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Competing Interests: Jonas Herrmann ist Proctor für HoLEP Operationen für Boston Scientific.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Holmium Laser Enucleation of the Prostate (HoLEP) was established 20 years ago as an alternative to Transurethral Resection of the Prostate (TUR-P) based on improved morbidity in patients with benign prostate syndrome (BPS). HoLEP can be applied independently to almost all sizes of prostate glands and is recommended in national and international guidelines. Although the HoLEP procedure has a good reputation, many patients still prefer conservative treatment due to fears of side-effects such as pain and urinary incontinence. The aim of this study was to identify patients' feelings, fears and perception of their HoLEP treatment based on Patient-reported Outcome Measures (PROMs) via questionnaires., Material Und Methods: During the time period from June to December 2020, 152 consecutive patients were treated by HoLEP due to BPS and were interviewed based on questionnaires right after their surgical treatment and 3 months later concerning their satisfaction as well as micturition and continence. Based on a written informed consent, 112 patients were included in the study, and a complete 3-month follow-up was available for 88 patients., Results: The mean volume of enucleated prostate tissue was 62.1 [g] and the mean prostate volume estimated pre-operatively (trans-rectal ultrasound) was 83.1 [cm3]. Overall patient-reported satisfaction with the hospital stay including surgical treatment was 94.6%; after 3 months it was 91.8%. Concerning micturition, 76.5% of the patients reported satisfaction after surgery and 80.4% were satisfied after 3 months. Urinary incontinence was reported in 8.3% initially and in 9.1% after 3 months. Positive answers to questions concerning the quality of life index [L] were obtained in 62.1% initially and their number increased to 85.7% after 3 months. The share of negative answers decreased from 11.7% after surgery to 3.4% within the 3-month follow-up., Discussion: HoLEP is a well-established treatment of BPS with lower side-effects compared with TUR-P according to the literature. To address doubts and misgivings, it is important to perform surveys on subjective patient satisfaction after the surgical procedure and over time. The high patient satisfaction could help future patients and the urologists treating them to establish the indication for HoLEP treatment earlier in order to avoid severe LUTS or catheterization., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Management of urolithiasis has undergone fundamental changes with the introduction of extracorporeal shock wave lithotripsy (ESWL) and percutaneous and ureterorenoscopic techniques in the 1980s. Since then, these minimally invasive techniques have been continuously optimized and specific laser techniques for stone disintegration have emerged. Besides the established holmium laser, other types of lasers are also emerging. Especially the thulium fiber laser is the subject of promising research due to its variable adjustment options. In terms of patient safety, both holmium and thulium techniques seem to be similar . While serious direct physical lesions are rare, there is increasing evidence of clinically relevant secondary thermal injury due to increased temperatures in the upper urinary tract during treatment. Our research group has recently demonstrated in both in vitro and in vivo (porcine animal model) experiments that monitoring the fluorescence spectra of calculi allows precise target differentiation between stone, tissue, and endoscope components. Consequently, pulse emissions were only emitted when stone material was detected. We believe that target monitoring will minimize the risk of laser-induced urothelial damage and decrease energy release into the upper urinary tract allowing adequate temperature management.

According to the current treatment algorithm, surgical treatment of benign prostatic syndrome (BPS) is the next step after a pharmacological treatment. In addition to conventional transurethral resection of the prostate (TURP), much interest is shifting towards alternative sugical techniques such as transurethral microwave therapy (TUMT),transurethral needle ablation of the prostate (TUNA) and several laser techniques.

Multidirectional and unidirectional glenohumeral instability constitute an important clinical problem, particularly in the athlete. Numerous methods have been described for treatment of glenohumeral instability, including closed management, open and arthroscopic procedures, but none have achieved universal success. The purpose of this study was to evaluate the effect of laser energy at non-ablative energy densities on the mechanical properties of joint capsular tissues in a rabbit model. Femoropatellar joint capsular tissues from 12 mature New Zealand white rabbits were harvested and divided using a randomized block design into three treatment groups with laser at 5 W, 10 W and 15 W, and one control group. Mechanical testing was performed before and after application of laser energy. The application of laser energy resulted in 9%, 26% and 38% reduction in capsular tissue length for the 5-W, 10-W and 15-W group, respectively. Laser energy caused a significant decrease in tensile stiffness in the 10-W and 15-W groups only (P < 0.05). Laser energy did not change the relaxation properties of capsular tissue at any energy density. The loads required to return specimens to their original length were significantly lower for the 5-W group than for the 10-W and 15-W groups. This study demonstrates that significant capsular shrinkage can be achieved with the application of non-ablative Ho:YAG laser energy without detriment to the relaxation properties of the tissue, although at higher energy densities, laser energy did lessen capsular stiffness properties.

