The Surgical Experience Influences the Safety and Efficacy of Photovaporization of Prostate with 180-W XPS GreenLight Laser: Comparison Between Novices vs Expert Surgeons Learning Curves

"Five-Step" Vaporization of the Prostate Using 180-W XPS Greenlight Laser in Patients with Benign Prostatic Hyperplasia of Large Volume: Improved Efficacy and Safety

Objective: To evaluate the safety and efficacy of 180-W XPS Greenlight laser "Five-step" photoselective vaporization of the prostate (PVP) in patients with benign prostatic hyperplasia (BPH) with prostate volume (PV) > 80 mL. Background: In patients with BPH with large PV, PVP often results in bleeding, unclear visual field, additional damage, and insufficient tissue vaporization. Methods: This single-center, retrospective study enrolled patients with BPH with PV > 80 mL treated with the Five-step PVP or the Conventional PVP from January 2018 to June 2021. Comorbidities, high-risk habits, and operative parameters were analyzed and compared. The short-term functional outcomes and postoperative complications were recorded over the 24-month follow-up. Results: Two hundred eligible patients were divided into the Five-step PVP and Conventional PVP groups (n = 100 each). These groups showed no differences in comorbidities, living habits, baseline perioperative parameters, operative time, lasing time, or energy use. However, a higher energy density (3.95 [interquartile range (IQR) 3.37, 4.52] vs 3.68 [IQR 3.17, 4.20] kJ/mL) and energy-time ratio (7.23 [IQR 6.12, 8.52] vs 6.72 [IQR 5.51, 7.87] kj/min p = 0.034) were obtained in the Five-step PVP group. Subgroup analysis of patients with PV ≥120 mL showed similar results. The short-term functional outcomes were similar between the two study groups with significant improvement from baseline, but the total prostate-specific antigen levels at 1 and 6 months were lower in the Five-step PVP group. Further, incidences of intraoperative bleeding, bladder mucosa injury, postoperative hematuria, and urinary tract infection were lower in the Five-step PVP group. In the Conventional PVP group, four patients required conversion to transurethral resection of the prostate in surgery and two patients required retreatment during the 24-month follow-up. Conclusions: The 180-W XPS Greenlight laser Five-step PVP has advantages of less bleeding, high vaporization efficiency, and low rates of perioperative complications, and, therefore, it is a promising treatment to improve short-term functional outcomes for patients with BPH with large PV.

Surgical reintervention requirements following GreenLight PVP: A single-center experience using three different laser device models

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.

Environmental Safety of the 180-W GreenLight Laser: A Pilot Study On Plume And Irrigating Fluids

OBJECTIVE

To analyze the chemical composition of the surgical smoke and the outflow irrigation fluid produced during a common endourological surgical procedure to treat benign prostatic obstruction (BPO).

METHODS

A prospective study was performed to analyze the surgical smoke generated during photoselective vaporization of the prostate (PVP) using the 180-W GL-XPS GreenLight Laser system. Surgical smoke samples were collected from 5 patients, and irrigation fluid samples were collected from 5 different patients. Qualitative organic compound determination was performed on both types of collected specimens using headspace-gas chromatography/mass spectrometry (HS-GC/MS) analysis.

RESULTS

Four organic compounds were identified in the analyses of the smoke samples: tetradecane, hexadecane, 7-methylpentadecane and 2,6-dimethyleptadecane. In the analysis of fluid samples, 16 organic elements were identified. Interestingly, two compounds present in the first group (7-methylpentadecane and 2,6-dimethyleptadecane) were not detected in the fluid samples from the second group. None of the sixteen compounds detected in the fluids were present in all of the samples. Overall, seven of these compounds can be classified as toxic for acute exposure, while 4 others may represent a health hazard.

CONCLUSION

We found that the different types of surgical smoke and irrigation fluids produced during PVP with a GreenLight Laser contain a limited number of organic compounds with a potential inhalation hazard. More studies are needed to understand the potential hazard for the exposed employees.

The Learning Curves for Laser Application in Urology Procedures: Review of the Literature

Introduction: Currently, a laser is a popular technology in urological surgeries. The important laserrelated 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 at their first cases.

High incidence of urinary tract infections after photoselective laser vaporisation of the prostate: a risk factor analysis of 665 patients

PURPOSE

Although photoselective laser vaporisation of the prostate (PVP) is a recognised alternative to transurethral resection in treating benign prostatic obstruction, there is limited data on the incidence and determinants of postoperative urinary tract infections (UTI). We assessed patients subjected to PVP, evaluating incidence and potential determinants of postoperative UTIs.

MATERIALS AND METHODS

Consecutive patients undergoing PVP between April 2010 and August 2018 were candidates for this retrospective cohort study. The primary outcome measure was microbiologically confirmed postoperative UTI. We fitted uni- and multi-variable Cox models to identify potential risk factors.

RESULTS

Among the 665 included patients, 20% developed postoperative UTIs. The overall incidence rate per 100 patient-days was 0.65 (95% confidence interval [CI] 0.55-0.77). Risk factors for postoperative UTIs were end-stage renal failure (adjusted hazard ratio [aHR] = 14.10, 95% CI 2.08-64.58; p = 0.001) and presence of at least one of the following factors in the 3 months preceding PVP: (i) placement of urinary catheter, (ii) bacteriuria, (iii) UTI, or (iv) antimicrobial treatment (composite aHR = 1.99, 95% CI 1.22-3.24; p < 0.001). There was no apparent association between choice or duration of antimicrobial prophylaxis and incident UTIs.

CONCLUSIONS

Our analysis revealed a high incidence of UTIs after PVP and served to identify certain preoperative risk factors. Neither the choice of antimicrobial regimen nor its duration affected the incidence of UTIs. Prolonged antimicrobials proved to be disproportionately high, warranting further scrutiny in randomised controlled trials.

Quality of life after photo-selective vaporization and holmium-laser enucleation of the prostate: 5-year outcomes

This study was aimed to compare serial long-term postoperative changes in quality-of-life (QoL) between photoselective-vaporization (PVP) using 120W-High-Performance-System and holmium-laser-enucleation (HoLEP) in benign-prostatic-hyperplasia (BPH) patients and to identify factors influencing the QoL improvement at the short-term, mid-term and long-term follow-up visits after surgery. We analyzed 1,193 patients with a baseline QoL-index ≥2 who underwent PVP (n = 439) or HoLEP (n = 754). Surgical outcomes were serially compared between the two groups at up to 60-months using the International-Prostatic-Symptom-Score (I-PSS), uroflowmetry, and serum PSA. We used logistic regression analysis to identify predictors of QoL improvement (a reduction in the QoL-index ≥50% compared with baseline) at the short-term (12-months), mid-term (36-months), and long term (60-months) follow-up after surgery. In both groups, the QoL-index was decreased throughout the entire follow-up period compared with that at baseline. There were no significant differences in postoperative changes from the baseline QoL-index between the two groups during the 48-month follow-up, except at 60-months. The degree of improvement in QoL at 60-months after HoLEP was greater than that after PVP. A lower baseline storage-symptom-subscore and a higher bladder-outlet-obstruction-index (BOOI) were independent factors influencing QoL improvement at the short-term. No independent factor influences QoL improvement at the mid- or long-term.