THE CIRCUMCISION REFERENCE LIBRARY


UROLOGY, Volume 25 Number 6: Pages 555-558,
June 1985.



CARBON DIOXIDE LASER TREATMENT
OF EXTERNAL GENITAL LESIONS

SAMUEL K. ROSEMBERG

From the Departments of Urology and Laser Surgery,
Sinai Hospital of Detroit, Harper-Grace Hospitals,
Detroit, Michigan


ABSTRACT—Our entire clinical experience with the use of carbon dioxide (CO2) laser in the treatment of 67 patients with diverse external genital lesions is presented. Successful eradication was accomplished in 61 patients with wide distribution of condylomatous lesions, with 88 per cent responding to a single laser treatment. Excellent cosmetic results, as well as complete disappearance of balanitis xerotica obliterans and erythroplasia of Queyrat, were observed in 5 additional patients. Laser therapy, although not an established treatment option, appears to be a safe alternative and should be considered in those patients with recurrent genital condylomata, balanitis xerotica obliterans, as well as erythroplasia of Queyrat, not responding to well-known treatment modalities.


Laser therapy has become a reality, and its enormous potential has opened additional avenues in the treatment of external genital lesions,1-7 urethral stricture disease,2 bladder neoplasms,3-4 staghorn calculus,5 etc.

The carbon dioxide CO2 laser is a member of a class of lasers called “molecular lasers.”6 The infrared beam emitted by the CO2 laser is absorbed by the tissues, converted into heat, resulting in cell vaporization. Water within the tissue evaporates at the temperature of laser impact greater than 100°C. The thermal response to CO2 laser energy varies with the water content of the particular cells. The greater the absorption, the more precise and controllable the tissue destruction. If absorption is poor, deep thermal effect will occur. Since epithelial cells have the greatest water content, absorption will be the greatest, and it is precisely this fact that makes CO2 laser an excellent tool for the treatment of external genital lesions.

Material and Methods

From July, 1978 to June, 1983, 61 male and 6 female patients with an age range between fifteen and fifty-three years were treated. Of these 67 patients, CO2 laser treatment was done on 47 patients under general anesthesia, and on 20 patients with local infiltration of 1% lidocaine (Xylocaine) supplemented by intravenous diazepam fentanyl sodium. From this total of 67 patients, 24 (18 males and 6 females have been the subject of previous reports (22 patients with distal urethral and meatal condylomata,7 1 case of balanitis xerotica obliterans,8 1 case of erythroplasia of Queyrat9). Thus, 40 new cases of recurrent genital condylomata (18 distal urethral and meatal, 12 penile shaft, 10 penile shaft and perineum) were treated in addition to 1 case of erythroplasia of Queyrat, and 2 cases of balanitis xerotical obliterans.

A 733 Sharplan CO2 laser, continuous wave mode, withan output of 30 wats, and an optical spot size of 2.0 mm was used. The laser was coupled to an OPMI I operating microscope and controlled by joystick micromanipulator. The average power required varied from 2 to 6 watts for lesions measuring 0.2 to 0.8 mm in diameter. Meatotomy was required in 10 patients for adequate exposure.

Balanitis xerotica obliterans and erythroplasia of Queyrat were managed with an average pewer of 3 watts, continuous wave mode, using the vertical-horizontal-oblique technique.10

Follow-Up and Results

All patients were followed at three-month intervals for at least six months, and advised to return if any occurrence was noted. Average follow-up ranged from two to thirty months. Of the 40 new cases of condyomatous lesions, 36 (90%) responded to a single laser treatment, the overall response (62 patients) being 88 per cent (7 recurrences). Most of the patients complained of mild to moderate initial dysuria during the first twenty-four to forty-eight hours, and were treated with oral administration of Urised. Postoperative urethral meatal calibration failed to reveal any stricture formation in patients with distal urethral and meatal lesions.

