Photoselective vaporization of the prostate. Review of cost implementation to BPH treatment

Incidence and management of BPH surgery-related urethral stricture: results from a large U.S. database

INTRODUCTION AND OBJECTIVES

Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management.

METHODS

A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.

RESULTS

Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%).

CONCLUSIONS

The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.

Efficacy and safety of 120-W GreenLight High-Performance System laser photo vaporization of the prostate: 3-year results with specific considerations

PURPOSE

High-Performance System (HPS) laser photo vaporization of the prostate (PVP) is a widely used procedure nowadays. The safety and efficacy of the procedure has been affirmed in general patients with benign prostatic hyperplasia (BPH), but data on the safety and efficacy in specific situations, such as in patients with a large prostate, patients taking anticoagulant or 5-alpha reductase inhibitor (5-ARI) medication, and patients with a history of acute urinary retention (AUR) or previous transurethral resection of the prostate (TURP), is lacking. We investigated the safety and efficacy of HPS laser PVP in these unique patient groups.

METHODS

The study was conducted from March 2009 to February 2012 among patients for lower urinary tract symptoms. Patients in whom BPH was diagnosed and who were treated with 120-W HPS GreenLight PVP were selected. Patients were divided into groups of prostate size above and below 80, anticoagulant medication, 5-ARI medication, AUR history, and TURP history on the basis of the preoperative history and physical examination.

RESULTS

A total of 533 patients observable for a follow-up period of more than 6 months were enrolled as the study population. The patients' mean preoperative prostate size was 51.0±32.7 mL and their mean prostate-specific antigen was 4.5±27.9 ng/mL. The average operating time was 24.5±12.2 minutes and the average applied energy during surgery was 152,184±89,495 J. Postoperative objective and subjective parameters in all groups were significantly improved compared with preoperative values.

CONCLUSIONS

Laser resection of the prostate is safe and effective. The results of HPS laser PVP were not influenced by prostate size, the use of anticoagulants, the intake of 5-ARI for BPH management, a history of AUR, a history of TURP, or other factors. Thus, this study was able to reconfirm the efficacy and safety of laser resection of the prostate.

[Photoselective vaporization of the prostate with Laser Greenlight HPS: current role, technical aspects and review of the literature]

Photoselective vaporization of the prostate with 120W HPS Greenlight laser is one of the most attractive modalities of surgical treatment for benign prostatic hyperplasia at present. The specific physical characteristics of this laser provides an excellent safety and effectiveness profile, making it the ideal technique for high-risk patients or patients ongoing oral anticoagulation. Moreover, the undeniable reduction of urethral catheterization time and hospital stay compared to transurethral resection of prostate (TURP) involves a much more comfortable postoperative period for patients. We have conducted a Medline/Pubmed search, presenting in this review the outcomes and current surgical techniques described in recent studies. We have also reviewed the controversial aspects and limitations attributed to this technique.

The evolution of KTP laser vaporization of the prostate

The search for a minimally invasive approach to the treatment of Lower Urinary Tract Symptoms (LUTS) suggestive of Benign Prostatic Hyperplasia (BPH) is probably as old as Transurethral Resection of the Prostate (TURP). In an effort to overcome the limitations and morbidities of TURP, and in light of evidence suggesting that medical treatment for BPH has a limited life-span, laser-based treatments have emerged during the last decade. Photoselective Vaporization of the Prostate (PVP) by the "GreenLight" KTP laser is considered one of the most promising options, one that is constantly evolving new technologies in prostate surgery. In this overview of KTP laser usage in BPH treatment, we will briefly discuss the evolution of this modality since it was first introduced and focus on the available evidence regarding safety, efficacy and cost parameters of its application.

Update on photoselective vaporization of the prostate

Photoselective vaporization of the prostate (PVP) with a potassium titanyl phosphate (KTP) laser may be the most promising new technology applied to the treatment of benign prostatic hyperplasia (BPH). The specific laser light characteristics and the ideal interactions between KTP lasers and prostatic tissue result in an even and efficient vaporization of the prostate and the formation of a clearly deobstructed prostate cavity. PVP can be a day-care procedure, with few hours of catheterization and minimal postoperative discomfort, offering outcomes at least equivalent to the reference standard transurethral resection of the prostate. Although larger studies are necessary to further define where PVP stands in the management of BPH, this review focuses on contemporary treatment techniques and their limitations, and comments on the outcomes of its current use.

Greenlight laser in benign prostatic hyperplasia: turning green into gold

PURPOSE OF REVIEW

The purpose of this review is to present recent clinical data published upon the photoselective vaporization of the prostate procedure and introduce new ideas about the future influence of this new technology upon the treatment of benign prostatic hyperplasia.

RECENT FINDINGS

Published studies have provided significant evidence that the photoselective vaporization of the prostate laser procedure is efficient, safe, easy to learn and early results show that it can compete with transurethral resection of the prostate. The major advantages of this technique are that it is a bloodless procedure, the patient goes home after a few hours and it can be applied to all patient categories. The cost of the photoselective vaporization of the prostate procedure is being investigated and a few studies addressing this issue seem to conclude that this surgical option is a cost effective decision. Lately, thoughts about early surgical intervention with the photoselective vaporization of the prostate laser are being expressed but properly designed studies are needed.

SUMMARY

The photoselective vaporization of the prostate laser procedure is getting worldwide fast recognition and it is the first time that transurethral resection of the prostate and open prostatectomy are being threatened. The cost of this procedure is being examined but it is difficult to draw solid conclusions since reimbursement strategies differ between various countries.