Evolution and success of holmium laser enucleation of the prostate
There was a time, up to almost the end of last century when it was thought that “big surgeons make big incisions “. However, towards the early eighties surgeons had started to resort to smaller incisions and terms such as “min-laparotomy” (or small incision for abdominal operations) came into vogue.
Laparoscopy in the nascent phase needed four or five ports to accomplish a task such as cholecystectomy or removal of gall bladder. In Urology, since the beginning of the latter half of last century, surgeons were constantly improving their skills of removing the obstructive prostate gland in elderly men suffering from urinary outflow obstruction.
This was fraught with complications, as removal of prostate was associated with bleeding, virtually blinding the surgeon working with a telescope inserted into the urinary tract trying to chip of the obstructive enlarged prostate gland using electric current (TURP). This resulted in complications like more bleeding and injury to adjacent organs like small and large intestine, and damage to control mechanism leading to Incontinence of urine. In addition, the procedure could risk the life of the patient due to absorption of fluid into the abdomen and vascular system causing swelling of brain and lungs.
However, advent of technology in the form of improved optics of the telescope and light source, along with better energy delivering systems helped the surgeon progress with reasonable confidence. Having said that, there was still a problem. The energy used was electric current which could cut the tissues and coagulate when bleeding occurred.
The setting of electric current was different for cutting and coagulation, which meant that a surgeon had to cut, cause bleeding and then coagulate the bleeder using a coagulative current. The cutting lead to bleeding and every time surgeon needed to control bleeding before making the next cut. This may sound ridiculous but this is a fact. Then there was a need to develop a technology which could coagulate the bleeder before being cut. This marked the entry of lasers in treatment of enlarged prostate.
Of the various lasers that came and disappeared towards the end of last century. Holmium is a precise cutting tool with a penetrating depth of 0.4 mm, making it the sharpest cutting Laser. The others like Thulium and KTP or the green light Lasers happen to be much blunter and have a wider coagulating and vaporising properties, at the cost of losing precision of Holmium.
The wide range of frequency of lumenis Holmium laser delivery makes it even more precise. It is important to note that the technology needs to be used by skilled and well trained personnel to deliver the desired results and there would be some complications, even if lower in percentage, with any surgical intervention for enlarged prostate gland.
Dr Rajesh Taneja is a Senior Consultant Urology, Andrology and Robotic Surgery at Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi