Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.
In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH1. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis2. The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect3. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid's arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.
Compared with traditional transurethral resection of the prostate (TURP), laser surgeries have gradually become more popular due to their better patient tolerance, lower amounts of intraoperative blood loss, efficacy, and shorter postoperative recovery4,5.
In recent years, the fastest growing techniques have involved the use of lasers of various wavelengths. At present, many types of lasers with different characteristics can be used to complete prostate enucleation. Since the diode laser was approved by the US FDA for prostatic hyperplasia in 2007, its use has gradually increased in the treatment of BPH because of its outstanding cutting ability and hemostasis effect6. The laser wavelength determines the degree of absorption by water and hemoglobin. A diode laser with a wavelength of 980 nm provides the highest combined absorption rate of water and hemoglobin. The tissue penetration ability is 0.5 mm, and it can produce coagulation effects in deeper tissue, which makes it have a very good tissue ablation and hemostasis ability7,8.
Many research centers have begun to use DiLEP for the treatment of benign prostatic hyperplasia. In practice, traditional DiLEP has a longer learning curve and presents no obvious advantages related to urinary sphincter protection9. Based on the above reasons, traditional DiLEP was modified in our center to improve the value of diode laser treatment in patients with BPH.
All methods described here have been approved by ethics committee of Beijing Hospital. Indications for surgery are according to the European Association of Urology guidelines for nonneurogenic male LUTS. Contraindications include suspected prostate cancer or detrusor dysfunction.
1. Instruments for operation
2. Preparation for operation
3. Procedure steps
A total of 40 patients with BPH who underwent DiLEP were included in one of our studies. An independent sample t-test was used as the statistical method. All patients successfully completed the operation. Almost all of the patients had the catheter removed within 5 days postoperative (Table 1). All patients returned to the hospital for follow-up examinations in the 1st, 3rd, and 12th months postoperatively. The International Prostate Symptom Score (IPSS)11 and Quality of Life (QoL)1 tools were used to screen for, rapidly diagnose, track the symptoms of, and guide the management of BPH. These can also be used to evaluate the efficacy of the BPH treatment. Compared to the baseline values, the International Prostate Symptom Score (IPSS) significantly decreased to 38.15%, 31.92%, and 18.70% at 1, 3, and 12 months postoperatively, respectively (all p < 0.001), and the QoL significantly decreased to 57.89%, 43.94%, and 20.78% (all p < 0.001, respectively). For objective parameters, compared to the baseline, the mean Qmax increased nearly 3x, and the mean postvoid residual during follow-up decreased nearly 4x. Compared to the preoperative values, postoperatively, the prostate volume decreased dramatically (p < 0.001) (Table 2).
The peri- and postoperative complications reported during this study are presented in Table 3. According to the modified Clavien Dindo classification system12, a widely used and authoritative tool for grading surgical complications, no intraoperative patient had complications, and only four cases reported Grade 1 postoperative complications12.
Figure 1: Circularly incise the bladder neck mucosa with a laser. Please click here to view a larger version of this figure.
Figure 2: Circularly incise the prostatic urethra mucosa at the proximal end of verumontanum with a laser. Please click here to view a larger version of this figure.
Figure 3: Incise the left lobe and right lobe at the apex of the prostate at 12 o'clock. Please click here to view a larger version of this figure.
Figure 4: Circularly incise the bladder neck mucosa with a laser. Please click here to view a larger version of this figure.
Figure 5: Find the surgical capsule at the 5 and 7 o'clock positions of the apex of the prostate and connect the 5 and 7 o'clock surgical capsule positions with a laser. Please click here to view a larger version of this figure.
Figure 6: In a counterclockwise direction, enucleate the right lobe at the 6 and 12 o'clock positions from the apex of the prostate to the bladder neck. Please click here to view a larger version of this figure.
Figure 7: In a clockwise direction, enucleate the left lobe at the 6 and 12 o'clock positions from the apex of the prostate to the bladder neck. Please click here to view a larger version of this figure.
Figure 8: Cut the enucleated prostatic tissue into small pieces using a morcellator and then remove the tissues from the bladder. Please click here to view a larger version of this figure.
Parameters | Data |
Age (y) | 73.35±7.84 |
Prostate volume (ml) | 106.40±19.01 |
Operative time (min) | 71.18±16.55 |
Perfusion fluid volume (L) | 28.02±13.80 |
Postoperative irrigation time (h) | 13.47±1.83 |
Decrease in hemoglobin (g/L) | 2.62±1.24 |
Catheter duration (d) | 4.25±0.08 |
Hospital stay (d) | 4.60±0.77 |
Follow-up time(m) | 12.45±1.75 |
Data are shown as mean ± SD;BPH: Benign prostatic hyperplasia; diode laser enucleation of the prostate; SD: Standard deviation |
Table 1: Perioperative data of 40 patients with BPH who underwent DiLEP.
