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Assessment of the learning curves for photoselective vaporization of the prostate using GreenLight™ 180-Watt-XPS laser therapy: Defining the intra-operative parameters within a prospective cohort
Abstract
To assess the learning curves for the intra-operative parameters of the GreenLight™ 180-W XPS for photoselective vaporization of the prostate (PVP).
A prospective study was conducted on 200 men who underwent PVP using the GreenLight™ 180-W XPS over 20 months. The population was divided into four consecutive equal groups. Evolution of lasing parameters was the main endpoint to reach an average energy of 5 kJ per prostate volume and to reach a lasing time/operative time (LT/OT) ratio of 66-80 %. Changes in the IPSS and prostate volume were also evaluated 12 weeks later.
Total energy delivered (energy/ml of prostate) and the LT/OT ratio significantly increased over time (p < 0.05). Urinary function significantly improved from baseline in all groups. The first lasing parameter endpoint was reached after the 75th patient (group 1) and the second endpoint (LT/OT ratio) after the 125th patient (group 3). Only the PSA level (p = 0.04) and prostate volume (p < 0.0001) decreased significantly in the 3rd and the 4th group. Post-operative complications occurred in 20 % of patients, which were primarily Clavien-Dindo grades 1 and 2, though there were no statistical differences between the four groups (p = 0.62). In-hospital stay and time to catheter removal were significantly shorter in the 3rd and 4th group.
The current study assessed the PVP learning curves within multiple intra-operative parameters. The PVP learning curves required at least 120 procedures until it met all intra-operative parameters of experts in this field.
... Campbell et al. [9] proceeded creating a working channel at 80 W power setting, and this was immediately increased to 120 W power once there was sufficient working space; therefore, power was increased further from 120 to 180 W as soon as there was sufficient space. Misrai et al. followed the technique previously described by Malek et al. [13,14]. Altay et al. [15] performed the procedure in a TURP-like manner. ...
... Despite the above-mentioned differences and the differences in surgical technique performed, all the functional outcomes were satisfactory and the surgery-related adverse events were similar and relatively rare. The most commonly used surgical strategy was described by the IGLU group, in 3 on 8 studies different techniques were used, anyway these variations don't seem to impact on complications rate and functional results [13,15,16]. An important issue in the infancy of each new surgical technique is, of course, a proper evaluation of the learning curve. ...
... The authors assessed the learning curves within multiple intra-operative parameters, showing that at least 120 procedures should be performed to reach an expert level of competence as defined by procedure duration and the effectiveness of volume reduction. Interestingly, they showed that the functional results (IPSS and PVR reduction and Qmax increase) were similar during the complete learning procedure, whereas the incidence of complications did not change during the learning curve [13]. Another very important issue They showed that there is a significant cost reduction in the postsurgical phase, characterized by shorter hospitalization times. ...
The aim of this study is to investigate the efficacy and safety of 180-W XPS GreenLight laser technology for photoselective prostate vaporization.
A systematic search of the electronic databases was performed. Inclusion criteria were: full-text peer-reviewed journal article, with original data analysis that evaluates the feasibility and the outcome only of 180-W XPS GL laser system. Data at baseline and during follow-up have been taken into account. Intra-operative and postoperative (functional results and complications) data were collected and analyzed.
We found 165 articles in our research, among which only nine articles were selected (total 991 patients). A certain grade of variability is present in all the studies in terms of scientific design, sample size and methods of reporting functional results and complications. Nevertheless, a homogenous benefit for patients in terms of symptom score improvement, post-void residual volume reduction and urinary max flow rate improvement was shown. According to Clavien-Dindo classification, 292 (83.7 %) adverse events were recorded ≤ grade 2. Adverse events ≥ grade 3 were 57 (16.3 %), among which bleeding, urinary retention and residual obstructive tissue represented the wide majority. No mortality was reported. Male sexual function was poorly investigated.
The 180-W XPS GL laser technique is feasible and safe, with a remarkable clinical benefit. Long-term evidence on outcomes and complications are suitable even in the sphere of male sexuality.
... The search identified 30 papers (Fig. 1). Of these, 10 papers were identified dealing with consecutive cohorts of patients treated with the 180-W XPS laser and describing patient's characteristics and outcome after treatment of LUTS due to BPH with the XPS laser [6][7][8][9][10][11][12][13][14][15]. The baseline characteristics are summarised in Table 1. ...
... In five of the studies 25-64% of patients were on anticoagulants. Aspirin was the most frequent used drug followed by warfarin (up to 18%) and clopidogrel (up to 8.5%) [6,[11][12][13]15]. The relation between anticoagulation and perioperative morbidity was not investigated in any of these studies. ...
... The duration of follow up ranged between zero and 9.4 months. The functional results of short-term follow-up were documented in eight papers [6][7][8][9][11][12][13][14][15]. The results are summarised in Table 3. ...
AimTo systematically review the literature regarding clinical outcomes of 180W XPS GreenLight laser (GL) vaporization for the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH).Methods
Recent publications in the field of 180 Watt GreenLight Laser (GL) vaporization for the treatment of LUTS due to BPH were identified by a literature search. It was searched for peer reviewed original articles in English language. Search items were: 180W lithium triborate laser or 180W greenlight laser or 180 watt lithium triborate laser or 180 watt greenlight laser or XPS greenlight laser. 30 papers published between 2012 and 2014 matched this search. Out of this collective 10 papers were identified dealing with consecutive cohorts of patients treated with the 180W XPS GreenLight® laser.ResultsTen papers included a total experience of 1640 patients. The only RCT in this field compares 180W XPS with transurethral resection of the Prostate (TURP). Functional outcomes and prostate volume reduction following GL vaporization were similar to TURP. Catheterization time and hospital stay were shorter in patients undergoing 180W XPS GL-vaporization (41 and 66 hours vs 60 and 97 hours respectively). Four papers compared the 180W XPS system to former GL devices demonstrating increased operation time efficiency and comparable postoperative voiding results and adverse events. One paper defined the learning curve to achieve an expert level according to the speed of the procedure and the effectiveness of volume reduction was met after 120 procedures.Conclusion
The 180W XPS GreenLight laser offers shorter operation times than the former devices. In the one randomised controlled trial comparison with TURP, volume reduction and functional results were comparable to those of TURP. Longer term studies are required.
... There has been a suggestion that the decreasing TURP experience had led to decreased knowledge of postoperative complications and is associated with increased surgical adverse events [6,7]. In addition, some of the surgical BPH procedures have long learning curves requiring over 100 cases for mastery [8]. ...
... A systematic review describes the HoLEP learning curve to be 30-40 cases [55, 56•]. Anatomical vaporization of the prostate with GreenLight has a learning curve of approximately 120 cases to achieve maximal benefit with minimal risk [8,57,58,59]. GreenLEP seems to have a shorter but wider range for its learning curve of 14-100 cases [60,61]. ThuLEP's learning curve ranges from 20 to 50 cases [46,62]. ...
Purpose of Review
Benign prostatic hyperplasia (BPH) is a common medical condition of older men that often requires medical or surgical therapy. Surgical options for BPH have grown exponentially over the last two decades. The numerous options and/or lack of access to them can make it challenging for new trainees to gain proficiency. We examine the literature for available BPH surgical simulators, learning curves, and training pathways.
Recent Findings
Each BPH surgical therapy has a learning curve which must be overcome. There is an abundance of TURP simulators which have shown face, content, and construct validity in the literature. Similarly, laser therapies have validated simulators. Newer technologies do have available simulators, but they have not been validated. There are strategies to improve learning and outcomes, such as having a structured training program.
Summary
Simulators are available for BPH surgical procedures and some have been implemented in urology residencies. It is likely that such simulation may make urologists more facile on their learning curves for newer technologies. Further studies are needed. Future directions may include integration of simulator technology into training pathways that include surgical observation and proctorship.
... In 2000, Malek was the first to describe the operative technique to perform PVP by means of the VHP laser system 14 and the concepts were lately adopted by Misrai for the XPS PVP. 15 In 2008, Muir et al. published the technical recommendations of the International Green-Light User (IGLU) group on HPS PVP. 16 a preliminary cystoscopy represents the first module of the procedure, allowing the localization of bladder neck and the ureteral orifices. ...
... The authors estimated the need for at least 120 cases to reach an expert level of competence. 15 Costs Studies aiming to compare XPS PVP to TURP with regard to average cost per patient affirm that laser vaporization provides a reduction in costs. 50,51 When comparing direct surgical costs, vaporization was found significantly more expensive than resection whilst it was cheaper with regard to the postsurgical phase: considering the total average cost of the two procedures, the advantage of PVP over TURP was found statistically significant (3277±6.56 ...
Introduction:
Intending to overcome Transurethral resection of the prostate (TURP) in terms of safety maintaining its efficacy profile, have led to the introduction of minimally invasive laser therapies to treat men with lower urinary tract symptoms (LUTS) secondary to Benign prostatic obstruction (BPO), each one with its unique properties. Aim of this review was to analyse and summarize all the existing data regarding the 180 W Xcelerated Performance System (XPS) Potoselective Vaporization of the Prostate (PVP).
Evidence acquisition:
A systematic review was conducted: 45 papers were identified. After excluding those not in English language, duplicates, case reports and "expert opinion" papers, 39 articles were reviewed.
Evidence synthesis:
The XPS emits a 532 nm wavelength generated using a lithium triborate crystal in a quasi-continuous mode through a 750 μm, continuously saline-cooled, metal capped MoXy™ fibre. This system has overcome the previous model in terms of surgical and functional outcomes. Although several techniques have been proposed, the IGLU modular one is considered the standard approach for 180 W PVP. Authors estimated the need for at least 120 cases to reach an expert level of competence. The GOLIATH study has proven the non-inferiority of XPS PVP to TURP. The procedure is safe and effective also in large glands but long operative times still represent an issue. Considering the total average costs, XPS PVP provides and advantage over TURP. International guidelines consider PVP the best option to manage patients receiving anticoagulants or with a high cardiovascular risk.
Conclusions:
PVP should be considered an adult technique and, as suggested by the EAU guidelines, is the best surgical option to manage patients receiving anticoagulant medication or with a high cardiovascular risk. The development of new surgical techniques such as APV, PEBE and seminal spearing approaches could represent a possibility to further implement the XPS indications. Dedicated unit could improve the management LUTS/BPO men.
... [5][6][7][8][9] However, a recent report suggested that PVP is associated with a steep learning curve of up to 75 cases to achieve competency and 125 cases to achieve proficiency. 10 Therefore, virtual reality (VR) simulators were introduced to train and assess postgraduate trainees (PGTs) outside of the operating room (OR). 11,12 One such VR simulator is The GreenLightÔ simulator (GL-SIM), which was developed by Dr. Robert M. Sweet (University of Minnesota). ...
... Parameters included were based on literature review of PVP outcomes, expert opinion, and parameters used by the GL-SIM to obtain the global score. 10,13,[18][19][20][21] The first parameter is safety consciousness. It is important for PGTs to be aware of the hazards of the 532 nm laser and what would happen when there is fiber damage. ...
Introduction and Objectives: Photo-selective Vaporization of the Prostate (PVP) is a frequently performed procedure by postgraduate trainees (PGTs). However, there is no PVP-specific objective assessment tool to evaluate the acquisition of PVP skills. The aim of the present study was to develop and validate an Objective Structured Assessment of Technical Skills tool for the PVP procedure (PVP-OSATS).
