Changing Paradigms: Green Laser Vaporization for Prostates over 80 mL: A Comparative Study

Introduction and Objectives: Benign prostatic enlargement (BPE) and big prostates are common. Photovaporization of the prostate (PVP) with Greenlight™ laser 180 W XPS is considered a reliable therapy for prostates <80 mL and an alternative for the treatment of bigger ones in selected cases. The aim of this study is to evaluate efficacy, safety, and functional outcomes of PVP among patients with prostates over and under 80 mL. Materials and Methods: After protocol approbation by our Institutional Ethics Committee, a cohort of 840 patients with BPE who underwent PVP with Greenlight laser between 2012 and 2019 in a single center was evaluated. Groups were stratified according to prostate volume, to less and greater than 80 mL (Groups 1 and 2, respectively). The primary outcomes were efficacy [prostate-specific antigen (PSA) drop, improvement of International Prostatic Symptom Score (IPSS), and quality of life] and variables regarding safety of the procedure. Peri-and postoperative outcomes were analyzed. Complications were assessed according to Clavien-Dindo classification. Overall patient satisfaction was evaluated with visual analog scale. Results: Preoperative variables showed no statistical difference among groups. Mean follow-up was 47 [interquartile range; IQR = 26-70] months. Longer operative time and a higher energy use was seen in bigger prostates (p < 0.001). Efficacy was similar between groups, with a reduction of ≥4 points in IPSS score in 83.1% and 89.5% in Groups 1 and 2 (p = 0.053), PSA drop was 1 ± 2.6 and 1.7 ± 4.7 (p = 0.32). Group 2 had a higher conversion rate (0.3% vs 4.9%, p < 0.001) and higher blood transfusion rate (0% vs 2.4%, p < 0.001). There were no differences in hospital stay, catheterization time, urethral stricture, or re-treatment rates. Conclusions: GreenLight PVP is a safe and effective procedure in prostates ≥80 mL. It shows the same advantages demonstrated for those under that volume, particularly short hospital stay and catheterization time. Surgeon's experience is important to avoid complications, such as conversion and transfusion. PVP should be considered a first-line alternative for the treatment of bigger prostates.