eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Interstitial Laser Coagulation of the Prostate: Treatment

Author: Stanley A Brosman, MD, Clinical Professor, Department of Urology, University of California at Los Angeles Medical School
Contributor Information and Disclosures

Updated: Aug 27, 2009

Treatment

Medical Therapy

Medical treatment therapy of benign prostatic hyperplasia (BPH) consists of 3 classes of agents: alpha-adrenergic blockers, 5aR inhibitors, and phytotherapeutics.

Alpha-adrenergic blockers

These represent a class of medicines that affect the rich supply of alpha-adrenergic receptors in the smooth muscles at the base of the bladder, the bladder outlet, and the smooth muscles within the prostate and proximal urethra. Blocking these receptors reduces tension in these smooth muscles, relieving the irritative symptoms manifested by urgency and frequency and improving urinary flow.

Several subtypes of the alpha-adrenergic receptors have been identified. The primary alpha-receptors in the prostatic urethra are alpha-1a and alpha-1d. The prostatic stromal tissue is largely alpha-1a. Alpha-adrenergic blockers can be divided into 3 groups, depending upon the affected receptor and their duration of action—nonselective, selective, and selective long acting.

The alpha-receptors in prostatic stromal tissue are largely the alpha-1a subtype. Inhibition of these receptors in the prostate and prostatic urethra reduces the symptoms associated with bladder outlet obstruction (BOO). Inhibition of the alpha-1d receptors diminishes the irritative symptoms, which frequently accompany this condition.

The 4 most common agents include terazosin, doxazosin, tamsulosin, and alfuzosin. These agents have similar therapeutic effects. They improve voiding dynamics and provide symptom relief. In contrast to the nonspecific inhibitors, these agents are long acting (once-per-day dosing) and have fewer adverse effects. Long-term outcome studies of these drugs indicate that their effectiveness persists indefinitely. Because they do not affect prostate growth, patients who are receiving only alpha-blockers often develop increasing difficulty with urination as their prostate enlarges.

Nonselective blockers were the first agents found to be effective but are rarely administered today because of adverse side effects. Selective alpha-adrenergic blockers include prazosin (Flomax), alfuzosin (UroXatral), and terazosin (Hytrin). These agents have fewer side effects compared with the nonselective alpha blockers. Recently, a new alpha-1a receptor selective blocker, silodosin (Rapaflo), was approved.

The most common adverse effects, which occur in less than 20% of patients, include dizziness (19%), postural hypotension (6%), lightheadedness, asthenia (6%), and nasal stuffiness. No sexual dysfunction develops, but all of these agents except alfuzosin may cause retrograde ejaculation. This is an advantage for many men.

Tamsulosin and alfuzosin are the most selective of these agents for the prostate/bladder receptors. Dizziness and lightheadedness are problematic for some patients; those who are taking antihypertensive medications need to be cautious when they first start these medications. The use of these agents in conjunction with any of the 5-phosphodiesterase inhibitors used in the treatment of erectile dysfunction is not contraindicated.

5-Alpha reductase inhibitors

These medications, finasteride and dutasteride, inhibit the 5aR enzyme responsible for the conversion of testosterone into DHT.

Two genes produce this enzyme. Type 2 is located predominately in the prostate and is blocked by both agents, but dutasteride also blocks type 1. This dual action is more effective in lowering DHT levels. DHT is the active agent within the cell, and, by decreasing its level, cellular function is altered and the glandular component of the prostate atrophies.

Prostate size is reduced and PSA levels are lowered because of these alterations. The PSA level is usually decreased by 50% after 6 months of therapy. A multiplier of 2 converts the PSA to a level that can be comparable with levels obtained prior to the institution of therapy. This PSA level reduction persists so that the multiplier is 2.5 at 7 years.

The 5aR inhibitors significantly affect the prostate but do not always translate into symptomatic improvement. Patients who are most likely to benefit are those with symptoms that are primarily due to prostate glandular hyperplasia and in men whose prostates are 40 mL or larger. Unfortunately, determining how much of the obstruction relates to glandular or stromal hyperplasia is not easy. Six months of treatment or longer is necessary to achieve the maximum benefit from this type of medication.

