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- Holmium Laser Ablation of the Prostate
- STEP 4
- Figure 2 Figure 3 Figure 1 Pre-Operative Obstruction
- TECHNIQUE
- SURGICAL RESULT Large open cavity and symptomatic relief for patient.
- Figure 4 Figure 5 Figure 7 Figure 6
- The opinions, recommendations expressed and video images shown in this Technique Spotlight are those of the author alone.
| Michael Gambla, MD Chief, Section of Urology Riverside Methodist Hospital Columbus, Ohio Holmium Laser Ablation of the Prostate with DuoTome ™ SideLite ™ Laser Fiber T E C H N I Q U E S P O T L I G H T 2016 6/5/07 4:42 PM Page 1 Holmium Laser Ablation of the Prostate with DuoTome ™ SideLite ™ Laser Fiber Holmium Laser Ablation of the Prostate for the Treatment of BPH As the population continues to age, the prevalence of BPH will grow as well. Currently, millions of men suffer from the symptoms of BPH, however, only a small portion will ever receive treatment, most of those being medically managed. Surgery for BPH is utilized in a small fraction of patients diagnosed, however, over the past 5 years, surgical laser treatments have been the fastest growing segment in the management of BPH. Laser ablation of the prostate is a minimally invasive surgical alternative to TURP for the treatment of BPH symptoms. Although different surgical lasers are marketed for the treatment of BPH, holmium laser ablation and enucleation of the prostate are perhaps the most studied to-date. Clinical data supporting holmium laser ablation of the prostate (HoLAP) shows its equivalency to TURP with fewer potential complications 1 , and long-term durability up to 7 years 2 . Globally, physicians have embraced the holmium laser technology for treating BPH. Treatment with the holmium laser has allowed urologists to treat a wider array of patients, and achieve successful clinical outcomes with fewer potential complications than the traditional TURP procedure. The following is a detailed description of the HoLAP surgical technique that has been effectively employed to achieve successful clinical outcomes for over 200 patients in my surgical practice. 2016 6/5/07 4:42 PM Page 2
SURGICAL TECHNIQUE Pre-operative assessment of the patient is critical to success. It is important to particularly assess and note the following clinical items:
Visualize the appropriate landmarks, which include the bladder neck, ureteral orifices, and trigonal ridge of the bladder. You will reference these landmarks throughout the procedure. Multiple passes over the bladder neck can induce scope trauma, which may cause increased and unnecessary bleeding (Figure 1). STEP 2: Ensure Proper Irrigation Continuous water flow is a very integral component of the procedure. Begin by distending the bladder with irrigant. Ensure continuous flow by either using suction or gravity drainage. Raise irrigation height to improve flow and visualization. TECHNIQUE: Patients with atonic bladders or with a strong history of retention should have outflow placed to suction, as their bladders will not empty irrigant as quickly. Failure to recognize this may lead to decreased visualization.
