Open prostatectomy versus 180-W XPS GreenLight laser vaporization: Long-term functional outcome for prostatic

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ORIGINAL ARTICLE

Open prostatectomy versus 180-W XPS GreenLight laser vaporization: Long-term functional outcome for prostatic

adenomas > 80 g

Adénomectomie voie haute versus vaporisation prostatique au laser GreenLight 180-W XPS : résultats fonctionnels à long terme pour les adénomes > 80 g

C. Lanchon

^a^,^b

, G. Fiard

^a^,^b

, J.-A. Long

^a^,^b^,∗

, V. Arnoux

^a

, D. Carnicelli

^a

, Q. Franquet

^a

, D. Poncet

^a

, E. Bey

^a

, J.-B. Lefrancq

^a

, S. Grisard

^a

, N. Peilleron

^a

, N. Terrier

^a

, B. Boillot

^a

, J.-J. Rambeaud

^a

, J.-L. Descotes

^a^,^b

,

C. Thuillier

^a

aServiced’urologie,CHUdeGrenoble,38043Grenoble,France

bUJF-Grenoble1,CNRS,Inserm,TIMC-IMAGUMR5525,38041Grenoble,France

Received17July2017;accepted13December2017 Availableonline10January2018

KEYWORDS Benignprostatic obstruction;

Openprostatectomy;

GreenLightlaser vaporization;

PVP;

Outcome

Summary

Introduction.—GreenLightphotoselectivevaporisationoftheprostate(PVP)offersanendo- scopicalternativetoopenprostatectomy(OP)for treatmentoflargeadenomas. Thisstudy compareslong-termfunctionaloutcomeofbothtechniquesinpatientswithBenignprostatic obstruction(BPO)>80g.

Materialandmethod.—DatafrompatientswhounderwentsurgicaltreatmentforBPO>80g fromJanuary2010toFebruary2015atourinstitutionwereretrospectivelycollectedandcom- paredaccordingtosurgicaltechnique.Patient’sdemographics,surgeon’sexperience,operative dataandlong-termfunctionalresultswereanalyzed,usingIPSSandInternationalcontinence society(ICS)malequestionnaireassociatedwith Qualityoflifescores(IPSS-QL andICS-QL).

Predictorsoflong-termoutcomewerealsoassessed.

∗Correspondingauthor.UJF-Grenoble1,CNRS,Inserm,TIMC-IMAGUMR5525,38041Grenoble,France.

E-mailaddress:[email protected](J.-A.Long).

https://doi.org/10.1016/j.purol.2017.12.008

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Results.—Intotal,111 consecutivepatients,57 PVPand54 OP,wereincludedinthestudy withameanfollow-up of24 and33monthrespectively. Patient’sage,Charlsonscore,pre- operativeIPSSandurinaryretentionratesweresimilar.Meanprostaticvolumewas superior intheOPgroup(142versus103g,P<0.001).TransfusionratewaslowerafterPVP(P=0.02), despiteamorefrequentanticoagulantuse.Lengthofhospitalstayandurinarycatheterization wereshorterafterPVP(P<0.001),withhoweverahigherrateofrecatheterization(RR=4.74) andrehospitalization(RR=10.42).Long-termscoreswere betterafter OPfor IPSS(1 versus 5,P<0.001),IPSS-QL,ICS,ICS-QL.Onmultivariateanalysis,prostaticresidualvolumewasthe onlypredictoroflong-termIPSSbutnotICS.

Conclusion.—Long-termfunctionaloutcomearebetterafterOPcomparedtoPVP.However, PVPoffersgoodresults,allowingtosafelyoperatepatientstakinganticoagulants,regardless ofprostaticvolume.Endoscopicenucleationmaythecompromisebetweenbothtechniques.

Levelofevidence.—4.

MOTSCLÉS Hyperplasiebenign deprostate; Adenomectomievoie haute;

Photovaporisation prostatique; GreenLight

Résumé

Introduction.—LavaporisationprostatiqueGreenLight(PVP)estunealternativeendoscopique àl’adénomectomievoiehaute(AVH).Cetteétudecomparelesrésultatsfonctionnelsàlong termedecesdeuxtechniqueschezlespatientsprésentantdesadénomes>80g.

