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Background and Objective: Research interests in laser prostatectomy continue to evaluate a variety of wavelengths and treatment parameters in an effort to optimize treatment. Recently, a semiconductor diode laser with a wavelength of 805 nm has become available for clinical use; however, free-beam noncontact applications were limited by the low power output (25 W). In this study in the canine prostate, the possible potentiating effects of intravenously administered indocyanine green (ICG) were evaluated with the 805 nm diode laser., Study Design/materials and Methods: A total of 16 fixed position, free-beam lasings were performed at 25 W for 60 sec in four dogs with eight lasings before and eight lasings after ICG administration. Endoscopic observations and measurements of lesion volumes were used to evaluate the laser-tissue interactions., Results: Prior to ICG administration, we observed that side fire irradiation produced primarily small coagulative lesions. Following ICG administration, however, immediate and more noticeable tissue vaporization occurred, although total lesion size was not increased. Pathologic review demonstrated less coagulation and hyperemia, but a larger vaporized cavity in the ICG treated tissue., Conclusion: These findings suggest intravenous ICG alters laser-tissue interaction with the 805 nm diode laser in the canine prostate. The use of the 805 nm diode laser with enhancing chromophores deserves further investigation.

Degenerate PCR primers were designed from the N-terminal amino acid sequence of a glutamyl aminopeptidase (PepA) from Lactococcus lactis. These primers were used to screen a lambda library for clones containing the gene (pepA) encoding PepA. The DNA sequence of a 2.1 kb fragment containing pepA was determined. The sequence revealed the presence of one complete and two incomplete open reading frames (ORFs). The complete ORF encodes a putative protein of 353 amino acids with a predicted N-terminal sequence identical to that determined for purified PepA. The pepA gene was subcloned on an Escherichia coli plasmid vector and production of active PepA was confirmed by means of a zymogram. Mutants of L. lactis in which the pepA gene was inactivated grew to normal cell densities in milk but exhibited a reduced growth rate during the exponential phase. Thus whilst PepA is required for optimal growth it is not essential.

Objectives: To assess the safety and efficacy of endoscopic laser ablation of the prostate (ELAP), performed with the Urolase fiber and the neodymium:yttrium-aluminum-garnet laser, compared to transurethral resection of the prostate (TURP) in patients with bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH)., Methods: In this multicenter, prospective, randomized study, a total of 151 patients were treated (ELAP, 76; TURP, 75) of whom 137 completed 1 year follow-up (ELAP, 67; TURP, 70). Safety parameters included measurement of preoperative and 24-hour postoperative sodium, hematocrit, and hemoglobin values and careful monitoring of adverse events. Efficacy was assessed with the American Urological Association symptom score (6), urinary flow rates, and residual urinary volume measurements., Results: There was 1 death in each group during the study period unrelated to the treatment procedure. There was a clinically significant improvement in all efficacy parameters in both groups. Between group comparisons favored TURP in maximum flow rate, residual urinary volume, and symptom score. ELAP had a better safety profile than TURP in the defined safety parameters of drop in hemoglobin and hematocrit values. In 16% of patients, a blood transfusion was required after TURP compared with no transfusions in the ELAP group. Urinary tract infections and dysuria were more frequent in the ELAP group., Conclusions: ELAP performed with the Urolase fiber is a useful alternative therapy to TURP in patients presenting with bladder outflow obstruction secondary to BPH.

Objective: To compare the diagnostic yield of ultrasonically guided and digitally guided systematic biopsies of the prostate., Patients and Methods: Fifty two patients with suspected but unproven carcinoma of the prostate underwent simultaneous transrectal ultrasonography (TRUS)-guided and digitally guided systematic biopsies of the prostate. A mean of 12 cores was obtained from each patient. On average more cores were obtained with TRUS guidance (mean 6.7) than with digital guidance (mean 5.3)., Results: Cancer was detected in 19 patients and the diagnosis was made by both techniques in 16. Two patients had tumour detected only with TRUS guidance and one only with digital guidance. No complications occurred., Conclusion: This study indicates that there is no significant difference between TRUS guidance and digital guidance to direct systematic biopsies of the prostate. The use of routine TRUS in screening programmes is now in doubt.

