Application Of Honeycomb Vaporization Technology In 1470nm Laser Enucleation Of The Prostate

Background and ObjectiveBenign prostatic hyperplasia(BPH)is one of the common uri nary system diseases in elderly men.As the disease progresses,lower urinary tract symptoms such as frequent urination and dysuria gradually worsen,affecting the quality of life of patients,and some patients require surgical treatment.The surgical methods of BPH mainly include open surgery and minimally invasive transurethral surgery.The effect of open surgery is reliable,but it has larger trauma,more perioperative complications,and slower postoperative recovery accordingly.With the development of medical technology,a variety of minimally invasive transurethral surgeries are used in the treatment of BPH.Transurethral resection of the prostate(TURP)is the most classic minimally invasive transurethral surgery.It has the advantages of less trauma,quicker postoperative recovery,and reliable results.It has basically replaced open surgery and has become the"gold standard" for surgical treatment of BPH.However,there is more bleeding during TURP,and with the increase of the prostate volume,the operation time is prolonged,and the incidence of complications is significantly increased.Urologists are constantly looking for new methods to treat BPH,so as to achieve the goal of "high safety and reliable efficacy." Among them,the application of laser technology is a major breakthrough in the course of BPH treatment.Laser has good hemostasis performance,perioperative blood loss is significantly reduced compared with TURP,and the treatment effect is reliable.It has been applied worldwide and has a tendency to replace TURP.The 1470nm laser is a new type of semiconductor laser with good coagulation hemostasis,tissue vaporization and cutting capabilities.Vaporization and enucleation are commonly used surgical methods currently.Vaporization is simple to operate and has a short learning curve,but the operation time is relatively long in the treatment of large BPH patients.Therefore,enucleation is often used in the treatment of patients with large BPH to shorten the operation time and obtain sufficient prostate tissue specimens for pathological diagnosis.The block of prostate tissue enucleated by 1470nm laser is usually crushed by a tissue pulverizer and then taken out.However,the surgery has the following problems:Firstly,the laser and tissue comminuted scopes need to be replaced repeatedly during the operation,which increases the operation time and the risk of urethral damage.Secondly,during the tissue pulverization process,there is a risk of the bladder wall damage and even bladder perforation.Thirdly,the price of the tissue pulverizer is expensive,which increases the expenditure of the hospital.We had used 1470nm laser vaporization and vaporization resection to solve the enucleated prostate tissue masses,and found that the removal efficiency of the tissue masses of these two methods was low,which significantly prolonged the operation time.To solve the problems above,we developed the 1470nm laser honeycomb vaporization technology,using the advantage of the high vaporization efficiency and good fiber directivity of 1470nm laser,combined with mushroom head technology,and applied it to the treatment of enucleated prostate tissue mass,thereby replacing tissue comminution.The lobes of the prostate are enucleated with a 1470nm laser fiber,and the enucleated tissue mass is connected to a small part of the prostate’s neck orifice to form a "pedicle"-like structure to make it relatively fixed.Expose the tip of the 1470nm optical fiber to the foremost end of the laser operating handpiece about 1cm,and insert the optical fiber into the prostate tissue block for vaporization,then quickly withdraw the fiber tip after penetrating the tissue block.Repeat the above action at the next insertion point.The insertion points are arranged in a honeycomb pattern.The distance between the two insertion points is about 5mm.The tissue block after the honeycomb vaporization becomes relatively loose,and the laser fiber can easily cut it into small pieces,and the specimen is flushed out through the laser scope sheath for pathological diagnosis.The purpose of pathological examination of prostate tissue specimens is to determine whether the tissues are benign or malignant.Microscopically identifying the cytological structure of prostate glands and the size of the specimen that can distinguish benign and malignant tissues(called effective specimen volume)is closely related to the detection rate of sporadic prostate cancer.Whether vaporization in a honeycomb shape can replace tissue pulverizers depends on the tissue removal speed,safety and pathological diagnostic value of obtaining prostate tissue specimens.At present,no relevant research reports have been found.This paper studies the above-mentioned problems through experiments in vitro and clinical applications,discusses the clinical application value and application