GreenLight PVP treatment for BPH (PVP)

Overview

The GreenLight PVP Laser System uses a green light laser to vapourise the prostate. A thin fibre is inserted into the urethra through a cystoscope, which is an instrument that allows the doctor to examine the bladder and prostate. A wide-open channel is created in the prostate allowing urine to flow much better than before. There is minimal if any bleeding and patients can either go home the same or next day.

For more information read below. It is also possible to download information about this:

National Institute for Clinical Excellence advice to patients regarding the GreenLight PVP system

LaserScope information to patients about the GreenLight PVP system

LaserScope Information to patients giving advice before and post procedure

Why have a laser prostatectomy?

The reasons are the same as for a TURP, which are:

• Urinary symptoms due to an enlarged prostate (BPH) that are bothersome and are not adequately improved by medicines, changing one's lifestyle

• Urinary symptoms due to BPH that are bothersome and cannot be treated by drugs or other minimally invasive techniques

• Urinary symptoms due to BPH proven to be due to bladder outlet obstruction on urodynamics with a desire to remove obstruction in order to avoid long term problems of bladder outlet obstruction

• The inability to pass urine without a catheter ('urinary retention')

• Kidneys that are not functioning properly because the prostate is blocking the bladder

• Recurrent urine infections due to obstruction caused by the prostate

• Bleeding from the prostate due its enlargement (BPH), which may not have improved with a 5-alpha reductase inhibitor like finasteride or dutasteride

• Prostate cancer ('channel TURP'): this is to allow urine to flow and is not intended to be curative

In addition, the treatment can be performed in patients who have abnormal clotting or are on drug thinners (e.g. aspirin, warfarin etc) in certain cases.

What are the advantages of a laser prostatectomy?

Urinary symptoms are reduced as much as for traditional surgery and significantly more than with the use of medication. In addition, there is shorter stay in hospital, shorter period or no catheterisation and less blood loss. There is much less bleeding, which is why the procedure can be performed on men taking aspirin.

The instrumentation for a laser prostatectomy is smaller than that used for a TURP, so, in theory, there should be a reduced chance of a urethral stricture.

Saline is used during the procedure to irrigate the area, and this is safer than the irrigation used to a TURP that can cause a rare but dangerous problem known as TUR syndrome.

How well does a laser prostatectomy work?

The GreenLight PVP works as well as TURP for small or moderate sized prostates. Providing men have bladder outlet obstruction, 9 in 10 men should experience a significant improvement in urinary symptoms after laser prostatectomy. Patients who had a catheter in should be able to pass urine with little problem.

What are the disadvantages of a laser prostatectomy?

The procedure takes slightly longer to perform than a standard TURP and is not so effective on very large glands.

As the prostate is vapourised, no tissue is available for analysis to determine if prostate cancer is present. After a TURP, there is prostatic tissue available that can be used for histological analysis.

Discomfort or pain on passing urine is more common after a laser prostatectomy than after a TURP. This may last a week or sometimes go on for several months. This is sometimes accompanied by needing to visit the toilet more often and urgently during the day and the night.

Sometimes, slough, which is dead prostatic tissue, may be passed after the laser prostatectomy. This may temporarily interrupt the flow of urine; TURP can also be affected by blood clots that has similar problems.

Complications can occur although these are rare and can follow inappropriate firing of the laser into the bladder and damaging the tissue in that area.

What are the alternatives to GreenLight PVP laser prostatectomy?

There are several procedures of which the most common are listed below.

• Transurethral Needle Ablation (TUNA) of the prostate: this is a less invasive procedure than laser prostatectomy, can be performed in day surgery or as an outpatient, with fewer problems and maintains normal ejaculation. Symptoms are improved after TUNA, but not quite as much as after laser prostatectomy.

• TURP: This is the gold standard treatment for BPH by which other treatments are judged. Compared to laser prostatectomy, There is more blood loss and a greater chance of needing a blood transfusion, a longer hospital stay and more post operative complication. There is less discomfort felt in the bladder and penis after this compared to laser prostatectomy and usually there is no slough to pass.

• Open prostatectomy: For this, an incision is made in the lower abdomen under general anaesthetic or when the skin is made numb from the waist down, and the prostate removed. Urinary symptoms are improved possibly slightly better than laser prostatectomy. A prolonged hospital stay is required and bleeding can occur sometimes requiring a blood transfusion. This option is reserved for very large prostates that are usually too large to be treated by one of the other options.

• Prostate stent: This is usually reserved for patients who are unsuitable for any other form of therapy. It is performed in day surgery, involves local anaesthesia, but is less effective than the other options.

• Transurethral Microwave Thermotherapy (TUMT): this is another minimally invasive option that works well in selected patients but still results in retrograde ejaculation.

Are any special tests required before laser prostatectomy?

To make sure that a man has the appropriate prostate that can be treated well by laser prostatectomy, the following tests or investigations are sometimes necessary in addition to those necessary to evaluate symptoms:

• Ultrasound scan of the prostate: an ultrasound probe is through the anus to scan the prostate. It may be uncomfortable, but no needles are used and it is not painful. This gives the size of the prostate which determines if the prostate is not too large for laser prostatectomy.

• T elescope examination of the bladder (flexible cystoscopy): this is to evaluate the shape of the prostate and rule out other potential reasons that may cause urinary symptoms or prevent treatment by laser prostatectomy.

In some men, biopsies from the prostate may need to be taken to exclude prostate cancer. If prostate cancer is found, then alternative treatments may be necessary.

