U.S. patent application number 10/876311 was filed with the patent office on 2004-11-25 for method and system for photoselective vaporization of the prostate, and other tissue.
This patent application is currently assigned to Laserscope. Invention is credited to Arnold, Ken, Coleman, Tony D., Davenport, Scott A., Garlich, Henry, Murray, Steven C., Nahen, Kester.
Application Number | 20040236318 10/876311 |
Document ID | / |
Family ID | 33459292 |
Filed Date | 2004-11-25 |
United States Patent
Application |
20040236318 |
Kind Code |
A1 |
Davenport, Scott A. ; et
al. |
November 25, 2004 |
Method and system for photoselective vaporization of the prostate,
and other tissue
Abstract
A method for photoselective vaporization of prostate tissue
includes delivering laser radiation to the treatment area on the
tissue, via an optical fiber for example, wherein the laser
radiation has a wavelength and irradiance in the treatment area on
the surface of the tissue sufficient because vaporization of a
substantially greater volume of tissue than a volume of residual
coagulated tissue caused by the laser radiation. The laser
radiation is generated using a neodymium doped solid-state laser,
including optics comprising LBO or BBO producing a second or higher
harmonic output with greater than 20 watts average output power.
The delivered laser radiation has a wavelength for example in a
range of about 200 nm to about 650 nm, and has an average
irradiance in the treatment area greater than about 10
kilowatts/cm.sup.2, in a spot size of at least 0.05 mm.sup.2.
Inventors: |
Davenport, Scott A.; (Half
Moon Bay, CA) ; Murray, Steven C.; (Santa Cruz,
CA) ; Coleman, Tony D.; (San Jose, CA) ;
Garlich, Henry; (Fremont, CA) ; Arnold, Ken;
(Soquel, CA) ; Nahen, Kester; (Mountain View,
CA) |
Correspondence
Address: |
HAYNES BEFFEL & WOLFELD LLP
P O BOX 366
HALF MOON BAY
CA
94019
US
|
Assignee: |
Laserscope
San Jose
CA
|
Family ID: |
33459292 |
Appl. No.: |
10/876311 |
Filed: |
June 24, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10876311 |
Jun 24, 2004 |
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10278723 |
Oct 23, 2002 |
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10278723 |
Oct 23, 2002 |
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09737721 |
Dec 15, 2000 |
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6554824 |
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60336481 |
Oct 24, 2001 |
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60338728 |
Nov 5, 2001 |
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60337810 |
Nov 5, 2001 |
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Current U.S.
Class: |
606/3 |
Current CPC
Class: |
A61B 2018/2272 20130101;
A61B 2018/00625 20130101; A61B 2018/00982 20130101; A61B 2018/2015
20130101; A61B 18/20 20130101; A61B 18/22 20130101; A61B 2018/00547
20130101; A61B 2017/00274 20130101 |
Class at
Publication: |
606/003 |
International
Class: |
A61B 018/18 |
Claims
What is claimed is:
1. A method for photoselective vaporization of tissue, comprising:
producing laser radiation using a laser system, including inducing
harmonic generation in the laser system using a non-linear crystal
comprising at least one of LBO and BBO, and outputting at least one
harmonic frequency as said laser radiation; and delivering said
laser radiation to a treatment area on a surface of the tissue, the
laser radiation having a wavelength in a range from about 200 to
about 1000 nm and having average irradiance in the treatment area
sufficient for removal of tissue. 532, endoscope, claim 10 replace,
20 W, 60 W as in the others. LBO only, BBO only
2. The method of claim 1, wherein the non-linear crystal comprises
LBO.
3. The method of claim 1, wherein the non-linear crystal comprises
BBO.
4. The method of claim 1, wherein oxyhemoglobin is a primary
chromophore of said tissue.
5. The method of claim 1, wherein said tissue comprises prostate
tissue.
6. The method of claim 1, including delivering said laser radiation
endoscopically
7. The method of claim 1, wherein the wavelength is about 532
nm.
8. The method of claim 1, the laser radiation being absorbed
substantially completely by the tissue within about 1 mm of the
surface, and having average irradiance in the treatment area
greater than 10 kiloWatts/cm.sup.2 in a spot size at least about
0.05 mm.sup.2.
9. The method of claim 1, the laser radiation being absorbed
substantially completely by the tissue within about 1 mm of the
surface, and having average irradiance in the treatment area
greater than 10 kiloWatts/cm.sup.2 in a spot size between about 0.1
and 0.8 mm.sup.2 in the treatment area.
10. The method of claim 1, the laser radiation being absorbed
substantially completely by the tissue within about 1 mm of the
surface, and having average irradiance in the treatment area
greater than 30 kiloWatts/cm.sup.2 in the treatment area.
11. The method of claim 1, wherein the delivered laser radiation
has an average irradiance in the treatment area greater than 20
kiloWatts/cm.sup.2.
12. The method of claim 1, including delivering a flow of irrigant
to the treatment area, and wherein the delivered laser radiation
passes through some of the irrigant before reaching the surface of
the tissue.
13. The method of claim 1, wherein said delivering comprises using
a transurethreal cystoscope, with an optical fiber having a side
firing optical element directing laser radiation from the fiber to
a treatment area on the tissue, and placing said side firing
optical element within about 1 mm, or less, of the treatment
area.
14. The method of claim 1, wherein said delivering comprises using
a endoscope, with an optical fiber directing laser radiation from
the fiber to a treatment area on the tissue.
15. The method of claim 1, including applying only local anesthetic
during said delivering.
16. The method of claim 1, wherein said producing includes
generating said laser radiation using a solid state laser with
greater than 60 Watts average output power.
17. The method of claim 1, wherein said producing includes
generating said laser radiation using a solid state laser with
greater than 20 Watts average output power.
18. An apparatus for photoselective vaporization of tissue,
comprising: a laser including non-linear optics producing a second
or higher harmonic output laser radiation having a wavelength in a
range from about 200 nm to about 1000 nm, wherein the non-linear
optics comprise at least one of LBO and BBO; an optical fiber
coupled to the laser, adapted to direct laser radiation from the
fiber to a treatment area on the tissue; and laser and optical
fiber being adapted to deliver the laser radiation with an average
irradiance in the treatment area sufficient for tissue removal.
19. The apparatus of claim 18, wherein the non-linear crystal
comprises LBO.
20. The apparatus of claim 18, wherein the non-linear crystal
comprises BBO.
21. The apparatus of claim 18, wherein oxyhemoglobin is a primary
chromophore of said tissue.
22. The apparatus of claim 18, wherein said tissue comprises
prostate tissue.
23. The apparatus of claim 18, wherein the laser comprises a solid
state laser with greater than 60 Watts average output power.
24. The apparatus of claim 18, wherein the laser comprises a solid
state laser with greater than 20 Watts average output power.
25. The apparatus of claim 18, wherein the wavelength is about 532
nm.
26. The apparatus of claim 18, wherein the average irradiance is
greater than 10 kiloWatts/cm.sup.2 and the optical fiber is adapted
to cause a spot size of at least about 0.05 mm.sup.2 in the
treatment area.
27. The apparatus of claim 18, wherein the laser comprises a
Neodymium doped solid state laser medium.
28. The apparatus of claim 18, wherein the laser and optical fiber
are adapted to deliver laser radiation having an average irradiance
in the treatment area greater than 20 kiloWatts/cm.sup.2.
29. The apparatus of claim 18, wherein the laser and optical fiber
are adapted to deliver laser radiation having an average irradiance
in the treatment area greater than 30 kiloWatts/cm.sup.2.
30. The apparatus of claim 18, wherein the laser and optical fiber
are adapted to deliver laser radiation having a spot size is less
than about 0.8 mm.sup.2 in the treatment area.
