The authors have no acknowledgements.

All methods described here have been approved by ethics committee of Beijing Hospital. Indications for surgery are according to the European Association of Urology guidelines for nonneurogenic male LUTS. Contraindications include suspected prostate cancer or detrusor dysfunction.
1. Instruments for Operation
<ol>
	<li>Ensure the availability of a LBO crystal laser with a maximum power of 160 W.</li>
	<li>Employ an endfiring laser fiber and saline solution for intraoperative bladder irrigating.</li>
	<li>Use a 26F laser resectoscope to acquire good vision and to enhance the resection efficiency.</li>
</ol>
2. Preparation for Operation
<ol>
	<li>Provide an intravenous antibiotic preoperatively (intravenous administration of cefuroxime sodium 1.5 g with 100 mL 0.9%sodium chloride solution 30 min before the operation) to all the patients.</li>
	<li>Before the anesthesia, make the patient lay down on the operation table. 
	Note: General anesthesia is effective and appropriate for this operation, Anesthetist will finally determine the mode of anesthesia depending on patient&#39;s general condition.</li>
	<li>Drape the patients in a sterile fashion in the dorsa lithotomy position.Do not perform any skin preparation.</li>
</ol>
3. Procedure Steps
<ol>
	<li>Vaporesection of the Median Lobe
	<ol>
		<li>Examine the whole bladder cavity and prostatic urethra carefully through the resectoscope after the bladder is distended. 
		Note: This step helps urologist to locate some key anatomic sings including bilateral ureteral orifice and verumontanum.</li>
		<li>Mark two lines initially. Ensure that these lines originate at 5 o&#39;clock and 7 o&#39;clock at the bladder neck and continue along the boundaries between the median and lateral lobes, finally terminating at the proximal margin of the verumontanum.</li>
		<li>Set laser power at 80 W. Vaporize the prostate tissue via a fiber by the laser vaporization along these lines until the white cyclic fibers are seen. 
		Note: This is the sign of prostatic capsule. The two lines are merged into single line adjacent to the verumontanum.</li>
		<li>Set laser power at 80 to 100 W. Mark several lines on surface of the middle lobe via laser fiber. Then divide the wedgeshaped middle lobe into several chunks according to these lines through vaporization technique. Then split each chunk from the middle lobe. Finally, remove the whole middle lobe.</li>
	</ol>
	</li>
	<li>Vaporesection of the Lateral Lobes
	<ol>
		<li>Vaporize the tissue at 12 o&#39;clock from the apex of the prostate to the bladder neck by rotating the cystoscope 180&#176;. Do not let the laser fiber go too close to the apex at 12 o&#39;clock which can cause postoperative urine incontinence. 
		Note: This technique enhances the resection rate of the tissue around the prostate roof.</li>
		<li>Identify the lower margin of both the lateral lobes clearly once vaporesection is complete.</li>
		<li>Before removing the lateral lobes, set another 2 similar grooves that originate from the bladder neck at 3 o&#39;clock and 9 o&#39;clock to the proximal end of the verumontanum.</li>
		<li>Remove the tissue of the lateral gland. Set the laser power at 80 to 100 W and mark several lines on the surface of the left lobe via laser fiber that divides the left lobe into several chunks according to these lines through vaporization technique. Then split each chunk from the lobe and finally remove the whole left lobe. Repeat this procedure to remove right lobe.</li>
		<li>Remove the remnant gland tissue along the existing boundary of the capsule.</li>
	</ol>
	</li>
	<li>Channel Trimming
	<ol>
		<li>Remember to trim some protruding tissues around the apex of the gland, to enhance the integrity of the cavity.</li>
		<li>To avoid intraoperative complications (i.e., capsule perforation or sphincter injury), use vaporization technique rather than resection to trim the tissue near the external urethral sphincter and lower the power to less than 80 Watt.</li>
	</ol>
	</li>
	<li>Hemostasis and Catheterization
	<ol>
		<li>Employ a glass syringe that matches the interface of the resectoscope to remove tissue chunk by water flow. Make sure there is no evidence of the residual tissue in the bladder and prostatic fossa through resectoscope, and identify the intact of the ureteral orifices.</li>
		<li>Employ a lower laser power (30 to 50 W) to stop bleeding around the surgical site. Keep an appropriate distance usually 3 to 5 mm between fiber and vessels to acquire a satisfying hemostasis effect.</li>
		<li>Remove the resectoscope from the urethra. Place a 22 French Foley catheter from urethral orifice to bladder cavity gently with 30 mL water in the balloon after sufficiently lubricating urethra by lidocaine gel.</li>
	</ol>
	</li>
	<li>Postoperative Care
	<ol>
		<li>Let the patient lay down on the bed for around 3 h postoperatively in the care unit until they completely wake up from anesthesia. Meanwhile, make sure patient monitors and medical oxygen are available during this time.</li>
		<li>Upon completely waking up, return the patient to the ward. Let the patient begin to drink some water and take some food. Record the urine output and pay attention to the color of the urine.</li>
	</ol>
	</li>
</ol>

