A randomized trial of photoselective vaporization of the prostate using the 80-W potassium-titanyl-phosphate laser vs transurethral prostatectomy, with a 1-year follow-up.

OBJECTIVE: To compare the potassium-titanyl-phosphate Greenlight(TM) 80-W laser ablation system for photovaporization of the prostate (PVP; Laserscope, San Jose, CA, USA) with transurethral resection of the prostate (TURP), as many technologies have been proposed as equivalent or superior to TURP without gaining widespread acceptance, due to lack of data from randomized trials. PATIENTS AND METHODS: In all, 120 patients were randomized to undergo either TURP or PVP after a full urological evaluation, which was repeated at 1, 3, 6 and 12 months after surgery. Irrigation use, duration of catheterization (DOC), length of hospital stay (LOS), blood loss, cost and operative time were also assessed. RESULTS: Both groups showed a significant increase in mean (sd) maximum urinary flow rate from baseline (P < 0.05); in the TURP group from 8.9 (3.0) to 19.4 (8.7) mL/s (154%), and in the PVP group from 8.8 (2.5) to 18.6 (8.2) mL/s (136%). The International Prostate Symptom Score (IPSS) decreased from 25.4 (5.7) to 10.9 (9.4) in the TURP group (53%), and from 25.3 (5.9) to 8.9 (7.6) in the PVP group (61%). The trends were similar for the bother and Quality of Life scores. There was no difference in sexual function as measured by Baseline Sexual Function Questionnaires. The DOC was significantly less in the PVP than the TURP group (P < 0.001), with a mean (range) of 13 (0-24) h vs 44.7 (6-192) h. The situation was similar for LOS (P < 0.001), with a mean (range) of 1.09 (1-2) and 3.6 (3-9) days in the PVP and TURP groups, respectively. Adverse events and complications were less frequent in the PVP group. Costs were also 22% less in the PVP group. CONCLUSIONS: This trial shows that PVP is an effective technique when compared to TURP, producing equivalent improvements in flow rates and IPSS with the advantages of markedly reduced LOS, DOC and adverse events. A long-term follow-up is being undertaken to ensure durability of these results.

KTP laser versus transurethral resection: early results of a randomized trial.

BACKGROUND AND PURPOSE: Many technologies have been mooted as equal to transurethral resection of the prostate (TURP) without gaining widespread acceptance because of the lack of randomized trials. The Greenlight laser system (Laserscope, San Jose, Ca.), an 80 W system for photovaporization of the prostate (PVP), was compared with TURP in such a trial. PATIENTS AND METHODS: A series of 120 patients was randomized to undergo TURP or PVP after evaluation, which was repeated at 1, 3, 6, and 12 months after treatment. Irrigation use, length of catherization (LOC), length of hospital stay (LOS), postvoiding residual volume, sexual function, blood loss, cost, and operative time also were assessed. RESULTS: To date, 76 patients are evaluable. Both groups showed a significant (P < 0.5) increase in maximum flow rate from baseline. In the TURP group, flow increased from 8.7 to 17.9 mL/sec (149%) and in the PVP group from 8.5 to 20.6 mL/sec (167%). The International Prostate Symptom Score decreased from 25.4 to 12.4(50.23%) in the TURP group and from 25.7 to 12.0 (49.83%) in the PVP group. Postvoiding residual volumes also showed significant decreases. Similar trends were seen in relation to bother and quality of life scores. There was no difference in sexual function as measured by a questionnaire. The LOC was significantly less in the PVP group (P < 0.001), the mean being 12.2 hours (range 0-24 hours) versus 44.5 hours for TURP (range 6-192 hours). A similar situation was seen in relation to LOS (P < 0.0001), with the mean of the PVP group being 1.08 days (range 1-2 days) and the mean for the TURP group being 3.4 days (range 3-9 days). Adverse events were less frequent in the PVP group, and the costs were 22% less. CONCLUSIONS: This trial demonstrates that PVP is effective compared with TURP, producing equivalent improvements in flow rates and IPSS with markedly reduced LOS, LOC, and adverse events. Long-term follow- up is being undertaken to assess the durability of these results.

Limitations of noncontrast CT for measuring ureteral stones.

BACKGROUND AND PURPOSE: Patients with renal colic are frequently evaluated in the emergency room with a helical noncontrast CT scan (NCCT) as the primary imaging modality. Treatment decisions are often based on the size of the ureteral stone(s). We wished to assess the accuracy of NCCT in estimating ureteral stone size compared with plain abdominal (KUB) films. PATIENTS AND METHODS: Forty-eight patients were identified who had ureteral stones seen on NCCT and KUB films performed on the same day. The number of consecutive images on which a ureteral stone was visible on NCCT was multiplied by the reconstruction interval of 5 mm to create a size estimate, which was compared with the measurements of the same stone seen on the KUB film. RESULTS: The NCCT overestimated stone size by approximately 30% to 50% compared with KUB. CONCLUSION: Counting the number of consecutive NCCT images depicting a ureteral stone is not an accurate method of stone measurement when a reconstruction interval of 5 mm is used. Urologists should consider stone measurement techniques carefully and understand the limitations of imaging studies when evaluating patients with symptomatic ureteral stones.

Robotic laparoscopic radical prostatectomy: setup and procedural techniques after 150 cases.

OBJECTIVES: To report our current methods of patient positioning, establishing the pneumoperitoneum, port placement, and helpful maneuvers during the procedure that have been refined over the course of our initial experience with robotic laparoscopic radical prostatectomy (RLRP). RLRP is gaining popularity as a minimally invasive technique for treating patients with organ-confined prostate cancer. Because this is a new procedure, strategies to optimize the surgical technique are constantly evolving. METHODS: Two genitourinary surgeons experienced in open surgery with no laparoscopic experience began performing RLRP in December 2003 after appropriate training and mentoring. During the course of the ensuing 150 cases, new techniques were developed in an attempt to simplify the operation and improve its outcome. RESULTS: We documented and illustrated techniques for patient positioning, safe and rapid placement of the initial camera trocar, use of the third working arm of the da Vinci Surgical System, trocar positioning, and prostatic retraction to assist with posterior dissection. CONCLUSIONS: We have described setup techniques and principles we developed during our experience with the da Vinci robotic system. These points of technique may be helpful for simplifying a procedure that is still in evolution.

Revisiting the role of radical surgery in early stage prostate cancer.

Is it time to walk the line between overtreating indolent disease and undertreating aggressive disease?