李世仁: 巨生iTrast奈米氧化鐵 (PEG formulation) phase I (2016)

奈米氧化鐵新藥 腎臟病友福音2015-06-08 04:25:54 經濟日報 記者高行／整理 近年慢性腎臟病患者日益增加，根據健保署統計，台灣洗腎人口密度位居世界第一，全台約有7萬名洗腎者，甚至每年還以接近3,000人的速度成長，腎臟是紅血球生成素的主要製造器官，因此慢性腎病患者普遍患有缺鐵性貧血。以美國為例，每年就有有25萬非洗腎病患與36萬洗腎病患必須做缺鐵性針劑鐵的治療，如以全球4.5億人口來看，約6.5%人口罹患第三期到第5期慢性腎病，其中40%更因缺鐵性貧血必須採用注射方式補充鐵劑來看，鐵劑補充市場需求非常龐大，預計在2015年世界針劑鐵補充藥物將達到16億美元的市場規模。過去慢性腎臟病患在缺鐵情況下，每周或隔周需到醫院施打鐵離子型針劑，一次療程需分成五到十次到院注射點滴，每次點滴需30到60分鐘，共需兩到三個月才能完成一次療程，這期間有可能發生高離子過敏現象，對於慢性腎病患者相當不便。工研院奈米生醫研究團隊利用尖端的奈米生醫技術，研發出非離子型的iTrast奈米氧化鐵藥物，具有易被巨噬細胞吸收的特性，有利於肝臟將藥物轉化成運鐵蛋白，進而達到治療缺鐵性貧血的效果。此藥物使用聚乙二醇做為賦形劑，引發過敏副作用現象較同型產品低，可避免嚴重過敏致死的現象，全安全性較高。因此，iTrast奈米氧化鐵藥物被認為發展前景甚佳，工研院已在2014年成立新創公司「巨生生醫」。其中，iTrast奈米氧化鐵預計在2016年進行第1期臨床試驗，最快將在2019年推出第一款新藥。據悉，iTrast奈米氧化鐵可以一次注射，不需要分次治療，且具有高度生物相容性與低毒性。iTrast奈米氧化鐵容易在肝臟內轉換成鐵蛋白儲存，待身體需要時再將鐵釋放到血液中，達到治療貧血目的，並降底過敏風險。透過一次注射補充鐵劑，能滿足全球急遽增加的鐵劑補充需求，更能為這些慢性腎病患者提供更簡易解決方式。巨生表示，當初因為相信開發出的奈米氧化鐵藥物有發展機會，及來自工研院的團隊有能力解決未來可能遭遇的問題，他毅然決然離開服務長達25年的工研院，帶領工研院團隊走上創業一途，迎向未來挑戰。巨生生醫未來將專注開發利基型藥物，著重在人體臨床與前臨床試驗階段的加值，提供奈米粒子及奈米微胞前端生技技術，並將產品授權給製藥公司。預計首項產品奈米氧化鐵藥物在四年後進入第二期臨床試驗，並有兩項應用授權，讓巨生生醫營運逐步邁向獲利階段，巨生生醫期許能未來成為台灣奈米藥物的出海口。（本文是華威國際合夥人、泰合及紅電醫董事長李世仁口述）

復星醫藥o2o 策略: 微醫集團 (掛號網) 引路醫療資源互換!

復星醫藥與掛號網簽定戰略合作協議，發展醫療電商平台28/05/2015 18:09《經濟通通訊社２８日專訊》復星醫藥（０２１９６）（滬：６００１９６）公布，和內地 最大互聯網醫療平台－－掛號網簽署了戰略合作協定，雙方將於Ｏ２Ｏ醫療上合作，圍繞醫藥電 商、醫療服務和投資合作等領域，全面展開長期且持續的戰略合作。其中，醫藥電商領域和醫療 服務領域的合作是雙方聚焦的重點。 另外，互聯網醫療服務也是兩大巨頭關注的焦點。雙方協定未來復星醫藥將引導其醫療資源中的醫生加入掛號網的微醫集團，掛號網利用平台優勢，為復星醫藥醫院資源中的專家組提供品 牌塑造、匹配對症患者、實現對症轉診、患者管理以及病歷管理等服務。雙方將整合包括醫生資 源在內的醫療資源對接。

 

 