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N., Ahyai, S., Bachmann, A., de la Rosette, J., Gilling, P., Gratzke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+and+meta-analysis+of+functional+outcomes+and+complications+following+transurethral+procedures+for+lower+urinary+tract+symptoms+resulting+from+benign+prostatic+obstruction:+An+update.">A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: An update.</a> Eur Urol. 67 (6), (2014).</li><li>Kang, H. W., Jebens, D., Malek, R. S., Mitchell, G., Koullick, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laser+vaporization+of+bovine+prostate:+A+quantitative+comparison+of+potassium-titanyl-phosphate+and+lithium+triborate+lasers.">Laser vaporization of bovine prostate: A quantitative comparison of potassium-titanyl-phosphate and lithium triborate lasers.</a> J Urol. 180 (6), 2675-2680 (2008).</li><li>Herrmann, T. R., Liatsikos, E. N., Nagele, U., Traxer, O., Merseburger, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EAU+Guidelines+Panel+on+Lasers,+Technologies.+EAU+guidelines+on+laser+technologies.">EAU Guidelines Panel on Lasers, Technologies. EAU guidelines on laser technologies.</a> Eur Urol. 61 (4), 783-795 (2012).</li><li>Braeckman, J., Denis, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+BPH+then+2000+and+now+2016+-+From+BPH+to+BPO.">Management of BPH then 2000 and now 2016 - From BPH to BPO.</a> Asian J Urol. 4 (3), 138-147 (2017).</li><li>Bachmann, A., Tubaro, A., Barber, N., d'Ancona, F., Muir, G., Witzsch, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+European+multicenter+randomized+noninferiority+trial+comparing+180+W+GreenLight+XPS+laser+vaporization+and+transurethral+resection+of+the+prostate+for+the+treatment+of+benign+prostatic+obstruction:+12-month+results+of+the+GOLIATH+study.">A European multicenter randomized noninferiority trial comparing 180 W GreenLight XPS laser vaporization and transurethral resection of the prostate for the treatment of benign prostatic obstruction: 12-month results of the GOLIATH study.</a> J Urol. 193 (2), 570-578 (2015).</li><li>Peyronnet, B., Pradere, B., Brichart, N., Bodin, T., Bertrand, P., Members of French Group of GreenLight Users, ., Bruy&#232;re, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+associated+with+photoselective+vaporization+of+the+prostate:+Categorization+by+a+panel+of+GreenLight+users+according+to+Clavien+score+and+report+of+a+single-center+experience.">Complications associated with photoselective vaporization of the prostate: Categorization by a panel of GreenLight users according to Clavien score and report of a single-center experience.</a> Urology. 84 (3), 657-664 (2014).</li><li>Cho, S. Y., Park, S., Jeong, M. Y., Ro, Y. K., Son, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=120W+GreenLight+high+performance+system+laser+for+benign+prostate+hyperplasia:+68+patients+with+3-year+follow-up+and+analysis+of+predictors+of+response.">120W GreenLight high performance system laser for benign prostate hyperplasia: 68 patients with 3-year follow-up and analysis of predictors of response.</a> Urology. 80 (2), 396-401 (2012).</li><li>Elmansy, H. M., Elzayat, E., Elhilali, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Holmium+laser+ablation+versus+photoselective+vaporization+of+prostate+less+than+60+cc:+Long-term+results+of+a+randomized+trial.">Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: Long-term results of a randomized trial.</a> J Urol. 184 (5), 2023-2028 (2010).</li><li>Hong, K., Liu, Y. Q., Lu, J., Xiao, C. L., Huang, Y., Ma, L. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+120W+thulium:+Yttrium-aluminum-garnet+vapoenucleation+of+prostates+compared+with+holmium+laser+enucleation+of+prostates+for+benign+prostatic+hyperplasia.">Efficacy and safety of 120W thulium: Yttrium-aluminum-garnet vapoenucleation of prostates compared with holmium laser enucleation of prostates for benign prostatic hyperplasia.</a> Chin Med J (Engl). 128 (7), 884-889 (2015).</li><li>Hermanns, T., Sulser, T., Fatzer, M., Baumgartner, M. K., Rey, J. M., Sigrist, M. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laser+fiber+deterioration+and+loss+of+power+output+during+photo-selective+80-W+potassiumtitanyl-phosphate+laser+vaporization+of+the+prostate.">Laser fiber deterioration and loss of power output during photo-selective 80-W potassiumtitanyl-phosphate laser vaporization of the prostate.</a> Eur Urol. 55 (3), 679-686 (2009).</li><li>Hermanns, T., Strebel, D. D., Hefermehl, L. J., Gross, O., Mortezavi, A., M&#252;ller, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lithium+triborate+laser+vaporization+of+the+prostate+using+the+120+W,+high+performance+system+laser:+High+performance+all+the+way?.">Lithium triborate laser vaporization of the prostate using the 120 W, high performance system laser: High performance all the way?.</a> J Urol. 185 (6), 2241-2247 (2011).</li><li>Schwartz, J., Renard, J., Wolf, J. P., Moret, M., Iselin, C. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High-power+potassium-titanyl-phosphate+laser+fibres+for+endovaporization+of+benign+prostatic+hyperplasia:+How+much+do+they+deteriorate+during+the+procedure?.">High-power potassium-titanyl-phosphate laser fibres for endovaporization of benign prostatic hyperplasia: How much do they deteriorate during the procedure?.</a> BJU Int. 107 (12), 1938-1942 (2011).</li><li>Son, H., Ro, Y. K., Min, S. H., Choo, M. S., Kim, J. K., Lee, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modified+vaporization-resection+for+photoselective+vaporization+of+the+prostate+using+a+GreenLight+high+-performance+system+120-W+Laser:+the+Seoul+technique.">Modified vaporization-resection for photoselective vaporization of the prostate using a GreenLight high -performance system 120-W Laser: the Seoul technique.</a> Urology. 77 (2), 427-432 (2011).</li><li>Mandal, S., Sankhwar, S. N., Kathpalia, R., Singh, M. K., Kumar, M., Goel, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Grading+complications+after+transurethral+resection+of+prostate+using+modified+Clavien+classification+system+and+predicting+complications+using+the+Charlson+comorbidity+index.">Grading complications after transurethral resection of prostate using modified Clavien classification system and predicting complications using the Charlson comorbidity index.</a> Int Urol Nephrol. 45 (2), 347-354 (2013).</li><li>Gong, Y. G., Liu, R. M., Gao, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Photoselective+vaporesection+of+the+prostate+with+a+front-firing+lithium+triborate+laser:+Surgical+technique+and+experience+after+215+procedures.">Photoselective vaporesection of the prostate with a front-firing lithium triborate laser: Surgical technique and experience after 215 procedures.</a> Eur Urol. 67 (6), 1142-1159 (2015).</li></ol>

