JIIMS.cdr


ABSTRACT
Objective: To determine safety of diode laser by studying post operative complications after endourological
procedures in co-morbid patients.
Study Design: A descriptive study.
Place & Duration of Study: Shalamar hospital, Lahore from June 2009 to June 2012.
Materials and Methods: We studied post-operative complications (up to 3 months) in 3 groups (prostatic
obstruction, bladder growths ,urethral strictures) of total180 patients with ASA III & IV. We assessed hematuria,
UTI, abdominal pain, suprapubic discomfort, urinary retention, dysuria, incomplete procedure, cardiac or
respiratory compromise, fluid overload, mortality, catheterization times and mean postoperative hospital stay
Results: In prostate group, mean age was 70.8±8.6 years and follow-up period was 3 months. Complications 
were: mild transient haematuria in 65 (100%), creamy urine in 50 (77%), urinary tract infection in 25 (38.4%),
dysuria in 16 (24.6%), retreatment required in 06 (9.2%), suprapubic discomfort in 3 (4.5%), TURP syndrome in 1
(1.5%) and significant hemorrhage requiring blood transfusion in 1 (1.5%),. In urethral strictures, the
complications were: microscopic hematuria in 80 (100%), urinary tract infection in 52 (65%) suprapubic
discomfort in 9 (11.2%), dysuria in 6 (7.4%) mild transient hematuria in 5 (6.2%). In bladder growths, the
complications were: mild transient haematuria in 30 (85.7%), creamy urine in 19 (54.2%), suprapubic discomfort
in 18 (51.`4%), dysuria in 9 (25.7%), urinary UTI in 8 (22.8%) , ablation performed in two sittings in 1 (2.8%). No
mortality in any group.
Conclusion: Diode laser is a safe and useful modality in patients with co-morbidities (ASA III and IV).

Key words: Diode laser, endourology, co-morbidity.

98

ORIGINAL ARTICLE

Introduction
Elderly patients with coexisting medical
conditions undergoing complex or major
surgery are high-risk. Range of surgery and
patient-related factors including ischaemic
h e a r t d i s e a s e , c h r o n i c o b s t r u c t i v e
pulmonary disease (COPD), advanced age,
poor exercise tolerance determine the

1
overall risk
B l e e d i n g re m a i n s a c o n c e r n i n a l l
endoscopic procedures, like morbidity and
mortality for transurethral resection of
prostate (TURP) have not changed for

2,3
decades.
Potential advantages of laser therapy over
traditional procedures include appreciably
good hemostasis, decreased morbidity,
minimal cardiac stress, and shorter hospital
-------------------------------------------------

Complications of Diode Laser in Endourological Procedures
in Co-morbid Patients
Farooq Hameed, Mohammad Imran Zahoor, Javed Aziz,  Saadat Hashmi, Abdul Jalil, Abdul Rehman

Correspondence:
Dr.  Farooq Hameed
Consultant Urologist
Shalamar Hoapital, Lahore
E-mail:farooqhameed4@gmail.com

4
stay.
High-powered diode laser systems are

5
available for endoscopic procedures. It has
a compact size, easy portability, and a
potential for lower capital and maintenance

3
costs. The current system (Biolitec) allows a
continuous wave mode to a flexible and
customizable pulsing regime with side or
bare end fire fibre . Diode laser has similar
wavelength characteristics to the Nd: YAG
laser (Neodymium:yttrium-aluminum-
garnett), but scatters less in tissue, high
simultaneous absorption in water and
hemoglobin and it is postulated to combine
high tissue ablative properties with good
hemostasis with significantly lower energy

3,6
consumption . Safety measures are similar
to Nd: YAG laser.
Clinical data regarding safety of diode laser
in endoscopic surgery is not frequently
available.

