Update on the Use of Interstitial Laser Coagulation in the Treatment of Benign Prostatic Hyperplasia
Introduction
INTRODUCTION Update on the Use of Interstitial Laser Coagulation in the Treatment of Benign Prostatic Hyperplasia Michael K. Brawer, MD Northwest Prostate Institute, Northwest Hospital, Seattle, WA [Rev Urol. 2005;7(suppl 9):S1–S2] © 2005 MedReviews, LLC y age 60, half of all men are affected by benign prostatic hyperplasia (BPH), an incidence rate that increases to 9 out of 10 among those men who live another 25 years.1 Many men with BPH will experience bothersome lower urinary tract symptoms (LUTS) that adversely affect their quality of life. It is this complex of irritative and obstructive symptoms that often prompt men to seek treatment. The available treatment options include medical, minimally invasive, and surgical therapies. Although many men do well on medical therapy, some may experience side effects or loss of efficacy; others may object to the cost of the medications B VOL. 7 SUPPL. 9 2005 REVIEWS IN UROLOGY S1 Treatment of Benign Prostatic Hyperplasia continued or to the prospect of a lifetime commitment to taking pills. Such patients will want alternatives to medical therapy. Transurethral resection of the prostate is considered to be the gold standard therapy for BPH; it is, however, associated with a high incidence of sexual side effects, especially retrograde ejaculation. Minimally invasive procedures, including transurethral microwave thermotherapy, transurethral needle ablation, water-induced thermotherapy, and interstitial laser coagulation (ILC), are technologies that have demonstrated promising results and may be done in an office setting under local anesthesia—a real benefit for those patients who may not be good surgical candidates or who may not be able to tolerate general anesthesia. This supplement is intended to provide an update to the urologist on the use of ILC for the treatment of BPH. In his overview of BPH, Claus Roehrborn, MD, asserts that the deceptively simple description of BPH belies the actual complexities inherent in the relationships among BPH, LUTS, benign prostatic enlargement, and bladder outlet obstruction and that successfully treating them requires a solid understanding of their definitions. He also observes that, although the etiology of BPH and LUTS is still poorly understood, the hormonal hypothesis contains many factors arguing in its favor. From among a plethora of treatment options available, he describes the minimally invasive treatment options as superior to medical treatments in the intermediate and long term, especially when considering such fac- S2 VOL. 7 SUPPL. 9 2005 tors as symptom and flow-rate improvement. He also indicates that tissue-ablative surgical treatment can be superior to both minimally invasive and medical therapies. Muta M. Issa, MD, describing the evolution of laser therapy in the treatment of BPH, notes 2 basic principles based on the final tissue effect— vaporization and coagulation. In the former, higher-density laser thermal energy is used, and the effects range from complete tissue vaporization to incision, resection, or enucleation of the obstructing prostatic tissue. The latter, ILC, requires relatively lower therapeutic temperatures, and the urethral preservation and lack of tissue vaporization or resection distinguishes it from conventional transurethral free-beam laser prostatectomy. Dr. Issa describes the Indigo® Optima Laser treatment system (Ethicon EndoSurgery, Inc., Cincinnati, OH) as the most widely used system for ILC, which, unlike other BPH laser therapies, can be satisfactorily performed using local anesthesia in the office setting. Noting that favorable outcomes with minimal adverse events are seen in a large portion of patients, Dr. Issa cautions that such results depend on proper surgical technique and operator experience. The emergence of minimally invasive therapies for the management of symptoms of BPH and the reality of a changing medico-economic environment have prompted Kalish R. Kedia, MD, to describe the need for a reliable local anesthesia protocol. The one for prostate anesthetic block is described as a safe, economical, and effective REVIEWS IN UROLOGY way to perform ILC and other minor endoscopic procedures in the office setting. Dr. Kedia believes urologists should not only be aware of these techniques but should become comfortable with them, given that most patients who undergo an in-office procedure with local or regional anesthesia experience little discomfort and recover quickly, allowing a prompt resumption of normal activities. Finally, my article describes the preliminary results of a multicenter study on the efficacy and safety of ILC versus -blockade in subjects with symptomatic BPH. I note that significant efforts have been made to develop minimally invasive approaches to treatment, both to lessen the morbidity of the standard operative procedures and to avoid a need for lifelong drug therapy. I describe the minimally invasive procedure of ILC, which can be performed under local, regional, or general anesthesia, as an operator-dependent procedure that allows the surgeon to control selectively the placement of the laser fiber to achieve optimum destruction of tissue. In presenting 6-month preliminary data from the randomized trial of -blockade versus ILC, I report that the latter is associated with a clinically significant decrease in American Urological Association symptom scores—a result superior to -blockers. Reference 1. Ercole B, Lee C, Best S, et al. Minimally invasive therapy for benign prostatic hyperplasia: practice patterns in Minnesota. J Endourol. 2005;19: 159-162.