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  • Holmium laser enucleation of the prostate technique for benign prostatic hyperplasia

    Kelly C. Douglas , Das Akhil, MD Department of Urology, Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA

    Holmium laser resection of the prostate (HoLRP) was first described by Gilling et al in 1995. HoLRP has now evolved into holmium laser enucleation of the prostate (HoLEP) with the advent of the intravesical soft-tissue morcellator. The procedure involves anatomical dissection of the prostatic tissue off the surgical capsule in a retrograde fashion using a high-powered holmium laser followed by intravesical morcellation of the prostatic tissue. Some groups believe that the HoLEP procedure is the endoscopic equivalent to a simple open prostatectomy and may be superior to transurethral resection of the prostate (TURP) or even open prostatectomy. The objective of this article is to explain the techniques for holmium laser enucleation of the prostate (HoLEP).

    Keywords: photovaporization, pelvic organ prolapse, mesh, transvaginal mesh,

    Feb 2012 (Vol. 19, Issue 1, Page 6131)
  • Management of pelvic organ prolapse

    Ahmed Faisal , Sotelo Tiffany, MD Pelvic Floor Center, George Washington University Hospital, Washington, DC, USA

    Symptomatic pelvic organ prolapse can afflict up to 10% of women. Urinary incontinence, voiding dysfunction or difficulty possibly related to bladder outlet obstruction are common symptoms. Infrequently hydronephrosis or defecatory dysfunction can be seen. The management of pelvic organ prolapse (POP) should start with adequate assessment of all pelvic floor complaints. If a patient is not symptomatic, surgical intervention is usually not indicated. While the use of a variety of graft materials are available today including porcine, dermal and synthetic grafts, that are used in some surgical approaches to pelvic organ prolapse, other more conservative approaches may prove beneficial to many patients. This article describes our approach to the patient with pelvic organ prolapse.

    Keywords: pessary, pelvic floor, BPH, radical prostatectomy, Calypso transponders,

    Dec 2011 (Vol. 18, Issue 6, Page 6050)
  • GreenLight 180W XPS photovaporization of the prostate: how I do it

    Zorn C. Kevin, Liberman Daniel, MD Department of Urology, University of Montreal Hospital Center (CHUM), Montreal, Quebec, Canada

    Transurethral resection of the prostate (TURP) is the most common surgical intervention for benign prostatic hyperplasia (BPH), largely due to lower urinary tract symptoms refractory to medical therapy. TURP remains the gold standard for men with prostates sized 30g-80g, while open prostatectomy has been the preferred option for men with glands larger than 80g-100 g and those with other lower urinary tract anomalies such as large bladder stones or bladder diverticula. Unfortunately, these procedures have complications including bleeding (often requiring transfusion in 7%-13% of cases), electrolyte abnormalities (2% TURP syndrome), erectile dysfunction (6%-10%), and retrograde ejaculation (50%-75%). The overall incidence of a second intervention (repeat TURP, urethrotomy and bladder neck incision) has been reported in 12% and 15% of men at 5 and 10 years following TURP. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm-Greenlight). Photoselective vaporization of the prostate (PVP), initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system (American Medical Systems, Minnetonka, Minnesota, USA), has been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser’s frequency, and resulting in a green light. Outcomes have demonstrated a reduced frequency and severity of clinical complications, however it was limited to smaller prostate sizes. In 2006, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced. This laser utilizes a diode pumped Nd:YAG laser light that is emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system. The HPS offered an 88% more collimated beam and smaller spot size, resulting in much higher irradiance or power density in its 2 predecessors (60W and 80W) with a beam divergence of 8 versus 15 degrees. The primary aim for this upgrade was to reduce lasing time and improve clinical outcomes while demonstrating the same degree of safety for patients. Limitations of the 120W system included treatment of large prostates greater than 80g-100g and increased cost related to fiber devitrification and fracture. In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. Internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback), better preserve the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with the opportunity to perform a more complete and rapid procedure. Published clinical data with the XPS is unfortunately lacking. The objective of this report is to detail our approach and technique for GreenLight XPS drawing on personal experience with both enucleation and vaporization techniques with various laser technologies along with having performed over 500 GreenLight HPS and 100 XPS procedures. In this regard, recommendations for training are also made, which relate to existing users of the 80W and 120W GreenLight laser as well as to new laser users.

    Keywords: outpatient, in office, adjuvant radiation,

    Oct 2011 (Vol. 18, Issue 5, Page 5918)
  • Transrectal implantation of electromagnetic transponders following radical prostatectomy for delivery of IMRT

    Canter Daniel , Kutikov Alexander , Horwitz M. Eric , Greenberg E. Richard, MD Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA

    Surgical treatment for men with localized prostate cancer open, laparoscopic, or robotically-assisted-- remains one of the therapeutic mainstays for this group of patients. Despite the stage migration witnessed in patients with prostate cancer since the introduction of prostate-specific antigen (PSA) screening, detection of extraprostatic disease at the time of surgery and biochemical recurrence following prostatectomy pose significant therapeutic challenges. Radiation therapy (RT) after radical prostatectomy (RP) has been associated with a survival benefit in both the adjuvant and salvage setting. Nevertheless, optimal targeting of the prostate bed following surgery remains challenging. The Calypso 4D Localization System (Calypso Medical Technologies, Seattle, WA, USA) is a target positioning device that continuously monitors the location of three implantable electromagnetic transponders. These transponders can be placed into the empty prostatic bed after prostatectomy to facilitate the delivery of radiation therapy in the post-surgical setting. In this article, we detail our technique for transrectal placement of electromagnetic transponders into the post-prostatectomy bed for the delivery of adjuvant or salvage intensity-modulated radiation therapy. We prefer this technique of post-surgical radiation therapy because it allows for improved localization of the target area allowing for the maximal delivery of the radiation dose while minimizing exposure of surrounding normal tissues. Although emerging, our initial oncologic and functional outcomes have been promising.

    Keywords: salvage radiation, vacuum erection device, erectile dysfunction, phosphodiesterase type-5 inhibitor,

    Aug 2011 (Vol. 18, Issue 4, Page 5844)
  • Management of post-prostatectomy erectile dysfunction

    Jamal E. Joseph , Engel D. Jason, MD Department of Urology, George Washington University Hospital, Washington, DC, USA

    The management of post-prostatectomy erectile function has been debated since the nerve sparing radical prostatectomy was first introduced. A number of penile rehabilitation protocols have been proposed with varying degrees of success and patient satisfaction. My management of post-prostatectomy erectile dysfunction has evolved based on an honest and critical appraisal of the literature and my own experience and research. A review of major studies published on the topic of post-prostatectomy penile rehabilitation is included here, in addition to a critical evaluation of my own clinical practice. After evaluating the efficacy of these various approaches, it is clear to me that a nerve sparing procedure is only one of many factors involved in recovering erectile function. Moreover, in addition to assessing a patients goals and their motivation for erectile function after prostatectomy, setting appropriate patient expectations is paramount to avoiding patient frustration. A frank evaluation and discussion with a patient and their partner is paramount to managing these expectations. A 'one size fits all' approach is not appropriate. Herein, I discuss the evolution of my approach to managing post-prostatectomy erectile dysfunction.

    Keywords: radical prostatectomy, salvage radiation, vacuum erection device, erectile dysfunction, phosphodiesterase type-5 inhibitor, rehabilitation,

    Jun 2011 (Vol. 18, Issue 3, Page 5726)
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