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ORIGINAL ARTICLE
Year : 2006  |  Volume : 22  |  Issue : 1  |  Page : 46-48
 

Safety of holmium laser prostatectomy in patients with cardiac pacemaker implant


Department of Urology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Narmada P Gupta
Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.24654

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   Abstract 

Objectives: The use of the standard monopolar electrocautery is associated with significant risks of implant malfunction in patients on a cardiac pacemaker. It is also associated with a risk of adverse cardiac events due to blood loss and fluid absorption. The properties of the holmium laser prevent the occurrence of these adverse events. We report the successful use of this technology in resecting the gland in patients on a permanent cardiac pacemaker implant. MATERIALS AND Methods: Six patients with permanent cardiac pacemaker implant were treated with holmium laser resection of prostate over a period of two years. Treated patients had bothersome prostatic symptoms and failed to respond to medical therapy. All patients were operated under spinal anesthesia using a high power VersaPulse® PowerSuiteTM Holmium laser source. Normal saline was used as irrigant. Intravesical tissue morcellator was also used to remove the larger fragments in two of the patients. Results : Median patient age was 60 years (range 56-73) and median prostate volume was 40cc (range 20-48cc). None of the patient required blood transfusion or had significant hyponatremia or Transurethral resection syndrome. No patients had any pacemaker malfunction or hemodynamic instability during the procedure or in immediate postoperative period. Improvement in maximum urine flow rate was observed from an average of 7 ml/sec in preoperative period to 22 ml/sec postoperatively at 3 month followup. Conclusions: Holmium laser prostatectomy offers the ideal modality of surgery in patients on a cardiac pacemaker. It helps to avoid additional preparation and minimizes the risk of device malfunction and adverse post operative events.


Keywords: Enucleation, azotemia, heart disease, pacemaker


How to cite this article:
Gupta NP, Kumar R, Yadav R. Safety of holmium laser prostatectomy in patients with cardiac pacemaker implant. Indian J Urol 2006;22:46-8

How to cite this URL:
Gupta NP, Kumar R, Yadav R. Safety of holmium laser prostatectomy in patients with cardiac pacemaker implant. Indian J Urol [serial online] 2006 [cited 2019 Jun 16];22:46-8. Available from: http://www.indianjurol.com/text.asp?2006/22/1/46/24654



   Introduction Top


Benign prostatic hyperplasia (BPH) is a disease of the elderly and a number of patients undergoing transurethral resection of the prostate (TURP) have concomitant cardiac disease and are on a cardiac pacemaker. TURP using the traditional monopolar electrocautery can be associated with malfunction of the pacemaker.[1],[2],[3],[4] The availability of Ho:YAG laser, a multipurpose, multispeciality surgical laser with excellent ablative and hemostatic properties has added another kind of energy to the expanding list of treatment options of BPH. Laser prostatectomy is now a well established therapy for BPH with results as good as with TURP.[5],[6] We report our experience with the use of Holmium laser for resection of prostate (HoLRP) in patients with permanent cardiac pacemakers.


   Materials and methods Top


Six patients with permanent cardiac pacemaker implant have undergone HoLRP over a period of two years at our institute. Preoperative evaluation in all patients included digital rectal examination, prostate specific antigen estimation, International prostate symptom score (IPSS), maximum urine flow rate estimation (Qmax ml/sec) and an ultrasound measurement of prostate volume. The procedure was performed with the patient under spinal anesthesia. We use a high power VersaPulse® PowerSuiteTM Holmium laser source. Laser energy was delivered through an end firing 550 mm fiber at 80 watts. A continuous flow resectoscope with a working element and inner sheath with a fiber-stabilizing guide was used. Normal saline was used as irrigant. The resection began by incising at 5 and 7 o' clock position of the bladder neck. These two incisions were then joined by a transverse incision at the level of the verumontanum and the middle lobe then undermined in a retrograde fashion toward the bladder neck. The lateral lobes were then resected by making incisions at 11 and 1 o'clock and joining these with the first two incisions at the level of the verumontanum with subsequent resection in retrograde fashion. Resected tissue was irrigated out manually using a Toomey syringe only in 4 of the cases. In 2 cases tissue morcellator was also used to remove the larger fragments. Preoperative prophylactic antibiotics were given and a 22 Ch catheter was routinely placed at the end of the procedure. All patients were assessed at 3 months after their surgery.


   Results Top


Median patient age was 60 years (range 56-73) and median prostate volume was 40cc (range 20-48cc). Preoperative symptom score of 22.0 (15-32) and Qmax of 7.0 ml/sec (3-11) was observed. Median operating time was 45 minutes (range 30-60). Weight of the tissue obtained was 6 g (range 4-9). Median difference in preoperative and postoperative hemoglobin was 0.6 gm %. None of the patient required blood transfusion or had significant hyponatremia or Transurethral resection syndrome. No patients had any pacemaker malfunction or hemodynamic instability during the procedure or in immediate postoperative period. The catheter was removed after a median duration of 16 hours (range 12-48). Median postoperative hospital stay was 36 (24-60) hours. At 3 month, the symptom score was 4.6 (3-8) and Qmax of 22 ml/sec (16-28) was noticed.


   Discussion Top


Despite the improvements in technology, the use of diathermy still constitutes a risk to patients with permanent pacemakers.[4] Serious pacemaker dysfunctions have been reported with the use of electrocautery during both open as well as endoscopic surgical procedures.[4],[7] Even though there has been an increase in the use of medical therapy for benign prostatic hyperplasia, transurethral resection of the prostate remains the gold standard in comparison with other modalities.

