BPH/Enlarged Prostate
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Green Light Photovaporization
of the Prostate (PVP)
The Green Light™ laser procedure is an effective, and safe procedure that is often recommended for men who are having symptoms of obstructive prostatism. These symptoms may include a slow stream, hesitancy, as well as a feeling of incomplete emptying. They are also often accompanied by urgency, frequency and nocturia (getting up at night to void).
In the past, the most common procedure recommended for this constellation of symptoms has been the TransUretheral Resection of the Prostate (TURP). Typically, this procedure is done in the hospital, under general or spinal anesthesia. The surgeon will use an instrument which when inserted into the penis allows for the removal of the obstructing portion of the prostate. After the procedure, the tissue is sent to the pathologist for examination. A catheter (a tube) is passed into the bladder and is left in place for 48 hours (occasionally longer). The TURP has been in use in one form or another for over 30 years. The results have proven durable, and it remains the "gold standard" to which all of our surgeries done for benign prostatic hyperplasia (BPH) must be compared for efficacy.
The Green Light™ laser is one of the newer procedures that are challenging the TURP in terms of its efficacy in treating the symptoms of BPH. Like the TURP, this procedure is done in the hospital, under either general, or a regional anesthetic. It is also performed utilizing instruments inserted into the penis.
The procedure will usually last for about 1 hour, during which the laser fiber will be used to vaporize the obstructing portion of the prostate, with the end result being a larger channel through which you will pass your urine. Unlike the TURP, this procedure does not provide us with the opportunity to examine tissue for the presence of prostate cancer. It is imperative, that for most men, we determine the PSA level during the course of the preoperative work up. We will then decide if a separate biopsy procedure is necessary. In the case where a biopsy is indicated, and prostate cancer is found, the PVP may not be the procedure of choice, and further discussions will be held to determine the best course of action.
Currently, we are performing the PVP procedure at The George Washington University Hospital. While the manufacturer's website notes that many patients are discharged from the hospital on the same day, catheter free, it has been our experience that 24 hours with the catheter in place saves a large number of patients from having to return to the hospital for a catheter during the post operative period. We will at times use the short stay unit (SSU) and keep patients over night, removing the catheter the next day prior to discharge. When the patient is allowed to go home on the day of the procedure, he will be taught how to remove the catheter on his own, the next morning. Alternate arrangements can be made for those individuals who do not stay overnight, and who are unable, or unwilling to remove the catheter on their own.
While the TURP and the PVP both result in removing a significant amount of the prostate, the PVP has some advantages as well as a few disadvantages when compared to the TURP. The advantages include decreased bleeding, shorter (or no) hospital stay, shorter period of catheterization, less chance of retrograde ejaculation, and a quicker return to work and full activity. The TURP does offer the advantage of having a tissue diagnosis, and a shorter period of time during which the patient has urgency, frequency, and some burning on urination. While the potential exists for either procedure to result in urinary incontinence, this remains highly unlikely, as does impotence occurring as a result of the surgeries.
Once you have decided that you wish to have the PVP, you will be asked to obtain preoperative clearance from your primary care physician. You will be scheduled for the procedure, and given instructions which will include the time at which you are to arrive at the hospital, have nothing to drink or eat beyond midnight the night before surgery, and to discontinue the use of aspirin, nonsteroidal anti inflammatory medications (Advil™, or Aleve™ egg.), as well as anticoagulants (in most cases). Taking a laxative the day before, or using a Fleets enema will prevent the urgent need to move your bowels during the postoperative period, and help to decrease the risk of bleeding, during this period of time.
Once the catheter is removed, you should be able to void. During the first few days after surgery, and rarely, extending for a period of months you may experience burning on urination, and the need to urinate more frequently, as well as urgently. There is an occasional individual who will have urge incontinence, which will result in some transient leakage prior to being able to get to the bathroom. If this happens to you, regularly, you should advise your physician, who may opt for medication to help quell these symptoms. Nocturia, (urinating at night) is the last, and least constant of the symptoms to resolve. Be patient, and withhold fluids within 3 hours of going to bed, as this may help the problem.
We advise our patients to take it easy for about 2 weeks post operatively. This means no lifting of objects over 25 pounds, as well as no straining. A stool softener is suggested, such as Colace ™ or other over the counter preparations. During the post-operative period of time, you may pass pink, or even red urine. Passing small clots is not unusual, as is passing what looks like white tissue, or mucous shreds.
The area that is vaporized during this procedure generally takes about 3 months to heal completely. During this period of time, if a urine specimen is checked it will show the presence of both white and red blood cells. This is often confused with the presence of an infection. In this case, however, it is less likely infection, and more likely an indication that the area has not yet healed.
Even after the initial 2 weeks the symptoms of burning, urgency and frequency can be bothersome. Patience is required, and will usually be rewarded with the desired result. In the few cases where retrograde ejaculation occurs (30-40%) one must understand that this is not harmful. It is not likely to reverse itself, and is a well-known side effect of this procedure and the TURP (85%).
This document has been prepared to inform you of the many issues that have arisen in our patient population. We believe that our experience with the PVP is much the same as that of others doing this procedure, across the country. Please feel free to ask your doctor to elaborate on any issues you may have questions.