World J Urol DOI 10.1007/s00345-014-1437-8
INVITED REVIEW
Update on Greenlight laser vaporization (PVP) 2014 Malte Rieken · Alexander Bachmann
Received: 10 October 2014 / Accepted: 31 October 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To asses the (1) outcomes and (2) intraoperative, perioperative, and long-term complications of photoselective vaporization of the prostate (PVP) with Greenlight laser. Methods A systematic review of outcomes and complications of PVP was conducted. The article selection process was performed according to PRISMA guidelines and included publications published between 2009 and 2014. Results All generations of PVP (80, 120, 180 W) lead to a significant improvement of micturition symptoms (IPSS, QoL) and voiding parameters (Q max, PVR volume) during follow-up. Data on sexual function are heterogeneous and suggest a trend toward decline in erectile function in men with sustained preoperative erection. The rate of intraoperative complications is low. Data on peri- and postoperative complications show a large variation that mainly can be attributed to heterogeneity in documentation. Conclusions PVP leads to a statistically significant and clinically relevant improvement of voiding parameters and micturition symptoms in patients with prostates 6 months) of PVP in RCTs Study
Number of patients Laser type (W) Urethral stricture n Bladder neck (%) Clavien–Dindo contracture n (%) Clavien–Dindo grade grade
Adenoma regrowth Urinary incontinence n (%) n (%) Clavien– Clavien–Dindo Dindo grade grade
Bouchier-Hayes [6] Elshal [8, 9]
PVP: 59 M-TURP: 50 PVP: 52 HOLAP: 57 PVP: 60 M-TURP: 57 PVP: 60 M-TURP:60 PVP: 10 M-TURP: 10 PVP: 50 M-TURP: 50 PVP: 50 M-TURP: 50 B-TURP
Mohanty [7] Al-Ansari [15] Pereira-Correia [17] Capitán [16] Kumar [19]
Lukacs [18]
PVP: 69 M-TURP: 70
80
0
0
6 (10.2), °3
0
80
4 (7.7), °3
5 (9.6), °3
4 (7.7), °3
2 (3.8), °2
80
1 (1.7), °3
1 (1.7), °3
0
NA
120
0
4 (7.4), °3
6 (11), °3
0
120
NA
NA
NA
NA
120
0
0
1 (2), °2
120
2 (4), °2 1 (2), °3 1 (1.7)
1 (1.7)
NA
NA
120
NA
NA
NA
NA
unlikely that these data will be provided in the near future. In that context, cohort studies seem largely insufficient to provide high-quality data as lost to follow-up is high. Second, in the period of literature research, no novel high-quality data on the safety and efficacy of PVP in comparison with open prostatectomy in patients with larger (>100 ml) prostates were published. Thus, high-level evidence on PVP in patients with large prostates is missing. Third, it has to be noticed that while the assessment of effectiveness of PVP seems standardized by questionnaires and measurable data, documentation of complications needs further improvement. Although the Clavien–Dindo Classification of complications may not seem perfectly suitable for the grading of complications in endourology, investigators should be encouraged to adhere to this classification. The comparative evaluation of surgical techniques is largely depending on the quality of data on complications. Thus, it is crucial that complications are not only documented but also graded according to the measures that had to be taken for resolution. Strict adherence will improve the quality of future clinical trials and ultimately the quality of treatment we are providing for our patients.
Conclusions Based on the evidence provided by several randomized studies, all generations of PVP (80 W, 120 W, 180 W) lead to a significant improvement of voiding parameters and symptoms. The rate of intra- and perioperative complications appears low.
