If I were u, I would do a lot of research on FLA before deciding. Last time when I google searched FLA, I could not find any published scientific papers or trials on the subject.
Without any scientific and clinically trial data on FLA, there is more risk. For holep, there are a lot of data which takes months to digest.
Some procedures sounds good on the surface and there are users said very good things about them. PAE is an example. Some users said, it was the best BPH surgery and worked like a miracle for them and no RE! But when I searched the latest sicientific literature and clinical trials, they reported more than 50% sexual dysfunction after PAE. Also quite a few patients reported PAE didn’t work at all or shortly after they need reoperation by other type of surgery. So public perception or promotion of a specific surger, sometime is different than the reality.
So be very careful about user experience. I would trust clinical trial results as they are less biased.
My understanding of FLA is that it was first developed to treat prostate cancer. It uses fiber laser inserted near cancer tissues in prostate and uses the photothermal effect to destroy cancer tissues under MRI guidance. This is like precision bombing. The laser is inserted through the peririum(?). Recently, it is adapted to treat BPH. It seems that FLA is just like GLL, both use laser to take out overgrown tissues, except one use thermal effect like RAZUM and one uses vaporaization. For BPH, the goal is to remove all the problem causing adenoma in the prostate. So I really don’t understand what is the advantage of using the focal user as oppose to holep. It seems to me holep has more advantages. Cost: FLA costs more than $120K snd holep costs less that $30K. Tissue removal: it is well known that HoLEP removes adenoma down to the capsule just like simple open prostatectomy, FLA seems to remove less tissues. Durability: holep has been shown to have reoperation rate of less than 5% over 10 years, doubted FLA will have similar durability. RE: holep gives RE, not sure about FLA. Point of entry: holep is thru the penis, FLA is thru the perimium(?) (can this avoid the external sphincter?)
Incontinence: for some surgeons, holep is less than 2%, not sure about FLA.
At one time, I was keen on aquablation which has 10% RE as oppose to holep’s 87%. I spent a lot of time in doing research. At the end, I gave it up because there is no long term data as I don’t want to be reoperated again.
I am ignorant about FLA. Plse correct me if I am wrong.
clinicaltrials.gov/ct2/show/NCT03131544
Here is a patient report.
patient.info/forums/discuss/had-fla-for-bph-done-feb-13-568652
I have seen two Doctors that are performing this treatment, Dr. Sperling, Florida, New York and California and Dr. Karamanian, in Texas.
Since the technique is so new it is difficult tiger insurance to pay.
DL had posted information about some research on older techniques that have been modified to reduce the chances of negative side effects.
patient.info/forums/discuss/retrograde-ejaculation-or-ejaculation-preservation-after-turp-greenlight-pvp-holep-or-urolift--668799
I read many posts on FLA from the link u provided. My impression is that a lot of talks but little or no results reported. One post talked about the advantages of FLA. the poster felt that MRI provides a real-time clearer image and therefore the precision of tissue removal ought to be better.
Just for me, I just don’t see how MRI images can be clearer than the optical scope used in holep, turp and GLL. On the contrary, I would think the optical scope is clearer than the MRI. Sure MRI has advantages over the optical scope but not in BPH surgery. I also don’t see how the focal laser can have more precision in removing the overgrown tissues than the holep laser and green light laser. On the contrary, it could be less precise because thermal effect is not that precise. One shoots the focal laser at a piece of tissue then weeks later, he finds there is a hole left behind as the dead cells were absorbed by the body. Also Precision is really not a big problem here. Removing the overgrown BPH tissues does not need micron size precision.
The poster in ur link reported that when he has sxx with his wife, only blood came out no semen. This is RE.
So I am really lost in understanding the advantage of FLA. I hope someone could educate me.
It is much different since it is an ablation technique. After my TUMT, another ablation technique, I had bleeding and had to have a catheter for a week. The experience after ablation will not be the same as an enucliation technique.
My intent was to provide information not to advocate for this technique. You have pointed out that other techniques have advanced, reducing chances negative side events.
I have friends that are aging and each of them will have to make their own decisions.
Hello Buster,
If my post gave the impression that u were promoting FLA, my apology. Actually, it was meant to clarify my understanding of FLA with u by starting a discussion with u as I thought u had experience on FLA whereas I know nothing about it. My goal is the same as u: provide (hopefully creditable) information to readers and hope they could make a better decision.
My understanding of FLA from casual reading is that it is an excellent tool for prostate cancer treatment. It uses both TRUS and real-time MRI to locate the cancer and direct the laser light to target. The laser heating causes cell death. The temperature of the tissue is carefully monitor so that good tissues are not damaged. I think the questions are all these advantages critical to treat BPH?