億觀 (學生創業, 台大應力所微流實驗室) iSperm 快速豬精液檢測 耗材億元商機

億觀生技 布局行動裝置顯微鏡 2015年 05月 29日【經濟日報記者陳昱翔／28日電】億觀生技今（28）日宣布，將於2015台北國際電腦展(Computex 2015)展出智慧型裝置搭配使用的「iSperm種豬精子檢測裝置」及「μHandy行動生物顯微鏡」兩款產品，全面搶攻市場商機。億觀生技表示，iSperm採用獨步全球的軟硬整合技術，能協助畜牧業者在1分鐘內完成種豬精液檢測，而設備購置成本也大幅縮減近9成；而「μHandy行動顯微鏡」則以輕巧設計及親民價格，鎖定中小學生物課堂，期能成為翻轉教室的推手。億觀生技已於去年起展開全球業務布局，iSperm迄今已成功打入台灣市場，並銷售至海外畜牧大國如中國大陸、日本、韓國、荷蘭、西班牙、愛爾蘭及菲律賓等地，目前正積極接洽當地經銷策略夥伴；至於μHandy方面，除了台灣之外，在美國、加拿大、紐西蘭等地已成功建立經銷體系。

【Meet創業之星】iPAD可觀察精子活躍度？億觀台灣首創 撰文者：張嘉伶 發表日期：2014/06/04    iPAD可以上網、可以玩遊戲，但可以觀察精子活躍度，這可能是第一次聽說，億觀生技公司的團隊靠著創意技術，開發出行動顯微軟硬體產品，iSperm種豬精子檢測裝置已經獲得多家種豬場採用，未來也能讓男性在居家使用精子檢測與追蹤，期望能用更便利的方式解決不孕症的問題。 億觀生技的創辦人，是臺大應力所博士林建明以及陳昌佑以及碩士蔣存超，加上中原大學電子所碩士畢業的林書聖、臺大經濟系曾冠穎等五人，一群年輕人可以擦撞出什麼樣的火花，在創辦的初期其實他們也曾迷惘過，在學術領域所學到的知識要如何應用至商品化，這一路走來是很艱辛。 當時這群學生還在台大進行研究時，因長期與台大醫院合作，認識了許多醫生，在一次台大跨領域午餐會，泌尿科蔡醫師拜訪台大應力所微流實驗室團隊，他提出一個男性家用精子檢測與追蹤的需求，期盼學生們能開發出有精確且可實際量產的技術。醫生認為此需求是因不孕症病患無法生育時，男性礙於面子隱私問題不願就醫，並常承擔極大心理與家族壓力、就醫檢查時的痛苦，若有此產品則能協助醫生做早期診斷與長期追蹤。研究團隊多年嘗試多項技術後，包括電訊號偵測、旋轉CD平台等，最後發展出行動裝置顯微方式來檢測精子，並決定由台大技轉出此技術，成立公司將其商品化。 目前擔任億觀執行長的林書聖表示，儘管研發出發點是希望幫男性精子做檢測，但公司第一項產品iSperm是種豬精子檢測裝置，iSperm種豬精子檢測裝置與農科院動物科技研究所長期合作，嘗試解決種公豬場與種母豬場例行精子分析需求，目前已完成量產並與國內多家種豬場接洽測試該產品，陸續將依豬場需求增加更多元的軟體服務。 但下一個階段就是要開發符合FDA醫療器材規範的家用精子檢測裝置，億觀技術長陳昌佑表示，家用精子檢測裝置可提供居家男性精子檢測、長期追蹤精子品質之需求，該資訊可輔助醫生進行診斷與治療，短中期目標為完成GMP廠建置與產品FDA認證；該開發產品與臺大醫院緊密合作，已著手進行臨床數據收集以及醫生、操作者之相關使用建議。 負責產品開發的林建明說，公司產品除了在iPAD裝上微型顯微鏡，比較困難的設計是要怎樣把精子放在鏡頭下面看又不能沾到手跟鏡頭，因此花了一年多時間終於設計出一個模板跟一個蓋子，這樣的套件算是耗材，每次觀察需要一個耗材，花費約1美元（約30元台幣），而估算全台的種豬數量，粗估光是耗材就有上億元的市場商機。 林建明表示，公司也開發出另一個產品是uHandy行動生物顯微鏡，此商品是針對一般消費性市場所設計，購買此顯微鏡可以裝在PAD或者iphone手機上，並會附送生物薄片，可以讓小朋友輕鬆觀察微小生物切片，還可以將此特殊照片上傳至網路上，商品預計在6月底前量產，會鋪貨至科教館或者科博館。  【創業教我的事】對正確事情，對人類有積極意義事情的執著堅持。