13
The reoperation rate seems comparable to TURP, with limitations in trials with longer follow-up. More evidence is needed to support the use of PVP in patients with large prostates. Conflict of interest M. Rieken: No conflict of interest. A. Bachmann: Principal investigator of the GOLIATH study, which was sponsored by American Medical Systems (AMS), is advisor for AMS, and receives honoraria for presentations. Ethical standard All human studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
References 1. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, N’Dow J, Nordling J, de la Rosette JJ (2013) EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including Benign prostatic obstruction. Eur Urol 64(1):118–140 2. Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, McVary K, Novara G, Woo H, Madersbacher S (2014) A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from Benign prostatic obstruction: an update. Eur Urol. doi:10.1016/j.eururo.2014.06.017 3. Rieken M, Bachmann A (2014) Laser treatment of benign prostate enlargement—which laser for which prostate? Nat Rev Urol 11(3):142–152 4. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17(1):1–12
World J Urol 5. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213 6. Bouchier-Hayes DM, Van Appledorn S, Bugeja P, Crowe H, Challacombe B, Costello AJ (2010) A randomized trial of photoselective vaporization of the prostate using the 80 W potassiumtitanyl-phosphate laser vs transurethral prostatectomy, with a 1-year follow-up. BJU Int 105(7):964–969 7. Mohanty NK, Vasudeva P, Kumar A, Prakash S, Jain M, Arora RP (2012) Photoselective vaporization of prostate vs. transurethral resection of prostate: a prospective, randomized study with one year follow-up. IJU 28(3):307–312 8. Elshal AM, Elmansy HM, Elhilali MM (2013) Two laser ablation techniques for a prostate less than 60 ml: lessons learned 70 months after a randomized controlled trial. Urology 82(2):416–422 9. Elzayat EA, Al-Mandil MS, Khalaf I, Elhilali MM (2009) Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results of a prospective randomized trial. J Urol 182(1):133–138 10. Hai MA (2009) Photoselective vaporization of prostate: five year outcomes of entire clinic patient population. Urology 73(4):807–810 11. Malde S, Rajagopalan A, Patel N, Simoes A, Choi W, Shrotri N (2012) Potassium-titanyl-phosphate laser photoselective vaporization for benign prostatic hyperplasia: 5-year follow-up from a district general hospital. J Endourol 26(7):878–883 12. Kim HS, Cho MC, Ku JH, Kim SW, Paick JS (2010) The efficacy and safety of photoselective vaporization of the prostate with a potassium-titanyl-phosphate laser for symptomatic benign prostatic hyperplasia according to prostate size: 2-year surgical outcomes. Korean J Urol 51(5):330–336 13. Kumar A, Vasudeva P, Kumar N, Nanda B, Mohanty NK (2012) Evaluation of the effect of photoselective vaporization of the prostate on sexual function in a prospective study: a single center experience of 150 patients. J Endourol [Epub ahead of print] 14. Bruyere F, Puichaud A, Pereira H, Faivre d’Arcier B, Rouanet A, Floc’h AP, Bodin T, Brichart N (2010) Influence of photoselective vaporization of the prostate on sexual function: results of a prospective analysis of 149 patients with long-term follow-up. Eur Urol 58(2):207–211 15. Al-Ansari A, Younes N, Sampige VP, Al-Rumaihi K, Ghafouri A, Gul T, Shokeir AA (2010) GreenLight HPS 120 W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. Eur Urol 58(3):349–355 16. Capitan C, Blazquez C, Martin MD, Hernandez V, de la Pena E, Llorente C (2011) GreenLight HPS 120 W laser vaporization versus transurethral resection of the prostate for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia: a randomized clinical trial with 2-year follow-up. Eur Urol 60(4):734–739 17. Pereira-Correia JA, de Moraes Sousa KD, Santos JB, de Morais Perpetuo D, Lopes-da-Silva LF, Krambeck RL, Muller VJ, Vaz FP (2012) GreenLight HPS 120 W laser vaporization vs
transurethral resection of the prostate (
INVITED REVIEW
Update on Greenlight laser vaporization (PVP) 2014 Malte Rieken · Alexander Bachmann
Received: 10 October 2014 / Accepted: 31 October 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To asses the (1) outcomes and (2) intraoperative, perioperative, and long-term complications of photoselective vaporization of the prostate (PVP) with Greenlight laser. Methods A systematic review of outcomes and complications of PVP was conducted. The article selection process was performed according to PRISMA guidelines and included publications published between 2009 and 2014. Results All generations of PVP (80, 120, 180 W) lead to a significant improvement of micturition symptoms (IPSS, QoL) and voiding parameters (Q max, PVR volume) during follow-up. Data on sexual function are heterogeneous and suggest a trend toward decline in erectile function in men with sustained preoperative erection. The rate of intraoperative complications is low. Data on peri- and postoperative complications show a large variation that mainly can be attributed to heterogeneity in documentation. Conclusions PVP leads to a statistically significant and clinically relevant improvement of voiding parameters and micturition symptoms in patients with prostates 6 months) of PVP in RCTs Study
Number of patients Laser type (W) Urethral stricture n Bladder neck (%) Clavien–Dindo contracture n (%) Clavien–Dindo grade grade
Adenoma regrowth Urinary incontinence n (%) n (%) Clavien– Clavien–Dindo Dindo grade grade
Bouchier-Hayes [6] Elshal [8, 9]
PVP: 59 M-TURP: 50 PVP: 52 HOLAP: 57 PVP: 60 M-TURP: 57 PVP: 60 M-TURP:60 PVP: 10 M-TURP: 10 PVP: 50 M-TURP: 50 PVP: 50 M-TURP: 50 B-TURP
Mohanty [7] Al-Ansari [15] Pereira-Correia [17] Capitán [16] Kumar [19]
Lukacs [18]
PVP: 69 M-TURP: 70
80
0
0
6 (10.2), °3
0
80
4 (7.7), °3
5 (9.6), °3
4 (7.7), °3
2 (3.8), °2
80
1 (1.7), °3
1 (1.7), °3
0
NA
120
0
4 (7.4), °3
6 (11), °3
0
120
NA
NA
NA
NA
120
0
0
1 (2), °2
120
2 (4), °2 1 (2), °3 1 (1.7)
1 (1.7)
NA
NA
120
NA
NA
NA
NA
unlikely that these data will be provided in the near future. In that context, cohort studies seem largely insufficient to provide high-quality data as lost to follow-up is high. Second, in the period of literature research, no novel high-quality data on the safety and efficacy of PVP in comparison with open prostatectomy in patients with larger (>100 ml) prostates were published. Thus, high-level evidence on PVP in patients with large prostates is missing. Third, it has to be noticed that while the assessment of effectiveness of PVP seems standardized by questionnaires and measurable data, documentation of complications needs further improvement. Although the Clavien–Dindo Classification of complications may not seem perfectly suitable for the grading of complications in endourology, investigators should be encouraged to adhere to this classification. The comparative evaluation of surgical techniques is largely depending on the quality of data on complications. Thus, it is crucial that complications are not only documented but also graded according to the measures that had to be taken for resolution. Strict adherence will improve the quality of future clinical trials and ultimately the quality of treatment we are providing for our patients.
