Live Web Conference with Panel of HoLAP Experts

On the Cutting Edge: Holmium Laser Ablation for BPH

Ramsay L. Kuo, MD

Web Conference Presenters

DirectorSt. Peter’s Hospital Kidney Stone

CenterAlbany, NY

Glenn M. Preminger, MD

Web Conference Presenters

Professor of Urologic SurgeryDirector, Comprehensive Kidney Stone Center

Duke University Medical CenterDurham, NC

Surendra M. Kumar, MD

Web Conference Presenters

Staff Urologist Department of Urology

Oakwood Annapolis HospitalSt. Joseph Mercy Hospital

Ann Arbor, MI

Steven R. Previte, MD

Web Conference Presenters

Clinical Associate Professor Boston University School of Medicine

Assistant Clinical ProfessorTufts University School of Medicine

Boston, MA

• Holmium laser physics– Holmium vs. KTP (GreenLight PVP)

• HoLAP indications and pre-operative patient evaluation

• HoLAP equipment

• HoLAP techniques and tips

• HoLAP outcomes– Long-term results– Comparison with TURP and GreenLight PVP

Agenda

Holmium Laser Physics

• 2140 nm wavelength

• Acts via thermal vaporization

• Tissue penetration only 0.5 mm in water (tissue)

• Can vaporize, cut, or coagulate tissue and fragment stones of any composition

Penetration Depth (mm)

0 1 2 3 4 5 6

Holmium Laser PhysicsHolmium Laser Physics

Nd:YAG Yellow KTP Red Holmium Blue

• Holmium energy has shallowest penetration depth of laser wavelengths utilized for tissue ablation

• No significant coagulation necrosis (i.e. Nd:YAG for VLAP) causing dysuria, urinary retention

Holmium Laser PhysicsHolmium Laser Physics

> 5 mm away

Coagulation

Cutting and ablating

No tissue effect

Near contact or defocused

Contact

• The holmium laser enables focused control of treatment with minimal collateral effect

• Hemostasis easily achieved with defocused beam

Comparison of Ablation Modalities

Holmium KTP (GreenLight)

Wavelength 2140 nm 532 nm

Absorption medium Water Hemoglobin

Penetration depth 0.5 mm 1-2 mm

Power requirements 120V 50 amp, 220V

Laser cooling system Contained water to air exchange External water

Laser fiber 550µ DuoTome 600µ ADDStat

Stone fragmentation Yes No

• Energy absorption– Holmium preferentially absorbed by water, KTP

by hemoglobin

– As ablation progresses deeper into gland, KTP slow because of less vascularized tissue near capsule

– Holmium has better safety profile as energy is dissipated by water (i.e. if fiber tip held few mm away from tissue, no effect)

HoLAP vs. GreenLight PVP (KTP) Key Differences

HoLAP vs. GreenLight PVP (KTP) Key Differences

• Ease of use

– GreenLight PVP unit requires dedicated water cooling and special plumbing modifications

– GreenLight PVP unit utilizes 50 Amp, 220 V circuit which is not standard OR power source

– KTP wavelength requires orange safety glasses, making bleeding points more difficult to visualize

HoLAP vs. GreenLight PVP (KTP) Key Differences

• Versatility

– KTP has no effect on stones, unable to cleanly incise tissue

– Holmium has multiple applications such as stricture incision and stone fragmentation (important if concurrent bladder stones)

HoLAP Indications

• Identical to those for TURP

– Can treat a wide variety of gland sizes

– Can simultaneously treat bladder calculi

– Hemostatic action of holmium wavelength enables treatment of coumadinized patients

Essential tests:• Patient history and physical (including DRE)

• Total PSA – Patients with > 10 year life expectancy

• AUA symptom score– ≥ 8 considered moderate severity, should be

treated

• Urinalysis

Pre-operative Evaluation

Optional tests:• Uroflowmetry

• TRUS volume estimation of prostate

• Post-void residual

• Cystoscopy– Assess for large median lobe and bladder calculi,

localize ureteral orifices

• Urodynamics– If history of urinary retention or suspicion of bladder

hypocontractility

Pre-operative Evaluation

HoLAP Equipment

VersaPulse PowerSuite 100 watt unit

DuoTome 550µ side-firing fiber

• 70° incident angle• 7.2F outer diameter

HoLAP Equipment

• Continuous flow resectoscope

– In conjunction with camera, light source, monitor

– 22-28F outer sheath (Storz, Olympus, Circon)

– Laser bridge stabilizes fiber tip and facilitates rotational motion over prostate surface

HoLAP Equipment

• Irrigant

– Normal saline

– Water

• Both allow clear visualization; normal saline completely eliminates any risk of dilutional hyponatremia (TUR syndrome)

HoLAP Technique

• Aperture of DuoTome fiber points toward prostate surface (red arrow)

• Always keep circumferential marker (blue arrow) within endoscopic view to prevent scope damage

• Do not extend fiber past cap anchor (black arrow)

HoLAP Technique

• Endoscopic view of DuoTome fiber with aiming beam and aperture of fiber tip directed at prostate surface

HoLAP Technique

100-watt laser:• Aiming beam on full• Ablation

– 2.0 J and 50 Hz – 3.2 J and 25 Hz

• Coagulation– 2.5 J and 40 Hz

HoLAP Technique

• Key point:

