In recent years the surgical treatment of benign prostatic hyperplasia has focused on minimally-invasive endoscopic procedures, promising the same functional outcomes but lower perioperative complications compared to traditional techniques such as open prostatectomy and transurethral resection of the prostate (TURP). However, many of these new procedures have not yet passed the test of time.

One of these new techniques is greenlight laser photoselective vaporization of the prostate (PVP) KTP, which uses a high-power laser light to vaporize step by step the prostatic tissue, a procedure described as having low rates of bleeding complications and a short period of postoperative urethral catheterization thus reducing the duration and costs of hospitalization.

Case report

We present the case of a 65-year old man who presented to our department describing urinary incontinence episodes with an ambiguous pattern. The symptoms began about two years prior to presentation, after he underwent a greenlight laser (KTP) PVP.

The patient described the urinary incontinence as small volumes, without voiding sensation, present also during the night, not associated with physical activities. He used two incontinence pads per day, every day during the last two years. He also described an annoying sensation on the urethra during the leakage, different from the normal micturition sensation but impossible to further describe. He added that when the sensation to void is present he can postpone the micturition long enough and he can store even about 400 mL of urine, but this happens rarely, according to a bladder diary he presented.

The medical history before the initial intervention revealed recurrent urinary tract infections with severe dysuria and pollakiuria which could have been caused by an acute prostatitis, which developed into chronic prostatitis, or by a hyperplasia of the prostate, but the patient didn’t have all the medical reports to allow a correct diagnosis. He had been treated for about one year with different antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs), but with poor results. Due to persistent symptomatology he decided to accept the indication to perform a greenlight laser photoselective vaporization of the prostate. He was not asked for a prostatic specific antigen (PSA) measurement before the intervention so this value is also not available. Also, no biopsy was performed before or during the PVP.

The patient reported that after the intervention he had to keep the urethrovesical catheter for seven days, longer than initially discussed prior to surgery. His physician explained that this was due to the fact that he had performed a more aggressive vaporization of the prostatic tissue to avoid symptom recurrence.

After removing the urethrovesical catheter he developed urinary incontinence and complained of pain in the perineal area. His incontinence had the same features as it had in the moment of presentation to our clinic, small quantities of urine leakage without stress incontinence features.

The evaluation after greenlight laser PVP procedure revealed no residual urine in the bladder after voiding, and at uroflowmetry he presented a maximum flow (Qmax) of 18 mL/sec. He underwent treatment for 3 months with antimuscarinics and he performed Kegel exercises as per the recommendation of his doctor, but without any improvement of the symptoms.

Six months after the surgical intervention he underwent another evaluation in a different service and a cystoscopy was indicated. The cystoscopic exam described a lesion of the striated sphincter and sclerotic proliferation of the tissue from the prostatic area, so a TURP was indicated.

Seven months after the laser vaporization the patient performed a TURP. The pathological result confirmed the presence of fibrosis and inflammatory tissue with no signs of malignancy.

After this procedure the incontinence symptoms were unchanged so he was again prescribed antimuscarinics, which had no effect.

He went to a third urologist, who diagnosed stress incontinence and proposed a ProAct antiincontinence treatment, consisting in the placement of a paraurethral device similar to an artificial sphincter, but with a lot of side effects as per the literature. He rejected this treatment and after some other examinations with other doctors the conclusion was that in time this symptomatology is going to become less prominent, so the patient was very confused and hopeless when he presented to us for examination.

After analyzing his medical reports our first diagnosis was urinary incontinence due to sphincter injury and we proposed an invasive urodynamic investigation, a pressure-flow evaluation, the first such procedure until then.

The patient had started treatment with solifenacin succinate 5 mg OD after searching the internet for alternatives, but he forgot to mention this drug in the anamnesis before the urodynamic tests. The pressure-flow exam was in normal parameters and no urinary leakage was observed during the test. After we presented him the results he revealed to us that he was under treatment with solifenacin succinate for 2 weeks and we decided to continue this treatment for 6 months but with 10 mg OD.

The repeated evaluation after this treatment revealed the same symptoms, a PSA level of 0.9 ng/mL and a sterile urine culture. By now, about one year had elapsed after the TURP intervention and we decided to perform a cystoscopic examination. Just before this, we noticed some urine leaking from his urethra. The exam itself was normal.

