Page 479 - Read Online

Campobasso et al. Mini-invasive Surg 2021;5:45 https://dx.doi.org/10.20517/2574-1225.2021.92 Page 7 of 9

underwent greenlight PVP with a median follow-up of 6 months, and the authors reported a re-treatment
[8]
rate of 1.5% and an incidence of bladder neck contracture of 1.93% in 569 patients at 5-year follow-up , in
line with our results. Unfortunately, in all cited articles, the authors performed only a descriptive analysis,
without analyzing risk factors for treatment failure. In our database analysis, apart from a descriptive
analysis of results, we analyzed the possible risk factors of treatment failure after greenlight PVP. In the
univariate and multivariate logistic regression models, three factors correlated with re-intervention:
preoperative urethral stricture (P = 0.013 and P = 0.036), incidence of early complications (P = 0.008 and P =
0.024), and prostate volume ≥ 100 mL (P = 0.003 and P = 0.010) [Table 4]. The correlation between the
incidence of early complications (burning urination, urgency, and urinary retention) and the risk of re-
treatment due to LUTS relapse may correlate with inefficacious vaporization due to inadequate adenoma
removal with excess energy absorption by the prostatic tissue, a factor which might have an inflammatory
and irritating effect. Obviously, this is a hypothesis not confirmed by our data in this analysis. In fact,
operative and lasing time as well as PSA changing at 12 months are similar in the two groups (P = 0.778, P =
0.978, and P = 0.674, respectively). However, in a recent paper of our group, where we analyzed risk factors
of postoperative acute urinary retention after greenlight laser procedures, lower lasing time, adenoma
volume < 40 mL, IPSS ≥ 19, and 5 alpha-reductase inhibitors (5-ARI) assumption were associated with a
higher risk of postoperative acute urinary retention, implying that an inefficacious vaporization and an
inflammatory component may play a role .
[18]
A further evaluation is necessary for patients with prostate volume ≥ 100 mL. In a recent analysis of ours
regarding functional results in patients with large prostate volume, the re-intervention rate in the ≥ 100 mL
group was 3.5% vs. 2.3% in the group with prostate volume < 100 mL with a mean follow-up of 25.0 months
[10]
(IQR: 16.5-35.0 months) . In the literature, the re-intervention rate of patients undergoing greenlight PVP
for large prostate volume is reported as 15.2% by Laine-Caroff (with a median follow-up of 54 months) ,
[19]
[20]
[21]
13.2% by Meskawi et al. , 6% for 200 mL prostate and 9% for 100-200 mL in a multi-institutional series ,
2.9% , 1.2% , and no re-treatment at 12 months reported by Altay et al. . In these papers, larger prostate
[24]
[23]
[22]
[23]
[20]
volume, low energy density, and a lower PSA reduction at 6 months after surgery or low energy density
are reported as risk factors for treatment failure.
Despite the good functional results associated with low morbidity, in these vaporization series, a large
prostate is a consideration which should be made concerning the enucleation technique. In a recent
nationwide database, including 58,346 patients (38,308 TURP and 20,038 HoLEP), the authors reported a
higher reoperation rate in the TURP group (4.50%) than in the HoLEP group (1.27%) (P < 0.01) with mean
follow-up durations of 51.6 and 47.6 months, respectively .
[25]
These data are in line with a randomized trial comparing greenlight PVP vs. B-TURP vs. HoLEP in large
prostate (80-150 mL), with 3 years of follow-up and a re-treatment rate of 6.7%, 9.7%, and 0%,
respectively . The authors postulated that pure enucleation may guarantee longer functional results than
[26]
[27]
vaporization or resection techniques. The experience in GreenLEP reported by Ferrari et al. with a study
population of 120 patients, a median prostate volume of 98.5 mL (IQR: 83.0-130.0 mL), and a median
follow-up of 18 months seems to go in this direction, with no reoperation. Obviously, more studies are
needed to confirm this finding.

Some limitations are present in our study, the first being the retrospective nature and the participation of 20
centers. An additional issue to be taken into consideration is the absence of enucleation procedures.
Nevertheless, the follow-up period is one of the longest in the literature. In our experience, the re-treatment
rate of 1.4% and the 2.6% rate of bladder neck contracture requiring endoscopic revision after a median of