Transperineal interstitial laser ablation of the prostate, a novel option for minimally invasive treatment of BPO

madman

Super Moderator
Abstract

Background:
In the algorithm of treatment of benign prostatic obstruction (BPO), the shift from medical therapy to surgery is steep in terms of invasiveness. Recently, a lively interest has developed in alternative micro-invasive options. Transperineal interstitial laser ablation (TPLA) was recently proposed for BPO treatment.

Objective: This work aims to illustrate the feasibility, efficacy, and safety profile of TPLA in BPO treatment.

Design, Setting, and Participants: We prospectively analyzed the results of TPLA performed between September 2018 and March 2019 for LUTS due to BPO, in men with prostate volume <100 ml.

Surgical Procedure: TPLA was performed in OR, under local anesthesia, using Soracte Lite-EchoLaserX4. Diode laser light is conveyed through 300mm optical fibers introduced transperineally by 21 Ga needles and placed at a secure distance from the urethra and bladder neck. EchoLaser Smart Interface eases needle positioning and increases safety.

Measurements: The primary endpoint was the variation of Qmax and IPSS at 1, 3 and 6 months. We also assessed the ejaculatory function and recorded complications. These outcomes were further investigated at 12 months by phone call.

Results and Limitations: 21 men with a prostate volume of 43.5 8.5 ml underwent TPLA. All were discharged after 24 h, keeping the transurethral catheter for 8.7 2.5d. At one month all patients but one discontinued medical therapy, showing significant advantage in Qmax (+3.4 5.7 ml/s; p < 0.01) and IPSS (-5.6 7.0; p < 0.01). Functional results were still progressing at 6 months, with Qmax (+4.7 6.0 ml/s; p < 0.01) and IPSS improvement (-13.1 4.7; p < 0.01). The ejaculatory function was preserved as the MSHQ-EjD increased (p < 0.05). The only complication was a prostatic abscess, treated with transperineal drainage and antibiotic.

Conclusions: TPLA is a micro-invasive treatment for BPO showing good functional and safety outcomes.

Patient Summary: This work illustrates the results of TPLA to treat LUTS due to BPO, showing high efficacy, preservation of the ejaculation, and low complication rate.




1. Introduction

The link between the obstruction due to benign prostatic hyperplasia (BPH) (benign prostatic obstruction, BPO) and lower urinary tract symptoms (LUTS) is well known and the ethiopatogenetic factor is the target of all the therapeutic options now available.

The treatment of LUTS is justified by the related worsening of quality of life. On the other hand, it is paramount to consider that the natural history of the pathology is progressive and can cause, if untreated, major complications. Thus, the ideal therapy should relieve the complaints of BPO, while interrupting the progressive damage to the lower and upper urinary tract, without causing side effects.

Several attempts were made in the last decades in order to set mininvasive treatments between medical therapy and surgery. Thermotherapy [1] and transurethral needle ablation (TUNA) [2] is probably the best known, and had some clinical diffusion in the past. Recently, Rezume [3– 5], i-Tind [6], Uro-lift [7], and prostatic artery embolization (PAE) [8] tried to fill the therapeutic gap, but the literature is still scant and inconclusive.

Transperineal interstitial laser ablation (TPLA) is probably the newest option and only one study with medium-term follow-up was published, showing promising results in line with the other mininvasive options [9]. Moreover, an international registry is ongoing to support, with evidence-based data, objective outcomes on symptom relief and urodynamic improvement.

*The aims of the present study are to describe a standardized technique of TPLA in patients with LUTS due to BPH, and report the perioperative and functional outcomes obtained in our preliminary experience with this technique.





5. Conclusion

TPLA is a simple, feasible procedure able to produce symptomatic and urodynamic improvements durable at one year. The reduced invasiveness, the outpatient vocation and the peculiar ability to preserve ejaculation candidates the procedure to become an intermediate option between medical treatment and surgery.

Gaetano De Rienzo had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
 

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madman

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Fig. 1 – Interstitial laser coagulative necrosis area. The laser light produces an area of coagulative necrosis of ellipsoidal shape that has a longitudinal diameter of 22,5 mm and a transversal diameter of 16mm and is localized for one-third behind the tip of the fiber, and for two-thirds in front of it.
Screenshot (7397).png
 

madman

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Fig. 2 – Patient position and needle positioning. The patient lays in the lithotomy position. One or two 21 G introducer needles for each lobe were inserted in the adenoma and one optical fiber per needle is placed.
Screenshot (7398).png
 

madman

Super Moderator
Fig. 3 – Multi-channel needle applicator. To ease the insertion of the needles, the transrectal US biplanar probe is combined with a multi-channel needle applicator, with dedicated software displaying a grid overlaying the US image.
Screenshot (7399).png

Screenshot (7400).png
 

madman

Super Moderator
Fig. 4 – Security distances. The security distance of the needle from the urethral lumen wall and the prostatic capsule should be 8mm, while the distance between the tip of the fiber and the bladder neck should be at least 15 mm.
Screenshot (7402).png

Screenshot (7403).png
 

madman

Super Moderator
Fig. 5 – Echolaser smart interface. The integrated Echolaser smart interface aids to improve the exact and safe needle position and safety of needle positioning.
Screenshot (7404).png

Screenshot (7405).png
 

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