31. The apparatus of claim 18, wherein the optical fiber includes a
side firing tip, and is further adapted for placement of said side
firing tip within about 1 mm, or less, of the treatment area.
32. The apparatus of claim 18, wherein the laser includes a
Q-switch.
33. The apparatus of claim 18, including an endoscope.
Description
RELATED AND CONTINUING APPLICATION INFORMATION
[0001] The present application is a continuation of U.S. patent
application Ser. No. 10/278,723 entitled METHOD AND SYSTEM FOR
PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE, AND OTHER TISSUE,
filed 23 Oct. 2002 (the '723 application). The '723 application is
a continuation-in-part of U.S. patent application Ser. No.
09/737,721, entitled METHODS FOR LASER TREATMENT OF SOFT TISSUE,
filed 15 Dec. 2000, now U.S. Pat. No. 6,554,824 issued 29 Apr.
2003. The '723 application claims the benefit of U.S. Provisional
Application No. 60/336,481, entitled METHOD FOR LASER TREATMENT OF
SOFT TISSUE, filed 24 Oct. 2001. The '723 application claims the
benefit of U.S. Provisional Application No. 60/338,728, entitled
METHOD FOR TREATING BENIGN PROSTATE HYPERPLASIA (BPH) USING LASER
LIGHT AND LOCAL ANESTHESIA, filed 5 Nov. 2001. The '723 application
claims the benefit of U.S. Provisional Application No. 60/337,810,
entitled METHOD FOR THE PHOTO VAPORIZATION OF HYPERPLASTIC PROSTATE
TISSUE, filed 5 Nov. 2001.
[0002] The present application is related to co-pending U.S. patent
application Ser. No. 10/279,087, filed 23 Oct. 2002, entitled
METHOD AND SYSTEM FOR TREATMENT OF BENIGN PROSTATIC HYPERTROPHY
(BPH), invented by Murray, et al.
[0003] The present application is related to U.S. application Ser.
No. ______ entitled METHOD AND SYSTEM FOR PHOTOSELECTIVE
VAPORIZATION OF THE PROSTATE, AND OTHER TISSUE, filed on even date
with the present application.
[0004] The present application is related to U.S. application Ser.
No. ______ entitled METHOD AND SYSTEM FOR PHOTOSELECTIVE
VAPORIZATION OF THE PROSTATE, AND OTHER TISSUE, filed on even date
with the present application.
BACKGROUND OF THE INVENTION
[0005] 1. Field of the Invention
[0006] The present invention relates generally to laser treatment
of soft tissue, and more particularly to photoselective
vaporization of the prostate PVP, and to photoselective
vaporization of other tissue.
[0007] 2. Description of Related Art
[0008] Benign Prostatic Hyperplasia (BPH) is a condition wherein
continued growth of the prostate restricts the passage of urine
through the lower portion of the bladder and the urethra. BPH is
often treated by surgically removing excess prostate tissue from
the transitional zone of the prostate that is pressing on the
urethra, which usually relieves the bladder outlet obstruction and
incomplete emptying of the bladder caused by the BPH.
[0009] Recently, the most commonly employed procedure for removal
of excess prostate tissue has been transurethral resection of the
prostate, also known as TURP. In the TURP procedure, the surgeon
utilizes a standard electrical cutting loop to shave off small
pieces of the targeted tissue from the interior of the prostate. At
the end of the operation, pieces of excised prostate tissue are
flushed out of the bladder using an irrigant.
[0010] While effective, the TURP procedure is known to cause
numerous side effects, including incontinence, impotence,
retrograde ejaculation, prolonged bleeding and TUR syndrome.
Recently, alternative procedures have been developed which reduce
or avoid the side effects associated with TURP. One class of
procedures involves "cooking" prostate tissue by heating it to a to
a temperature above 45 degrees Celsius, causing tissue coagulation.
Typically this is accomplished using electrically resistive
elements such as: radio frequency (RF), microwave, or
long-wavelength lasers. An example of a procedure of this nature is
discussed in U.S. Pat. No. 6,064,914 by Trachtenberg
("Thermotherapy Method"). Because these procedures leave the
thermally-treated tissue in place, post-procedure edema, dysuria,
and retention rates are relatively high. Further, use of thermal
procedures requires the patient to be catheterized for several days
following the procedure, and may cause extensive and unpredictable
scarring of the intra prostatic urethra.
[0011] Another class of procedures involves vaporizing or ablating
the targeted tissue using laser light. These procedures generally
avoid the high infection rates and scarring problems of
thermally-based procedures. However, laser ablation of prostate
tissue has to date, required the use of an expensive laser capable
of generating high-power laser light. The high cost of purchasing
or leasing such a laser results in a concomitant increase in the
cost of the procedure. Finally, the ablation process typically
occurs slowly, resulting in a lengthy procedure time.
[0012] The Ho:YAG laser and its fiberoptic delivery system is an
example of a laser that is commonly used for ablating prostate
tissue. The Ho:YAG laser generates pulses of 2100 nm light that are
strongly absorbed by water in the prostate tissue and in the saline
irrigant positioned between the distal end if the fiberoptic and
the tissue. The absorption coefficient of water is so high at 2100
nm that 50% of the light is absorbed within 0.2 mm of water.
Consequently even a thin layer of irrigant positioned between the
distal end on the fiberoptic and the tissue will absorb a large
fraction of the laser light. Furthermore with the short pulse
durations (Tp<0.5 ms) and large pulse energies (Ep>1.0 joule)
used for ablating prostate tissue the irrigant is explosively
boiled creating a shock wave that tears tissue. Because water is
such a large constituent of prostate tissue and blood, there is
essentially no selective absorption by blood. This combination of
violent tissue disruption and the superficial unselective light
penetration leads to poor hemostasis.
[0013] Nd:YAG lasers operating at 1064 nm have also been used for
ablating prostate tissue. Although 1064 nm light is hemostatic at
high power levels its low absorption in blood and prostate tissue
leads to inefficient ablation and a large residual layer of
thermally denatured tissue several millimeters thick. After
surgery, the coagulated, thermally denatured tissue swells and
leads to transient urinary retention, which can cause long
catheterization times, painful urination, and high infection
rates.
[0014] Frequency doubled Nd:YAG lasers operating at 532 nm in a
Quasi continuous mode at power levels up to 60 watts have been used
to efficiently and hemostatically ablate prostate tissue. These
lasers are pumped by CW krypton arc lamps and produce a constant
train of Q-switched pulses at 25 kHz. The high Q-Switch frequency
makes the tissue effects indistinguishable from CW lasers of the
same average power. The 532 nm light from these lasers is
selectively absorbed by blood leading to good hemostasis. When
ablative power densities are used, a superficial layer of denatured
prostate tissue less than 1 mm is left behind. This thin layer of
denatured tissue is thin enough that the immediate post surgical
swelling associated with other treatment modalities is greatly
reduced. This reduced swelling leads to short catheterization times
and less dysuria. At high powers, 532 nm lasers induce a
superficial char layer (an absorptive, denatured layer) that
strongly absorbs the laser light and greatly improves the ablation
efficiency. The problem with the existing 532 nm lasers used to
date is that they are large, expensive, inefficient, and have a
highly multi-mode output beam that makes them inefficient for
ablating prostate tissue. Furthermore, residual coagulation of
tissue due to the procedure remains significant using the
techniques known in the prior art, as discussed below.
[0015] High power densities are required for rapid and efficient
vaporization of prostate tissue. The difficulty of achieving higher
average output power densities is that when high input powers are
supplied to the laser element from an excitation source such as an
arclamp a large amount of heat is generated in the lasing element.
This heat induces various deleterious effects in the lasing
element. In particular the temperature difference between the
coolant and the hot lasing element generates a thermally induced
graded index lens that decreases the beam quality of the laser and
causes the laser to operate with more transverse optical modes than
it would otherwise.
