Greenlight Prostatectomy: A Challenge to the Gold Standard?

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.

The efficacy of green light laser prostatectomy in the management of urinary retention due to prostate hyperplasia

To evaluate the efficacy and safety of 120 W potassium titanyl phosphate (KTP) in the treatment of urinary retention (UR) due to benign prostate hyperplasia in high-risk patients. Forty-six male patients with mean age of 73.78 ± 9.82 years who اhad UR and underwent 120 W KTP laser vaporization of the prostate between January 2015 and June 2017 were included. We evaluated perioperative parameters including serum prostate specific antigen, prostate volume, period of postoperative catheterization, vaporization time, delivered energy, hospitalization period, as well as intraoperative and postoperative complications. In the follow-up protocols, International Prostate Symptom Score and quality-of-life questionnaire (IPPS-QoL) and postvoid residual volume (PVR) were also assessed. The mean follow-up period was 15.57 ± 9.26 (1-42) months. All patients get rid of UR, except 1 patient (2.1%) remained on Foley catheter and standard TURP was done. Mean vaporization time was 8.57 ± 4.19 min, and mean energy delivered was 51.7 ± 29.9 kJ. No intraoperative complications were observed and no blood transfusion was done. The mean postoperative IPSS at the last follow-up was 9.64 ± 6.65 and the QoL score was 1.61 ± 1.31. Green light laser prostatectomy is a safe, simple, and effective procedure for the treatment of UR secondary to BPH in high-risk patients. Short hospitalization, low rate of intra operative and postoperative complications with rapid improvements in the objective, and subjective voiding parameters are important considerations of this procedure.

Outcome analysis of transurethral resection versus potassium titanyl phosphate-photo selective vaporization of the prostate for the treatment of benign prostatic hyperplasia; a randomized controlled trial with 4 years follow up

OBJECTIVE

Photovaporization of prostate (PVP) is a newer surgical modality of benign prostatic hyperplasia (BPH) which is gaining importance recently. There are a few randomized controlled trials that showed safety and efficacy of PVP in comparison with transurethral resection of prostate (TURP) with limited follow-up period (<2 years). Here, we are presenting a comparative study performed on potassium titanyl phosphate (KTP) PVP laser versus TURP for the treatment of BPH with long-term follow-up period.

MATERIAL AND METHODS

After institutional ethical clearance, 150 patients were prospectively included in the study from January 2010 to March, 2012. Improvement of International Prostate Symptoms Score (IPSS), Qmax, post-void residual (PVR) urine, International Index of Erectile Function (IIEF)-5 score and complications were assessed at 12, 24, 36 and 48 months.

RESULTS

Mean age of the study group was 65.3±7.86 years in the TURP and 63.6±8.12 years in the PVP groups (p=0.45). IPSS symptom score improved significantly in both TURP and KTP groups (p<0.003). There was improvement in Q max during follow-up in both groups (p<0.001) which was maintained at 48 months. Most of the patients in both groups were satisfied with symptoms and bothersome at 48 months. All the sexual parameters are similar to both groups except retrograde ejaculation. Overall complication noted in 23 patients (15.33%).

CONCLUSION

Both KTP Laser PVP and TURP afford durable relief from symptoms of BPH at 48 months follow-up. Both procedures are safe and associated with minimal complications. Both procedures do not have any detrimental effect on sexual function on long-term follow-up. Quality of life remains high even at 4 years in both groups.

Durability and complications of photoselective vaporisation of the prostate with the 120W high performance system GreenLight™ lithium triborate laser

INTRODUCTION

The aim of this study was to examine the durability of photoselective vaporisation of the prostate (PVP) with the 120W GreenLight HPS(®) laser (American Medical Systems, Minnetonka, MN, US), and to examine the incidence, nature and factors associated with complications from the procedure.

METHODS

Clinical records of PVP patients were reviewed to compare details between patients who developed complications and those who did not. Kaplan-Meier survival curves were used to assess durability. Cox regression was used to examine associations between complications and perioperative factors.

RESULTS

Successful outcomes were maintained in 84% of 117 patients at the 2-year follow-up appointment. Complication rates were low and comparable with transurethral resection of the prostate (TURP). Complications were developed by 18 patients (15.4%) over a mean follow-up duration of 20.8 months. The most common complications were residual prostate requiring another surgery (5/117, 4.3%) and urethral stricture (4/117, 3.4%). Patients with complications had significantly longer catheterisation duration. Length of hospital stay, lasing energy, pre and postoperative levels of prostate specific antigen (PSA), pre and postoperative maximum flow rate (Qmax), and age at surgery were not found to influence development of complications.

CONCLUSIONS

Results from PVP with an HPS(®) laser are durable. Complications are low and compare favourably with TURP. Lasing energy, PSA, Qmax, patient age and length of stay are not associated with development of complications. However, a longer postoperative catheterisation after PVP is associated with development of complications.

