The PVP Procedure
How well do patients tolerate PVP with local or minimal anesthesia?
Dr. Malek: I don't have experience with that, but I've seen it done. There doesn't seem to be any difference between local anesthesia and general anesthesia. Anyone who is going to have this procedure can have a local pudendal block supplemented by IV sedation, as developed by Dr. Hai. As far as I'm concerned, it's perfectly doable and very feasible.
Dr. Hai: I started doing the procedure using spinal anesthesia because that is the standard with TURP. I have done my last 35 or 40 outpatient cases under local anesthesia with a pudendal block and IV sedation. Most patients are amazed that there was no pain or discomfort.
Dr. Nseyo: We are not using local anesthesia. We usually give the patient a choice of anesthesia, either general or spinal. Most of my treatments are under 30 minutes for 50-g prostates, so the anesthesia time is short anyway.
What pre- and postoperative procedures do you normally follow for PVP?
Dr. Malek: The presurgical procedures are standard for any BPH procedure- flow rate, residual volume, cystoscopy, serum creatinine, CBC, and a preanesthetic evaluation. Patients also need a prostate exam, ultrasound of the prostate to measure volume and confirm absence of nodules or areas requiring biopsies, and a measure of PSA levels. We have to make sure that we are not dealing with any form of occult malignancy that's escaping our detection.
We give antibiotics intraoperatively and for a week or 10 days postoperatively, just to be on the safe side. I usually perform the procedure in the mornings and insert a catheter, which is removed the next morning. With the last 7 or 8 patients I've treated with the 80-watt laser, I could easily have taken the catheter out on the day of surgery since the urine was so clear and the patients were so comfortable. However, I don't want anyone to fail and be recatheterized, so I haven't done that yet.
I tell my patients not to do anything strenuous-lifting, pulling, pushing, intercourse, etc-postoperatively for about 4 to 6 weeks after surgery. They can, however, do routine, normal everyday activities, such as going to the office, 1 or 2 days after surgery.
Dr. Hai: A preoperative evaluation should be performed prior to PVP to rule out any significant coexisting disease that might simulate lower urinary tract symptoms. Patients should undergo a complete urodynamic and symptomatic evaluation in order to properly diagnose BPH. Prior to PVP, physicians may choose to prescribe preoperative antibiotics and should instruct patients to discontinue anticoagulant therapy 1 week before.
At the end of the procedure, patients should be assessed for indwelling catheterization. If a catheter is required, a 16 to 22 Fr Foley catheter with a 5 to 30 cc balloon is used. After adequate recovery, patients may go home the same day of treatment. I will prescribe an oral lower GI antibiotic for 3 to 5 days, a nonsteroidal anti-inflammatory agent for 2 to 3 days (unless contraindicated) and analgesics (if required).
I instruct patients to increase their fluid (water) intake and to avoid coffee, tea, carbonated drinks, alcoholic beverages, citrus juices, spicy foods, and smoking for 2 to 3 days, and strenuous exercise and heavy lifting (including bike riding) for 2 weeks. Patients are allowed to return to their normal activities, including employment and sexual intercourse, within 2 weeks after treatment. Unlike TURP, where patients must stay home for 4 to 8 weeks after surgery, patients having PVP can return to desk jobs within 2 to 3 days and to heavy, strenuous work in 1 to 2 weeks. I usually see patients for a postoperative follow-up visit 2 weeks after the procedure.
Dr. Nseyo: Preoperatively, we do a complete history and physical examination and assess the patient's voiding symptoms, determine the prostate size by ultrasound, and get a urinalysis to make sure there isn't an infection present. We also rule out cancer through PSA levels and digital rectal examination.
Prior to the procedure, we will routinely do a cystoscopy to assay the urethra, prostatic urethra, and bladder, and to determine where the orifices are and where each ureter is coming into the bladder. From here, we map out the procedure, usually starting at the median lobe, then progressing to the lateral aspect, and finishing at the anterior lobe.
Although there isn't much bleeding, we insert a Foley catheter and keep the patient overnight just for his comfort. The catheter is removed during the 24-hour follow-up exam the next day, and the patient goes home. I usually prescribe antibiotics to protect against infection. So far, we haven't had to give any pain medication, except for bladder spasm during the time the catheter is in place. We check the patients weekly by telephone and see them again 7 days after the surgery. A month later, we assay their urination and occasionally, at 3 months, examine the size of the prostate to give us some level of confidence as to how well we are doing.
As far as returning to work, I tell patients that they can go back after a week, but they can't drive for the immediate 72 hours, which is the norm for any type of surgery.
What is the incidence and duration of catheterization with PVP?
Dr. Malek: I catheterize my patients for less than 24 hours. I want experience with more patients before eliminating the overnight catheterization.
