Transperineal laser ablation for treating lower urinary tract symptoms of benign prostatic hyperplasia

Benign prostatic hyperplasia, also known as benign prostatic obstruction or benign prostatic enlargement, is a common condition that affects older people with a prostate. Stromal and epithelial cells increase in number, causing the prostate to get bigger. It usually occurs in the periurethral region of the prostate, with large discrete nodules compressing the urethra. Symptoms include hesitancy during urination, interrupted or decreased urine stream (volume and flow rate), nocturia, incomplete voiding and urinary retention.

Mild symptoms are usually managed conservatively. Drugs may also be offered, such as alpha-adrenoceptor blockers and 5 alpha-reductase inhibitors. If other treatments have not worked, surgical options include transurethral resection of the prostate (TURP), transurethral vaporisation, holmium laser enucleation, insertion of prostatic urethral lift implants, prostatic artery embolisation or prostatectomy (see NICE's guideline on lower urinary tract symptoms in men). Potential complications of some of these surgical procedures include bleeding, infection, urethral strictures, incontinence and sexual dysfunction. Many of these procedures require general anaesthetic, regional anaesthetic or sedation.

The procedure uses a percutaneous transperineal approach to ablate the prostate with laser energy. The aim is to reduce the prostate volume, leading to reduced urinary tract symptoms.

The procedure can be done as a day-case procedure under local, regional or general anaesthesia. Continuous saline irrigation of the urethra and bladder is done with a catheter in place during the entire procedure. The person having the procedure is placed in a lithotomy position. Using transrectal ultrasound guidance and real-time monitoring using a dedicated software planning tool, one or two 21‑gauge introducer needles per lobe (depending on the basal volume and shape of the prostatic gland) are inserted transperineally into the prostatic tissue. A laser fibre is then introduced through the needle.

Low powers (3 to 5 watts) and low laser light energy (up to 1800 J per fibre and illumination) are delivered from the diode laser system for several minutes to heat and destroy the prostate tissue around the tip of the fibre, according to a standard protocol. If needed, a second illumination can be done to treat a larger area. The maximum volume treated in a session and the extent of the ablation vary according to the prostatic volume, anatomy and surgeon preference.