Laser Prostatectomy: Checkup on the Promises

Clinical Challenge

CLINICAL CHALLENGE Laser Prostatectomy: Checkup on the Promises James Choi, MD, Edward F. Ikeguchi, MD, Alexis E. Te, MD, Steven A. Kaplan, MD Columbia College of Physicians & Surgeons New York, N.Y. Voiding symptoms caused by benign prostatic hyperplasia are responsible for significant compromise in the quality of life of many men. As our population ages, more men are seeking medical evaluation and treatment for this condition. In addition, with the recognition that this benign condition rarely creates significant life-threatening medical problems, there has been a movement toward less invasive therapies that are associated with the least possible iatrogenic morbidity. Among the currently available, minimally invasive techniques is laser prostatectomy. Is it standing up to its rival, transurethral resection of the prostate, or lagging behind? [Rev Urol. 1999;1(3):170-176] Key words: Benign prostatic hyperplasia (BPH) • Prostatectomy • Laser ransurethral resection of the prostate (TURP) remains the reference standard in the surgical management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). Despite the advances in treatment and refinements in technology, however, the incidence of intraoperative and postoperative complications associated with TURP, such as significant bleeding, TUR syndrome, incontinence, urethral strictures, and sexual dysfunction, remains substantial.1-3 Attempts at developing office-based surgical therapies with lower morbidity and efficacy rivaling TURP have led to the emergence of several minimally invasive techniques. Currently available are transurethral electrovaporization of the prostate (TUVP), transurethral needle ablation (TUNA), high-intensity focused ultrasound (HIFU), transurethral microwave therapy (TUMT), and laser prostatectomy. Laser prostatectomy has been advocated as a technology that provides minimal morbidity while attempting to ameliorate bladder outlet obstruction. An array of techniques, laser generators, and fibers have been used and are currently being tested for the laser management of BPH. These new laser procedures can deliver sufficient heat to the prostate so that either coagulation necrosis or frank vaporization occurs, depending on the amount of energy delivered to the tissue. Essentially, laser prostatectomy can be divided into 3 different procedures: visual laser ablation of the prostate (VLAP), interstitial laser coagulation (ILC), and holmium laser resection of the prostate (HoLRP). Each will be reviewed. T 170 REVIEWS IN UROLOGY SUMMER 1999 Prostatectomy Visual Laser Ablation of the Prostate (VLAP) Development of VLAP began when Roth and Aretz demonstrated the feasibility of using a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with a right-angled deflecting mechanism to create coagulative necrosis of the prostate in an animal model.4 Johnson and colleagues adopted this technology and invented a cystoscopic device to deliver the laser beam at a right angle into the parenchyma of the human prostate.5 This preliminary human clinical trial suggested that noncontact laser coagulation of the prostate was a safe and effective treatment for patients with BPH in which tissue coagulation led to secondary sloughing of the prostatic tissue.5 Surgical Technique. Surgery is performed under general anesthesia, regional anesthesia, or local prostatic block.6 With the patient in the dorsal lithotomy position, a standard transurethral approach to the prostate is utilized with a rigid cystoscope. An Albarran deflecting bridge is used to direct the fiber to the desired area of treatment. Nd:YAG continuous wave laser can be delivered to the prostatic tissue, using either a ProLase (Endocare, Inc, Aliso Viejo, Calif) or Urolase (CR Bard, Inc, Covington, Ga) side-firing laser fiber.7-10 The amount of energy delivered to each patient is dependent on the time of exposure and power utilized (measured in watts). To date, the optimal laser dosimetry for the management of BPH has not been established. Randomized clinical trials comparing low-power slow heating (15 W for 180 seconds) versus high-power rapid heating (50 W for 60 seconds) noncontact Nd:YAG laser regimens for the management of BPH showed the low-power regimens to be as effective and safe as the high-power regimen. More importantly, the same trials also suggest that the spatial distribution of lesions and overlapping of treated sites had a more significant impact on ultimate outcome.11 The studies cited have used power ranges of 40 to 80 W of uninterrupted free-beam laser energy to BPH tissue in intervals of 30 to 60 seconds. Most commonly, systematic 4-quadrant (2, 4, 8, and 10 o’clock positions) laser applications to the prostatic lateral lobes are performed. Depending on