Evaluation of greenlight photoselective vaporization of the prostate for the treatment of high-risk patients with benign prostatic hyperplasia

Standardization of 532 nm Laser Terminology for Surgery in Benign Prostatic Hyperplasia: A Systematic Review

Introduction: The use of GreenLight™ laser technology to remove the prostatic transitional zone transurethrally has grown considerably in recent years. This increased utilization has resulted in an increase in the number of terms that are used to describe various laser techniques. Variable terminology complicates literature analysis and publication, which can cause confusion when performing reviews and comparisons of the techniques in the available literature. It has therefore become necessary to simplify and standardize terminology used to describe transurethral prostate debulking procedures using the 532 nm laser to simplify communication on these techniques. Materials and Methods: We conducted a search on September 17, 2019, in the following databases: Ovid MEDLINE^®, Ovid EMBASE, and PubMed. Results: Of the 1115 unique records found in our database search, a total of 27 articles were selected for inclusion. Of the 16 search terms used, we found that 4 terms could be used to describe the fundamental technique associated with each search term. These terms include "vaporization," "vaporesection," "vapoenucleation," and "enucleation." Conclusions: Standardizing terminology leads to an efficient consolidation of terms based on the above outcomes. This will streamline the literature search process for future publications and facilitate comparison of varying techniques.

Management of greenlight laser plus transurethral resection of prostate for elderly men

The study is aiming to evaluate the treatment safety and efficacy of greenlight laser photovaporization of the prostate (PVP) combined with transurethral electrovaporization resection (TUVP) for elderly (≥ 70 years) men with lower urinary tract symptoms due to benign prostatic hyperplasia (BPH/LUTS) with a large prostate volume (≥ 80 mL). One hundred twelve BPH/LUTS patients treated with PVP were divided into 2 groups according to prostate volume (PV), the outcomes of the 2 groups were assessed at 12 months after the operation. Patients in the PV ≥ 80 group (n = 51) had a higher level of maximum detrusor pressure (Pdet.max) than those in the PV < 80 group (n = 61) (97.14  ±  36.68 vs 70.70 ± 32.55, P < .001). Pdet.max level of the 2 groups was significantly decreased at the end of follow-up. International Prostate Symptom Score questionnaires (IPSS) score, maximum flow rate (Qmax), and residual urine volume (PVR) were significantly improved in comparison to the preoperative status (P < .001). PVP combined with TUVP can significantly improve outcomes (IPSS, Qmax, PVR) and is a safe and effective technique for elderly BPH/LUTS patients with a large prostate volume.

Comparison between complication rates of laser prostatectomy electrocautery transurethral resection of the prostate: A population-based study

INTRODUCTION

We compare the complication rates and length of stay (LOS) of laser transurethral resection of the prostate (L-TURP) versus electrocautery transurethral resection of the prostate (E-TURP) in a population-based cohort. L-TURP has shown enhanced intraoperative safety and equivalent efficacy relative to E-TURP in several high volume centres.

METHODS

Relying on the Florida Datafile as part of the Healthcare Cost and Utilization Project State Inpatient Databases (SID) between 2006 and 2008, we identified 8066 men with benign prostate hyperplasia who underwent L-TURP or E-TURP. Chi-square and Mann-Whitney tests were used to compare baseline characteristics. A multivariable linear regression model was used to analyze the effect of L-TURP versus E-TURP on complication rates and LOS.

RESULTS

Overall complication rates did not differ significantly for L-TURP compared to E-TURP in univariable (8.8 vs. 7.4%, p = 0.1) and multivariable analyses (odds ratio [OR]: 1.06, confidence interval [CI]: 0.85-1.32, p = 0.6). Individuals undergoing E-TURP were less likely to experience a LOS in excess of 1 day (46.2 vs. 59.7%, p < 0.001). A lower risk to experience a LOS in excess of 1 day was confirmed for patients undergoing L-TURP after a multivariable linear regression model (OR: 0.37, CI: 0.23-0.58, p < 0.001), but not for a LOS in excess of 2 days (OR: 0.96, CI: 0.83-1.10, p = 0.2).

CONCLUSIONS

Patient characteristics and perioperative safety were similar for L-TURP and E-TURP patients. However, LOS patterns demonstrated a modest benefit for L-TURP compared to E-TURP patients.