[0016] The M.sup.2 parameter is a well established convention for
defining the beam quality of a laser and is discussed in pages
480-482 of Orazio Svelto and David C. Hanna, Principles of Lasers,
Plenum Press, New York, 1998, which is incorporated herein by
reference. The beam quality measures the degree to which the
intensity distribution is Gaussian. The quantity M.sup.2 is
sometimes called inverse beam quality rather than beam quality but
in this application it will be referred to as beam quality. M.sup.2
is defined as 1 M x 2 ( x f ) N G ( x f ) G = 4 ( x f ) N G ,
[0017] where .pi. refers to the number 3.14 . . . , .sigma. is used
to represent the spot size, the subscripts x and f represent the
spatial and frequency domains along the x-axis, respectively, and
the subscripts G and NG signify Gaussian and non-Gaussian,
respectively. The x-axis is transverse to the direction of
propagation of the beam. The beam quality in any direction
transverse to the beam may be essentially the same. Therefore the
subscript x is dropped from the M.sup.2 elsewhere in the
specification. The beam widths or us are determined based on the
standard deviation of the position, where the squared deviation of
each position is weighted by the intensity at that point. The beam
width in the frequency domain .sigma..sub.f is the beam width of
the beam after being Fourier transformed.
[0018] The formula usually used for calculating the angular
divergence, .theta. of a beam of light of wavelength .lambda. is
strictly valid only for a beam having a Gaussian intensity
distribution. The concept of beam quality facilitates the
derivation of the angular divergence, .theta., for the beam with a
non-Gaussian intensity distribution, according to 2 = M 2 ( 2 x )
.
[0019] For example, a TEM00 laser beam has a high beam quality with
an M.sup.2 of 1, whereas by comparison, high power surgical lasers
operate with M.sup.2 values greater than 100.
[0020] The Applicants have recognized that high power lasers
typically have an M.sup.2>144. The larger number of modes makes
M.sup.2 larger and makes it difficult to focus the light into
small, low numerical aperture fibers and reduces the ability to
project high power density light onto tissue. As a result, the
vaporization efficiency of CW arclamp pumped 532 nm lasers on
prostate tissue is significantly reduced.
[0021] Other aspects and advantages of the present invention can be
seen on review of the drawings, the detailed description and the
claims, which follow.
SUMMARY OF THE INVENTION
[0022] Photoselective vaporization of tissue, such as the prostate
for treatment of BPH, is based upon applying a high intensity
radiation to prostate tissue using a radiation that is highly
absorptive in the tissue, while being absorbed only to a negligible
degree by water or other irrigant during the operation, at power
densities such that the majority of the energy is converted to
vaporization of the tissue without significant residual coagulation
of adjacent tissue. Unlike prior art techniques for treatment of
BPH, the procedure may be conducted under local anesthesia, and
patients are usually able to go home a couple of hours after the
procedure. The procedure results in fewer side effects than prior
art techniques, including lower incidence of dysuria and hemouria.
Patients may be treated without requiring post-operative
catherization of the urethra.
[0023] According to one embodiment of the invention, a method for
treating BPH comprises the steps of providing a solid-state laser
having a laser element positioned to receive pump radiation from an
excitation source; in some cases modulating the source to cause the
laser to emit pulsed laser light; and delivering the laser light to
targeted tissue. Various solid-state lasers may be used for this
purpose, including (without limitation), a Q-switched laser using a
frequency doubling crystal such as potassium-titanyl-phosphate
(KTP), pumped using a diode array, an arc lamp or a flash lamp.
While Q-switching induces short, "micro-pulses," a "macro-pulse"
duration of the laser light is preferably in the range of 0.1 to
500 milliseconds, induced by for example modulating the pump energy
with the desired macro-pulse length. The wavelength of the laser
light is preferably between 200 and 1000 nm. The laser light is
preferably delivered to the targeted prostate tissue through an
optical fiber terminating at or near a distal end in a side-firing
probe. However the side-firing probe is not essential.
[0024] Operation of the solid-state laser in a "macro-pulsed" mode
is more efficient in inducing rapid tissue ablation than a CW laser
of the same average power. This is in part because the
macro-pulsing is more efficient in inducing "char" formation, a
mild carbonization in which the tissue typically darkens slightly
but does not necessarily turn completely black. Although char
formation is not essential to efficient rapid ablation it is
helpful because the darkened tissue is better at absorbing light.
The macro-pulsed laser is also more efficient and has higher beam
quality, with M.sup.2 values typically less than 144, than a
continuous wave laser with same average output power.
[0025] According to a second embodiment of the invention, a method
for treating soft tissue comprises the steps of providing a
solid-state laser having a laser element positioned to receive pump
radiation from a pump radiation source; modulating the pump
radiation source to cause the laser element to emit laser light
having a pulse duration of between 0.1 milliseconds and 500
milliseconds and an output power exceeding 20 watts; and delivering
the laser light to targeted tissue.
[0026] According to a third embodiment of the invention, a method
for treating BPH comprises the steps of providing a solid-state
laser having a laser element positioned to receive pump radiation
from a pump radiation source; Q-switching the laser to generate a
quasi-continuous wave (CW) beam having an output power exceeding 60
watts; and, delivering the beam to targeted prostate tissue.
[0027] According to a fourth embodiment of the invention, a method
for treating BPH comprises the steps of providing a solid-state
laser having a laser element positioned to receive pump radiation
from a pump radiation source such as a laser diode; Q-switching the
laser to generate a quasi-continuous wave (CW) beam having an
output power exceeding 20 watts with an M.sup.2 less than 144; and
delivering the beam to prostate tissue.
[0028] It has been recognized that as more and more laser energy is
consumed by vaporization of the tissue, the amount of laser energy
leading to residual tissue coagulation gets smaller, i.e. the
amount of residual coagulation drops, and the side effects
attendant to the residual injury caused by the surgery drop
dramatically. Thus, the extent of the zone of thermal damage
characterized by tissue coagulation left after the procedure gets
smaller with increasing volumetric power density, while the rate of
vaporization increases. Substantial and surprising improvement in
results is achieved. It has been recognized that increasing the
volumetric power density absorbed in the tissue to be ablated, has
the result of decreasing the extent of residual injury of the
surrounding tissue. This recognition leads to the use of higher
power laser systems, with greater levels of irradiance at the
treatment area on the tissue, while achieving the lower levels of
adverse side effects and a quicker operation times.
[0029] Although the invention can be generalized other types of
tissue, one embodiment of the invention provides a method for
photoselective vaporization of prostate tissue. According to this
embodiment, the method includes delivering laser radiation to the
treatment area on the tissue, via an optical fiber for example,
wherein the laser radiation has a wavelength and irradiance in the
treatment area on the surface of the tissue sufficient because
vaporization of a substantially greater volume of tissue than a
volume of residual coagulated tissue caused by the laser radiation.
In one embodiment, the laser radiation is generated using a
neodymium doped solid-state laser, including optics producing a
second or higher harmonic output with greater than 60 watts average
output power, and for example 80 watts average output power, or
more. The laser radiation is coupled into an optical fiber adapted
to direct laser radiation from the fiber to the treatment area on
the surface of the tissue. For the treatment of prostate, the fiber
optic is inserted via transurethral cystoscope, including lumens
for delivering irrigants to the treatment area, and for direct
visualization during the treatment.
[0030] In other embodiments, the delivered laser radiation has a
wavelength in a range of about 200 nm to about 650 nm, and has an
average irradiance in the treatment area greater than about 10
kilowatts/cm.sup.2, in a spot size of at least 0.05 mm.sup.2. More
preferably, the irradiance is greater than about 20
kilowatts/cm.sup.2., and even more preferably greater than about 30
kilowatts/cm.sup.2. The spot size in preferred systems is for
example less than about 0.8 mm.sup.2.