We studied the post operative complications
(up to 3 months) in 180 patients between

Materials and Methods



99

June 2009 and June 2012 in Shalamar
h o s p i t a l , L a h o re . D e p e n d i n g u p o n
diagnosis, patients were divided into 3
groups (with Prostatic obstruction, bladder
growths and urethral strictures) and
complications in each group were studied.
In all cases of BPH, pharmacological
treatment had been tried. Physical
examination including digital rectal
examination (DRE), Prostate specific
antigen (PSA), abdominal ultrasound scan
( t r a n s - r e c t a l s c a n o n l y i n c a s e o f
disagreement between DRE and the
abdominal ultrasound scan) were carried
out for prostatic obstruction and bladder
growth. Retrograde urethrogram was done
for urethral strictures. All operations were
done in spinal (60 %) or combined
spinal/epidural, epidural alone or general
anesthesia.)
We used 980 nm Diode laser (Biolitec,
Germany) with 1000 ìm core optical fibers
(side-fire), 600 ìm end fire with a spot
diameter of 1 mm. The output power
ranged from 50 W to 140 W during the
surgery. The mean applied energy was 130 ±
70 kJ. Vapo-resection (Coagulation and
resection of bigger prostates, vaporization
and sample collection for small lesions) was
performed using laseroscope / resectoscope
of 26 Fr. The strictures were dealt with by
vaporizing the tissue when passing, using
the contact technique or non-contact mode
depending on the characteristics of the
tissue. Saline solution was used as irrigation
during ablation and 1.5% Glycine during
sample collection.
The antibiotic prophylaxis consisted of three
intravenous doses of 1g of Cefoperazone
/Sulbactam , at induction, at 12 and 24 hrs
post operative period respectively. Patients
needing anticoagulation were switched
over to Enoxaprin 4000 i.u. sub cutaneous
injection before the procedure. All
procedures were performed by a single
experienced surgeon with a dedicated team.
In post operative period, patients were

a s s e s s e d f o r t r a n s i e n t , s i g n i f i c a n t
h a e m o r r h a g e n e e d i n g t r a n s f u s i o n ,
microscopic hematuria, urinary tract
infection, abdominal or flank pain,
suprapubic discomfort, urinary retention,
dysuria, incomplete procedure, cardiac or
respiratory compromise, fluid overload ,
mortality, catheterization times and mean
postoperative hospital stay. Patients were
discharged from the hospital within 48
hours when urine was bloodless.

Patients from all age groups needing
endoscopic laser treatment for BPH, bladder
growths, and urethral strictures having
1. Co-morbidities

a. altered renal function, (Creatinine >
2.0)

b. COPD
c. bleeding / clotting disorders with

international normalization ratio
(INR) >1.5

d. myocardial dysfunction, ejection
fraction up to 30%)

2. American society of Anesthesiologists
(ASA) grade III and IV

3. Refused surgical treatment due to high
risk

Exclusion criteria:
Patients with ASA grade I & II
Follow up:
Follow up intervals postoperatively in out
patient clinic were within 5 days for removal
of catheter, 15 days, one month, 2 month and
3 months. Any clinical event, adverse effects
and additional interventions or repeat
surgery was noted.
For cases of ablation of prostate and bladder
growths, follow up intervals were within 5
days for removal of catheter (upto 7 days for
some cases of bladder growths), 15 days, one
month, 2 month and 3 months.
In case of urethral strictures, the catheter
was removed depending upon the severity
of the condition and were followed upto 3
months.

Inclusion Criteria:



100

Results
Prostate Group: Mean age of patients was
70.8±8.6 years. One patient having prostate
>260 gms developed significant post
operative haemorrhage and needed
transfusion. The patients having prostates
>100 gms developed retention within 1
week and were re-operated. Dysuria was
moderate, disappeared in all cases by
s y m p t o m a t i c t re a t m e n t w i t h i n t h e
following two weeks. UTI was noted in
patients having indwelling catheter for > 3
months. Patient with TURP syndrome was
readmitted and electrolyte imbalance was
corrected. Further results are in Table I.
Stricture Urethra group: Microscopic
hematuria and gross hematuria both settled
within 24 hrs in all patients. Post operative
infection was noted in already infected urine
which settled by two weeks antibiotics
followed by suppressive dose. Further
results are in Table II.
Bladder Growth group: Urinary retention
occurred only in cases of indwelling catheter
> 3 months. Creamy urine lasted for 2-3
months and settled. Dysuria persisting up to
2 weeks was noted in widespread bladder
tumours. Further results are in Table III.

