title: Vaporize, anatomically vaporize or enucleate the prostate? The flexible use of the GreenLight laser.
abstract: OBJECTIVE
  GreenLight laser has gained increasing acceptance as a less invasive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH/LUTS). Three surgical options were developed: standard photovaporization (PVP), anatomical PVP and GreenLight enucleation of prostate (GreenLEP); however, literature lacks a direct comparison among the procedures. Aim of the present study is to compare the three techniques in a multicentre series of patients.
  
  
  METHODS
  Data were collected from consecutive patients with indication to surgical management of BPH/LUTS in five institutions. Patients underwent standard PVP, anatomical PVP or GreenLEP according to surgeon preferences. Standard parameters associated with transurethral prostate surgery were documented prior surgery and during the follow-up. Patients' perception of improvement was measured using a single-item scale. Early (within first 30 post-operative days) and delayed post-operative complications were recorded. Descriptive statistics, univariate and multivariate analysis were used.
  
  
  RESULTS
  We evaluate 367 consecutive patients (mean age 69.1 years). Median prostate size and PSA were 68 ml (IQR 50-90) and 2.8 ng/ml (IQR 1.7-4.3), respectively. The median operative time and applied energy were 60 min (IQR 45-75) and 250 kJ (IQR 160-364). Catheterization time and median post-operative stay were 1 and 2 days. No patient was transfused. The overall median Qmaxvalues increased for 8-19 ml/s (p < 0.05), median International Prostate Symptoms Score decreased from 24 to 7 (p < 0.05). A total of 7.4% urinary retention, 33.4% bothersome storage symptoms, 2.5% short-term stress incontinence were recorded. Three heart attacks, one pulmonary embolism and one death occurred. Prostate volume was a predictive factor for post-operative storage symptoms (p = 0.049). Nine percentage of patients experienced long-term complications (4, 0.9 and 0.9% of urethral stricture, bladder neck contracture and prostatic fossa sclerosis, respectively) with 2.5% of long-term stress urinary incontinence (conservatively managed). The reintervention rate was 6%. Late complications were associated at univariate analysis with pharmacological therapy (combination therapy vs. alpha blockers alone vs. none: p value = 0.042) and with the surgical approach (standard PVP vs. anatomical PVP vs. GreenLEP p value = 0.011). The patients' perception of satisfaction was 68% "greatly improved", 27% "improved", 4% "not changed" and 1% "worsened" with no differences between techniques.
  
  
  CONCLUSIONS
  The availability of three different GreenLight laser techniques allows surgeons with different skills to safety use this technology that remains effective with high patient satisfaction. Anatomical vaporization seems to guarantee the best balance between functional outcomes, surgical procedures and complications.
authors.affiliation: Department of Urology, ASL Abruzzo 02, Chieti, Italy. lucacindolo@virgilio.it.|Department of Urology, "S. Pio da Pietrelcina" Hospital, Via S. Camillo de Lellis 1, 82, 66054, Vasto, Italy. lucacindolo@virgilio.it.
authors.forename: Luca
authors.initials: L
authors.lastname: Cindolo
authors.affiliation: Department of Urology, "Santa Maria degli Angeli" Hospital, Pordenone, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Ruggera
authors.affiliation: Department of Urology, Azienda Ospedaliera Città della Salute e della Scienza di Torino - Sede Molinette, Turin, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Destefanis
authors.affiliation: Department of Urology, "Santa Croce e Carle" Hospital, Cuneo, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Dadone
authors.affiliation: Department of Urology, Hesperia Hospital, Modena, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ferrari
mesh_terms: D000368:Aged; D006801:Humans; D053685:Laser Therapy / Q000009:adverse effects / Q000379:methods; D053844:Lasers, Solid-State / Q000009:adverse effects / Q000627:therapeutic use*; D007902:Length of Stay; D059411:Lower Urinary Tract Symptoms / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D009929:Organ Size; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D011467:Prostate / Q000473:pathology*; D011470:Prostatic Hyperplasia / Q000150:complications / Q000473:pathology / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: BPH; GreenLight laser 180 watt; LUTS; Patient satisfaction; Prostate photovaporization