This study was sponsored by National Key R&#38;D Program of China (2017YFC0840100 and 2017YFC0840102).

Here, we share our experiences with PVRP. First, PVRP enabled better exposure of the prostate capsule with proper demarcation and reduced the risk of capsule perforation. Second, the tissue removal should be carried out along the surgical capsule, especially with the groove at 12 o&#39;clock, which facilitates tissue resection around the roof of the prostatic urethra and provides a satisfactory tissue removal rate. Third, it is essential to remove the middle lobe initially to acquire a wider channel in the prostatic urethra and enhance the operative visualization. In cases with large middle lobes with bladder neck involvement, we strongly recommend that markers should be drawn on the middle lobe before it is removed separately. Fourth, unlike the thulium laser, LBO laser cannot be absorbed by water, thus, the potential risk of tissue perforation is increased when the laser beam is concentrated at a certain place for a long time. This issue can be easily avoided by distending the bladder, frequently moving the fiber tip, and decreasing the output power when the fiber tip is close to the bladder neck and prostate apex. Finally, for the great majority of the glands, the LBO laser produced a satisfactory hemostatic effect.
We usually decrease the output power to about 50 Watt and maintain an appropriate distance between the fiber tip and hemorrhage site, otherwise excessive tissue vaporization may incur capsule perforation.
The exception to this is bleeding in the bladder neck where the vascularity shows huge variability among patients; in highly vascular areas, LBO laser may be inappropriate for the management of hemorrhage. The likelihood of severe bleeding seems to correlate with the prostate volume, and bipolar TURP loop should be employed in these cases. In one of our studies, four of 35 procedures were converted to TURP to achieve hemostasis. Other researchers reached a similar conclusion that bleeding is the most common intraoperative complication and is also the main reason for longer operative time6. A hemostat can reportedly help manage intractable bleeding during the procedure16. There is a learning curve for beginners to fully grasp the hemostasis technique. So, for the sake of safety during the procedure, we strongly recommend that beginners should not choose the case whose prostate volume is more than 80 mL.
LBO laser showed a significant advantage in for the treatment of BPH and markedly improved both the subjective and objective parameters of patients compared to their baseline data. In addition, the PVRP technique enabled the collection of specimens for pathological examination.
Compare to existing procedure in BPH treatment, PVRP demonstrates satisfactory short-term clinical outcomes and safety in the treatment of LUTS. In addition, this promising technique has apparent advantages in enhancing tissue resection rate and obtaining pathological specimens. With some equipment improvement and procedure adjustment, this technique could provide a blueprint for the prostate enucleation protocol with Lithium Triborate Crystal Laser in the future.