Dr. Hai: About 60% of patients are discharged with catheters. These patients include those who have been in chronic urinary retention, have decompensated bladders, or are at risk of bleeding. It is better for these patients to have catheters, and I have no qualms about leaving a catheter in if it's for the betterment of the patient and he will have fewer symptoms. The catheters are removed 8 to 24 hours postoperatively, so the patients don't mind having them. Those individuals who do not have a catheter must void before being discharged. We want to be certain that they are urinating normally.
Dr. Nseyo: It is my practice to catheterize all my PVP patients since most of them are older and come from long distances. I practice at a quaternary referral center in the VA system, so many patients come from out of town. I don't want to risk sending them home immediately and having complications; therefore, I keep them overnight with a catheter. This practice is not predicated by the treatment, but is my clinical judgment based on their distance from home.
What do you think explains the short duration of catheterization?
Dr. Malek: First of all, you immediately create a TURP-like cavity. Second, our animal studies revealed that the response to KTP-laser injury was far less than to any other form of injury induced on the prostate. When we used the YAG laser alone in the dog prostate, there was a tremendous amount of collagen formation in the prostatic fossa, whether we used low-power coagulation or high-power vaporization with YAG. When using the KTP laser at 60 watts to vaporize, there is practically no collagen. This is a huge difference. Instead of having a relatively rigid tube that's produced by TURP or YAG laser, the tube produced by KTP laser, which is probably just as large as that of TURP, is very pliable; it's very flexible, and it distends. This is why people can urinate as well as they do after PVP, with a 200% improvement in their flow rate.
Dr. Hai: There are 2 main reasons. The first is that we have excellent bleeding control because of the affinity of the KTP laser to hemoglobin, which seals off the blood vessels and results in no bleeding. The second is that there is no late sloughing of the tissue since the KTP laser does not damage deeper tissue. The depth of penetration and the removal of tissue is exactly where you vaporized the tissue. With other forms of laser, such as the YAG laser, there is a lot of tissue damage deeper to where you did the lasing. The tissue would therefore slough off and cause obstruction.
Dr. Nseyo: The laser does not coagulate tissue; it vaporizes it so that there isn't any tissue left behind to break off and cause bleeding later on. The high-power KTP laser also seals the blood vessels at the same time it vaporizes.
Are there any complications associated with PVP?
Dr. Malek: The ones we've had in 71 patients include nonurologic fever in 3% of patients (due to pneumonia and allergic reaction to sulfa), mild dysuria in 6%, delayed hematuria in 3%, epididymitis in 2%, and bladder neck contracture in 2%.
None of the patients experiencing dysuria ever complained. When they came for reevaluation at 3 months and I specifically asked them if they had any form of discomfort postoperatively, they said, "Yes, some burning for the first few days." Only one patient had burning for 2 weeks. None of them required medications or bothered to call me. This number is vastly lower than that reported for holmium:YAG laser.
The cases of delayed hematuria were a result of strenuous activity. One patient sat on a lawn mower and mowed the lawn within 2 or 3 weeks of the procedure, and the other ran for an hour on a treadmill.
Dr. Hai: The complications have been absolutely minimal. Mild dysuria may occur-the patient feels a slight burning/discomfort sensation. This is especially true in patients who have had a catheter. Discomfort is relieved by any anti-inflammatory agent. We have not seen any major bleeding. One patient had a bleeding problem because the procedure had to be done while he was on warfarin. We left the catheter in place for 2 days. We have not had any strictures, bladder neck contractures, delayed bleeding, or urinary retention.
Dr. Nseyo: I haven't really seen any complication yet, but I don't think I've done enough procedures to see any major problems.
What is the learning curve for PVP?
Dr. Malek: There are 2 prerequisites for learning PVP. The first is knowing how to do a TURP, and the second is being familiar with laser application. Probably 5 to 10 uncomplicated cases with smaller prostates of 20 to 40 cc are needed to get a good feel for how things look and how things develop before delving into larger prostates that would anatomically be more difficult to manage. PVP is not something a urologist can learn by looking at a tape; it requires some form of preceptorship.
Dr. Hai: The learning curve is very short because urologists are very conversant with using continuous flow cystoscopy, endoscopic procedures, and most have performed TURPs. It's basically the PVP technique that they need to learn. I would say that a physician who is actively practicing urology and does 2 or 3 procedures under a preceptorship, watches the procedure being performed, or attends a training session, should be able to do it on his own. It is important that the instructor is very familiar with the technique. In my clinic, we have physicians from all over the country coming to learn the procedure. After seeing me do it, they feel comfortable doing it on their own. I do suggest that they start with a smaller gland initially, about 30 to 35 g, and as they gain experience, they can move on to larger glands.
Dr. Nseyo: I think the learning curve is very short. It is nothing compared with the holmium:YAG laser prostatectomy, which is very steep. I did my preceptorship with Dr. Hai. After coming back and talking to him on the phone, I was able to get started. I've trained my residents and they were all able to do the procedure. Urologists will come to realize that PVP is easier to learn than TURP.