the size of the prostate, laser application may be repeated every 2 cm along the length of the prostatic urethra between the bladder neck and verumontanum to all obstructing tissue. In addition, posteriorly directed (6 o’clock) laser applications may be used for any median lobe tissue. All patients receive perioperative antibi- 60%, postvoid residual urine volumes had decreased by approximately 40%, and the American Urological Association (AUA) symptom index had decreased by approximately 50%. Multicenter, prospective, randomized studies comparing the safety and efficacy of VLAP to TURP have also shown that VLAP is a useful alternative therapy in treating patients with LUTS secondary to BPH.7,10 Clinical evaluation at 1-year follow-up showed that patients undergoing VLAP had comparable LUTS improvement to patients with TURP. VLAP is associated with significantly less morbidity, shorter procedure time, and hospital stay. The most significant adverse event in patients Multicenter, prospective, randomized studies comparing the safety and efficacy of VLAP to TURP have . . . shown that VLAP is a useful alternative therapy in treating patients with LUTS secondary to BPH. otic prophylaxis. Postoperatively, patients are maintained on catheter drainage through a 16F urethral catheter or suprapubic tube. An attempt at urethral catheter removal is generally performed on the first postoperative day, and the patient is given a voiding trial. The procedure is performed on either an inpatient or outpatient basis at the surgeon’s and patient’s discretion. Outcome. Transurethral free-beam Nd:YAG laser coagulation of obstructing BPH tissue has been the most common clinically employed laser technique, providing excellent hemostasis, minimal morbidity, and proven efficacy in relieving symptoms of bladder outlet obstruction and improving quality of life.7,8,10,12,13 Multicenter prospective studies of Nd:YAG laser prostatectomy have reported long-term efficacy in a significant number of patients.8 At 1year follow-up, peak urinary flow rates were increased by an average of undergoing VLAP has been transient postoperative dysuria, related to the effects of necrosis and sloughing of tissue after the procedure. The reoperation rates following laser prostatectomy have not been significantly different from those of TURP: 2.1% to 2.8% per year for TURP and 2.7% in laser prostatectomy series.14 In addition, it has been shown that individuals with coagulopathy can safely undergo Nd:YAG laser prostatectomy, with its superior hemostasis and lower physiologic stress.15,16 Lastly, in studies directly comparing costs of laser prostatectomy to standard TURP, a relative cost benefit favoring laser prostatectomy has been shown.17 Conclusion. At first glance, the published data support continued utilization of this modality. However, the urologic community, for the most part, has abandoned VLAP for a number of reasons. These include significant postoperative symptom morbidity, cost, and, more importantly, SUMMER 1999 REVIEWS IN UROLOGY 171 Prostatectomy continued the presence of other modalities that give similar or better results. Interstitial Laser Coagulation (ILC) of the Prostate ILC was first studied as a therapy for patients with soft-tissue neoplasms during the 1980s and has been used for patients with unresectable localized tumors in the brain, head, neck, liver, breast, and pancreas.18 ILC has a technical advantage over other contact or noncontact lasers in that it uses relatively low power laser light (2 to 20 W) to cause coagulative necrosis in tissue. The decreased energy requirements are due to direct contact between the laser fiber and the prostatic tissue, which results in enhanced laser energy absorption by the surrounding tissue as well as decreased laser energy loss to irrigation fluids and reflection. During ILC, cells throughout the target volume are heated to temperatures that exceed protein denaturation thresholds, typically 60oC.19 This photothermal effect induces coagulative necrosis. ILC also causes a photochemical Figure 1. Indigo laser apparatus. 