Although transurethral resection of the prostate (TURP) is still accepted as the gold standard in benign prostatic hyperplasia (BPH) surgical treatment, laser surgeries have gradually become more popular due to the better patient tolerance, less intraoperative blood loss, satisfactory efficacy, and shorter postoperative recovery1,2,3. Currently, the most commonly used lasers for the BPH treatment worldwide are generated by lithium potassium titanyl phosphate or lithium triborate (LBO) crystals4,5. Traditionally, these are classified as sidefiring lasers compared to other types of laser, such as holmium laser and thulium laser.
Photoselective vaporization of the prostate (PVP) surgery could considerably decline TURP syndrome due to saline irrigation6,7, and compared to other types of lasers, the reliable efficacy of lower urinary tract syndrome (LUTS) by PVP was verified by a series of studies8,9,10. However, PVP associated with side-firing laser emission also has some disadvantages, including an energy loss of nearly 20% and a short lifespan of the laser fiber11,12,13. Moreover, PVP increases the possibility of missed diagnosis of prostate cancer due to complete tissue vaporization.
The introduction of Photoselective Vaporesection of the Prostate (PVRP) with an end-firing fiber successfully overcame most of the disadvantages of PVP mentioned above. First, the tip is capable of transmitting laser to the tissues with almost no energy loss intraoperatively. Second, when fiber debris collects on the tip, it is straightforward to maintain the ideal output power by simply removing the affected parts. Finally, laser resection enables the collection of specimens for postoperative pathologic examination. Hence, using this protocol in treating BPH could enhance the tissue removal rate, save the operative time and improve the intraoperative safety.

<table><tbody><tr><td>FLARE surgical Laser Fiber</td><td>REALTON</td><td></td><td>The FLARE Surgical laser Fiber is a 600 micron fiber with an straight tip that transmits the laser energy directly. this product is packaged sterile for disposable use and should not be re-sterilized or reused. Dispose of properly after use.</td></tr><tr><td>AURORA Surgical Green Laser System</td><td>REALTON</td><td>pvp-160-021</td><td>The AURORA Surgical green laser system is a diode-pumped, frequency-doubled Nd:YAG solid state laser. The AURORA Surgical green laser system features a &amp;ldquo;Plug and Play&amp;rdquo; capability that self-adjusts to the facility&amp;rsquo;s individual voltage requirements, eliminating the need for electrical modifications. The laser system also includes an air-cooled internal mechanism, ensuring safe operating temperatures with no external water connections. Laser energy emission and system status selection is activated through a surgeon-controlled, color-coded footswitch or system touch screen feature located in the laser console.</td></tr></tbody></table>

photoselective vaporesection of the prostate via an end-firing lithium triborate crystal laser

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging male population. Although it is not a life-threatening disease, BPH causes problems that seriously impact the quality of life. Here, we introduce a new technique called photoselective vaporesection of the prostate (PVRP) in treating BPH, which can be seen as a variation of photoselective vaporization of the prostate (PVP). This procedure presents several advantages compared to the PVP technique including less laser energy loss, less intraoperative complications as well as more tissue resection rate.

