Laser Sphincterotomy and Ablation of the Prostate Using a Sapphire Chisel Contact Tip Firing Neodymium:Yag Laser

Abstract

I report a modified technique for use of a contact laser for urological endoscopic surgery in spinal cord injury patients. Instead of the usual technique of passing the laser probe for surface vaporization, subsurface buttonholes were drilled with subsequent incision of the overlying tissue. As a result, creation of an adequate channel was expedited with excellent hemostasis. A total of 40 spinal cord injury patients (mean age 50.1 years, range 28 to 76) underwent transurethral surgery for bladder outlet obstruction using a sapphire contact laser tip. Of the patients 50% had undergone previous transurethral surgery and were not voiding well. Urodynamic studies demonstrated detrusor-sphincter dyssynergia in 37 patients (92.5%). Avoiding cystoure- throgram was done in 83% of the patients and showed vesicoureteral reflux in 17%. On cystoscopic examination 32.5% of the patients had an associated enlarged prostate, 32% stricture of the bulbous urethra and 20% bladder neck stenosis. Apart from transurethral sphincterotomy in these patients, ablation of the prostate, stricture and eradication of bladder neck stenosis, as indicated, were also done with the contact laser. Blood loss was approximately 25 to 50ml. per procedure except for 2 initial patients with a blood loss of 100 to 150ml. Approximately 3,500 to 8,900 joules accumulated energy were used for transurethral sphincterotomy and 11,000 to 37,000 joules for transurethral resection of the prostate. An indwelling Foley catheter was placed postoperatively for a mean of 3 days (range 1 to 8). All patients were followed for 6 to 23 months (mean 13.1). Four patients failed laser transurethral sphincterotomy: 1 due to inadequate initial incision and 3 who initially underwent laser transurethral incisions of the prostate and had persistent detrusor-sphincter dyssynergia (all had relief following laser transurethral sphincterotomy). All subsequent patients are voiding well with a wide open bladder neck and posterior urethra as shown on a voiding cystourethrogram.