Carbon Dioxide Laser 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, with an 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

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