Methods: This study was conducted in two phases. Phase 1 included the development of PVP-OSATS and assessment of its reliability and construct validity. Panel discussion among experts lead to development of the PVP-OSATS tool with 12 parameters, each scored from 1 (worst) to 5 (best) with a maximum score of 60. Laser prostatectomy experts and PGTs from Post-Graduate Years (PGY) 4 and 5 were recruited. Inter-rater reliability, using Cohen’s and Fleiss’s kappa, was calculated for all parameters. To assess for construct validity, PGTs were compared with experts. Phase 2 included assessment of the concurrent validity of this novel tool. This was performed by recruiting Quebec urology PGTs between PGY-3 and 5 to test their PVP skills during semi-annual Objective Structured Clinical Examination (OSCE) using the validated GreenLightTM simulator.
Results: During phase 1, 116 intra-operative PVP-OSATS assessments were collected; 102 for PGTs and 14 for experts. Cohen’s and Fleiss’s kappa were adequate (k≥0.6) for all 12 parameters, confirming adequate inter-rater reliability. There was significant difference between PGTs and experts in all PVP-OSATS parameters (p≤0.01) except for respect for anatomical landmarks and instrument damage. During phase 2, there was significant positive correlation between PVP-OSATS scores inside the operating room and global scores obtained by the GreenLight simulator (r=0.814; p<0.001).
Conclusion: This study reports inter-rater reliability, construct, and concurrent validity of PVP-OSATS as a novel PVP-specific objective assessment tool.
... This is in contrast to the more recently developed HoLEP procedure, for which extensive investigation led to a figure of 20-60 cases (according to functional outcomes and operative efficiency markers) [65]. Finally, a single study identified a learning curve of 120 cases for the GreenLight procedure (for energy delivered and functional outcomes) [66]. ...
... HoLEP [65] 20-60 OT, enucleation ratio efficiency, morcellation efficiency, CR, IPSS, Q max GreenLight [66] 120 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 6 ) X X X -X X X the board for urologic procedures [8,9]. Methods such as elearning and observership can be a good initial step in any curriculum, providing a foundation of theoretical knowledge ( Fig. 1). ...
Context:
Urology is at the forefront of minimally invasive surgery to a great extent. These procedures produce additional learning challenges and possess a steep initial learning curve. Training and assessment methods in surgical specialties such as urology are known to lack clear structure and often rely on differing operative flow experienced by individuals and institutions.
Objective:
This article aims to assess current urology training modalities, to identify the role of simulation within urology, to define and identify the learning curves for various urologic procedures, and to discuss ways to decrease complications in the context of training.
Evidence acquisition:
A narrative review of the literature was conducted through December 2015 using the PubMed/Medline, Embase, and Cochrane Library databases.
Evidence synthesis:
Evidence of the validity of training methods in urology includes observation of a procedure, mentorship and fellowship, e-learning, and simulation-based training. Learning curves for various urologic procedures have been recommended based on the available literature. The importance of structured training pathways is highlighted, with integration of modular training to ensure patient safety.
Conclusions:
Valid training pathways are available in urology. The aim in urology training should be to combine all of the available evidence to produce procedure-specific curricula that utilise the vast array of training methods available to ensure that we continue to improve patient outcomes and reduce complications.
Patient summary:
The current evidence for different training methods available in urology, including simulation-based training, was reviewed, and the learning curves for various urologic procedures were critically analysed. Based on the evidence, future pathways for urology curricula have been suggested to ensure that patient safety is improved.
... In a prospective study on the learning curve for PVP using the GreenLight TM 180-W XPS laser, Misrai et al 10 investigated the statistics of 200 consecutive patients, who had undergone PVP. Many parameters were evaluated, including lasing time (LT), operating time (OT), LT/OT, urinary function, prostate specific antigen (PSA) serum level change, prostate volume change, hospital stay, time to Foley catheter removal, and complications based on the Clavien-Dindo score. ...
Introduction: Currently, a laser is a popular technology in urological surgeries. The important laser-related issue is the time when a surgeon reaches an acceptable level of safety and efficacy using laser technology.
Methods: In this review, we aimed to assess the learning curves of three types of surgeries in urology, including photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP), and retrograde intra-renal surgeries (RIRSs). Here, we searched Medline, Web of Science, Google Scholar, EMBASE, and Scopus for such keywords as Urology, laser, laser vaporization, prostate, nephrolithiasis, benign prostatic hyperplasia (BPH), and learning curve.
Results: We evaluated 14 studies about PVP, 17 about RIRS, and 29 studies about HoLEP. Also, we separately discussed the learning curves of these three kinds of surgeries in detail.
Conclusion: All the urologists, even expert surgeons, should attend a formal training course and have a skilled tutor present in their first cases.
... The current study suggests that surgeon experience may have an impact on the occurrence of late complications. While a 20-case volume may be sufficient to acquire the vaporization skill, it takes over 100 procedures to reach an expert level of competence as defined by procedure duration and the effectiveness of volume reduction [21,22]. We assessed our data for both 75 cases and 100 cases as a cut-off in defining the experience level, and we found out that the outcomes did not change. ...
Objective
To assess the incidence, risk factors, and timing of specific causes of reoperations following PVP.
Material and Methods
A retrospective analysis of data on men who underwent GreenLight PVP between 2004 and 2019 in a single center and required surgical intervention for bladder neck contracture (BNC), urethral stricture (US), or persistent/recurrent prostate adenoma.
Results
The overall rate of reoperations was 13.8% during a 61-month median follow-up of 377 patients. Reoperations were due to BNC, US, and adenoma in 7.7%, 5.6%, and 4.8% of cases, respectively. The median interval until reoperation for US (11 months) was significantly shorter. None of the risk factors had any relevance to US. In patients who underwent reoperation for BNC, lasing time and energy were significantly lower, and the prostate volume was smaller; however, the multivariate analysis only identified shorter lasing time as a predictor. In patients who had reoperation for persistent/recurrent adenoma, the PSA was increased, while the prostate volume was non-significantly high, and performance by less-experienced surgeons was associated with a higher rate of reoperations (p < 0.05). A longer lasing time predicted an increased risk of reoperation for adenoma in multivariate analysis.
Conclusions
An unselective utilization of PVP may result in a relatively high rate of reoperations. The correlation of BNC with shorter lasing time may imply a higher risk after PVP of smaller prostates. A longer lasing time predicts an increased risk of reoperation due to persistent/recurrent adenoma, which may be related to higher prostate volumes and inefficient PVP by less-experienced surgeons.
... Despite GreenLight laser photovaporization (PVP) having been standardized and described at all levels, from standard PVP to more complex procedures involving enucleation (13,14), there is a lack of studies evaluating how to safely train novice surgeons with prior endoscopic experience in PVP using robust and standardized metrics. Moreover, while several studies aimed at evaluating the safety and efficacy of PVP focused the analysis on the number of procedures required in order to achieve proficiency (15)(16)(17), data are limited by the heterogeneous criteria used to assess the learning curve (18)(19)(20)(21). ...
Objectives: To evaluate the feasibility and safety of a proctored step-by-step training program for GreenLight laser anatomic photovaporization (aPVP) of the prostate.
Methods: Data from patients undergoing aPVP between January 2019 and December 2020 operated by a single surgeon following a dedicated step-by-step proctored program were prospectively collected. The procedure was divided into five modular steps of increasing complexity. Preoperative patients' data as well as total operative time, energy delivered on the prostate and postoperative data, were recorded. Then, we assessed how the overall amount of energy delivered and the operative times varied during the training program. Surgical steps were analyzed by cumulative summation. Univariable and multivariable regression models were built to assess the predictors of the amount of energy delivered on the prostate.
Results: Sixty consecutive patients were included in the analysis. Median prostate volume was 56.5 mL. The training program was succesfully completed with no intraoperative or meaningful post-operative complications. The energy delivered reached the plateau after the 40th case. At multivariable analysis, increasing surgeon experience was associated with lower amounts of energy delivered as well as lower operative times.
Conclusions: A step-by-step aPVP training program can be safely performed by surgeons with prior endoscopic experience if mentored by a skilled proctor. Considering the energy delivered as an efficacy surrogate metrics (given its potential impact on persistent postoperative LUTS), 40 cases are needed to reach a plateau for aPVP proficiency. Further studies are needed to assess the safety of our step-by-step training modular program in other clinical contexts.
... This series also showed that acute urinary retention, urinary incontinence, hemorrhage, urinary tract infection and erectile dysfunction were the complications seen after TURP. Our results differ from those of MISRAI et al. who finds complications related to the equipment, including the excessive temperature of the irrigation serum which caused burns of the urethra and / or the bladder, and the intraoperative complications linked to the gesture, essentially rectal wounds [24] . They are also similar to those of FOURNIER et al., Who in their study on the complications of transurethral resection of the prostate in relation to the 100 report hemorrhage, acute retention of urine when the bladder catheter is removed, orchiepididymitis and urinary tract infection [21] . ...
... One surgeon with experience with GreenLight PVP [12] (VM) but no previous endoscopic enucleation experience performed all procedures in accordance with the technique previously described by Gomez Sancha et al. [9]. A Green-Light XPS™ 532-nm laser generator (Boston Scientific) was used for all cases, and HPS™ 120-W laser fibres were utilised for the GreenLEP procedure. ...
PurposeThis study sought to compare perioperative outcomes and morbidities for open simple prostatectomy (OSP) and endoscopic green laser enucleation of the prostate (GreenLEP). Methods
In a single department, all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and all consecutive patients undergoing GreenLEP between July 2013 and January 2017 were prospectively enrolled. Perioperative data, information regarding early postoperative complications for up to 6 months and outcomes were collected and retrospectively compared. ResultsOverall, 204 patients were enrolled in each group. The baseline characteristics of patients in both groups were comparable. Intraoperative time was significantly longer for the OSP group than for the GreenLEP group (67 versus 60 min; p < 0.0001). The OSP group had significantly longer catheterisation (5 versus 2 days; p < 0.0001) and hospitalisation times (7 versus 2 days; p < 0.0001) than the GreenLEP group. The overall rate of complications was significantly higher after OSP than after GreenLEP (37.2 versus 20.6%; p = 0.0003); both Clavien–Dindo grade 3a complications (8.8 versus 0.98%) and Clavien–Dindo grade 3b complications (2.4 versus 3.4%) were observed. The transfusion rate was higher after OSP than after GreenLEP (8.3 versus 0.5%; p = 0.0001). The rehospitalisation rate was similar for both groups (7.8 versus 8.3%; p = 0.99). Conclusions
The results of this single-centre cohort study confirm those of similar prior investigations addressing endoscopic enucleation of the prostate. Compared with OSP, GreenLEP may have a more desirable perioperative profile with lower morbidity. In contrast, GreenLEP and OSP were associated with similar 6-month rehospitalisation rates.
... We found clinically and statistically significant improvements in all functional parameters (IPSS, Qmax, and PVR) between baseline and the 3-month follow-up, similar to that reported by other researchers using the 180-W LBO laser. [5][6][7][8] The prostate volume decreased by 47% and PSA concentration by 42%, similar to the findings of Bachmann et al. 5 and Misrai et al. 11 Although the 180-W LBO laser has been associated with good perioperative and functional outcomes, it is not without complications. Intraoperative bleeding was observed in 10 (4.3%) of our 233 patients, but no difference in frequency was found between the anticoagulation and nonanticoagulation groups. ...
