1. BPH - Evaluation and Treatment
The GreenLight PVP Workshop PowerPoint Presentation gives an overview of how a KTP laser works, how different lasers generate different tissue effects, and why a high power KTP laser is the ideal tool to treat BPH. The Photoselective Vaporization of the Prostate (PVP) procedure is explained. The presentation closes with clinical data of a multi-center study and a single center long-term durability study.
The presentation is designed as 60 minute workshop didactic. It should be supplemented by a lecture on laser safety included in the file “GreenLight PVP Workshop Presentation – Laser Safety Supplement”
We encourage urologists to include their own experience in the presentation. Sample slides can be found at the beginning and end of the presentation. These slides can easily be customized by replacing the placeholders “<>” with specific information. The slides entitled “Personal Experience” are hidden by default. To show them in the presentation, select the slides and select the “Hide Slide” button in the Slide Show pull-down menu.
To give presenters some guidance in how to narrate the slides, a manuscript was prepared that can be found in the note section of each slide. Please review the manuscript before giving a presentation as it contains specific details about the PVP Procedure. The manuscript extends in some parts beyond the content that can actually be covered in a real presentation. Some text slides spell out the synopsis of preceding illustrations or videos. These text slides are intended to re-emphasize take home messages.
For questions or suggestions, please contact Kester Nahen, Ph.D., Laserscope Director of Professional Education and Clinical Applications, phone (408) ,
The presentation can directly be run from the CD-ROM. To run the presentation from a hard drive, the Power Point file (ppt) and video clips (wmv, mpg) must be copied to the same folder on the computer’s hard drive.
The speakers of the computer should be turned off during the presentation as some video clips include an unrelated voice-over.
The presentation was prepared with Power Point 97 on a Windows 2000 PC.
C. Ryan Barnes, M.D.
Virginia Urology

2. BPH (Benign Prostatic Hyperplasia)
What is BPH?
BPH is a medical term for enlarged prostate. It is not cancer and does not lead to cancer.
It is a quality of life condition
It is very common affecting millions of men
Half of all men over age 50
Symptoms increase with age

3. Illustration of Normal Prostate Anatomy

4. Illustration of the Prostate Anatomy with BPH

5. BPH Symptoms Feeling a repeated & instant need to urinate
Interrupting your sleep to urinate
Waiting for urine to start flowing
Weak stream
Pain or burning during urination
Inability to completely empty the bladder

6. BPH Symptoms Obstructive Irritative Weak stream Hesitancy
Intermittency
Straining
Inability to completely empty
Irritative
Frequency
Urgency
Nocturia

7. Differential Voidings symptoms may be caused by: Bladder cancer/CIS
Prostate cancer
UTIs
Urethral stricture
Distal ureteral stones
Bladder stones

8. Initial Evaluation Detailed medical history Physical exam Urinalysis
including DRE and neurologic exam
Urinalysis
Serum creatinine no longer mandatory
PSA
Symptom assessment (AUA-SS, IPSS)

9. IPSS

10. Optional Evaluation International Prostate Symptom Score (IPSS)
Voiding diary
Bladder scan or cath PVR
Urine flow rate
Urodynamic study

11. How can it be treated? Watchful Waiting Drug Therapy Surgery
alpha blockers
5-alpha reductase inhibitors
Combination
Surgery
Radio Frequency
Microwave Therapy
Transurethral laser procedures
Vaporization
Enucleation
Transurethral resection (TURP)
Simple prostatectomy
Urethral lift

12. Medical Therapy Alpha adrenergic blockers 5-alpha reductase inhibitors
Combination therapy
Medical agents are less effective than surgery, but associated with fewer and less severe adverse events

13. Alpha adrenergic blockers
Alfuzosin 10mg
Silodosin 4,8mg
Tamsulosin 0.4,0.8mg
Doxazosin 2,4,8mg
Terazosin 1-10mg
Prazosin or phenoxybenzamine are not recommended

14. Clinical effectiveness (4-6 pt improvement) is equal at max dose
Differences only in side-effect profile
Side effects
Orthostatic hypotension/dizziness
Asthenia
Ejaculatory problems
Nasal congestion

15. 5-alpha reductase inhibitors
Finasteride
Dutasteride
Effective for symptoms (3-5 point change) in patients with prostatic enlargement
Decrease prostate size and increase flow rates
Reduce chance for acute urinary retention as well as surgical interventions

16. 5-alpha reductase inhibitors
Potential adverse effects
Decreased libido
Ejaculatory dysfunction
Erectile dysfunction
Gynecomastia

17. Combination therapy
Long term followup (at least 5 year) suggests combination therapy is more effective than monotherapy with either agent
MTOPS (Medical Therapy of Prostate Symptoms)
Reduction in
Progression
Reduction in Retention
Reduction in Surgery
Alpha blocker
39%
31% 0%
Reductase Inhib
34%
67%
64%
Combination
79%

18. Indications for Procedural Intervention
Failure of medical therapy
Recurrent UTIs
Bladder stones
Hematuria
Retention
Renal Impairment

19. Radiofrequency Ablation

20. TUNA

21. TUNA

22. Microwave Thermotherapy Prolieve TM
Dual-action thermodilatation technology that both heats & dilates the prostate leading to necrosis
45 minute treatment time

23. Laser Treatment of BPH Greenlight PVP TM (532nm) Protouch TM (1470nm)
Holmium (2100nm)
Thulium (2000nm)
Evolve TM (980nm)

24. Laser Procedure
Before we go into the details of the procedure, let me show you some short video clips of a GreenLight PVP Procedure.
Gland size for this video is 55 cc, treatment time was 25 min.

25. How Long with a Catheter?
Recovery room: 50%
Within 24 hours: 95%
Consider leaving in longer if:
very large gland
bladder function questionable

26. Post-Operative Care Antibiotic Non-steroidal anti-inflammatory (opt.)
Mild analgesic (opt.)
No strenuous activities or sex for 2 wks
Return to normal activities in 2 or 3 days

27. Pre-Laser Treatment
This is a pre-op picture.

28. Immediate Post-Laser Treatment
This picture, taken immediately post-PVP, shows the capsular fiber and the typical roughness of the tissue at the end of the procedure. It may not look as clean as a TURP but...

29. 3-Months Post-Laser Treatment
as you see here, 3 months post PVP, a smooth epithelial lining has formed. The small fibers that you saw immediately post-op were released the first days and weeks after the procedure.
The speaker may want to mention at this point that the sloughing of the thin coagulated tissue layer can cause some mild hematuria. A few drops of blood can be seen in the urine when the dead tissue sloughs off and the tissue underneath isn’t fully epithelialized yet.

30. Lateral Lobes Obstructing Bladder Neck pre-op
Here is a picture of a 41 cc gland pre-op. The patient had a Qmax of 8.1 milliliters per second.

31. 2-yr. Follow-up Mid Prostatic Fossa
This is the fossa 2 years after PVP.

32. Lasers - Conclusion Safety - relatively bloodless
Procedure time equal to TURP
No continuous bladder irrigation
Catheter free less than 24 hours
Outpatient
Patients can return to work within 2-3 days
Durability excellent (85% without recurrence of symptoms at 10 years)
Let me conclude by saying that the PVP procedure can be considered safe. It’s virtually bloodless and even patients on anti-coagulants can be treated.
The procedure is relatively fast with treatment times comparable to TURP. There is no need for continuous bladder irrigation and the patient is typically catheter free in less than 24 yours. PVP is an outpatient procedure which results in cost reductions. The patients can return to work within a couple of days. For the surgeon, it is a relatively short learning curve.

33. Monopolar TURP
Standard of care; effective, durable, low retreatment rates
Requires non-isotonic solution presenting risk for dilutional changes and fluid shifts
60 minutes resection
TURP syndrome – hyponatremia, AMS, seizures
Need for blood transfusion (5%)
Improvements in technology, technique, and monitoring have lessened complications

34. Bipolar TURP
Normal saline irrigation
TURP syndrome is rare

35. Open/Robotic Simple Prostatectomy
Very effective
Removal of entire adenoma
Leaves peripheral prostatic tissue (still at risk for prostate cancer)
Open
Significant risk for transfusion
2-3 day hospital stay
Robotic (transvesical/retropubic)
Select patients

36. Urethral Lift Advantages In-office procedure Preserves sexual function
No new and lasting problem with erections or ejaculation
Rapid, durable relief
Typically return to normal within 5-9 days
Typically no catheter
Disadvantages
Some discomfort, small amount of blood in urine, and increased urgency after procedure (as with any transurethral procedure)
Mayo Clinic:
Roehrborn Urology Clinics 2016
McVary et al. J Sex Med 2013
Shore et al. Can J Urology 2014

37. How the UroLift® System Works
The UroLift delivery device is placed through the urethra to access the enlarged prostate.
UroLift Implants are placed through a needle that comes out of the delivery device to lift the enlarged prostate tissue out of the way.
The UroLift delivery device is removed, leaving a more open urethra.

38. UroLift® Animation
New Animation Here
MAC Rev A

39. UroLift® Treatment Images
Before Treatment: Obstructed Channel
After Treatment: Open Channel
PRE
POST
Images courtesy of Dr. Peter Chin, Wollongong, NSW, Australia

40. Post-Treatment Expectations
Symptom improvement may start within 2 weeks, may continue to improve up to 3 months
Some irritation such as pain upon urinating, small amount of blood in urine, pelvic discomfort or urgency for some time after the procedure
Typically return to preoperative activity level within 5-9 days
Symptom relief lasts for 4 years or longer
4 years is the maximum length of published clinical follow-up thus far
Roehrborn Urology Clinics 2016
Chin et al. Urology 2012
Shore et al. Can J Urology 2014

41. Questions & Answers

42. References
Contemporary Diagnosis and Management of Benign Prostatic Hyperplasia. Claus Roehrborn, MD 2007
Contemporary Diagnosis and Management of Diseases of the Prostate. Issa/Marshall, MD 2004
Malek, R. Long term PVP follow up data (unpublished)