What do I need to do before a laser prostatectomy?

You should take your normal medication as before the procedure. Ask your doctor if you should stop aspirin 7 days before the operation. In addition, you may need to stop warfarin, so be sure to check what needs to be done. You may need a blood test before surgery to determine if all is well. In some cases, you may be allowed to continue with warfarin.

If you have symptoms that might indicate a urine infection, antibiotics may need to be given to make it safe to have the procedure. Symptoms such as pain passing urine, increased visits to the toilet, bladder discomfort, offensive smelling urine or feeling unwell may indicate a urine infection. The urine should be checked by a health professional.

No food should be eaten 6 hours and no fluid drunk 4 hours before the planned time of laser prostatectomy.

Patients have not reported any pain during the procedure. You and your doctor will discuss appropriate sedation.

Most patients can go home a few hours after the procedure. Sometimes, you may need to spend the night in hospital and go home the following morning. This is more likely if your procedure is done late in the day, or if you travelled a long distance to reach the hospital.

What happens during a laser prostatectomy?

Under general anaesthesia (i.e. asleep) or spinal anaesthesia (i.e. numb from the waist down), a telescope examination is made of the prostate and bladder using a camera mounted on the end of a tube passed through the water pipe (urethra). The laser is introduced and the prostate vapourised.

A catheter is placed in the urethra and then the patient returns to the ward.

What happens immediately after a laser prostatectomy?

You will return back to the ward. A catheter will be in place draining the bladder. This may have a slightly red colour. Usually, this will stay in either 6 hours or overnight. There may be a little discomfort, but it is unusual to have pain. Drinking plenty of fluids (8 cups a day or 3 litres/day) will ensure a good flow of urine. The catheter may cause you to have bladder spasms or to feel the need to urinate. These symptoms can be improved by medication if necessary.

You will be given antibiotics while you are in the hospital to prevent infection and a drug to reduce inflammation (e.g. diclofenac). These will probably continue for 1 week after the procedure. You should be able to get out of bed and a walk around soon after returning from the operating theatre.

The catheter is held in place by a balloon inflated with water. When the balloon is deflated, the catheter slips out. You may feel pain when you urinate because the prostatic urethra will still be healing. After removal of the catheter, the desire to pass water may be very urgent and it may sting. This improves gradually, but may take as long as a few months. If you have difficulties, it may be helpful for you to try to hold on for 10 minutes each time you wish to pass water. Medication can also help. Another exercise is to stop passing urine in midstream and count to three. This helps improve your control. Do not worry if you experience some dribbling of urine at this stage. Providing your bladder is emptying completely, you will be able to go home. Sometimes, an ultrasound scan of the bladder will be performed to check the bladder is empty.

What is life like after laser prostatectomy?

Many patients obtain immediate relief of symptoms and dramatic improvement in your urine flow usually within 24 hours of the procedure. In some patients, it may take up to 8 weeks for the urinary flow to improve and there may actually be a deterioration in the flow with increased need to visit the toilet during the day and night. This occurs because some prostate ('slough' i.e. lasered prostate) may need to be passed in the urine before the flow can be improved.

You will probably be taking an antibiotic, anti-inflammatory and possibly a drug to calm the bladder for the first week or so.

Contact your doctor if

• your urine is so red that it is difficult to see through it

• if it contains clots or bits of tissue (slough) if you feel significant or increasing discomfort

In general, you should:

• Continue drinking a lot of water to flush the bladder.

• Avoid straining when moving your bowel.

• Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.

• Avoid caffeine and alcohol

• Don't do any heavy lifting for 2 weeks

• Don't drive or operate machinery until you feel ready and for at least 1 to 2 weeks

By six to eight weeks after the operation, urination should be easier and less frequent, although you may have to get up at night to urinate. Months may go by before you feel completely normal. Generally, the longer you had the problem before you were treated, the longer your recovery time will be.

How long is the recovery time? How soon can I return to normal activities?

Most patients can resume normal activities within the week. This would include a desk job and driving a car, which you should be able to resume within a couple of days. You will have to avoid more strenuous activities, as well as lifting more than 30 pounds or riding a lawnmower for example, for about 2 weeks following the GreenLight PVP Laser procedure.

Will I still be able to have sex following the PVP procedure?

The GreenLight PVP Procedure should not affect your ability to have an erection or an orgasm. Some men have reported retrograde ejaculation, or “dry climax” following the procedure. If you are sexually active now, you can look forward to remaining sexually active.

Can I have PVP if I have failed TUNA or TUMT?

Yes, many patients who have failed these treatments have been successfully treated with PVP.

Can I have PVP if I had a TURP?

Yes, absolutely

My doctor has told me that I am not a candidate for TUNA, TUMT, ILC, or WIT…and has recommended that I have a TURP? Can I still have the PVP procedure?

As a rule, if you are a suitable candidate for TURP, you can be considered a good candidate for PVP. Prostate size or length does not generally rule you out as being a good candidate for PVP; however, your doctor will need to make that determination, based upon your individual condition.

Will I still need to take my prostate medication following the PVP procedure?

No. Your doctor will tell you when you can stop taking these medications.

How do I know if I am a candidate for PVP?

Only your urologist can determine if you are a candidate, based upon your history & physical examination, as well as his clinical judgement.

How long can I expect the effects of the procedure to last?

Clinical studies show that the procedure is very long lasting. Very few patients require re-treatment. We do not know how long you can expect improvement until more data is gathered from clinical studies.