Photoselective vaporization of prostate vs. transurethral resection of prostate: A prospective, randomized study with one year follow-up

Objectives:

To evaluate in a prospective, randomized study, the efficacy and safety profile of photoselective vaporization of prostate (PVP) using a 80W potassium titanyl phosphate (KTP) laser when compared to standard transurethral resection of prostate (TURP) in patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE).

Materials and Methods:

Between February 2009 and August 2009, 117 patients satisfying the eligibility criteria underwent surgery [60 PVP{Group A}; 57 TURP{Group B}]. The groups were compared for functional outcome (both subjective and objective parameters), perioperative parameters and complications, with a follow up of one year. P value<0.05 was considered statistically significant.

Results:

The baseline characteristics of the two groups were comparable. Mean age was 66.68 years and 65.74 years, mean IPSS score was 19.98 and 20.88, mean prostate volume was 44.77 cc and 49.02 cc in Group A and B, respectively. Improvements in IPSS, QOL, prostate volume, Q max and PVRU at 12 months were similar in both groups. PVP patients had longer operating time, lesser perioperative blood loss, shorter catheterization time and a higher dysuria rate when compared to TURP patients. The overall complication rate was similar in the two groups.

Conclusions:

In patients with LUTS due to BPE, KTP-PVP is an equally efficacious alternative to TURP with durable results at one year follow up with additional benefits of lesser perioperative blood loss, lesser transfusion requirements and a shorter catheterization time. Long term comparative data is awaited to clearly define the role of KTP-PVP in such patients.

Photoselective laser vaporization of the prostate in the treatment of bladder outlet obstruction in advanced-stage prostate cancer: a single-center experience

BACKGROUND AND PURPOSE

The study in China is the first on photoselective vaporization of the prostate (PVP) applied to bladder outlet obstruction (BOO) or urinary retention from advanced-stage prostate cancer (PCa). The aim is to evaluate the efficacy and safety of PVP in the treatment of patients with BOO secondary to advanced-stage PCa.

PATIENTS AND METHODS

Forty-five patients (mean age 76.13±5.88 years, range 62-89 years) with BOO or urinary retention secondary to advanced-stage PCa received PVP with a potassium-titanyl-phosphate laser. The treatment outcome was evaluated with subjective and objective tests at 1, 3, 6, and 12 months after PVP using the International Prostate Symptom Score (IPSS), quality of life (QoL) score, postvoid residual (PVR) urine volume, and maximum urinary flow rate (Qmax). The operative time, indwelling catheterization time, and operative complications were also observed.

RESULTS

All 45 patients recovered without incident. The mean operative time was 50±7.6 minutes. The catheterization duration was 3.2 days (range 2-7 days). There was significant improvement in Qmax from 7.29±0.93 to 12.16±2.75 mL/sec after treatment at 12 months. Mean PVR volume decreased from 210.94±179.49 to 54.45±33.16 mL. Mean IPSS score decreased from preoperative 28.19±3.64 to postoperative 14.61±2.81 (P<0.05), QoL score decreased from 5.03±0.69 to 3.66±0.65 (P<0.05). There were no intraoperative adverse events. Postoperative complications included mild transient hematuria in 12 (26.7%) patients and mild dysuria in 11 (24.4%) patients within 4 weeks.

CONCLUSIONS

The clinical results suggest that PVP is a safe, efficient, and less-invasive treatment for patients with BOO or urinary retention secondary to advanced-stage PCa.

Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence

PURPOSE OF REVIEW

Different transurethral prostatic laser systems are available. In 2011, new Oxford evidence levels (LoEs) were published with significant changes compared with the former version. They are easier to use and incorporate more clinical aspects. Randomized trials of laser systems used before 2002, except Holmium laser, were not included in this critical evidence analysis, as these techniques are not in clinical use any more.

RECENT FINDINGS

Twenty-five [18 Holmium enucleation of the prostate (HoLEP) and seven photoselective vaporization of the prostate (PVP)] randomized trials covering transurethral electroresection of the prostate or HoLEP, PVP or Thulium laser enucleation were identified. According to evidence levels, there is a large gap in terms of long-term follow-up. The majority of randomised controlled trials are of low quality. Typically with HoLEP, many articles were published covering the same patient population (LoE II). Only one randomised controlled trial was published with Tm:YAG prostatectomy (LoE II) and none with diode lasers (980-1340 nm, LoE IV-V). Large cohort studies (LoE III-IV) provide additional evidence for PVP and HoLEP, typically for subgroups.