The results of 320 patients after holmium:YAG laser treatment in comparison to conventional mechanical methods during a 2-year period were analyzed in a prospective, randomized study. The following knee injuries were included in the study: meniscal lesion, chondromalacia, combined meniscal/cartilage lesion, rheumatoid synovitis and femoropatellar pain syndrome. Because strict inclusion criteria were used, the patient series is homogeneous, not only in terms of sex, age, injured side and intrasurgical diagnosis, but also because the initial values of the Lysholm score modified after Klein are similar. After 2 years, the results of the laser series were significantly improved, whereas the results for the conventional series, especially for chondromalacia and synovitis, did not show the same improvement. Analysis of the effect of various instrumentation and the laser system itself show differing results for the different knee disorders. The hemostatic effect of the holmium-YAG laser was excellent during surgery for all knee disorders, including surface treatment. The operation time for laser surgery was not prolonged, as is often stated. This study shows that chondromalacia, combined meniscal-cartilage lesions and chronic rheumatoid synovitis are treated more effectively and with better results with the holmium-YAG laser than with conventional arthroscopic methods. Furthermore, laser treatment of meniscectomy and lateral retinacular release is also better than mechanical techniques. This study demonstrates the feasibility of the holmium-YAG laser for arthroscopic surgery. A combination of different instruments seems to be most effective.

As in the knee joint, lasers can be used during ankle arthroscopy for their resective and ablative properties. Reports on arthroscopic treatment of degenerative and post-traumatic disorder of the ankle by conventional techniques are encouraging. We have used laser in ankle arthroscopy in three main situations: (1) When exuberant scar tissue from previous capsulo-ligamentous damage (e.g. after ankle sprain) symptomatically restricts range of motion and causes pain (ankle impingement). Laser is used in this case at middle energy, as a resector. (2) In the presence of cartilaginous lesions, as in osteoarthritis, flake fractures or osteoarthritis, flake fractures or osteochondrosis dissecans. Here laser is used at lower energy to reshape the cartilaginous surface without resective effect ("welding"). (3) When impaired range of motion is due to osteophytic rims, mainly at the anterior tibia, resulting from previous capsular lesions. Laser is then used at high energy to cut excessive bone. A series of 16 patients underwent ankle arthroscopy at our clinic, mainly for post-traumatic disorders, including impingement, osteochondrosis dissecans and osteoarthritis. The most frequently encountered intraarticular findings were impingement by post-traumatic synovitis and scar tissue of the anterio-lateral and postero-lateral compartments, with or without an osteophytic rim of the distal anterior tibial border. Scar tissue, synovitis and osteophytes were debrided in half of the patients purely mechanically (with arthroscopic scissors or shaver) and in the other half with the holmium laser. The results are encouraging; 50% of patients had no symptoms at all at follow-up (9.5 months on average), and another 38% were satisfied with a significant improvement. In two cases, no improvement at all occurred: one patient complained of persistent pain with lack of objective findings and is believed to have developed "insurance neurosis." The other had severe postinfectious osteoarthritis that was operated too late in the course to influence pain positively. Concerning the clinical, functional and subjective follow-up results there was no relevant difference between the two groups. We recommend ankle arthroscopy to treat post-traumatic impingement syndromes of the antero-lateral, antero-medial and postero-lateral compartments of the ankle joint; the use of lasers seems to have a slightly better analgetic effect, allows an easier approach than is the case with shavers or other bulky arthroscopic resectors, and allows shaping of convex resection surfaces, which cannot be performed with a shaver.

Arthroscopic widening of the subacromial space in the case of outlet impingement syndrome has many advantages over the open procedures. Arthroscopic subacromial decompression in case of impingement syndrome if refractory to conservative therapy, is an established procedure. The purpose of this study was to evaluate the results of arthroscopic subacromial decompression using the holmium:YAG laser and compare them with the result of the conventional arthroscopic procedure. In a prospective study, 47 patients with stage II and III impingement syndrome were divided into two groups. The first group (20 patients) underwent conventional arthroscopic subacromial decompression. The second group (27 patients) underwent arthroscopic subacromial decompression performed with the holmium:YAG laser. The results were assessed using the constant score preoperatively and postoperatively with a follow-up of at least 1 year for each patient. Improvement in the laser group was seen in the criteria of motion and pain. Abduction power, found to be improved after 1 week and 6 weeks in earlier investigation, showed no significant improvement at the follow-up time of 1 year. The average score of both groups increased after 1 year: in the laser group from 57.4 preoperatively to 75.3, in the conventional group from 49.7 to 65.7. There were no specific complications due to the laser application.

