Laser Resection of the Prostate: Information & Specialists in Laser Resection

Prostate hyperplasia can often be treated with medication. If this is not sufficient, surgical removal of prostate tissue is necessary. During this procedure, glandular tissue is removed from the inner part of the prostate. If successful, this leads to

• improved bladder function,
• a stronger urine stream,
• a reduction in symptoms, and
• complete bladder emptying without residual urine.

In most cases, the surgery is performed using a minimally invasive technique. No skin incisions are necessary. Instead, an instrument is inserted through the urethra.

The global standard surgical procedure is transurethral resection of the prostate (TURP). Numerous randomized studies demonstrate the good long-term outcomes of TURP. However, it carries procedure-related risks, which include the introduction of irrigation fluid and/or blood loss.

Various laser procedures have also been developed as alternatives to TURP. The goal was to provide a treatment that is less invasive than TURP.

A laser is a high-energy, focused beam of light that generates heat upon contact with tissue. This localized heat burns or vaporizes tissue and can thus cut or vaporize prostate tissue (vaporization). The type of effect on the tissue depends on the energy and wavelength of the laser light used.

Laser procedures have been used in the treatment of benign prostatic hyperplasia for nearly 30 years.

Generally speaking, the initial costs for the necessary laser technology are relatively high. The laser fibers required for patient treatment are single-use instruments with the GREENLIGHT laser. They significantly increase the cost of every procedure of this type compared to TURP. For the patient, nothing fundamentally changes, regardless of which procedure is used.

Various types of lasers have a gentle effect. However, they are less effective at removing proliferating prostate tissue.

Procedures currently in use include

• holmium laser enucleation (HOLEP),
• KTP laser vaporization of the prostate, and
• the continuous-wave (CW) laser (thulium laser).

These procedures differ in the wavelength and energy of the laser light used. In other words, they differ in their energy effect on the tissue and their penetration depth.

Holmium Laser Enucleation

The holmium:YAG laser has not proven effective as an instrument for vaporization (tissue vaporization). This laser is therefore used for what is known as laser enucleation of the prostate.

The laser is housed in an instrument inserted into the urethra. Doctors use this to cut out the inner portions of the prostate. These prostate fragments are then broken down in the bladder and flushed out. The surgical principle involves removing as much of the enlarged inner portions of the prostate as possible.

The goal is the same as with TURP, although blood loss is generally lower with holmium resection. Controlled comparative studies have shown good results that are comparable to those of TURP.

This technique is complex to perform. As a result, this method has not become widely adopted.

GREENLIGHT Laser

GREENLIGHT laser resection uses the potassium titanyl phosphate (KTP)-YAG laser exclusively to vaporize the inner prostate tissue.

Technically, it is an Nd:YAG laser (wavelength 532 nm) frequency-doubled using a KTP crystal. This wavelength lies in the visible, green range of the color spectrum. This is why the laser is also called the GREENLIGHT laser.

The laser causes superficial tissue destruction in well-vascularized tissue. Only minimal bleeding occurs during the procedure. This characteristic results from the laser’s shallow penetration depth into the tissue and the high absorption of laser energy, primarily by the red blood pigment (hemoglobin).

This procedure is therefore also referred to as “photoselective.” Tissue ablation is performed step by step under direct visualization.

GREENLIGHT lasers have been upgraded from an initial power output of 60 W (which resulted in long operating times) to 120 W. This has led to more efficient and faster tissue ablation.

The advantage lies in very minimal blood loss, making this procedure particularly suitable for treating high-risk patients.

Controlled comparative studies have shown results that are quite comparable to those of TURP.

THULIUM Laser

Another procedure uses what is known as a continuous-wave (CW) laser. It has a wavelength of 2 micrometers (2-micron continuous-wave laser). This wavelength is comparable to that of the holmium laser. With the CW laser, the infrared light is strongly absorbed by the intracellular water in the tissue.

The penetration depth into the tissue is only 0.5 mm, and the absorbed energy is converted into heat. This causes the prostate tissue to vaporize, leaving behind a relatively thin layer of coagulated tissue.

This laser is therefore also used for vaporization with minimal blood loss.

Laser procedures are associated with minimal blood loss. This is a fundamental advantage compared to TURP. However, this is not necessarily of significant importance for every patient: In a typical TURP procedure, blood loss is minimal and manageable. Blood loss is even lower with the GREENLIGHT laser than with HOLMIUM resection.

All surgical procedures on the prostate involve the use of an irrigation fluid. Another advantage of laser procedures is that less irrigation fluid enters the patient’s circulatory system. For patients with cardiovascular disease, the influx of large amounts of irrigation fluid can be dangerous.

When tissue is ablated with the GREENLIGHT laser, a superficial layer of dead tissue remains. This layer is gradually shed during the healing process, which takes several weeks. During this phase, patients may experience noticeable symptoms when urinating, but these symptoms eventually subside.

With TURP and the HOLMIUM laser, tissue ablation results in clean incision margins. Consequently, the healing phase is shorter in these cases.

Tissue removal using vaporization techniques is less complete than with TURP. This can result in an inadequate surgical outcome in terms of improving bladder function. In such cases, a secondary procedure is necessary.

Another potential drawback of GREENLIGHT laser resection is the vaporization of the tissue. This means that no tissue remains for examination by a pathologist. In contrast, this is possible with HOLMIUM resection and TURP.

The inability to perform a pathological examination is a disadvantage in cases where prostate cancer is suspected.

Compared to TURP, the two laser procedures mentioned are less invasive. “Invasive” essentially means “stressful” and “prone to complications.”

Laser procedures carry a significantly lower risk of bleeding and hemorrhage. They therefore carry a lower risk of complications. This is particularly important for patient groups who

• must take anticoagulant medications or
• have severe cardiovascular diseases.

On the other hand, the healing phase following GREENLIGHT resection usually takes longer. Therefore, the term “burdensome” must be put into perspective.

Scientific studies have shown that holmium enucleation and GREENLIGHT laser resection are effective procedures. Nevertheless, there are differences:

Comparison of TURP versus holmium enucleation (HoLEP)

Individual studies have predominantly reported good efficacy for HoLEP. In direct comparative studies, patients treated with HoLEP had

• a shorter duration of postoperative catheterization and
• a shorter hospital stay

than patients treated with TURP in the same study.

Comparison of TURP versus GreenLight Vaporization

In a total of three available direct comparative studies,

• slightly lower blood loss with the laser,
• a higher rate of postoperative bleeding for TURP,
• but also a significantly higher rate of necessary repeat surgeries for vaporization

.

To date, there have been only a few studies comparing the THULIUM laser with TURP.

The decision to use one of the laser surgical procedures depends largely on the size of the prostate.

The advantages of the GREENLIGHT laser are most pronounced in small and medium-sized prostates.

The HOLMIUM procedure is particularly advantageous for very large prostates but is unsuitable for small ones.

In addition, the doctor must always consider the

• patient’s specific circumstances,
• pre-existing conditions, and
• specific risks

in order to make a sound overall recommendation.