Matérielsetméthodes.—Lesdonnéesdespatientsayantbénéﬁciéd’untraitementchirurgical pouradénome>80g dejanvier2010àfévrier2015ontétérecueilliesrétrospectivementet comparées.Lesrésultatsfonctionnelsàlongtermeontétéanalysés,enutilisantlesquestion- nairesdelasociétéinternationaledecontinence(ICS),l’IPSSainsiquelesscoresdequalitéde vie(IPSS-QLetICS-QL).

Résultats.—Autotal,111patients consécutifs,57PVPet54 OP,ontétéinclusdansl’étude avec un suivimoyen de 24 et 33 mois respectivement. L’âge, lescore de Charlson, l’IPSS préopératoireetlestauxdepatients enrétentionétaientsimilaires.Le volumeprostatique moyenétaitsupérieurdanslegroupeAVH(142contre103g,p<0,001).Letauxdetransfusion étaitinférieuraprèsPVP(p=0,02),malgréuneutilisationd’anticoagulantsplusfréquente.Les duréesd’hospitalisationetdesondageétaientpluscourtesaprèsPVP(p<0,001),avecuntaux deresondageplusélevé(RR=4,74) ainsiquederé-hospitalisation(RR=10,42).Les scoresà longtermeétaientmeilleursaprèsAVHpourl’IPSS(1contre5,p<0,001),IPSS-QL,ICS,ICS-QL.

Enanalysemultivariée,levolumerésiduelprostatiqueétaitleseulfacteurprédictifdel’IPSS.

Conclusion.—LesrésultatsfonctionnelsàlongtermesontmeilleursaprèsAVHqu’aprèsPVP.

Cependant, la PVPoffre de bonsrésultats, permettant de l’utiliser chez des patients sous anticoagulants,quelquesoitlevolumeprostatique.L’énucléationendoscopiquepeutêtrele compromisentrelesdeuxtechniques.

Niveaudepreuve.— 4.

Introduction

The increasing development of new laser technologies in benign prostaticobstruction (BPO) hasenabled tooffer a truealternativetostandardtreatment,eveninlargeade- nomas. Compared to open prostatectomy (OP), they aim toprovidesimilarfunctionaloutcome,whilereducingmor- bidity.Holmium laserenucleation (HoLEP)of theprostate hasshowninrandomizedcontrolledtrialstooffercompara- bleimmediateandlong-termresultstobothtransurethral resectionoftheprostate (TURP)[1]andOP[2,3],making

itapossible ﬁrstchoice treatmentregardless of prostatic volume[4].

Similarly,Greenlightlaserphotoselectivevaporizationof theprostate (PVP) hasproven tobea safe alternative to TURPinmenwithmoderateprostatevolumes,withequiv- alentlong-termresultsinarecentmulticenterprospective study[5].However,fewstudiesassessedPVPinhighprostate volumes,andevenfewercomparedfunctionalresultstoOP oranalyzedlong-termoutcomeinpatients.

This aimof this studywastocompare long-term func- tionaloutcomeofPVPusingthelatest180W-XPSGreenlight

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Table1 Baselinecharacteristicsoftreatedpatients.

OP n=54

PVP n=57

P-value Age(yr)

Mean(±SD) 74(±9) 77(±9) 0.09

Charlsonscore

Mean(±SD) 4(±1.7) 5(±2) 0.15

Prostaticvolume(cm³)

Mean(±SD) 142(±58) 103(±25) <0.001^*

Preoperativeanticoagulantuse n(%)

6(11) 22(39) 0.001^*

Preoperativeaspirinuse n(%)

8(15) 16(28) 0.11

Preoperativeurinaryretention n(%)

31(57) 39(68) 0.24

PreoperativePVR n(%)

19(42) 17(50) 0.50

PreoperativeIPSS Mean(±SD)

20(±7) 18(±6) 0.59

PreoperativeIPSS-QL

Mean(±SD) 4(±1) 4(±1) 0.82

PreoperativePSA

Mean(±SD) 10.1(±7.9) 7.3(±5.4) 0.09

IPSS:Internationalprostatesymptomscore;IPSS-QL:IPSS-qualityoflifescore;PSA:prostatespeciﬁcantigen;PVR:postvoidresidual.

