Holmium Laser Ablation of the Prostate (HoLAP) Versus KTP Laser Vaporization of the Prostate
Holmium Laser Ablation of the Prostate (HoLAP) Versus KTP Laser Vaporization of the Prostate
Many options currently exist to relieve the symptoms caused by benign prostatic hyperplasia
 (BPH). At present, transurethral resection of the prostate (TURP) serves as the surgical
 standard to which all other operative treatments are compared. Although TURP provides
 excellent short and long-term results, this procedure has many potential risks and
 complications. The desire to avoid the potential risks of TURP and still achieve results of
 comparable durability has led to the development of alternative surgical procedures.

 One such surgical alternative in the treatment of BPH is holmium laser ablation of the
 prostate (HoLAP). HoLAP has been compared to TURP in a randomized clinical trial with
 comparable outcomes in both uroflow rate and symptom score improvements (Mottet, et al 1999).
 Use of the holmium laser in treating BPH provides specific advantages over TURP. The risk of
 dilutional hyponatremia is eliminated, as the holmium laser can be used in conjunction with a
 normal saline irrigant. In addition, the hemostatic properties of the holmium laser results
 in superior hemostasis, thus minimizing the risk of bleeding. HoLAP has been utilized for
 prostate glands up to 60 grams in volume, as larger glands become more inefficient to treat
 using a tissue vaporization technique.

 Recently, another laser technology has been introduced for the surgical treatment of BPH, the
 potassium titanyl-phosphate (KTP) laser. This modality can also be used to vaporize
 obstructive prostate tissue, and has been studied through single arm clinical studies.
 Short-term results are promising, with significant improvements in voiding symptoms and urine
 flow rates as well as minimal associated morbidity. However, to date a randomized comparison
 study between HoLAP and KTP laser vaporization of the prostate has not been reported. A group
 of investigators with extensive experience with both procedures intends to objectively
 compare these two procedures in a randomized clinical trial.
The traditional surgical therapy for BPH is a transurethral resection of the prostate
 (McConnell et al, 1994). This surgery involves the insertion of a telescope (resectoscope)
 transurethrally into the prostate and bladder. An electrocautery loop attached to the
 resectoscope is then used to core out the inside of the prostate until the surgical capsule
 of the prostate is reached. A large catheter is left in the bladder for at least 1 day and
 saline irrigation of the bladder is often required for post-operative bleeding. Once the
 urine is clear, the catheter is removed and the patient undergoes a voiding trial. If voiding
 is successful, the patient is discharged home.

 TURP produces excellent short and long-term results and remains a standard of care for the
 surgical treatment of BPH. Unfortunately, this durable procedure has many potential risks and
 complications including bleeding requiring blood transfusion (~5%), intraoperative
 complications (e.g. prostate capsule perforation), urethral and bladder injury, dilutional
 hyponatremia and the TUR syndrome, urinary tract infection (~5-10%), incontinence (~1%),
 erectile dysfunction (~5%), bladder neck contracture or urethral stricture (~5%), and delayed
 bleeding resulting in clot retention or secondary procedures to control bleeding. (American
 Urological Association [AUA] Guideline on Management of Benign Hyperplasia (2003). Chapter 1:
 Diagnosis and Treatment Recommendations Journal of Urology, 170: 530, 2003.)

 One alternative to TURP that has been shown in a randomized clinical trial to reproduce the
 excellent results of TURP has been holmium laser ablation of the prostate (HoLAP) (Mottet et
 al, 1999). HoLAP is a simple procedure to perform in smaller prostate glands (ideally < 60
 gm) and recently reported results suggest that this procedure produces good results that are
 durable up to 7 years (Gilling et al, 2002).

 A new technology for use during prostate ablation is the high power potassium
 titanyl-phosphate (KTP) laser (Malek et al, 2000). This surgical procedure involves the use
 of the Laserscope™ KTP laser (San Jose, CA) to vaporize obstructing prostatic tissue in a
 technique similar to HoLAP. Most investigators have reported no significant complications
 with this new technology and in most cases, significant improvements in American Urological
 Association symptom scores and urine flow rates have been documented (Malek et al, 2000).
 Unfortunately, no randomized comparison study between HoLAP and KTP laser prostatectomy has
 been performed.
Inclusion Criteria:

 -  Ability to give informed consent

 -  Lower urinary tract symptoms (LUTS) felt to be secondary to bladder outlet obstruction
 from benign prostatic hyperplasia

 -  Maximum urinary flow rate < 15 ml/sec, voided volume ≥ 125 cc

 -  American Urological Association symptom score ≥ 9

 -  Transrectal ultrasound determined prostate volume ≤ 60 cc

 Exclusion Criteria:

 -  Inability to give informed consent

 -  Maximum urinary flow rate ≥ 15 ml/sec

 -  Transrectal ultrasound determined prostate volume > 60cc

 -  AUA symptom score < 9

 -  Active urinary tract infection

 -  Bleeding diathesis

 -  Neurological disease that is felt to affect the bladder or a history of a neurogenic
 or chronically decompensated bladder

 -  Known prostate cancer

 -  Active bladder cancer (within the last 2 years)

 -  Prostate specific antigen (PSA) > 4.0 unless previous negative biopsy

 -  Urinary retention

 -  Post-void residual (PVR) > 300 cc