A total of 35 patients who underwent PVRP were included in one of our studies. The mean patient age was 72.1 &#177; 7.1 years (range 53-85 years).
Perioperative data are listed in Table 1. The mean laser emission time accounted for nearly 50% of the mean operative time. The blood loss in most patients was &#60; 200 mL. However, the average deviated due to some moderate bleeding cases. Almost 90% of the patients had the catheter removed within 6 days postoperatively.
All patients returned to the hospital for follow-up examinations at the 1st and the 3rd month postoperatively (Table 2). Examinations including urinalysis combined with urine culture were performed to check for postoperative urinary tract infection (UTI).
International Prostate Symptom Score (IPSS) and Quality of Life (QoL) are tools used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of BPH. It also can be used to evaluate the efficacy of BPH treatment. Compared to baseline values, the mean subgroup IPSS and QoL scores improved dramatically during follow-up. The IPSS storage score, IPSS voiding score, IPSS nocturia score, and the QoL score significantly decreased by 75.3%, 83.6%, 51.4%, and 71.7%, respectively (all P &#60; 0.001). For the objective parameters, the mean prostate volume and the serum level of the total prostatespecific antigen decreased to 42.6% and 36.2%, respectively. The mean Qmax increased nearly 2-fold compared to the baseline and reached a maximum of 15.6 mL/s. The mean postvoid residual during followup was only 11.9 &#177; 6.5 mL. Table 3 presents the peri and postoperative complications. According to the modified ClavienDindo classification system15 a widely used and authoritative tool for grading surgical complications, only two cases were Grade 3B, one was a prostate capsule perforation and the other was a bladder neck contracture. Prostate capsule perforation was identified in a single case, which did not require specific therapy. No other perioperative complications were found. Three patients experienced high febrility due to acute UTI caused by extendedspectrum betalactamase Escherichia coli on postoperative days 5-6; all three patients received antibiotics and recovered rapidly. Five patients complained of urgency and frequency, but the urine culture revealed no abnormalities in three of them which could exclude UTI. The other two patients were diagnosed with UTI according to urine culture and recovered after effective antibiotic courses. Only a single patient experienced persistent urinary incontinence in the early postoperative period without evidence of UTI. This urinary incontinence was fully resolved after pelvic floor muscles training for several weeks. Another patient with difficulty in voiding was diagnosed with bladder neck contracture through cystoscopy. This was resolved after a bladder neck incision was performed under general anesthesia on the 40th day after PVRP.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57336/57336fig1.jpg" /> 
Figure 1: Key steps of photoselective vaporesection of the prostate. (A) Mark two lines originally at 5 o&#39;clock and 7 o&#39;clock at the bladder neck. These lines continue along the boundaries between the median and lateral lobes. (B, C) Vaporize the prostate tissue via laser vaporization along these lines, they are merged into single line adjacent to the verumontanum. Mark several lines on the surface of the middle lobe via laser fiber, divide the middle lobe into several chunks through vaporization technique and then split each chunk from the middle lobe, finally remove the whole middle lobe. (D) Vaporize the tissue at 12 o&#39;clock from the apex of the prostate to the bladder neck. (E) Set another two similar grooves that originated from the bladder neck at 3 o&#39;clock and 9 o&#39;clock to the proximal end of the verumontanum. (F-I) Remove the tissue of the lateral glands, the technique is similar to middle lobe resection. (J) Channel trimming. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57336/57336fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="5">Perioperative data of 35 patients with benign 
			prostatic hyperplasia who underwent photoselective 
			vaporesection of the prostate&#160;</td>
		</tr>
		<tr>
			<td colspan="5">Data are shown as mean &#177; SD, or otherwise noted. TURP: Transurethral resection of the prostate; BPH: Benign prostatic hyperplasia; SD: Standard deviation.</td>
		</tr>
		<tr>
			<td colspan="4">Parameters</td>
			<td>Data</td>
		</tr>
		<tr>
			<td colspan="4">Mean operative time (min)</td>
			<td>119.4 &#177; 41.1</td>
		</tr>
		<tr>
			<td colspan="4">Mean laser time (min)</td>
			<td>58.9 &#177; 22.3</td>
		</tr>
		<tr>
			<td colspan="4">Blood loss (ml)</td>
			<td>204.6 &#177; 129.4</td>
		</tr>
		<tr>
			<td colspan="4">Bladder irrigation during the operation (L)</td>
			<td>40.4 &#177; 14.2</td>
		</tr>
		<tr>
			<td colspan="4">Convert into TURP (n)</td>
			<td>4</td>
		</tr>
		<tr>
			<td colspan="4">Postoperative pathology report, n</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="4">BPH</td>
			<td>33</td>
		</tr>
		<tr>
			<td colspan="4">Prostate cancer</td>
