Medicine
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Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser
Chapters
Summary May 9th, 2018
Here we present a protocol to perform Photoselective Vaporesection of the Prostate (PVRP) for benign prostatic hyperplasia (BPH) treatment.
Transcript
The overall goal of this procedure is to treat benign prostatic hyperplasia in a minimally invasive manner. This method can be used to effectively treat benign prostatic hyperplasia while preserving tissue for postoperative pathological examination. Other advantages of this technique include a low rate of laser energy loss and fewer intraoperative complications.
The implication of this technique extend toward the therapy of benign prostatic hyperplasia as it's safer and quicker than traditional method. Generally, people new to this method will struggle until they have mastered the transurethal resection of the prostate. Visual demonstrations of this method is critical as several key steps are difficult to learn by text instruction alone.
Thirty minutes before beginning the procedure, administer a preoperative antibiotic. To begin the procedure, have the patient lay down on the operating table in the dorsal lithotomy position and cover the patient with a sterile drape. Next, distend the bladder with 300 to 400 milliliters of saline and use a 26 F laser resectoscope to examine the whole bladder cavity and prostatic urethra.
Use a lithium triborate crystal laser to mark two lines starting at five and seven o'clock on the bladder neck continuing along the boundaries between the median and lateral lobes and merging adjacent to the proximal margin of the verumontanum. Set the laser power to 100 watts and use laser vaporization along the lines to vaporize the prostate until white cyclic fibers are observed. Adjust the laser power to 120 watts and use the laser fiber to mark several more lines on the surface of the wedge-shaped middle lobe.
Using vaporization, divide the middle lobe into several chunks along the lines splitting each chunk from the middle lobe. Then remove the whole middle lobe. For vaporesection of the lateral lobes, rotate the cytoscope 180 degrees to vaporize the tissue at 12 o'clock from the apex of the prostate to the bladder neck.
When the vaporesection is complete, locate the lower margins of both lateral lobes and set another two grooves originating from the bladder neck at three and nine o'clock to the proximal end of the verumontanum. To remove the tissue of the lateral gland, use the laser fiber to mark several lines on the surface of the left lobe. Vaporize the left lobe into several chunks along the lines and split each chunk from the lobe.
Then remove the whole left lobe and remove the remnant gland tissue along the existing boundary of the capsule. To enhance the integrity of the cavity, set the laser to 80 watts and vaporize any protruding tissue around the apex of the gland. Next, use a glass syringe that matches the interface of the resectoscope to remove any final tissue chunks by water flow.
Use the resectoscope to confirm a lack of residual tissue in the bladder and prostatic fossa and the integrity of urethral orifices. Use the laser fiber to stop the bleeding around the surgical site. After removing the resectoscope, lubricate the urethra with iodine gel.
Then insert a 22 French Foley catheter from the urethral orifice to the bladder cavity and gently fill the balloon with 30 milliliters of water. In this representative study of 35 patients who underwent photoselective vaporesection of the prostate, the mean laser emission time accounted for nearly 50%of the mean operative time and the blood loss in most patients was less than 200 milliliters. Almost 90%of the patients had the catheter removed within six days postoperatively.
All patients returned to the hospital for followup examinations at one and three months postprocedure. According to the modified Clavien-Dindo classification system, only two cases of perioperative complications were grade 3b and only one case required treatment. Three patients experienced high febrility due to an acute Urinary Tract Infection or UTI on postoperative days five to six and all three patients received antibiotics and recovered rapidly.
Five patients complained of urgency and frequency, but in three patients, the urine culture revealed no abnormalities allowing UTI to be excluded. The other two patients were diagnosed with UTI and recovered after effective antibiotic courses. Only a single patient experienced persistent urinary incontinence in the early postoperative period without the evidence of the UTI that was fully resolved after several weeks of pelvic floor muscles training.
Another patient had difficulty voiding and was diagnosed with bladder neck contracture via cystoscopy that was resolved after a bladder neck incision under general anesthesia on day 40 after the original procedure. Once mastered, this procedure can be completed in two hours if it is performed properly. While attempting this procedure, it is important to take care to avoid the intraoperative complications.
After watching this video, you should have a good understanding of how to photoselectively vaporesect prostate for the alleviation of the symptoms associated with benign prostatic hyperplasia.
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