[0031] Accordingly, in one embodiment, the second harmonic output
of the neodymium dope solid-state laser is applied using a side
firing tip on the optical fiber. The side firing tip, which causes
a diverging beam to be directed out of the optical fiber, is placed
close to the tissue, within about 1 mm from the side of the side
firing tip to contacting the side of the tip. Close placement
increases the irradiance delivered to the treatment area so that
higher irradiance is available with solid-state lasers generating a
60 to 80 watts average output power.
[0032] According to the present invention, the efficiency of the
vaporization and the reduction of injury to residual tissue are
sufficient that the procedure may be carried out while applying
only local anesthetic during the delivery of laser energy, and
throughout the procedure. For example, a procedure according to the
present invention includes applying intraurethral topical
anesthesia such as lidocaine, either a periprostatic block or a
perirectal block, oral and/or intravenous drugs such as fentanel or
Demerol, chilled irrigant, and irrigant containing anesthesia.
[0033] Furthermore, embodiments of the invention include the
delivery of the laser energy using a Q-switched, solid-state laser
which produces micro-pulses in combination with applying pump power
to the laser medium in a sequence a pulses so that output radiation
is produced in macro-pulses having a peak power of greater than 200
watts, and more preferably about 240 watts or greater. The peak
irradiance in the treatment area during the pulses is thereby
substantially increased, and preferably greater than 50
kilowatts/cm.sup.2, and as much as 90 kilowatts/cm.sup.2 in some
embodiments of the invention.
[0034] Other aspects and advantages of the present invention can be
seen on review the figures, the detailed description, and the
claims which follow.
BRIEF DESCRIPTION OF THE DRAWINGS
[0035] FIG. 1 depicts a laser system for implementing the tissue
ablation methods of the invention;
[0036] FIG. 2 depicts a side-firing probe for use with the system
of FIG. 1;
[0037] FIG. 3 depicts an exemplary output waveform of the FIG. 1
laser when the laser is operated in a macro-pulsed mode; and
[0038] FIG. 4 depicts an exemplary output waveform of the FIG. 1
laser when the laser is operated in a quasi-CW mode.
[0039] FIG. 5 is a block diagram of a laser system adaptable for
use according to the present invention.
[0040] FIG. 6 is a block diagram of an alternative laser system
adaptable for use according to the present invention.
[0041] FIG. 7 is a diagram of a transurethral cystoscope, adaptable
for use according to the present invention.
[0042] FIG. 8 illustrates absorption depth in prostate tissue for
532 nm light.
[0043] FIG. 9 illustrates absorption depth in prostate tissue for
1064 nm light.
[0044] FIG. 10 is a diagram of a beam path from an end view of a
side firing tip, according to one embodiment of the present
invention.
[0045] FIG. 11 is a diagram of a beam path from a side view of the
side firing tip of FIG. 10, according to one embodiment of the
present invention.
[0046] FIG. 12 is a heuristic diagram illustrating operation of the
present invention.
DETAILED DESCRIPTION
[0047] FIG. 1 is a block diagram depicting an exemplary laser
system 100 which may be employed for implementing the present
invention. Laser system 100 includes a solid-state laser 102, which
is used to generate laser light for delivery through optical fiber
106 to target tissue 104. As will be discussed in further detail
herein below, laser 102 is capable of being operated in a
"macro-pulsed" mode, wherein the laser light is emitted as
macro-pulses having relatively long pulse durations.
[0048] Laser 102 more specifically comprises a laser element
assembly 110, pump source 112, and frequency doubling crystal 122.
In the preferred embodiment, laser element 110 outputs 1064 nm
light which is focused into frequency doubling crystal 122 to
create 532 nm light. According to one implementation, laser element
assembly 110 may be neodymium doped YAG (Nd:YAG)crystal, which
emits light having a wavelength of 1064 nm (infrared light) when
excited by pump source 112. Laser element 110 may alternatively be
fabricated from any suitable material wherein transition and
lanthinide metal ions are disposed within a crystalline host (such
as YAG, Lithium Yttrium Fluoride, Sapphire, Alexandrite, Spinel,
Yttrium Orthoaluminate, Potassium Gadolinium Tungstate, Yttrium
Orthovandate, or Lanthanum Scandium Borate). Laser element 110 is
positioned proximal to pump source 112 and may be arranged in
parallel relation therewith, although other geometries and
configurations may be employed.
[0049] Pump source 112 may be any device or apparatus operable to
excite laser element assembly 110. Non-limiting examples of devices
which may be used as pump source 112, include: arc lamps,
flashlamps, and laser diodes.
[0050] A Q-switch 114 disposed within laser 102 may be operated in
a repetitive mode to cause a train of micro-pulses to be generated
by laser 102. Typically the micro-pulses are less than 1
microsecond in duration separated by about 40 microseconds,
creating a quasi-continuous wave train. Q-switch 114 is preferably
of the acousto-optic type, but may alternatively comprise a
mechanical device such as a rotating prism or aperture, an
electro-optical device, or a saturable absorber.
[0051] Laser 102 is provided with a control system 116 for
controlling and operating laser 102. Control system 116 will
typically include a control processor which receives input from
user controls (including but not limited to a beam on/off control,
a beam power control, and a pulse duration control) and processes
the input to accordingly generate output signals for adjusting
characteristics of the output beam to match the user inputted
values or conditions. With respect to pulse duration adjustment,
control system 116 applies an output signal to a power supply (not
shown) driving pump source 112 which modulates the energy supplied
thereto, in turn controlling the pulse duration of the output
beam.
[0052] Although FIG. 1 shows an internal frequency doubled laser,
it is only by way of example. The infrared light can be internally
or externally frequency doubled using non-linear crystals such as
KTP, Lithium Triborate (LBO), or Beta Barium Borate (BBO) to
produce second harmonic 532 nm green light, and higher harmonics.
The frequency doubled, 532 nm wavelength and the shorter wavelength
higher harmonic beams are better absorbed by the tissue, and
promote more efficient tissue ablation.
[0053] In one preferred embodiment the resonant cavity control
system is that described in U.S. Pat. No. 5,151,909, which is
incorporated by reference as if fully set forth herein.
[0054] Laser 102 further includes an output port couplable to
optical fiber 106. Output port 118 directs the light generated by
laser 102 into optical fiber 106 for delivery to tissue 104.
Mirrors 124, 126, 128, and 130 direct light from the lasing element
110 to the frequency doubling crystal 122, in addition to forming
the resonant cavity of the laser. Mirrors 124, 126, 128, and 130
are configured for focusing the light to form an image just in
front of the frequency doubling crystal 122 on the side closer to
mirror 130, and to compensate for thermal lensing in the lasing
element. Although mirrors 124, 126, 128, and 130 are illustrated as
flat and parallel to the walls of the laser, typically the focusing
is achieved by curving and/or angling the mirrors. Alternatively
transmissive optical elements could be used to focus the light and
compensate for the thermal imaging. Mirrors 124, 128 and 130
reflect both the wavelength of light produced by the lasing element
(e.g. 1064 nm) and the wavelength of the frequency doubled light
(e.g. 532 nm). Mirror 126 only reflects the light originating from
the lasing element 110 (e.g. 1064 nm) but is transparent to the
frequency doubled light (e.g. 532 nm), forming an output window.
Higher harmonic outputs may also be generated from the 1064 nm
line, or other line amplified in the laser, including third and
fourth harmonics, for shorter wavelengths. Other laser systems may
be used, including but not limited to Sapphire lasers, diode
lasers, and dye lasers, which are adapted to provide the output
power and wavelengths described herein, including wavelengths in
the ranges from 200 nm to 1000 nm and from 1100 nm to 1800 nm, for
example.