SUMMARY

In 2011, higher evidence on HoLEP and PVP has been published. Evidence levels for HoLEP and PVP are comparable with meta-analysis (LoE II). However, evidence that laser prostatectomy is better than transurethral electroresection of the prostate in terms of efficacy is lacking (LoE II). All lasers are safer in terms of perioperative bleeding (LoE II).

GreenLight™ laser in the treatment of lower urinary tract symptoms due to benign prostatic enlargement

For more than a decade, laser technology has facilitated a minimally invasive surgical method to treat patients with bladder outlet obstruction caused by benign prostatic hyperplasia. This article critically assesses the features of the GreenLight™ laser and its potential use in the treatment of lower urinary tract symptoms in benign prostatic hyperplasia patients. Recently, a significant body of evidence in the literature on good clinical outcomes in 1-year follow-up periods has been enriched with the findings from a few randomized trials, in which this device is compared with other minimally invasive or standard approaches. In turn, very few patients in the GreenLight laser study groups reach the end point of a 3- or 5-year follow-up time. However, most patients who underwent GreenLight laser treatment were treated successfully with a good clinical outcome and a minor rate of peri- and post-operative complications. Furthermore, it can be implemented in high-risk patients who are undergoing anticoagulation therapy. Bearing in mind the inherent characteristics of using a laser for treatment, one obvious consequence is that no pathological specimen remains for further study. This implies the necessity of suitable patient selection in whom the risk of prostate cancer should be minimal. In terms of cost-effectiveness, one should consider applying this method when dealing with patients who have a moderately enlarged prostate volume.

Current laser treatments for benign prostatic hyperplasia

The latest technical improvements in the surgical armamentarium are remarkable. In particular, advancements in the urologic field are so exceptional that we could observe the flare-up of robot-assisted laparoscopic radical prostatectomy for prostate cancer and laser prostatectomy for benign prostatic hyperplasia (BPH). Photoselective vaporization of the prostate (PVP) and holmium laser prostatectomy are the most generalized options for laser surgery of BPH, and both modalities have shown good postoperative results. In comparison to transurethral prostatectomy (TURP), they showed similar efficacy and a much lower complication rate in randomized prospective clinical trials. Even in cases of large prostates, laser prostatectomy showed comparable efficacy and safety profiles compared to open prostatectomy. From a technical point of view, PVP is considered to be an easier technique for the urologist to master. Furthermore, patients can be safely followed up in an outpatient clinic. Holmium laser enucleation of the prostate (HoLEP) mimics open prostatectomy because the adenomatous tissue is peeled off the surgical capsule in both procedures. Therefore, HoLEP shows notable volume reduction of the prostate similar to open prostatectomy with fewer blood transfusions, shorter hospital stay, and cost reduction regardless of prostate size. Outcomes of laser prostatectomy for BPH are encouraging but sometimes are unbalanced because safety and feasibility studies were reported mainly for PVP, whereas long-term data are mostly available for HoLEP. We need longer-term randomized clinical data to identify the reoperation rate of PVP and to determine which procedure is the ideal alternative to TURP and open prostatectomy for each patient.

Impact of prostate volume on the efficacy of high-power potassium-titanyl-phosphate photoselective vaporization of the prostate: a retrospective, short-term follow-up study on evaluating feasibility and safety

PURPOSE

We determined the impact of prostate volume on the efficacy of the high-power (80 W) potassium-titanyl-phosphate (KTP) photoselective laser vaporization of the prostate in men with lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

Patients were stratified into 3 groups according to prostate volume: '< 40 g' (n = 49) and '40-59 g' (n = 49) and '≥ 60 g' (n = 22). Median follow-up was 9 months (range 6 to 21).

