Cullen Jumper: Dartmouth Hitchcock Medical Center, Urology 5B, 1 Medical Center Drive, Lebanon, NH 03756, USA. e-mail: firstname.lastname@example.org
Study Type – Therapy (case series)
Level of Evidence 4
What's known on the subject? and What does the study add?
Laser prostatectomy is a commonly performed procedure for BOO, and has been shown to have short- and medium-term results equivalent to the gold standard procedure (i.e. TURP) in various studies. It also has an advantage over TURP in that it can be performed on patients who are taking anticoagulant medication. However, patients in most studies are admitted to the hospital overnight on continuous bladder irrigation and are discharged home the next day.
The present study shows that it is safe and feasible to perform laser prostatectomy in an ambulatory fashion with discharge of patients within hours of their surgery. The discharge pathway is associated with minimal morbidity or the need for admission after surgery, and the reported short-term results are in accordance with the available literature on laser prostatectomy.
• To investigate the feasibility and safety of a rapid ambulatory discharge pathway after holmium laser ablation of the prostate (HoLAP) for the treatment of benign prostatic hyperplasia.
PATIENTS AND METHODS
• The study group comprised a cohort of 65 consecutive patients undergoing HoLAP scheduled as a day surgical case by a single surgeon between January 2007 and December 2009.
• Patients were discharged from day surgery with a catheter in place, and returned for a voiding trial on postoperative day 3.
• Preoperative, intra-operative and postoperative parameters were reviewed with follow-up data for the 90-day global postoperative period.
• Statistical analysis employed Student's t-test with P < 0.05 (two-tailed) being considered statistically significant.
• The mean (range) patient age was 64 (41–87) years; mean (range) American Society of Anesthesiologists score was 2.2 (1–4); mean (sd) operation duration was 44 (17) min; and mean (sd) time after surgery until discharge was 149 (51) min.
• Postoperative complications included catheter occlusion (1.5%) and admission for haematuria (1.5%).
• There were no re-admissions after discharge from the hospital.
• Within the 90-day global period, 13 patients described lower urinary tract symptoms (20%), five patients had postoperative urinary retention (7.7%) and one patient had a urinary tract infection (1.5%).
• After surgery, mean American Urological Association Symptom Score decreased from 21.3 to 7.6 (P < 0.001); mean quality of life score decreased from 4.04 to 1.38 (P < 0.001); and mean post-void residual decreased from 190.2 to 46.4 mL (P < 0.001).
• In appropriately selected patients, HoLAP can be safely performed as an ambulatory case with a rapid discharge pathway and minimal morbidity during the 90-day global period.
The prevalence of BPH in the general population of men increases steadily with increasing age, peaking at an estimated 88% of men in the ninth decade of life. Although not all men with histological evidence of BPH are symptomatic, the percentage of men with moderate or severe LUTS also rises as with increased age, and reaches over 50% in men in the seventh decade of life . The economic burden of BPH on the private sector alone in the USA, accounting for direct and indirect costs, has been estimated at $3.9 billion yearly as of 2005 . With the ageing population of men in the USA, the costs associated with BPH can be expected to rise in the future.
To individual men, BPH can have a significant negative impact on quality of life. Population-based studies such as the Olmstead County study have shown that worsening urinary function and rising AUA symptom index scores correlate with a decreasing quality of life . Moreover, BPH can lead ultimately to more serious adverse outcomes such as urinary retention, bladder stones and renal failure.
TURP is recognized as the gold-standard of surgical treatment for BPH. However, there are problems inherent with this traditional surgery. Patients treated with TURP are generally hospitalized at least overnight, with common complications including bleeding and a prolonged need for continuous bladder irrigation. Transurethral resection (TUR) syndrome as a result of the use of glycine during the procedure is a rare but much more serious complication. The incidence of mild to moderate TUR syndrome has been estimated at 0.5–8%, with a mortality rate of 0.2–0.8%; however, the mortality rate of severe TUR syndrome may be as high as 25% .
In recent years, laser prostatectomy procedures have been increasingly used as minimally invasive alternatives to traditional TURP. Holmium laser ablation of the prostate (HoLAP) has been shown to have equivalent results with respect to TURP in a few randomized prospective trials with long-term follow-up [5–7]. The procedure has a decreased risk of bleeding as a result of the sealing action of the laser. Because an isotonic saline is used for a HoLAP, there is no risk for TUR syndrome. The holmium laser is also familiar to most urologists, who commonly use it in their practices. A frequently cited advantage of laser ablative procedures is that they can be performed as an outpatient surgery. Same-day discharge rates, when defined as discharge within 23 h, have been reported to be as high as 86% . However, there is a lack of published data regarding HoLAP performed in an ambulatory fashion. The present study reports the results of 65 consecutive HoLAP procedures performed as part of a rapid ambulatory discharge pathway.
PATIENTS AND METHODS
Institutional Review Board approval was obtained from the Human Investigation Committee at Concord Hospital for the present retrospective study. Between January 2007 and December 2009, 65 consecutive patients underwent HoLAP scheduled as a day surgical case by a single surgeon (R.L.Y.). Charts were reviewed for data on postoperative admission rate, complications and morbidity during the 90-day global period. Preoperative, intra-operative and postoperative parameters were also reviewed.
Preoperative evaluation comprised a complete medical history and physical examination, including DRE, urinalysis, ultrasonographic post-void residual urine volume (PVR), PSA level and an AUA symptom score. Patients with prostate nodules or a higher PSA level had negative prostate biopsies before HoLAP. Patients with prostate cancer were excluded from the present study.