Balanitis xerotica obliterans recurred twenty-four months after the original laser application in the first patient we treated and repeat therapy resulted in complete eradication and no further recurrence after eight months (Fig.1). Two additional patients, twenty-eight and thirty-two months, respectively, continue to be free of recurrence. Erythroplasia of Queyrat has been followed after CO2 laser vaporization for thirty-six months and fourteen months respectively, with no recurrence.

Comment

Condyloma acuminatum has been considered by many to be a disease of minor importance, even though it may be a premalignant lesion and could assume major proportions. Successful treatment requires accurate determination of the location and extent of involvement. In 1944, Culp and Kaplan11 described the use of podophyllin in 200 cases; 81.5 per cent were cured with a single application, and the recurrence rate was 4.5 percent. In 1975, Dretler and Klein12 introduced the use of 5-fluorouracil (5-FU) (Efludex 5%) in patients with intraurethral lesions, reporting total eradication in 19 of 20 patients. Although the efficacy of this modality is well appreciated, our personal experience has been disappointing since patients tend to complain of severe pain and irritation in the perimeatal and distal urethral region which prompts discontinuation of treatment. In 1982 we reported on the guidelines for the treatment of condyloma acuminata7 with CO2 lase with successful eradication with one single treatment in 96.6 per cent of 22 cases treated. None of the patients had meatal adherence or spraying of the urinary stream, although initial dysuria was always present during the first twenty-four to forty-eight hours following treatment.

Because of the potential malignant behavior of erythroplasia of Queyrat treatment modalities have included electro-desiccation,13 fulguration,14 cryotherapy,15 irradiation,16 which carry high failure rates, fulguration and surgical resection being mutilating procedures.17

In 1975, Dretler et al.12 reported on the use of topical 5-FU recommending a twice daily application, preferably under foreskin or condom occlusion for a period of four to five weeks. Marked erythema, edema, burning, and stinging required temporary discontinuance of therapy. The reported success rate with this approach is 100 per cent (13 cases).

In 1980, Rosemberg et al.9 reported on the first case of erythroplasia of Queyrat successfully treated with CO2 rapid superpulse laser, with complete disappearance and excellent functional and cosmetic results. Patient discomfort was minimal. Our second case reported in this article (Fig. 2) had the same postoperative results as reported in 1980, making the CO2 laser, in our opinion, superior to 5-FU topical application, since only one outpatient treatment is required which can be performed with local anesthetic infiltration.

Balanitis xerotica obliterans is a chronic progressive sclerosing disease of the male genital tract for which a multitude of different treatments are advocated, depending on its anatomic location. All of these modalities include circumcision,18 meatal dilatation and meatomy,19 intralesional steroid injection,20 etc., and generally offer palliation rather than permanent cure. The ability to predict and control the depth of surgical injury, by variation of the power and time characteristics (watts X time = joules = energy) enables the CO2 laser to completely vaporize these sclerosing lesions, with exceptional cosmetic results. So far, the very first patient has remained symptom-free for twenty-four months before recurrence was noted. Re-treatment has resulted in complete eradication and symptom-free status after eight months. Our second and third cases continue to be symptom-free thirty-two and twenty-eight months respectively (Fig. 3). Again, outpatient single treatment, local anesthetic infiltration, minimal postoperative discomfort, and exceptional postoperative appearance all combine to offer a superion alternative to the well-known treatment modalities.

The guidelines for the treatment of condylomata acuminata with CO2 laser have been previously described. Nevertheless, two important steps deserve to be re-emphasized: (1) selection of an adequate power, and (2) surgical technique.

It has been previously stated that laser vaporization of any particular lesion should always be accomplished by selection of the lowest possible average power, and that adjustments be made accordingly during the surgical procedure. One of the most commonly noted errors amongst physicians newly trained in laser surgery is the use of excessive wattage which in turn results in deep burns with subsequent increase in postoperative patient discomfort.

It must be remembered that the total mass ablated by a laser beam which strikes a target tissue in one fixed place is directly proportional to the total power of the beam, and to the time of application, and that the same factors apply to mass ablation of a moving laser beam, but vaporization will be somewhat less if total beam power and time of application are the same as for the stationery beam. Thus, the newly trained laser surgeon should always select the lowest possible power output for any particular lesion amenable to laser vaporization.