RESULTS

No differences in age and follow-up duration were observed in the three groups. At baseline, no significant differences were noted in the three groups in terms of the International Prostate Symptom Score (IPSS) (21.4, 19.4 and 19.1; p = 0.412) as well as the maximum flow rate (Qmax) (10.2, 9.2, and 8.6 mL/s; p = 0.291) and post-void residual (PVR) (66.2, 80.4, and 71.5 mL; p = 0.856). The mean operative times were 30.9, 46.9, and 58.6 minutes (p< 0.001) and total median energy deliveries for each group were 62.3, 97.6, and 135.9 kJ, respectively (p< 0.001). No severe intraoperative complication was observed. At the last follow-up, these parameters improved significantly regardless of prostate volume, and the IPSS (11.1, 9.4, and 12.3; p = 0.286) as well as Qmax (15.9, 15.9, and 14.2 mL/s; p = 0.690) and PVR (33.7, 28.4, and 14.2 mL; p = 0.395) were not significantly different among the groups.

CONCLUSION

Although a larger prostate requires more time and energy delivery, photoselective laser vaporization of the prostate is safe and efficacious for patients with LUTS regardless of prostate volume.

Treatment satisfaction after 1 year high-power potassium-titanyl-phosphate photoselective vaporization of the prostate

To investigate the factors that influence treatment satisfaction after high-power potassium-titanyl-phosphate (KTP) laser vaporization of the prostate, we compared the characteristics between patients who were satisfied and those who were not satisfied. In all, 97 patients aged between 53-82 years (median age 67 years) underwent high-power KTP laser vaporization of the prostate for lower urinary tract symptoms due to benign prostatic hyperplasia. At 12 months postoperatively, 60 patients were satisfied with the treatment, whereas 37 were dissatisfied. Although there were no differences in International Prostate Symptom Score (IPSS) values at baseline, the satisfied group scored better in total IPSS at 1, 3, 6, and 12 months postoperatively (P < 0.05). At baseline, the maximum flow rate (Qmax) was lower in the dissatisfied group and remained low throughout the follow-up period, with the exception of 1 month postoperatively (P < 0.05), compared with the satisfied group. There were no differences in other objective data between the two groups, including post-void residual and the number of voids based on the frequency-volume charts. In a multivariate model, a higher bladder contractility index was associated with a greater likelihood of treatment satisfaction 12 months after high-power KTP laser vaporization (odds ratio 1.024, 95% confidence interval 1.001-1.048, P < 0.05). Patients who were not satisfied following the surgery had a smaller improvement in subjective symptoms and Q(max). In addition, our findings suggest that the relative risk of treatment dissatisfaction following high-power KTP laser vaporization was increased in patients with weak detrusor contractility.

Photoselective laser vaporization prostatectomy versus transurethral prostate resection: a cost analysis

PURPOSE

Laser procedures to treat symptomatic benign prostatic hyperplasia are becoming more common despite concern for potentially increasing cost burdens often associated with new technologies.

MATERIALS AND METHODS

Actual costs associated with photoselective laser vaporization prostatectomy and transurethral prostate resection were measured using the EPSi and TSI (Eclipsys) hospital cost accounting systems at 2 large tertiary referral centers for the first 12 months that GreenLight HPS was performed. Only patients who presented for photoselective laser vaporization prostatectomy or transurethral prostate resection as the principal treatment during the hospital visit were included in study.

RESULTS

A total of 250 men underwent transurethral prostate resection and 220 underwent photoselective laser vaporization prostatectomy, including 194 (78%) and 209 (95%), respectively, treated on an outpatient basis with less than 23 hours of hospitalization. Overall costs of laser vaporization were lower than those of transurethral prostate resection ($4,266 +/- $1,182 vs $5,097 +/- $5,003, p = 0.01). Average inpatient length of stay was also longer in the resection group.

CONCLUSIONS

The actual costs of photoselective laser vaporization prostatectomy at our affiliated hospitals are lower than those of transurethral prostate resection. The primary reason is likely that most patients who undergo laser vaporization are treated on an outpatient basis compared to those who undergo resection. While significant complications are uncommon, those that prolong inpatient hospitalization such as hyponatremia (transurethral resection syndrome), which is associated with transurethral prostate resection but not with photoselective laser vaporization prostatectomy, can add substantial expense. Further studies are warranted to investigate these findings on a broader scale.

Therapeutic options in the treatment of benign prostatic hyperplasia

Current theraputic options for the treatment of symptomatic benign prostatic hyperplasia (BPH) are reviewed. Therapeutic options for mild lower urinary tract symptoms (LUTS), as defined by the American Urological Association, are generally treated medically. Moderate to severe LUTS can be treated medically or with surgical therapy. Current medical and surgical treatments for LUTS secondary to BPH are reviewed and evolving treatments are explored.

