The surgical learning curve for endoscopic GreenLight™ laser enucleation of the prostate: an international multicentre study.

OBJECTIVES: To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP). SUBJECTS/PATIENTS AND METHODS: A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3-month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement. RESULTS: In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P < 0.001), lower IOC rate (P < 0.001), higher 3-month postoperative reduction in IPSS (P = 0.004), and higher probability of Pentafecta achievement (P < 0.001). The relationship between surgical experience and enucleation time/IOCs appeared as non-linear, with a steep slope reduction within the first 100 cases and a plateau observed after 200 cases, whilst the IPSS improved rapidly early in the learning curve process and plateaued after ~100 procedures. Finally, there was a linear improvement in Pentafecta achievement, with a plateau observed after 270 cases. CONCLUSION: Surgical experience has a significant impact on the perioperative outcomes for GreenLEP procedures. After adjusting for patient and prostate characteristics, plateau results were achieved after a long learning curve. A more intensely mentored and structured training schedule might allow quicker and safer adoption of the procedure.

Prospective Assessment of the Sexual Function After Greenlight Endoscopic Enucleation and Greenlight 180W XPS Photoselective Vaporization of the Prostate.

OBJECTIVE: To evaluate the impact of Greenlight 180W photoselective vaporization of the prostate (PVP) and endoscopic enucleation of the prostate (GreenLEP) on ejaculatory and erectile functions. MATERIALS AND METHODS: Between January 2014 and September 2016, 440 men with low urinary tract symptoms or complications related to benign prostate obstruction with prostate >80 g and sexually active, underwent a PVP or GreenLEP performed by experienced surgeons at a single institution. Patients were matched in a 1:1 fashion according to preoperative transrectal ultrasonography prostatic volume and cardiovascular risk factors (smoking, diabetes, and hypertension). RESULTS: One hundred patients in each group were included. Mean prostatic volume were 110 g (95%CI: 101-118) and 107 g (95%CI: 99-115) in the GreenLEP and PVP groups, respectively (P = .68). Mean total energy delivered in the PVP group was 4.42 kJ/g (4.2-4.6). Surgical retreatment was required in 9 patients (10.1%) in the PVP group and none in the GreenLEP group (log rank test: P = .002). Mean prostate specific antigen level and International Prostate Symptom Score score were significantly lower in the GreenLEP group than in the PVP group at 3, 12, and 24 months (P <.001). Preserved antegrade ejaculation was reported in 24 patients (26.9%) in the PVP group vs 1 patient (1.2%) in the GreenLEP group at 12 months (P <.001). In multivariate analysis, age, history of coronary artery disease, and surgical treatment with PVP were independent factors of IIEF-5 decline. CONCLUSION: Despite a poor rate of preserved antegrade ejaculation, GreenLEP was associated with better erectile function outcomes possibly due to greater improvement of low urinary tract symptoms.

Does mechanical morcellation of large glands compromise incidental prostate cancer detection on specimen analysis? A pathological comparison with open simple prostatectomy.

OBJECTIVE: This study sought to compare the incidental prostate cancer (iPCa) detection rate between pathological specimens from green laser enucleation of the prostate (GreenLEP) and open simple prostatectomy (OSP). MATERIALS AND METHODS: In two institutions, the charts of all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and the data of all consecutive patients who underwent GreenLEP with tissue morcellation between July 2013 and January 2018 were also collected. Preoperative demographics and pathological findings were recorded. iPCa detection rate was retrospectively compared between the GreenLEP and OSP groups in a propensity score model, including all predetermined variables: Age, preoperative PSA level and prostate volume. RESULTS: Of 738 patients, 402 were included in the propensity-score matching analysis, and they were equally distributed among groups. The overall iPCa detection rates were similar in both groups (9.9% vs. 8.5%; p = 0.73), and there were no statistically significant differences in terms of tumour stage, Gleason score or the rate of clinically significant iPCa, although the number of cassettes analysed was significantly higher in the morcellation group than in the OSP group. No predictive factors for iPCa were identified. CONCLUSIONS: The results of the present study suggest that the mechanical morcellation of large glands had no influence on iPCa detection. Compared with a specimen from standard OSP, a large morcellated tissue sample allows adequate pathological evaluation and does not alter a pathologist's ability to detect iPCa.