At about 6 weeks after the patient had finished the treatment with solifenacin succinate we repeated the urodynamic tests (Figure 1) and the results were in normal parameters with the exception of a higher level of bladder pressure during the filling phase, about 10 cm H₂O. There was no leakage during the test.

 

 

 Figure 1. A pressure-flow exam revealing a higher bladder pressure than normal

After this last evaluation we concluded that the patient suffered from stress urinary incontinence due to intrinsic sphincteric deficiency after a surgical intervention on the prostate, with no evidence of overactive bladder on urodynamic tests. But the symptomatology is not very typical for this diagnosis, the leakage is not constantly present and it is in small volumes of urine during the filling phase of the bladder and sometimes the patient is able to fill his bladder without having any incontinence. On the other hand, the patient did not accept an artificial sphincter or other similar device.

Considering that a higher than normal pressure is present in the bladder during the filling phase we thought that decreasing this pressure may prevent urinary leakage, so we decided to perform a set of 30 intradetrusorian injections with botulinum toxin 500 Speywood units.

After this treatment the symptoms subsided and after 2 months another urodynamic investigation reveals a storage pressure of 3-4 cm H₂O, with no leakage or detrusor instability (Figure 2). About 2 years after this treatment the patient has no urinary incontinence and he is not taking any drugs. No other intradetrusorian injection was repeated. Ultrasonographic exploration reveals no postvoiding residual urine and a normal upper urinary tract, while the urine culture is sterile and the PSA is 0.68 ng/mL.

 

PVP is a relatively new technique, intended for the treatment of benign prostatic hyperplasia; we found no similar cases in the medical literature, reporting this unspecific symptomatology after the procedure. Taking into account the fact that after the intervention the urethral catheter was kept for 7 days, which is unusual for this type of procedure according to other medical reports from this medical field that present a period of 24 hours of keeping an urethral catheter and the explanation of the physician who did the intervention that he had performed a more aggressive vaporization of the prostatic tissue to avoid the recurrence of symptoms (according to patient’s reports during the anamnesis) we may hypothesize that during the intervention some complications might have occurred, and could be responsible for the postoperative symptoms. On the other hand, as per the patient’s story, we may speculate that his original symptoms were more likely caused by prostatitis and not by benign prostatic hyperplasia. The case is interesting because it has some particular aspects. First, it is unclear if the leakage was cured by the botulinum toxin treatment or if it was only a coincidence and the incontinence went away by itself as some other physicians had predicted would happen, because during the urodynamic tests there was no clear evidence of detrusor instability and 2 years after the treatment with botulinum toxin the symptoms of incontinence are still absent although the effect of this treatment is not so long lasting. Also the preoperative investigations were incomplete, there was no value available for PSA levels, and no prostatic biopsy had been performed, so we cannot know for sure what kind of condition was in the prostatic tissue. Since no signs of malignancy are currently present, we consider that a malignant etiology can be excluded. Furthermore, the mechanism of incontinence was not clearly explained. The urodynamic explorations underlined only an increased filling pressure in the bladder, with no signs of incontinence or detrusor overactivit

An incomplete preoperative evaluation, in addition to the use of a surgical technique that has not established itself over time, led to the appearance of a bothersome symptomatology for about 2 years, which demoralized the patient. Due to a lack of complete preoperative evaluation prior to the greenlight laser PVP KTP we were faced with an unclear diagnosis, but the persistent symptoms forced us to try to find a solution. At the beginning it was very difficult to make a reasonable choice for some treatment alternative, especially when we had realized the failure of the use of different antimuscarinic drugs. Decreasing the filling pressure in the bladder, when it has a borderline value, can solve this kind of incontinence problems without modifying the voiding parameters. The long period with no evidence of urinary incontinence after the administration of the botulinum toxin was a surprise for both the patient and our team, and it can be considered a very good result for the patient and physicians. If his symptoms will return, we will most likely repeat the injection. In the meantime, we continue to monitor the patient, who has displayed good evolution and at his 2 years follow-up after treatment in our clinic, he has no urinary incontinence and no current need for further treatment.

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2.Plata M, Trujillo CG, Domínguez C, et al. Photoselective vaporization with KTP 180-W green laser for the treatment of lower urinary symptoms secondary to benign prostatic enlargement: Effectiveness and safety at midterm follow-up. J Endourol 2015;29:1253-7. [Crossref]

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