Name: Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser (Video) | JoVE Journal
Uploaded: 2018-05-09T14:00:00.000+00:00
Duration: 7 min 17 s
Description: Learn photoselective vaporesection of the prostate for treating benign prostatic hyperplasia using a lithium triborate crystal laser. This minimally invasive technique preserves tissue for pathological examination with fewer complications.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

The authors have no acknowledgements.

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
<ol>
	<li>Ensure the availability of a LBO crystal laser with a maximum power of 160 W.</li>
	<li>Employ an endfiring laser fiber and saline solution for intraoperative bladder irrigating.</li>
	<li>Use a 26F laser resectoscope to acquire good vision and to enhance the resection efficiency.</li>
</ol>
2. Preparation for Operation
<ol>
	<li>Provide an intravenous antibiotic preoperatively (intravenous administration of cefuroxime sodium 1.5 g with 100 mL 0.9%sodium chloride solution 30 min before the operation) to all the patients.</li>
	<li>Before the anesthesia, make the patient lay down on the operation table. 
	Note: General anesthesia is effective and appropriate for this operation, Anesthetist will finally determine the mode of anesthesia depending on patient&#39;s general condition.</li>
	<li>Drape the patients in a sterile fashion in the dorsa lithotomy position.Do not perform any skin preparation.</li>
</ol>
3. Procedure Steps
<ol>
	<li>Vaporesection of the Median Lobe
	<ol>
		<li>Examine the whole bladder cavity and prostatic urethra carefully through the resectoscope after the bladder is distended. 
		Note: This step helps urologist to locate some key anatomic sings including bilateral ureteral orifice and verumontanum.</li>
		<li>Mark two lines initially. Ensure that these lines originate at 5 o&#39;clock and 7 o&#39;clock at the bladder neck and continue along the boundaries between the median and lateral lobes, finally terminating at the proximal margin of the verumontanum.</li>
		<li>Set laser power at 80 W. Vaporize the prostate tissue via a fiber by the laser vaporization along these lines until the white cyclic fibers are seen. 
		Note: This is the sign of prostatic capsule. The two lines are merged into single line adjacent to the verumontanum.</li>
		<li>Set laser power at 80 to 100 W. Mark several lines on surface of the middle lobe via laser fiber. Then divide the wedgeshaped middle lobe into several chunks according to these lines through vaporization technique. Then split each chunk from the middle lobe. Finally, remove the whole middle lobe.</li>
	</ol>
	</li>
	<li>Vaporesection of the Lateral Lobes
	<ol>
		<li>Vaporize the tissue at 12 o&#39;clock from the apex of the prostate to the bladder neck by rotating the cystoscope 180&#176;. Do not let the laser fiber go too close to the apex at 12 o&#39;clock which can cause postoperative urine incontinence. 
		Note: This technique enhances the resection rate of the tissue around the prostate roof.</li>
		<li>Identify the lower margin of both the lateral lobes clearly once vaporesection is complete.</li>
		<li>Before removing the lateral lobes, set another 2 similar grooves that originate from the bladder neck at 3 o&#39;clock and 9 o&#39;clock to the proximal end of the verumontanum.</li>
		<li>Remove the tissue of the lateral gland. Set the laser power at 80 to 100 W and mark several lines on the surface of the left lobe via laser fiber that divides the left lobe into several chunks according to these lines through vaporization technique. Then split each chunk from the lobe and finally remove the whole left lobe. Repeat this procedure to remove right lobe.</li>
		<li>Remove the remnant gland tissue along the existing boundary of the capsule.</li>
	</ol>
	</li>
	<li>Channel Trimming
	<ol>
		<li>Remember to trim some protruding tissues around the apex of the gland, to enhance the integrity of the cavity.</li>
		<li>To avoid intraoperative complications (i.e., capsule perforation or sphincter injury), use vaporization technique rather than resection to trim the tissue near the external urethral sphincter and lower the power to less than 80 Watt.</li>
	</ol>
	</li>
	<li>Hemostasis and Catheterization
	<ol>
		<li>Employ a glass syringe that matches the interface of the resectoscope to remove tissue chunk by water flow. Make sure there is no evidence of the residual tissue in the bladder and prostatic fossa through resectoscope, and identify the intact of the ureteral orifices.</li>
		<li>Employ a lower laser power (30 to 50 W) to stop bleeding around the surgical site. Keep an appropriate distance usually 3 to 5 mm between fiber and vessels to acquire a satisfying hemostasis effect.</li>
		<li>Remove the resectoscope from the urethra. Place a 22 French Foley catheter from urethral orifice to bladder cavity gently with 30 mL water in the balloon after sufficiently lubricating urethra by lidocaine gel.</li>
	</ol>
	</li>
	<li>Postoperative Care
	<ol>
		<li>Let the patient lay down on the bed for around 3 h postoperatively in the care unit until they completely wake up from anesthesia. Meanwhile, make sure patient monitors and medical oxygen are available during this time.</li>
		<li>Upon completely waking up, return the patient to the ward. Let the patient begin to drink some water and take some food. Record the urine output and pay attention to the color of the urine.</li>
	</ol>
	</li>
</ol>