			<td>2</td>
		</tr>
		<tr>
			<td colspan="4">Catheterization time (days)</td>
			<td>7.4 &#177; 2.0</td>
		</tr>
		<tr>
			<td colspan="4">Postoperative hospital stay (days)</td>
			<td>7.3 &#177; 1.4</td>
		</tr>
	</tbody>
</table>
Table 1: Perioperative data of 35 patients with benign prostatic hyperplasia who underwent photoselective vaporesection of the prostate. Data are shown as mean &#177; SD or otherwise noted. TURP: Transurethral resection of the prostate; BPH: Benign prostatic hyperplasia; SD: Standard deviation.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="6">Pre- and post-operative functional parameters of 35 patients with benign prostatic hyperplasia who underwent photoselective vaporesection of the prostate</td>
		</tr>
		<tr>
			<td colspan="6">Data are shown as mean &#177; SD. *Significant differences between pre- and post-operative 1 month groups; &#8224;Significant differences between pre- and post-operative 3 months groups; &#8225;Significant differences between postoperative 1 month and postoperative 3 months groups. IPSS: International Prostate Symptom Score; QoL: Quality of life; Qmax: Maximal urinary flow rate; tPSA: Total prostate-specific antigen; SD: Standard deviation. 
			&#160;</td>
		</tr>
		<tr>
			<td>Parameters</td>
			<td>Preoperative (n = 35)</td>
			<td>Postoperative 1 month (n = 35)</td>
			<td>Postoperative 3 months (n = 35)</td>
			<td>F</td>
			<td>P</td>
		</tr>
		<tr>
			<td>Storage scores in IPSS</td>
			<td>8.9 &#177; 3.3*,&#8224;</td>
			<td>4.4 &#177; 3.6&#8225;</td>
			<td>2.2 &#177; 1.9</td>
			<td>33.025</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Voiding score in IPSS</td>
			<td>11.0 &#177; 3.2*,&#8224;</td>
			<td>4.1 &#177; 3.9&#8225;</td>
			<td>1.8 &#177; 1.7</td>
			<td>86.58</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Nocturia score in PSS</td>
			<td>3.7 &#177; 1.1*,&#8224;</td>
			<td>2.4 &#177; 1.1&#8225;</td>
			<td>1.8 &#177; 0.9</td>
			<td>29.15</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>QoL score</td>
			<td>4.6 &#177; 0.9*,&#8224;</td>
			<td>2.3 &#177; 1.5&#8225;</td>
			<td>1.3 &#177; 1.0</td>
			<td>107.08</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Prostate volume</td>
			<td>81.1 &#177; 36.6*,&#8224;</td>
			<td>35.4 &#177; 14.2&#8225;</td>
			<td>34.0 &#177; 14.1</td>
			<td>45.83</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Qmax</td>
			<td>5.3 &#177; 3.9*,&#8224;</td>
			<td>12.5 &#177; 3.4&#8225;</td>
			<td>16.0 &#177; 4.3</td>
			<td>58.84</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>tPSA</td>
			<td>5.8 &#177; 4.6*,&#8224;</td>
			<td>3.1 &#177; 2.8&#8225;</td>
			<td>2.1 &#177; 1.7</td>
			<td>12.21</td>
			<td>&#60;0.001</td>
		</tr>
	</tbody>
</table>
Table 2: Pre- and post-operative functional parameters of 35 patients with benign prostatic hyperplasia who underwent photoselective vaporesection of the prostate. Data are shown as mean &#177; SD. *Significant differences between pre- and post-operative 1-month groups; &#8224;Significant differences between pre- and post-operative 3-months groups; &#8225;Significant differences between postoperative 1-month and postoperative 3-months groups. IPSS: International Prostate Symptom Score; QoL: Quality of life; Qmax: Maximal urinary flow rate; tPSA: Total prostate-specific antigen; SD: Standard deviation.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="3">Peri- and post-operative complications in 
			35 patients with benign prostatic hyperplasia who 
			underwent photoselective vaporesection of the prostate</td>
		</tr>
		<tr>
			<td colspan="3">Complications were graded according to the modified Clavien-Dindo classification system. TURP: Transurethral resection of the prostate.</td>
		</tr>
		<tr>
			<td>Complications</td>
			<td>Patients, n (%)</td>
			<td>Grade</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Acute urinary tract infection</td>
			<td>3 (8.6)</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Prostate capsule perforation</td>
			<td>1 (2.9)</td>
			<td>3b</td>
		</tr>
		<tr>
			<td>Blood transfusion</td>
			<td>0</td>
			<td>2</td>
		</tr>
		<tr>
			<td>TURP syndrome</td>
			<td>0</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Bladder wall injury</td>
			<td>0</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Ureteric orifice injury</td>
			<td>0</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Urethra sphincter injury</td>
			<td>0</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Urinary tract infection</td>
			<td>2 (5.7)</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Urinary incontinence</td>
			<td>1 (2.9)</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Bladder neck contracture</td>
			<td>1 (2.9)</td>
			<td>3b</td>
		</tr>
		<tr>
			<td>Postoperative bleeding</td>
			<td>0</td>
			<td>2</td>
		</tr>
	</tbody>
</table>
Table 3: Peri- and post-operative complications in 35 patients with benign prostatic hyperplasia who underwent photoselective vaporesection of the prostate. Complications were graded according to the modified Clavien-Dindo classification system. TURP: Transurethral resection of the prostate.

