GreenLight laser is considered to be the most modern and minimally invasive surgical option for BPH / enlarged prostate. David Robbins, MD is among a select group of urologists in the United States that have been requested by Boston Scientific, the manufacturer of GreenLight Laser, to be part of the teaching faculty for the GreenLight Laser technology. Dr. Robbins is the only certified instructor for GreenLight laser in South Florida. Dr. Robbins routinely leads courses teaching other urologists about the benefits of GreenLight Laser surgery for enlarged prostate. Dr. Robbins has lead lecture series and taught GreenLight Laser surgery throughout the United States, Puerto Rico, and South America including Lima, Peru, Santiago, Chile, as well as Cali, Medellin and Bogota Colombia. Dr. Robbins additionally lead one of the surgical technique courses at the American Urological Association annual meeting in San Francisco in 2018. The surgical technique developed by Dr. Robbins and his colleagues on the teaching staff at Boston Scientific are currently being used to create an international standard of care for minimally invasive GreenLight Laser BPH treatment. Dr. Robbins is also involved in the development of preoperative standard work up recommendations and a teaching curriculum for Green Light that will be used around the world.
Dr. Robbins is able to treat patients with advanced and difficult to treat BPH conditions such as those with enlarged prostates greater than 150 grams, patients in urinary retention, patients with obstruction and bladder stones and even patients who are required to remain on blood thinners. Dr. Robbins is routinely referred patients by other urologists to handle more complex BPH patients that otherwise may have needed more invasive open surgical procedures. When choosing a surgeon to help you with your symptoms for enlarged prostate, experience does matter when it comes to optimal outcomes. Please contact us and allow us to help you relieve your bothersome symptoms of BPH / enlarged prostate.
Miami urologists Dr. David Robbins and Dr. Amery Wirtshafter are proud to offer their patients the option of GreenLight Laser surgery for the treatment of BPH (enlarged prostate). GreenLight Laser Surgery is a minimally invasive outpatient surgical option for BPH (enlarged prostate) that is performed using a video camera placed in the urethra without the need for a surgical incision. GreenLight Laser surgery combines the effectiveness of the traditional surgical procedure known as transurethral resection of the prostate (TURP), but with fewer side effects, shorter catheterization and a quicker, less painful recovery. GreenLight Laser for enlarged prostate is currently considered the most advanced and minimally invasive surgical option for the definitive surgical treatment of BPH or enlarged prostate.
GreenLght Laser surgery uses laser energy introduced via a laser fiber placed though a small camera introduced into the patients urethra. The GreenLight Laser energy is used to vaporize and remove enlarged prostate tissue that is obstructing urine flow thereby resulting in an open and unobstructed channel for urine to flow through. Patients are able to go home the same day of the procedure and will only require a foley catheter for a day or two after the procedure. Patients can then return to a life that’s free of BPH symptoms without the need for daily prostate medications.
GreenLight Laser Therapy is typically an outpatient procedure; meaning you can return home hours after the procedure, and can return to normal, non-strenuous activities within days. The GreenLight Laser system delivers the ultimate in BPH treatment — freedom from urinary symptoms, freedom from compromise, freedom to live life the way you choose.
Miami urologists Dr. Robbins and Dr. Wirtshafter have extensive experience with Green Light laser therapy for enlarged prostate and have been providing this therapy to patients in Miami and the surrounding region for years with outstanding results.
Green Light laser vaporization photoselective vaporization therapy for BPH can be considered the most important surgical advancement in the treatment of BPH for the past three decades. The GreenLight Laser PVP system is unique in its utilization of the latest generation of high energy potassium-titanyl-phosphate (KTP) laser energy delivered through a fiber optic cable. It is specifically designed for vaporization of prostate tissue. The concept of Green Light laser vaporization is to completely eliminate prostate tissue while simultaneously photocoagulating prostate blood vessels thereby creating an open prostatic channel without any bleeding.
The mechanism of action of the Green Light laser is through the production of laser energy with a wavelength of 532 nanometers which has a specific affinity for the pigment of hemoglobin, a component of red blood cells. When the laser energy interacts with tissue, it is converted to vapor and is then eliminated though a system of continuous irrigation through the surgeon’s camera. Simultaneously, the blood vessels of the prostate are sealed by the laser because of its affinity for hemoglobin thereby virtually eliminating all bleeding and permitting the patient to go home the same day as the surgery with a catheter for as short as 1-2 days prior to being able to void spontaneously with significantly improved flow.
