New technology-based procedure will be less invasive when treating prostate problems. David Labanyi reports on a laser procedure which allows for more efficient treatment for an enlarged prostate
Treatment of the enlarged prostate - a condition that causes problems for about 40 per cent of men - could soon become less invasive with the introduction of a new laser-based technology to a number of private Irish hospitals.
The procedure is used to treat a non-cancerous growth of the prostate which tends to manifest itself when the man has problems emptying his bladder. This is known as clinical benign prostatic hyperplasia (BPH).
The prostate gland resembles a washer at the opening of the bladder. The prostate grows as men get older. They start at roughly the size of a chestnut for a man in his 20s and can grow to the size of a mandarin or a tennis ball for men aged over 60 and over.
While the phenomenon is common to nearly all men, for approximately 40 per cent this growth causes problems. There are a number of treatment options for severe cases including surgery which, to date, has required a hospital stay of anything up to five days.
However, an alternative to this may soon be available in the State following the development of laser technology, known as photoselective vaporisation of the prostate (PVP) technology.
Kilian Walsh, is a consultant urologist at King's Hospital in London which has been using this technology for two years. He says the main benefit to using lasers to treat BPH is a reduced hospital stay.
"The main advantage is that this makes the procedure truly a day-case procedure. So instead of a patient having to spend three to five days in hospital they can have the procedure and go home the same evening.
"Within the prostate there are two pathologies; cancer and BPH. This technology is purely for the benign enlargement of the prostate," says Walsh.
The laser uses green light which is taken up by red, blood-rich tissue or organs such as the prostate, which is quite a vascular organ.
"Lasers were introduced about 10 years ago but their long term success was not as good as the transurethral resection of the prostate (TURP) operation, which has been the standard since the 1950s.
"The laser emits a greenlight which is most effective in vaporising vascular organs such as the prostate which has a rich blood supply, the green laser works best in a red environment."
Walsh says the laser technology is not a time-saving device for surgeons. "Technically it doesn't mean you can do that many more procedures. Perhaps you can improve your productivity a little but it means the patient can home get home quicker."
The majority of patients at King's Hospital are now having green light laser treatment for symptomatic prostatic enlargement.
"There are two or three reasons for that. It's certainly not that the TURP is any less good. It's patient choice and also, logistically, because its easier to treat people in a day surgery setting," he says.
TURP cannot be done as a day case and always requires a short hospital stay. The laser surgery also goes through the urethra, using a small fibre. It uses pulsing lasers to create tremendous heat which vaporise the surrounding tissue. The pulsing prevents the heat from distributing beyond the tissue being operated on.
However, Walsh cautions that the long-term validity of the laser treatment has yet to be assessed. "It is new technology which looks promising. But the long-term validity has yet to be assessed. Early results up to a year seem equivalent to TURP but five-year results are needed to say it is a better procedure than TURP."
TURP involves using a fiber-optic telescope to look down the urethra and core out the obstructing part of the prostate using electrocautery.
With both procedures there are side effects, including some pain and, particularly with TURP, bleeding. With TURP there is a requirement to use a catheter for a number of days.
Comparative studies on the two procedures are only now becoming available. One of the first was recently presented at the American Urological Association's annual conference which was held between May 21st and May 26th in Texas.
An Irish-trained urologist, David Bouchier-Hayes, based in Melbourne, was part of a team which published results at the conference of a randomised trial comparing PVP and BPH. The study took 120 patients requiring surgery for enlarged prostate and randomised them to either TURP or PVP.
Interim results demonstrated that while both procedures improved flow rates the PVP group had significantly shorter hospital stays and length of time requiring a catheter.
One potential downside of the new technology is cost. Each laser-based procedure requires a disposable laser fibre, which costs approximately €1,000.
The machine costs approximately €100,000. According to Walsh whether this makes the procedure viable depends on how a country's health economics works.
"Certainly in the UK it is far more economically viable. From an NHS point of view any saving in bed days was considered enough to make it economically viable."
Kiaran O'Malley, a consultant urologist at the Mater has visited the centre in King's Hospital and studied the laser procedure. He says that the Department of Urology at the Mater campus is very impressed with the new technology and its results, and is anxious to develop the service soon. The Mater Private is currently in negotiations with the VHI to see whether PVP will be included on its list of procedures, a move which would signal its introduction there. The procedure is available in Britain through BUPA.
"PVP would also allow us to take on certain higher risk patients that are unsuitable for TURP; patients on anti-platelet or anti-coagulant therapy for example. For medical staff the learning curve is quite short especially for urologists already competent with existing procedures," says O'Malley.
Because BPH is not considered an emergency procedure the waiting list for surgery was often several years. "Since the National Treatment Purchase Fund that is not the case. In the Mater our waiting list for the TURP procedure is probably about four to six months although I believe in certain parts of the country the wait is still long and one can wait upwards of two years just to be evaluated in outpatients for BPH."
O'Malley predicts the laser treatment will soon be available in Ireland and will co-exist with standard procedures.
"There is no question but that performing surgery on enlarged prostates as a day case means you can safeguard beds much more easily and efficiently because you can promise patients exactly when they are coming in."