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No. 014. Holmium:YAG Laser Bladder Neck Incision Prior to Brachtherapy in Obstructed Patients Reduces Post Procedure Complications. Hepburn A. Meiklejohn P. Fraundorfer M. Tauranga Hospital, New Zealand. Results

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No. 014

Holmium:YAG Laser Bladder Neck Incision Prior to Brachtherapy in Obstructed Patients Reduces Post ProcedureComplications

Hepburn A. Meiklejohn P. Fraundorfer M. Tauranga Hospital, New Zealand

Results

117 patients included with an mean follow up 32 months (6-91). Average age 65 years (47-79). Average prostate size 37cc (17-66cc)

Pre-treatment mean maximum flow rate was 10 ml/sec (5-15ml/sec). IPSS mean score 12. 28 patients had IPSS scores >20. Post procedure mean flow rate 25ml/sec. Average increase 9ml/sec.

91 (78%) patients reported subjective improvement in urinary symptoms post brachytherapy with 18 (15%) no change and 8 (7%) experiencing worse symptoms [fig.3] (mainly poor flow and frequency). No patients reported incontinence.

6patients (5%) went into urinary retention for more than 24hrs requiring self-catheterisation [Fig. 3]. 1 patient required ISC for 3 months, 2 required ISC for 1 month, 1 required ISC for 1 week and one required ISC for 3 days. 1 patient could not tolerate ISC and required an IDC for 1 week. None of these patients required further surgery.

3 patients (2.5%) required surgical intervention [Fig. 4]. These were an optical urethrotomy, a cystoscopy/bladder neck dilation and cystodiathermy to minor radiation cystitis. These occurred at 18 months,6 months and 3 months post operation respectively. No resection operations such as TURP were performed.

Of the 28 patients with IPSS scores >20 none required any surgical intervention or suffered from retention

Introduction

Patients with bladder outflow obstruction have been deemed inappropriate for low dose brachytherapy. This is due to a 20 - 30% risk of prolonged post treatment retention and worsening urinary symptoms. Approximately half of patients with retention ultimately require a transurethral resection of prostate (TURP) with unacceptably high rates (20-40%) of post resection incontinence. TURP prior to treatment is an option but this can complicate brachytherapy and delay treatment by at least 6 months [1,2]

In this series we report the outcomes of patients with obstruction who underwent a laser bladder neck incision (BNI) 3 weeks prior to brachytherapy.

Aim

Holmium laser BNI improves flow rates and symptoms without the need to remove the lateral lobes. Low dose brachytherapy is considered inappropriate in patients with bladder outlet obstruction and in post TURP patients. Post TURP patients have a lower risk of retention, but due to a variable defect in prostate tissue effective implantation is difficult. Our aim is to assess whether a laser BNI prior to brachytherapy reduces post operative complicationsand can avoid pre-treatment TURP.

Unlike TURP this method leaves enough prostatic tissue to safely and effectively implant seeds. Can this method allow patients previously deemed unsuitable for brachytherapy to more safely undergo this treatment?

Methods

Single centre brachytherapy patients between October 2003 and April 2011were included. These patients had a maximum urine flow rate <15ml/sec. While volume studies were performed under general anaesthetic 3 weeks prior to brachytherapy, a Holmium:YAG laser BNI was performed. This procedure utilised the 100W Versa Pulse Lumenis Ho:Yag Laser with a 550-μm end firing fibre using the initial stage of the HOLEP technique developed by Fraundorfer and Gilling [3]. Two incisions were made at the 5 and 7 o’clock position down to capsule [Fig. 1] and tissue was resected between these incisions [Fig. 2]. Urinary catheters were kept in for 12 hours post BNI. Flow rates were then rechecked immediately prior to Iodine 125 seed implantation (3 weeks after BNI).

Data collected included post brachytherapy rates of retention, need for surgical intervention and subjectivesatisfaction of urinary symptoms. Subset analysis of patients with pre-treatment IPSS scores of >20 was also performed.

Conclusions

Compared with the unacceptably high rates of post operative retention and urinary toxicity in brachytherapy patients with bladder obstruction, our series showed that laser BNI prior totreatment lowered these risks. The rate of post procedure retention was 5%. This is equal or better to outcomes in non obstructed men[1]. 3% of patients required minor surgical intervention. None underwent TURP or similar and thus avoided the associated risk of incontinence. Not only was the complication rate low it also improved flow rates and subjectively reduced pre-treatment lower urinary symptoms.

Laser bladder neck incision reduces post brachytherapy complications to a rate where the obstructed patient can be considered for low dose brachytherapy.

Figure 1. Initial incision. Two incisions are made at 5 and 7 o’clock from veru to bladder neck isolating median lobe tissue

  • References
  • Langley S & Laing. Iodine seed prostate brachytherapy: an alternative first-line choice early prostate cancer. Prostate Cancer and Prostatic Diseases 7, 201–207 2004
  • Kollmeier MA et al. Urinary morbidity and incontinence following transurethral resection of the prostate after brachytherapy. Journal Of Urology 173(3):808-812 2005
  • Gilling P Holmium Laser Enucleation of the Prostate (HoLEP). BJU International Volume 101, Issue 1, pages 131–142 2008
  • Kovacs G et al GEC/ESTRO-EAU recommendations on temporary brachytherapy using stepping sources for localised prostate cancer. Radiotherapy and Oncology 74 137–148 2005

Figure 2. Resulting channel. Incision at the capsule between the two initial incisions is developed in front of veru to bladder neck. This tissue is pushed into the bladder and retrieved.

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