[0055] While a bare fiber may be utilized for certain procedures,
optical fiber 106 preferably terminates in a tip 140 having optical
elements for shaping and/or orienting the beam emitted by optical
fiber 106 so as to optimize the tissue ablation process.
[0056] FIG. 2 depicts a side-firing probe tip 200, which may be
used as tip 140 (FIG. 1). The tip 140 is treated to deflect light
sideways. Some examples of methods for deflecting the light
sideways are to include a light scattering material in the tip 140
and/or to place a reflective element in the tip 140. The reflective
element could be angled at 45.degree., for example; to deflect the
light at 90.degree. with respect to the axis of the fiber 106.
Side-firing probe tip 200 includes an optically transparent sleeve
202 having a transparent window 204 (which may be constructed as a
cutout in the wall of sleeve 202 through which the beam is emitted
in a direction transverse to the optical axis of fiber 106.) An
acceptable range of angles in which to deflect the light beam is
between about 40 to 120 degrees with respect to the axis of the
fiber. The preferred embodiments use an angle of either 70 or 100.
The angle of 80.degree. is preferred from the standpoint of the
ease in manufacturing the tip 200 and the angle of 90.degree. is
preferred from the standpoint of the ease in aiming the side firing
light.
[0057] In a typical mode of operation, optical fiber 106 is held
within an endoscope such as a cystoscope or similar instrument that
allows the clinician to precisely position the distal end of the
optical fiber adjacent to the targeted tissue. The endoscope also
has channels for supplying and removing an irrigant solution to and
from the tissue. In addition, light and image guides are also
included for illuminating and imaging the tissue so that the
clinician may direct the laser light and assess the progress and
efficacy of the ablation procedure.
[0058] FIG. 3 illustrates an exemplary output waveform applied to
tissue 104 when laser 102 is operated in the macro-pulsed mode.
Each macro-pulse 302 is defined by a train of Q-switched
micro-pulses 304. While a relatively small number of micro-pulses
302 are depicted for purposes of clarity, an actual macro-pulse may
comprise hundreds or thousands of component micro-pulses 304. In
the preferred embodiment there are between 2 and 12,200
micro-pulses per macro-pulse.
[0059] An arc lamp, for example, when used as the pump source 112,
is kept at a low power level between pulses that are preferably
just enough to maintain the arc. These low pump powers are below
the lasing threshold of the laser; as a consequence, there is no
laser output between macro-pulses.
[0060] As mentioned above, the pulse duration or width D (FIG. 3)
of the output beam is governed by the modulation of pump source
112, and more specifically by the period during which the pump
source 112 is maintained in an "on" or high-power condition. In
other words, the longer the pump source 112 is maintained in an on
condition, the longer the pulse width. Typically, laser 102 will be
capable of delivering pulses 302 having pulse durations D in the
range of 1 to 20 milliseconds (2 to 490 micro-pulses) or 1 to 50
milliseconds (2 to 1,220 micro-pulses) and average output powers
preferably exceeding 60 watts and preferably up to 100 or 200
watts. The ratio of D to the period of the macro-pulses defines the
duty cycle, which is typically between 10 and 50%.
[0061] In accordance with one embodiment of the invention, a laser
system 100 of the foregoing description is employed to treat BPH by
ablating targeted prostate tissue 104. The clinician may utilize an
endoscope or similar instrument to guide the distal end and tip 140
of optical fiber 106 into alignment with the targeted prostate
tissue 104. Laser system 100 is then operated in the macro-pulsed
mode so that laser 102 generates laser light having the pulsed
waveform depicted in FIG. 3 and delivers it through optical fiber
106 to tissue 104.
[0062] It is known that irradiation of prostate tissue 104 may
initially cause tissue heating resulting in the formation of a char
layer. This char layer is highly optically absorptive in the
wavelengths emitted by laser 102, which thereby facilitates
efficient absorption of the laser light and resultant ablation of
tissue 104. However, the formation of the char layer is not
essential for efficient ablation. Prior art techniques for
treatment of BPH by laser ablation (such as the technique described
by Kuntzman et al. in "High-Power (60-Watt)
Potassium-Titanyl-Phosphate Laser Vaporization Prostatectomy in
Living Canines and in Human and Canine Cadavers," Urology, Vol. 49,
No.5 (1997)) utilized a quasi-CW laser to irradiate the prostate.
Although such lasers do produce moderately high average powers,
they have a large number of transverse modes and as such, produce
highly divergent light when focused into small fiberoptics. This
leads to less than optimal power densities when the laser light is
directed at tissue. As a consequence, these lasers are not
particularly efficient at inducing formation of a char layer, and
ablation rates are relatively slow, significantly lengthening
procedure times. Further, since formation of the char layer takes
place at relatively low rates, undesirable thermal damage to deeper
tissue layers may occur. In contrast, it has been found that a
macro-pulsed beam, such as that generated by laser 102, promotes
rapid formation of a char layer even at moderate output energy
levels, thereby helping to accelerate ablation rates and reducing
procedure time.
[0063] The macropulsing can also increase efficiency because the
threshold voltage required for lasing while macropulsing (the
operating threshold) is lower than the initial threshold voltage
for lasing (cold threshold).
[0064] Macropulsing is also more efficient for producing green
light because the conversion of infrared light to frequency doubled
light increases as the square of the infrared light intensity. The
higher peak powers of the macro-pulsed infrared light leads to
higher second harmonic conversion efficiency. For example, at any
given time, the input power and output power of a frequency-doubled
laser using KTP are related according to
Po=A(Pi).sup.2,
[0065] Where A is an experimentally determined positive constant.
This equation relates the peak input power to the peak output
power. However, the average input power and output power for a duty
cycle of k percent are given by
<Pi>=k(Pi) and
<Po>=k(Po)=kA(Pi).sup.2=A(<Pi>).sup.2/k,
[0066] where the brackets "< >" indicate an average value of
the enclosed quantity. Thus, decreasing the duty cycle from 100% to
50% (i.e. reducing k from 1 to 0.5) while simultaneously doubling
the peak input power Pi results in no change to the average input
power <Pi> and a doubling of the average output power
<Po>. Pulse modulating or macropulsing using Q-switching, for
example, enables reaching higher average output powers with less
thermal lensing due to the lower input power.
[0067] Additionally, it is possible that the frequency doubling
crystal has nonlinearly increasing output power as a function of
the input power. In other words the second derivative of the output
power with respect to the input power may be positive, in which
case the rate of increase of the output power increases with
increasing input power. Specifically, in such a case the functional
dependence of the instantaneous or peak output power, Po, on the
instantaneous or peak input power, Pi, is such that
d.sup.2(Po)/d(Pi).sup.2>0.
[0068] When this is true, and Po is an increasing function of Pi,
the higher peak input power results in a more efficient laser
because ratio of the output to input power increases.
[0069] Pump source modulation of the laser can produce high peak
power macro-pulses and affect the efficiency of the average power
output. Macro-pulse in excess of a steady state power can
substantially improve the initiation of the vaporization of
prostate tissue. The higher peak power of the macro-pulse rapidly
initiates charring which in turn serves as an additional
chromophore for the incident energy and enhances the vaporization
rate. A 30% macro-pulse duty cycle is sufficient to increase the
average power output of an arc lamp pumped laser to greater than 80
watts. Additionally the pump modulation generates macro-pulse with
pulse powers greater than 240 watts.
[0070] By way of a non-limiting example, prostate tissue 104 may be
efficiently and rapidly ablated when laser 102 is operated at an
output power of 80 to 100 watts, a pulse duration of 1-50
milliseconds, and a wavelength of 532 nm.