<ol><li>Capitán, C., Blázquez, C., Martin, M. D., Hernández, V., de la Peña, E., Llorente, C. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/21658839">GreenLight HPS 120W laser vaporization versus transurethral resection of the prostate for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia: A randomized clinical trial with 2-year follow-up.</a> Eur Urol. 60 (4), 734-739 (2011).</li>
<li>Cornu, J. N., Ahyai, S., Bachmann, A., de la Rosette, J., Gilling, P., Gratzke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+systematic+review+and+meta-analysis+of+functional+outcomes+and+complications+following+transurethral+procedures+for+lower+urinary+tract+symptoms+resulting+from+benign+prostatic+obstruction%3A+An+update%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: An update.</a> Eur Urol. 67 (6), (2014).</li>
<li>Kang, H. W., Jebens, D., Malek, R. S., Mitchell, G., Koullick, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laser+vaporization+of+bovine+prostate%3A+A+quantitative+comparison+of+potassium-titanyl-phosphate+and+lithium+triborate+lasers%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Laser vaporization of bovine prostate: A quantitative comparison of potassium-titanyl-phosphate and lithium triborate lasers.</a> J Urol. 180 (6), 2675-2680 (2008).</li>
<li>Herrmann, T. R., Liatsikos, E. N., Nagele, U., Traxer, O., Merseburger, A. S. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/22285403">EAU Guidelines Panel on Lasers, Technologies. EAU guidelines on laser technologies.</a> Eur Urol. 61 (4), 783-795 (2012).</li>
<li>Braeckman, J., Denis, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Management+of+BPH+then+2000+and+now+2016+-+From+BPH+to+BPO%5BTitle%5D)+AND+%22Asian+J+Urol%22%5BJournal%5D)">Management of BPH then 2000 and now 2016 - From BPH to BPO.</a> Asian J Urol. 4 (3), 138-147 (2017).</li>
<li>Bachmann, A., Tubaro, A., Barber, N., d'Ancona, F., Muir, G., Witzsch, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+European+multicenter+randomized+noninferiority+trial+comparing+180+W+GreenLight+XPS+laser+vaporization+and+transurethral+resection+of+the+prostate+for+the+treatment+of+benign+prostatic+obstruction%3A+12-month+results+of+the+GOLIATH+study%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-month results of the GOLIATH study.</a> J Urol. 193 (2), 570-578 (2015).</li>
<li>Peyronnet, B., Pradere, B., Brichart, N., Bodin, T., Bertrand, P., Members of French Group of GreenLight Users,, Bruyère, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Complications+associated+with+photoselective+vaporization+of+the+prostate%3A+Categorization+by+a+panel+of+GreenLight+users+according+to+Clavien+score+and+report+of+a+single-center+experience%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">Complications associated with photoselective vaporization of the prostate: Categorization by a panel of GreenLight users according to Clavien score and report of a single-center experience.</a> Urology. 84 (3), 657-664 (2014).</li>
<li>Cho, S. Y., Park, S., Jeong, M. Y., Ro, Y. K., Son, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((120W+GreenLight+high+performance+system+laser+for+benign+prostate+hyperplasia%3A+68+patients+with+3-year+follow-up+and+analysis+of+predictors+of+response%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">120W GreenLight high performance system laser for benign prostate hyperplasia: 68 patients with 3-year follow-up and analysis of predictors of response.</a> Urology. 80 (2), 396-401 (2012).</li>
<li>Elmansy, H. M., Elzayat, E., Elhilali, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Holmium+laser+ablation+versus+photoselective+vaporization+of+prostate+less+than+60+cc%3A+Long-term+results+of+a+randomized+trial%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: Long-term results of a randomized trial.</a> J Urol. 184 (5), 2023-2028 (2010).</li>
<li>Hong, K., Liu, Y. Q., Lu, J., Xiao, C. L., Huang, Y., Ma, L. L. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834003/">Efficacy and safety of 120W thulium: Yttrium-aluminum-garnet vapoenucleation of prostates compared with holmium laser enucleation of prostates for benign prostatic hyperplasia.</a> Chin Med J (Engl). 128 (7), 884-889 (2015).</li>
<li>Hermanns, T., Sulser, T., Fatzer, M., Baumgartner, M. K., Rey, J. M., Sigrist, M. W., et al. <a target="_blank" href="http://www.europeanurology.com/article/S0302-2838(08)00326-6/fulltext">Laser fiber deterioration and loss of power output during photo-selective 80-W potassiumtitanyl-phosphate laser vaporization of the prostate.</a> Eur Urol. 55 (3), 679-686 (2009).</li>
<li>Hermanns, T., Strebel, D. D., Hefermehl, L. J., Gross, O., Mortezavi, A., Müller, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Lithium+triborate+laser+vaporization+of+the+prostate+using+the+120+W%2C+high+performance+system+laser%3A+High+performance+all+the+way%3F%5BTitle%5D)+AND+%22J+Urol%22%5BJournal%5D)">Lithium triborate laser vaporization of the prostate using the 120 W, high performance system laser: High performance all the way?</a> J Urol. 185 (6), 2241-2247 (2011).</li>
<li>Schwartz, J., Renard, J., Wolf, J. P., Moret, M., Iselin, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((High-power+potassium-titanyl-phosphate+laser+fibres+for+endovaporization+of+benign+prostatic+hyperplasia%3A+How+much+do+they+deteriorate+during+the+procedure%3F%5BTitle%5D)+AND+%22BJU+Int%22%5BJournal%5D)">High-power potassium-titanyl-phosphate laser fibres for endovaporization of benign prostatic hyperplasia: How much do they deteriorate during the procedure?</a> BJU Int. 107 (12), 1938-1942 (2011).</li>
<li>Son, H., Ro, Y. K., Min, S. H., Choo, M. S., Kim, J. K., Lee, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Modified+vaporization-resection+for+photoselective+vaporization+of+the+prostate+using+a+GreenLight+high+-performance+system+120-W+Laser%3A+the+Seoul+technique%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">Modified vaporization-resection for photoselective vaporization of the prostate using a GreenLight high -performance system 120-W Laser: the Seoul technique.</a> Urology. 77 (2), 427-432 (2011).</li>
<li>Mandal, S., Sankhwar, S. N., Kathpalia, R., Singh, M. K., Kumar, M., Goel, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Grading+complications+after+transurethral+resection+of+prostate+using+modified+Clavien+classification+system+and+predicting+complications+using+the+Charlson+comorbidity+index%5BTitle%5D)+AND+%22Int+Urol+Nephrol%22%5BJournal%5D)">Grading complications after transurethral resection of prostate using modified Clavien classification system and predicting complications using the Charlson comorbidity index.</a> Int Urol Nephrol. 45 (2), 347-354 (2013).</li>
<li>Gong, Y. G., Liu, R. M., Gao, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Photoselective+vaporesection+of+the+prostate+with+a+front-firing+lithium+triborate+laser%3A+Surgical+technique+and+experience+after+215+procedures%5BTitle%5D)+AND+%22Eur+Urol%22%5BJournal%5D)">Photoselective vaporesection of the prostate with a front-firing lithium triborate laser: Surgical technique and experience after 215 procedures.</a> Eur Urol. 67 (6), 1142-1159 (2015).</li>
</ol>

