紅光雷射攝護腺汽化術 公佈日期：2013-03-13財團法人彰化基督教醫院雲林分院泌尿科吳盛川醫師 攝護腺肥大治療新選擇【紅光雷射攝護腺汽化術 攝護腺肥大是許多年長男人的毛病，免不了要吃藥動刀。多數熟男都因攝護腺肥大的問題造成生活上極大的困擾，攝護腺肥大已經是五十歲以上男士的專利，年紀大的男性常會因為攝護腺肥大而造成夜尿、頻尿、排尿困難；還有另一種慢性攝護腺炎偏愛年輕及中年的男士，尤其是慢性攝護腺炎會有一些拖泥帶水的症狀，對日常生活常造成極大的困擾。攝護腺肥大是怎麼形成的？攝護腺又稱為前列腺，是專屬男性生殖系統的一部份，其功能是分泌部份的精液以及某些激素，可以幫助精液液化、保護及滋養精細胞，並保護泌尿生殖道免受感染。男人的攝護腺發育有兩個高峰期，一個是出生到十五歲，此時體積大約長到十五公克；第二個高峰大約是在四、五十歲以後，其發育原因不明，可能與男性賀爾蒙有關係。隨著年齡的增長，以及荷爾蒙的刺激，男人過了30歲後，攝護腺內尿道附近的腺體會出現增生現象，50歲以上開始有攝護腺腫大的毛病，影響排尿，因此中老年男性常發生解尿遲緩、頻尿、滴尿、夜尿或尿不乾淨的困擾。增生的組織一旦壓迫到尿道，就會有一直滴滴答答的現象產生，而影響到生活品質。依國民健康局的資料顯示，50歲的男性朋友約有50%以上會有攝護腺肥大的毛病，隨著年齡的增加，60歲以上有60%，80歲以上罹患此症的比例則高達百分之百。但根據統計一般民眾就醫率偏低；老先生們有的礙於面子羞於就診，有些人擔心年紀大無法承受手術的風險而置之不理；或是忍痛至膀胱漲痛無法忍受緊急送醫，成為急診的常客。泌尿科在過去二十年來一直在思考能否有更好的方式可以取代「經尿道攝護腺刮除術」，現在有了更好的選擇也就是「雷射攝護腺汽化術」。這個手術基本上是透過雷射光纖傳導經尿道膀胱鏡深入攝護腺組織，在光纖前端會有一個光指引需要汽化的地方，以高能量的雷射將多餘的攝護腺肥大組織瞬間汽化掉，有些患者因年邁，或合併其他疾病如腦中風、糖尿病、心臟血管疾病、慢性阻塞肺部疾病等，使用傳統手術時風險增加，較不適合施以傳統手術。因此，高齡患者可使用「紅光攝護腺汽化術」，不但安全性高、風險少且不會出血，也不會影響到性生活。目前，國內坊間頗熱門的綠光雷射手術，很多人都聽過，因為「綠光雷射攝護腺汽化手術」是以高能量532nm綠光雷射，透過汽化的方式，能夠在幾乎不出血的情況下除去多餘的攝護腺組織，解決排尿的困難，並可在短時間內恢復生活作息。而本院自德國引進的是能量提高至980nm的「紅光雷射攝護腺汽化手術」，提供更快速更好的治療。對於高危險患者如心臟病、氣喘方面疾病又患有攝護腺肥大的病患，可快速改善患者排尿異常的問題。這台機器提供了比綠光雷射更穩定的輸出能量與電壓，而且更提高能量的雷射光束照射，使組織汽化的速度優於綠光雷射。此外，由於凝結層比綠光雷射更薄，因此熱傷害將降到最低，目前國外已開始陸續有醫院放棄綠光雷射而改採紅光雷射了。一般病患若是擔心經尿道刮除術可能引發的副作用，可考慮選擇目前最先進的「紅光攝護腺汽化術」，一般術後1-2天即可出院。另外，因手術中出血量很少，更適合年紀大、健康狀況不佳或有心血管疾病或需長期服用抗凝血劑的患者。攝護腺肥大是男人的宿命，平日保養，除儘量避免酒精、辛辣等刺激性食物外，更應該多吃蔬果、適度運動、不要憋尿，當症狀開始影響到日常生活時，就應該找專業泌尿科醫師尋求治療，以免造成自身痛苦，家人困擾。
綠光雷射復原期短 攝護腺肥大患者新選擇NOWnews今日新聞 2015年 05月 28日10:20 「剛過完70大壽的吳爺爺，身體向來硬朗，最近感冒吃藥，沒想到幾天後卻因為尿不出來，膀胱脹痛而就醫，詳細檢查發現是攝護腺出問題……」、「年近花甲的父親，最近上廁所總是好久才出來，是攝護腺肥大嗎？」是不是只要年紀比較長的男性，就會有攝護腺問題的困擾呢？ 康寧醫院泌尿科主任林碧海表示，目前醫學上雖然尚未有證據證實造成攝護腺肥大的成因，但專家們大致認為年紀和雄性激素，是造成攝護腺組織增生的主因。一般來說，年過50歲的男性，攝護腺會隨著年齡逐漸增大，過於肥大的攝護腺會擋住膀胱的開口，進而影響排尿的功能。 為了讓尿液通過受到擠壓而變小的尿道，膀胱必須更加用力，膀胱壁也因此而增厚，使得膀胱的儲尿容量變小，也變得敏感容易受刺激，即使膀胱裡面只有少量尿液，也會增加收縮次數，造成嚴重頻尿。嚴重者，可能會導致急性尿滯留，甚至影響輸尿管以及腎臟的正常機能。康寧醫院泌尿科醫師胡光能進一步說明，微生物非常容易在膀胱滯留的尿液中孳生，且容易造成感染，滯留的尿液一旦濃縮結晶後，會引發膀胱結石，可能症狀包括腹部疼痛與壓迫感、不正常深色的尿液、血尿、排尿困難、頻尿、排尿中斷、陰莖疼痛或不適、尿路感染、排尿灼痛、發燒、尿失禁等。目前治療攝護腺肥大的方式，依照病況的程度有藥物治療、經尿道電刀攝護腺切除術及開腹手術等選擇。藥物為第一線治療法，有不必動刀、無麻醉風險的優點，若藥物無法控制時，則須透過電刀攝護腺切除術或開腹手術，但會有出血過多、尿失禁或勃起障礙等缺點。胡光能指出，隨科技進步，患者可以選擇綠光雷射攝護腺汽化術，這是一種低侵入性手術，利用高能量綠光雷射打通攝護腺尿道，將增生出來壓迫到尿道的攝護腺組織瞬間汽化分解，幾乎不會傷害周邊組織，且能馬上解除排尿困難的症狀，過程中幾乎不會出血，並減少術後導尿管留置時間，改善術後血尿狀況，縮短住院天數。 另外，對於患有高血壓、心臟病等慢性病、心血管疾病，或是不適合採用傳統攝護腺刮除手術等高風險族群來說，綠光雷射攝護腺汽化術是安全性高、併發症少的一項好選擇，術後僅需按照平日生活作息、多喝水即可。 臨床上，目前治療攝護腺肥大的雷射手術中，以綠光雷射汽化術的雷射燒灼深度影響周邊組織機率少，擁有超過500篇國際文獻佐證。至於攝護腺肥大會不會演變成攝護腺癌？胡光能解釋，雖然兩種病症是個別獨立不相干的，但有可能同時發生。因此，完整的鑑別檢查顯得格外重要。
