Prostatic laser surgery is a popular option to transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), but its range of techniques have varying safety and efficacy profiles. A report from Tauranga Public Hospital, New Zealand, reviews the various methods, indicating that some laser therapies might one day even supersede TURP as a gold standard for prostatic surgery.
The study, “A Review of Laser Treatment for Symptomatic BPH (Benign Prostatic Hyperplasia),“ was published in the journal Current Urology Reports.
Holmium Laser Enucleation of the Prostate (HoLEP) evolved from early methods using the holmium laser in combination with ablation, resection, and combination techniques. HoLEP is by far the best documented laser technique with an excellent track record. Several large clinical trials show that the method improves maximum urinary flow rate by 157-470 percent, and post-void residual urine by at least 80 percent. Studies also show reductions in lower urinary tract symptoms (LUTS) of more than 70 percent, and improvements in quality of life by more than 60 percent.
In addition, HoLEP also has a first-rate safety profile in extremely large prostates. Follow-up studies have shown HoLEP to be superior to TURP with greater symptom improvements after 12 months, with two recent five-year follow-up studies confirming the long-term safety of the procedure.
The most frequently reported side effect, described by 11–12 percent of patients, is transient urinary incontinence. Since laser energy has the beneficial ability to coagulate tissue, blood vessels are immediately sealed, with less blood loss and a lower risk for fluid absorption. Given that prostatic laser surgery techniques also use saline for irrigation, HoLEP is associated with a very low incidence of TUR syndrome, a life-threatening condition mainly linked to the absorption of glycine used as an irrigation fluid during TURP.
In addition, studies have shown that significant complications such as bleeding, conversion to open procedure, bladder injury and systemic infection occur only in less than 1 percent of individuals. Some early studies indicated that HoLEP might be linked to adverse long-term effects on sexual function, but these studies did not use proper rating techniques and new research has indicated that HoLEP has no adverse long-term effects on sexual function.
Thulium laser techniques have evolved in much the same way as holmium lasers. Since the techniques are newer and still evolving, the evidence base is rather scattered with few studies investigating each technique. When researchers performed analyses of published studies pooling data from all the different techniques, thulium prostatic laser surgery methods showed improvements in LUTS symptoms and quality of life comparable to TURP.
Thulium laser techniques also have an encouraging safety profile, with features similar to TURP, but with a lower risk for TUR syndrome. Few studies have reported on sexual function-related complications but noted retrograde ejaculation to be common. Erectile function, however, does not seem to be affected by the procedures.
Photoselective Vaporization, also known as GreenLight systems, encompasses two different prostatic laser surgery techniques. Although they use the same wavelength of light, three different power settings are used, resulting in varying clinical outcomes. Despite this, studies comparing GreenLight to TURP have often grouped the 80 W and 120 W lasers.
While the 80 W laser is considered safe and efficient, it is associated with longer operation times. A recent analysis of published studies of 120 W GreenLight laser systems found that the method had better safety profile, with shorter catheterization times, hospital stays, and a reduced risk of blood transfusion, as well as low TUR syndrome rates. Effects on sexual function are also comparable to TURP.
The most current addition, the 180-W Greenlight XPS laser system, has just completed a Phase 4 clinical trial in small prostates. The 12-month follow-up data showed that the method was somewhat comparable to TURP, with about 70 percent reduction in symptom scores.
Diode laser vaporization of the prostate, and more recently, diode laser enucleation of the prostate (DiLEP), are newer methods using a range of different wavelengths. Several retrospective studies and case series have found the methods both safe and efficient, but only one randomized clinical trial has scrutinized diode laser vaporization, comparing it to TURP.
The trial found TURP to be linked to better outcomes, measured after 24 months. More recent studies of DiLEP found perioperative outcomes more favorable compared to TURP, with shorter postoperative catheterization time and hospital stays and symptomatic relief comparable to TURP.
The main adverse effects of laser techniques, particularly affecting diode laser therapy, are irritation and retrograde ejaculation, however, a study found these effects to be as frequent as in TURP.
Neodymium-yttrium-aluminium-garnet (Nd-YAG) laser prostatectomy is a technique that largely has fallen out of favor since studies have shown TURP to give better functional outcomes. The Nd-YAG laser has also been plagued with associations to persistent dysuria and is now considered redundant.
Currently, the most widely used and well-established laser techniques are the HoLEP and GreenLight methods. Both suffer a drawback compared to TURP: a long learning curve for HoLEP laser surgeons and longer operation times for GreenLight. Other methods need to be studied in larger randomized clinical trials to allow drawing definitive conclusions about safety and efficacy.