British Journal of Urology (1998), 81, 518–519

The results of holmium laser resection of the prostateM.J. MACKEY, C.P. CHILTON, P.J . GILLING*, M. FRAUNDORFER*and M.D. CRESSWE LL†Derby City General Hospital, Derby, UK, *Tauranga Hospital and †Rotorua Hospital, New Zealand

Objective To assess the results of holmium–laser resec- Results There was a large and sustained improvementin symptom scores and urinary flow rates, with notion of the prostate (HOLRP) in the treatment of

benign prostatic hyperplasia. mortality and low morbidity.Conclusion We recommend this technique as an alterna-Patients and methods Between 1994 and 1997, 967

patients underwent HOLRP in Tauranga, New tive to transurethral resection in the surgical treat-ment of bladder outlet obstruction due to benignZealand, and in Derby, United Kingdom. The patients

were followed at 1, 3 and 6 months after treatment prostatic hypertrophy.Keywords Benign prostatic hyperplasia, holmium laserusing measurements of symptom score and urinary

flow rate. resection of the prostate

Peri-operatively, the duration of the operation, laserIntroduction

energy used, weight of tissue resected, duration of cath-eterization and hospital stay, and any complicationsThe holmium laser is emerging as a versatile multi-

purpose tool in urology; it is becoming accepted as were recorded. The standard practice was to leave atwo-way silicone catheter in place overnight; this wasthe modality of choice for intracorporeal lithotripsy

of urinary calculi [1,2]. It also has many soft-tissue removed the next morning and the patients dischargedthat day once satisfactory voiding was established. Theapplications in urology [3] and is now being used to

perform prostatic resection. The wavelength (2.1 mm) standard clinical follow-up comprised an estimate of theAUA score and Q

maxat 1, 3 and 6 months after surgery.and tissue-absorption characteristics (0.44 mm) of the

holmium laser allow endoscopic delivery by bare fibre, In all, 967 patients underwent HOLRP (mean age 69years, range 44–89) and the mean prostate volume wasand precise cutting and vaporization of prostate tissue

in an almost bloodless field. The development of the 52 mL (range 10–200).higher power laser (60–80 W, Versapulse Select byCoherent, UK) and refinement of the resection technique

Resultshas enabled a rapid and safe prostatic resection; wereport our experience in 967 patients. The mean (range) duration of the operation was 43

(5–140) min, the laser energy used 86 (48–342) kJ andthe mean weight of tissue resected 8 (1–62) g. The mean

Patients and methods(range) duration of catheterization was 1.5 (0.5–21)days and the mean hospital stay 1.1 days. There wereThe current technique of holmium-laser resection of the

prostate (HOLRP) was developed in 1994 in Tauranga, no peri-operative deaths or cases of TUR syndrome.Two patients required a blood transfusion, two requiredNew Zealand by Gilling et al. and has been described

previously [4]. Slight variations in operative technique re-catheterization because of secondary bleeding (onepatient was anticoagulated). The post-operative irritativehave developed but all methods essentially enucleate the

prostate at the level of the surgical capsule, resulting in symptoms were similar to those occurring after TURPand significantly less than after Nd:YAG coagulationa cavity identical to that produced during TURP. All

patients underwent a routine pre-operative assessment prostatectomy [5]. Table 1 shows the Qmax

and AUAscores before and after surgery; there was a large andusing symptom scoring (AUA) and a measurement of

peak urinary flow rate (Qmax

); in addition most patients sustained improvement in both variables after treatment.The magnitude of improvement in these variables washad their prostate volume estimated from TRUS.similar to that expected with TURP by electrosurgery.

Accepted for publication 16 December 1997

518 © 1998 British Journal of Urology

RESULTS OF HOLMIUM LASER RESECTION OF THE PROSTATE 519

Table 1 The mean (sd) AUA symptom scores and peak urinary small enough to evacuate via the resectoscope sheath,flow rates before and after treatment using the Ellick evacuator or Toomey syringe. This is

sometimes diBcult to gauge, so a modified loop grabberNumber Q

max(mL/s) AUA score

has been designed to extract larger pieces whole. Becauseof the potential risk of stricture formation using the loopgrabber technique, an endoscopic morcellator is beingBefore 967 8.8 (2–16) 20.6 (7–34)developed to overcome the problems; this will enableAfter (months)