172 REVIEWS IN UROLOGY SUMMER 1999 and photoacoustic effect, but to a lesser degree. Another important feature of ILC is that energy is delivered to the periurethral tissue through an applicator, which prevents any energy from being delivered to the ure- laser fiber is advanced into the prostate. The tip of the laser fiber is sufficiently rigid to allow perforation into the tissue without a trocar. A visible marker on the laser fiber is used to reach the desired depth within the Another important feature of ILC is that energy is delivered to the periurethral tissue through an applicator, which prevents any energy from being delivered to the urethra. thra. As a consequence, there is generally no sloughing of necrotic tissue from the urethra with its consequent problems such as dysuria. The necrotic material is absorbed with time; the result is an atrophic, shrunken prostatic gland. During this process, a TURP-like cavity or “defect” is gradually formed. Surgical Technique. Wavelengths ranging from approximately 800 to 1,100 nm have demonstrated relatively deep penetration in water and tissues.20 The first approach was done using an Nd:YAG (1,064 nm) laser. Various diode lasers at wavelengths of 805 nm (Diomed 25, Cambridge, England), 830 nm (Indigo 830e, Indigo Medical Inc./Johnson & Johnson, Cincinnati, Ohio), and 980 nm (Domier prototype, Germering, Germany) have been evaluated clinically. We will describe the technique of ILC based on the Indigo 830e (Figure 1). There are 3 components to the Indigo 830e laser system: a portable diode laser unit with an adjustable wattage (O to 20 W), a specialized fiberoptic delivery system that allows optical monitoring of tissue temperatures, and a laser. If this optical feedback system detects any charring of tissue, the laser automatically turns off.21,22 The majority of ILC is performed under regional or general anesthesia. Cystourethroscopy is performed to delineate any pertinent landmarks and identify the treatment target. Using the cystoscope, the diffuser-tip prostate. The fiber is inserted at an angle of approximately 25 to 35 degrees relative to the axis of the urethra, beginning at the apex directly proximal to the external sphincter. Intraoperative transrectal ultrasonography can be used to confirm the placement of the fiber inside the prostate. Laser energy is applied in each location for 3 to 4 minutes, with variation of wattage to deliver a tissue temperature of approximately 85oC in any given zone (Figure 2). The application of laser energy for longer periods at lower power is recommended; the operator can reposition the laser fiber during treatment, and the target can be coagulated without extensive tissue disruption. The size of the target zone is approximately 2.0 x 2.0 x 2.2 cm. Further applications may be performed in each of the lateral lobes at intervals of 2 to 3 cm toward the bladder neck. The median lobe can be punctured 1 or more times toward the lumen of the bladder. Once the procedure has been completed, a suprapubic or urethral catheter is placed for approximately 48 hours. Outcome. Clinical trials of ILC have shown significant improvement in AUA symptom score, peak urinary flow rate, and prostate size. Muschter and Hofstetter reported a nonrandomized, retrospective review of 239 patients who underwent ILC with the Nd:YAG laser as a treatment for BPH.23 The AUA symptom score improved from an average of 25 pre- Prostatectomy treatment to an average of 6 at 1 year postoperatively. Peak urine flow rate improved from 8 mL pretreatment to 18 mL at 1 year. Prostate volume was also noted to decrease from 47.4 cc to 31 cc at 1 year follow-up. Similar findings were reported with patients undergoing ILC with the Indigo 830nm laser with follow-up of 6 months to 1 year.24,25 Although postoperative complications were rare in these studies, approximately 12% of patients reported transient postoperative irritative voiding symptoms. Drainage with a Foley catheter or suprapubic tube averaged more than 10 days. Retrograde ejaculation was reported in 7% of patients. Approximately 9.6% of patients required retreatment during the 12 months of follow-up. Fay and colleagues recently reported a randomized, prospective study comparing the efficacy of ILC versus TURP in 44 patients. Results at 6 months postoperatively showed comparable improvement of AUA symptom scores. Patients who received TURP, however, showed significantly better peak urinary flow rates.26 Conclusion. ILC of the prostate is a novel therapy, which can improve symptoms associated with BPH by reducing the volume of prostate. Although ILC is associated with certain disadvantages, such as prolonged catheterization, this technique can be adapted easily to the urologic community. Holmium Laser Resection of the Prostate (HoLRP) The potential advantages of VLAP have been overshadowed by its disadvantages. Patients were generally dissatisfied with the need for an indwelling urethral or suprapubic catheter for prolonged periods. Furthermore, the coagulated tissue caused severe irritative symptoms in a significant proportion of patients, resulting in an overall delay in symptomatic improvement.27-29 Holmium: Figure 2. Laser fiber inserted into lateral lobe of prostate. Note the zone of coagulation necrosis. YAG (Ho:YAG) laser resection of the prostate (HoLRP) combines the minimal morbidity of VLAP with the immediate tissue removal and voiding outcomes traditionally associated with TURP. The Ho:YAG wavelength (2140 nm) has been used in a number of urologic