* Statisticallysigniﬁcant.

lasercomparedtoOPinpatientswithlargeprostaticade- nomas.

Material and method

Datafrompatientswhounderwentsurgicaltreatmentatour institutionforBPO>80gfromJanuary2010toFebruary2015 wereretrospectivelycollected.Approval fromourinstitu- tionalethicscommitteewasobtainedforthisstudy(CECIC Rhône-Alpes-Auvergne,Grenoble,IRB5891).

Data assessment

Patientswere divided into 2 groups according to surgical technique(PVPorOP). The followingdatawerecollected in both groups: demographics, Charlson score, prostatic volume (PV) on ultrasound, anticoagulant use, preopera- tiveurinarystatus(IPSS,PSA,urinaryretention),surgeon’s experience, operative data (operative time, blood loss), perioperativefollow-up(transfusion,lengthofhospitalstay andurinarycatherization),early(<30d)anddelayed(>30d) adverseevents(AEs),long-termfunctionaloutcome.

EarlyAEsweregraded accordingtoClavien-Dindoclas- siﬁcationand divided intotwo categories: minor(Clavien grade I, II) and major (Clavien grade III, IV). Functional outcome on latest follow-up was assessed using IPSS and IPSS-QualityofLifescore(IPSS-QL)andcontinencewiththe International ContinenceSociety (ICS) malequestionnaire andICS-QualityofLife(ICS-QL).Whenlong-termIPSSandICS scoresweremissing,patientswerecontactedtocalculate

theirlatestscores.PSAlevelandresidualultrasonographic prostatevolumewerecollectedusingpostmail.

Technique

The type procedure (PVP or OP) wasdecidedindividually accordingtothesurgeon’sexperience,patient’spreference, Charlson score and anticoagulant use. OP consisted in a transvesical open enucleation of the prostatic adenoma.

PVP wasperformed usinga 180-WGreenLight XPS^TM laser (AmericanMedicalSystems^®).

Surgeon’swereconsideredexperiencedforthetechnique afterperforming>50PVP,accordingtoliterature[6,7].

Statistical analysis

Patients werecompared according tothe type of surgery they received. Continuous variables were reported using mean values with standard deviation (SD) and compared using the independent Mann-Whitney U-test. Categorical variables were reported as counts and proportions (%) and compared using the ␹² test or Fisher exact test as appropriate.

Multiple linear regression was performed to identify independent predictors of long-term IPSS and ICS scores.

Variables attaining P≤0.05 on univariate analysisor con- sideredclinicallyrelevantwereincludedinthemultivariate analysis.

StatisticalanalysiswasobtainedwithSPSS^®,version21.

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Table2 Operativeandperioperativeparameters.

OP n=54

PVP n=57

P-value

Operativetime(OT,min)

Mean(±SD) 69(±24) 73(±18) 0.16

Lasingtime(LT,min)

Mean(±SD) — 50(±14.8) —

LT/OTratio(%)

Mean(±SD) — 60(±26) —

Totalenergydelivered(kJ) Mean(±SD)

— 383(±150) —

Energyperprostatevolume(kJ/cm³) Mean

— 4(±1) —

Transfusionrate n(%)

6(11) 2(3) 0.02^*

NoofPRBCs Mean(±SD)

2(±2) 2(±0) 0.02^*

Lengthofcatheterization(d) Mean(±SD)

6(±2) 3(±4) <0.001^*

Recatherization n(%)

2(4) 10(18) 0.03^*

Urinaryincontinence n(%)

6(11) 14(25) 0.06

Lengthofhospitalstay(d)

Mean(±SD) 8(±2) 5(±5) <0.001^*

Rehospitalisation n(%)

1(2) 11(19) 0.004^*

EarlyAEs,n(%)

Minor(ClavienI,II) 13(24) 21(37) 0.16

Major(ClavienIII,IV) 4(7) 3(5) 0.71

Total 17(32) 24(42) 0.33

DelayedAEs,n(%)

Minor 7(13) 8(14) 1.00

Major 0(0) 3(5) 0.24

Total 7(13) 11(19) 0.44

LT:lasingtime;OT:operativetime;PRBCs:packedredbloodcells.