– DEFINE THE LEVEL OF THE CAPSULE INITIALLY

Two methods:

1. Proximal lobe ablation

2. Creation of floor grooves

HoLAP TechniqueProximal Lobe Ablation

• Initial ablation of proximal median lobe near bladder neck

• Can also be done at proximal lateral lobe if no significant median lobe

• Ablation deepened to capsular level (circumferential fibers)

• Median lobe ablation proceeds distally to verumontanum, matching initial depth defined proximally

HoLAP TechniqueProximal Lobe Ablation

• Proceed with lateral lobe ablation working proximal to distal

• Do not aggressively ablate tissue at apex of lateral lobes

HoLAP TechniqueCreation of Grooves

• Initial grooves created along sulci lateral to median lobe (7 and 5 o’clock)

• Grooves progress from bladder neck to verumontanum

• Deepen both grooves to level of surgical capsule

• Ablate median lobe between grooves

HoLAP TechniqueCreation of Grooves

• Proceed with lateral lobe ablation working proximal to distal

• Do not aggressively ablate tissue at apex of lateral lobes

HoLAP Technique

• When starting treatment of each lobe, hold tip over surface of prostate and rotate tip of fiber back and forth

• As ablation deepens toward capsular level then approach nodules or tags of tissue at their bases to free them

• Never bury the fiber tip into the tissue

HoLAP Troubleshooting

• Avoid burying fiber tip into tissue (speeds cap degradation)

• Increase energy settings and reduce frequency (i.e. try 3.2 J and 25 Hz)

• Check appearance of fiber cap (may need to replace fiber in long cases)

• Do not focus on superficial tags of adenoma

Treatment rate is slowing:

HoLAP Troubleshooting

Control of bleeding points:

• “Defocus” beam by holding tip of fiber 1-2 mm from bleeding point

• Vaporize tissue surrounding bleeding point to define it

• Utilize settings of 2.5 J and 40 Hz

• May use SlimLine (end-firing) 550µ fiber to provide more focused coagulation

HoLAP Post-op

3 Months Post-op

Immediate Post-op

Long-term HoLAP Results

Tan, et al: BJU Int 92:707-9, 2003

• 79 patients (mean age 67 years, mean TRUS volume 40.5 g) underwent HoLAP from 9/94 to 5/95

• 34 patients completed follow-up assessment (median 7.4 years of follow-up)

Long-term results of high-power holmium laser vaporization (ablation) of the prostate

Long-term HoLAP Results

Tan, et al: BJU Int 92:707-9, 2003

34797979N

15.2

9.4

1 month

14.5

8.3

3 months

10.018.8Mean

AUA SS

Mean Qmax

(ml/sec)16.89.2

7 yearsBaseline

• 5/34 pts (15%) required reoperation (1 BNI, 1 TURP, 2 HoLEP, 1 bladder stone removal)

Long-term HoLAP Results Summary

HoLAP resulted in:

• 83% improvement in Qmax

• 47% decrease in AUA symptom score

• Durable outcomes over 7 years

• 15% reoperation rate comparable to TURP

HoLAP vs. TURP Experience

• No clinically significant bleeding during or after procedure– Better visualization

– Clear field of view

– No transfusions

• No risk of fluid absorption or hyponatremia– Superior safety profile

– Can treat high risk patients

HoLAP vs. TURP Experience• No post-op pain

– Narcotics not needed

• HoLAP is outpatient procedure

– Longer hospital stay with TURP (usually overnight)

• HoLAP has short learning curve

• Continuous bladder irrigation often not needed

HoLAP vs. PVP Experience

• Efficiency and hemostasis seem equivalent with smaller glands

• HoLAP more uniform vaporization rate regardless of prostate size

• PVP may start faster but end slower

– More efficient when surface is vascular

– Less efficient as you move deeper into tissue

HoLAP vs. PVP Experience• PVP post-op irritative symptoms more pronounced

– Especially when capsule not reached

– When treating larger glands (> 40-50 cc)

– The bigger the gland, the greater the symptoms

– Symptoms may be present for extended periods

– Some patients need re-treatment for relief

• HoLAP better tolerated post-op

– Superficial penetration

– Less coagulative necrosis

HoLAP vs. PVP Experience

• Delayed bleeding has occurred after PVP of larger glands

– None after HoLAP

• Orange glasses used for PVP are more difficult to work with

– Especially in presence of bleeding

HoLAP vs. PVP Additional Benefits

• Holmium laser is mobile, PVP is not- Does not require water cooling - Does not require special electrical hookup

• Holmium laser is multipurpose, PVP is not- Stones, tumors, strictures

Getting Started with HoLAP• Observe at least 2 to 3 cases

• Optimally, have 2 cases mentored

• Starting on your own

– 30 to 40 cc prostate glands

– Keep tip of DuoTome fiber in endoscopic view during treatment

– Rotate scope and fiber to gain access to tissue; avoid extending fiber too far beyond scope tip

Panel Conclusion• The holmium laser has proven to be a

versatile tool, with HoLAP providing advantages that make the procedure our preferred choice for treating BPH

• HoLAP is safe and effective with little risk of complications even with larger glands, making it preferable to standard TURP and GreenLight PVP.

Thank You

Questions?