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  • 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)
  • Ureteroileal anastomotic strictures after a Bricker ileal conduit: 50 case assessment of the impact of conversion from a slit incision to a shield shaped ileotomy

    Cheng Marina , Looney W. Stephen , Brown A. James, MD Division of Urology, Medical College of Georgia, Augusta, Georgia, USA

    PURPOSE: Ureteroileal anastomotic stricture is a late complication of Bricker ileal conduits. We report our utilization of a 'shield shaped' rather than a standard slit ileotomy. MATERIALS AND METHODS: We retrospectively reviewed a single surgeon's experience performing Bricker ileal conduits, initially using a slit incision, then a shield shaped ileotomy. Patient demographics, type of ileotomy, indication, history of prior radiation or chemotherapy, development of postoperative ureteroileal anastomotic stricture, date of stricture diagnosis, imaging modality, stricture treatment, outcome, and length of follow up were recorded. RESULTS: A total of 50 ileal conduit patients were identified between 2001-2009. A traditional slit incision ileotomy was performed in 25 patients (Group 1) and a shield shaped ileotomy was performed in the following 25 (Group 2). After excluding 1 patient in each group that died within 90 days postoperatively, a total of 95 renal units were anastomosed, (Group 1: 24 patients, 48 renal units, 2001-2005; and Group 2: 24 patients, 47 renal units, 2006-2009). A total of 8 (8.3%) ureteroileal anastomotic strictures were identified: 6 (12.5%) in Group 1, including 1 with bilateral strictures, and 2 (4.3%) in Group 2. Stricture diagnosis occurred at 1, 4, 4, 5, 14 and 42 months in Group 1, and at 6 and 10 months in Group 2. Mean follow up was 24.2 (2-85) months and 12.3 (2-26) months for each cohort, respectively. No increase in postoperative anastomotic leakage was identified. CONCLUSIONS: Modifying the standard ileotomy slit to a shield shaped incision does not eliminate postoperative anastomotic strictures. This technique provides greater visualization of the suture line, making it technically easier to perform.

    Keywords: posterior urethral valves, adulthood, late diagnosis, outcome,

    Apr 2011 (Vol. 18, Issue 2 , Page 5644)
  • High intensity focused ultrasound (HIFU)

    Barkin Jack, MD Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada

    INTRODUCTION: Curative treatments for localized prostate cancer, from least invasive to most invasive, include brachytherapy, cryosurgery, three-dimensional conformal radiation therapy, external beam radiation therapy, and radical prostatectomy. A patient with localized, low risk or intermediate risk prostate cancer who is diagnosed at an early age and receives one of these treatments has only an approximately 50% chance of maintaining an undetectable prostate-specific antigen (PSA) level, good spontaneous erections, and total continence by 5 years after treatment. OBJECTIVE: This article discusses transrectal high intensity focused ultrasound (HIFU) treatment of localized prostate cancer using the Sonablate 500 (Focus Surgery, Indianapolis, IN, USA) device, which the author has adopted in favor of the Ablatherm (EDAP, TMS S. A., Lyons, France) device, the other HIFU device approved for use in Canada. METHOD: Characteristics of the ideal prostate cancer include stage T1-T2b, less than 40 cc in size, and with an anterior-posterior dimension of up to 35 mm high. The anterior zone of the prostate is treated before the posterior zone. The procedure involves 2 to 3 second bursts of ultrasound energy, followed by 3 second cooling cycles. In each treatment lesion, the physician achieves a temperature of 100 C at the focal point. The device allows for real-time visualization of tissue response following the delivery of ultrasound energy. CONCLUSION: HIFU is a minimally invasive, outpatient treatment for localized prostate cancer that provides similar short term and medium term cure rates and considerably less morbidity and side effects than other treatments. Although the effectiveness of HIFU has not yet been demonstrated in large, long term studies, this treatment option should be discussed with patients who have just been diagnosed with low risk or intermediate risk prostate cancer and desire aggressive, noninvasive, curative therapy, with potentially a lower incidence of side effects compared to conventional therapy.

    Keywords: prostate cancer, HIFU,

    Apr 2011 (Vol. 18, Issue 2 , Page 5634)
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