I found there is a good picture of how FLA works in
Sciencedaily.com/releases/2016/06/160610094434.htm
Laser ablation becomes increasingly viable treatment for prostate cancer
Date:June 10, 2016
Source: University of California - Los Angeles Health Sciences
“UCLA researchers have found that focal laser ablation -- the precise application of heat via laser to a tumor -- is both feasible and safe in men with intermediate risk prostate cancer.”
“"Our feeling was that if you can see prostate cancer using the fusion MRI and can put a needle in the spot to biopsy it, why not stick a laser fiber in the tumor the same way to kill it," Marks said. "This is akin to a lumpectomy for breast cancer. Instead of removing the whole organ, target just the cancer inside it. What we are doing with prostate cancer now is like using a sledgehammer to kill a flea."
So FLA means precision bombing of cancer cells and the question is whether such precision has any advantage or needed for BPH treatment.
Read the following only if want to understand FLA.
From
ncbi.nlm.nih.gov/pmc/articles/PMC4080850/
Focal Laser Ablation for Localized Prostate Cancer: Principles, Clinical Trials, and Our Initial Experience (2014)
Ted Lee, BS, Neil Mendhiratta, BA, [...], and Herbert Lepor, MD
“There is increasing evidence that multiparametric magnetic resonance imaging (mpMRI) localizes the site(s) of clinically significant prostate cancer prior to prostate biopsy.7 These suspicious MRI focal abnormalities can be biopsied directly in the MRI unit or under transrectal ultrasound (TRUS) guidance using software that co-registers and fuses the MRI and ultrasound (US) images.8 In many cases, MRI image-guided biopsy identifies a single clinically significant cancer. Although prostate cancer is typically a multifocal disease, the index, or dominant, lesion is typically predictive of extraprostatic extension and disease progression.9–11 The majority of the secondary tumor sites are composed of small Gleason 6 disease, which represent no immediate threat.12 It is theoretically possible to focally ablate only the index lesion, thereby achieving oncologic control while minimizing treatment-related morbidity by minimizing collateral damage to adjacent structures.
Focal ablation of prostate cancer is an evolving treatment strategy that destroys a predefined region (or target) of the prostate that harbors the clinically significant cancer. A number of energy sources have been investigated for focal ablation of the prostate, including cryotherapy,13 high-intensity focused ultrasound (HIFU),14 photodynamic therapy,15 and laser ablation.16 Although long-term oncologic control has yet to be demonstrated, all of these targeted ablative options are associated with marked decrease in treatment-related complications. One of the advantages of laser technology is that the ablation can be performed with real-time MRI imaging. Because the target lesion are almost always defined by the MRI, laser ablation is currently the most accurate way to deliver ablative energy to the intended target. Other advantages of laser ablation include its homogeneous tissue necrosis, relatively low cost, and wide availability.17 MRI-guided focal ablation allows treatment monitoring using MR thermometry and real-time visualization of the targeted treatment zone.18,19
.........
Laser ablation refers to the destruction of tissue using a focused beam of electromagnetic radiation emitted from a laser. Other terms for laser ablation include photothermal therapy, laser interstitial therapy, and laser interstitial photocoagulation.
The principle of focal laser ablation therapy is to destroy a tissue target using laser radiation energy. The resulting rapid temperature elevation of the targeted tissue induces protein denaturation, resulting in in vivo tissue destruction. Prostate tissue is well suited for focal laser ablation due to its optical absorption rate without excess vascularity, which allows for finely controlled ablation.20
Effective focal laser ablation for the treatment of prostate cancer requires (1) accurate delivery of the laser energy to the target tissue, (2) sufficient thermal destruction to reliably destroy the target tissue, and (3) minimal thermal destruction to surrounding tissues and neurovascular structures. Each step provides its own set of technical challenges, but ongoing advances in image acquisition and analysis, bioheat transfer modeling, and laser delivery technology make laser ablation of prostate cancer feasible today.