Prior to advancing the laser fiber through the scope, ensure that the scope port has been opened, reducing potential damage to the fiber during insertion. Check for presence of the red aiming beam at the fiber tip. Slide the adjustable handpiece further down along the fiber allowing for adequate fiber length through the scope. Tighten the handpiece so that it can be manipulated during the case to rotate the fiber. TECHNIQUE: Fiber Extension from Scope - If the solid circumferential line on the fiber cap is not visible, the fiber is not extended far enough out of the scope. Activation of the laser fiber without adequate extension may cause damage to the scope lens. If the fiber is extended too far beyond the scope, excess vibration during ablation may occur, which can potentially damage the fiber (Figure 2). STEP 4: Bladder Neck Incision TECHNIQUE: Coagulation of Prostatic Urethra Prior to the bladder neck incision, this technique can be utilized to reduce intraoperative bleeding, particularly bleeding caused by scope trauma. Hold the fiber away from the tissue, which defocuses the beam. Lightly paint the tissue looking for change from pink to white. The recommended setting for this technique is 2J and 50Hz, resulting in 100W of power (Figure 3). T E C H N I Q U E S P O T L I G H T The proper OR equipment and setup is very important to the success of the procedure: • 100W VersaPulse ® PowerSuite ™ Holmium Laser • Irrigant (Saline or Sterile Water) • DuoTome
™ SideLite
™ Laser Fiber • Rigid Dilators • 26F Continuous Flow Resectoscope • Outflow: Gravity/Suction • Laser Bridge/Fiber Stabilizing Guide > 7.5F 5. Vascularity of Prostatic Urethra 2. Prostate Length 6. Elevation of Bladder Neck 3. Presence of Median Lobe 7. Preoperative Overactive Bladder 4. Enlargement of Lateral Lobes 8. Hypertonic vs. Atonic Bladder Figure 2 Figure 3 Figure 1 Pre-Operative Obstruction continued on back page > 2016 6/5/07 4:42 PM Page 3 STEP 4: Bladder Neck Incision (continued from page 3) Assess the prostate and begin at the bladder neck creating deep grooves at the 5 and 7 o'clock positions utilizing the 100W settings previously mentioned. Continue ablation until the capsular fibers appear. Widen and deepen grooves to better identify the bladder fibers. This technique will allow for maximum flow through the prostate. Continue these grooves out to the verumontanum. Next, connect the 2 channels by ablating the central remaining tissue. Ablate the floor of the prostate within the grooves above (Figure 4).
is between the 5 and 7 o’clock positions. TECHNIQUE: Fiber Tip Distance From Tissue - This is a very important procedural technique. Ideally, the fiber tip should be near, but not touching tissue. Be careful not to bury the fiber tip into tissue, which may cause the fiber to overheat and potentially degrade (Figure 5).
After the capsular fibers have been identified, proceed from the 5 and 7 o’clock positions, ablating laterally and upward to the 11 and 1 o’clock positions. Follow the capsular fibers while ablating (Figure 6).
motion of the laser fiber. This will result in a smooth, clean, even appearance to the prostatic tissue upon completion.
are created, as discussed above. This will isolate the median lobe and allow for complete removal of the tissue. Typically, this tissue is ablated prior to engaging the lateral lobes.
energy. Creating this energy effect may provide a more consistent, controlled approach to ablation. Confirm landmarks again, and continue linking up capsular fibers and ablating laterally.
Ensure removal of any remaining obstructive tissue prior to ending ablation. The creation of a large open cavity with visualization of the capsule, completes the ablation procedure (Figure 7).
Distributed by: Boston Scientific Corporation One Boston Scientific Place Natick, MA 01760-1537 www.bostonscientific.com/urology Ordering Information 1.888.272.1001 © 2007 Boston Scientific Corporation or its affiliates. All rights reserved. MVU6490 5M 6/07-6/09
Bladder Neck Fibers Capsular Fibers
™ SideLite ™ Laser Fiber Sources: 1 Mottet et al. Randomized Comparison of Transurethral Electroresection and Holmium: YAG Laser Vaporization for Symptomatic Benign Prostatic Hyperplasia. J Endourol, 13: 127-130, Mar 1999. 2 Tan A, Gilling P, et al. Long Term Results of High Power Holmium Laser Vaporization (Ablation) of the Prostate. BJU International, 92 (7): 707-709, Nov 2003 CAUTION: Federal Law (USA) restricts this device to sale by or on the order of a physician. Refer to package insert provided with the product for complete Instructions for Use, Contraindications, Potential Adverse Effects, Warnings and Precautions prior to using this product. DuoTome SideLite and VeraPulse PowerSuite are trademarks of Lumenis Ltd. DuoTome SideLite Laser Fiber is manufactured by Lumenis Ltd, and is distributed by Boston Scientific Corporation. The opinions, recommendations expressed and video images shown in this Technique Spotlight are those of the author alone. Boston Scientific makes no representations or warranties as to the accuracy or completeness of the information set forth herein. Legal manufacturer: 2400 Condensa St. Santa Clara, CA 95051 Toll Free: 877.586.3647 2016 6/5/07 4:42 PM Page 4 Yüklə 27,42 Kb. Dostları ilə paylaş:
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