Objective: To assess how elderly and medically unfit patients cope with day case surgery in a urological unit using sedoanalgesia., Patients and Methods: One hundred patients (mean age 78 years, range 59-97) either over the age of 75 years, or with an American Society of Anesthesiologists (ASA) status of 3 or 4 (58 patients) were studied before and after surgery to assess their medical condition, home circumstances and how they coped with their first day after the operation., Results: Ninety patients found the procedure good or acceptable and 86 thought having their operation and going home on the same day was a good idea., Conclusion: Elderly and medically unfit patients can be treated safely with no serious complications using sedoanalgesia in a well organized Day Unit equipped with full monitoring facilities.

A number of endoscopic laser strategies have been employed in the treatment of symptomatic benign prostatic hyperplasia at our hospital. The post-operative results in 102 patients are presented. Sidefiring fibres were coupled with the Nd:YAG laser to produce a deep coagulative necrosis within the prostatic adenoma. This approach was associated with a short operative time and a delay of up to three months before treatment effect. Contact laser techniques (with both the 1064 nm and 805 nm lasers) were used to vaporize prostatic tissue in an attempt to produce a defect similar to that following TURP. This provided an immediate treatment effect with early removal of catheters. The operative time, however, was long and this limited the procedure to glands of less than 40 ccs. The hybrid approach (combining laser prostatotomies with coagulation) provided an immediate relief of obstruction with an additional delayed effect as the coagulated cavity matured. All approaches were associated with minimal haemorrhage and limited morbidity with encouraging improvements in both symptom scores and uroflowmetry. The various advantages and disadvantages of each endoscopic laser strategy are discussed.

A global analysis of surgical bed dynamics in a District General Hospital over a typical 18 working day period is presented. All surgical specialties are represented. A total of 2,484 bed days were studied. Bed occupancy was 92 per cent. Seven per cent of bed capacity was occupied by acute medical patients. The operation cancellation rate was 7 per cent. Fifteen per cent of beds were closed for financial reasons. The study of admission and the stay and discharge policies of different specialties indicated that potential cost improvements could be made by the introduction of more day surgery, day of surgery admission, efficient discharge, ring fencing of beds and improved hospital data collection. While these recommendations are financially desirable, their impact on patients and staff remains to be seen.

Recently great interest has been generated in alternatives to transurethral resection for benign prostatic hyperplasia. Lasers are currently being assessed, but marketing has for the moment outstripped basic science. A cystoscopic approach was used delivering Nd:YAG or KTP laser energy via forward and sidefiring fibers and contact tip devices in 51 patients. The sidefiring device is intended to coagulate a volume of prostate that subsequently sloughs, leaving a cavity. Treatment of the apical and middle lobe tissue using this technique was unsatisfactory. A further disadvantage was the interval between treatment and improvement in urine flow, which was approximately 6 weeks. The use of temporary prostatic stents has helped to overcome this delay in treatment effect. Encouraging early results have been achieved using forward-firing fibers to treat apical and middle lobe tissue. The use of contact tip devices to perform bloodless prostatotomies in combination with sidefire or bare fiber has also proved useful. Laser prostatectomy is an exciting field with considerable potential but remains in the developmental stage.

The specific antagonist flumazenil has been shown to reverse the central actions of benzodiazepines. Its use, in day-case procedures performed under benzodiazepine sedation, offers the potential for enhanced patient recovery. However, concern has been expressed over the possibility of resedation given the short elimination half-life of flumazenil. A randomised, double-blind, placebo controlled trial was therefore designed to assess patient recovery profiles after flumazenil. A total of 44 adults were entered into the trial. Recovery was assessed by means of a battery of psychomotor tests performed pre- and postoperatively. Psychomotor function in patients receiving flumazenil returned to, or near to, baseline levels within 15 min of administration--an improvement maintained throughout the 6 h test period. Patients receiving placebo did not recover fully until the 2 h test point--significant differences between the two groups existing at 15 min and 1 h. In this study, flumazenil effectively reversed midazolam-induced sedation without evidence of resedation. The implications for day-case surgery are discussed.