[0071] In accordance with a second method embodiment of the
invention, laser system 100 may be utilized to ablate other types
of tissue 104. Treatment of tissue 104 is performed in a manner
substantially identical to the technique for treating BPH disclosed
above. The clinician may utilize an endoscope or similar instrument
to guide the distal end and tip 140 of optical fiber 106 into
alignment with the prostate tissue 104. Laser system 100 is then
operated in the macro-pulsed mode so that laser light having the
pulsed waveform depicted in FIG. 3 is generated by laser 102 and
delivered through optical fiber 106 to tissue 104. To achieve
adequate results, laser system 100 is adjusted to emit a beam
having a pulse duration between 0.1 and 500 milliseconds, and an
output power of at least 20 watts. Upon vaporization of the
required volume of tissue 104, (which may be assessed via an
imaging channel contained in the endoscope), the output beam of
laser 102 is turned off.
[0072] In a third method embodiment of the invention, treatment of
BPH is effected by operating laser 102 in a quasi-CW mode at an
output power greater than 60 watts. The increased denaturization of
the tissue is dramatic with increases in power, suggesting a
threshold effect. As depicted in FIG. 4, laser 102 generates a
continuous train of Q-switched micro-pulses 400 when operated in
quasi-CW mode. The laser light is then delivered via optical fiber
106 to targeted tissue 104. Operation in a quasi-CW mode at powers
above 60 watts facilitates formation of char and consequent rapid
ablation rates, whereas operation in a quasi-CW mode at powers
below 60 watts forms char more slowly and causes more thermal
damage to underling tissue.
[0073] A fourth embodiment of this invention is to produce a high
power, high beam quality laser that can project high power density
laser light onto tissue. To do this the number of transverse
optical modes supported by the resonator needs to be kept as low as
possible.
[0074] Small M.sup.2 and high average powers can be achieved by
reducing the degree of thermal lensing in the laser element. Using
laser diodes as the excitation source is one effective way of
greatly reducing both the size of the lasing element and the
thermal gradient responsible for creating the thermal lens. The
reason for this is that while 2-10% of the light produced from a
flashlamp or arc lamp is converted into useful laser light 30-60%
of the light emitted from laser diodes can be converted to laser
light. Since the energy that is not converted to laser light is
converted into heat, laser diodes deposit significantly less heat
in the lasing element and as a consequence create a less powerful
thermal lens. In this manner laser diodes can be used to pump
crystalline laser elements or fiber lasers to produce high beam
quality lasers. Slab and waveguide lasers that can be pumped by
laser diodes, arc lamps, or flashlamps are another method of
creating low M.sup.2 lasers. This is because the thermal gradient
produced in slab lasers is linear across the thin dimension of the
slab and not radially dependent in contrast to a typical
cylindrical lasing element. The linear thermal gradient does not
produce a thermal lens resulting in low M.sup.2 values.
[0075] For example, as a result of the low M.sup.2 some embodiments
of this invention are capable producing laser light that upon
exiting a flat end of a fiber having a diameter of 600 .mu.m has a
divergence of 15.3.degree. or lower; 15.degree. or lower;
10.degree. or lower; or 5.degree. or lower, and the power density
can be 13,400 watts per cm.sup.2, or greater.
[0076] FIG. 5 shows a block diagram of a preferred laser system
according to the present invention. In FIG. 5, a laser resonator is
defined by end mirror 10, turning mirrors 12 and 14, and end mirror
16. All of these mirrors are high reflecting (greater than 99.8%)
at the 1064 nm line. An optical path 24 is defined by these
mirrors. A gain medium 18 comprising a Nd:YAG rod is mounted along
the optical path within a lamp housing 29. An arc lamp 28 is also
mounted within the housing and supplies pump power to the gain
medium in response to current generated in power supply 30. Also in
the optical path 24 is a Q-switch 20 between the lamp housing 29
and the turning mirror 12. A non-linear crystal 22 is mounted
between the turning mirror 14 and the back mirror 16. This
non-linear crystal is preferably a KTP crystal aligned for
frequency doubling to generate a 532 nm beam. Mirrors 16 and 14 are
highly reflective at 532 nm, while mirror 12 is transmissive and
operates as an output coupler for the 532 nm beam.
[0077] Thus, the laser resonator is designed for resonating at a
first frequency, i.e., 1064 nm along the Z-shaped optical path 24.
A second frequency derived from the 1064 nm beam is generated in
the KTP crystal 22. This beam travels along the path 26a and is
extracted from the resonator to supply an output beam along path
26b.
[0078] The output beam along path 26b passes through a controllable
attenuator 36, a beam splitter 38, which supplies a portion of the
output beam to a surgical detector 40, and a component group 42 as
described in more detail below. The attenuator, detector, and
component group are all coupled to a data processing system 34,
across lines 34j, 34k, and 34p.
[0079] The Q-switch 20 is controlled by Q-switch driver 21, which
is, in turn, coupled to data processor 34 across line 34i. In the
preferred system, the Q-switch is an acoustic-optic Q-switch.
[0080] Similarly, the power supply 30 generates an electrical power
signal for controlling the arc lamp 28. This power signal is
controlled by the data processor 34 across line 34h and by drive
circuitry 32 across line 32a. Drive circuitry 32a is controlled by
the data processor across lines 34a through 34g. A sensor 57 is
coupled with the data processor to sense an environmental
condition, such as temperature or humidity, that affects operation
of the laser system. A modem 56 is connected to the data processor
34, providing an interface for remote access to memory in the data
processor. Finally, a control panel 35, by which a user can supply
input signals and parameters, is provided. This control panel 35 is
connected to the data processor 34 across line 34n.
[0081] In alternative systems, the non-linear crystal may be
mounted outside the resonant cavity of the resonator. Also, it may
be used for extracting outputs other than the second harmonic, such
as sum-of-frequency derivation or the like.
[0082] The wavelength used according to the present invention for
BPH treatment should be strongly absorbed in the prostate tissue to
help initiate and maintain tissue vaporization without creating
deep tissue heating. The wavelength also must be minimally absorbed
by the irrigant it used during the procedure, typically water. The
532 nm light produced by the system of FIG. 5, is both strongly
absorbed in oxyhemoglobin and weakly absorbed in water.
Oxyhemoglobin is readily present in prostate tissue and serves as
an efficient chromophore for 532 nm light. The differential in
absorption coefficients between oxyhemoglobin and water at 532 nm
is approximately 5 orders of magnitude (10.sup.5). In other
embodiments, wavelengths in the range from 200 nm-650 nm are used,
which have strong oxyhemoglobin absorption and relatively weak
water absorption (>10.sup.2.times.). In yet other embodiments,
wavelengths in the range from 200 nm to 650 nm range are used,
which have strong oxyhemoglobin absorption and relatively weak
water absorption (>10.times.).
[0083] Of course, as shown in FIG. 6, in which like components have
the same reference numerals as in FIG. 5, alternative pump power
sources, such as laser diode arrays, other lasers for longitudinal
pumping, and others, can be used as suits the needs of a particular
gain medium and application of the laser system. Representative
laser diodes include laser diodes providing output in the range of
805 to 820 nm in wavelength with an input power to the array of
pumping diodes in the range of 300 to 500 Watts. The laser diodes
used for pump energy are operated in a modulated macro-pulse mode,
or in a continuous mode, as suits a particular implementation.
[0084] The laser systems shown in FIGS. 5 and 6 can be modified by
removing both the Q-switch and the external surgical attenuator.