Parameters | Pre-operative | 1m | 3m | 12m | P-value |
Qmax (ml/min) | 7.12±2.94 α,β,γ | 21.19±2.18 | 22.24±2.02 | 19.73±1.80 | <0.001 |
PVR(ml) | 113.22±33.56 α,β,γ | 27.30±3.98 | 25.05±4.21 | 31.10±6.65 | <0.001 |
IPSS | 23.15±7.44 α,β,γ | 8.37±2.49 | 7.37±1.94 | 4.33±1.79 | <0.001 |
QOL | 3.80±0.88 α,β,γ | 2.20±0.89 | 1.67±0.65 | 0.79±0.66 | <0.001 |
PV(ml) | 106.40±19.01 | —— | —— | 22.08±4.28 | <0.001 |
Qmax = maximum flow rate; PVR = postvoid residual; IPSS = International Prostate Symptom Score; QoL = quality of life; PV = prostate volume | |||||
α:Significant differences between pre- and post-operative 1 month groups; β:Significant differences between pre- and post-operative 3 months groups; γ:Significant differences between pre- and post-operative 12 month |
Table 2: Data at baseline and at 1, 3, and 12 months postoperatively parameters.
Complications | Patients, n (%) | Grade |
Intraoperative | ||
Prostate capsule perforation | 0 | 3b |
Blood transfusion | 0 | 2 |
TURP syndrome | 0 | 4 |
Bladder wall injury | 0 | 2 |
Ureteric orifce injury | 0 | 2 |
Urethra sphincter injury | 0 | 2 |
Postoperative | ||
Bladder convulsion | 2 (5%) | 1 |
Urge urinary incontinence | 2 (5%) | 1 |
Stress urinary incontinence | 0 | 2 |
Re-place the catheter | 0 | 1 |
Complications were graded according to the modifed Clavien-Dindo classifcation system |
Table 3: Peri- and post-operative complications of 40 patients with BPH who underwent DiLEP.
At present, the 980-mm diode laser is beginning to be used for the treatment of BPH5. Few reports have described related clinical studies. Compared to the effect of TURP in the treatment of BPH, many studies have shown that DiLEP causes less blood loss, achieves better urination function, and has shorter catheter retention times9,13,14,15.
Here, we share our experiences with mDiLEP. In our study, compared with traditional DiLEP9,16,17, we circularly incised the bladder neck mucosa and the prostatic urethra mucosa at the proximal end of the verumontanum with a laser before enucleation. Then, we connected the concentric circles of the bladder neck and the apex of the prostate at 12 o'clock. This is called a Cupid's arrow. Although this procedure seemed to increase the operation time, it did not increase the total operation time relative to results described in other studies. It also brings many benefits: First, the urethral sphincter is protected from injury because we circularly incised the prostatic urethra mucosa at the proximal end of the verumontanum18. The preserved urethral mucosa at the apex of the prostate can function like an anal cushion, allowing the urethral sphincter to work better, improving the prevention of urine leakage. For the above reasons, no patient reported stress urinary incontinence in this study. Second, surgeons can operate within a delimited surgical area by circularly incising the bladder neck mucosa with a laser, which can protect ureteral orifices from injury. These two steps are not performed in traditional operations. Some studies11,19,20 have reported that the incidences of urethral sphincter and ureteral orifice injuries are relatively high, especially for inexperienced surgeons, and the occurrence of these complications is a heavy burden for doctors and patients. Third, the operator can define the scope of surgery by incising the bladder neck mucosa and the prostatic urethra mucosa at the proximal end of the verumontanum. This helps the surgeon find the prostate surgical capsule, reduces the occurrence of prostate capsule perforation, and facilitates the enucleation of the median and lateral lobes21. According to our experience, this operation involving a Cupid's Arrow was much easier to master and facilitates the promotion of this new technology.
Compared to existing procedures used in BPH treatment, DiLEP demonstrates satisfactory short-term clinical outcomes. In addition, this promising technique has obvious advantages in that it prevents urinary continence. However, more research is needed to demonstrate the long-term efficacy of this technique. Only in this way can this technique be developed into a blueprint for a prostate enucleation protocol in the future.
The authors have nothing to disclose.
The authors would like to acknowledge the support of the National Key Research and Development Program of China (Grant 2017YFC840102).
HU Diode Laser | Beijing L.H.H.Medical Science Development Co., Ltd | HU-150 | Wavelength: 980nm Maximum Power: 150W Operation Mode: Continuous and pulsed |
Optical Fiber | Beijing L.H.H.Medical Science Development Co., Ltd | YYGX600 | Fiber core diameter: 600 μm Fiber length: 2m |
Morcellator System | Beijing L.H.H.Medical Science Development Co., Ltd | PXQ-01 | Rotate Speed: 100-3000rpm MAX. Vacuum Pressure: -80KPa Rated Output Torque: 12mNm Blade Size: Φ5.0*390mm; Φ3.5*390mm Blade Work Mode: Corotation alternates reversal |