Because they affect prostate growth patterns, 5aR inhibitors should theoretically be effective over a long period. A study compared the effects of an alpha-blocker, a 5aR inhibitor, a combination of the two, and placebo. The combination therapy was shown to be more efficacious than either single agent, and all showed better results when compared with the placebo control group.

The combination of these agents is helpful in reducing the incidence of urinary retention. Patients with BPH who are at very high medical risk of surgery should receive these agents to help prevent further prostatic enlargement.

They also are useful in reducing bleeding caused by invasive prostate surgery such as TURP. When used for this purpose, at least 2 weeks of therapy is recommended, and 2 months may be even better, when possible.

The agents that shrink the prostate the fastest are the luteinizing hormone–releasing factor (LHRH) agonists or antagonists, which work by suppressing testosterone production. These agents and the antiandrogens, which block the androgen receptors on the cell, are used to treat prostate cancer. They are not approved for use in BPH; however, short-term use is effective, particularly for men with urinary retention.

The most frequently used phytotherapeutics include saw palmetto, which is the fruit of Sabal serrulata (Serenoa repens), the root of Hypoxis rooperi, the bark of Pygeum africanum, pollen extract, the seeds of Cucurbita pepo, the leaves of the trembling poplar, and the roots of Echinacea purpurea.

Various mechanisms explain their actions, as follows:

• Antiandrogenic effect
• Antiestrogenic effect
• Decrease in sex hormone–binding globulin
• Inhibition of fibroblast and epidermal growth factors
• Interference with prostaglandin metabolism

Phytotherapeutic agents usually are offered in combinations. Preliminary studies show that some patients claim symptom improvement, which has led to further investigations indicating that potential benefit of these agents exists in men with mild-to-moderate symptoms.

No specific dosage is indicated for these agents. The recommendations of the manufacturer can be followed. Many of these agents are available in combinations. No specific adverse effects have been reported for these agents, but concerns have been raised about their use prior to surgery and the possibility of a coagulopathy.

Surgical Therapy

Various interventional therapies are available to treat patients in whom medical therapy has failed or is not tolerated because of adverse effects.^2,3 In some instances, the changes in a patient's urinary tract may have progressed to the point that medical therapy is inappropriate. Patients with hydronephrosis, renal insufficiency caused by obstruction, urinary tract bleeding, recurrent infections, or bladder stones need to have an immediate remedy and often should not wait until medications become effective.

Invasive surgeries include retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy.⁴ These procedures are usually performed in men with prostates larger than 80 mL in volume, when concomitant large bladder stones are present, or an associated problem needs to be surgically corrected.⁵

Minimally invasive surgery can be performed in most patients. These procedures can be performed with general, spinal, epidural, or conscious sedation or local anesthesia. These surgeries are usually performed on an outpatient bases either in the hospital, a surgery center, or in the office.

Transurethral resection of the prostate

For years, the standard surgical treatments were TURP or open prostatectomy (eg, classic suprapubic prostatectomy, retropubic prostatectomy).

These procedures have been proven to offer patients the most rapid symptom relief for a long duration. They offer minimal mortality rates, low morbidity, and the opportunity for permanent symptom relief.

In the past 10 years, less invasive procedures have been introduced. These include transurethral needle ablation (TUNA), which is a radiofrequency tissue-ablation therapy that can be performed in the office with local anesthesia. A current is passed through the antennae after insertion through a cystoscope. The antennae are extended from the probe and inserted into the prostatic tissue The microwave radiofrequency transmission produces heat between the 2 antenna needles. The heat is produced for a defined time, usually 2-3 minutes, and the antennae are withdrawn and inserted into a different part of the prostate. This process is repeated until the lateral lobe tissue is thoroughly treated. Middle-lobe tissue has been difficult to treat, but newer probes can treat these lobes. In properly selected patients, the results seem to be comparable with those of similar technologies.

Water intensity hyperthermia (WIT) is an office-based procedure in which a special 2-balloon catheter is placed into the bladder. One balloon is inflated in the bladder to hold it in position. The second is inflated within the prostatic urethra to a dimension of approximately 50 F. Hot water (45°C) is circulated through this balloon for 45 minutes. Patients usually need to wear a catheter for 7-10 days. This procedure has not been shown to have long lasting benefit, nor does it relieve the symptoms in many patients.