MRI assessment of tissue effects after 180-W XPS greenlight laser vaporization of the prostate.

BACKGROUND AND OBJECTIVE: Photoselective vaporization of the prostate (PVP) is an alternative to transurethral resection of the prostate (TURP) in the surgical management of Benign Prostate Obtruction (BPO), with a better hemostatic effect due to a coagulation depth of several millimeters. The objective of this study was to prospectively assess the tissue effects of PVP by Magnetic Resonance Imaging (MRI). MATERIALS AND METHODS: From December to February 2014, ten patients were included in a prospective study and underwent PVP performed by a single surgeon with the Greenlight™ laser 180-W XPS. A multiparametric MRI of the prostate (Siemens 3T Verio) was achieved the day before the procedure and post-operatively (2 days, 7 days, 3 and 6 months after the procedure). The prostate volume after tissue removal was determined. The depth of necrosis in the prostatic and peri-prostatic tissues were assessed at six different locations. RESULTS: The median age and pre-operative prostate volume were 70 years (64-76) and 48.1 ml (19-74.4), respectively. Median prostate volume significantly decreased post-operatively (P < 0.001): At 6 months, median prostate volume reduction was 44.2% (38.7-49.5) (P = 0.001) compared to pre-operative setting. Two and 7 days after the procedure, mean depths of necrosis were 2.5 mm (0-3) and 1.3 mm (0-2.4), respectively. No necrosis was reported 3 and 6 months after the procedure. CONCLUSIONS: PVP with Greenlight™ XPS 180-W is associated with a significant reduction of prostate volume. The depth of necrosis is low and homogeneous, resulting in a limited risk of peri-operative complications. Lasers Surg. Med. 49:577-581, 2017. © 2017 Wiley Periodicals, Inc.

Prospective evaluation of ambulatory laser vaporization of the prostate for benign prostatic hyperplasia.

BACKGROUND AND OBJECTIVE: Photoselective vaporization of the prostate (PVP) is an alternative to transurethral resection of the prostate in the surgical treatment of benign prostatic hyperplasia (BPH). Our objective was to prospectively evaluate the feasibility, safety, and efficacy of ambulatory photoselective vaporization of the prostate for benign prostatic hyperplasia. MATERIALS AND METHODS: We prospectively collected data of all consecutive patients who underwent ambulatory PVP with the Greenlight(®) laser 180-W XPS at two centers between May 2012 and June 2013. Patients' characteristics, perioperative data, postoperative outcomes, complications, and patient's satisfaction were evaluated. Successful ambulatory care procedure was defined as the ability to leave the hospital in the evening of the operation. RESULTS: The ambulatory procedure was intended in 134 patients. Mean age was 67 years. Mean prostate volume was 54 ml, and Median American Society Anesthesiologists (ASA) score was 2. Ambulatory procedure was successful in 121 patients (90%). At 3 months, International Prostate Symptom Score (7.3 ± 4.9), maximal urinary flow rate (20.8 ± 7.6 ml/s), postvoid residual urine (19.2 ± 71 ml), and quality of life (1.6 ± 1.4) were significantly improved (P < 0.001). Fourteen patients (10.5%) had complications that were all minor (Clavien ≤ 2). Two patients had to be readmitted to the hospital. The majority of patients (89%) were satisfied with ambulatory care. Failure to complete ambulatory procedure was mostly related to logistical problem (70% of the cases). CONCLUSIONS: Ambulatory PVP is feasible with functional results and complications comparable to that of traditional hospitalization. Ambulatory care yields high patient's satisfaction.