[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 KTP‐(greenlight‐) laser – principles and experiences

The most recent advance in laser technology for transurethral prostatectomy is represented by the KTP laser. A potassium-titanyl-phosphate-(KTP-) crystal doubles the frequency of pulsed Neodymium: Yttrium-Aluminum-Garnet (Nd:YAG) laser energy to a 532 nm wavelength, which is in the green electromagnetic spectrum (Greenlight-laser) and is selectively absorbed by hemoglobin and not at all by water. Reducing the wavelength leads to a completely different interaction between laser beam and prostatic tissue. In contrast to the early clinical experiences with the Nd:YAG lasers in which vaporization was observed as a side-effect during the procedure, the new KTP laser offers an immediate and efficient vaporization, leading to real tissue ablation. Because of the instant and nearly complete absorption in blood, the depth in vascularized tissue such as prostate is only 0.8 mm. The superficial coagulation prevents the large tissue necrosis that is seen with the Nd:YAG laser, leading to long lasting irritative symptoms due to sloughing of necrotic tissue. Initial experiences, made with a 60W KTP system, demonstrated that the procedure was as effective as conventional transurethral resection of the prostate (TURP) with a lower intraoperative complication rate. In order to speed up vaporization of the prostate laser power has been increased to 80W. The 80W KTP laser combines the tissue debulking properties of TURP and the favourable safety profile of laser surgery. With the new 120W High Performance System, introduced in 2006, vaporization will become more powerful and faster. Initial reports are awaited.

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.

Safety and Effectiveness of Photoselective Vaporization of the Prostate (PVP) in Patients on Ongoing Oral Anticoagulation

OBJECTIVES

Ongoing oral anticoagulation (OA) contraindicates transurethral electroresection of the prostate. We evaluated the safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing OA with coumarin derivatives, aspirin, or clopidogrel, complaining of symptomatic benign prostatic hyperplasia (BPH).

METHODS

We evaluated perioperative parameters, functional outcome, and adverse events up to 24 mo postoperatively of patients on OA, and compared results with 92 men at normal risk without anticoagulant therapy undergoing PVP for the same indication (control).

RESULTS

Within 40 mo, 116 men on OA were included, with 31% (n=36) receiving coumarin derivatives; 61% (n=71), aspirin; and 8% (n=9), clopidogrel. Mean prostate volume (62+/-34ml vs. 57+/-25ml; p=0.289) and mean operation time (67+/-28min vs 63+/-29min; p=0.313) were comparable with control. We observed no bleeding complications necessitating blood transfusions. Average postoperative decrease of haemoglobin was 8.6% for patients on OA versus 8.8% for control. At 3, 6, 12, and 24 mo postoperatively, improvement of the International Prostate Symptom Score ranged from 60-70%; postvoid residual volume, 80-88%; and average maximum urinary flow rate, 116-140%, respectively. Postoperative complications were low and comparable with control.

CONCLUSIONS

PVP is characterized by excellent haemostatic properties and very low intraoperative complication rate even in patients on OA. On the basis of our perioperative results, we recommend PVP as first-line procedure for patients with symptomatic BPH at high risk of bleeding.

Potassium titanyl phosphate laser prostatectomy: a review

PURPOSE OF REVIEW

High-powered potassium titanyl phosphate laser (GreenLight PV) has gained attention as a minimal access alternative for the treatment of prostate obstruction. This article reviews the recent data and technical refinements of potassium titanyl phosphate laser prostatectomy.

RECENT FINDINGS

The technique is similar to transurethral resection of the prostate in improving symptoms and urinary flow but with minimal morbidity. Striking advantages of this technique include minimal catheter times, true day-case surgery and the virtual abolition of blood transfusions. The absence of intraoperative irrigant absorption (transurethral resection syndrome) in this technique allows high-risk patients, or those with massive prostates, to be safely treated with minimal hospitalization.

SUMMARY

The availability of a safe and effective technique to overcome the considerable drawbacks of open prostatectomy and transurethral resection of the prostate is a major advance. Although randomized studies are limited, multicentre prospective data from a variety of clinical settings show similar benefits and promising durability over 3-5 years.