Another advantage to the Green Light laser is the ability to continue prostate vaporization on larger prostate glands for a prolonged period of time without having to worry about the electrolyte disturbances common to the TURP procedure. This is because the Green Light laser procedure is performed using saline irrigation as opposed to the glycine irrigation required to conduct the electrical energy used during a TURP.
Therefore, according to contemporary literature and certainly urologist personal testimonial, there is no procedure better than Green Light laser to treat BPH by virtue of many significant advantages including:
GreenLight Laser can result in a low incidence of urethral stricture disease and bladder neck contracture which seems to be lower than that with TURP. Retrograde ejaculation (dry orgasm) is common after TURP and GreenLight Laser surgery due to the absence of antegrade propulsion of semen off the backstop of the bladder neck. This may be an important factor for young men considering GreenLight Laser and is important to discuss preoperatively.
Immediately following a minimally invasive GreenLight Laser procedure, patients will have a catheter in place to drain the bladder. Patients are discharged to home following the procedure and then can follow up in the office in 1-3 days to have the catheter removed. The length of time with the catheter following the procedure is typically dictated by the size of the prostate, with extremely large prostates requiring longer post operative catheter times. After the catheter is removed, patients should immedicately notice that the strength of their urinary stream is improved given their more open prostate channel as demonstrated in the images below. Patients however will commonly experience mild burning with urination and frequency that may last several days. Soon after the GreenLight Laser procedure patients will begin to notice a decrease in urinary frequency and need to wake up at night to urinate as the bladder begins to relax and accomodate to a more open prostate channel without obstruction.
Before and After GreenLight Laser Vaporization of the Prostate
Miami urologists Dr. David Robbins and Dr. Amery Wirtshafter are now among a select group of urologists in Miami who are able to offer their patients treatment with the GreenLight Laser XPS system. GreenLight Laser XPS is the latest cutting edge laser therapy for the treatment of BPH with nearly twice the power output of the traditional GreenLight Laser HPS system providing for significantly improved vaporization of prostate tissue and better patient outcomes.
Miami urologists David Robbins MD and Amery Wirtshafter MD are recognized world wide for their expertise in treating the most complex cases of BPH or enlarged prostate using the GreenLight Laser XPS system. Our Miami urologist have been performing GreenLight Laser surgery since the technology was first introduced and because of this long term commitment and expertise with GreenLight Laser technology Dr. Robbins and Dr. Wirtshafter have a close relationship with American Medical Systems, the parent company of GreenLight Laser technology. As a result of our expertise and knowledge of GreenLight Laser surgery, we have had the unique opportunity to treat patients from all around the globe. Patients have traveled to Miami for GreenLight Laser surgery with Dr. Robbins and Dr. Wirtshafter from Colombia, El Salvador, Nicaragua, Panama, Uruguay, Trinidad, Jamaica, Puerto Rico and the Bahamas. Our international GreenLight Laser program welcomes patients from all additional regional countries including Brazil, Argentina, Peru, Venezuela, Chile, Ecuador, Bolivia, Paraguay, Guyana, Suriname, French Guiana, Mexico, Honduras, Guatemala, Belize and Costa Rica. Please feel free to contact us to inquire about our international program for GreenLight Laser XPS procedures.
Just a little note to express to you my gratitude and admiration for the excellent results on the Green Laser Light surgery you performed on me due to my BPH problem about eleven months ago. After the surgery, I followed all your instructions and after approximately one and half months of my surgery, I was complete recuperated. I feel very good, never get up at night for any reason and all my BPH problems are gone. Thank you very much for your knowledge and professionalism, you are great.
Dr. Robbins: six hundred characters are not nearly enough to express my deep appreciation for your help. Putting aside your undeniable expertise, I found that for me your most valuable asset is your ability to project your own confidence in your knowledge and talents on to your patient and help him face what is a rather traumatic experience with less of the fear that any surgical procedure usually inspires. A simple 'thank you' is not enough but in this instance it will have to suffice. it means much more than those words alone could ever convey.
I want to thank you for my Green Light laser vaporization surgery and results. It took me exactly three days, after the surgery, to get back to work. I wish you a long and energetic life, so you can help many more patients. Once again, Thanks!!!"