conditions over the past several years.30 Due to the short absorption length (0.4 mm) and very narrow zone of coagulation (2 to 3 mm on each side), the holmium laser causes vaporization rather than coagulation. Thus, it has had minimal association with many of the unwanted side effects associated with the Nd:YAG laser (1064 nm), such as irritative voiding symptoms.31 During HoLRP, prostate tissue can be resected in a relatively bloodless manner to immediately obtain a TURP-like channel. Surgical Technique. Surgery is performed under general or regional Main Points • TURP is still the standard for surgical treatment of patients with symptoms of the lower urinary tract that are secondary to BPH. • The amount of energy delivered by the laser to the tissue determines the result: tissue necrosis or vaporization. • Although studies compare VLAP favorably with TURP, VLAP has largely given way to other modalities because of postoperative morbidity and cost. • With ILC, using laser energy at lower power for longer periods is recommended. • With the use of HoLRP, postoperatively tissue is available for histologic analysis. • Laser prostatectomy may be on the upswing in the United States. SUMMER 1999 REVIEWS IN UROLOGY 173 Prostatectomy continued Figure 3. Holmium laser system. anesthesia. The dual wavelength VersaPulse Select laser (Coherent Inc, Palo Alto, Calif) generates a maximum average power of 60 W when a pulsed mode is used (Figure 3). The energy level is set at 2.4 J at a frequency of 25 pulses per second and is delivered via an end-firing 550 µm bare fiber (Slimline; Coherent Inc). A continuous flow resectoscope sheath is used with saline irrigation. The maneuver after insertion of the resectoscope and orientation in the prostatic urethra is a bilateral bladder neck incision. This defines the depth and amount of tissue to be removed. A transverse incision just above and proximal to the verumontanum is then made to connect these 2 incisions. The median lobe is ultimately undermined and detached back into the bladder. If the median lobe is very large, it is cut into smaller pieces prior to detachment. Resection of each lateral lobe is done by first defining the distal limits. Incisions are made at the 5 and 7 o’clock positions, proximal to the 174 REVIEWS IN UROLOGY SUMMER 1999 verumontanum. Subsequent incisions are made at the 1 and 11 o’clock positions over the entire length of the prostate to define the upper margin of the lateral lobe excision. The lobe is then released, commencing distally, until only a bridge of tissue remains at the bladder neck. If the lobes are large, they are cut into smaller pieces to facilitate subsequent removal prior to detachment (Figure 4). Prostate pieces are removed from the bladder at the end of the procedure. A 20F urethral catheter is introduced, and the patient usually remains in the hospital overnight. The catheter is removed the following morning, and the patient is discharged once he has voided.32 Outcome. HoLRP has proven effective in the surgical management of bladder outlet obstruction due to BPH. In several nonrandomized, retrospective studies addressing the safety and efficacy of Ho:YAG for the relief of LUTS secondary to BPH, patients treated with HoLRP showed immediate improvement in voiding.32-34 Mean postoperative catheterization time was 1.4 days, and over 90% of patients receiving HoLRP underwent a successful first postoperative voiding trial.33 There were no significant perioperative or postoperative complications. Mild initial hematuria was noted by 17% of patients and resolved in a mean of 3.2 days.32 No patient required transfusion. Dysuria and urgency were common symptoms during the first postoperative week; however, no patient required significant intervention or treatments. The AUA symptom score and peak urinary flow rate at 1-, 3-, and 6-month follow-up showed significant improvement of both parameters.33,34 The authors noted the similarity of their results to other studies of conventional TURP. Another important similarity to TURP, unlike other laser prostatectomy techniques, is that HoLRP can provide TURP-like prostatic “chips” Figure 4. Prostate tissue after holmium laser treatment. for histologic evaluation. A disadvantage of VLAP and ILC is the absence of a tissue specimen. Although a large amount of tissue is vaporized during HoLRP, approximately 25% of the estimated resected prostate is still available for histologic analysis.32,34 In a randomized, prospective comparison of VLAP versus HoLRP, patients treated with HoLRP showed significantly better outcomes than patients treated with VLAP.35 The mean catheter times were 1.4 days for HoLRP and 11.6 days for VLAP. These times included 9% of HoLRP and 36% of VLAP patients who required recatheterization after an initial voiding