Accurate ablation of the target is accomplished through transperineal or transrectal introduction of a laser fiber into the focal abnormality. Applying real-time, three-dimensional (3D) MRI reconstructions, Stafford and colleagues18 demonstrated that laser applicators were positioned within a mean ± SD of 1.1 ± 0.7 mm of the target site in seven canine prostate models. Accurate laser fiber localization to soft tissue targets is feasible, and real-time MRI during the ablative procedure allows precise estimates of the extent of tissue necrosis.21
Destruction of tissue is mediated by thermal conversion of focused electromagnetic energy, which raises tissue temperature causing coagulative necrosis. Because the heating effect on tissue depends both on the heat energy delivered and the depth of penetration, the extent of tissue destruction is dependent on the wavelength of the laser radiation. The laser originally used for interstitial laser ablation was the infrared emitting 1064 nm Nd:YAG laser. Although the Nd:YAG laser is commonly employed for focal laser ablation, small 1064 nm diode lasers are gaining popularity due to their portability, power, and cost effectiveness.22
van Nimwegen and associates23 described histologic changes to ex vivo canine prostate tissue samples as a function of irradiation time, intensity, and subsequent temperature change. Accordingly, supraphysiologic temperatures (above 42°;C) will result in tissue destruction with longer heating times.23 Spatiotemporal temperature monitoring of the tissue during laser application confirmed a linear increase in temperature with longer radiation time and radiation intensity, as well as exponentially decreasing changes in temperature with tissue depth. These relationships among laser energy, tissue temperature, and tissue viability are critical in dosimetric planning for tissue ablation.
Minimal thermal destruction to surrounding tissues and neurovascular structures is achieved through real-time monitoring during the tissue ablation. This can be achieved by proton-resonance frequency (PRF) shift MR thermometry, which allows near real-time quantification of temperature using changes in the phase of gradient-recalled echo (GRE) images to estimate relative temperature changes (ΔT).24 Peters and colleagues21 demonstrated that PRF shift MR thermometry correlates with temperature measurements of histologically determined areas of tissue necrosis in in vivo canine prostate models. Additionally, Stafford and colleagues found an excellent correlation (r2 = .94) between actual tissue damage seen on 3D T1-weighted MRI and predicted tissue damage using MR thermometry and an Arrhenius damage integral.18 Real-time MR thermometry represents an important tool to optimize ablation of target lesions with minimal thermally induced damage to surrounding tissue and important physiologic structures.”
I am looking forward to the results of the clinical trial for FLA-BPH. It is a small trial so I am sure some more research will be needed.
clinicaltrials.gov/ct2/show/NCT03131544
There are some interesting diagrams that give an general overview of what happens with a number of prostate surgeries.
prostatelasercenter.com/focal-laser-ablation/bph-treatment/
I have read that one patient reported that he spent $20,000 on his surgery. Obviously insurance is not covering this treatment.
Hello Buster,
The website u provided contained useful info on FLA. Quote:
“In order to minimize the risks of BPH treatment, Prostate Laser Center, PLLC uses an FDA approved laser system to insert a very thin (1.85 mm) laser fiber through the rectum into the prostate under MRI guidance. By monitoring the laser energy in two different planes in real time, Dr. Karamanian can see the neurovascular bundles (responsible for erectile function) and ejaculatory ducts and avoid hitting them. This laser system is so precise, that its most common use is in the brain.
While there are no guarantees in medicine, risks to the neurovascular bundles, internal urinary sphincter, and prostatic urethra are minimized. With this treatment option, the risk of retrograde ejaculation is less than 10% and the risk of erectile dysfunction is minimal.
Because we do not carve through the underlying anatomy, but rather ablate the excess tissue, initially patients urinary function gets worse before it gets better (due to swelling). This is why our BPH patients will keep the urinary catheter in for a week after the procedure. Most men return to baseline urinary function in three weeks and have significant improvement 6-8 weeks following the procedure.”
From the above, the advantages for FLA are:
1) avoid hitting the neurovascular bundles (responsible for erectile function) and
2) avoid hitting the ejaculatory ducts
3) less than 10% RE
4) risk of erectile dysfunction is minimal.
Using HoLEP as an example, holep also does not hit the neurovascular bundles and the ejaculatory ducts. Also the risk of erectile dysfunction is minimal.
Thus the only advantage FLA left is less than 10% RE. I don‘t understand why FLA has 10% RE unless it uses the technique of ejaculation preservation. A word of caution, the perception of PAE is that it has 0% RE and erectile dysfunction. However, when I checked clinical trial results and papers, higher than 50% of patients suffer sexual dysfunction after PAE.
More:
I missed the following sentence : “While there are no guarantees in medicine, risks to the neurovascular bundles, internal urinary sphincter, and prostatic urethra are minimized.”
At the end of the website, there is a drawing showing how turp and holep removed the internal sphincter and the urethra. However, it does not show how FLA can preserve the urethra and the internal sphincter.