Table I. Complications in prostate group  (n= 65)

Table II. Complications in Urethral Stricture
(n = 80)

Table III. Complications in bladder growths
n = 35

Table IV.  Mean Hospital stay and catheterization
time



101

Discussion
Use of laser for the treatment of BPH and
bladder tumours is the most commonly
used alternative to TUR to decrease

7,8
morbidities. For Nd:YAG, laser, it
required longer catheterization periods
because of the longer time required for
expelling the necrotic tissue. Reports of long

9
term results with KTP laser are limited.  We
removed catheter within 3 days because of
effective coagulation and hemostasis except
for prostatic obstruction with indwelling
catheter for > 3months or complicated
strictures of posterior and bulbar urethra .
Rapid vaporization and hemostasis is

9,10,11
possible by diode laser. We easily
obtained tissues of prostate and bladder
growths for biopsy. The architectural
pattern in resected tissue was well
m a i n t a i n e d f o r h i s t o p a t h o l o g i c a l
evaluation. An ex vivo study showed that
diode laser has a higher tissue ablation
capacity than KTP laser, and shorter

9
operative time. Using vapo-resection
technique ,we obtained clean sharp cuts
with almost blood-less field.
W. Cecchetti et al obtained a bloodless sharp
cut and easy vaporization with minimum
carbonization and edema in 22 cases. They
found diode laser a good compromise
between absorption and coagulative effects

11
on the tissue .
Seitz et al treated 10 patients with BPH with
diode laser. Ten patients were followed up at
1 month and 8 patients were followed up at 6
and 12 months. No serious postoperative

12
haematuria was reported. We found, mild
transient hematuria in almost all patients
which settled within 4 hours.
Erol et al (2009) studied 47 patients with
diode laser prostatectomy. The commonest
complication was mild-moderate irritative
symptoms (23%) which resolved within the 
f i r s t t w o w e e k s . A l a t e b l e e d i n g
complication (requiring hospitalisation)
was encountered in one patient at 4 weeks.

13
Mean operative time was 53 minutes.
Chen et al (2010) treated 55 patients of BPH.
They reported 10 patients with transient
dysuria. Acute urinary retention in two men
was resolved by removal of sloughed tissue
via TURP. Two patients underwent TURP
due to insufficient vaporisation or regrowth
of prostatic tissue (reoperation rate 7%).
The three studies (Seitz et al; Erol et al; Chen
et al) reported no serious intraoperative
complications or postoperative haematuria.
Lengths of hospital stay were 4.7 (SD 2.3)
days in Seitz et al (2007) and 2.8 (SD 1.8) days

12,14
in Chen et al (2010). In our study, almost
all patients were discharged within 48 hours
after surgery.Clemente Ramos and Luis

15
Miguel evaluated diode laser treatment of 
BPH, focused on the peri-operative
m o r b i d i t y. T h e y f o u n d p r o s t a t e
vaporization effective with minimal

15
morbidity.
The application of lasers in treating urologic
disorders has gained widespread clinical
a c c e p t a n c e i n m u l t i p l e s u r g i c a l
indications.15 Safety has also been
demonstrated in patients with large
prostates and patients receiving anti

16
coagulant therapy or in retention.

The early results showed a virtually
bloodless surgery with sharp cut. With
acceptable complication rate, diode laser is
relatively safe and useful modality in
patients with co-morbidities (renal failure,
Chronic obstructive pulmonary disease,
myocardial dysfunction, ( ASA III & IV).

1 Pearse R M. Perioperative management of the

high-risk surgical patient in Bailey and Love's

short practice of surgery. 25th ed © 2008 Edward

Arnold (Publishers) Ltd, p215

2 Lanzafame RJ. Applications of lasers in

laparoscopic cholecystectomy. J Laparoendosc

Surg 1990;1:33-6.

3 Mulligan ED, Lynch TH, Mulvin D, Greene D,

Conclusion

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