The use of the laser in the treatment of prostate adenoma (benign prostatic hyperplasia) is not a new technique. By the mid-1990s, this technology had been the object of a certain interest which had probably not resulted in lack of technological maturity. Recently, a renewed interest in the use of the laser in benign prostatic hypertrophy is again felt by the urological community.
Laser prostate surgery is a mildly aggressive surgical procedure that treats urinary trauma symptoms related to prostate adenoma, also known as hypertrophy or benign prostatic hyperplasia (BPH). The laser will make it possible to remove the adenoma tissues that hinder the free flow of the urine.
What is the laser ?
Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. It is electromagnetic radiation whose spectrum also includes radio waves, microwaves, infrared radiation, visible light, ultraviolet radiation, x-rays and gamma rays (1).
All these radiations have in common their speed of propagation: that of light (18,600 miles / s). Their wavelength and energy differentiate them: the shorter the wavelength, the greater the energy. The lasers used in urology have wavelengths ranging between 400 and 10,000 nm; They are mainly used for treatment of prostate affections and destruction of stones.
Their mode of action is the vaporization of tissues which requires machines producing high energy radiation. This principle is used in different ways to create several types of surgical actions: volatilizing tissues, incising them, resecting prostate chips, enucleating a prostate lobe, etc. Regardless of the technique applied, the univocal result sought is the de-obstruction of the prostatic urethra.
It has been developed to facilitate the treatment of adenoma and shorten the patient’s hospitalization and convalescence while avoiding certain complications. It has several well-established advantages over other more conventional surgical treatments, including:
- Reduced risk of bleeding. Low-risk hemorrhagic surgery is a very attractive option in elderly and fragile subjects, particularly those under anticoagulant or antiplatelet therapy or in patients with coagulation disorders.
- A significant reduction in the length of hospital stay. It can usually be performed with a single night of hospitalization postoperatively or in outpatient hospitalization.
- Quick recovery. The resumption of personal and professional activities is generally acquired after convalescence from 7 days to 2 weeks.
- A shorter duration of bladder sampling. In most cases, this surgery requires the maintenance of a bladder catheter for less than 24 hours.
- An improvement in the patient’s voiding conditions more quickly noticeable.
Techniques and modes of action
The treatments are performed by endoscopy, introducing the instruments to operate and the laser through the urethra canal, so without any cutaneous incision.
There are several types of surgical lasers and several types of surgery.
All lasers use the energy of a narrow light beam of monochromatic coherent light to vaporize the prostatic tissues by absorbing the water they contain.
There are two main modes of action:
- Vaporization by the laser which volatilizes the tissues responsible for the obstruction to increase the caliber of the urethral canal in the portion where it passes through the prostate.
- Laser ablation of these same tissues.
In practice, there are several types of laser devices available to carry out three main types of intervention:
- Photosensitive vaporization of the prostate (PVP) or vaporization with KTP laser.
AMS’s Greenlight laser, which emits green radiation (2), acts on prostate tissue. It vaporizes them because of the very high heat that it releases. It is suitable for BPH of low degree due to the necessary processing time. The more powerful last generation devices make it possible to treat larger prostates, but often at the cost of a more significant postoperative irritative symptomatology.
- The vapo-resection of the adenoma by the Holmium lasers of Lumenis or the laser Thullium like the Revolix of Lisa Laser (3).
Here, energy is strongly absorbed by water, which makes its action very precise and prevents penetration of energy deep into the tissues. The vapo- resection cuts the adenoma of the prostate into fine tissue chips, which are then removed by washing through the urethral canal through the metallic jacket of the endoscopic resonator. This technique is well suited for prostates of small or medium volume which can be the source of an intense urinary discomfort.
- The Enucleation is an endoscopic surgical procedure that completely removes BPH, comparable to simple prostatectomy or open-label adenomectomy. It is complete and removes all tissues from the prostate that make it difficult to urinate. It is best suited for the treatment of bulky prostates. The Holmium laser (Hollow Laser Enucleation Prostate) and the Thullium laser (ThULEP) are suitable for its realization.
The prostatic lobes are enucleated alternately in the bladder. The radiation allows them to cleave the prostate in the plane of the capsule. Then, a morcellator reduces the tissues into fine chips easily aspirated by the sheath of the resector to allow their elimination through the canal of the urethra.
This procedure, more technically difficult, is suitable for the treatment of all prostates regardless of their volume. It requires special training by the surgeon but has a number of advantages:
- Very large quantities of prostatic tissue are removed and can be subjected to pathological examination for possible prostate cancer.
- The procedure is usually definitive and unlikely to cause recurrences. All adenomatous tissue has been removed and rarely repels.
With enucleation, the surgeon reduces most of the prostate volume, but there remains a thin tissue shell (the peripheral part), which must be monitored so as not to disregard the further development of prostate cancer, Always possible and independent of the treatment of the adenoma of the prostate.
Près de 20 ans après son avènement en urologie, la technologie laser a acquis une maturité suffisante pour être utilisée de manière routinière comme traitement chirurgical de l’adénome de la prostate.
1) Mula M ISSA : The Evolution of Laser Therapy in the Treatment of Benign Prostatic Hyperplasia. Rev Urol, 2005, v7 (suppl.9), 15-19
2) Abdel-Rahmène AZZOUZI; Prostate laser: principles and presentation of the material. Part 1: Theory; P Urol, 2009, v19, No. 1, 23-28
3) Abdel-Rahmène AZZOUZI; Prostate laser: principles and presentation of the material. Part 2: Practice; P Urol, 2009, v19, No. 2, 40-47p- hh- + 63