"I really can't say enough good things about the laser procedures performed as an outpatient at Aventura Hospital by Dr. David Robbins. Essentially 2 procedures were done with 2 different lasers: (1) Diminish a large bladder stone to make it small enough to evacuate the urinary bladder and (2) Vaporize residual scar tissue on the prostate using a "green light" laser. After just about a week from having the procedures, I am completely free of any pain or discomfort, am able to do my normal work and perform my usual routine. I am a very active 76 year old male. In fact, after having the catheter removed (it was only in for less than 48 hours) I was virtually without post procedural pain. Approximately 13 years ago, I had invasive urological surgery and I was unable to resume work & normal tasks for more than a month. In my opinion having the option of using the less invasive laser is a no brainer. "
I want to thank you for convincing me to have the GreenLight Laser procedure for my enlarged prostate (BPH). Like most men, I tried to ignore the symptoms and hoped they would go away. Having surgery on my penis was not on top of my to do list. The meds helped but I was still waking up 3 or 4 times a night and peeing became an event. After your assurances regarding the Green Light procedure, I finally had it done on 9/22/11. Wow, what a difference. I doubt I could have put out a cigarette before, now I can extinguish a forest fire. I went from being one of those crappy leaky squirt guns to a super soaker. Race horses are jealous of the way I pee now. Wish I done it sooner. The anticipation was way worse than the reality of the surgery. It really wasn't a big deal. Please tell the Green Light people, I want to be president of their fan club. "
"Dear Dr. Robbins - I just wanted to take a moment to thank you for such a positive experience this past week when my husband had surgery to remove his bladder stones and treat his enlarged prostate. We dreaded the whole thing and had postponed the inevitable long past the time when he should have dealt with it. Had we known that you and your staff would make the experience so stress-free, we would have scheduled his surgery sooner. He was up and around in no time and is feeling so much better now. We really appreciate the care and attention you showed and just wanted to make sure you knew how much that meant to us. You can be certain that we will recommend you highly in the future. Thank you!"
"Estimado Dr. Robbins:
Le escribo desde Uruguay para contarle que la evolución de la cirugía ha sido muy satisfactoria. He mejorado mucho los síntomas previos y siento que sigue mejorando. Persiste una discreta hematuria esporádica- tal cual Ud. lo adelantó y discretos ardores, también esporádicos. Por lo demás todo va muy bien. Aprovecho para darle nuevamente las gracias, no solo por su calidad técnica, sino también por habernos hecho sentir en todo momento muy tranquilos y contenidos. Le repito que si algún día visita este rincón del mundo, encantados seremos sus anfitriones. En algunas semanas le envío noticias nuevas.
Reciba Ud. un saludo afectuoso de mi señora y mío."
prostate anatomyThe prostate gland is a walnut sized glad located in the male pelvis that sits between the bladder and the urethra just above the rectum. Urine passes through the prostate like a train through a tunnel as it passes into the male urethra during urination.
The exact function of the prostate is still largely unknown. The prostate contributes a small amount of fluid to the semen that assists the sperm to survive and navigate the female reproductive tract leading to fertilization of an egg. The majority of the seminal fluid is contributed by the seminal vesicles which are grape-like sacs attached to the posterior surface of the prostate. The prostate does not play any role in sexual desire or erectile function.
Benign Prostatic Hypertrophy (BPH) or enlarged prostate is also known as Benign Prostatic Growth or Benign Prostatic Enlargement. BPH is a non-cancerous enlargement of the prostate glad that affects more than 50% of men over the age of 60.
Although BPH (enlarged prostate) universally affects all aging males, it does so in varying degrees. Despite extensive basic science and clinical research on this subject, the pathogenesis of BPH remains poorly understood. What is clear is that BPH (enlarged prostate) is a complex disease with a multifactorial etiology involving both age and hormonal status.
There are two main periods of growth of the prostate. The first occurs during puberty when the prostate is known to double in size. The second period of growth begins in the third decade of life and continues throughout life eventually resulting in symptoms of BPH (enlarged prostate) in the aging male.
All men who live past a certain age will develop BPH on a microscopic level, however only 50% of these men develop macroscopic growth of the prostate meaning that they have a measurable physical increase in size of the prostate. Of those who have macroscopic BPH, only 50% will actually have clinical symptoms such as urgency, frequency, nocturia, decreased force of stream, difficulty initiating void and even incontinence. It is interesting that there are some men with extremely large prostates with minimal symptoms and other men with very small prostates and highly bothersome symptoms.