trial. Although a 1-year follow-up study showed no significant difference in AUA symptom scores between these 2 groups, immediate postoperative dysuria scores were significantly worse in the VLAP group compared with the HoLRP group. In addition, patients who received HoLRP had significantly higher peak flow rates at 1 and 6 months follow-up. Gilling and colleagues reported a randomized, prospective study comparing the efficacy of HoLRP with TURP in 73 patients; follow-up was 3 months.36 The results showed that HoLRP patients had significantly less perioperative morbidity, postoperative catheterization time, need for hospital stay and nursing care, and postoperative bladder irrigation time. AUA Prostatectomy Table One-Year Follow-up Results on Laser Treatments for BPH Laser type Study VLAP (Nd:YAG) Kabalin8 72 Qmax Pre Post 8.8 18.0 HoLRP (Ho:YAG)* Cresswell34 411 7.7 22.8 23.6 4.9 Muschter23 239 8.0 18.0 25.0 6.0 24 8.4 16.8 23.2 7.2 ILC (Nd:YAG) ILC (Indigo) No. of patients 25 Williams AUA score Pre Post 20.0 8.0 12. 13. 14. *6 months’ results 15. symptom scores and peak flow rates at 3 months were also comparable. Conclusion. HoLRP combines the advantages of conventional TURP with those of the standard Nd:YAG laser prostatectomy—namely, a relatively bloodless procedure, short hospital stay, early catheter removal, immediate symptomatic improvement, and retrieval of tissue for histologic analysis. The procedure can be learned in a short period by most urologists skilled in prostate resection. It represents an important utility of the holmium laser, which has a true multipurpose wavelength for which there are numerous uses in urologic practice. However, the need for availability (within the United States) and learning of tissue morsalization remain major impediments to widespread use of this technique. Summary Attempts at developing office-based surgical therapies with lower morbidity and efficacy rivaling TURP have led to the emergence of several minimally invasive techniques (Table). To date, laser prostatectomy has been a technology that has not fulfilled its original promise of a low morbidity procedure. Due to the postoperative morbidity and availability of other technology, including refinements of TURP, the use of laser prostatectomy has dropped precipitously within the United States. However, the current availability of ILC has recently increased the usage of and enthusiasm for this technology. The future will portend the ultimate role of lasers in the urologic armamentarium of therapies for BPH. ■ 16. 17. 18. References 1. Thorpe AC, Cleary R, Coles J, et al. Deaths and complications following prostatectomy in the northern region of England. Br J Urol. 1994;74:559-565. 2. Wasson JH, Reda DJ, Bruskewitz RC, et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995;332:75-79. 3. Horninger W, Unterlechner H, Stasser H, Bartsch G. Transurethral prostatectomy: mortality and morbidity. Prostate. 1996;28:195. 4. Rodi RA, Aretz TH. Transurethral ultrasoundguided laser-induced prostatectomy (TULIP procedure): a canine prostate feasibility study. J Urol. 1991;146:1128-1135. 5. Johnson DE, Levinson AK, Costello AJ. Transurethral lase prostatectomy using a right angle laser delivery system. SPIE. 1991;1421:3641. 6. Leach GE, Sirls L, Ganabathi K, et al. Outpatient visual laser-assisted prostatectomy under local anesthesia. Urology. 1994;43:149-153. 7. Costello AJ, Lusaya DG, Crowe HR. Transurethral laser ablation of the prostate: long-term results. World J Urol. 1995;13:119122. 8. Kabalin JN, Gill HS, Leach GE, et al. Prospective multicenter ProLase II clinical trial of neodymium:yttrium-aluminum-garnet laser prostatectomy. Urology. 1997;50:63-65. 9. Cowles RS III, Kabalin JN, Childs S, et al. A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia. Urology. 1995;46:155-160. 10. Anson K, Nawrocki J, Buckley J, et al. A multicenter, randomized, prospective study of endoscopic laser ablation versus transurethral resection of the prostate. Urology. 1995;46:305-310. 1995. 11. Orihuela E, Motamedi T, Pow-Sang M, et al. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. Randomized clinical trial comparing low powerslow heating versus high power-rapid heating noncontact neodymium:yttrium-aluminumgarnet laser regimens for the treatment of benign prostatic hyperplasia. Urology. 1995;45: 783-789. Kabalin JN, Gill HS, Bite G. Laser prostatectomy performed with a right-angle firing neodymium:YAG laser fiber at 60 watts power setting. J Urol. 1995;153:1502-1505. Kabalin JN, Bite G, Doll S. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients. J Urol. 1996;155:181-185. McConnell JD, Barry MJ, Bruskewitz RC, et al. Clinical Practice Guideline Number 8: Benign Prostatic Hyperplasia: Diagnosis and Treatment. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research, Public Health Service: 1994. AHCPR Publication 94-0582. Kabalin JN, Gill HS. Urolase laser prostatectomy in patients on warfarin anticoagulation: a safe treatment alternative for bladder outlet obstruction. Urology. 1993;42:738-740. Kingston TE, Nonnenmacher AK, Crowe H, et al. Further evaluation of transurethral laser ablation of the prostate in patients treated with anticoagulant therapy. Aust NZ J Surg. 1995;65:4043. Kabalin JN, Butler ED. Costs of minimally invasive laser surgery compared with transurethral electrocautery resection of the prostate. West J Med. 1995;162:426-429. Malone DE, Wyman DR, Moote DJ, et al. Sonographic changes during hepatic interstitial laser photocoagulation: an investigation of three optical fiber tips. Invest Radiol. 1992;27:804-813. Muschter R. Interstitial thermotherapy. In: Sosa RE, Albala DM, Jenkins AD, et al, eds. Textbook of Endourology. Philadelphia, Pa: WB Saunders Co; 1996:278-292. Boulnois JL. Photophysical processes in recent medical laser devepments: a review. Lasers Med Sci. 1986;1:47-64. Muschter R, Hofstetter A. Technique and results of interstitial laser coagulation. World J Urol. 1995;13:109-114. William JC. Using interstitial laser coagulation to treat BPH. Cont Urol. 1998;9(8):25-36. Muschter R, Hofstetter A. Interstitial laser therapy outcomes in benign prostatic hyperplasia. J Endourol. 1995;9:129-135. Muschter R, de la Rosette JJ, Whitfield H, et al. Initial human clinical experience with diode laser interstitial treatment of benign prostatic hyperplasia. Urology. 1996;48:223-228. Williams JC. Interstitial laser coagulation of the prostate: introduction of a volume-based treatment formula with 12-month follow up. World J Urol. 1998;16:392-395. Fay R, Chan SL, Kahn R, et al. Initial results of a randomized trial comparing interstitial laser coagulation therapy to transurethral resection of the prostate. J Urol. 1997;157(4);151a. Dixon CM. Lasers for the treatment of benign prostatic hyperplasia. Urol Clin North Am. 1995;22:413-422. Narayan P, Tewari A, Fournier G, Toke A. Evaporation of the prostate for benign prostatic hyperplasia. Urology. 1995;45:776-782. Keoghane SR, Cranston DW, Lawrence KC, et al. The Oxford Laser Prostate Trial: a double-blind randomized controlled trial of contact vaporization of the prostate against transurethral resection; preliminary results. Br J Urol. 1996;77(3):382-385. Johnson DE, Cromeens DM, Price RE. Use of the SUMMER 1999 REVIEWS IN UROLOGY 175 Prostatectomy 31. 32. 33. 34. 35. 36. Incontinence continued Holmium:YAG laser in urology. Lasers Surg Med. 1992;12:353-363. Conrad S, Henke R-P, Reek C. Effects of Holmium:YAG laser energy on human benign prostatic hyperplasia tissue: a histologic ex-vivo study. J Urol. 1996;155 (suppl). Abstract 1573. Gilling PJ, Cass CB, Cresswell MD, Fraundorfer MR. Holmium laser resection of the prostate: preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology. 1996;47:48-51. Kabalin JN. Holmium:YAG laser prostatectomy: results of U.S. pilot study. J Endourol. 1996;10:453-457. Cresswell M, Cass CB, Fraundorfer MR, Gilling PJ. Holmium:YAG laser resection of the prostate: preliminary experience with the first 400 cases. NZ Med J 1997;110:76-78. Gilling PJ, Cass CB, Malcolm A, et al. Holmium laser resection of the prostate versus neodymium:yttrium-aluminum-garnet visual laser ablation of the prostate: a randomized prospective comparison of two techniques for laser prostatectomy. Urology. 1988;51:573-577. Gilling PJ, Fraundorfer MR, Kabalin JB. Holmium:YAG laser resection of the prostate (HoLRP) versus transurethral electrocautery resection of the prostate (TURP): a prospective randomized, urodynamics-based clinical trial. J Urol. 1997;157:149A. COMING continued recruited. The study identified 32 QOL items related to urinary incontinence, more than half of which were not previously described. Compared with expert-defined QOL items related to urinary incontinence obtained from the literature, the patient-defined items were related more to coping with embarrassment and interference from incontinence than on prevention of performing activities. Dr. Resnick’s team concluded that experts and patients view the impact of urge incontinence on QOL differently: Experts often focus on functional impact; patients tend to cite the effect on their emotional well-being and on their activities. I think looking over the top 5 most frequently cited incontinence-related QOL items can help us as clinicians to understand our patients better. • Need for preemptive strategies to avert urge urinary incontinence • Lack of self-control • Adaptation of daily routine • Shame • Fear of public embarrassment ■ IN THE ROLE OF RECOMBINANT ERYTHROPOIETIN IN MEN UNDERGOING RADICAL RETROPUBIC PROSTATECTOMY 176 REVIEWS IN UROLOGY SUMMER 1999