The Q-switch and surgical attenuator are removed because the
modulated pump power provides a great deal of flexibility in
controlling the output power of the laser not attainable using a
Q-switch. The data processing system can be programmed to maintain
a constant thermal load in the laser system while varying the peak
pump power widely. Thus, the peak current and duty cycle of the
pump power source can be adjusted in such a way to keep the average
pump power constant, but the second harmonic power during the ready
and work modes adjusted by selecting the peak current and duty
cycle. Although it may be necessary to use attenuators in the
beamline during the ready mode in order to extract an aim beam,
such attenuators may well be eliminated for the work mode. The
average power does not have to be constant, rather it can be
maintained at levels which keep thermal focusing of the gain medium
within the range of stability of the resonator.
[0085] A representative laser system adapted for delivery of energy
as described above, comprises an 80 watt average power, 532 nm
output wavelength, solid state, intra-cavity frequency doubled
Nd:YAG laser. To obtain optimal efficiency, an arc lamp pump source
is modulated at a period of 4.5 ms with a 16 ms duty cycle,
generating 285 watts peak macro-pulse power. An intra-cavity
acousto-optic AO Q-switch is used to further modulate the energy at
a period of 40 kHz with a 450 us micro-pulse. The laser energy is
coupled to a side firing fiber optic delivery device for delivery
to prostate tissue.
[0086] The laser system uses a combination touch screen and control
knob user interface to assist the operator in setting up the
surgical parameters, including power levels and pulse sequence
specifications. The average power setting is prominently displayed
on the screen. Parameter adjustments are made by first activating
(touching) the desired parameter box on the screen and then turning
the knob. The laser system uses a secure card key interface to
enable the laser. The system is transportable. The system offers
convenient storage and a fiber delivery device pole.
[0087] An example of an endoscope, in particular a transurethral
cystoscope, for use with the present invention is shown in FIG. 7.
The cystoscope has a distal end 200 and a proximal end 201. The
distal end 200 includes a tongue member 202 for pushing tissue away
from a treatment area in the region 204. Laser radiation is
directed sideways from opening 206 in to the region 204, by a side
firing fiber optic component. Water or saline solution is delivered
and removed from the treatment area via lumens in the probe. A
viewing optic is also placed in the opening 206, by which the
surgeon is able to view the treatment area during the procedure. On
the proximal end 201 of the cystoscope, an input port 203 and an
output port 205 for flow of the irrigant is provided. Also, a fiber
port 207 is used for insertion and removal of the fiber optic
delivering laser radiation to the treatment area. A light source
connector 209 is used for supplying light to the treatment area for
visualization. A telescope 211, which can be coupled to a video
camera, or looked into directly, is also included on the
representative cystoscope.
[0088] The vaporization of prostate tissue using oxyhemoglobin as
the primary chromophore is related to the incident power density,
or irradiance, which can be expressed in Watts/cm.sup.2. The
overall rate of prostate tissue vaporization is a function of the
spot size, absorption depth, and the power density. A large spot
with high power density, and rapid absorption is ideal to rapidly
vaporize tissue. A high power light source is required to achieve a
large spot, high power density treatment beam. Peak laser power,
average laser power, beam quality, delivery device design and
delivery device placement all affect the efficiency of
vaporization. A treatment beam 28.5 Kw/cm.sup.2 average irradiance
with a 85.5 Kw/cm.sup.2 peak irradiance macro-pulse, with a spot
size between about 0.2 and 0.5 mm.sup.2, rapidly vaporizes
tissue.
[0089] The BPH treatment procedure can be outlined as follows for
one embodiment of the invention, using a laser system as described
above with reference to FIG. 5.
[0090] Equipment/Set-up
[0091] 21-24 french continuous flow cystoscope
[0092] Laser
[0093] Side firing probe
[0094] Filter (eye safety filter for the monocular or the video
camera)
[0095] Sterile water
[0096] Cystoscope eye piece or video system for direct
visualization
[0097] Anesthesia
[0098] Any of the following or combinations of the following:
General, spinal nerve block, topical, periprostatic block,
perirectal block, pudental block & intravenous drugs
[0099] This procedure does not require general or spinal
anesthesia
[0100] Technique/Process
[0101] Prep patient following standard protocol for cystoscopic
procedures
[0102] Administer anesthesia
[0103] Dilate the urethra
[0104] Insert cystoscope
[0105] Insert side firing delivery device
[0106] Begin flow of sterile water
[0107] Cystoscopy to assess gland
[0108] Position fiber near tissue to be removed and active the
laser
[0109] Use a sweeping motion to vaporize desired tissue
[0110] Continue vaporization until the capsule is reached
[0111] Monitor vaporization efficiency, remove and clean fiber as
required
[0112] Debulk desired lobes, median & lateral lobes
[0113] Fill bladder with water, remove cystoscope, observe
discharge
[0114] If necessary insert foley catheter
[0115] The rapid vaporization with thin coagulation zone contribute
to the hemostasis during the procedure. Because of minimal thermal
damage to existing tissue, there is a low incidence of side
effects, making such symptoms as Dysuria, Incontinence and
Impotence which often occur in prior art techniques, very
unlikely.
[0116] Further, the procedure causes minimal bleeding. Great
outcomes are achieved for patients suffering BPH, including
improved urine flow rate, improved post-void residual, and improved
symptom scores on BPH tests. The procedure often achieves immediate
obstruction relief, and post operative catheterization is not
always required.
[0117] A typical photoselective vaporization of the prostate PVP
procedure will use the following steps:
[0118] A. At the investigator discretion, van buren sound the
urethra in a standard fashion prior to insertion of the continuous
flow cystoscope.
[0119] B. Subjects will be administered general, spinal or local
(prostatic block & oral and topical anesthesia) anesthesia at
the discretion of the Surgeon. In some embodiments, the procedure
is performed without the use of general anesthesia or spinal nerve
blocks, using only local anesthesia such as any combination of
intraurethral topical anesthesia such as lidocaine, either a
periprostatic block or a perirectal block, oral and/or intravenous
drugs such as fentanel or Demerol, chilled irrigant, and irrigant
containing anesthesia.
[0120] C. Vaporization will be performed with the Laserscope ADD
(Angled Delivery Device) fiber, which is a 600 um bare fiber with a
quartz capsule over the 70 degree lateral deflecting quartz element
and a spot diameter of 1.2 mm at 2 mm.
[0121] D. The laser fiber will be introduced through the lumen of a
standard 22 Fr continuous flow laser cystoscope, and sterile water
will be used as the irrigant.
[0122] E. KTP laser energy will be generated by a high power 532 mm
laser capable of delivering 80W of KTP laser power to tissue.
[0123] F. Lasing will be performed under direct visualization using
a free beam technique, holding the fiber 1-2 mm away from the
tissue and vaporizing the lateral lobes beginning at the bladder
neck.
[0124] G. The visible laser beam will be slowly moved along the
length and breadth of the lateral lobe as the tissue is vaporized.
The laser will be carefully directed toward the apical tissue
making sure to protect the external sphincter.
[0125] H. Both lateral lobes will be vaporized evenly to the level
of the capsular fibers.
[0126] I. The median lobe will be vaporized evenly to the level of
the transverse fibers of the vesicle neck. If the median lobe is
too large, then it should be partially vaporized before ablation of
the lateral lobes to facilitate the movement of the scope and
irrigation, and then the remainder will be flattened out later
during the procedure.
[0127] J. The procedure should preserve the distal crista
urethralis and the verumontanum.
[0128] K. The end point of the procedure should be judged by the
size and appearance of the large transurethral resection-like
cavity and by the diminished efficacy of the vaporization effect at
the prostatic capsule. The median and lateral hypertrophic tissue
must be vaporized to the level-of the transverse fibers and any
lingering loose fibers should be removed prior to completion of the
treatment.
[0129] L. Rarely will arterial bleeders be encountered, however, if
an arterial bleeder is encountered, then coagulate the vessel at a
distance of approximately 3 to 4 mm.
