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Prostate Laser Vaporization (Greenlight KTP Laser)

Devices of different powers are available for laser vaporization of the prostate: the first-generation KTP laser has a power of 80 watts, and devices of the second and third generations have a power of 120 or 180 watts. Synonyms: Greenlight laser therapy, photoselective prostate vaporization. Review literature: (Kuntz, 2006).

fig. laser vaporization of the prostate:
Left: 30-degree angle view from the verumontanum to the bladder neck.
Middle: greenlight laser probe with pilot beam.
Right: View after prostate laser vaporization.

Indications for Laser Vaporization of the Prostate

The indications for laser vaporization of the prostate are, in principle, not different from the indications of transurethral resection of the prostate (TURP). Symptoms due to benign prostatic hyperplasia should be treated with medication until complications make surgery necessary:

• Recurrent urinary retention
• Bladder stones
• Recurrent urinary tract infection
• Recurrent hematuria
• Postrenal kidney failure due to insufficient bladder emptying

The most common indication for laser vaporization of the prostate is moderate to severe symptoms of prostatic hyperplasia, which lower the quality of life and cannot be alleviated with medication (see section Alpha blockers and medical treatment of BPH).

Due to the special coagulation ability of the greenlight laser therapy, surgery is possible despite the presence of coagulation disorders, anticoagulation therapy or antiplatelet therapy. The likelihood of a TUR syndrome is considerably lower since an isotonic irrigation solution is used during the procedure. The risk of postoperative bleeding is very low. Greenlight laser vaporization should be preferred to TURP in high-risk cardiac patients. Disadvantages of laser prostate vaporization are the high costs of the laser probe and prostate ablation without histology. Surgery time is longer in patients with a large prostate volume (>60 ml), and prostate ablation becomes less efficient due to overlying necrotic tissue.

Contraindications to Laser Prostate Vaporization

• Low life expectancy
• Untreated urinary tract infection
• Consider endoscopic enucleation or simple prostatectomy for very large adenomas (> 75–120 ml)
• Need for bladder diverticula surgery: consider open prostatectomy at lower prostate gland volumes
• Bladder stones: consider open prostatectomy depending on prostate volume and stone burden
• Contraindications for a lithotomy position
• Complex urethral disease (after hypospadias surgery)

Surgical Technique of Laser Prostate Vaporization

Anesthesia for Prostate Laser Vaporization:

Spinal anesthesia or general anesthesia.

Perioperative Antibiotic Prophylaxis:

Perioperative antibiotic prophylaxis is recommended. Since laser vaporization leaves behind a necrotic zone within the prostatic fossa, urinary tract infections are common after the procedure. A prophylactic lose-dose antibiotic treatment for 7 days is often prescribed.

Preoperative Preparations:

lithotomy position. Disinfection of external genitals, lower abdomen, and perineum. Sterile draping. Provision of body-warm irrigation solution.

Cystoscopy:

Check the urethral width, prostate size, and exclude bladder pathology (stones, diverticulum or carcinoma) with a cystoscopy.

Greenlight Laser Vaporization:

Insert the laser probe through the working channel of a cystoscope with continuous saline irrigation flow and a 30-degree optical lens. The vaporization begins at the bladder neck and is continued to the apex circularly. This guarantees a good flow of the irrigation solution to optimize the view and to remove the vaporization bubbles [fig. greenlight laser vaporization of the prostate]. Insert an 18 French Foley catheter after the vaporization.

Postoperative Management after Laser Vaporization of the Prostate

• Removal of the catheter after 1–2 days
• Control micturition
• Prophylactic low-dose antibiotic treatment for approximately seven days

Complications of Greenlight Laser Treatment

Bleeding:

The intraoperative risk of bleeding is significantly reduced (in comparison to TURP). Later, during the healing of the necrotic prostate tissue, bleeding with the need for interventions may occur in patients with oral anticoagulation treatment. 

Urinary tract infections:

Laser vaporization leaves behind a necrotic prostatic fossa; urinary tract infections are common after the procedure.

Further complications:

Retrograde ejaculation, urethral stricture, bladder neck stricture, persistent symptoms or urinary retention due to inadequate prostatic tissue ablation. External sphincter injury with urinary incontinence.

References

  Deutsche Version: KTP (greenlight) Laservaporisation der Prostata