As the prostate enlarges, it slows down the flow of urine as it passes from the bladder to the urethra just like a kink in a garden hose. In the early phases of obstruction caused by the prostate the patient experiences few symptoms because the bladder is able to compensate for increased resistance to the flow of urine by increasing the force of its contraction during urination. However, as the degree of obstruction increases, the patient begins to experience a host of symptoms that has come to be known as “prostatism” or “LUTS” (Lower Urinary Tract Symptoms). These bothersome symptoms are well known to that aging male and are typically the catalyst for making an appointment to see a urologist.
Symptoms of obstruction include decreased force of urinary stream, difficulty initiating urination, intermittent or prolonged urination, post void dribbling, sensation of incomplete emptying, urgency of urination, urinary retention and incontinence. Many of these symptoms can be attributed to changes that occur in the bladder as a result of having to force urine through an obstructed prostate. Similar to how skeletal muscle responds to increasing resistance and exercise, the smooth muscle of the bladder wall becomes stronger and thicker over time contracting with even minimal quantities of urine.
Urinary Retention is a situation that occurs when the obstruction from BPH (enlarged prostate) advances to the point when an individual can no longer empty his bladder because the prostate is literally blocking the urethra completely. This requires a trip to the emergency room to place a tube called a foley catheter through the penis into the bladder that allows the urine to exit.
BPH (enlarged prostate) can result in inability to completely empty in the bladder so that there is always a residual amount of urine left in the bladder after voiding. This stagnant urine environment can allow for crystals in the urine to aggregate and form bladder stones of varying number and size. In extreme cases these stones can fill up the entire bladder. Treatment options for this condition include open surgery to remove the stone or endoscopic surgery using cameras through the penis thereby allowing the use of lasers or ultrasonic energy to break up the stones.
Gross Hematuria (blood in the urine):
In certain circumstances benign prostate growth can result in spontaneous bleeding resulting in blood tinged urine or even large blood clots passing through the penis. Individuals on blood thinners such as aspirin, plavix and Coumadin are more susceptible to spontaneous prostate bleeding. Nonetheless anyone with gross hematuria requires a work up to rule out other possible causes including infection, stones and cancer of the kidney, bladder or prostate.
Urinary Tract Infections (UTIs):
Incomplete bladder emptying creates a more favorable environment for the growth of bacteria potentially resulting in a urinary tract infection.
Flexible cystoscopy is a test in which a small flexible tube with a camera on the end is introduced into the bladder to allow the urologist to directly visualize the urethra, prostate and bladder. This test is invaluable to the urologist in allowing him to visualize changes in the urinary tract that are associated with BPH (enlarged prostate). Prior to entering the bladder the urologist will see the prostate. When the prostate is causing obstruction, the lateral lobes of the prostate that are normally separated may be seen touching each other or “kissing”. Additionally, there may be a median lobe, which is a component of the prostate not seen in all men that grows directly from the bladder neck at the 6 o’clock position. The median lobe, when enlarged can block the urethra like a ball valve mechanism. Cystoscopy also allows for evaluation of secondary changes in the bladder caused by obstruction from BPH. The bladder’s lining which is typically smooth becomes thickened as a result of the increased pressures needed to pass urine though an obstructed prostatic urethra. The urologist will see changes such as trabeculations (crossing muscular fibers), cellules and even a diverticulum (a large outpouching of the bladder lining). Cystoscopy is an office based procedure that typically takes less than 5 minutes to perform and generally causes minimal discomfort to the patient.
Uroflow is a simple test used to measure the flow rate of urine during voiding. A device is used to measure the flow of urine and a computer plots a curve of volume per time. A flow less than 10 cc/sec is considered consistent with obstruction. There are several confounding factors that influence the results of this test, but its benefits are significant in that it is easy to perform and completely non invasive.
This test can be employed for men with symptoms of BPH that are not responding to medical therapy and are considering a surgical intervention. This test allows the urologist to make objective measurements of the true bladder pressure and flow rate as it is measured in real time. The test typically takes 15-30 minutes to perform and involves placement of a small catheter in the bladder used to measure bladder pressure and a small catheter in the rectum used to measure intra-abdominal pressure.
