Outpatient Simultaneous Treatment of Benign Prostatic Hyperplasia and Bladder Lithiasis with GreenLight™ and Holmium Laser *

Introduction

B enign prostatic hyperplasia (BPH) affects more than 50% of men over 60 years old. In most of them, lower urinary tract symptoms develop that may be obstructive, irritative, or both, and necessitate pharmacologic or surgical management. ¹ This last option is to be chosen whenever an obstruction caused by BPH and bladder lithiasis coexists. This condition is frequently observed in this type of patient. It causes a large number of symptoms, as well as more frequent and complicated urinary tract infections and hematuria. ² Bladder stones are 5% of urinary lithiasis. ³ Although there are several causes for, and predisposing factors to, the formation of these stones, their association with BPH is observed in almost 85% of the cases of bladder lithiasis. ⁴

Surgical management must deal with both problems—namely, the complete extraction of bladder stones and the resolution of the BPH-related obstruction. Traditionally, they are managed by means of open surgery or transurethral resection of the prostate (TURP), and suprapubic or endoscopic lithotripsy using traditional lithotripsy methods (pneumatic, mechanical, etc). Such procedures require a urinary catheter with bladder irrigation, sometimes suprapubic drainage, and hospitalization for more than 24 hours.

With the arrival of new technologies during the last decade and the growing use of laser in urology, new horizons have opened up for these patients: The use of holmium laser for the management of urinary lithiasis, which has been proven to produce excellent results with the use of small telescopes. ⁵ The results of GreenLight^™ (American Medical Systems, Minnetonka, MN) for prostate vaporization are similar to those of TURP, both with respect to the reduction of prostate volume and the improvement of symptoms with less morbidity. ⁶ The high effectiveness associated with a low complications rate resulting from prostate GreenLight laser vaporization has increased the chance to treat more complex cases, such as patients receiving anticoagulation medications, cases with associated bladder lithiasis, as well as the possibility to surgically manage larger glands.

The major attraction of the combined treatment described in this article is based on the possibility of resolving both disorders through the same route (transurethral), with small-caliber instruments, and on an outpatient basis. This article is intended to evaluate our experience in the combined treatment of BPH and bladder lithiasis with GreenLight laser and holmium laser, respectively.

Patients and Methods

From August 2006 to May 2009, 20 patients with prostatic hyperplasia and bladder lithiasis were treated on an outpatient basis. Although most of the patients were receiving medical treatment for BPH, they all had a surgical indication because of the bladder lithiasis. The size of stones was 1 to 4 cm in major diameter, measured with abdominal ultrasonography and/or simple radiography of the urinary tract. Neither the number of calculi nor their composition was an exclusion criteria. First, the stones were treated, and then the GreenLight laser vaporization of prostate was conducted, both at the same surgical time. The Lumenis Versa Pulse^® Power Suite™ 20 W holmium laser was used to fragment bladder calculi. Fiber caliber was 600 μm in all cases. The technique consisted of cutting the calculus with a transversal line first, then with another line crossing it to obtain four fragments, and to continue fragmenting them separately. Small stones were directly extracted.

Once the calculus or calculi had been fragmented in small pieces, fragments were aspirated. Then, the prostate was vaporized with GreenLight PV 80 W or Green Light HPS with a maximum power of 120 W, according to prostate size. A 23F continuous-flow cystoscope with a long bridge for laser fiber was used. In this series, most of the patients underwent transabdominal ultrasonography to assess the stone and prostate size.

The presurgical evaluation consisted of a medical record with IPSS-QoL (International Prostate Symptom Score and Quality of Life Questionnaire), physical examination, postmicturition residual volume and calculus size (by ultrasonography), simple radiography of the urinary tract, and flowmetry in patients with spontaneous micturation, blood test for prostate-specific antigen, and urine culture.