Watch this Scientific Journal Video about Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser at JoVE.com

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

Here we present a protocol to perform Photoselective Vaporesection of the Prostate (PVRP) for benign prostatic hyperplasia (BPH) treatment.

The occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem with a high incidence in the aging ...

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Nanyang Technological University

Research

JoVE Journal

Medicine

8.0K Views.  Beijing Hospital, National Center of Gerontology. Hier presenteren we een protocol voor het uitvoeren van Photoselective Vaporesection van de prostaat (PVRP) voor behandeling van benigne prostaat hyperplasie (BPH).

Video: Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

Evaluation of Nanoparticle Uptake in Tumors in Real Time Using Intravital Imaging

Current technologies for tumor imaging, such as ultrasound, MRI, PET and CT, are unable to yield high-resolution images for the assessment of nanoparticle uptake in tumors at the microscopic level1,2,3, highlighting the utility of a suitable xenograft model in which to perform detailed uptake analyses. Here, we use high-resolution intravital imaging to evaluate nanoparticle uptake in human tumor xenografts in a modified, shell-less chicken embryo model. The chicken embryo model is particularly well-suited for these in vivo analyses because it supports the growth of human tumors, is relatively inexpensive and does not require anesthetization or surgery 4,5. Tumor cells form fully vascularized xenografts within 7 days when implanted into the chorioallantoic membrane (CAM) 6. The resulting tumors are visualized by non-invasive real-time, high-resolution imaging that can be maintained for up to 72 hours with little impact on either the host or tumor systems. Nanoparticles with a wide range of sizes and formulations administered distal to the tumor can be visualized and quantified as they flow through the bloodstream, extravasate from leaky tumor vasculature, and accumulate at the tumor site. We describe here the analysis of nanoparticles derived from Cowpea mosaic virus (CPMV) decorated with near-infrared fluorescent dyes and/or polyethylene glycol polymers (PEG) 7, 8, 9,10,11. Upon intravenous administration, these viral nanoparticles are rapidly internalized by endothelial cells, resulting in global labeling of the vasculature both outside and within the tumor7,12. PEGylation of the viral nanoparticles increases their plasma half-life, extends their time in the circulation, and ultimately enhances their accumulation in tumors via the enhanced permeability and retention (EPR) effect 7, 10,11. The rate and extent of accumulation of nanoparticles in a tumor is measured over time using image analysis software. This technique provides a method to both visualize and quantify nanoparticle dynamics in human tumors.

We present a novel approach to quantify nanoparticle localization in the vasculature of human xenografted tumors using dynamic, real-time intravital imaging in an avian embryo model.

Current technologies for tumor imaging, such as ultrasound, MRI, PET and CT, are unable to yield high-resolution images for the assessment of nanoparticle ...

Selective Area Modification of Silicon Surface Wettability by Pulsed UV Laser Irradiation in Liquid Environment

The wettability of silicon (Si) is one of the important parameters in the technology of surface functionalization of this material and fabrication of biosensing devices. We report on a protocol of using KrF and ArF lasers irradiating Si (001) samples immersed in a liquid environment with low number of pulses and operating at moderately low pulse fluences to induce Si wettability modification. Wafers immersed for up to 4 hr in a 0.01% H2O2/H2O solution did not show measurable change in their initial contact angle (CA) ~75&#176;. However, the 500-pulse KrF and ArF lasers irradiation of such wafers in a microchamber filled with 0.01% H2O2/H2O solution at 250 and 65 mJ/cm2, respectively, has decreased the CA to near 15&#176;, indicating the formation of a superhydrophilic surface. The formation of OH-terminated Si (001), with no measurable change of the wafer&#8217;s surface morphology, has been confirmed by X-ray photoelectron spectroscopy and atomic force microscopy measurements. The selective area irradiated samples were then immersed in a biotin-conjugated fluorescein-stained nanospheres solution for 2 hr, resulting in a successful immobilization of the nanospheres in the non-irradiated area. This illustrates the potential of&#160;the method for selective area biofunctionalization and fabrication of advanced Si-based biosensing architectures. We also describe a similar protocol of irradiation of wafers immersed in methanol (CH3OH) using ArF laser operating at pulse fluence of 65 mJ/cm2 and in situ formation of a strongly hydrophobic surface of Si (001) with the CA of 103&#176;. The XPS results indicate ArF laser induced formation of Si&#8211;(OCH3)x compounds responsible for the observed hydrophobicity. However, no such compounds were found by XPS on the Si surface irradiated by KrF laser in methanol, demonstrating the inability of the KrF laser to photodissociate methanol and create -OCH3 radicals.

We report on a process of in situ alteration of HF treated Si (001) surface into a hydrophilic or hydrophobic state by irradiating samples in microfluidic chambers filled with&#160;H2O2/H2O solution (0.01%-0.5%) or methanol solutions using pulsed UV laser of a relative low pulse fluence.

The wettability of silicon (Si) is one of the important parameters in the technology of surface functionalization of this material and fabrication of ...

