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Advanced laser treatment for Benign enlargement of prostate and Stones

The urinary system consists of the kidneys, ureters, bladder, and urethra. Function of the urinary system is to eliminate waste from the body, regulate blood volume as well as blood pressure, control levels of electrolytes, and regulate blood pH. The female and male urinary systems are very similar, differing only in the length of the urethra. In male near the bladder neck, urethra runs through a walnut like gland called “prostate’’.

As age increases, prostate increases in size and causes blockage in urinary passage, leading to symptoms like poor flow of urine, intermittent stream, frequent urinations, urgency, etc. Treatment options for benign prostatic enlargement are based on the severity of symptoms, how much the symptoms affect a man’s daily life, and a man’s preferences which include lifestyle changes, medications, minimally invasive procedures and open surgery.

There have been major advancements in treatment of benign enlargement of prostate (BEP/BPH). We now have very effective drugs and most patients with prostatic enlargement are now managed with medicines instead of surgery. Only those patients who do not respond well to medicines require surgery. Prostate surgery in the past was about taking out the prostate through a cut in lower abdomen. However, this was taken over by transurethral no-cut surgery (TURP) decades ago. Even though it was a no-cut surgery, some problems remained, like severe bleeding and inability to manage very large prostate glands.

With introduction of lasers in urological treatment, this deficiency of severe bleeding and inability to manage very large prostate is well taken care of. With Holmium laser enucleation of prostate, there is minimum bleeding, larger glands can be easily removed in one sitting, catheters can be removed faster and patient can be discharged early with early return to work. Holmium laser is now well accepted technique and very desirable in large gland.

Stones are usually formed in kidneys due to lack of hydration and deposition of salts. These may grow silently in the kidney until they block the kidney and cause severe pain. Most stones are small and pass out spontaneously or with help of some medicines. Stone size influences the rate of spontaneous stone passage. For example, up to 98% of small stones (less than 5 mm in diameter) may pass spontaneously. The stones which are larger (more than 5 mm) or those with a further complication like fever, infection, or renal failure more often require surgical removal.

The existence of kidney stones was first recorded thousands of years ago, and lithotomy (open stone surgery) for the removal of stones is one of the earliest known surgical procedures. Legendary Indian surgeon ‘’Sushruta’’ (600 BC) was one of the first surgeons to treat urinary stones. In 1901, a stone discovered in the pelvis of an ancient Egyptian mummy was dated 4,800 BC. Famous people who were kidney stone formers include Napoleon I, Epicurus, Napoleon III, Peter the Great, Louis XIV, George IV, Oliver Cromwell, etc.

Stones were removed by instruments and techniques that may seem barbaric now, but paved the way for development of open followed by percutaneous and now scar less stone surgeries. With time, miniaturization of endoscopes occurred and stones could be accessed by smaller cuts/holes in the body, thus called mini-PCNL, micro-PCNL, super mini-PCNL etc.

Another scar-less technique called extracorporeal shock wave lithotripsy (ESWL) was popular in past as a day care procedure. This technique was good for soft, small and favourably located calculi in the urinary collecting system. But in case of hard, large and multiple stones, this would usually require multiple sittings and thus leads to loss of time, loss of money and a poorer clearance rate.

Even before miniaturization of percutaneous access, scientists had discovered flexible ureteroscope, first use reported as early as 1964. This made access possible to the kidney through the outlet of urinary tract (urethra). However, there was no technology to break the stones through these flexible ureteroscope. This was made possible with advancements of lasers, especially Holmium Laser. The thin and flexible laser delivery fibres have made possible treatment in the most distal and earlier inaccessible parts of Kidney (Calyces) via flexible ureteroscopes. This technique, referred to as retrograde intrarenal surgery (RIRS), has replaced the earlier techniques of extracorporeal lithotripsy (ESWL) and is now preferred by most patients over the more invasive techniques like PCNL.

The main advantages of RIRS are that it is a no- cut, scar-less surgery, poses lesser risk of severe complications like bleeding, enable an early recovery, early discharge (24 hours) and faster return to work. The limitations of RIRS are that it cannot be used as primary modality for very large stones like Staghorn Stones. However, it serves as a very useful adjunct in treatment of these stones as well, as many patients require 2 stage surgeries for such stones and RIRS can be done as salvage procedure after the first percutaneous procedure. RIRS has also enabled no-cut access to kidneys which are not in normal position inside the body like ectopic kidneys, horseshoe kidneys, mal-rotated kidneys, post-transplant kidneys etc. In the western world RIRS is now the most commonly performed treatment of kidney stones followed by ESWL and then PCNL. In India, however percutaneous procedures still form the bulk of kidney stone treatment and only few centres are providing the facility of RIRS on regular basis. This is because of the costly instrumentation and advanced skill and training required RIRS. However, RIRS is becoming more and more popular as more urologists are learning the technique and more patients are demanding for same.

Advantages of MOSES Technology are:

1. 20% reduction in procedure time thus making treatments faster and more efficient
2. 60% reduction in retropulsion, thus minimising the incidents of ureteral stone migration into the kidney
3. 25% reduction in fragmentation time thus providing optimized energy transmission

MOSES Technology for Holmium laser has turned out to be the most versatile laser as it can be used not just for treatment of stones and prostate, but also for various other urological disorders like stricture urethra, ureteroceles, and bladder tumours.

Written by
Dr. Pragnesh Desai, MBBS, DNB, M.Ch (Urology) &
Dr. Anant Kumar, MBBS, MS, M.Ch (Urology), DNB (Urology)