scope of vaporization in a honeycomb shape in 1470nm laser enucleation of the prostate,and provides reference and basis for the clinical promotion and application of cellular vaporization.Part Ⅰ Experimental study of 1470nm laser honeycomb vaporization in vitro Purposes1.To compare the clearance speed of prostate tissue with 1470nm laser honey-comb vaporization and vaporization.2.To study the influence and value of prostate tissue specimens obtained by 1470nm laser honeycomb vaporization on pathological diagnosis.Methods1.Establish an in vitro model of prostate laser surgeryThe bladder,prostate and part of the urethra were taken out from fresh corpses of Chinese garden dogs and stored in normal saline at 4℃.We removed the fat tissue around the bladder and prostate,leaving the prostate,bladder neck and part of the urethra only.Then numbered the treated prostates,10 cases in each of the vaporization group and the honeycomb vaporization group.Fixed the prostate in the bladder of the COOK flexible ureteroscope simulator.The laser scope entered the bladder through the urethra of the simulator,and the normal saline was continuously flushed with a pressure of 60cmH2O.2.Surgical methodsVaporization of the prostate by 1470nm laser The 1470nm laser vaporization power was set to 150W.Using laser direct fiber to vaporize the prostate with a steady round-trip fan sweeping motion on the surface of the gland.The operation was stopped after the laser emission time reached 5 minutes.Honeycomb vaporization of the prostate by 1470nm laser The 1470nm laser vaporization power was set to 150W.1470nm laser direct fiber was quickly inserted into the dog’s prostate to vaporize the gland.The tip of the fiber penetrated the prostate and then was quickly withdrawn.Repeated the above action at the next insertion point.The insertion points were distributed in a honeycomb pattern.The distance between the two insertion points was about 5mm.The vaporized tissue mass was loose and spongy,and the laser fiber could easily cut it into small pieces that could be punched out of the laser scope sheath.The operation was also stopped after the laser emission time reached 5 minutes.3.Observation indicatorsMeasured the volume of the prostate before and after the operation,and calculated the volume of the prostate removed and the speed of tissue removal.Measured the volume of prostate tissue specimens obtained after honeycomb vaporization and sent them for pathological examination.Estimated the proportion of normal prostate tissue(tissues that can identify the cytological structure of the prostate gland under the microscope)in the tissue section under the microscope,and calculate the effective specimen volume obtained-Effective specimen volume(ml)=volume of prostate tissue specimen obtained by surgery(ml)*proportion of normal prostate tissue in pathological sectionsResults1.The tissue removal rate of 1470nm laser honeycomb vaporization was(1.30±0.09)ml/min,and the tissue removal rate of vaporization was(0.53±0.08)ml/min.The difference in tissue removal rate between the two surgical methods was statistically significant(P<0.05).2.The volume of specimen obtained by 1470nm laser cellular vaporization was(2.27±0.27)ml,the percentage of normal prostate tissue under the microscope was(34.0±8.4)%,and the effective specimen volume was(0.76±0.18)ml.Conclusions1.1470nm laser honeycomb vaporization tissue removal speed is significantly faster than vaporization.2.The specimens obtained by honeycomb vaporization can be used for pathological diagnosis,but the amount of effective specimens obtained is less due to the loss when vaporization,coagulation and necrosis during the operation,so the value of pathological diagnosis is limited.Part Ⅱ Clinical application of honeycomb vaporization technology in 1470nm laser enucleation of prostatePurposes1.To evaluate the safety of 1470nm laser enucleation of the prostate combined with honeycomb vaporization.2.To evaluate the therapeutic effect of 1470nm laser enucleation of the prostate combined with honeycomb vaporization.3.To evaluate the pathological diagnostic value of prostate tissue specimens obtained by 1470nm laser enucleation of the prostate combined with honeycomb vaporization.Methods1.Patients grouping and surgical methodsThe patients who met the inclusion criteria of this study were divided into three groups according to the prostate volume.Small volume group:PV≤40ml;medium volume group:40ml<PV<80ml;large volume group:PV≥80ml.In order to ensure a balanced number of patients in each group,no new patients would continue to be included after the number of patients included in each group reached 120.Before the operation,all patients were selected according to the random principle for 1470nm laser prostate vaporization or 1470nm laser prostate enucleation combined with tissue comminuted or 1470nm laser prostate enucleation combined with honeycomb vaporization.Forty-eight patients were excluded due to postoperative pathological diagnosis of