Results

Inthestudyperiod,111consecutivepatientsunderwentsur- gicaltreatmentforBPO>80g,including54OPand57PVP.

Baselinecharacteristics, operativeand immediatepostop- erativedataarelistedinTable1andTable2.

Demographics and immediate results

Patient’sage,Charlsonscoreandpreoperativeurinarystatus (IPSS,postvoidresidual,urinaryretentions)weresimilarin bothgroups(Table1).Meanprostaticvolumewassuperior intheOPgroup(142vs103g,P<0.001)whereasmorePVP patientsweretakinganticoagulants(11vs39%,P=0.001).

Operative time was similar between the 2 techniques (P=0.16,Table 2). Nopatients in thePVP grouprequired conversiontoTURP.MeanbloodlossafterOPwas574cm³. ComparedtoOP,PVPwasassociatedwithalowertransfusion rate(P=0.02),shorterlengthofhospitalstay(P<0.001)and urinarycatheterization (P<0.001), withhowever a higher

rateof unsuccessful voiding trials leading torecatheriza- tion (18% vs 4%, P=0.03, RR=4.74) and rehospitalization (19%vs1%,P=0.004,RR=10.42).Finally,earlyincontinence wasmorefrequentafterPVP,thoughthisdifferencewasnot signiﬁcant.

Early and delayed adverse events

Overall early AEs were similar in both groups (P=0.33, Table2),withmostlyminorcomplicationsClavienIorII.The mostfrequentearlycomplicationinOPpatientswasmacro- scopichematuriawithprolongedbladderirrigationwhereas itwaspostoperativeurinaryretentionneedingrecatheriza- tionin the PVP group (Table 3). Early reintervention was necessaryfor 4patientsin theOPgroup and3inthePVP group.ReasonsforreinterventionafterOPwere:2foruri- nary leakages,1 laparotomy for haemostasis in a patient withWaldenströmdiseasewhosuffereredcataclysmichem- orrhage and 1 evacuation of Retzius’s space hematoma.

AfterPVP,3patientsrequiredendoscopicclotremoval,one

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Table3 Earlyanddelayedadverseevents.

Adverseevents OP

(n=54)

PVP (n=57)

P-value

EarlyAEs(<1monthaftersurgery) Clavien-DindogradeI—II,n(%)

Isolatedfever 1(2) 0(0) 0.49

Bleeding 3(7) 0(0) 0.11

Urinaryclotremoval 5(9) 7(12) 0.76

Transfusion 12(23) 5(9) 0.04^*

Recatheterization 2(4) 10(18) 0.03^*

Urinarytractinfection 1(2) 5(9) 0.21

Other 1(2) 1(2) 1.00

Total 24(44) 28(49)

Clavien-DindogradeIII—IV,n(%)

Retzius’sspacehematoma 1(2) 0(0) 0.49

Reinterventionforurinaryleakage 2(4) 0(0) 0.38

Reinterventionforbleeding 1(2) 3(5) 0.61

Total 4(7) 3(5) 0.43

DelayedAEs(>1monthaftersurgery) Minor

Hematuria 2(4) 2(4) 1.00

Urinarytractinfection 2(4) 3(4) 1.00

Epididymitis 1(2) 0(0) 0.49

Urinaryretention 1(2) 3(5) 0.61

Other 1(2) 0(0) 0.49

Total 7(13) 8(14) 1.00

Major

Meatusstenosis 0(0) 1(2) 0.49

Urethralstricture 0(0) 1(2) 0.49

Endoscopicclotremoval 0(0) 1(2) 0.49

Total 0(0) 3(5) 0.24

associatedwith complementaryprostate resection.Those reinterventionswereneededon3patientsunderanticoag- ulantswholeftinitiallyhospitalandneededreadmissionat day5,8and9.