Urocuff™ Study for BPH
At Urological Consultants of Florida, we are one of the few centers in the Miami region that offer our patients a minimally invasive option for measuring the pressure flow relationship typically only demonstrated via a urodynamic evaluation.
Urocuff™ is the first non-invasive test that can accurately identify good surgical candidates and provide an objective basis for managing Flomax and similar medications. Many men who have been reluctant to undergo the catheterization necessary for conventional urodynamics can now be tested quickly and comfortably.
The Urocuff machine uses a method similar to that for blood pressure measurement. A penile cuff (similar to a blood pressure cuff) is fitted to the patient who is then asked to void in the normal way. An estimate of bladder pressure and a measurement of maximum flow rate are obtained and plotted on a nomogram to allow categorization into obstructed, not obstructed, or “diagnosis uncertain” groups.
There are various treatments for BPH that are highly dependent on patient factors such as age, duration of urinary symptoms, prior urological treatment and comorbid medical conditions. The two basic treatment algorithms include medical and surgical therapy.
Surgical treatment for BPH is always a secondary option and is only considered when medical therapy has been attempted, but has not alleviated the symptoms of benign prostatic hyperplasia sufficiently to allow for the patient to have a satisfactory quality of life with regard to his urinary symptoms. The principal focus of surgical therapy is to eliminate prostate tissue with the goal of relieving obstruction from the prostate and improving the flow of urine as it exits the bladder.
Before the invention of medical therapy for BPH and endoscopic therapies with cameras, the only option for treatment of urinary obstruction from BPH was an open suprapubic or retropubic prostatectomy. This surgery consists of making an large incision into the patients belly, opening a hole in the bladder, incising the capsule of the prostate and literally using a finger to shell out the entire prostate. While considered very effective, this surgery could be associated with bleeding, a prolonged hospital course, and need to leave a foley catheter or suprapubic tube for an extended period of time. Although this procedure is performed infrequently nowadays with the invention of medical therapy and endoscopic surgical options such as TURP and Green Light laser, it is still the most effective method for treating BPH in patients with prostates that are extremely large.
With the invention of surgical cameras or “telescopes” the TURP became the gold standard of care and has remained that way for many years. During a TURP, the urologist uses an electrical loop attached to the end of a surgical camera to shell out small pieces of prostate tissue and clear a channel in the prostate. TURP has an excellent success rate and is certainly less invasive than an open prostatectomy. However, TURP does have some drawbacks and potential complications. First of all, the tissue bleeds as it is cut leading in some patients to the need for blood transfusions or a prolonged hospital stay waiting for the bleeding to stop. The electrical energy using during a TURP could also injure the nerves around the prostate that cause erections potentially leading to erectile dysfunction. Additionally, one of the biggest concerns during a TURP is “TUR Syndrome” which is an electrolyte disturbance involving sodium that occurs when the body absorbs glycine. Glycine is the irrigation fluid that is used during a TURP which is beneficial in that it allows the conduction of electricity needed to perform a TURP, however it has less sodium that the body and when absorbed it can dilute the sodium level in the body and cause potentially dangerous side effects such as altered mental status and loss of consciousness. Additional potential side effects from TURP include urethral stricture, bladder neck contracture, urge incontinence and retrograde ejaculation.
Soon after the invention of the TURP, it was not long before the drug companies entered the market of BPH therapy. The first medications on the market were alpha blockers which are a class of medications which relax the smooth muscle component of the prostate. They improve voiding symptoms and flow by making the hole in the prostate less tight, however they do not decrease the mass of the prostate or diameter of the hole like surgical therapies do. The first alpha blockers on the market were Hytrin and Cardura. Newer medications on the market include Flomax, Uroxatral and Rapaflo. Possible side effects of these medications include retrograde ejaculation and dizziness. Retrograde ejaculation is a decreased or absent ejaculation during orgasm and is caused by the prevention of closure of the bladder neck during ejaculation.
5 alpha reductase medications such as Proscar and Avodart are often used in conjunction with alpha blockers especially in men with larger sized prostates. These medications block the conversion of testosterone to dihydrotestosterone which is the active form of testosterone that causes prostate growth. These medications literally shrink the size of the prostate up to 50% by six months. In conjunction with alpha blockers these medications can synergistically improve symptoms and decrease the risk of complications of BPH such as urinary retention, prostate bleeding and the need for surgical therapy.