Lasers, like any medical device, must be used with skill and common sense. When confronted with multiple external condylomatous lesions, the perimeter should be established in order to be able to encompass all the abnormal areas within a specific square surface. Do not vaporize condylomatous lesions whose total boundaries have not been identified. All the recurrences in this series have been outside the field of laser irradiation, suggesting that the new outbreaks were in fact at an incubating stage, not clinically apparent, or very small lesions missed during the vaporization process.

Once the boundaries for the surface area to be treated have been established, the vertical-horizontal-oblique technique will assure an even, smooth removal of all lesions from surface to base. By operating the laser in this fashion, the heat conducted to the underlying tissue; distributed evenly along the surface of the lesion, resulting in minimal coagulation necrosis, the end result being a fine cosmetic result. Thus in our experience, CO2 laser therapy appears to be a safe adjunct, and offers an alternative treatment modality for those recurring lesions frustrating patients and their urologists.

Department of Urology
Harper-Grace Hospital
Detroit, Michigan 48230

References

   1. Rosemberg SK, et al: Rapid superpulse carbon dioxide laser treatment of urethral condylomata, Urology 27: 149 (1981). [PubMed]
   2. Bulow DM, et al: Laser investigations of the strictured urethra, Invest Urol 16: 403 (1979).
   3. Okada K, et al: Transurethral neodymium-YAG laser surgery for bladder tumors, Urology 20: 404 (1982). [PubMed]
   4. Rothenberger K, et al: Transurethral laser coagulation for treatment of urinary bladder tumors, Lasers Surg Med 2: 23 (1983). [Abstract]
   5 Brazilov B, et al: The clinical use of CO2 laser beam in the surgery of kidney parenchyma, ibid 2: 81 (1981). [PubMed]
   6. Fuller TA: The physics of surgical lasers, ibid 1: 5 (1980). [Abstract]
   7. Rosemberg SK, et al: Some guidelines to the treatment of urethral condylomata with CO2 laser, J Urol 127: 906 (1982).
   8. Rosemberg SK, et al: Carbon dioxide treatment of balanitis xerotica obliterans, Urology 19: 539 (1982).
   9. Rosemberg SK, et al: Carbon dioxide rapid superpulse laser treatment of erythroplasia of Queyrat, ibid 16: 181 (1980).
10. Rosemberg SK, et al: Continuous wave carbon dioxide laser treatment of giant condylomata acuminata of the distal urethra and perineum: technique, J Urol 126: 827 (1981). [PubMed]
11. Culp OS, and Kaplan IW: Condyloma accuminata— two hundred cases treated with podophyllin, Ann Surg 120: 29 (1944). [Full Text]
12. Dretler SP, and Klein LA: The eradication of intraurethral condyloma acuminata with 5% fluorouracil cream, J Urol 11: (1975) 195.
13. Graham JH, and Helwig EB: A clinicopathologic and histochemical study, Cancer 32: 1396 (1973).
14. Graham JD, et al: Premalignant cutaneous and mucocutaneous disease, in: Dermal Pathology, New York, Har-Rowe 1972, p 597.
15. Klinger ME, and Northrip RU: The erythroplasia of Queyrat: two case reports, J Urol 63: 173 (1950).
16. Baker L: Discussion of erythroplasia of Queyrat, Arch Dermatol 108: 733 (1973).
17. Anderson L, et al: Erythroplasia of Queyrat; carcinoma in situ, Scand J Urol Nephrol 3: 303 (1967).
18. Fairgrieve J, and Parker RA: Acquired phimosis in the elderly caused by lichen sclerosus et atrophicus, Br J Urol 31: (1959).
19. Kherzl AA, Dovnis A, and Dunn M: Balanitis xerotica obliterans, ibid 51: 229 (1979).
20. Poyter JH, and Levy J: Balanitis xerotica obliterans: effective treatment with topical and sublesional corticosteroids. Ibid 39:420 (1967).


Citation:
(File revised 23 March 2008)

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