Q1：長遠來看，公司想成為一家何種類型的公司？下一步的目標是什麼？你們如何完成？ 公司期許能成為一家國際性的生技公司，下一步短期目標是推廣iSperm產品，進行通路鋪設、媒體曝光等，期望在一年內達損益兩平；中長期目標為家用精子檢測裝置的量產與FDA法規認證，已長期與台大醫院密切合作，具配全盤規劃。

Q2：要達到下一步目標，團隊目前缺乏的資源是？ 資金需求進行家用精子檢測裝置GMP建廠、臨床試驗、FDA申請、與產品量產、行銷推廣。團隊 Team 5人 公司服務 Project 公司期望提供以人為本的相關產品，利用跨領域的技術整合，提高光、電產業的附加價值並跨足醫療產業，提供病患更好的醫療器材並協助台灣產業升級轉型。種豬精子檢測裝置，希望強化台灣畜產業價值，讓畜產業不再仰賴進口昂貴儀器與耗材，節省其成本並幫助台灣農業增加競爭力。家用精子檢測裝置期許能幫助男性及早了解其精子品質，對不孕症患者提供長期追蹤的服務，協助欲生育小孩的夫妻能順利受孕，降低家庭壓力與醫院檢查不便之痛苦。成立時間 Founded Time 2012年9月 主要用戶 User 豬農、醫院、一般消費者。商業模式 Business Model 銷售硬體iSperm以及耗材、銷售uHandy高解析行動顯微鏡

林書聖 億觀生技, 共同創辦人兼執行長 林書聖現任億觀生技執行長。曾任職於兆赫電子資深工程師與工業技術研究院系統晶片科技中心與資訊通訊研究所工程師，擁有跨領域產品設計、開發與整合多年經驗，就讀台灣大學應用力學研究所博士班期間，與一群實驗室夥伴共同創辦億觀生技，開發領先全球之行動顯微鏡技術。  

iLife Discoveries: FDA核准基因檢測: 乳癌復發風險測試與用藥指引(MammaPrint & Blueprint)

FDA Approved New Gene Test can Help Some Breast Cancer Patients Avoid Chemoby Shirley Johanna onMay 28, 2015 at 6:41 PM Cancer News - A new gene test can help oncologists by providing deeper insights into tumors and reduce the use of unnecessary chemotherapy for some breast cancer patients. FDA Approved New Gene Test can Help Some Breast Cancer Patients Avoid Chemo Launched by genetics and genomics company ILife Discoveries in the capital on May 21, the new "MammaPrint & Blueprint" test will help evaluate the risk of distant recurrence of breast cancer. It will help oncologists in identifying patients who can safely forego chemotherapy. "The test can help doctors reduce the use of unnecessary chemotherapy by identifying the risks and its need," Anand Gupta, founder of iLife Discoveries, said in a statement. Not all cancers have the same physiology nor do all tumors follow the same path of development. MammaPrint is a 70-gene assay intended as a prognostic test for women of all ages. According to Ramesh Sarin, senior consultant (surgical oncology) at Indraprastha Apollo Hospitals, with an FDA approved 70 gene-Mammaprint test now available, "we can predict the behavior of tumor by looking at its genomic profiling and manage the patient accordingly". Blueprint is a molecular assay used in addition to the MammaPrint test in a target population of patients with early stage (stage I or II) breast cancer. By identifying the breast cancer subtype, BluePrint allows determination of a patient's potential level of responsiveness to chemotherapy more accurately as compared to currently available technologies, with better correlation to long-term clinical treatment outcomes. "Blueprint along with MammaPrint helps us to pick and choose a proper treatment for the patient based on their specific functional subtype and overall risk of recurrence," said Ajay Sharma, medical oncologist at Rajiv Gandhi Cancer Hospital. Through the gene test results, patients are stratified into two distinct groups - low risk (good prognosis) or high risk (poor prognosis) of distant recurrence. Unlike other tests, the patient is given definitive "low risk" and "high risk" results, eliminating the uncertainty of an intermediate risk score which can affect up to 39 percent of patients tested, the statement added. Source: Medindia

 

攝護腺肥大手術比一比: 紅光PK綠光 雷射攝護腺汽化術

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