Looking at surgery in a new light

Looking at surgery in a new light – laser surgery for benign prostate disease

Robert Dinsmoor

A man who is diagnosed with benign prostatic hypertrophy (BPH) can follow one of several courses. One option is to do nothing and see what develops. In most cases the enlarged gland eventually pinches the urethra, interfering with urination or causing incontinence. When this happens some men obtain relief from medications, but if symptoms persist surgery may be required.

Many patients are put off by the prospect of undergoing transurethral resection of the prostate (TURP), the standard surgical approach. Like any other invasive procedure, TURP causes serious side effects in a few people. Recently some medical centers and group practices have been promoting laser surgery as a less invasive, less traumatic way to treat BPH in older men. This has piqued the curiosity of patients who are eager for an alternative to standard surgery, but it has also raised concerns about safety and effectiveness.

Results of several large clinical trials using a novel side-firing laser are expected soon. In the meantime some experts say that this device offers the most promising alternative to TURP that they’ve seen so far. They hasten to add that the Food and Drug Administration (FDA) has not approved side-firing lasers specifically for the treatment of BPH, although these devices have been sanctioned for “general use in urologic surgery.” Last year the FDA ruled that side-firing lasers could not be advertised for treating BPH until their effectiveness and safety had been demonstrated in direct comparison with TURP. Until these data are published, urologists can use lasers to treat BPH at their own discretion.

Illuminating the differences

The “gold standard” for BPH treatment, against which all others must be measured, is TURP. In this procedure the part of the prostate blocking the urethra is scraped away by means of a special electrocautery instrument inserted through the penis. The procedure requires a general or spinal anesthetic, two or three days in the hospital, and a recovery period of about three weeks. When the prostate is very large and the time needed to perform TURP would increase the risk for serious complications, the enlarged portion of the gland is removed through an abdominal incision. Open prostatectomy requires general or spinal anesthesia and about a week in the hospital.

The several types of laser surgery now being investigated also require that a device be inserted into the penis. A laser fiber is guided, via the urethra, through the prostate. As the fiber is rotated and moved along the urethra, light energy widens the channel by destroying the inner layers of the prostate that impinge on the urethra. The dead tissue is shed and carried off in the urine.

Laser surgery can be done on an outpatient or overnight basis, requires only spinal anesthesia, and has a shorter, less restricted recovery period. In preliminary studies the technique appears to be nearly as effective as TURP in relieving symptoms such as difficult urination. However, it is not as effective as TURP in improving urinary flow rate, and men who undergo the procedure may be more likely to need further treatment. The laser’s effects on bleeding, impotence, urinary incontinence, and retrograde (back into the bladder) ejaculation remain unclear, although in preliminary studies they appear comparable to TURP. On the down side, patients are usually unable to urinate for some time after laser surgery and may need to use a catheter. And men about to have laser surgery should first have a random prostate biopsy, followed by regular tests for prostate-specific antigen, because the tissue normally examined for cancer as part of prostate surgery is destroyed.

In transurethral ultrasound-guided laser-induced prostatectomy (TULIP), the surgeon uses an ultrasound machine to guide the laser to the prostate tissue responsible for the clog. The light-carrying fiber is protected and stabilized by a balloon, which is inflated after insertion. In a simpler procedure called visual laser ablation of the prostate (VLAP), the urologist uses a cystoscope to see directly into the urethra.

Both approaches have their critics. Some cost-conscious experts say that TULIP’s reliance on state-of-the-art ultrasound equipment makes the procedure too technical and expensive for use in many medical centers. It is currently available only to participants in experimental protocols. VLAP, on the other hand, draws fire from urologists who say that is low-tech approach yields satisfactory results only when used by expert surgeons.

Beam me up, doc?

Most surgeons agree that lasers will probably play a valuable role in treating BPH in the future. But they say more information is needed before they can determine who is a suitable candidate for the procedure, what is the optimal energy level and duration of laser use, and whether ultrasound guidance is really needed.

A man who is thinking about laser surgery for BPH must remember that the procedure is new and must be considered experimental until it receives FDA approval. Although short-term results are encouraging, the long-term effectiveness and the likelihood of side effects have not been established and will probably vary from one type of laser to another.

Patients who wish to proceed at their own risk should ask what training their doctor has had with the laser surgery (the absolute minimum should be a two-day course with hands-on experience), how many procedures he or she has performed, and how the laser’s success and complication rates compare with TURP’s for at least one year after treatment. They should also find out if the surgery is oart of an FDA-approved research protocol, which may experts believe is the only setting in which laser surgery for BPH should be used.

“I was somewhat skeptical about laser prostatectomy when it was first introduced because it was accompanied by an inappropriate marketing approach,” said urologist John D. McConnell, an associate professor at the University of Texas Southwestern Medical Center who chairs the federal committee charged with writing guidelines for BPH treatment. “However, given what is evolving now, I think we will probably be using some laser modality to resect prostate tissue at the turn of the century.”

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