Objective
To evaluate the safety and efficacy of the 180-W GreenLight XPS laser system for the treatment of benign prostatic hyperplasia in patients taking oral anticoagulants.
Methods
All consecutive patients admitted for lower urinary tract symptoms associated with benign prostatic hyperplasia from November 2012 to October 2016 and who underwent photoselective vaporization of the prostate with the 180-W GreenLight XPS laser were included in the study. The perioperative outcomes examined were the operating time, laser time, energy usage, and duration of postoperative catheterization. Functional parameters (International Prostate Symptom Score, maximum urinary flow rate, and post-void residual urine volume), prostate volume, and serum prostate-specific antigen concentration were examined at baseline and 3 months. Perioperative complications, if any, were noted.
Results
All functional parameters (International Prostate Symptom Score, maximum urinary flow rate, and post-void residual urine volume) significantly improved from baseline to 3 months. A small number of patients experienced at least one minor adverse event. There was no difference in the rate of adverse events between patients who were and were not taking anticoagulants.
Conclusions
Photoselective vaporization with a 180-W laser is an efficacious and safe treatment for benign prostatic hyperplasia, even in patients taking anticoagulant medications.
... The use of a training simulator resulted in improvements in operating times, error rates and instrument costs. Clinically, Misrai et al. performed a single surgeon series and reported that 120 consecutive cases were required to optimize operating time (33). In this series, following the learning curve, total energy to prostate tissue efficiency increased over time. ...
Benign prostatic hyperplasia (BPH) is a common pathology causing lower urinary tract symptoms (LUTS) and may significantly impact quality of life. While transurethral resection of the prostate (TURP) remains the gold standard treatment, there are many evolving technologies that are gaining popularity. Photoselective vaporization of the prostate (PVP) is one such therapy which has been shown to be non-inferior to TURP. We aimed to review the literature and discuss factors to optimise patient outcomes in the setting of PVP for BPH. A comprehensive search of the electronic databases, including MEDLINE, Embase, Web of Science and The Cochrane Library was performed on articles published after the year 2000. After exclusion, a total of 38 papers were included for review. The evolution of higher powered device has enabled men with larger prostates and those on oral anticoagulation to undergo safely and successfully PVP. Despite continued oral anticoagulation in patients undergoing PVP, the risk of bleeding may be minimised with 5-Alpha Reductase Inhibitor (5-ARI) therapy however further studies are required. Pre-treatment with 5-ARI's does not hinder the procedure however more studies are required to demonstrate a reliable benefit. Current data suggests that success and complication rate is largely influenced by the experience of the operator. Post-operative erectile dysfunction is reported in patients with previously normal function following PVP, however those with a degree of erectile dysfunction pre-operatively may see improvement with alleviation of LUTS.
... 2,11 In terms of acquiring expert level proficiency, an additional study estimated that up to 120 cases may be needed to obtain expert level proficiency in the procedure. 12 In line with our findings, Aydin, et al. performed a study that included 46 participants who were grouped by level of experience. Twenty five participants were considered novice, and had no operative or endoscopic experience. ...
... Several studies have evaluated the learning curve for HoLEP and have suggested that a range of 40-70 cases is needed to achieve a stable outcome level [11,12,23]. Very few studies have aimed to assess the learning curve for PVP [24] and none have assessed the learning curve for GreenLEP. Our findings suggest a tendency towards a shorter learning curve for GreenLEP compared to HoLEP: 14-30 first consecutive cases compared to 22-40 cases, respectively, depending on the definition used. ...
PurposeTo compare the learning curves, perioperative and early functional outcomes after HoLEP and GreenLEP. Methods
Data from the first 100 consecutive cases treated by GreenLEP and HoLEP by two surgeons were prospectively collected from dedicated databases and analysed retrospectively. En-bloc GreenLEP and two-lobar HoLEP enucleations were conducted using the GreenLight HPS™ 2090 laser and Lumenis™ holmium laser. Patients’ characteristics, perioperative outcomes and functional outcomes after 1, 3 and 6 months were compared between groups. ResultsTotal energy delivered and operative times were significantly shorter for GreenLEP (58 vs. 110 kJ, p < 0.0001; 60 vs. 90 min, p < 0.0001). Operative time reached a plateau after 30 procedures in each group. Length of catheterization and hospital stay were significantly shorter in the HoLEP group (2 vs. 1 day, p < 0.0001; 2 vs. 1 day, p < 0.0001). Postoperative complications were comparable between GreenLEP and HoLEP (19 vs. 25 %; p = 0.13). There was a greater increase of Qmax at 3 months and a greater IPSS decrease at 1 month for GreenLEP, whereas decreases in IPSS and IPSS-Q8 at 6 months were greater for HoLEP. Transient stress urinary incontinence was comparable between both groups (6 vs. 9 % at 3 months; p = 0.42). Pentafecta was achieved in four consecutive patients after the 18th and the 40th procedure in the GreenLEP and HoLEP group, respectively. Learning curves ranged from 14 to 30 cases for GreenLEP and 22 to 40 cases for HoLEP. Conclusion
Learning curves of GreenLEP and HoLEP provided roughly similar peri-operative and short-term functional outcomes.
... Перспективи подальших досліджень Отримані результати відкривають перспективу подальшого вдосконалення фотоселективної вапоризації добро якісної гіперплазії передміхурової залози за рахунок дослідження можли востей нового методу -лТб (літій-триборат) 180 ват-XPs зеленого лазера [8]. ...
p>роботу присвячено патофізіологічному аналізу впливу лікування доброякісної гіперплазії передміхурової залози за допомогою КТФ-лазера на показники
когнітивних функцій, системи крові, водно-сольового обміну та функції нирок у хворих віком 50–60 років. Прооперовано 9 хворих на доброякісну гіперплазію передміхурової залози за допомогою калій–титаніл–фосфатлазера (КТФ-лазера) у віковій групі 50–60 років. Використано: клініко-інструментальні, біохімічні, гематологічні, хімічні, фізіологічні, статистичні методи. Положення щодо високої технологічності КТФ-лазера підтверджено комплексом достовірних позитивних кореляційних зв’язків, які вказують на
факт, що за даного методу лікування не тільки не має змін з боку досліджуваних параметрів, але й зберігається структура їх профілю, що продемонстровано як для ММse, так і тесту малювання годинника. Водночас, не виявлені вірогідні регресійні залежності між тестом малюванням годинника до та після операції у пацієнтів вікової групи 50–60 років та наявність різних форм діаграм багатофакторного регресійного аналізу до та після операції вказують на можливість подальшого вдосконалення зазначеного методу лікування.</p
... 20 In addition, when considering photoselective vaporization of the prostate using the Green-Light laser, a study has suggested that this may lie in the region of 120 cases. 21 However, these are single studies, and therefore despite widespread claims of longer learning curves associated for HoLEP, it is in fact difficult to compare both procedures with current evidence within the literature. The present study additionally highlights the difficulty of performing the HoLEP procedure. ...
... 2 Furthermore, to improve the efficiency, they recommend a 66%-80% laser time-to-operating time ratio. 6,7 There is also a suggestion that there may be a significant learning curve involved when switching from TURP to PVP. 8 Reported intraoperative and postoperative complications of PVP are similar to TURP and include capsular perforation, bleeding, damage to the bladder or ureteral orifices, injury to other adjacent structures, and bladder neck contracture. 9 One rarely reported and difficult-to-manage complication after PVP or TURP is the development of a prostatosymphyseal fistula (PSF). ...
... 22 Other authors reported the need for auxiliary TURP for hemostasis and residual tissue removal during PVP-XPS in 3.8% to 27.4% of cases. 23,24 Moreover, Bachmann et al showed significant association of the use of auxiliary TURP with larger prostate size in patients treated with XPS where monopolar TURP was used in 6.5% of patients with prostates 40 to 80 ml vs 16% with prostates larger than 80 ml. 23 In the current study, although significantly more patients were using 5ARIs in the PVEP group, they had more bleeding requiring auxiliary TURP for hemostasis. ...
Purpose:
After the advent of the GreenLight XPS™ (180 W) 532 nm laser, photoselective vapo-enucleation of the prostate could compete with holmium laser enucleation of the prostate as a size independent procedure. We assessed whether photoselective vapo-enucleation of the prostate-XPS is not less effective than holmium laser enucleation of prostate for improvement of lower urinary tract symptoms secondary to benign prostatic hyperplasia.
Materials and methods:
A randomized controlled noninferiority trial comparing holmium laser enucleation of the prostate to photoselective vapo-enucleation of the prostate-XPS 180 W was conducted. I-PSS, flow rate, residual urine, prostate specific antigen and prostate volume changes as well as perioperative and late adverse events were compared. Noninferiority of I-PSS at 1 year was evaluated using a 1-sided test at 5% level of significance. The statistical significance of other comparators was assessed at the (2-sided) 5% level.
Results:
Overall 50 and 53 patients were included in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively. Operative time, hospital stay and time to catheter removal were comparable between the groups. There was significant, comparable improvement in I-PSS and post-void residual urine volume at 1, 4 and 12 months. After 4 months prostate size reduction was significantly higher in the holmium laser enucleation of prostate group (74.3% vs 43.1%, p=0.001). At 12 months maximum urine flow rate was significantly higher in the holmium laser enucleation of prostate group (26.4 ±11.5 vs 18.4 ±7.5 ml per second, p=0.03). Re-intervention was needed in 2 and 3 cases in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively (p=1.0). Mean estimated cost per holmium laser enucleation of prostate procedure was significantly lower than per photoselective vapo-enucleation of the prostate procedure.
Conclusions:
Compared to holmium laser enucleation of prostate, GreenLight XPS laser photoselective vapo-enucleation of the prostate is safe, noninferior and effective in treatment of benign prostatic hyperplasia.
Objectives
To report 5-year outcomes, need and predictors of retreatment post greenlight laser photoselective vaporization (GL.PVP) and vapo-enucleation (GL.PVEP), as long-term data on safety and efficacy of GL.PVP and GL.PVEP and on the prostate using XPSTM system are still pending.
Patients and methods
Primary outcome was the need for retreatment (medical treatment and reintervention) for recurrent BOO. Time-to-event (retreatment) analysis, perioperative events, change in the urinary outcome measures at different follow-up visits, early and late complications and PSA kinetics were reported.
Results
Between September 2014 and April 2017, 248 patients underwent GL/XPS procedures. GL.PVP and GL.PVEP were carried out for 157 (63.3%) and 91 (36.7%) patients with mean prostate sizes of 60 ± 18 and 100 ± 22 cc, respectively. After a mean duration of 62 ± 9-month follow-up, overall retreatment rate (medical and interventional) was 23% (57 patients). It was comparable between both GL.PVP and GL.PVEP cases: 38 (24.2%) and 19 (20.9%) patients, P = 0.5, respectively. Significantly more surgical reintervention rate was reported after GL.PVP compared to GL.PVEP (P = 0.03). In retreatment group, more intraoperative bleeding (P = 0.02), early postoperative hematuria (P = 0.03), higher median preoperative PSA (P = 0.02) and less postoperative one-year percent PSA reduction (P = 0.02) were detected. Lower postoperative one-year percent PSA reduction independently predicts retreatment with a cut-off point of 64.2% (58.2% sensitivity, 73.4% specificity, AUC 0.647, 95% CI 0.52–0.76).