All the patients received general anesthesia and antibiotic prophylaxis with intravenous ciprofloxacin 200 mg at induction or according to an antibiogram in the case of a positive urine culture. The antibiotic therapy continued for 5 to 10 days after surgery. A 20F two-way Foley catheter was left in place for 12 to 24 hours after surgery. As a routine, the discharge of patients was scheduled 3 to 4 hours after surgery, and the catheter was removed in the office the next morning. It was recorded if any patient had to be hospitalized for any complication in the procedure or if hospitalization was decided beforehand.

The subsequent evaluation consisted of a new IPSS-QoL, ultrasonography of the bladder and prostate to measure postmicturition residual volume, and uroflowmetry at 3, 6, and 12 months. Intraoperative and perioperative complications (30 days after the procedure), total surgical time, and need for reoperation were recorded. A video demonstration of this technique is available online at www.liebertonline.com/end

Results

The procedure was simultaneously completed in 19 of 20 scheduled patients. Prostate vaporization had to be postponed for a second time in one patient because of prolongation of surgical time in a large bladder lithotripsy. The mean age was 66.3 (49–85) years. The mean stone size was 2.3 (1–4) cm, and the mean prostate volume was 56.5 (30–108) cc. The holmium laser energy was set between 0.6 and 1.2 J (mean 1.0), and the frequency between 6 and 15 Hz (mean 10). A transversal line is marked in the calculus, which is then disintegrated into small fragments. Figure 1 shows the time of lithiasis fragmentation. The mean operating time was 115 (50–190) minutes.

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FIG. 1.

Calculus disintegrated into small fragments.

The follow-up was 2 to 33 months with a mean of 10.5 months. Table 1 shows the variations in the parameters of pre- and postsurgical evaluation. No residual lithiasis was observed in any of the 19 patients. Besides intraoperative confirmation, we routinely perform bladder ultrasonography 30 days from the procedure.

There was a significant percentage change in maximum flow, postmicturition residual volume, and IPSS, which were 129.5%, 88.4%, and 68.3%, respectively. There was a 43.2% reduction in prostate volume. With regard to complications, only one patient was hospitalized after the procedure because of prolongation of surgery time caused by multiple lithiasis. That patient needed more time to recover from anesthesia. He was discharged 24 hours after surgery. Prolonged dysuria (for more than 30 days) was observed in three (15.7%) patients; urinary tract infection after surgery developed in three (15.7%) patients. They were treated with specific antibiotic therapy without further complications. Moderate hematuria developed in two (10.5%) patients, and they were treated conservatively. No blood transfusions or bladder irrigation were needed. None of the patients in this series were receiving anticoagulation therapy. No urethral or bladder neck stenosis was observed to date.

Discussion

The likelihood of transurethally managing successfully BPH that is associated with bladder lithiasis on an outpatient basis is a clearly attractive and minimally invasive option. Traditionally, the treatment of these patients necessitated the performance of a TURP in glands weighing less than 60 or 70 g and bladder lithotripsy, either through a transurethral or suprapubic route. ^4,7 For larger glands, an open adenomectomy and the extraction of calculi are scheduled. Both procedures require from 2 to 7 days of hospitalization with catheter and bladder irrigation. Furthermore, suprapubic drainage is needed when the suprapubic approach is used. During the last decade, the new laser technologies applied to urology have allowed significant developments for this condition.

Potassium-titanyl-phosphate laser produces a minimum tissue edema, thus causing the improvement of the IPSS to be faster. The use of a saline solution as irrigation liquid allows glands of different sizes to be managed without the risk of causing post-transuethral resection (TUR) syndrome, compared with TURP that has a 2% chance of causing it. ⁸ During recent years, the endoscopic fragmentation of calculi has been performed mainly with pneumatic (Swiss Lithoclast^®) or electrokinetic (EKL-compact lithotriptor^®), mechanical, or ultrasound energy, or even with extracorporeal lithotripsy. ⁹ The problem with these methods, in spite of being simple and safe, is that the calculus may move on contact with the pneumatic probe and that scopes of higher caliber are needed. Mechanical lithotripsy is still used, but less often, in many areas. Moreover, fragmentation of extremely hard calculi may become very monotonous.