Transurethral microwave thermotherapy (TUMP) is a minimally invasive procedure that can be performed in the office. These procedures involve placing a specially designed catheter into the urethra and a temperature probe into the rectum. The prostate is heated for about 30-60 minutes, depending on the device, and the prostatic temperature should exceed 45°C.

Trock et al⁶ reported on the results of 541 men from 6 institutions who were treated with the Targis cooled thermotherapy system. Compared with baseline measurements, the AUA symptom score improved by 55%, peak urine flow increased by 51%, and quality-of-life scores by 53%. The authors noted that it may take 6 months before the maximum benefits have been obtained.

Interstitial laser therapy

Interstitial laser coagulation (ILC) candidates include men with obstructive uropathy from BPH and the following:

• Patient no longer wants to take medication
• Medications are not effective or cause adverse effects
• Patients taking anticoagulants
• Poor surgical candidates
• Men who wish to avoid retrograde ejaculation
• Men concerned with impotency caused by one of the standard procedures
• Men in urinary retention
• Men who are obstructed with prostate cancer

Newer procedures include the following:

• Bladder neck and prostate transurethral incision
• Transurethral electrovaporization
• Transurethral needle ablation using radiofrequency energy
• Intraurethral stents
• Hyperthermia with microwave energy
• Thermotherapy
• High-intensity focused ultrasound
• Prostatic injections with alcohol to produce tissue necrosis
• Intraprostatic injections with BOTOX® to paralyze the smooth muscles in the urethra and prostate
• Various laser procedures

Laser techniques include the following:

• Side-firing YAG lasers (may be visualized through a cystoscope or ultrasound)
• Visual side-firing contact vaporization (PPV)
• Laser resection using a holmium-YAG laser^7,8
• Laser balloon therapy
• Green light laser therapy⁹
• Interstitial laser therapy

Advantages of laser therapy include the following:

• Minimal bleeding
• No TURP syndrome; less irrigation fluid is used during the procedure
• Patients on anticoagulants can be treated.
• Short learning curve
• Less chance for retrograde ejaculation
• Procedures can occur on an outpatient basis or in the office.

Disadvantages of laser therapy include the following:

• New techniques without long-term follow-up studies
• No tissue for the pathologist
• Catheter stays in place for a longer period of time compared to a TURP.
• Delay in achieving desired result
• Irritative symptoms last longer.
• Equipment and fibers are expensive.

Preoperative Details

• Evaluate the prostate anatomy prior to the procedure to assist the surgeon with the proper procedure plan.
• Conduct urodynamic testing with uroflowmetry and pressure-flow studies if clinically indicated.
• Using rectal examinations and PSA, carefully evaluate patients for the presence of prostate cancer.
• Because no tissue is obtained with ILC, consider performing a prostate ultrasound (to determine the size of the gland) and a biopsy prior to ILC surgery.
• Some urologists have suggested limiting this procedure to patients with prostates less than 40 g. However, this author and others have treated patients with 100-g prostates, and they have improved, although patients with smaller prostates are better candidates.
• An enlarged median lobe is not a contraindication for ILC. Some experts have suggested that the enlarged median lobe be treated with either transurethral laser incision or transurethral vaporization while the ILC is performed on the lateral lobes. This sometimes involves a change in instruments and extends the time of the procedure, but it has worked well.
• Start patients with infected urine on antibiotics several days prior to the procedure.
• Perform bowel cleansing in some patients to avoid straining in the postoperative period.
• Inform patients that they will have a catheter in place at the conclusion of the procedure. The time involved for the edema induced by the procedure and satisfactory urination to occur takes days to weeks, although 5-7 days is common in uncomplicated cases.
• Consider starting the patient on Proscar at least several weeks before the procedure to help minimize operative and postoperative bleeding. This is most helpful in patients who are on anticoagulants and in people with larger prostates.