Median (range in months) time to event was 20 (1–60) for all cases and 13.5 (1–42) and 30 (18–60), P = 0.7, for GL.PVP and GL.PVEP groups, respectively.
Conclusion
Greenlight laser XPS is an effective, durable and versatile tool in treating benign prostatic obstruction. Durability of the outcome is predictable with more postoperative PSA reduction.
Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.
Purpose:
We evaluated a system for noninvasive quantitative motion tracking to recognize differences in the movement pattern of experienced surgeons and beginners. Since performing endoscopic procedures requires extensive training, and tissue damage due to disruptive movements with sudden acceleration is possible, the learning curve for beginners is of clinical relevance. Steepening this curve may improve patient outcome.
Materials and methods:
We used a commercial gyroscope sensor with a wireless data link, which was attached to the resectoscope handle (RH). After recording, orientation was retrieved by application of the calculated rotation matrices to the RH vector relative to the sensor under the boundary condition of rotational movement around and quasi-constant distance to the pivot point at pelvic floor level. Data alignment, normalization, interpolation, and analysis were performed in custom software scripts.
Results:
Experienced surgeons and beginners were recorded in n = 36 and n = 14 holmium laser enucleation of the prostate (HoLEP), respectively. Prostate size, patient age, and recorded procedure duration were comparable. Mean lever angle of the individual normalized motion patterns was considerably lower (19.28 ± 0.54° [SEM]) in the advanced than in the beginners' group (24.52 ± 1.00°; p = 0.0001). Further parameters such as velocity and motion variation demonstrated additional differences between both groups.
Conclusions:
We demonstrate the feasibility of motion tracking in HoLEP. Pronounced differences exist between different stages of surgeon experience with this procedure. The method can easily be adopted to aide young surgeons in resectoscope handling and identification of improvable motion patterns. Damage to the pelvic floor and surrounding tissue may thus be reduced.
Purpose:
To evaluate the efficacy and safety of benign prostatic obstruction (BPO) surgery in patients with preoperative urinary catheterization.
Patients and methods:
We conducted a multi-institutional retrospective study including all patients who failed a trial without catheter (TWOC) after acute urinary retention (AUR) between January 2017 and January 2019. Patients with neurogenic bladder, prostate cancer or urethral stricture were excluded from the analysis. Patients underwent either monopolar/bipolar transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), prostate artery embolization (PAE), open prostatectomy (OP) or endoscopic enucleation. The primary endpoint was 12-month urinary catheter free-survival without using benign prostatic hyperplasia (BPH)-medications.
Results:
One hundred and seventy one consecutive men (median age: 71 years; median prostate volume: 75 cm³) underwent BPO-surgery including 48 (28%) TURP, 62 (36.3%) PVP, 21 (12.3%) endoscopic enucleation, 15 (8.8%) PAE and 25 (14.6%) OP. The median duration of preoperative urinary catheterization was 69 days (IQR 46-125). The twelve-month urinary catheter free-survival rate was 84.8% (145/171). Satisfactory voiding returned to 121 patients (70.8%). On backward stepwise multivariable analysis, PVP (OR 0.27[0.10-0.69]; p=0.008), PAE (OR 5.27[1.28-27.75]; p=0.03), endoscopic enucleation (OR 0.08[0-0.49]; p=0.023), OP (OR 0.10[0.01-0.57]; p=0.034), Charlson score (OR 1.36[1.14-1.66]; p=0.001) and number of preoperative TWOC failure (OR 2.53[1.23-5.51]; p=0.014) were significantly associated with catheter free-survival.
Conclusions:
In this multi-institutional retrospective study including patients with preoperative catheterization, the overall success rate of BPO-surgery was 70.8% after one-year follow-up. Compared to TURP, enucleation methods and PVP were associated with better catheter free-survival, while PAE was associated with higher risk of AUR recurrence.
Purpose:
To test the non-inferiority of Bipolar (B.TUVP) compared to Greenlight laser (GL.PVP) vaporization of the prostate in reduction of BPH-related LUTS in randomized trial.
Methods:
Eligible patients with 30-80ml prostate were randomly allocated to GL.PVP/XPSTM (58) and B.TUVP (61). Non-inferiority of symptoms score (IPSS) at 24 months was evaluated. All perioperative parameters were recorded and compared. Urinary (IPSS, Q.max and PVR) and sexual (IIEF-15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change of PSA and health-resources related cost of both procedures were depicted and compared.
Results:
Baseline and perioperative parameters were comparable between the two groups. At 1, 4, 12 and 24 months; 117, 116, 99 and 96 patients were evaluable respectively. Regarding urinary outcome measures, there was no significant difference between both groups. Mean IPSS at one and two years was (7.1±3, 7.9±2.9) following GL.PVP and (6.3±3.1, 7.2±2.8) following B.TUVP (P=0.8, 0.31) respectively. At 24 months the mean difference in the IPSS was 0.7 (95%CI -0.6-2.3, P=0.6). Median postoperative PSA reduction was 64.7% (25-99) and 65.9% (50-99) following GL.PVP and was 32.1% (28.6-89.7) and 39.3% (68.8- 90.5) following B.TUVP P= 0.006 and 0.005 at 1 and 2 years respectively. After 2 years, retreatment for recurrent BOO was reported in 8 (13.8%) and 10 (16.4%) following GL.PVP and B.TUVP groups respectively (P=0.8). The mean estimated cost per B.TUVP procedure was significantly lower than per GL.PVP procedure after 24 months (P=0.01) CONCLUSIONS: In terms of symptoms control, B.TUVP was not inferior to GL.PVP at 2 years. Durability of the outcome needs to be tracked. The cost issue of GL.PVP is a critical concern compared to B.TUVP.
Purpose:
The main objective of this multicentric retrospective pilot study was to evaluate the one-year follow-up safety (i.e. minor (Clavien-Dindo I-II) and major (Clavien-Dindo ≥III) complications) of holmium enucleation of the prostate (HoLEP), GreenLight photo selective vaporization of the prostate (GL PVP) and TURP performed after KT. The secondary objectives were to evaluate the efficacy and to assess the impact of these procedures on graft function.
Materials and methods:
We retrospectively included all KT recipients who underwent a HoLEP or GL PVP or TURP for benign prostatic hyperplasia (BPH) in three French university centers.
Results:
From January 2013 to April 2018, 60 BPH endoscopic surgical procedures in KT recipients were performed: 17 HoLEP (HoLEP group), 9 GL PVP (GL PVP group) and 34 TURP (TURP group). Age, BMI, preoperative serum creatinine, preoperative IPSS, preoperative Qmax, preoperative PSA, medical history of AUR, UTI and indwelling urethral catheter were similar in all study groups. Mean preoperative prostate volume was higher in HoLEP group. The rate of overall post-operative complications was statistically higher in the HoLEP group (11/17 (64.7%) versus 1/9 (11.1%) versus 12/34 (35.3%) in HoLEP group, GL PVP group and TURP group, respectively, p=0.02), with higher rate of long term UTI and AUR. Qmax improved in all groups after surgery. Delta POM 12 - preoperative serum creatinine was similar in the all groups.
Conclusions:
Although our study is underpowered, the rate of post-operative complications is higher with HoLEP procedure, in comparison with GL PVP, for the treatment of BPH after KT. One-year efficacy is similar in HoLEP, GL PVP and TURP groups. Further prospective randomized controlled trials are needed to confirm our results.
Purpose:
The study aimed to evaluate progression of GreenLight-XPS 180 W photoselective vaporization of the prostate (GL-XPS) with respect to effectiveness, efficacy, and safety over time at a tertiary referral high volume center.
Methods:
The retrospective study included 375 men who underwent GL-XPS for symptomatic benign prostate obstruction (BPO) between June 2010 and February 2015. Primary outcome measurements were operation time (OT; min) and effective laser time (LT; min of OT) analyzed with regard to prostatic volume (PV; mL) (group 1 <40 mL up to 4 >80 mL in 20 mL steps) and the year of surgery (2010-2015).
Results:
The median age was 72 years (range 64-79), the median PV was 58 mL (range 33-98) and the median PV increased from 42 mL in 2012 to 80 mL in 2015. The OT and LT clearly correlated with the PV, being doubled for glands of median 95 mL compared to median 30 mL while the applied laser energy per LT likewise steadily increased. Overall, both OT and LT could be significantly reduced each year by 37% (OT; p < 0.05) and 36% (LT; p < 0.05) within 5 years. The hospital stay (days) and catheterization time (days) remained constant, without any changes over time. The overall complication rate (Clavien-Dindo >2) ranged from 36 to 15% between 2010 and 2015. The pre (median 22 + 4) and postoperative International Prostate Symptom Score-Quality of Life (median 5 + 1) showed a sufficient reduction in symptomatic BPO.
Conclusion:
GL-XPS is a safe and effective surgical method for symptomatic BPO. Our single center experience showed a significant improvement of both OT and effective LT within 5 years whilst maintaining stable low complication rate and high patient satisfaction.
Purpose of review:
GreenLight photoselective vaporization (GL-PV) is now established in the treatment of benign prostatic enlargement. The present review outlines the available technical armamentarium and summarizes the current best evidence on functional and safety outcomes. Moreover, future technical developments and refinements are presented.
Recent findings:
GL-PV has evolved to be the most commonly performed procedure, second to conventional transurethral resection of the prostate (TURP) for surgical management of benign prostatic obstruction (BPO). On the basis of the data published in the randomized controlled Goliath study, GL-PV with 180-W technology is noninferior in terms of functional outcomes compared with TURP considering short and intermediate follow-up with a complication-free rate of around 80% after 24 months.The ongoing push towards high-power lasers can be explained by their more effective tissue ablative effect, leading to shorter operating times. Comparative analysis between high-power and low-power laser systems demonstrated similar retreatment rates and most institutions are, therefore, now performing 180-W GL-PV.Performed as an outpatient procedure, GL-PV is cost-effective with a low hospital re-admission rate. Plasma kinetic vaporization of the prostate (PKVP) has recently emerged as a potential contender in the field; also GreenLight enucleation of the prostate (GreenLEP) might be even more effective than GL-PV.
Summary:
GL-PV appears to be a well tolerated surgical alternative for patients suffering from BPO. Long-term follow-up data from 120-W and 180-W laser systems are still pending. Potential competitors have recently been brought to the market and further trials and long-term data will show, whether GL-PV will stand the test of time. Regardless of technical specifications, surgeon's experience remains essential to achieve good functional and safety outcomes.
Introduction:
GreenLight photoselective vaporisation of the prostate (PVP) offers an endoscopic alternative to open prostatectomy (OP) for treatment of large adenomas. This study compares long-term functional outcome of both techniques in patients with Benign prostatic obstruction (BPO)>80g.
Material and method:
Data from patients who underwent surgical treatment for BPO>80g from January 2010 to February 2015 at our institution were retrospectively collected and compared according to surgical technique. Patient's demographics, surgeon's experience, operative data and long-term functional results were analyzed, using IPSS and International continence society (ICS) male questionnaire associated with Quality of life scores (IPSS-QL and ICS-QL). Predictors of long-term outcome were also assessed.
