The Effectiveness of the Nd-YAG Laserin Destroying Superficial Bladder Tumours

J. RANDALL, D.G. ARKELL Department of Urology, Dudley Road Hospital. Birmingham, UK

Correspondence to Mr J. Randall, 71, The Hurst, Moseley, Birmingham B 13 ODA. UK

Abst rac t . Fifty-five bladder tumours, in 12 patients, were treated by coagulation using the neodymium-yt t r ium aluminium garnet (Nd-YAG) laser. All the tumours were superficial, grade I or II, and varied in size from 5 to 30 mm. Laser energy was applied using a quartz-fibre delivery system via a rigid cystoscope under general anaesthesia. Up to ten tumours were treated at any one cystoscopy. One patient underwent t ransurethral resection oftumours larger than 30 mm combined with laser coagulation of smaller lesions.

Fifty-four tumours were completely destroyed by the laser. Six patients (50~7~) had recurrent tumours on review cystoscopies performed one to eight months after the initial treatment. However, only one tumour was found at the site of previous laser coagulation, indicating incomplete tumour destruction. This was successfully eradicated by a further laser coagnlation.

Coagulation of superficial bladder tumours with Nd-YAG laser energy during rigid cystoscopy under general anaesthesia is therefore an effective t reatment for superficial non-invasive bladder tumours, although the recurrence rate is unaffected.

INTRODUCTION

The neodymium-yt t r ium aluminium garnet (Nd-YAG) laser has been shown to be highly effective in destroying superficial bladder can- cer (11. It has been suggested that there is a lower recurrence rate after laser coagulation compared with the accepted recurrence rate of 50-70% after per-urethral diathermy or resec- tion (2). Its advantages are: (a) its ability to penetrate deeply into the bladder wall and com- pletely coagulate a predictable volume of tissue (3); (b) it does not cause shedding of malignant cells into the bladder cavity which might im- plant on healthy urothelium; (c) it can be used to seal the mucosal lymphatics around a tumour before coagulating it (4).

Recent reports quote recurrence rates of 18% (5) and 34% (6). Although there is circumstan- tial evidence, it has never been proven that re- currence of bladder carcinoma is due to either implantation of tumour cells or submucosal lymphatic spread. Recurrences may arise as new lesions in abnormal urothelium which has been affected by widespread pre-neoplastic change. If so, then improving the effectiveness of local t reatment can only reduce recurrence of

incompletely treated turnouts. The recurrence rate at other sites in the bladder will reflect the degree of mucosal abnormality and may be in- dependent of the method of treatment. Beisland et al (7) obtained a recurrence rate of 41~. in non-irradiated areas of the bladder. Initial optimism that the laser can prevent recurrence or invasion at sites other than those of the tre- ated tumours may therefore be unfounded.

We have used an Nd-YAG laser to treat a series of patients with superficial bladder carci- noma, and we report our initial results.

MATERIALS AND METHODS

Tumours were treated by laser coagulation via a rigid cystoscope under general anaesthesia. The laser source was a Fiberlase 100 Nd-YAG laser (Pilkington Medical Systems Ltd) instal- led in a modified operating theatre incorporat- ing all the safety features required for laser work. Laser energy was conducted into the bladder by an insulated quartz fibre delivery system (Pilkington Medical Systems Ltd) in conjunction with an ACMI cystourethroscope fitted with a modified Albarran bridge (Fig. 1).

Paper recetved 29 October 1987 Lasers In Medical Science Vol 3:17 1988 (~ Bafllie.re Tir~dall

18 J. Randall, D.G. Arkell

Fig. 1. The modified Albarran bridge to show the quartz fibre enclosed within the lever.

To pro tec t the opera to r ' s eye f rom back- sca t t e red laser l ight, the cystoscope eyepiece was covered with a f i l ter absorb ing l ight at the 1060 nm w a v e l e n g t h of Nd-YAG laser light. 1 M 67 3

P rev ious au tho r s h a v e shown tha t the opti- 2 F 47 1 m a l laser power level for effective coagula t ion 3 M 86 1 w i thou t r isk of pe r fo r a t i ng b ladder or ad jacent 4 M 79 2 in tes t ine is 4 0 - 4 5 W (3, 8). Before s t a r t i ng 5 M 78 17 clinical work wi th the laser, a p r e l i m i n a r y 6 M 69 1

7 F 72 13 s tudy us ing cadave r b ladders was pe r fo rmed to 8 F 78 2 ver i fy th is (9). The l a se r was therefore used a t 9 F 68 5 40 W power, in 9.9-s pulses. With the aid of the 10 F 66 1 vis ible h e l i u m - n e o n a i m i n g laser, Nd-YAG 11 M 79 4 laser ene rgy was di rected on to each b ladder 12 M 67 5 t u m o u r in a s ide-to-side m a n n e r unt i l all a r eas

Mean = 71.3 years Total = 55 had been t r ea t ed and tu rned white. Up to 30 pulses were used pe r pa t ien t , and the total e n e r g y dose var ied f rom 2 to 6500 J according to the n u m b e r and sizes of tumours .

