Holmium Laser Prostatectomy in Pictures
The Holmium Laser is a powerful tool used to treat patients presenting with bladder outflow obstruction. Patients will present with moderate to severe lower urinary tract symptoms. There is typically a history of hesitancy, poor urinary flow, incomplete bladder emptying, post void dribbling and frequent visits to the toilet at night. Most patients will have received treatment with medication to relax the smooth muscle of the prostate and the bladder neck, an alpha blocker, such as Tamsulosin (Flomax) or Alfusosin (Xatral) or to shrink the prostate, a 5 alpha reductase inhibitor, such as Finasteride (Proscar) or Dutasteride.
The urinary flow rate will typically show a prolonged void with a maximum flow of less then 10 ml/s, which is dramatically improved after surgery.
The endoscopic appearances of the prostate will show occlusive enlargement of the middle and lateral lobes responsible for the physical obstruction experienced by the patient. It is this central portion of the prostate which has to be removed during the procedure.
The final appearances demonstrate a large cavity in which all of this central tissue has been removed.
Our initial experience with the Holmium laser has been encouraging and has included over 120 patients since 2004. It has allowed us to treat patients who would otherwise be considered unfit for prostate surgery. There is no need for patients to stop aspirin preoperatively and we have treated patients on anticoagulants and haemophiliac without any need for transfusion. We have been able to treat large prostates in excess of 100g and although the procedure takes appreciably longer the advantages of reduced bleeding, reduced catheter time and reduced inpatient stay are obvious.
In general, catheters are removed on the evening of surgery or early the next morning and most patients discharged within 24 hours of surgery. Patients with larger prostates, the elderly and those on anti-coagulants tend to stay a little longer. There is an immediate improvement in the urinary flow, with only mild discomfort, which compares well with TURP and vapourisation laser techniques.
Holmium Laser Ablation (HoLAP) is an alternative to Enucleation and Morcellation. The procedure is technically identical with the PVP or Green Light Laser in which a side fire laser carrier allows the laser energy to be applied directly on to the prostate tissue, vapourising it. The vapourisation or ablative approaches have been of limited use in the past and it has only been with the development of more powerful lasers (100 watt) that it has become a practicable procedure. Vapourisation seems a useful technique which can be applied to smaller prostates, it is less demanding surgically, it creates a reasonable cavity and early outcomes are encouraging.