Intraoperative Details

• Consider using a regional anesthetic, spinal or epidural, or local anesthetic (periprostatic block) for this procedure.
• Consider infiltrating the periprostatic area with a local anesthetic, instilling the urethra and bladder with a soluble anesthetic, inserting a belladonna and opium (B&O) rectal suppository, and providing the patient with an intravenous sedation.
• Place a 23F cystoscope sheath into the urethra under direct vision and inspect the prostatic urethra and bladder. If the patient has a bladder neck contracture from fibrous tissue or a very large middle lobe, consideration can be given to incising the bladder neck with a bare-tip laser fiber. This fiber is available with the indigo laser system. This would lessen the chance of further obstruction, but it also increases the risk of retrograde ejaculation. Alternately, transurethral vaporization can be used. The lateral and middle lobes can be treated with the ILC probe.
• Insert the laser probe into the open port of the endoscopic instrument until the tip is visible. The end of the probe has a fine point to facilitate its introduction into the tissue, and a circular black band on the probe is located 1 cm from the end. Accurate placement of the fiber is critical in achieving a good outcome. Using a stabilizing element helps to direct the probe into the desired location.
• Determine the configuration of the prostate. Note its length, the presence of a middle lobe, and the location of the verumontanum.
• The middle lobe can be treated first.
• Probe placement is critical. Advance the probe through the cystoscope and insert it directly into the base of the middle lobe tissue. The probe usually is introduced at least as far as the black band, but the depth of insertion should vary according to the size of the prostate. The probe may be advanced further for very large middle lobes or to a lesser degree in small glands. Usually a single probe placement is adequate, but an additional probe insertion and treatment may be necessary for large middle lobes. The probe will produce an area of tissue destruction of about 3 mL as long as the desired temperature is maintained for 80% of the time.
• Activate the laser unit with the foot pedal so the temperature will begin to increase.
• If the probe is placed properly, the temperature will rise to 80-85°C within the first half-minute and remain at that temperature for the duration of the therapy. If the temperature does not rise quickly, the probe is likely placed improperly. The tip of the probe may be in the bladder or just superficial in the urethra. If this occurs, retract or reinsert the probe until the temperature begins to rise and is sustained at the appropriate level. If retracting beyond the black mark is necessary, stop the laser treatment to avoid proximal laser injury.
• Hold the probe in position for 1.5 or 3 minutes depending on the device being used. Afterward, the laser unit automatically stops supplying energy. Probe position needs to be monitored continuously because altering its position is easy while attempting to hold the probe still. A video system is recommended for this purpose.
• Withdraw the laser probe and place it into a new site.
• Depending on the length of the gland, usually treat 2 areas of each lateral lobe by inserting the probe into the tissue to the depth of the black band, or deeper for large glands, and activating the laser unit. The areas of tissue necrosis may overlap. If the probe is introduced into a site that has been treated previously, the temperature rises very rapidly and selecting a different site may be necessary. No harm exists in creating overlapping areas of tissue destruction. If the probe is inserted too deeply and enters the bladder, the temperature will drop, indicating poor probe placement.
• Many patients have glands 40-60 mL in size; therefore, 5 insertions are adequate if a middle lobe is present. More insertions are not necessarily better because the position of each treated area seems to be the most important feature.
• Glands in the 100-mL range may require 8-10 insertions; 2 in the middle lobe and 4 in each lateral lobe.
• Drain and irrigate the bladder often to maintain visibility because each puncture into the prostate produces some bleeding. Do not use heated water for irrigation, which would affect the temperature readings and make determining when the probe tip is out of position or has entered the bladder more difficult.
• Usually, one probe is adequate for each procedure, but probes are known to burn out or break; therefore, ensure that a second probe is available, particularly if treating a large prostate.
• At the conclusion of the procedure, insert a Foley catheter. Use a 20-22F, 3-way catheter if the bleeding is moderate so that continuous 3-way irrigation can be performed. Otherwise, a standard Foley can be used. A B&O suppository can be inserted for postoperative analgesia if not inserted earlier.
• Place a suprapubic tube in patients with atonic bladders who may require catheter drainage for several weeks or longer or if the patient cannot tolerate urethral catheters. This is advantageous in determining when the patient is urinating well enough to remove the catheter, without having to go through a series of catheter removals and replacements.

