Transperineal laser ablation of the prostate (TPLA) for selected patients with lower urinary tract symptoms due to benign prostatic obstruction: a step-by-step guide

Objective: Transperineal interstitial laser ablation of the prostate (TPLA) has been shown to be a novel option for minimally invasive treatment of benign prostatic obstruction (BPO). Herein we provide an educational step-by-step overview of our technique of TPLA, focusing on the standardization of its surgical steps, the logistical aspects of its performance in an outpatient setting, as well as its early perioperative and functional outcomes. Patients and surgical procedure: The procedure can be performed in the outpatient clinic with the patient in a lithotomic position. After local disinfection, two 21G transperineal needles are introduced and located in the middle of each lobe, under ultrasound guidance, with their orientation parallel to the longitudinal axis of the gland. A needle placement verification is required to guarantee the right security distances from the urethra and from the bladder neck. Once the fibers are placed, the energy can be delivered. The starting power energy is 5 W, reduced in about 2 minutes to 3,5 W, when a cavity starts to grow with vapor formation resulting in bubbles hyperechoic images at US. Results: Overall, 30 patients underwent TPLA at our Institution between April 2021 and December 2021. The median prostate volume at TRUS was 42 ml (IQR 40-53). The median time to complete the procedure was 31.5 min (IQR 28-37). All patients were discharged within 8 hours of hospital stay (median 6.4h; IQR 5.9-7.2). No perioperative Clavien-Dindo grade ≥2 were recorded. An objective improvement in the postoperative flowmetry indexes and quality of life was recorded for all patients, who preserved ejaculatory function. Conclusions: Our experience provides additional evidence supporting the feasibility and safety of TPLA for the treatment of carefully selected patients with LUTS due to BPO.