Conclusions Based on the evidence provided by several randomized studies, all generations of PVP (80 W, 120 W, 180 W) lead to a significant improvement of voiding parameters and symptoms. The rate of intra- and perioperative complications appears low.
13
The reoperation rate seems comparable to TURP, with limitations in trials with longer follow-up. More evidence is needed to support the use of PVP in patients with large prostates. Conflict of interest M. Rieken: No conflict of interest. A. Bachmann: Principal investigator of the GOLIATH study, which was sponsored by American Medical Systems (AMS), is advisor for AMS, and receives honoraria for presentations. Ethical standard All human studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
References 1. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, N’Dow J, Nordling J, de la Rosette JJ (2013) EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including Benign prostatic obstruction. Eur Urol 64(1):118–140 2. Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, McVary K, Novara G, Woo H, Madersbacher S (2014) A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from Benign prostatic obstruction: an update. Eur Urol. doi:10.1016/j.eururo.2014.06.017 3. Rieken M, Bachmann A (2014) Laser treatment of benign prostate enlargement—which laser for which prostate? Nat Rev Urol 11(3):142–152 4. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17(1):1–12
World J Urol 5. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213 6. Bouchier-Hayes DM, Van Appledorn S, Bugeja P, Crowe H, Challacombe B, Costello AJ (2010) A randomized trial of photoselective vaporization of the prostate using the 80 W potassiumtitanyl-phosphate laser vs transurethral prostatectomy, with a 1-year follow-up. BJU Int 105(7):964–969 7. Mohanty NK, Vasudeva P, Kumar A, Prakash S, Jain M, Arora RP (2012) Photoselective vaporization of prostate vs. transurethral resection of prostate: a prospective, randomized study with one year follow-up. IJU 28(3):307–312 8. Elshal AM, Elmansy HM, Elhilali MM (2013) Two laser ablation techniques for a prostate less than 60 ml: lessons learned 70 months after a randomized controlled trial. Urology 82(2):416–422 9. Elzayat EA, Al-Mandil MS, Khalaf I, Elhilali MM (2009) Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results of a prospective randomized trial. J Urol 182(1):133–138 10. Hai MA (2009) Photoselective vaporization of prostate: five year outcomes of entire clinic patient population. Urology 73(4):807–810 11. Malde S, Rajagopalan A, Patel N, Simoes A, Choi W, Shrotri N (2012) Potassium-titanyl-phosphate laser photoselective vaporization for benign prostatic hyperplasia: 5-year follow-up from a district general hospital. J Endourol 26(7):878–883 12. Kim HS, Cho MC, Ku JH, Kim SW, Paick JS (2010) The efficacy and safety of photoselective vaporization of the prostate with a potassium-titanyl-phosphate laser for symptomatic benign prostatic hyperplasia according to prostate size: 2-year surgical outcomes. Korean J Urol 51(5):330–336 13. Kumar A, Vasudeva P, Kumar N, Nanda B, Mohanty NK (2012) Evaluation of the effect of photoselective vaporization of the prostate on sexual function in a prospective study: a single center experience of 150 patients. J Endourol [Epub ahead of print] 14. Bruyere F, Puichaud A, Pereira H, Faivre d’Arcier B, Rouanet A, Floc’h AP, Bodin T, Brichart N (2010) Influence of photoselective vaporization of the prostate on sexual function: results of a prospective analysis of 149 patients with long-term follow-up. Eur Urol 58(2):207–211 15. Al-Ansari A, Younes N, Sampige VP, Al-Rumaihi K, Ghafouri A, Gul T, Shokeir AA (2010) GreenLight HPS 120 W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. Eur Urol 58(3):349–355 16. Capitan C, Blazquez C, Martin MD, Hernandez V, de la Pena E, Llorente C (2011) GreenLight HPS 120 W laser vaporization versus transurethral resection of the prostate for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia: a randomized clinical trial with 2-year follow-up. Eur Urol 60(4):734–739 17. Pereira-Correia JA, de Moraes Sousa KD, Santos JB, de Morais Perpetuo D, Lopes-da-Silva LF, Krambeck RL, Muller VJ, Vaz FP (2012) GreenLight HPS 120 W laser vaporization vs
transurethral resection of the prostate (