For the HoLAP, a 100-W Lumenis® holmium laser (Lumenis, Yokneam, Israel) was used with a 550-micron side firing laser fibre. Laser settings were 2.0 J, with a rate of 40–50 Hz. After laser ablating all obstructive adenoma, a urethral catheter was placed and the bladder was hand-irrigated. After the surgeon deemed the catheter drainage acceptable, the case was terminated with the catheter on straight drainage.
Patients were discharged from same-day surgery if they met discharge criteria with the urethral catheter on a leg bag. Discharge criteria included adequate pain control with oral pain medication, urine that was no darker than light pink and the ability to tolerate a regular diet. A voiding trial was performed on postoperative day 3. Follow-up data at 1 and 3 months were reviewed, including AUA symptom scores, PVR and complications. Statistical analysis was performed using Student's t-test. P < 0.05 (two-tailed) was considered statistically significant.
As shown in Table 1, the mean (range) patient age was 64 (41–87) years. The mean (range) American Society of Anesthesiologists score was 2.2 (1–4). Intra-operative and perioperative data are shown in Table 2. Mean (sd) operation duration was 44 (17) min. Mean (sd) total energy delivered was 119.18 (51.85) kJ. There were no intra-operative complications. Mean (sd) time after surgery until discharge from the hospital was 149 (51) min.
Table 1. Preoperative characteristics (n= 65)
ASA, American Society of Anesthesiologists; PVR, post-void residual urine volume; QoL, quality of life.
PSA level (ng/mL)
Prostate weight (g)
Percentage on BPH medication (%)
Table 2. Operative data
Operation duration (min)
Total energy (kJ)
Ambulatory stay (min)
Admission rate (%)
In total, one (1.5%) patient was admitted after surgery for haematuria and was discharged the next day. There was one (1.5%) patient who returned to the emergency room for urethral catheter occlusion and was discharged from the emergency room. Both were graded as Clavien class I complications. There were no re-admissions after discharge from the hospital. No patients required blood transfusion, and there were no cases of TUR syndrome.
To date, patients have been followed up at 1- and 3-month intervals after surgery. Within the 90-day global postoperative period, 13 (20%) patients described irritative LUTS, five (7.7%) patients had postoperative urinary retention and one (1.5%) patient had a UTI (Table 3). Mean (sd) AUA symptom score showed a statistically significant improvement from 21.3 (6.9) before surgery to 11.3 (6.6) and 7.6 (5.7) at 1 and 3 months after surgery (P < 0.001). Mean quality of life score improved significantly from 4.04 (1.06) before surgery to 1.96 (1.6) at 1 month (P < 0.001) and 1.38 (1.4) at 3 months (P < 0.001) after surgery. Mean preoperative PVR decreased significantly from 190 (270) mL to 55 (80) mL and 46 (54) mL at 1 and 3 months after surgery (P < 0.001).1
Table 3. Postoperative complications
Emergency room visit
The results obtained in the present study show that HoLAP can be performed safely as a planned ambulatory surgery with a rapid discharge pathway. The mean (range) time from the termination of the procedure to when the patient left the hospital was 149 (55–265) min. Only one patient required postoperative admission for haematuria, which represents a postoperative admission rate of 1.5%. Additionally, one patient returned to the emergency room for catheter occlusion and was discharged home from the emergency room, for a return to emergency room rate of 1.5%. This shows that patients may be discharged after a brief stay in the recovery room with a minimal risk of the need for admission or subsequent return to the hospital after discharge. This pathway is in stark contrast to TURP, where patients are admitted overnight for continuous bladder irrigation. There is little information in the available literature concerning the safety and feasibility of such ambulatory discharge pathways for the surgical treatment of BPH. As more procedures are being carried out in ambulatory surgical centres, it becomes increasingly important to establish the safety of performing these procedures in an ambulatory setting.
A major potential benefit to discharging patients on the day of surgery is the decrease in hospital charges associated with an overnight admission. For example, the cost of photoselective vaporization with the Greenlight HPS™ (American Medical System Incorporation, Minnetonka, MN, USA) has recently been compared with the cost of TURP, and it was found that photoselective vaporization costs less (mean [sd], $4266 [$1182] for photoselective vaporization vs $5097 [$5003] for TURP), probably as a result of the decreased costs associated with the outpatient vaporization procedure . A recent cost–utility analysis of various surgical treatment modalities for BPH also concluded that initial holmium laser ablation was more cost-effective than traditional TURP . In addition to improved cost-effectiveness, an ambulatory surgery has the benefits of minimizing patient exposure to the hospital environment and the attendant risk of hospital-acquired infections, as well as potentially increased patient comfort when recovering from surgery at home as opposed to in the hospital.
The holmium laser allows for an ambulatory discharge pathway mainly by virtue of its sealing property, which minimizes postoperative bleeding and thus obviates the need for bladder irrigation. In addition, the haemostatic effect of the laser allows most patients to avoid the need for a blood transfusion. In the present study, no patients required blood transfusion. Furthermore, the rare but potentially lethal complication of TUR syndrome is avoided by the use of saline as the intra-operative bladder irrigant. In addition to the holmium laser, other laser systems, such as the GreenLight™ system, have been shown to have similar hemostatic effects that minimize postoperative bleeding and avoid the need for continuous bladder irrigation after surgery. The main drawback to systems designed specifically for tissue ablative procedures is that they require the purchase or use of a separate system dedicated to those procedures. HoLAP utilizes a laser system with which most urologists have experience and to which most urologists already have ready access for the treatment of urolithiasis.
In conclusion, the results obtained during the global postoperative period reported in the present study show that laser prostatectomy with a rapid ambulatory discharge pathway is safe. These short-term postoperative results are similar those reported in previous studies on laser procedures [11,12] performed for BPH. Longer-term data collection is ongoing and will be used to assess the durability of this procedure.
The authors acknowledge support from the LeBaron Foundation and the Concord Hospital Trust.