Postoperative Details

• In the recovery room, follow surgeon discretion and the level of bleeding to decide whether to connect the catheter to 3-way irrigation or straight drainage. The authors' preference is to use 3-way irrigation immediately postoperatively, then convert to straight drainage and plug the irrigation channel when appropriate. The duration of catheter drainage is at the discretion of the physician.
• After the anesthetic wears off and the patient's condition stabilizes, he may be discharged with the catheter or keep the patient overnight in the hospital. Many elderly, fragile men remain in the hospital unless someone at home is capable of caring for them.
• Instruct the patient on how to care for the catheter, whether it is a urethral or suprapubic tube.
• Maintain antibiotic therapy while the catheter is in place and for 3-5 days after the catheter has been removed. Sometimes a urinary antibiotic, such as nitrofurantoin, may be sufficient. Some patients will require an anticholinergic, such as oxybutynin, to help limit bladder spasms while the catheter is in place.
• Following removal of the catheter, employ antibiotics if a urinary infection is evident.
• Allow the patient to become ambulant after returning home and with minimal restrictions.
• Inform the patient that no dietary restrictions are necessary and that resuming any preoperative medications is safe. Limiting caffeine intake while the catheter is in place may help reduce any bladder spasms.
• If the patient was taking coumadin, ensure that the urine is clear before the patient resumes that medication or, if needed, treat the patient with injections of Lovenox.

Follow-up

• Patients may return to the office 5-7 days following the procedure.
• If the patient is doing well, remove the catheter after filling the bladder for a voiding trial.
• If the patient can void, the catheter can be left out. If not, replace the catheter.
• Patients with suprapubic catheters can have this tube plugged or clamped. If they are urinating without difficulty and emptying the bladder reasonably well, remove the catheter either immediately or several days later.
• The pattern of normal urination is not anticipated to occur for approximately 6 weeks, although voiding continues to improve at 6 months. After this period, patient voiding problems greatly diminish and the patients tend to be free of problems for a long period of time.
• Follow uroflow determinations, symptoms scores and residual urine measurements to check patient recovery progress.
• Check the urine for signs of infection.
• After 3 months, a PSA can be obtained to establish a new baseline.
• Additional follow-up studies are performed at the discretion of the urologist.

For excellent patient education resources, visit eMedicine's Prostate Health Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Enlarged Prostate and Bladder Control Problems.

Complications

Bleeding

The initial complication associated with interstitial laser coagulation (ILC) is bleeding that may last for several days and may occur intermittently for several weeks. Muschter and Hofstetter report significant hemorrhage in 5 of 239 (2.1%) patients, with 1 requiring a transfusion.¹⁰ The laser produces excellent tissue coagulation and hemostasis; however, the multiple punctures into the prostate produce bleeding that can last several days. This is particularly true in patients receiving anticoagulants. The bleeding is self-limiting, but leaving the catheter in place until the urine is clear is advisable. Preoperative use of finasteride or dutasteride has been suggested to help limit intraoperative and postoperative bleeding. A minimum of 2 weeks of therapy is needed for this potential benefit. The medication can be stopped once the catheter is removed, the patient is voiding well, and any gross hematuria has resolved.

Prolonged catheter drainage

The second complication is prolonged catheter drainage. Most patients need to be catheterized for 5-7 days. Muschter et al report a mean catheterization time of 18.3 days, but this report was conducted with older technology. Currently, physicians are prescribing patients alpha-adrenergic blockers to shorten the catheterization period. Re-evaluate patients who still cannot void after 4 weeks because they most likely cannot void spontaneously. If the patient originally had a severely atonic bladder, the situation may be permanent. Persistent retention may be managed with a repeat laser procedure, TURP, or continued catheter drainage.

Other complications

Other potential problems include urinary tract infection, epididymitis from prolonged catheter drainage, or a urethral stricture from the catheter. Muschter et al reported an initial series of 239 patients with a stricture rate of 3.8% and bladder neck contracture in 1.7%. Persistent obstruction caused a re-treatment rate of 9.6%.

In a more recent series of 112 men that used newer technology, Muschter et al report no major complications, but 3 (2.7%) patients required reoperation.¹¹

Arai (1996) reported no serious treatment-related complications in a 3-month study of 50 patients.¹²

Troublesome complications occurred in 12.6% of patients who reported irritative symptoms. Although urgency or stress incontinence can occur early in the postoperative period, no reports show sustained incontinence or prolonged irritative symptoms.

Proper selection of patients and increased experience with this technique has demonstrated that the procedure is safe with few major complications. Significant bleeding occurs in less than 2% of patients, retrograde ejaculation occurs in 15%, and strictures or bladder neck contracture occurs in 1%.

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