Laser therapy for benign prostatic hyperplasia BPH is the most prevalent disease entity in elderly men. In the late 1980s, lasers became a novel way to open a wider channel and improve voiding dynamics. Many different techniques under the term laser prostatectomy have evolved. Individual techniques may vary greatly, but the 2 main tissue effects include coagulation and vaporization. Coagulation occurs when somewhat diffusely focused laser energy heats tissue and temperatures reach as high as 100°C. Proteins denature, and necrosis ensues. This results in subsequent sloughing of necrotic tissue (ie, a debulking of the prostate). This process may take as long as several weeks to complete and often initially results in edema, which transiently increases prostate volume (and therefore may require short-term urethral catheterization). The principle representative procedures in the laser coagulation category include visual laser ablation of the prostate (VLAP) using Nd:YAG and interstitial laser coagulation (ILC). VLAP uses a direct transurethral viewing source (eg, cystoscope and video) along with a laser that is supplemented by a visible (usually helium-neon) aiming beam. Interstitial coagulation using a diode laser is another coagulative technique in which optical fibers are introduced transurethrally or perineally directly into the prostate. This can cause large-volume necrosis with atrophy while preserving the urethral mucosa. In several studies these coagulative procedures have proven to have unacceptably high adverse events, namely irritative voiding, dysuria, and other storage symptoms, as well as high reoperation rates. Additionally, more efficient and improved laser applications such as Ho:LEP and photo-vaporization (PVP) techniques have shown to be more effective largely replacing VLAP and ILC.43 Vaporization occurs when greater laser energy is focused (increased power density) and tissue temperatures reach as high as 300°C. This causes tissue water to vaporize and results in an instantaneous debulking of prostatic tissue. The high-power (80-W) potassium-titanyl phosphate laser (KTP, or Greenlight) is commonly used for its vaporization effects on prostate tissue. This procedure is associated with significantly less bleeding and fluid absorption than standard transurethral prostate resection. Because of this, the KTP laser is safely used in seriously ill patients or those receiving oral anticoagulants. Additionally, the KTP laser's ease of use has made it an attractive option for urologists. Drawbacks to the KTP procedure compared with traditional TURP include the lack of tissue obtained for postoperative pathological analysis and the inability to diagnose and unroof concomitant prostatic abscesses.