Results:
In total, 111 consecutive patients, 57 PVP and 54 OP, were included in the study with a mean follow-up of 24 and 33 month respectively. Patient's age, Charlson score, preoperative IPSS and urinary retention rates were similar. Mean prostatic volume was superior in the OP group (142 versus 103g, P<0.001). Transfusion rate was lower after PVP (P=0.02), despite a more frequent anticoagulant use. Length of hospital stay and urinary catheterization were shorter after PVP (P<0.001), with however a higher rate of recatheterization (RR=4.74) and rehospitalization (RR=10.42). Long-term scores were better after OP for IPSS (1 versus 5, P<0.001), IPSS-QL, ICS, ICS-QL. On multivariate analysis, prostatic residual volume was the only predictor of long-term IPSS but not ICS.
Conclusion:
Long-term functional outcome are better after OP compared to PVP. However, PVP offers good results, allowing to safely operate patients taking anticoagulants, regardless of prostatic volume. Endoscopic enucleation may the compromise between both techniques.
Level of evidence:
4.
Background:
The learning curve for photoselective vaporisation of the prostate (PVP) has never been assessed accurately.
Objective:
To compare 180-W GreenLight XPS PVP learning curves for three surgeons with different levels of surgical experience and different institutional backgrounds.
Design, setting, and participants:
A multicentre retrospective study of the first patients treated with PVP by three operators in three different centres (n=152 in group 1, n=112 in group 2, n=101 in group 3) was conducted. Surgeon 1 had performed >600 PVP procedures (120-W GreenLight HPS laser) since 2007, while surgeons 2 and 3 had no previous experience with GreenLight PVP. Surgeon 1 mainly treats both benign prostatic hyperplasia (BPH) and urologic oncology, surgeon 2 primarily focuses on urologic oncology, and surgeon 3 mostly treats BPH. Surgeon experience was analysed as a continuous variable in terms of consecutive procedures performed.
Intervention:
PVP using a 180-W GreenLight XPS laser.
Outcome measurements and statistical analysis:
The learning curve was analysed in terms of changes over time for the following variables: operative time, the vaporisation time/operative time ratio, and the energy delivered/prostate volume ratio. The primary endpoint was a trifecta of (1) energy delivered >5kJ/ml of prostate, (2) vaporisation time/operative time ratio of 66-80%, and (3) no postoperative complications.
Results and limitations:
Patient baseline characteristics differed significantly among the centres in terms of age, prostate volume, and International Prostate Symptom Score (IPSS). Most perioperative outcomes favoured group 1 over group 3 over group 2. Functional outcomes, such as a decrease in IPSS at 1 mo for the first 50 patients (-15 vs -13.6 vs -13.3; p<0.0001) and an increase in maximum flow at 1 mo for the first 50 patients (+14.2 vs. +7 vs. +9.4; p<0.0001), favoured group 1 over group 3 over group 2. The trifecta achievement rate was significantly higher in group 3 over group 1 over group 2 (26.7% vs 14.4% vs 5.4%; p<0.0001). In multivariate analysis adjusting for age, American Society of Anesthesiologists score, and preoperative prostate volume, the only factors predictive of trifecta achievement were surgeon experience (p<0.0001) and surgeon identity (p<0.0001). The study limitations include selection bias, short follow-up, and a lack of consensus regarding learning curve assessment and definition.
Conclusions:
More than 100 PVP procedures were required to reach an intraoperative parameter plateau regardless of surgeon expertise and institutional background. Both surgeon background and expertise seemed to influence perioperative outcomes during the GreenLight XPS PVP learning curve.
Patient summary:
Both surgeon background and expertise seem to influence perioperative outcomes during the learning curve when using a GreenLight XPS laser for photoselective vaporisation of the prostate.
Objective:
Long-term outcome after prostate photovaporization (PVP) remains largely unknown, especially when performed on enlarged prostates. However, new vaporisation techniques (e.g., laser enucleation) are increasingly used. Our aim was to compare postoperative results after standard PVP to those of an anatomical technique.
Materials and methods:
This bicentric prospective study included males treated for enlarged prostate caused by benign prostatic hyperplasia using a GreenLight laser. Patients were preoperatively assessed according to prostate volume, post-void residual volume (PVR), maximum urinary-flow rate (Qmax), prostatic specific antigens, and International prostate symptom score (IPSS). Peroperative data included vaporization time, energy delivered, and operative length. Postoperative data at 1, 3, 6 and 12 months were compared with initial data; all complications were recorded. Comparisons were made between the conventional vaporization technique versus anatomical vaporization, which initially differentiated the peripheral zone of the prostate using an enucleation technique but no morcellation.
Results:
Records from 106 surgical patients between December 2012 and December 2013 were analyzed. Operative length, vaporisation time, and energy used were greater in the anatomical PVP group. The average length of hospital stay (2.0 vs. 2.5 days), time with a catheter (1.3 vs. 1.9 days), IPSS (5.0 vs. 6.4), PVR (15.5 vs. 11.7mL), and Qmax (19.9 vs. 19.7mL/s) were comparable between the two groups. However, more complications occurred (27% vs. 37%), including stress urinary incontinence (0% vs. 8%) when using anatomic vaporization.
Conclusion:
Despite comparable groups and similar functional results, anatomical PVP caused more stress incontinence. However, the learning curve between the two techniques may explain this difference.
Level of evidence:
4.
BACKGROUND AND OBJECTIVES
Our objective was to describe the progressive introduction of photoselective vaporization of the prostate (PVP) in an academic department of urology in an outpatient care setting and report our outcomes after the first 100 cases.
PATIENTS AND METHODS
Since May 2014, XPS GreenLight™ (Boston Scientific-AMS, USA) PVP in the treatment of benign prostatic hyperplasia was introduced in our department. A prospective local registry was opened to collect patients' demographics, preoperative characteristics and surgical outcomes including operative time, length of stay, catheterization time, and postoperative complications as well as functional outcomes. We also assessed limitations to the outpatient care setting.
RESULTS
Conversion to TURP was reported in 6 % for uncontrolled bleeding. Overall, 21 % patients needed more than 1-day catheterization. After 6 months of follow-up, 3 patients (prostate volume 50, 117, and 178mL) had reintervention (second PVP). Ninety days' complications were reported to be up to 6 % (3 urinary obstructions, 1 prostatitis, 1 transfusion and a severe sepsis). After 8 months, an 80 % plateau of outpatient care setting was achieved. Anesthesiologists counter-indicated outpatient care in 59 % of the cases.
CONCLUSIONS
A progressive introduction of the PVP in an outpatient care setting is associated with a low complication rate. A plateau was achieved in less than 100 procedures. The major limitation of the outpatient care setting was patients' competitive comorbidities and not disease characteristics.
LEVEL OF EVIDENCE
4.
Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Endoscopic management of benign prostatic obstruction is based on resection, vaporization, or enucleation. Enucleation provides the best efficacy and long-term outcome. Lasers have advantages in patients at high risk of bleeding. Holmium enucleation is the best evaluated technique, but has a steep learning curve. Greenlight photovaporization is a safe alternative to transurethral resection of the prostate (TURP) in prostates of less than 100 mL, especially in patients at high risk of bleeding. Bipolar devices can be used for resection, vaporization, and enucleation and provides efficacy results similar to TURP in the short term with better safety.
Introduction:
Photovaporization of the prostate by the Greenlight(®) laser (GL) has been strongly developed this past few years in France, representing nearly 30% of surgery for BPH, making France the second GL user worldwide after USA. The objective of this study was to assess the French surgeons practices with the Greenlight(®) laser.
Material and methods:
During the 4th meeting of French Greenlight(®) users group (GUGL), was proposed a questionnaire on the management of patients and the GL technique. The questionnaire covered the operator's characteristics (age, experience with the GL, etc.), the treatment strategy, preoperative management (anticoagulants…) and postoperative management (ambulatory, removal catheter…) as well as the surgical technique (fiber type, energy used, etc.).
Results:
Among the 117 participants, 64 answered to the questionnaire (55%). Fifty-six percent chose GL, whatever was the prostate volume, simple prostatectomy was the most commonly alternative used for high prostate size (39%). The aspirin was pursued by 89% of practitioners perioperatively. Conversely, clopidogrel was continued by only 19% and anticoagulant by only 14%. Seventy-three percent of participants commonly used classic vaporization and only 3% used new techniques (GreenLEP). During procedure, 72% used energy between 120W and 160W. Sixty percent used transrectal ultrasound during surgery (32% throughout the procedure). Only 16% of surgeons made ambulatory procedure and almost 33% never. Surgeons with over 3years of experience (vs.<3years) used the technique regardless of the volume in 67% vs. 23.5% (P=0.002).
Conclusion:
In France Greenlight use is still heterogeneous for the patient's management. New techniques which are currently developing (GreenLEP, vapo-enucleation) are still marginal. Ambulatory is still insufficiently used and need to be developed. The experienced surgeon led to wider indication for the technique.
Level of evidence:
3.
Purpose:
To compare patient outcomes after 180 W XPS Greenlight photoselective vaporization of the prostate (PVP) and Green laser enucleation of the prostate (GreenLEP) used to surgically manage benign prostatic obstruction (BPO).
Materials and methods:
Two groups of 60 consecutive patients with enlarged glands (>80 mL) underwent either GreenLEP or PVP (performed by the same surgeon and including his learning curve) and were retrospectively evaluated. Perioperative data from both groups were compared.
Results:
Operative time was significantly shorter in the GreenLEP group (60 vs 82 min, p<0.0001). The complication rates were comparable between the groups. At 2 months, urinary incontinence was significantly higher in the GreenLEP group (25% vs. 3.4%, p<0.0001) but incontinence rates were similar at 6 months (3.4 % vs. 0%, p=0.50). At 6 months, the I-PSS, QOL and PVR had similarly decreased in the two groups after the procedure (compared to baseline), whereas the Qmax value had greatly improved, significantly favoring the GreenLEP group (+78% vs. +64%, p<0.0001). The prostate size and PSA level reductions were significantly higher in the GreenLEP group (74% vs. 57%, p<0.0001 and 67% vs. 40%, p=0.007). The unplanned readmission rates were similar in both groups (16.7% vs. 6.7%, p=0.16).
Conclusions:
PVP and GreenLEP were safe and provided satisfactory short-term functional outcomes in patients with a prostate volume over 80 mL. However, the surgical time was longer in the PVP group, which also had a higher rate of unplanned readmission and lower decreases in the PSA level and prostate size.
Although photoselective vaporization of the prostate (PVP) is considered one of the most promising alternatives to transurethral radical prostatectomy, a longer operative time, an unsatisfactory tissue removal rate, and the absence of postoperative pathology samples remain the main criticisms for this procedure.
To describe the novel technique of photoselective vaporesection of the prostate (PVRP) with a front-firing lithium triborate (LBO) laser and to report our initial experience.
This is a prospective study of 215 patients undergoing PVRP between November 2011 and March 2013. Their average age, prostate size, and International Prostate Symptom Score (IPSS) were 70.3±7.3 yr, 70.4±34.0ml, and 24.9±5.0, respectively.
The operative technique is detailed in the accompanying video.
