Photovaporization Benefits Elderly With Prostate Hyperplasia

Kate Johnson

March 18, 2016

MUNICH — Laser photovaporization is safe and effective for older men with benign prostatic hyperplasia and lower urinary tract symptoms, according to two new studies.

The findings, presented here at European Association of Urology 2016 Congress, provide reassurance to urologists who are increasingly offering this option to their octogenarian patients.

"Such patients are generally more likely to have comorbid conditions and to require chronic anticoagulation, which places them at high risk for complications," said Ganesh Sivarajan, MD, from the NYU Langone Medical Center in New York City, who was not involved in either study.

"Our experience has been very similar to these studies," he told Medscape Medical News. "We often recommend photovaporization as the best option for these patients."

The first study involved a prospective series of 369 patients with benign prostatic hyperplasia who were treated at the Centre Hospitalier Régional Universitaire de Tours in France from December 2005 to February 2014.

The mean age of the 147 men in the study cohort who were 80 years and older was 84.7 years; the mean age of the 222 men younger than 80 years was 68.8 years.

At baseline, American Society of Anesthesiologist scores were significantly higher in the older men than in the younger men (2.6 vs 1.8; P < .001), and the older men were more likely to have urinary catheters (67% vs 24%; P < .001).

The use of aspirin was more common in the older men than in the younger men (42% vs 22%; P = .001), as was the use of clopidogrel (18% vs 13%; P = .28).

"We used more spinal anesthesia for patients over 80 years" (59% vs 44%; P = .009), reported lead investigator Benjamin Pradere, MD.

 
Photovaporization is effective and safe, without more complications in patients over 80 years old.
 

However, surgery time and postoperative catheterization were similar in the two groups, as were 3-month quality of life, peak flow, and postvoid residual rates.

At 6 months, International Prostate Symptom Score (IPSS) was significantly lower, indicating milder symptoms, in the younger men than in the older men (P = .02). However, by 12 months, this difference had disappeared (P = .29).

The rate of the occurrence of at least one complication was similar in the older and younger men (40.5% vs 39.4%; P = .83).

Roughly 92% of the complications in both groups were Clavien-Dindo grade II or less, most of which were gross hematuria or stress incontinence in the first months, although one older man experienced a Clavien-Dindo V complication.

There was also a nonsignificant trend toward higher rates of transfusion in the older than the younger men (4.2% vs 0.0%; P = .06).

"Photovaporization is effective and safe, without more complications in patients over 80 years old, and it's feasible under spinal anesthesia," Dr Pradere concluded.

Urinary Retention Study

The second study involved 181 consecutive patients who underwent photovaporization for urinary retention over a 2-year period in the United Kingdom.

Mean age in the study cohort was 74.8 years, 59 (32.6%) of the men were older than 80 years, median prostate volume was 70 mL, and 31 men (17.1%) were identified as having low-pressure chronic urinary retention.

"Deobstruction was achieved in 94.5% of patients, despite large prostate volumes, advanced age, and the presence of low-pressure chronic urinary retention," said Savvas Omorphos, MD, from Mid Yorkshire Hospitals NHS Trust Urology in Wakefield, United Kingdom.

At 3 months, 73.0% of the men reported complete satisfaction, and only 10 men (5.5%) had a catheter.

The rate of 30-day complications was 27.1%, and 94.4% of those were of Clavien-Dindo I complications. Of the 49 men who experienced complications, 21 were older than 80 years.

Two of the main advantages of laser photovaporization are "excellent urinary functional outcomes, with a lower risk of perioperative and postoperative bleeding, and the fact that the procedure can often be performed on a purely outpatient basis, without any need for postoperative hospitalization," Dr Sivarajan explained.

"Both of these advantages favor its use in elderly patients, as they are likely to benefit from a limited hospital stay and limited periods without anticoagulation," he added.

"There are a growing number of older men on anticoagulation, and there have been several series showing that laser photovaporization can be done safely in this context without having to stop the anticoagulation," said session chair Henry Woo, MD, associate professor of surgery at the University of Sydney in Australia.

New outcome data on this treatment in older men are important for clinicians. "The elderly introduce other special factors that we need to bear in mind. There are both physical and cognitive issues that occur with aging that can impact the recovery and response to treatment," he told Medscape Medical News.

Two of Dr Pradere's coauthors are proctors for American Medical Systems–Boston Scientific. Dr Omorphos and Dr Sivarajan have disclosed no relevant financial relationships. Dr Woo reports that he was previously a member of the advisory board for American Medical Systems.

European Association of Urology (EAU) 2016 Congress: Abstracts 962 and 961. Presented March 14, 2016.

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