A cost-minimisation analysis comparing photoselective vaporisation (PVP) and transurethral resection of the prostate (TURP) for the management of symptomatic benign prostatic hyperplasia (BPH) in Queensland, Australia

OBJECTIVES

To compare the costs of photoselective vaporisation (PVP) and transurethral resection of the prostate (TURP) for management of symptomatic benign prostatic hyperplasia (BPH) from the perspective of a Queensland public hospital provider.

PATIENTS AND METHODS

A decision-analytic model was used to compare the costs of PVP and TURP. Cost inputs were sourced from an audit of patients undergoing PVP or TURP across three hospitals. The probability of re-intervention was obtained from secondary literature sources. Probabilistic and multi-way sensitivity analyses were used to account for uncertainty and test the impact of varying key assumptions.

RESULTS

In the base case analysis, which included equipment, training and re-intervention costs, PVP was AU$ 739 (95% credible interval [CrI] -12 187 to 14 516) more costly per patient than TURP. The estimate was most sensitive to changes in procedural costs, fibre costs and the probability of re-intervention. Sensitivity analyses based on data from the most favourable site or excluding equipment and training costs reduced the point estimate to favour PVP (incremental cost AU$ -684, 95% CrI -8319 to 5796 and AU$ -100, 95% CrI -13 026 to 13 678, respectively). However, CrIs were wide for all analyses.

CONCLUSIONS

In this cost minimisation analysis, there was no significant cost difference between PVP and TURP, after accounting for equipment, training and re-intervention costs. However, PVP was associated with a shorter length of stay and lower procedural costs during audit, indicating PVP potentially provides comparatively good value for money once the technology is established.

The Twister laser fiber degradation and tissue ablation capability during 980-nm high-power diode laser ablation of the prostate. A randomized study versus the standard side-firing fiber

The objective of this work is to test the ablation capability and fiber degradation of the novel Twister fibers (TW), in both the large (LTW) and the standard (STW) sizes, against the standard side-firing (SF) fiber in a clinical setting during the treatment of BPH patients using the 980-nm high-power diode laser (HPDL). One hundred and twenty BPH patients treated with HPDL (Ceralase300, Biolitec AG, Jena, Germany) were randomized to receive treatment by one of the three fibers. Operative time corrected to tissue volume, laser treatment time, and laser energy were measured. Ablation rate was calculated as follows: the decrease of the prostate volume after 6 months/laser time. The fibers' resistance to degradation was defined by the laser energy needed to degrade the fiber completely. Preoperative prostate volume of 76 ± 38, 70 ± 39, and 88 ± 49 cc decreased by 49 ± 16, 51 ± 20, and 63 ± 16% for the SF, STW, and LTW fibers, respectively. This difference was highly significant when the LTW was compared to the other two fibers (p < 0.001). Prostate volume reduction post-operatively within each group as compared to the pre-operative volume was highly significant (p < 0.001). The ablation rate was highest in LTW, being 1.31 ± 0.59, 1.09 ± 0.51, and 1.54 ± 0.44 cc/min for the SF, STW, and LTW fibers, respectively. The LTW fiber resisted degradation more than the other fibers and the STW more than the SF fiber (p < 0.001). This study demonstrates the higher ablation efficiency and resistance to degradation of the LTW fiber as compared to the STW and SF fibers. The STW fiber has a similar ablation rate of the SF fiber but resists degradation better.

Panurethral stricture after photovaporization of the prostate for benign prostatic hyperplasia

PURPOSE

To report the development of panurethral stricture disease and other lower urinary tract abnormalities as a complication of photovaporization of the prostate (PVP).

PATIENTS AND METHODS

We evaluated three patients who were referred for the treatment of urethral stricture disease after PVP. Evaluation included antegrade cystoscopy, urethroscopy, retrograde urethrography, and cystourethrography.

RESULTS

All three patients had panurethral stricture disease, and a low capacity bladder with bilateral vesicoureteral reflux had developed in one patient as a complication of PVP.

CONCLUSIONS

Although not previously reported, a potential complication of PVP is devastating panurethral stricture disease.

Long-Term Follow-Up Results of Photoselective Vaporization of the Prostate with the 120 W Greenlight HPS Laser for Treatment of Benign Prostatic Hyperplasia

Purpose

With the use of 12 months of follow-up data, this study was conducted to evaluate the efficacy of photoselective vaporization of the prostate (PVP) with the 120 W Greenlight high performance system (HPS) laser for the treatment of symptomatic benign prostatic hyperplasia.

Materials and Methods

Data were collected from 104 patients who were diagnosed with benign prostatic hyperplasia and who underwent PVP with the 120 W Greenlight HPS Laser. Postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum urinary flow rate (Qmax), and postvoid residual volume (PVR), were assessed and compared with preoperative baseline values.