prostate cancer or failure to complete the 3-month follow-up or incomplete data.A total of 312 patients completed the study.2.Observation indicators2.1 Observation indicators during perioperative periodAverage operation time,intraoperative blood loss,postoperative bladder irrigation time,postoperative indwelling catheter time,surgical complications(prostate capsule perforation,rectal injury,Bladder injury,acute urinary retention after urinary catheter removal,postoperative bleeding,etc.).2.2 Determination of effective specimen volumeEffective specimen volume(ml)=volume of prostate tissue specimen obtained(ml)*Proportion of normal prostate tissue in pathological sections2.3 Follow-up indicators for 3 months after surgery:Qmax,PVR;IPSS score,QOL score;Postoperative complications(secondary bleeding,gross hematuria,urinary incontinence,acute epididymitis,urethral stricture,etc.)3.Data ProcessingSPSS 21.0 statistical software was used to perform statistical processing on the data.Results1.In the small volume group,medium volume group and large volume group,the Qmax,PVR,IPSS and QOL scores after the three surgical methods were significantly improved compared with preoperative data(P<0.001).2.Small volume group:The average operation time of enucleation combined with honeycomb vaporization group[(34.1±9.1)min]was the shortest,followed by the average operation time of enucleation combined with tissue comminution group[(39.7±11.1)min],and the average operation time of vaporization group[(42.2±12.7)min]was the longest,(P<0.05).The comparison of the three surgical methods including intraoperative blood loss,postoperative bladder irrigation time,postoperative indwelling catheter time,complication rate and therapeutic effect were not statistically significant(P>0.05).3.Middle volume group:The average operation time of vaporization group[(78.7±25.8)min]and blood loss[(85.0±36.4)ml]were the longest(more)(P<0.05).There was no significant difference in operative time[(67.8±22.4)vs(62.6±19.5)min]and blood loss[(69.9±20.7)vs(72.4±18.1)ml]between enucleation combined with honeycomb vaporization and enucleation combined with tissue comminuted(P>0.05).There was no statistically significant difference among the three surgical methods in indicators such as postoperative bladder flushing time,catheter indwelling time,complication rate and treatment effect(P>0.05).4.Large volume group:The average operation time of enucleation combined with tissue comminution group[(78.0±15.8)min]was the shortest,followed by enucleation combined with honeycomb vaporization group[(91.7±18.6)min],and vaporization group[(104.4±31.0)min]was the longest(P<0.05).There was no significant difference in blood loss[(90.6±23.4)vs(95.9±20.0)ml]between enucleation combined with honeycomb vaporization and enucleation combined with tissue comminution group(P>0.05),and both were significantly less than vaporization group[(117.3±43.2)ml](P<0.05).There was no statistically significant difference among the three surgical methods in terms of postoperative bladder irrigation time,catheter indwelling time,and complication rate(P>0.05).There was no statistically significant difference in the therapeutic effect of enucleation combined with honeycomb vaporization and enucleation combined with tissue comminution group(P>0.05),and both were significantly better than vaporization group(P<0.05).5.Regardless of the size of the prostate,the volume of prostate tissue specimens obtained by enucleation combined with honeycomb vaporization procedure,the proportion of normal prostate tissue under the microscope,and the effective specimen volume were significantly lower than those of enucleation combined with tissue pulverization group(P<0.001).Conclusions1.1470nm laser enucleation of the prostate combined with honeycomb vaporization treatment of BPH has a reliable clinical effect.2.In the treatment of small volume BPH patients,the operation time of 1470nm laser prostate enucleation combined with honeycomb vaporization is shorter than that of enucleation combined with tissue comminution.For patients with medium-volume BPH,the operation time of the two is similar.In the treatment of large volume BPH patients,the operation time of enucleation combined with honeycomb vaporization is significantly longer than that of enucleation combined with tissue comminution.3.Prostate tissue specimens obtained by 1470nm laser enucleation of the prostate combined with honeycomb vaporization can be used for pathological diagnosis,but the volume and quality of the specimen are inferior to 1470nm laser enucleation of the prostate combined with tissue comminution.4.When the 1470nm laser enucleation of the prostate is used to treat small and medium volume BPH patients,honeycomb vaporization can be used instead of tissue comminution to solve the enucleated prostate tissue mass.However,the pathological diagnostic value of obtained prostate tissue samples is limited,and there is a possibility of missed diagnosis of sporadic prostate cancer.