Similarly,overalldelayedAEs,occurringafter1monthof surgery,werecomparableinbothgroups(P=0.44),although 3majordelayedcomplicationsoccurredinPVPpatientsand none in the OP group. AEs encountered after PVP were:

1caseofhematurianeedingendoscopicclotremoval,1ure- thral stricture and 1 meatus stenosis leading toiterative dilations.

Finally,3patientsrequiredre-treatmentafterPVP(at1, 6and12months)andnoneafterOP.

Long-term outcome

Long-termfunctionaloutcomecouldbeassessedin42(78%) patientsintheOPgroupand43(75%)inthePVPgroup,with ameanfollow-upof35monthsand28monthsrespectively (Table4).

IPSSandIPSS-QLscoresshowedimprovementcompared tobaselineinbothgroups,althoughpreoperativeIPSSwas availableinalimitednumberofpatients.However,results werebetterafterOPthanafterPVPforIPSS(P<0.001),IPSS- QL(P=0.01),ICS(P=0.002)andICS-QL(P<0.001).

Long-termPSAandprostatevolumeonultrasoundwere lowerintheOPgroupcomparedtoPVP(1.5vs4.3ng/mL, P=0.001and30vs55cm³,P=0.001respectively).Theper- sistenceofpostvoidresidual(PVR)urinewassimilarinboth groups.

Predictors of long-term functional outcome

Onmultivariateanalysis,afteradjustingforinitialprostatic volume,Charlsonscore,surgeon’sexperience,surgicaltech- niqueandpreoperativeurinaryretention,residualprostatic volumewastheonlypredictoroflong-termIPSS(P=0.005, Table5).PreoperativeIPSSwasnotusedinthismodeldue themissingdatathatcouldskewtheresults.

Onthecontrary,Charlsonscorewastheonlypredictorof long-termICS,thoughitreachedstatisticallimit(P=0.05).

Surgicaltechnique,surgeon’sexperienceorresidualvolume did not appearto predict long-term continence (P=0.86, P=0.97andP=0.15respectively).

Discussion

We report here the ﬁrst study comparing long-term results of the latest 180W-XPS Greenlight system toopen

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Table4 Long-termfunctionalresults.

OPn=42 PVPn=43 P-value

Follow-up(month)—mean(±SD) 35(±19) 28(±12) —

IPSS—mean(±SD) 1(±2) 5(±5) <0.001^*

IPSS-QL—mean(±SD) 0(±1) 1(±1) 0.01^*

ICS—mean(±SD) 0(±1) 3(±6) 0.002^*

ICS-QL—mean(±SD) 0(±0) 1(±2) <0.001^*

Noofprotections—mean(±SD) 0(±0) 1(±1) 0.0004^*

PostoperativePVR—n(%) 3(9) 8(20) 0.20

PSA(ng/mL)—mean(±SD) 1.5(±1.0) 4.3(±2.8) 0.001^*

PSAreduction(%)—mean(±SD) 82(±12) 45(±36) 0.001^*

PV(cm³)—mean(±SD) 30(±8) 55(±25) 0.001^*

PVreduction(%)—mean(±SD) 74(±9) 47(±20) 0.001^*

ICS:Internationalcontinencesocietymalequestionnaire;ICS-QL:ICS-qualityoflifescore;IPSS:Internationalprostatesymptomscore;

IPSS-QL:IPSS-qualityoflifescore;PV:prostaticvolume;PVR:postvoidresidual.

Table5 Predictorsoflong-termIPSSandICSscoresonmultivariateanalysis.