Perioperative data were collected. The patients were followed up at 3, 6, 12 mo after PVRP, and functional outcomes and complications were assessed.
The mean operation time was 44.1±22.6min. The mean hemoglobin decrease was 0.37±0.21g/dl. The catheterization time was 23.9±15.2h and the postoperative hospital stay was 1.8±0.8 d. Significant improvements were observed in maximum flow, IPSS, and postvoid residual urine at each follow-up time point. Compared to preoperative values, prostate volume and serum prostate-specific antigen fell by 67% and 63%, respectively, at 3 mo after PVRP. No major complications were noted. Application of a hemostat for a front-firing LBO laser makes it easy to handle intractable intraoperative bleeding. The main limitation of this study is the short follow-up period. The influence of PVRP on sexual function and the learning curve remain to be evaluated.
PVRP is a novel technique that is effective and safe for treatment of benign prostatic hyperplasia. This technique retains the excellent hemostatic property of LBO lasers and has a short operation time and a high tissue removal rate. The problem of the lack of postoperative tissue samples for PVP is also overcome in PVRP.
We have developed a novel technique named photoselective vaporesection of the prostate (PVRP) with a front-firing green laser. Our results show that PVRP retains the excellent hemostatic property of a green laser, but has a much shorter operation time and a higher rate of tissue removal than photoselective vaporization of the prostate (PVP). This technique also solves the problem of the lack of postoperative tissue specimens and the difficulty of handling intractable intraoperative bleeding. According to our initial results, PVRP is a novel technique superior to PVP in the treatment of benign prostatic hyperplasia.
Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Purpose of review:
This article discusses enucleation and vaporization procedures which have been developed on the surgical techniques of holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP) by reviewing the most recent publications.
Recent findings:
Enucleation procedures have been described using holmium, thulium, diode or GreenLight lasers in addition to bipolar energy sources. Most of the current literature for these enucleation procedures consists of initial descriptions of the surgical techniques or prospective series from single centres, although the availability of prospective randomized trial for these procedures other than HoLEP is limited. PVP have been described using 80-W, 120-W, or 180-W GreenLight lasers. To date, only sparse literature is available for thulium or bipolar vaporization of the prostate.
Summary:
A variety of alternative vaporization and enucleation procedures are available for transurethral treatment of benign prostatic obstruction. Only very few PRT have been published for these procedures limiting their evidence for the treatment of benign prostatic obstruction. To date, best evidence is still available for the HoLEP and PVP procedure.
Transurethral resection of the prostate (TURP) is the most common surgical intervention for benign prostatic hyperplasia (BPH), largely due to lower urinary tract symptoms refractory to medical therapy. TURP remains the gold standard for men with prostates sized 30g-80g, while open prostatectomy has been the preferred option for men with glands larger than 80g-100 g and those with other lower urinary tract anomalies such as large bladder stones or bladder diverticula. Unfortunately, these procedures have complications including bleeding (often requiring transfusion in 7%-13% of cases), electrolyte abnormalities (2% TURP syndrome), erectile dysfunction (6%-10%), and retrograde ejaculation (50%-75%). The overall incidence of a second intervention (repeat TURP, urethrotomy and bladder neck incision) has been reported in 12% and 15% of men at 5 and 10 years following TURP. Alternative therapies have been developed with the aim of reducing the level of complications while maintaining efficacy. These include microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm-Greenlight). Photoselective vaporization of the prostate (PVP), initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system (American Medical Systems, Minnetonka, Minnesota, USA), has been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser's frequency, and resulting in a green light. Outcomes have demonstrated a reduced frequency and severity of clinical complications, however it was limited to smaller prostate sizes. In 2006, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced. This laser utilizes a diode pumped Nd:YAG laser light that is emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system. The HPS offered an 88% more collimated beam and smaller spot size, resulting in much higher irradiance or power density in its 2 predecessors (60W and 80W) with a beam divergence of 8 versus 15 degrees. The primary aim for this upgrade was to reduce lasing time and improve clinical outcomes while demonstrating the same degree of safety for patients. Limitations of the 120W system included treatment of large prostates greater than 80g-100g and increased cost related to fiber devitrification and fracture. In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. Internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback), better preserve the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with the opportunity to perform a more complete and rapid procedure. Published clinical data with the XPS is unfortunately lacking. The objective of this report is to detail our approach and technique for GreenLight XPS drawing on personal experience with both enucleation and vaporization techniques with various laser technologies along with having performed over 500 GreenLight HPS and 100 XPS procedures. In this regard, recommendations for training are also made, which relate to existing users of the 80W and 120W GreenLight laser as well as to new laser users.
The aim of the study was to evaluate the applicability of the modified Clavien classification system (CCS) in grading perioperative complications of transurethral resection of the prostate (TURP).
All patients with benign prostatic hyperplasia submitted to monopolar TURP from January 2006 to February 2008 at a non-academic center were evaluated for complications occurring up to the end of the first postoperative month. All complications were classified according to the modified CCS independently by two urologists, and the final decision was based on consensus. If multiple complications per patient occurred, categorization was done in more than one grade. Results were presented as complication rates per grade.
Forty-four complications were recorded in 31 out of 198 patients (overall perioperative morbidity rate: 15.7%), and their grading was generally easy, non-time-consuming and straightforward. Most of them were classified as grade I (59.1%) and II (29.5%). Higher grade complications were scarce (grade III: 2.3% and grade IV: 6.8%, respectively) There was one death (grade V: 2.3%) due to acute myocardial infarction (overall mortality rate: 0.5%). Negative outcomes such as mild dysuria during this early postoperative period or retrograde ejaculation were considered sequelae and were not recorded. Nobody was complicated with severe dysuria. There was one re-operation due to residual adenoma (0.5%).
The modified CCS represents a straightforward and easily applicable tool that may help urologists to classify the complications of TURP in a more objective and detailed way. It may serve as a standardized platform of communication among clinicians allowing for sound comparisons.
The technical recommendations of an international group of experts on photoselective vaporization of the prostate (PVP; GreenLight PV) for benign prostatic hyperplasia are described. Their experience stems from the treatment of over 3500 patients at five centres in Europe and the United States. The objectives of this physician-based initiative are to optimize the results achieved with PVP by standardizing the procedure, as well as to recommend training requirements.
Objectif
Établir des recommandations de bonne pratique pour la démarche diagnostique, le suivi et le traitement d’une hyperplasie bénigne de prostate (HBP).
Méthode
Une revue systématique de la littérature a été réalisée. Le niveau de preuve des publications sélectionnées a été évalué. Des recommandations ont ensuite été établies et gradées par un groupe de travail, puis relues par un groupe de relecteurs selon la technique du consensus formalisé.
Résultats
La terminologie de l’International Continence Society (ICS) a été adoptée. Les objectifs du bilan initial sont multiples : affirmer que les symptômes du bas appareil urinaire (SBAU) sont liés à l’HBP, évaluer la gêne provoquée par les SBAU et rechercher une obstruction sous-vésicale compliquée. L’interrogatoire avec réalisation d’un score symptomatique, et l’examen physique comprenant un toucher rectal, l’examen d’urine, la débitmétrie et la mesure du résidu post-mictionnel font parti du bilan de première intention recommandé pour explorer des SBAU d’un homme afin de répondre aux questions posées ci-dessus. Le catalogue mictionnel est optionnel dans ce bilan initial, mais recommandé si les symptômes de la phase de remplissage sont prédominants. Le dosage du PSA est utile chez les patients pour lesquels le diagnostic d’un cancer modifierait la prise en charge des SBAU. Lorsqu’un traitement chirurgical est envisagé, un dosage de la créatininémie et du PSA, ainsi qu’une échographie de l’appareil urinaire sont recommandés. L’information du patient sur le caractère bénin mais éventuellement progressif de sa pathologie est recommandée. En l’absence de gène et de complication, une surveillance annuelle est recommandée. Le traitement médical repose sur la phytothérapie, les alpha-bloquants et les inhibiteurs de la 5-alpha-réductase, les deux derniers pouvant être associés. L’association d’un anticholinergique et d’un alpha-bloquant peut être proposée à des patients déjà traités par alpha-bloquant seul ayant des SBAU de la phase de remplissage persistants, et en l’absence d’obstruction sous-vésicale sévère (résidu post-mictionnel supérieur à 200 mL ou débit maximum inférieur à 10 mL/s). Les inhibiteurs de la phosphodiestérase de type 5 peuvent être proposés aux patients présentant une dysfonction érectile associée à des SBAU. En cas d’HBP compliquée, ou lorsque le traitement médical est inefficace ou mal toléré, une solution chirurgicale est discutée. Tout traitement doit être décidé en tenant compte de la symptomatologie et de la gêne du patient, de l’anatomie prostatique, du degré d’obstruction et du retentissement éventuel sur l’appareil urinaire, des co-morbidités du patient, de l’expérience du praticien, et du choix du patient en termes de bénéfice, de risque et d’effets indésirables attendus. Outre la chirurgie classique (adénomectomie sus-pubienne, résection trans-urétrale de prostate, incision cervivo-prostatique), les options chirurgicales ayant le plus haut niveau de preuve quant à leur efficacité sont la résection électrique bipolaire, la photovaporiation laser en longueur d’onde 532 nm, et l’énucléation par laser Holmium.
Conclusion
Sont ici présentées les premières recommandations de l’Association française d’urologie sur le bilan initial, le suivi et le traitement des troubles mictionnels en rapport avec une HBP.
Objective:
To present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS).
Evidence acquisition:
We conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality.
Evidence synthesis:
Men with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment-resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30-80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental.
Conclusions:
These symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (www.uroweb.org/gls/pdf/12_Male_LUTS.pdf).
To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH).
A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique.
Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate.
Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.
CONTEXT: The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology. OBJECTIVE: To review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes. EVIDENCE ACQUISITION: Standardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999-2000 and 2009-2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms. EVIDENCE SYNTHESIS: The systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%). CONCLUSIONS: Uniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.
Background:
Wide variations in acquisition protocols and the lack of robust diagnostic criteria make magnetic resonance imaging (MRI) detection of prostate cancer (PCa) one of the most challenging fields in radiology and urology.
Objective:
To validate the recently proposed European Society of Urogenital Radiology (ESUR) scoring system for multiparametric MRI (mpMRI) of the prostate.
Design, setting, and participants:
An institutional review board-approved multicentric prospective study; 129 consecutive patients (1514 cores) referred for mpMRI after at least one set of negative biopsies.
Intervention:
Transfer of mpMRI-suspicious areas on three-dimensional (3D) transrectal ultrasound images by 3D elastic surface registration; random systematic and targeted cores followed by core-by-core analysis of pathology and mpMRI characteristics of the core locations. The ESUR scores were assigned after the procedure on annotated Digital Imaging and Communications in Medicine archives.
Outcome measurements and statistical analysis:
Relationships between ESUR scores and biopsy results were assessed by the Mann-Whitney U test. The Yates correction and Pearson χ(2) tests evaluated the association between categorical variables. A teaching set was randomly drawn to construct the receiver operating characteristic curve of the ESUR score sum (ESUR-S). The threshold to recommend biopsy was obtained from the Youden J statistics and tested in the remaining validation set in terms of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.
