablation of the prostate; HoLEP = holmium laser enucleation of the
obstruction and BPH is not as clear. Prostatic stents may be either
prostate; Ho:YAG = holmium: yttrium–aluminum–garnet; ILC = interstitial laser coagulation;
permanent or temporary.
KTP = potassium–titanyl–phosphate; Nd:YAG = neodynium: yttrium–aluminum–garnet;
VLAP = visually guided laser ablation of the prostate.
Permanent stents (UroLume
®
, Memotherm
®
) allow tissue ingrowth
Figure 2: The Spanner™ versus CoreFlow™
that results in the stent being embedded in the urethral wall. Long-
Prostatic Stent
term failure rate with these stents is 20–30% and is due to
encrustation or UTI, causing chronic pain.
56
Moreover, permanent
stents must be removed before any transurethral procedure. The
thermo-expandable permanent stent seems to be easier to remove
than previous types of stent.
57
Temporary stents are made of either biodegradable or non-absorbable
materials, allowing for easy removal. Migration, UTI and encrustation
are the most common problems found in first and second-generation
stents (Prostacoil
®
, Memokath
®
). No data on the efficacy of
biodegradable stents in BPH have been reported. New stents (The
Spanner™, CoreFlow™) whose design is similar to the proximal 4–6cm
of a Foley catheter are currently under investigation (see Figure 2);
potential advantages seem to be the easy introduction and removal
Malek and co-workers
52
first observed an 82% mean symptoms score and the low percentage of UTIs, migration and encrustation.
58
The
improvement at six and 12 months post-operatively and a mean placement of prostatic stents is relatively easy and is usually
increase in peak flow rate of 255 and 278%, respectively. PVP was performed on an outpatient basis under regional, topical or monitor-
associated with minimal complications, such as temporary dysuria assisted anaesthesia.
(7%), haematuria (4%) and bladder neck stenosis (2%); no blood
transfusions were required and the urethral catheter was always Potential candidates for a definitive stenting of the prostatic urethra
removed within 24 hours. Ejaculation abnormalities were reported in are patients with BPO unfit for surgery or high-risk patients with
27% of the patients. A further evaluation after five years of follow-up chronic urinary retention who failed a trial without a catheter.
still showed a persistent improvement in symptoms and urinary flow Temporary stenting could be proposed for men who have undergone
rate.
53
Bachmann and co-workers,
54
in a prospective but non- minimally invasive therapy to provide short-term relief of BPO, which
randomised trial, compared the safety and clinical outcome of PVP commonly occurs after these procedures,
59,60
or patients who have
and TURP after a period of six months. PVP permitted bloodless failed a trial without a catheter who are waiting for surgery. As an
tissue vaporisation, with comparable clinical improvement to TURP. A alternative to TURP or in an elective setting, prostatic stents must still
mean symptom score reduction of 71% in PVP and 72% in TURP was be considered investigational until large-scale data are available.
obtained. PVP was associated with early post-operative catheter
removal and a shorter hospital stay. Otherwise, TURP presented a Conclusions
10.8% risk of severe bleeding. PVP has also been safely performed in In an era of increased life expectancy, older patients who seek
patients with large prostates, with comparable clinical results to treatment in order to improve symptoms and avoid difficulties
open prostatectomy.
50–55
associated with BPH can safely choose from among several medical
or surgical options and expect good results. Thus, physicians should
PVP is considered an ideal treatment for patients on oral take care to counsel patients about BPH treatments and their related
anticoagulant or trombocyte aggregation inhibitor therapy, or those advantages and side effects, taking into account the availability of
with a high anaesthesiological risk,
55
as often happens in the case of methods and the patient’s clinical condition, including the severity
frail and older people. It is also considered to be a urologist-friendly of symptoms and bladder outlet obstruction, in order to identify the
procedure, but no study to date has correctly evaluated the learning appropriate treatment for each patient. n
18 EUROPEAN UROLOGICAL REVIEW