This study was sponsored by National Key R&#38;D Program of China (2017YFC0840100 and 2017YFC0840102).

Here, we share our experiences with PVRP. First, PVRP enabled better exposure of the prostate capsule with proper demarcation and reduced the risk of capsule perforation. Second, the tissue removal should be carried out along the surgical capsule, especially with the groove at 12 o&#39;clock, which facilitates tissue resection around the roof of the prostatic urethra and provides a satisfactory tissue removal rate. Third, it is essential to remove the middle lobe initially to acquire a wider channel in the prostatic uret...

Although transurethral resection of the prostate (TURP) is still accepted as the gold standard in benign prostatic hyperplasia (BPH) surgical treatment, laser surgeries have gradually become more popular due to the better patient tolerance, less intraoperative blood loss, satisfactory efficacy, and shorter postoperative recovery1,2,3. Currently, the most commonly used lasers for the BPH treatment worldwide are generated by lithium potassium titanyl phosphate or lithium triborate (LBO) crystals4,5. Traditionally, these are classified as sidefiring lasers compared to other types of laser, such as holmium laser and thulium laser.
Photoselective vaporization of the prostate (PVP) surgery could considerably decline TURP syndrome due to saline irrigation6,7, and compared to other types of lasers, the reliable efficacy of lower urinary tract syndrome (LUTS) by PVP was verified by a series of studies8,9,10. However, PVP associated with side-firing laser emission also has some disadvantages, including an energy loss of nearly 20% and a short lifespan of the laser fiber11,12,13. Moreover, PVP increases the possibility of missed diagnosis of prostate cancer due to complete tissue vaporization.
The introduction of Photoselective Vaporesection of the Prostate (PVRP) with an end-firing fiber successfully overcame most of the disadvantages of PVP mentioned above. First, the tip is capable of transmitting laser to the tissues with almost no energy loss intraoperatively. Second, when fiber debris collects on the tip, it is straightforward to maintain the ideal output power by simply removing the affected parts. Finally, laser resection enables the collection of specimens for postoperative pathologic examination. Hence, using this protocol in treating BPH could enhance the tissue removal rate, save the operative time and improve the intraoperative safety.