Results and limitations:
Higher T2-weighted, dynamic weighted imaging and dynamic contrast-enhanced ESUR scores were observed in areas yielding cancer-positive cores. The proportion of positive cores increased with the ESUR-S aggregated in five increments (ESUR-S 3-5: 2.9%; ESUR-S 6-8: 11.1%; ESUR-S 9-10: 38.2%; ESUR-S 11-12: 63.4%; and ESUR-S 13-15: 83.3%; p<0.0001). A threshold of ESUR-S ≥ 9 exhibited the following characteristics: sensitivity: 73.5%; specificity: 81.5%; positive predictive value: 38.2%; negative predictive value: 95.2%; and accuracy: 80.4%. Although the study was not designed to compare repeat biopsy strategies, more targeted cores than random systematic cores were found to be positive for cancer (36.3% compared with 4.9%, p<0.00001).
Conclusions:
In the challenging situation of repeat biopsies, the ESUR scoring system was shown to provide clinically relevant stratification of the risk of showing PCa in a given location.
Photoselective vaporisation (PVP) of the prostate is being used increasingly to treat symptomatic benign prostatic hyperplasia, due to the associated lower morbidity. Holmium laser enucleation of the prostate was considered to be the treatment with the highest evidence; however, evidence for PVP has dramatically increased recently.
To conduct a systematic review and meta-analysis of level 1 evidence studies to determine the effectiveness of PVP versus transurethral resection of the prostate (TURP) for surgical treatment of benign prostatic hyperplasia. Outcomes reviewed included perioperative data, complications, and functional outcomes.
Biomedical databases from 2002 to 2012 and American Urological Association and European Association of Urology conference proceedings from 2007 to 2011 were searched. Trials were included if they were randomised controlled trials, had PVP as the intervention, and TURP as control. Meta-analysis was performed using a random effects model.
Nine trials were identified with 448 patients undergoing PVP (80 W in five trials and 120 W in four trials) and 441 undergoing TURP. Catheterisation time and length of stay were shorter in the PVP group by 1.91 d (95% confidence interval [CI], 1.47-2.35; p<0.00001) and 2.13 d (95% CI, 1.78-2.48; p<0.00001), respectively. Operation time was shorter in the TURP group by 19.64 min (95% CI, 9.05-30.23; p=0.0003). Blood transfusion was significantly less likely in the PVP group (risk ratio: 0.16; 95% CI, 0.05-0.53; p=0.003). There were no significant differences between PVP and TURP when comparing other complications. Regarding functional outcomes, six studies found no difference between PVP and TURP, two favoured TURP, and one favoured PVP.
Perioperative outcomes of catheterisation time and length of hospital stay were shorter with PVP, whereas operative time was longer with PVP. Postoperative complications of blood transfusion and clot retention were significantly less likely with PVP; no difference was noted in other complications. Overall, no difference was noted in intermediate-term functional outcomes.
Evidence supporting the widespread use of GreenLight High Performance System (HPS) 120-W photoselective vaporization of the prostate (PVP) is lacking.
To assess the noninferiority of PVP compared with transurethral resection of the prostate (TURP) on urinary symptoms and the superiority of PVP over TURP on length of hospital stay.
A multicenter randomized controlled trial was conducted.
Patients underwent monopolar TURP or PVP with the GreenLight HPS 120-W laser.
International Prostate Symptom Score (IPSS), Euro-QOL questionnaire, uroflowmetry, Danish Prostate Symptom Score Sexual Function Questionnaire, sexual satisfaction, and adverse events were collected at 1, 3, 6, and 12 mo. The two groups were compared using the 95% confidence interval (CI) of median difference for testing noninferiority of the IPSS at 12 mo and the student t test for testing the difference in length of hospital stay.
A total of 139 patients (70 vs 69 men in each group) were randomized. Median IPSS scores at 12-mo follow-up were 5 (interquartile range [IQR]: 3-8) for TURP versus 6 (IQR: 3-9) for PVP, and the 95% CI of the difference of the median was equal to -2 to 3. Because the upper limit of the 95% CI was >2 (the noninferiority margin), the hypothesis of noninferiority could not be considered demonstrated. Median length of stay was significantly shorter in the PVP group than in the TURP group, with a median of 1 (IQR: 1-2) versus 2.5 (IQR: 2-3.5), respectively (p<0.0001). Uroflowmetry parameters and complications were comparable in both groups. Sexual outcomes were slightly better in the PVP group without reaching statistical significance.
The present study failed to demonstrate the noninferiority of 120-W GreenLight PVP versus TURP on prostate symptoms at 1 yr but showed that PVP was associated with a shorter length of stay in the hospital.
NCT01043588.
The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice.
Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice.
Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified.
Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure.
In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.
Photoselective vaporisation of the prostate has evolved from the GreenLight 80-W KTP powered laser to the latest 180-W XPS laser involving a MoXy fibre.
Evaluate the prevalence of perioperative complications and short-term outcome for the first time with the XPS laser in men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE).
Prospective data were collected from consecutive patients at seven centres worldwide during June 2010 and March 2011. Indication for surgery was based on the European Association of Urology and the American Urological Association guidelines. Patients receiving anticoagulants or those with retention were included and analysed separately.
180-W XPS GreenLight laser prostatectomy using the MoXy fibre.
Standard parameters associated with transurethral prostate surgery and perioperative prevalence of surgery-associated problems or complications were documented.
A total of 201 patients were included in the study. Mean follow-up was 5.8 mo (standard deviation [SD]: 2.8; range: 1-12 mo). A quarter of the patients had a prostate volume≥80 ml. For prostates between 51 and 60 ml, a mean of 300 kJ (SD: 112) of energy was applied (lasing time: 35.0 min; SD: 15). Statistically significant improvements were noted in all key parameters postoperatively. The prevalence of perioperative complications was low. Limitations of the study are short duration of follow-up and limited number of available patients for the functional follow-up.
The 180-W GreenLight XPS laser is a new effective treatment option with a low prevalence of perioperative complications for patients suffering from LUTS due to BPE.
The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology.
To review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes.
Standardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999-2000 and 2009-2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms.
The systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%).
Uniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.
High-level evidence to support the use of photoselective vaporization of the prostate (PVP) is limited.
Assess the efficacy and safety of GreenLight HPS 120-W laser PVP compared with transurethral resection of the prostate (TURP).
A randomized clinical trial was performed with 50 patients having lower urinary tract symptoms due to benign prostatic hyperplasia in each treatment arm.
Random allocation to PVP or TURP.
International Prostate Symptom Score (IPSS), quality of life (QoL), and changes in maximum flow rate (Qmax) were the main end points. Patients were evaluated at a follow-up time of 2 yr. Five patients were lost to follow-up. A last observation carried forward analysis was done.
Both laser PVP and TURP resulted in the same IPPS reduction at 2 yr (-15.7 and -14.9, respectively; p=0.48) and in the same gain in Qmax (+14.5 ml/s and +13.1 ml/s, respectively; p=0.65). QoL was equivalent for both treatment modalities. These results were independent of prostate size, American Society of Anesthesiologists risk category, and prior indwelling catheter. No statistically significant differences were detected between arms in terms of complication rates. In the laser PVP group, three patients were readmitted to the hospital and two developed a urethral stricture. In the TURP group, two patients were readmitted, six developed a urethral stricture, and two developed bladder neck sclerosis. In-hospital stay and time to catheter removal were significantly shorter with PVP. Limitations are the potential lack of power to detect differences in the complications between groups and the lack of blindness due to the nature of the intervention.
GreenLight HPS 120-W laser PVP is as effective as TURP for symptom reduction and improvement of QoL. No differences were seen in the response of storage and voiding symptoms. Laser PVP and TURP have the same complication rate. Length of stay is shorter for laser PVP group.
There are few reports of the clinical outcomes of photoselective vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH) using the 120-W lithium triborate (LBO) laser. The present study evaluates clinical outcomes of 76 men treated with the 120-W LBO laser by an experienced PVP surgeon with 12 months follow up. The International Prostate Symptom Score (IPSS), peak flow rate (Qmax) and post-void residual (PVR) were examined at baseline and at 3 and 12 months. These parameters at baseline and 12 months were 20 ± 7.0, 7.6 ± 3.5 mL/s, 155 ± 155 mL and 8.1 ± 6.1, 22.5 ± 10.3 mL/s, 59 ± 87 mL, respectively. Clinically, meaningful improvements in IPSS, Qmax and PVR were observed at 3 months and sustained at 12 months. There were few adverse events, with only 5.3% of patients requiring recatheterization. Clinical outcome at 12 months was similar to that at 3 months and to other published series.
Holmium laser enucleation of the prostate (HoLEP) and 532-nm laser vaporisation of the prostate (with potassium titanyl phosphate [KTP] or lithium borate [LBO]) are promising alternatives to transurethral resection of the prostate (TURP) and open prostatectomy (OP).
To assess safety, efficacy, and durability by analysing the most recent evidence of both techniques, aiming to identify advantages, pitfalls, and unresolved issues.
A Medline search of recently published data (2006-2008) regarding both techniques over the last 2 yr (January 2006 to September 2008) was performed using evidence obtained from randomised trials (level of evidence: 1b), well-designed controlled studies without randomisation (level of evidence: 2a), individual cohort studies (level of evidence: 2b), individual case control studies (level of evidence: 3), and case series (level of evidence: 4).
In the last 2 yr, several case-control and cohort studies have demonstrated reproducibility, safety, and efficacy of HoLEP and 80-W KTP laser vaporisation. Four randomised controlled trials (RCTs) were available for HoLEP, two compared with TURP and two compared with OP, with follow-up >24 mo. Results confirmed general efficacy and durability of HoLEP, as compared with both standard techniques. Only two RCTs were available comparing KTP laser vaporisation with TURP with short-term follow-up, and only one RCT was available comparing KTP laser vaporisation with OP. The results confirmed the overall low perioperative morbidity of KTP laser vaporisation, although efficacy was comparable to TURP in the short term, despite a higher reoperation rate.
Although they are at different points of maturation, KTP or LBO laser vaporisation and HoLEP are promising alternatives to both TURP and OP. Sufficient data proves HoLEP's durability for most prostate sizes at long-term follow-up; KTP laser vaporisation needs further evaluation to define the reoperation rate. Increasing the number of quality prospective RCTs with adequate follow-up is mandatory to tailor each technique to the right patient.
To evaluate the learning experience, in addition to its impact on outcomes, in patients with benign prostatic hyperplasia (BPH) who undergo photoselective vaporization of the prostate (PVP).
The study included 74 Japanese patients who underwent PVP. All patients were assessed for treatment efficacy in outcome variables including the International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, peak urinary flow rate (Q(max)), and post-void residual urine volume (PVR) at 12 months after PVP. The impact of the learning curve in terms of efficacy and morbidity following PVP were also analyzed.
There was a significant improvement in each outcome variable after surgery. The median (25% and 75%) values of the improved rate (IR) at 12 months after PVP were 75% (57%, 87%), 67% (50%, 83%), 103% (50%, 176%), and 85% (68%, 96%) in IPSS, QOL score, Q(max) and PVR, respectively. The IR in each outcome variable did not significantly change as the surgeon's experience increased. The time required for tissue vaporization of the adenoma and the total applied laser energy, along with the vaporized weight, significantly increased, but the efficiency of tissue vaporization did not increase as experience increased. A significant correlation was not evident between the learning curve and the total incidence of adverse events or blood loss following PVP.