The use of electrocautery in standard TURP can be associated with significant hazards in the cardiac patient on a pacemaker. The problems include damage to the pulse generator, pacemaker reprogramming, induction of rise in capture threshold and ventricular fibrillation.[2],[3],[4] These problems arise due to the high electromagnetic fields generated by the mono-polar electrocautery, which can be detected by the pacemakers. Apart from proper grounding of the electrocautery, placement of the earthing pad under the buttocks and the availability of an emergency defibrillator, precautions include the availability of an external magnet, intensive monitoring and even a cardiologist in the operating suite.[3]

An additional problem in operating on these patients is their limited cardiac reserve.[1] These patients cannot tolerate large shifts in fluid volume as may occur following bleeding or fluid absorption during surgery. Preventive measures include optimizing pre-operative blood volume, quick surgery with simultaneous hemostasis.

Holmium laser seems to offer the ideal energy source for resection of the prostate in these circumstances. There are no electromagnetic fields generated and thus no effect on the functioning of the pacemaker. Moreover, the low depth of penetration of the holmium laser permits simultaneous hemostasis, minimizing the blood loss and fluid shifts. The surgery can be performed effectively and safely with no complications arising out of the paced state of the patient. None of our patients had any change in the pacing frequency during the surgery or required any additional intervention. The blood loss was minimal as demonstrated by the small change in hemoglobin level. The resected tissue weight ranged from 4 to 9 grams. It is a known fact that a significant amount of tissue (up to 75%)[8],[9],[10] gets evaporated during the procedure. This especially happens with Holmium laser resection of prostate (HOLRP) compared with the procedure of enucleation. With increase in our experience we have now started performing enucleation of prostate. However, in the cases presented in this paper we had performed HOLRP which may be reason behind getting small amount of prostatic tissue as compared to TURP or HOLEP.

Many other surgical techniques utilizing energy sources other than electrical current and resulting in minimal fluid resorption during the procedure can also be employed safely in patients with cardiac pacemaker implants although the results may vary according to the technique employed. These include PlasmaKinetic energy,[11] Potassium-titanyl-phosphate (KTP) laser vaporization,[12] Transurethral microwave thermotherapy[13] and High Intensity Focused Ultrasound.[14]


   Conclusions Top


Holmium laser prostatectomy offers the ideal modality of surgery in patients on a cardiac pacemaker. It helps avoid additional preparations and minimizes the risk of device malfunction and adverse post operative events.

 
   References Top

1.Greene LF, Myers GH Jr, McCallister BD. Transurethral resection of the prostate in patients with cardiac pacemakers. Br J Urol 1969;41:572-8.   Back to cited text no. 1  [PUBMED]  
2.Fein RL. Transurethral resection of the prostate with an in situ internal cardiac pacemaker. J Urol 1967;97:137-9.   Back to cited text no. 2  [PUBMED]  
3.Levine PA, Balady GJ, Lazar HL, Belott PH, Roberts AJ. Electrocautery and pacemakers: Management of the paced patient subject to electrocautery. Ann Thorac Surg 1986;41:313-7.  Back to cited text no. 3  [PUBMED]  
4.Kellow NH. Pacemaker failure during transurethral resection of the prostate. Anaesthesia 1993;48:136-8.  Back to cited text no. 4  [PUBMED]  
5.Gilling PJ, Fraundorfer MR, Kabalin JB. Holmium laser resection of the prostate (HOLRP) versus transurethral resection of the prostate (TURP): A prospective randomized, urodynamic-based clinical trial. J Urol 1997;157:149A.  Back to cited text no. 5    
6.Duc AL, Gilling PJ. Holmium laser resection of the prostate. Eur Urol 1999;35:155-60.  Back to cited text no. 6    
7.Nercessian OA, Wu H, Nazarian D, Mahmud F. Intraoperative pacemaker dysfunction caused by the use of electrocautery during a total hip arthroplasty. J Arthroplasty 1998;13:599-602.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Bukala B, Denstedt JD. Techniques in Endourology. Holmium: YAG Laser Resection of the Prostate. J Endourol 1999;13:215-8.  Back to cited text no. 8  [PUBMED]  
9.Gilling PJ, Cass CB, Cresswell MD, Fraundorfer MR. Holmium laser resection of the prostate preliminary results of a new method for the treatment of benign prostatic hyperplasia. Urology 1996;47:48-51.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Matsuoka K, IIDA S, Tomiyasu K, Shimada A, Noda S. Transurethral Holmium laser resection of the prostate. J Endourol 2000;163:515-8.  Back to cited text no. 10  [PUBMED]  
11.Karaman MI, Kaya C, Ozturk M, Gurdal M, Kirecci S, Pirincci N. Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate:1-year follow-up. J Endourol. 2005;19:734-7.   Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Sulser T, Reich O, Wyler S, Ruszat R, Casella R, Hofstetter A, et al . Photoselective KTP laser vaporization of the prostate: First experiences with 65 procedures. J Endourol 2004;18:976-81.   Back to cited text no. 12    
13.Rubeinstein JN, McVary KT. Transurethral microwave thermotherapy for benign prostatic hyperplasia. Int Braz J Urol 2003;29:251-63.   Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Sullivan L, Casey RW, Pommerville PJ, Marich KW. Canadian experience with high intensity focused ultrasound for the treatment of BPH. Can J Urol 1999;6:799-805.  Back to cited text no. 14  [PUBMED]  




 

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    Abstract
    Introduction
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    Results
    Discussion
    Conclusions
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