Engineering

One Minute, Sub-One-Watt Photothermal Tumor Ablation Using Porphysomes, Intrinsic Multifunctional Nanovesicles

We recently developed porphysomes as intrinsically multifunctional nanovesicles. A photosensitizer, pyropheophorbide &alpha;, was conjugated to a phospholipid and then self-assembled to liposome-like spherical vesicles. Due to the extremely high density of porphyrin in the porphyrin-lipid bilayer, porphysomes generated large extinction coefficients, structure-dependent fluorescence self-quenching, and excellent photothermal efficacy. In our formulation, porphysomes were synthesized using high pressure extrusion, and displayed a mean particle size around 120 nm. Twenty-four hr post-intravenous injection of porphysomes, the local temperature of the tumor increased from 30 &deg;C to 62 &deg;C rapidly upon one minute exposure of 750 mW (1.18 W/cm2), 671 nm laser irradiation. Following the complete thermal ablation of the tumor, eschars formed and healed within 2 weeks, while in the control groups the tumors continued to grow and all reached the defined end point within 3 weeks. These data show how porphysomes can be used as potent photothermal therapy (PTT) agents.

We developed novel intrinsic multifunctional nanovesicles called porphysomes, which have structure-dependent fluorescence self-quenching and unique photothermal properties, thus functioning as potent photothermal therapy agents. We formulated porphysomes using high pressure extrusion and investigated their photothermal therapy efficacy in a xenograft tumor model.

We recently developed porphysomes as intrinsically multifunctional nanovesicles. A photosensitizer, pyropheophorbide &alpha;, was conjugated to a ...

Bioengineering

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate (HoLEP).

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the quality of life. BPH includes 2 major treatments: medication and surgery. Surgical treatment is often the most effective and final intervention. Holmium laser enucleation of the prostate (HoLEP), one of the most efficient surgical procedures for BPH, is conducted transurethrally. During surgery, the most important and most difficult part is to locate the surgical capsule of the prostate, which is consistent to the idea of anatomic surgery. Different skills may be needed in treating different parts of the prostate. HoLEP tends to be efficient and safe with good hemostatic properties, and able to treat bladder calculus, which may be the complications of BPH. The technique is particularly suitable for prostate of varying volumes and sizes. Indeed, HoLEP also presents certain disadvantages, such as a long learning curve and costly equipment. Regardless, this method may be the "new standard" and the excellent method for the surgical treatment of BPH.

Surgical Treatment for Benign Prostatic Hyperplasia: Holmium Laser Enucleation of the Prostate HoLEP.

Here we present a safe and efficient protocol, holmium laser enucleation of the prostate, to treat benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) commonly occurs among elderly males. The condition causes symptoms in the lower urinary tract, thereby reducing the ...

Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia Using a 980 nm Diode Laser

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH1. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis2. The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect3. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid&#39;s arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.

Here, we present a protocol for modified 980 nm diode laser enucleation to treat large volume benign prostatic hyperplasia.

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. ...

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

Focal Laser Ablation of Prostate Cancer: An Office Procedure

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually similar to a fusion biopsy and is performed under local anesthesia in a clinic setting; treatment time is usually less than one hour. Laser insertion is guided by ultrasound; lesion targeting is via magnetic resonance imaging-ultrasound (MRI/US) fusion, as in targeted prostate biopsy. Real-time ablation monitoring is achieved utilizing a thermal probe adjacent to the laser fiber. The video demonstrates procedure planning, patient preparation, various steps during the procedure, and treatment monitoring. Safety, feasibility, and efficacy of this approach have been established during a previous trial. Outpatient FLA under local anesthesia is an option for management of intermediate risk prostate cancer.

This article presents and describes an outpatient treatment for prostate cancer using focal laser ablation. Laser catheter placement is guided by MRI-ultrasound fusion imaging in a fashion similar to prostate needle biopsy. Treatment is monitored in real-time with a thermal probe, placed adjacent to the laser fiber.

In this article, we describe and illustrate an outpatient procedure for focal laser ablation (FLA) of prostate cancer (PCa). The procedure is conceptually ...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...

Laser-assisted Selective Ablation of Porcine Corneal Endothelial Cells: A Technique to Induce Focused Porcine Corneal Endothelial Injury for Ex Vivo Studies

Source: Holzhey, A. et al., <a href="https://www-jove-com.remotexs.ntu.edu.sg/v/60542">Development of a Noninvasive, Laser-Assisted Experimental Model of Corneal Endothelial Cell Loss.</a> J. Vis. Exp. (2020)
This video demonstrates a non-invasive laser-assisted procedure to selectively damage the corneal endothelial cells in the porcine eye. The developed ex vivo model of endothelial cell damage can be used to study diseases of the corneal endothelium.

Source: Holzhey, A. et al., Development of a Noninvasive, Laser-Assisted Experimental Model of Corneal Endothelial Cell Loss. J. Vis. Exp. (2020)
This ...

Photoselective Vaporesection of the Prostate via an End-firing Lithium Triborate Crystal Laser

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