[0130] M. The cystoscope is removed and, if necessary, a foley
catheter is inserted at the physician's discretion.
[0131] N. This is an outpatient procedure and subjects will be
released from the hospital as outpatients per the discretion of the
Surgeon.
[0132] FIGS. 8 and 9 illustrate the different optical penetration
depths of the 532 nm wavelength and 1064 nm wavelength used in
prior art procedures. See, S. L. Jacques. Laser-tissue interaction.
Photochemical, photothermal, and photomechanical. Surg. Clin N. Am.
1992;72(3):531-558. The optical penetration depth of the 1064
wavelength beam from Nd:YAG laser beam is about 10 mm, which is 13
times larger than the penetration depth of the second harmonic 532
wavelength laser beam, which is about 0.8 mm. As a result, the 1064
laser power is spread out over a much larger tissue volume than the
power of the KTP laser. In case of the 1064 laser as shown in FIG.
9, the temperature at the tissue surface barely reaches 100.degree.
C. Therefore, only a small portion of tissue gets vaporized. But a
huge volume of tissue gets coagulated (see space between
100.degree. C. and 60.degree. C. isotherm). The consequences are
the formation of edema in a huge volume of coagulated tissue,
swelling of the prostate, and the patient going into retention with
catheterization times of several weeks.
[0133] The 532 laser beam, in contrast, is substantially completely
absorbed within less than about 1 mm of the surface of prostatic
tissue. The laser power is confined to a very small tissue volume.
The high volumetric power density results in a fast heating of the
tissue and efficient tissue vaporization. Volumetric power density
delivered to tissue is a function of the absorption depth,
irradiance in Watts/cm.sup.2 and spot size on the surface of the
tissue. The coagulation zone is very thin because of the small
optical penetration depth of the 532 wavelength, and because
substantially all of the radiation is converted to vaporization
rather than residual heat.
[0134] Other wavelengths which are substantially completely
absorbed within less than about 1 mm of the surface of the
prostatic tissue include wavelengths less than about 650 nm, for
example between about 200 nm and 650 nm.
[0135] FIGS. 10 and 11 illustrate a profile of a beam delivered to
tissue using one representative side firing optical fiber, to show
spot size as a function of distance from the side of the optical
fiber. FIG. 10 is an end view, showing a fiber 600, cladding 601 on
the fiber, an air space 602, and a tip 603 through which the beam
is directed by a reflecting face on the fiber. The cross-section of
the beam is represented by the crossing lines 604 and 605. As
shown, the beam has a width in this dimension of about 0.35 mm at 1
mm from the side of the tip 603. At about 2 mm from the side of the
tip 603, the width is about 1 mm. At about 3 mm distance from the
side of the tip 603, the beam width is about 2.2 mm.
[0136] FIG. 11 is a side view, with like components given the same
reference numbers. The beam width in this dimension is represented
by lines 606 and 607. As shown, the beam has a width in this
dimension of about 0.7 mm at 1 mm from the side of the tip 603. At
about 2 mm from the side of the tip 603, the width is about 1 mm.
At about 3 mm distance from the side of the tip 603, the beam width
is about 1.5 mm.
[0137] Thus, the spot size at 1 mm from the side of the tip is
defined basically by an elipse having a major axis of 0.7 mm, and a
minor axis of 0.35 mm. The area of the spot at 1 mm is around 0.2
mm.sup.2. At 2 mm from the side, the area of the spot is about 0.8
mm.sup.2.
[0138] For rapid procedures, according to the present invention,
the spot size should be large enough that the operator can remove
tissue at a reasonable rate, and see the results of a single pass
of the spot over a region of tissue. If the spot size is too small,
the rate of the operation is too slow. Also, if the spot size is
too big, then the procedure is difficult to control precisely. A
preferred spot size is less than about 1 mm.sup.2, and more
particularly between about 0.8 mm.sup.2 and about 0.05 mm.sup.2.
Other apparatus may be used for delivery of the beam with the
desired spot size, including embodiments without diverging beams,
and embodiments with converging beams.
[0139] The irradiance of the beam at 1 mm from the side of the tip
for an 80W average power laser as described above is about 30
kiloWatts/cm.sup.2. According to the present invention, it is
desirable to provide a wavelength between about 650 and 200 .mu.m,
with a spot size on the surface of the tissue less than about 0.8
mm.sup.2, and preferably greater than about 0.05 mm.sup.2, with an
irradiance greater than about 10 kiloWatts/cm.sup.2, and more
preferably greater than 20 kiloWatts/cm.sup.2, and even more
preferably 30 kiloWatts/cm.sup.2 or higher.
[0140] FIG. 12 shows, heuristically, how vaporization rate and
coagulation rate depend on the volumetric power density. The
vaporization rate (in mm/s) is defined as tissue depth that is
vaporized per time interval. The coagulation rate (in mm/s) is
defined as the depth of residual coagulated tissue that remains
after a certain time of vaporization.
[0141] Below a certain volumetric power density, referred to as a
"vaporization threshold" in FIG. 12, no tissue gets vaporized. All
laser energy stays inside the tissue. Tissue coagulation occurs
where the tissue temperature rises above approximately 60.degree.
C. As the volumetric power density is increased a bigger and bigger
tissue volume gets coagulated.
[0142] At the vaporization threshold, vaporization starts. Above
the vaporization threshold the vaporization rate can be considered
to increase linearly with the volumetric power density for the
purpose of understanding the present invention, and as described by
a steady state model for continuous wave laser tissue ablation,
known by those familiar with the art of laser-tissue
interaction.
[0143] As more and more laser energy is consumed by vaporization of
the tissue, the amount of laser energy leading to residual tissue
coagulation gets smaller, i.e. the amount of residual coagulation
drops. Thus, extent of the zone of thermal damage characterized by
tissue coagulation left after the procedure gets smaller with
increasing volumetric power density, while the rate of vaporization
increases. Substantial and surprising improvement in results is
achieved.
[0144] Publications about visual laser ablation of the prostate
(VLAP) that is performed with an Nd:YAG laser at 1064 nm have shown
that this type of laser is not able to vaporize a significant
amount of tissue. Histology studies have shown that the 1064 nm
laser induces deep coagulation in the tissue that results in edema
and delayed tissue sloughing. This effect was described by
Kuntzman, et al., High-power potassium titanyl phosphate laser
vaporizatino prostatectomy. Mayo Clin Proc 1998:73:798-801. Thus,
in the heuristic diagram of FIG. 12, the VLAP procedure is believed
to lie around point 650, barely above the vaporization threshold.
Also, prior art technologies using 532 nm with spot sizes on the
order of 1 mm.sup.2 with average output power of 60 Watts, are
believed to lie, heuristically, around point 651 in the FIG. 12.
Kuntzman et al present results for the coagulation depth of a 60 W
continuous wave 532 nm laser, with suggested operation at a
distance of 2 mm from the side of the tip, yielding less than 5
kiloWatts/cm.sup.2 irradiance.
[0145] As the laser power is further increased to 80 W, and the
side firing probe is placed less than 1 mm from the tissue for a
small spot size, the ablation rate further increases and the
coagulation rate further drops, so that the procedure lies
heuristically at point 652 in FIG. 12.
[0146] A 80 Watt KTP laser can be used to easily reach irradiance
levels that vaporize substantially more tissue than is left as
residual coagulation after the procedure. More precisely, the
vaporization rate is substantially higher than the coagulation rate
as given by the definition above, using high irradiance levels that
are easily achieved with higher power lasers.
[0147] While the invention has been particularly shown and
described with reference to preferred embodiments thereof, it will
be understood by those skilled in the art, that various changes in
form and details may be made therein without departing from the
spirit and scope of the invention, as defined by the appended
claims.
* * * * *