PVP is a safe and effective treatment option for patients with BPH, providing good treatment efficacy and minimal bleeding, even when the surgeon has minimal experience.
In a search for potential therapeutic strategies for benign prostatic hyperplasia (BPH) that would be associated with less morbidity than transurethral resection of the prostate, various types of laser prostatectomy have been used. Although the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser allows performance of prostatectomy in an almost bloodless field and without absorption of irrigant, the remaining necrotic tissue causes bladder outlet obstruction and related symptoms for 5 to 7 days after treatment. In contrast, the potassium titanyl phosphate (KTP) laser has been found to vaporize tissue with minimal coagulation of the underlying structures. With use of the KTP laser, heat is concentrated into a small volume, the tissue is ablated by rapid vaporization of cellular water, and a 2-mm rim of coagulated tissue is left. After favorable results were obtained in studies of canine prostates and human cadavers, we implemented clinical use of 60-W KTP laser prostatectomy in selected patients. In 10 patients with symptomatic BPH who ranged in age from 52 to 80 years, outpatient KTP laser prostatectomy yielded significantly increased mean peak urinary flow rates (from 8.0 mL/s preoperatively to 19.4 mL/s within 24 hours after the procedure). No patient had hematuria, dysuria, or incontinence after removal of the catheter, and no patient required recatheterization. One patient, however, had urgency, and two other patients became febrile during the 24-hour observation period. Overall, KTP laser vaporization prostatectomy can provide immediate relief from obstructive symptoms of BPH and is not associated with dysuria.
We prospectively studied a cumulative cohort of men with obstructive benign prostatic hyperplasia who underwent potassium-titanyl-phosphate (KTP) laser vaporization prostatectomy to determine the safety and efficacy of this procedure.
A total of 55 men with symptomatic bladder outlet obstruction due to benign prostatic hyperplasia were treated with a 60 W. KTP laser produced by a prototype Laserscopedagger generator and delivered through a side-deflecting fiber with a 22Fr continuous flow cystoscope. Sterile water was used for irrigation. The prostatic lobes were vaporized to within capsular fibers. Mean lasing time plus or minus standard deviation was 44 +/- 19 minutes.
Mean prostate volume plus or minus standard deviation was 43 +/- 14 ml. No patient had any significant blood loss or fluid absorption, or required blood transfusion. Foley catheters did not require irrigation and were removed less than 24 hours postoperatively. All patients remained satisfied with voiding outcome, which changed significantly (p <0.0001). Mean improvement in American Urological Association symptom score at 3, 6, 12 and 24-month intervals was 75%, 79%, 82% and 82%, respectively. Mean increase in peak flow rate at the same intervals was 250%, 242%, 255% and 278%, respectively. Complications included mild transient dysuria in 7%, bladder neck contracture in 2% and delayed hematuria in 4% of patients. None of the patients required re-catheterization or reoperation, or had incontinence or newly developed impotence. Of the sexually active patients 15% and 9% had retrograde ejaculation at 1 and 2 years, respectively.
Our observation in a 2-year period indicates that 60 W. KTP laser vaporization prostatectomy is safe and effective for quickly relieving bladder outlet obstruction with minimal postoperative complications, a high rate of patient satisfaction and, to date, a generally good outcome.
Men with lower urinary tract symptoms secondary to benign prostatic hyperplasia who are at high cardiopulmonary risk or on oral anticoagulation are often denied surgical treatment. Potassium-titanyl-phosphate (KTP) laser vaporization at 80 W is a novel, rapidly emerging technique that promises instant hemostatic tissue ablation. We evaluated the merits of this procedure in patients at high risk and those on long-term anticoagulation.
The prospective study included 66 patients with severe lower urinary tract symptoms who underwent 80 W KTP laser vaporization of the prostate. All patients were at high cardiopulmonary risk, having presented with an American Society of Anesthesiology score of 3 or greater. Additionally, 29 patients were being treated with ongoing oral anticoagulant therapy (26) or had a severe bleeding disorder (3).
In all 66 patients KTP laser vaporization was performed successfully. Mean preoperative prostate volume +/- SD was 49 +/- 30 ml and mean operative time was 49 +/- 19 minutes. No major complication occurred intraoperatively or postoperatively and no blood transfusion was required. Postoperatively 48 of 62 catheterized patients (77%) did not require irrigation. Average catheterization time was 1.8 +/- 1.4 days. Two patients required reoperation due to recurrent urinary retention. At 1, 3, 6 and 12 months mean urinary peak flow increased from 6.7 +/- 2 ml per second preoperatively to 18.5 +/- 9, 18.9 +/- 10, 19.2 +/- 8 and 21.6 +/- 7 ml per second, respectively. Mean International Prostate Symptom Score decreased from 20.2 +/- 6 to 11.7 +/- 7, 7.9 +/- 7, 6.9 +/- 5 and 6.5 +/- 4, respectively.
Our initial experience indicates that 80 W KTP laser vaporization is a virtually bloodless and, hence, safe but effective treatment option in seriously ill patients or those on oral anticoagulants.
In a prospective manner we evaluated the learning experience of an endourologist inexperienced with holmium laser prostate enucleation and its impact on surgical outcome. We also reviewed the literature to document technical features of holmium laser prostate enucleation at different institutions.
Patient demographic, perioperative and followup data were analyzed. To assess the impact of the learning curve on postoperative outcome patients were divided into group 1--patients 1 to 50, group 2--51 to 100 and group 3--101 to 162. The effect of the learning curve and weight of resected tissue on enucleation and morcellation efficiency was studied.
Holmium laser prostate enucleation was successfully completed in 93.82% of patients. Eight patients required conversion to transurethral prostate resection. Enucleation and morcellation efficiency was 0.49 and 2.75 gm per minute, respectively. Enucleation efficiency attained a plateau after 50 cases. Postoperative outcome was compared in the 3 patient groups. There was a higher incidence of capsular perforation and stenotic urethral complications in group 1. In the literature a mean of 57.09% of tissue (range -9.6 to 81.9%) was retrieved after holmium laser prostate enucleation and mean efficiency was 0.52 gm per minute (range -0.11 to 1.09). Efficiency increased proportionally with resected prostate weight.
An endourologist inexperienced with holmium laser prostate enucleation can perform the procedure with reasonable efficiency after about 50 cases with an outcome comparable to that of experts, as described in the literature. During the learning curve conversion to transurethral prostate resection can be done without any harm to the patient.
To evaluate long-term outcomes and reoperation rate of holmium laser enucleation of the prostate (HoLEP) for patients with symptomatic enlarged prostate, including patients who were operated during the learning curve.
A retrospective analysis of 118 patients who underwent HoLEP between March 1998 and February 2001 at our institution. This analysis represented our initial experience with the technique reflecting our learning curve. The voiding outcome parameters, operative duration time, enucleation time, morcellation time, eucleated tissue weight, catheterization time, hospital stay, and complications were recorded.
The mean patient age was 76.5 yr (range: 59-93) and the mean preoperative prostate volume was 59.3 cc (range: 20-172). The mean follow-up period was 49.4+/-28.1 mo. The mean catheter time and hospital stay was 1.3 and 1.5 d, respectively. Seventy-eight percent of the patients were discharged home within 24h after surgery. For the patients (n=26) who had objective data at 6 yr postoperatively, mean maximum flow rate increased from 6.3 to 16.2ml/s and mean postvoid residual urine decreased from 232 to 41.2ml (p<0.0001). Mean International Prostate Symptom Score improved from 17.3 to 5.6 (p<0.0001). Bladder-neck contracture and urethral stricture developed in 0.8% and 1.7% of patients, respectively. The reoperation rate for recurrent benign prostatic hyperplasia obstruction was 4.2%.
HoLEP represents a safe and effective treatment for patients with symptomatic enlarged prostate. The improvement in outcome parameters is durable, and the late complications and reoperation rate are very low.
To compare the effectiveness and the safety of photoselective vaporization of the prostate (PVP) to open prostatectomy (OP) for the surgical treatment of large prostatic adenomas.
A total of 125 patients with prostate glands >80ml were randomly allocated to PVP (n=65) or OP (n=60) and prospectively evaluated at 1, 3, 6, and 12 mo postoperatively. International Prostate Symptom Score (IPSS) and peak urinary flow rate (Q(max)) were chosen as primary treatment-related end points.
The patients who underwent PVP experienced a longer length of operation time, shorter time of catheterization, and shorter hospital stay. Adverse events were minor and of similar profiles in both groups, although patients who underwent OP showed a higher transfusion rate. All functional parameters improved significantly compared to baseline values in both groups. The IPSS did not differ between the two groups at 3, 6, and 12 mo postoperatively. Patients who underwent OP scored better in the IPSS quality of life score at 6 and 12 mo postoperatively. No significant differences between the two groups in the Q(max), postvoid residual urine volume, and International Index for Erectile Function-5 questionnaire were detected. At 3 mo prostate volume was significantly lower in the OP group compared to the PVP group (median value 10ml vs. 50ml; p<0.001) and remained as such throughout follow-up, whereas prostate-specific antigen values reached statistical difference at 6 mo (median value 2ng/ml vs. 2.4ng/ml; p=0.028).
Our results indicate that for a 12-mo period PVP is a highly acceptable treatment alternative to OP.
Long-term data of photoselective vaporization of the prostate (PVP) for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is scanty.
Evaluate the long-term efficacy and the complication rate in 80-watt (W) PVP.
500 consecutive patients with LUTS secondary to BPH underwent PVP between September 2002 and April 2007. The mean follow-up was 30.6+/-16.6 (5.2-60.6) mo.
All patients underwent 80-W PVP performed by seven surgeons.
We evaluated perioperative parameters, including operation time, delivered energy, changes of hemoglobin and serum sodium, catheterization, and hospitalization time as well as intraoperative and postoperative complications. Patients presenting for follow-up had data assessed on the International Prostate Symptom Score and quality-of-life questionnaire (IPPS-QoL), maximal flow rate (Q(max)), and post-voiding residual volume (Vres).
Mean patient age was 71.4+/-9.6 (46-96) yr, with a mean preoperative prostate volume of 56.1+/-25.3 (10-180) ml. Mean operation time was 66.4+/-26.8 (10-160) min, and mean energy delivery was 206+/-94 (2.4-619.0) kJ. Despite ongoing oral anticoagulation in 45% of the patients (n=225), no severe intraoperative complications were observed. Mean catheterization and postoperative hospitalization time was 1.8+/-1.2 (0-10) and 3.7+/-2.9 (0-35) d, respectively. The mean IPSS after 3 yr was 8.0+/-6.2, the QoL score was 1.3+/-1.3, the Q(max) was 18.4+/-8.0 ml/s, and the Vres was 28+/-42 ml. The retreatment rate was 6.8%. Urethral and bladder neck strictures were observed in 4.4% and 3.6% of the patients, respectively. Localized prostate cancer was diagnosed during follow-up in six patients.
PVP is a safe and effective procedure for treatment of LUTS secondary to BPH. Patients on ongoing oral anticoagulation can be safely operated on. PVP leads to an immediate and sustained improvement of subjective and objective voiding parameters. The late complication rate is comparable to that of transurethral electroresection of the prostate.