BERKELEY, CA (UroToday.com) - Radical prostatectomy is a widely recognized, standardized, curative procedure for organ-confined prostate cancer. However, radical prostatectomy is still associated with significant morbidity. Moreover, radical prostatectomy is also not indicated for patients with life expectancies of less than 10 years as well as individuals who are either not fit for surgery or who are wary of the potential side effects of this surgery. Accordingly, a number of minimally-invasive therapies are being developed as alternative modalities, including high-intensity focused ultrasound (HIFU). With the increased incidence of all types of prostate cancer treatment, a significant increase in complications has also occurred. Specifically, stricture at the vesicourethral anastomosis or urethral strictures represent relatively common postoperative complications. In the current study, we present our clinical experiences to evaluate the efficacy and safety of the holmium:yttrium-aluminium-garnet (YAG) laser in the treatment of urethral/bladder neck strictures occurring secondary to HIFU for prostate cancer.
Between February 2007 and July 2010, holmium:YAG laser urethrotomies were performed in 11 patients for bladder neck strictures or prostatic urethral strictures. After institutional review board approval, the medical records of these 11 patients were reviewed. All surgical treatments were performed under spinal or general anesthesia with a rigid endoscope (8-26F) and 550-μm end-firing laser fiber at 2J and frequency 30 to 50Hz. Under direct retrograde vision, deep incisions were typically made into the fibrotic scar tissue at the 5 and 12 o’clock or another position, if necessary. In addition, any remaining scar tissue that appeared to have the potential to hinder urine flow was removed by vaporization (Figure 1). Finally, a urethral Foley catheter was placed and left for several days.
In total, 11 patients were included in this study; 9 patients were diagnosed with bladder neck strictures and 2 patients prostatic urethral strictures. The patients’ pre-operative characteristics are summarized in Table 1. The median operation time was 27.0 minutes (range: 10-70 minutes), and no serious perioperative or postoperative complications were reported. The median time for urethral Foley catheter removal was 3.0 days (range: 1-14 days), and the median postoperative hospital stay was 2.0 days (range: 1-6 days). The median follow-up period after laser treatment was 12.0 months (range: 4-35 months). After treatment, significant improvements were observed in the maximal flow rate and residual urine volume, though not in voided volume. The total international prostate symptom score, voiding score, and quality of life score also improved significantly, however no significant difference occurred in the storage score when compared with the preoperative values (Table 2). Of the 11 patients, 7 patients (63.6%) reported satisfactory results without recurrence after the first laser treatment. However, 4 patients (36.4%) did require repeat endoscopic laser treatment. The median recurrence time after the first laser treatment was 2.5 months (range: 2-12 months). Although one patient (9.1%) did require a third treatment 2 months later, all of these individuals were ultimately satisfied with the end result, as determined by symptoms and uroflowmetric assessment. Of note, 2 patients did subsequently require artificial urinary sphincter implantation for stress urinary incontinence, all of whom had a history of urinary incontinence prior to the initial laser treatment. In addition, they had twice been treated with endoscopic holmium:YAG laser treatment. They underwent AUS implantations 12 months later after last laser treatment and reported satisfaction with their treatment course 6 months later without, developing any additional recurrent bladder neck contracture or AUS erosion.
This study has several limitations. First, various laser powers (60-100W) were used here, as per the previous experience of the performing surgeon and the intraoperative situation, though similar variances (5-40W) were also present in other previous laser urethrotomy case series. Moreover, the higher laser powers that were used in the present study may also have affected the results. Second, the number of patients included in the present study was relatively small (11 patients) and the follow-up period (median: 12.0 months; range: 4-35) was relatively short. However this was also the case in other similar studies regarding Holmium:YAG laser urethrotomy for the treatment of strictures secondary to radical prostatectomy for prostate cancer. Specifically, these studies also only enrolled a small number of patients (10-24 patients) and had follow-up periods ranging from 3 months to 72 months. However, little is known about post-HIFU bladder outlet obstruction. To our knowledge, our study is the first use of the holmium:YAG laser in the urethral/bladder neck strictures after HIFU for prostate cancer.
Holmium:YAG laser therapy may represent a safe, effective and minimally-invasive treatment for urethral/bladder neck strictures after HIFU for prostate cancer. Holmium:YAG laser therapy offers the advantages of minimal trauma to peripheral local tissue and allows for preservation of the continence mechanism. Future prospective studies with longer follow-up period and larger cohorts that compare holmium:YAG laser treatment with other therapeutic modalities will be clearly needed to further confirm these findings.
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Figure 1.: Removal, by vaporization, of remaining scar tissue that may potentially hinder urine flow
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Table 1.: Patients’ characteristics
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| Table 2.: Uroflowmetry and IPSS/QoL data before and after treatment |
Written by:
Won Jin Cho as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Assistant Professor
Chosun University Hospital
588 Seosuk-dong, Dong-gu
Gwangju 501-757
Republic of Korea
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