The first applications of laser in surgery of the locomotor apparatus in the early 1980s used the haemostatic properties of laser to diminish the amount of substitution of coagulation factors in haemophiliac patients. Only since the early 1990s has a device been available in corporating the pulsed holmium:YAG laser which works in a fluid medium without relevant side effects. Apart from haemostasis, the cutting function and tissue ablation, together with the thermal shrinking effect, are exploited in arthroscopy and percutaneous disc decompression. Now that the biophysical mechanisms of action have been elucidated, nothing stands in the way of the use of infrared lasers in open surgery of the locomotor apparatus in some indications. In a prospective clinical study we included 30 consecutive patients who underwent open laser surgery from November 1992 to August 1994, for the following indications: the sparing haemostatic tissue ablation was used for synovectomy or for bony resection in osteophytes and osteochondromas of different locations, an osteoid osteoma and a painful sacral hyperplasia in the presence of incomplete sacral meningomyelocele. With bleeding eliminated, the shaping was much easier. The non-ablative shrinking produced less tissue loss and a stabilizing strengthening of tissue at the margins of soft tissue resections, e.g. in jumper's knee, tennis elbow and Achilles tendon cysts. All laser functions that are useful in open surgery have also been used in sequestered disc herniations that are inaccessible a percutaneous procedure and, in spinal decompression, for remodelling of the posterior spine contour. An analgesic effect of laser limited the postoperative administration of analgesic drugs to an average of 3 days. No complications related to the laser treatment were observed. At follow-up 12-21 months after operation, 25 of the 30 patients in this heterogeneous population showed complete or near-total healing of the operated pathological finding, and a further 3 patients showed significant improvement. To what extent these very encouraging results will persist will be shown by long-term observation.

Current arthroscopic treatments do not address satisfactorily the capsular redundancy frequently associated with the Bankart lesion in recurrent anterior dislocation. Although the Bankart lesion heals, many of the recurrences after arthroscopic procedures are due to capsular redundancy and the laxity of glenohumeral ligaments. We propose that laser-assisted capsular shrinkage (LACS) be combined with arthroscopic labrum reattachment. As shown by Market et al., significant capsular shrinkage can be achieved by the application of non-ablative Ho:YAG laser energy without detrimental effects to the relaxation properties of the tissue. For 1 year we have used LACS together with labrum suture in 18 shoulders in 18 patients (mean age 24.6 years). All patients suffered from chronic anterioinferior recurrent dislocation. The labrum suture was realized by an anterior reattachment (REVO screws, Linvatec, USA) or by transglenoid suture. Two or three sutures were passed through the torn labrum with 2/0 non-absorbable suture material. The LACS procedure was performed with a holmium:YAG laser (VersaPulse, Coherent, USA) at an energy of 10 W (1 J, 10 Hz) with a 30 degrees curved handpiece. All patients were immobilized in a sling for 4 weeks postoperatively. Physical therapy was begun at 1 month with passive and active exercise. To date, none of the patients have had a recurrence. Seven of 18 patients returned to their previous sports activity, and at the same level. None of the patients had an iatrogenic lesion due to the laser application or labrum suture. Compared to the other shoulder, the loss of external rotation with the arm 90 degrees abducted was 30 degrees at 4 weeks and 10 degrees at 4 months. We think that the LACS procedure is a good treatment for the capsular redundancy that is frequently associated with Bankart's lesion in recurrent anterior dislocation and is probably responsible for the high failure rate in current arthroscopic procedures. Our results are short-term results, but we expect the capsular shrinkage associated with the labrum reattachment will provide a long-term success rate that is comparable to open procedures.

The in vitro study presented helps to clarify the biophysical mechanisms and tissue interactions of the holmium laser at the point of impact on the surface of cartilage-bone specimens investigated in different experimental settings. A striking event is the creation of a vapor bubble that opens up access for the laser beam through the fluid medium. This bubble shows a reproducible dynamic behavior function of the laser irradiance and the angle of incidence of the delivery fiber. These determine directly the amplitude of the pressure waves induced when the bubble collapses. Apart from this acoustic effect, which is correlated with epicentric histological features that can hardly be considered biologically relevant, a thermal effect is recognized that is finally responsible for the ablation and tissue damage. It induces typical histological alterations that can be observed along the laser beam axis, with a penetration function mainly of the irradiance but also of the angle of incidence. Nevertheless, at a pulse energy of 1 J and an irradiation angle of 30 degrees, the recorded overall depth of the immediate histological changes was down to 500-600 micrometers. Thus, in realistic working conditions, the damage observed after cartilage sealing with the holmium laser remains within an absolutely acceptable range. This is in agreement with the better results compared to mechanical cartilage debridement that have been reported in previous prospective clinical studies.

The Ho:YAG laser has been found to be a safe and efficacious adjunct to many arthroscopic shoulder procedures. The curved, thin handpieces are easily manipulated around the surfaces of the joint. Postoperative inflammation is minimized, and a versatile instrument that can cut, coagulate, ablate, and cauterize has obvious benefit where optimal visualization is required. The potential for chondral contouring and bone resection is currently being studied, and the use of laser-induced thermal contraction of soft tissue collagen may add some exciting possibilities to the treatment of joint instabilities.

Various laser devices (CO2, CO, Nd: YAG, and holmium: YAG lasers) have been used on pig livers and on dog kidneys for comparison with conventional surgical instruments (electroscalpel, cryoscalpel, and scalpel). CO2 and CO lasers caused the least tissue damage, followed by the holmium laser; severe damage was caused by the Nd: YAG laser. The order was reverse for coagulative effect. The conventional reference instruments showed a weaker hemostatic effect. Surfaces cut by laser healed in four to eight weeks without complications. Remnants of charred tissue in various quantities could still be detected after eight weeks in all cases where CO2, CO, and Nd: YAG lasers had been used. This obviously did not affect scar formation.