In a 2005 study of KTP laser treatment in candidates for transurethral resection of the prostate (TURP), no patients developed significant postoperative gross hematuria although more than half of the patients were on antiplatelet therapy immediately prior to surgery.[7] In this study, prostates with volumes of up to 136 mL were safely treated, although some required prolonged operative times of up to 99 minutes. After a mean follow-up of 3.5 years, most patients in this study saw at least a 50% improvement in their American Urological Association Symptom Index (AUA-SI) and a 100% improvement in peak urinary flow rate (Qmax). A higher-powered 120-W LBO laser (GreenLight HPS) was developed and even more recently the 180-W LBO system (GreenLight XPS) has been marketed to improve upon current vaporization speed. Whether these newer generation KTP lasers are clinically superior to their predecessor remains to be seen. Laser energy has been used to incise or enucleate prostate adenomas down to the capsule, making this procedure the endoscopic analog of open simple prostatectomy. The Ho:YAG is ideally suited for this task because it creates precise incisions, cuts by vaporizing tissue with adequate hemostasis, and leaves minimal collateral damage. Advantages of this method include the availability of a specimen for histologic examination, less postoperative catheter time, and the ability to excise large adenomas. Drawbacks include greater training time and the need to transport the adenoma (in toto or portioned) into the bladder to morcellate it prior to removal. Meta-analyses have shown the efficacy of Holmium laser enucleation of the prostate (HoLEP) to be similar to TURP, at times favoring TURP, particularly with larger glands. Gilling et al found that urodynamic proven relief of obstruction favored HoLEP for prostates of more than 50 g. When comparing HoLEP with traditional TURP using pooled data, Tan et al suggested that catheterization time, hospital stay, and blood loss were significantly lower in the HoLEP group. In addition, Jaeger et al found HoLEP for recurrent lower urinary tract symptoms after failed prior BPH surgery to be safe and effective, with similar efficacy and incidence of complications regardless of prior transurethral prostate surgery. HoLEP has also been shown to be a safe and effective treatment for BPH regardless of age, with similar overall morbidity, hospital stay, and 1-year functional outcomes among all age groups, ranging from age 50-59 year to up to 80 years. For some time, the criterion standard treatment for BPH has been TURP and the standard by which all of the above techniques are compared. TURP is used less frequently because of associated complications, including bleeding and transurethral resection (TUR) syndrome and the improved efficacy of medical therapies. Additionally, the preponderance of urology patients taking chronic oral anticoagulants and anti-platelet therapy mandate the need for techniques that can be safely performed in this setting. In general, the laser prostatectomies mentioned above have added safety and less perioperative pain compared with TURP. Less bleeding occurs and the operative time is usually less; therefore, most types may be performed on patients who are receiving anticoagulants. Laser modalities are safer than TURP in the perioperative period, although some may have a similar long-term complication profile. The coagulative approaches have been largely abandoned because of post-operative symptomatology and the availability of other modalities. Vaporization techniques, particularly Greenlight PVP, has achieved widespread popularity, largely because of its ease of use and the ability to perform these procedures on an outpatient basis. HoLAP is also a viable vaporization technique and in fact a RCT showed essentially equivalent efficacy and complication rates when compared with Greenlight PVP. Only operative time favored PVP. HoLAP requires the most technical expertise with a correspondingly steep learning curve but is likely the optimal endoscopic approach to the very large gland. Although all of the modalities mentioned are efficacious, none is efficacious enough to make the old-fashioned TURP obsolete.
Laser treatment of urothelial malignancies Various laser energies have been used to treat bladder and upper urinary tract urothelial tumors. Most commonly, holmium and Nd:YAG are used in this setting. They are used through quartz fibers, which are directed endoscopically. The Nd:YAG laser energy is used to coagulate and ablate with a thermal effect that extends deeper than other lasers. Holmium is more precise, with less of a coagulative effect. The advantages of laser therapy for tumor ablation include less bleeding; consequently, catheter drainage is usually unnecessary. A lower incidence of stricture formation results when compared with electrocautery because fibrotic reaction is minimal. This technique decreases the need for anesthesia, causes less postoperative pain, and allows a quicker return to work. The Ho:YAG laser can be used through a flexible cystoscope to ablate recurrent superficial bladder tumors in an office setting. A recent review of patients treated with the flexible cystoscope reported a high degree of satisfaction because this method avoided the need for general anesthesia, and 83% of the patients scored their pain as 2 or less out of a possible 10. No pathology specimen is available; thus, determining depth of invasion is impossible unless multiple prior biopsy samples were obtained. Another drawback, especially with the Nd:YAG laser, is that the area of destruction is deep and notfully visualized. Some reports of bowel perforation exist when treating bladder dome lesions even without visible bladder perforation secondary to the effect of Nd:YAG. In this setting, Ho:YAG is a better choice. Photodynamic therapy is another form of tumor ablation in which a systemically administered compound is absorbed or retained preferentially by cancer cells and converted by laser light to a toxic compound. This compound usually acts through oxygen radicals to destroy malignant cells. Lasers are ideally suited for this form of therapy because of their monochromaticity and small, maneuverable delivery systems. An example of this type of therapy involves Photofrin II, a hematoporphyrin that is retained by malignant cells long after it clears healthy epithelium. By using an argon laser to excite the dye rhodamine B, a red light of 630 nm is produced that can be aimed at the entire bladder several days after administering the Photofrin. This is especially promising for TCC–carcinoma in situ (CIS), which shows complete response
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