<table><tbody><tr><td>FLARE surgical Laser Fiber</td><td>REALTON</td><td></td><td>The FLARE Surgical laser Fiber is a 600 micron fiber with an straight tip that transmits the laser energy directly. this product is packaged sterile for disposable use and should not be re-sterilized or reused. Dispose of properly after use.</td></tr><tr><td>AURORA Surgical Green Laser System</td><td>REALTON</td><td>pvp-160-021</td><td>The AURORA Surgical green laser system is a diode-pumped, frequency-doubled Nd:YAG solid state laser. The AURORA Surgical green laser system features a &amp;ldquo;Plug and Play&amp;rdquo; capability that self-adjusts to the facility&amp;rsquo;s individual voltage requirements, eliminating the need for electrical modifications. The laser system also includes an air-cooled internal mechanism, ensuring safe operating temperatures with no external water connections. Laser energy emission and system status selection is activated through a surgeon-controlled, color-coded footswitch or system touch screen feature located in the laser console.</td></tr></tbody></table>

photoselective vaporesection of the prostate via an end-firing lithium triborate crystal laser

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging male population. Although it is not a life-threatening disease, BPH causes problems that seriously impact the quality of life. Here, we introduce a new technique called photoselective vaporesection of the prostate (PVRP) in treating BPH, which can be seen as a variation of photoselective vaporization of the prostate (PVP). This procedure presents several advantages compared to the PVP technique including less laser energy loss, less intraoperative complications as well as more tissue resection rate.

A total of 35 patients who underwent PVRP were included in one of our studies. The mean patient age was 72.1 ± 7.1 years (range 53-85 years).
Perioperative data are listed in Table 1. The mean laser emission time accounted for nearly 50% of the mean operative time. The blood loss in most patients was &lt; 200 mL. However, the average deviated due to some moderate bleeding cases. Almost 90% of the patients had th...

Here we present a protocol to perform Photoselective Vaporesection of the Prostate (PVRP) for benign prostatic hyperplasia (BPH) treatment.

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging ...

photoselective-vaporesection-prostate-via-an-end-firing-lithium

Research

JoVE Journal

Medicine

This video demonstrates a non-invasive laser-assisted procedure to selectively damage the corneal endothelial cells in the porcine eye. The developed ex vivo model of endothelial cell damage can be used to study diseases of the corneal endothelium.

Laser-assisted Selective Ablation of Porcine Corneal Endothelial Cells: A Technique to Induce Focused Porcine Corneal Endothelial Injury for Ex Vivo Studies

We developed novel intrinsic multifunctional nanovesicles called porphysomes, which have structure-dependent fluorescence self-quenching and unique photothermal properties, thus functioning as potent photothermal therapy agents. We formulated porphysomes using high pressure extrusion and investigated their photothermal therapy efficacy in a xenograft tumor model.

One Minute, Sub-One-Watt Photothermal Tumor Ablation Using Porphysomes, Intrinsic Multifunctional Nanovesicles

We report on a process of in situ alteration of HF treated Si (001) surface into a hydrophilic or hydrophobic state by irradiating samples in microfluidic chambers filled with H2O2/H2O solution (0.01%-0.5%) or methanol solutions using pulsed UV laser of a relative low pulse fluence.

Selective Area Modification of Silicon Surface Wettability by Pulsed UV Laser Irradiation in Liquid Environment

The goal of this protocol is to use laser-capture micro-dissection as an effective method to isolate pure populations of cell types from heterogeneous prostate tissues for downstream RNA analysis.

Laser-capture Microdissection of Human Prostatic Epithelium for RNA Analysis

Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.

Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

This article presents and describes an outpatient treatment for prostate cancer using focal laser ablation. Laser catheter placement is guided by MRI-ultrasound fusion imaging in a fashion similar to prostate needle biopsy. Treatment is monitored in real-time with a thermal probe, placed adjacent to the laser fiber.<br...

Focal Laser Ablation of Prostate Cancer: An Office Procedure

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Overtreatment is often administered to patients with low-risk prostate cancer; super-active surveillance can help avoid such overtreatment.

A New Technique for Treating Low-risk Prostate Cancer&#8212;Super Active Surveillance

Learn photoselective vaporesection of the prostate for treating benign prostatic hyperplasia using a lithium triborate crystal laser. This minimally invasive technique preserves tissue for pathological examination with fewer complications.

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

Explore More Videos