Variable ␤ IC95% P-value

IPSS Initialprostaticvolume −0.27 −0.09;0.01 0.14

Charlsonscore 0.17 −0.34;0.98 0.32

Surgeon’sexperience −0.14 −4.50;1.94 0.41

Surgicaltechnique 0.30 −1.20;6.60 0.16

Preoperativeurinaryretention −0.62 −10.55;1.64 0.10

Prostaticresidualvolume 0.63 0.03;0.12 0.005^*

ICS Initialprostaticvolume −0.06 −0.07;0.06 0.77

Charlsonscore 0.41 −0.004;1.75 0.05^*

Surgeon’sexperience 0.17 −2.50;6.09 0.39

Surgicaltechnique 0.22 −2.99;7.42 0.38

Preoperativeurinaryretention −0.06 −6.57;5.23 0.83

Prostaticresidualvolume 0.32 −0.02;0.11 0.20

prostatectomy in patients needing surgery for BPO with volumesover80cm³.

In the era of robotic and minimally invasive surgery, openprostatectomy remains agoldstandard treatmentof largeprostaticadenomas.Lasertherapies areincreasingly expanding, aiming to reduce morbidity related to open surgery,whileobtainingthesamefunctionalresults.High- levelstudieshaveshownHoLEPtoachievebothgoals[2,3,8]

whichis sofar theonlylasertherapytoberecommended as possible 1st choice alternative according to European guidelines[4].Growingevidencesupportsthefeasibilityand safetyofGreenlightPVPinlargeprostates[9—13],though moststudieswereconductedusingoldersystems(80W-KTP and120W-HPS) anddatacomparinglong-term outcometo traditionalOPareverylimited.

PVP in large prostates: perioperative outcome

Thepresent studyshowedPVPinprostates>80cm³tobe feasibleandefﬁcient,leadingtoafastrecoveryforpatients.

NoconversionstoTURPwererequired,andoperatingtime

was not extended compared to OP. Alivizatos, who con- ductedtheonlyrandomizedtrialcomparingGreenlightPVP toopenprostatectomy,reportedsimilarresultsthoughoper- atingtimewaslongerwhenperformingaPVPcomparedto OP (80 vs 50min respectively) [10]. However, mean prostaticvolume,particularlyintheOPgroup,waslargerinour cohort(130cm³comparedto96 cm³ forAlivizatos)which couldexplainthisdifference.

The main beneﬁtsof PVPcompared toadenomectomy defended by supporters of this technique is the reduction of urinary catheterization time and hospital stay [5,10,14],leadingtoafasterreturntohealthstatus.Time to catheter removal and discharge after OP [10,15] and PVP [10,14], in this study, were comparable to current literature, and supports this premise as catheterization time was divided by 2 and hospital stay by 1.6. Yet, recatheterization and rehospitalization rates were also foundtobe drasticallyincreasedafterPVP (RR=4.74and RR=10.42respectively),whichwasrarelyreportedbyother authors, but could constitute a limit patient’s should be awareof.

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As to the reduction of perioperative morbidity compared to open surgery, transfusion rate after PVP was significantly lower, despite nearly 40% of patients taking anticoagulants,confirmingtheappeal of thistechniquein thissubgroupofpatients.Earlyanddelayedadverseevents were acceptable and mostly minor for both techniques accordingtoClavien-Dindoclassification.PVPdidnotshow toreduceoverallincidenceofAEscomparedtoOP,aswhat itgained intransfusionrates, it lost inurinary retentions andrecatheterization.

Long-term outcome

Long-termfollow-op showed PVPaswell as OPtohave a satisfyinglong-lasting outcome for patients withall func- tionalparametersimprovedfrombaseline inboth groups, althoughIPSSandICSscoresremainedstatisticallyinfavor ofOP. However,ameanIPSS of 5at 28 monthsafterPVP isveryacceptable.Inhisrecentmulticenterstudy,Hueber [12]alsoreportedameanIPSSof5at24monthsafterPVPin prostatesover80g.Inourcohort,themostfrequentsymp- tomsdescribedbypatientswerepersistentnocturiaanda certaindegreeof urgency.Yet,qualityof lifescoreswere excellentforbothtechniques.

Average prostatic residual volume on ultrasound was larger after PVP compared to OP, and could indicate an incomplete vaporization and a less optimal treatment in thesepatients.Meanenergydensitydeliveredwas4kJ/cm³, whichissimilartoHueber(3.8kJ/cm³)[12]andhigherthan Alivizatos(196kJ for an average volumeof 93 cm³) [10].