Patients

Two pa t i en t s wi th newly p resen t ing superf ic ia l b l adde r ca r c inoma and ten wi th r ecu r r en t dis- ease had a to ta l of 55 t u m o u r s t rea ted . These were so l i t a ry in four pa t i en t s and mul t ip le in e igh t (Table 1). All were superf icial t r ans i t i ona l

Table 1. Cases

Patient Sex Age (years) Number of tumours

Table 2. Sizes of tumours

Size (mm) Number of tumours

5 23 10 23 15 3 20 3 25 2 30 1

Total = 55

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Nd-YAG Laser Therapy for Superficial Bladder Tumours

cell carcinomas, grade I or II. Lesions ranged in size from 5 to 30 mm (Table 2). One patient with multiple tumours had two lesions larger than 30 mm in addition to the smaller lesions t reated by laser coagulation. These were removed by a subsequent t ransurethral resection. The newly diagnosed carcinomas were biopsied before laser coagulation.

All patients had follow-up cystoscopies at three-monthly intervals after laser t reatment , and any recurrent or residual tumours were t reated by further laser coagulation.

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DISCUSSION

We have found that coagulation with Nd-YAG laser energy can successfully t reat superficial bladder tumours up to 30mm in diameter. There is a low complication rate, and none of the patients required a catheter postoperatively. No bladder perforations occurred using the laser at or below 45 W of power. However, our recurrence rate was higher than those of pre- vious authors lTable 3). Six out of our 12 pa-

Table 3. Previously reported recurrence rates

RESULTS

Ease of use

Using the modified Albarran lever, there was good access to tumours in all parts of the blad- der. Tumours in the bladder vault, which would have been dill]cult to resect safely, were easily coagulated with the laser.

Efficacy in destroying tumours

Of the 55 tumours treated, 54 were successfully treated. Only one patient was left with residual tumour at the site of a treated lesion on follow- up cystoscopy, indicating incomplete destruc- tion of the tumour. In the other patients the sites of treated lesions were marked by a white scar characteristic of healing after laser coagulation.

Recurrence rate

Six patients developed recurrent tumours at in- tervals varying from three to eight months after initial t reatment . These included the two pa- tients who had large numbers of tumours.

Complication rate

No bladder perforations occurred. Two tumours bled during laser application but this was due to the initial biopsy. In one patient, the haemor- rhage was controlled with the laser by giving one additional pulse at 50 W power; the other patient required diathermy. None of the pa- tients experienced postoperative pain or haematuria . Postoperative catheterization was not required.

Procedure Tumour recurrence rate

A. Per-urethral diathermy,' TUR

B. Laser coa~lation 50-70'~. 18% (ref. 5) 34% (ref. 6)

49% (ref. 7) 8q'~ local, 41% in non-irradiated

area

t ients have had recurrent tumours despite short follow-up periods. Neither of the tumours bi- opsied before laser application recurred. The number of new tumours was unrelated to the number originally treated, but both of the pa- tients who had more than ten tumours t reated developed recurrences. These patients were at greatest risk of recurrence, and it is for this type of patient that a reduction in recurrence rate is part icularly desirable. We are monitoring these patients to see if there is any long-term reduc- tion in recurrence rate that is not apparent in the short term.

Although the laser is an expensive method of t reatment , its use in day case surgery should prove cost-effective (10). It is part icularly suit- able for patients with rapidly recurring, small, non-infil trating tumours and for poor-risk pa- t ients who would otherwise require general anaesthesia. By employing the laser with a flexible cystoscope under local anaesthesia, a large number of patients could be successfully managed on a walk-in basis (11). However, we feel that early optimism that the laser can re- duce the risk of recurrence or invasion at sites other than those of the treated tumours may be unfounded.

REFERENCES

1 Hofstetter A, Frank F, Keiditsch E, Bowering R. Endo- scopic neodymium-YAG laser application for destroying bladder tumors. Eur Urol 1981, 7:278-82

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2 Rothenberger K, Pensel J, Hofstetter A e t a [ . Trans- ure thra l laser coagulation for t rea tment of ur inary bladder tumours. Lasers Surg Med 1983, 2:255-60

3 Pensel J, Hefstet ter A, Frank F et al. Temporal and spatial profile of the bladder serosa in intravesical neodymium-YAG laser irradiation. Eur Urol t981, 7:298-303

4 Zimmerman I, Stern J, F rank F et al. Interception of lymphatic drainage by Nd-YAG laser irradiation in ra t ur inary bladder. Laser" Surg Med 1984, 4:167-72

5 Malloy TR, Wein AJ, Shanberg A. Superficial tran- sitional cell carcinoma of the bladder t reated with the neodymium-YAG laser: a study of the recurrence rate within the first year. J Urol 1984, 131:251A

6 Smith JA, Middleton RG. Lasers in urologic surgery. Chicago: Year Book Medical Publishers, 1985:53

J. Randall, D.G. Arkell

7 Beisland HO, Sander S, Fossberg E. Neodymium-YAG laser irradiation of urinary bladder tumours. Urology 1985, 25:559-63

8 Staehler G, Halldorsson T, Langerholc J, Bilram R. Endoscopic applications of the Nd-YAG laser in urology,; theory, results, dosimetry. Urol Res 1981, 9 :45-9

9 Arkell DG, Randall J. The ins ta l la t ion and use of a neodymium-YAG laser in a urology depar tment . (In preparation.)

10 Editorial. Superficial bladder cancer: drugs or dia- thermy. Lancet 1986, 1:479-80

11 Fowler CS. Fibrescopic Nd-YAG laser t r ea tment of superficial bladder tumours in outpatients. Lasers Med Sci 1987, 2:29-32

Key words: Neodymium-YAG laser; Cystoscopy; Superficial bladder cancer; Recurrence rates

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