Direct comparison of Green Light Laser XPS Photoselective Vaporization of the Prostate (PVP) and Green Laser En Bloc enucleation of the prostate (GreenLEP) in enlarged glands > 80 ml: A study of 120 patients

Purpose: To compare patient outcomes after 180 W XPS Greenlight photoselective vaporization of the prostate (PVP) and Green laser enucleation of the prostate (GreenLEP) used to surgically manage benign prostatic obstruction (BPO). Materials and Methods: Two groups of 60 consecutive patients with enlarged glands (>80 mL) underwent either GreenLEP or PVP (performed by the same surgeon and including his learning curve) and were retrospectively evaluated. Perioperative data from both groups were compared. Results: Operative time was significantly shorter in the GreenLEP group (60 vs 82 min, p<0.0001). The complication rates were comparable between the groups. At 2 months, urinary incontinence was significantly higher in the GreenLEP group (25% vs. 3.4%, p<0.0001) but incontinence rates were similar at 6 months (3.4 % vs. 0%, p=0.50). At 6 months, the I-PSS, QOL and PVR had similarly decreased in the two groups after the procedure (compared to baseline), whereas the Qmax value had greatly improved, significantly favoring the GreenLEP group (+78% vs. +64%, p<0.0001). The prostate size and PSA level reductions were significantly higher in the GreenLEP group (74% vs. 57%, p<0.0001 and 67% vs. 40%, p=0.007). The unplanned readmission rates were similar in both groups (16.7% vs. 6.7%, p=0.16). Conclusions: PVP and GreenLEP were safe and provided satisfactory short-term functional outcomes in patients with a prostate volume over 80 mL. However, the surgical time was longer in the PVP group, which also had a higher rate of unplanned readmission and lower decreases in the PSA level and prostate size. M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 3 INTRODUCTION Lower urinary tract symptoms caused by benign prostatic obstruction (BPO) are highly prevalent in men older than 50 years of age. Surgery is indicated in cases of complicated BPO or moderate-to-severe symptoms with insufficient drug treatment efficacy, according to European guidelines. Greenlight photoselective vaporization of the prostate (PVP) has been emphasized in recent years as a viable alternative to transurethral resection of the prostate, with comparable short-term functional outcomes for smallto medium-sized prostates. However, in recent years, several studies have raised concerns regarding the efficacy of photoselective vaporization of the prostate (PVP) with 80 W and HPS-120 W Greenlight laser in larger glands with high long-term reoperation rates, and evidence supporting the use of the GreenLight XPS 180 W for PVP in larger prostates is limited. When prostate volumes exceed 80 mL, enucleation techniques using open prostatectomy or holmium-laser enucleation of the prostate (HoLEP) are currently the most established available options. HoLEP has significantly lower perioperative morbidity rates and shorter hospital stays, and it has favorable outcomes compared to open prostatectomy and transurethral resection of the prostate. However, to date, this technique has failed to spread widely in current clinical practice because it is technically demanding and has a long learning curve. Green-laser enucleation of the prostate (GreenLEP) has recently been advocated as a new endoscopic enucleation procedure to excise the transitional zone as a single piece “en-bloc” using a GreenlightTM laser with a 120-W side firing fiber. However, in the literature, there is a lack of clinical data supporting GreenLEP. The aim of this study was to compare the efficacy of the XPS 180 W Greenlight PVP and Green laser “en-bloc” enucleation of the prostate (GreenLEP) procedures in relieving BPO in enlarged prostate volumes > 80 ml. M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 4 MATERIALS AND METHODS Population. Between April 2011 and March 2014, men who were referred for lower urinary tract symptoms related to BPO and who underwent surgery were retrospectively reviewed. The first 120 consecutive patients with a TRUS prostate measurement >80 mL who underwent either PVP (as previously described) or a GreenLEP procedure were included in the present single-center study. There were two distinct eras during the study period: during the first era (2011-2012) PVP was used for all patients, regardless of the prostate volume. During the second era (2013-2014), we started to perform GreenLEP procedure and this technique was used in all patients with prostate> 80 mL. Hence, the choice between the two surgical techniques did not depend on patients’ characteristics. The patients provided informed consent to undergo enucleation with the GreenlightTM laser. All men who underwent prostate cancer, and pelvic radiotherapy were excluded from the analysis. Surgical techniques. A Greenlight XPS 532-nm laser generator (American Medical Systems, Minnetonka, MN, USA) was used for all cases. The type of laser fiber used depended on which technique was utilized. For pure PVP, the MoXy fiber was utilized. For the GreenLEP group, the HPS 2090 fibers were used, along with the 120 W system. The HPS fiber was chosen for enucleation because it is more solid than the Moxy fiber, which allowed mechanical dissection of adenoma with the end of the fiber. GreenLEP was conducted with a WolfTM double-flow endoscope 24.5-Fr, with continuous irrigation of the bladder with saline. At the end of the procedure, a morcellator with a single-use, Wolf-Piranha blade was used in all cases. All procedures were performed by a single surgeon (VM) with no previous enucleation experience. The 60 GreenLEP cases presented here indicate his learning curve. He learnt GreenLEP by watching videos of a proctor who had a large experience of this enucleation technique. The PVP included in this study were his first cases with prostates> M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 5