Holmium laser is capable of rapidly fragmenting any kind of calculi because of the generation of energy pulses of 400 to 2500 mJ. Its use in the management of bladder lithiasis has shown complete fragmentation with no injury to the bladder wall. ¹⁰ The fragments obtained are smaller, and therefore their aspiration through the cystoscope is easy, with no need for a cystotomy. This is specifically important in patients with a history of bladder cancer, pelvic radiation, and abdominal surgeries. ¹¹ Furthermore, the use of low caliber instruments minimizes urethral trauma, thus diminishing the risk of urethral strictures.

The proper selection of patients is essential to obtain satisfactory results, taking into account that bladder lithiasis may be associated with prostatic hyperplasia. If possible, it is advisable to resolve both conditions simultaneously. One of the most representative series published in connection with the combined treatment is that of Chitouru and associates, ¹² who conducted treatments of ballistic bladder lithotripsy with transurethral prostatectomy in 120 patients. They obtained full fragmentation of calculi in 97.5% of the patients with a mean resected tissue weight of 30 g. Shah and colleagues ¹¹ obtained 100% calculus-free subjects after treating them with holmium laser, both for lithiasis and prostatic hyperplasia. Nevertheless, the mean hospitalization time in this series was 34.8 hours.

Surgical management of prostatic hyperplasia was not needed in all the cases: O'Connor and coworkers ¹³ conducted an endoscopic stone removal together with medical treatment for prostatic hyperplasia (alpha blockers or finasteride) in 23 patients and obtained satisfactory results. Millán Rodríguez and colleagues ¹⁴ treated patients with bladder calculi smaller than 4 cm² with extracorporeal shockwave lithotripsy and prescribed medical treatment for the prostatic condition.

In our experience, the stones were fully removed in 100% of the cases and, like other authors, we consider that this kind of energy is to be chosen for the management of lithiasis. ¹¹ No blood transfusion was needed, as compared with TURP, where a 4% rate of transfusions is reported. Such transfusions may even reach 30% in patients receiving anticoagulant agents. ^{15 –17}

Complications were low. The most frequent ones were urinary tract infection in three cases and slight hematuria in two cases. Only one patient needed hospitalization after the procedure for 24 hours because of a slow recovery from anesthesia, and another patient needed to have the treatment of his BPH rescheduled because of the duration of the procedure. We decided not to perform the GreenLight vaporization of the prostate because it took us 5 hours to fragment a very hard stone in a highly diverticulated bladder. We believe that the stone size (3 cm) and hardness were the major factors that determined a lengthy procedure along the bladder diverticula and prolonged the fragment evacuation time. In other words, the combined treatment is perfectly feasible on an outpatient basis, with the inherent cost reduction. The other alternatives to conduct the procedures on a combined basis are very difficult to be performed routinely on an outpatient basis.

With respect to surgical time, we have observed that it is very variable and depends mainly on the consistency and number of calculi to be removed. As a practical rule, we calculate the time for prostate vaporization as 1 minute per cc of total prostate volume, depending on several factors such as the weight of the adenoma in general and median lobe in particular, the size of the calculi to be fragmented, and, obviously, the experience of the surgeon.

We think that one of the advantages of the GreenLight procedure is that it is easy and natural to learn for most urologists used to TURs, whereas the holmium enucleation has a rather steep learning curve. Another advantage of the GreenLight laser is that the procedure is performed using a small caliber scope (23F) whereas the holmium laser needs a larger caliber scope to insert the morcellator. This has a potential to damage the urethra in a lengthy procedure.

Conclusions

The combined treatment of patients with prostatic hyperplasia associated to bladder lithiasis by means of GreenLight laser vaporization and holmium laser lithotripsy is performed safely on an outpatient basis yielding excellent results.