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Prostate Laser Vaporization (Greenlight KTP Laser)

Devices of different power are available for laser vaporization of the prostate: the first generation KTP laser has a power of 80 watts, devices of the second and third generation have a power of 120 or 180 watts. Synonyms: Greenlight laser therapy, photoselective prostate vaporization. Review literature: (Kuntz, 2006).

fig. laser vaporization of the prostate:
Left: 30 degree angle view from the verumontanum to the bladder neck.
Middle: greenlight laser probe with pilot beam.
Right: View after prostate laser vaporization.

Indications for Laser Vaporization of the Prostate

The indications for laser vaporization of the prostate are, in principle, not different to the indications for transurethral resection of the prostate (TURP). Symptoms due to benign prostatic hyperplasia should be treated with medication, until complications make surgery necessary:

• Recurrent urinary retention
• Bladder stones
• Recurrent urinary tract infection
• Recurrent hematuria
• Postrenal kidney failure due to insufficient bladder emptying

The most common indication for laser vaporization of the prostate are moderate to severe symptoms of prostatic hyperplasia, which lower the quality of life and cannot be alleviated with medication (see section Alpha blockers and medical treatment of BPH).

Due to the special coagulation ability of the greenlight laser therapy, surgery is possible despite the presence of coagulation disorders, anti-coagulation therapy or antiplatelet therapy. The likelihood of a TUR syndrome is considerably lower, since an isotonic irrigation solution is used during the procedure. The risk of postoperative bleeding is very low. Greenlight laser vaporization should be preferred to TURP in high-risk cardiac patients. Disadvantages of the laser prostate vaporization are the high costs of the laser probe, prostate ablation without histologic examination and disadvantages of the prostate ablation in large prostate glands with the development of a large necrotic zone.

Contraindications to Laser Prostate Vaporization

• Large prostate adenomas (> 75 ml) should be treated with open suprapubic prostatectomy
• Need for bladder diverticula surgery: consider open prostatectomy at lower prostate gland volumes
• Bladder stones: consider open prostatectomy depending on prostate volume and stone burden
• Inguinal hernia: consider open prostatectomy and hernia repair at the same time
• Contraindications for a lithotomy position
• Low life expectancy
• Untreated urinary tract infection

Surgical Technique of Laser Prostate Vaporization

Anesthesia for Prostate Laser Vaporization:

Spinal anesthesia or general anesthesia is recommended.

Perioperative Antibiotic Prophylaxis:

Perioperative antibiotic prophylaxis is recommended. Since laser vaporization leaves behind a necrotic zone within the prostatic fossa, urinary tract infections are common after the procedure. A prophylactic lose-dose antibiotic treatment for 7 days is often done.

Preoperative Preparations:

The patient is placed in lithotomy position. Disinfection of the external genitalia, the lower abdomen and the perineum. Sterile draping.

Cystoscopy:

Check for the width of the urethra, prostate size and absence of bladder stones or bladder tumors.

Greenlight Laser Vaporization:

The laser probe is inserted through a resectoscope with continuous saline irrigation flow and 30 degree viewing angle. The vaporization begins at the bladder neck and is continued to the apex circularly. This guarantees a good flow of the irrigation solution to optimize the view and to remove the vaporization bubbles [fig. greenlight laser vaporization of the prostate]. Insert a 18 French Foley catheter after the vaporization.

fig. greenlight laser vaporization of the prostate:
Left: 30 degree angle view from the verumontanum to the bladder neck.
Middle: greenlight laser probe with pilot beam.
Right: View after prostate laser vaporization.

Postoperative Management after Laser Vaporization of the Prostate

• Removal of the catheter after 1–2 days
• Control micturition
• Prophylactic low-dose antibiotic treatment for approximately 7 days

Complications of Greenlight Laser Treatment

Bleeding:

The intraoperative risk of bleeding is greatly reduced (in comparison to TURP). Later during healing of the necrotic prostate tissue, bleeding with need for interventions may occur in patients with oral anticoagulation treatment.

Urinary tract infections:

Laser vaporization leaves behind a necrotic prostatic fossa, urinary tract infections are common after the procedure. A prophylactic lose-dose antibiotic treatment for 7 days is often done.

Further complications:

Retrograde ejaculation, urethral stricture, bladder neck stricture, persistent symptoms or urinary retention due to inadequate prostatic tissue ablation. External sphincter injury with urinary incontinence.

References

  Deutsche Version: KTP (greenlight) Laservaporisation der Prostata