1 967 19.3 (6–48) 9.2 (1–27) large pieces or even complete lobes to be resected intact3 503 21.1 (8–61) 7.0 (0–24) and then removed by morcellation from the bladder6 323 22.3 (7–61) 4.8 (0–15) without prior reduction, thereby decreasing the operative

duration considerably.In conclusion, HOLRP provides a precise anatomical

dissection of the prostate which, whilst readily learned,Discussion requires surgical expertise. The peri-operative morbidity,

duration of catheterization and hospital stay are less thanThe HOLRP technique mimics conventional TURP, as athat after electrosurgical TURP. Further development ofprecise anatomical resection and the measures of voidingthe morcellation technique may render both retropubicperformance (AUA symptom score and Q

max) suggest a

prostatectomy and TURP by electrosurgery obsolete. Thesimilar eBcacy. The advantages over electrosurgicalresults presented here require validation in prospectiveTURP include a reduction in the duration of catheteriz-randomized trials; currently, a randomized prospectiveation and hospital stay, less bleeding during and afterurodynamically controlled trial is being undertaken insurgery, and avoidance of the TUR syndrome. TheNew Zealand.occurrence of significant secondary haemorrhage is rare,

allowing patients to return to normal activities in severaldays. The patients also require less nursing and medical Referencestime after treatment. We believe that this procedure

1 Bagley D, Erhard M. Use of the holmium laser in the uppercould be performed as day-case surgery, with catheter

urinary tract. Tech Urol 1995; 1: 25–30removal on the same day in selected cases. 2 Matsuoka K, Shimada A, Iida S et al. Holmium-yttrium-

We prefer to estimate prostate volume using TRUS aluminum-garnet laser for endoscopic lithotripsy. Urologybefore surgery, as the volume correlates reasonably well 1995; 45: 947–52with the duration of resection and thus allows operating 3 Razvi HA, Chun SS, Denstedt JD, Sales JL. Soft-tissue

applications of the holmium:YAG laser in urology. J Endourollists to be planned more eCectively. The technique is1995; 9: 387–9eCective for all patients who would traditionally undergo

4 Gilling PJ, Cass CB, Cresswell MD, Fraundorfer MR. Holmiuma standard TURP. Fully anticoagulated patients andlaser resection of the prostate: preliminary results of a newpatients with large prostates (>100 mL TRUS volume),method for the treatment of benign prostatic hyperplasia.can safely undergo HOLRP. A separate analysis of theUrology 1996; 47: 48–52results from patients in acute urinary retention has been

5 Gilling PJ, Cass CB, Cresswell MD, Kennett KM, Mackey MJ,reported elsewhere [6]; the results are similar to those

Fraundorfer MR. The evolution of the use of the holmiumexpected with electrosurgical TURP. laser for the treatment of benign prostatic hyperplasia.

We estimate that 50–60% of the tissue ‘resected’ is in pressvaporized during resection, so the weight of tissue 6 Kabalin JN, Mackey MJ, Cresswell MC, Fraundorfer MR,resected is apparently less than that during TURP by Gilling PJ. Holmium5Yag laser resection of the prostate

(HOLRP) for patients in urinary retention. J Endourol 1997;electrosurgery. Fortunately, the tissue obtained has only11: 293–5a thin layer of thermally damaged artefact and is thus

still suitable for standard histological examination.The technique is relatively simple to learn but it is Authors

challenging to enucleate the prostate cleanly at theM.J. Mackey, MBChB, Urology Fellow.

capsular level. The duration of the resection is similar toC.P. Chilton, FRCS, Consultant Urologist.

that for TURP with prostates of <80 mL (estimated by P.J. Gilling, FRACS, Consultant Urologist.TRUS). Large prostates (>80–100 mL) can be enu- M. Fraundorfer, FRACS, Consultant Urologist.cleated quickly, but division of the lobes into pieces small M.D. Cresswell, Consultant Urologist.enough to be evacuated from the bladder is slow and Correspondence: Mr M.J. Mackey, 52B Argyle Street, Herne

Bay, Auckland, New Zealand.tedious. Ideally, the lobes should be divided into pieces

© 1998 British Journal of Urology 81, 518–519