MisraiassessedthelearningcurveforPVP,andconcludeda meanenergydeliveredof5kJ/cm³wasnecessarytoachieve optimumvaporization[7],suggestingthatthough satisfac- tory,ourresultscanfurtherbeimproved.Moreover,larger postoperativevolumes afterPVP couldexplain thehigher recatheterizatonrate,anditispossibleoptimizingthetech- nique would reduce recatheterization as well asimprove long-termoutcome.

Indeed,onmultivariateanalysis,postoperativeprostatic volumewastheonlypredictoroflong-termIPSS.Thetype ofsurgery(PVPorOP)didnotrevealtopredictneitherlong- termIPSSnorICS.Thissuggeststhatthemorethoroughthe treatment, thebetter are functionalresults. On the con- trary,incomplete vaporizationmay lead toless favorable outcome. Hence, thekey point toa successfulsurgery in thelongrunistoobtainthecompleteremovaloftheade- noma, regardless of initial volume or surgical technique.

Thus,PVPcouldachievesimilarlong-termfunctionalresults toopenprostatectomyandbecomeaﬁrstchoicetreatment oflargeadenomas, providedvaporizationis completeand prostaticresidualvolumelefttoaminimum.Additionally, endoscopicenucleation may be the compromise between the2 techniques, byguaranteeinga complete removalof theadenoma,thusleadingtoequivalentlong-termresults thanOP,all-the-whileprovidingthesameadvantagesasPVP intermsofbloodloss.

Limitations

Themainlimitationofourstudyisitsretrospectivenonran- domizednature,withtherefore2populationsthatwerenot perfectlycomparable.Initialprostaticvolumeandantico-

agulant use were different, suggesting patients with high prostatic volumes were more likely to be offered open surgery,whereasPVPwaspreferredincaseofanelevated riskofbleeding.However,populationsweresimilarinterms ofageandCharlsonscoreandpreoperativeurinarystatus.

Giventheretrospectivedesignofthestudy,wewerenot abletoreportthepatientshavingcontinuedananticoagu- lanttherapyandthosewhohadinterruptedit.

Bladderendoscopicandultrasonographiccharacteristics werenotassessedsincenoendoscopicevaluationwasper- formed before open prostatectomy and data concerning endoscopicconstatationsonoperative reportswererarely available. This is a bias since it is known that this char- acteristics impactdeeply functionalresults. Furthermore, preoperative IPSS wasoftenmissing, makingit impossible toevaluateitapotentialpredictoroflong-termIPSS.

Finally, our mean energy delivered of 4kJ when using PVPisalittlebelowoptimumvalueanditis possiblethat an increase to5kJwould improvefunctional outcomefor patients.

IntheGoliathstudy,recoverydatasignifcantlyfavoured GreenLight System over TURP, thus greatly supporting GreenLight XPS for BPHtreatment duringshort-termstay.

Even though our study was notdesigned asa cost analysis,costadvantagemaybestillgreaterwhencomparedto OP.Estimatedonaday-casebasis,lasertherapywassignif- cantlymorecost-effectivethanTURPwitha25%reduction in procedural cost, lowerindirect costs, and lowerﬁnan- cialburdenbasedonefﬁcacyandadverse-eventoutcomes.

Wethinkthatonselectedpatients,daycase management ispossibleevenforlargeprostatesandisabletooffsetthe probe’scost.

Conclusion

PVP of large prostatic adenomas is safe and effective withsatisfyinglong-lasting functionalresults,althoughOP remainedsuperiorintermsoflong-termIPSSandICSscores.

However, the main predictor of postoperative IPSS is the remainingprostaticvolume,whichsurgeonsshouldbeaware of when performing a PVP in order to achieve a complete vaporization of the adenoma. Furthermore PVP is anattractivealternativeinpatientstakinganticoagulants, enablingtoofferasafeoptionregardlessofprostaticvol- ume.Endoscopicenucleationmaythecompromisebetween bothtechniques.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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