Results

The mean age of the patients was 71.1±7.7. The baseline mean prostate-specific antigen level was 3.8±2.7 ng/ml, the mean prostate size was 43.9±20.6 g, the mean preoperative IPSS was 18.4±8.5, the mean QoL score was 4.1±1.0, the mean Qmax was 9.9±5.5 ml/sec, and the mean PVR was 89.6±207.1 ml. During surgery, the mean operation time was 21.8±11.3 minutes, the mean lasing time was 16.9±10.5 minutes, and the mean total applied energy was 170,068±63,181 J. At 1 month, significant improvements were observed in total IPSS (11.5±6.7, p<0.05), voiding symptom score (6.1±5.4, p<0.05), and QoL score (2.2±1.5, p<0.05); however, there were no significant improvements in storage symptom score (4.8±3.8, p=0.06), Qmax (12.6±10.2, p=0.06), and PVR (40.1±30.5, p=0.41). However, 3 months after surgery, all postoperative follow-up parameters showed significant improvements, and the 6- and 12-month data showed sustained improvement of postoperative follow-up parameters.

Conclusions

Significant improvements were observed in subjective and objective voiding parameters, which were evident at 3 months after PVP and were sustained throughout a period of 12 months after PVP.

Comparative Analysis of the Efficacy and Safety of Photoselective Vaporization of the Prostate for Treatment of Benign Prostatic Hyperplasia according to Prostate Size

Purpose

This study was conducted to perform a comparative analysis of the efficacy and safety of photoselective vaporization of the prostate (PVP) for treatment of benign prostatic hyperplasia (BPH) in men with a prostate volume greater than 60 cc.

Materials and Methods

The clinical data of 249 men with symptomatic BPH who underwent PVP between January 2006 and June 2008 were retrospectively analyzed. All patients were classified into two groups according to their prostate volume (group A, <60 cc; group B, ≥60 cc). The preoperative evaluation included a digital rectal exam, urinalysis, prostate-specific antigen levels, International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximal flow rate (Qmax), postvoid residual urine volume (PVR), and transrectal ultrasonography. The total operative time, used energy (kJ), urethral Foley catheter indwelling period, and the number of hospital days were recorded afterward. The IPSS, QoL score, Qmax, and PVR were evaluated at 1, 3, 6, and 12 months postoperatively.

Results

In both groups, significant improvements in the subjective and objective voiding parameters were achieved and these improvements were sustainable for at least 1 year with minimal complications. During the follow-up period, the PVR in group B significantly increased. Retrograde ejaculation and urethral stricture were the common complications in both groups. There was no significant difference in the incidence rate.

Conclusions

PVP is safe and efficacious, with durable results for men with symptomatic BPH and large prostate volumes.

Short-term outcomes of Greenlight HPS laser photoselective vaporization prostatectomy (PVP) for benign prostatic hyperplasia (BPH)

PURPOSE

We evaluated our initial experience with the GreenLight HPS laser, a technologically improved version of the potassium-titanyl-phosphate (KTP) laser for PVP.

MATERIALS AND METHODS

Transurethral PVP was performed using a GreenLight HPS side-firing laser system. Patients had American Urological Association Symptom Score (AUASS), Quality of Life (QoL) score, Sexual Health Inventory for Men (SHIM) score, serum prostate specific antigen (PSA), maximum flow rate (Qmax) and post void residual (PVR) determinations and volumetric prostate measurements with transrectal ultrasonography (TRUS). Laser and operative times and energy usage were recorded. AUASS, QoL, SHIM, Qmax and PVR were evaluated 1, 4, 12, 24, and 52 weeks post-surgery. Serum PSA and TRUS were obtained at 12 weeks and serum PSA was repeated at 52 weeks.

RESULTS

Seventy consecutive patients with a median age of 67 (45-86) years underwent GreenLight HPS laser PVP from July 2006 through March 2008. Median prostate volume was 61.6 (20.9-263.0) mL with a median PSA of 1.4 (0.1 -10.1) ng/mL. Mean laser and operative times and energy usage were 13 (3-34) minutes, 30 (6-100) minutes and 85 (11-235) kJ, respectively. All were outpatient procedures with 49 (70%) patients catheter-free at discharge. No urethral strictures or urinary incontinence were noted. Median AUASS decreased from 22 to 8, 6, 5, 5, and 4 (p<0.001) while the median Qmax increased from 9.4 to 20.4, 20.3, 21.2, 18.8, and 20.0 mL/s (p<0.001) during the follow-up period.

CONCLUSIONS

At one year, our experience suggests that GreenLight HPS laser PVP is safe and effective for treating lower urinary tract symptoms secondary to BPH.

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.