The description and drawing seem to suggest that the FLA laser targets only overgrown tissues outside of and surrounding the prostatic urethra. When these tissues die, they will be absorbed by the body. A hole will then be left behind at where the dead tissues were. . And presumably, the urethra is no longer pressed by the overgrown tissues as they were absorbed and thus the urethra will expand to its original size before BPH occurred. Since the FLA laser does not enter thru the penis and thru the urethra, indeed it should spare the internal sphincter and not cause RE. And indeed, it the the nerve bundles can be avoided, it should not affect erection. In theory, this is how it works according to info provided by Buster’s website. We don’t have any info on real life performance. This is my current understanding based on the info provided by Buster.
Please correct me if I am wrong.
So FLA works the same way as RESUM, both use heat to cause cell death. Both use the same assumption, when the layer of cells surrounding the prostatic urethra are dead and are later absorbed by the body, these dead cells no longer press on and constrict the urethra. As a result, the urethra sprints back to its original size before BPH occurred. The exception is the FLA laser enters the adenoma from outside of the prostate whereas The needle of the RESUM enters the adenoma from the urethra. For heat delivery, FLA is far more precise than RESUM.
I therefore expect the result of FLA similar to RESUM.
For RE and ED, see ref 6.
Convective radiofrequency water vapor thermal therapy for benign prostatic hyperplasia: a single office experience
Daniel Mollengarden, Kenneth Goldberg, Daniel Wong & Claus Roehrborn
Prostate Cancer and Prostatic Diseases
volume 21, pages 379–385 (2018)
References
1. Ebbing J, Bachmann A. Anesthesia-free procedures for benign prostate obstruction: worth it? Curr Opin Urol. 2015;25:32–39.
2. Lourenco T, Pickard R, Vale L, Grant A, Fraser C, MacLennan G, et al. Minimally invasive treatments for benign prostatic enlargement: systematic review of randomised controlled trials. BMJ. 2008;337:a1662.
3. Roehrborn CG. Prostatic urethral lift: a unique minimally invasive surgical treatment of male lower urinary tract symptoms secondary to benign prostatic hyperplasia. Urol Clin North Am. 2016;43:357–69.
4. Dixon CM, Cedano ER, Pacik D, Vit V, Varga G, Wagrell L, et al. Two-year results after convective radiofrequency water vapor thermal therapy of symptomatic benign prostatic hyperplasia. Res Rep Urol. 2016;8:207–16.
5. Roehrborn CG, Gange SN, Gittelman MC, Goldberg KA, Patel K, Shore ND, et al. Convective thermal therapy: durable 2-year results of randomized controlled and prospective crossover studies for treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. J Urol. 2017;197:1507–16.
6. McVary KT, Gange SN, Gittelman MC, Goldberg KA, Patel K, Shore ND, et al. Erectile and ejaculatory function preserved with convective water vapor energy treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: randomized controlled study. J Sex Med. 2016;13:924–33.
7. Mynderse LA, Hanson D, Robb RA, Pacik D, Vit V, Varga G, et al. Rezum system water vapor treatment for lower urinary tract symptoms/benign prostatic hyperplasia: validation of convective thermal energy transfer and characterization with magnetic resonance imaging and 3-dimensional renderings. Urology. 2015;86:122–7.
8. Dixon CM, Rijo Cedano E, Mynderse LA, Larson TR. Transurethral convective water vapor as a treatment for lower urinary tract symptomatology due to benign prostatic hyperplasia using the rezum((r)) system: evaluation of acute ablative capabilities in the human prostate. Res Rep Urol. 2015;7:13–8.
9. McVary KT, Gange SN, Gittelman MC, Goldberg KA, Patel K, Shore ND, et al. Minimally invasive prostate convective water vapor energy ablation: a multicenter, randomized, controlled study for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. J Urol. 2016;195:1529–38.
10. Dixon C, Cedano ER, Pacik D, Vit V, Varga G, Wagrell L, et al. Efficacy and safety of rezum system water vapor treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. Urology. 2015;86:1042–7.
11. Hoffman RM, Monga M, Elliott SP, Macdonald R, Langsjoen J, Tacklind J, et al. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;9:CD004135.
12. Bouza C, Lopez T, Magro A, Navalpotro L, Amate JM. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol. 2006;6:14.
13. Thomas JA, Tubaro A, Barber N, d’Ancona F, Muir G, Witzsch U, et al. A multicenter randomized noninferiority trial comparing greenlight-xps laser vaporization of the prostate and transurethral resection of the prostate for the treatment of benign prostatic obstruction: two-yr outcomes of the goliath study. Eur Urol. 2016;69:94–102.
14. Donnell RF. Minimally invasive therapy of lower urinary tract symptoms. Urol Clin North Am. 2009;36:497–509.