Green Laser Enucleation of the Prostate “En bloc Technique”: Surgical Technique and Initial Experience

Abstract

Introduction and Objectives: Green laser “en bloc” enucleation of the prostate (GreenLEP) is an alternative enucleation technique for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. All endoscopic enucleation of the prostate procedures require significant endoscopic surgical skills and have a steep learning curve. The aim of this study is to demonstrate the GreenLEP surgical technique step-by-step and report our initial experience. Material and Methods: We report our single surgeon's (E.R.) initial experience with this novel technique. Thirty patients underwent GreenLEP between July 2015 and March 2016 in our institution with prostate volumes between 60 and 140 cc. All patients were evaluated preoperatively and after surgery (at 1, 3, and 6 months) by prostate-specific antigen, prostate volume, International Prostate Symptom Score, quality-of-life score, maximum flow rate, and postvoid residual urine volume, and all the complications were recorded. The surgery was performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180W device; American Medical Systems, Minnetonka, MN), 2090 side-fire laser fiber at the following power settings: 80W for cutting, 25W for coagulation, and a Piranha™ morcellation system (Richard Wolf GmbH, Germany) using single-use blade. Results: The mean operative time was 64 minutes (range: 55–95 minutes) and the mean amount of retrieved prostate tissue was 70 g (range 40–120 g). There was no need for blood transfusion. Capsular perforation occurred in four cases. We did not have any case of bladder injuries related to the morcellation procedure. The postoperative catheterization time (same as hospital stay) was 48 hours, except in two cases: one of incomplete morcellation because of bleeding and required an endoscopic second look (morcellation for residual adenoma), and the other required open surgery conversion for removal of the enucleated adenoma (poor vision because of venous bleeding caused by surgical perforation of the capsule during enucleation). Transient urinary incontinence was present in three cases and was completely resolved in 2 months. Three months later, all the parameters evaluated preoperatively showed significant improvement. Conclusions: GreenLEP appears to be a safe alternative enucleation technique for the complete removal of en bloc adenomatous prostate tissue. Regardless of gland size, it is particularly advantageous for the treatment of large prostates (not recommended for small glands). Endoscopic laser enucleation of the prostate is feasible with a side-firing fiber. This technique is probably easier to learn in a progressive pathway, that is, vaporization, vapoenucleation, and finally enucleation. These promising results warrant further studies to assess long-term outcomes. No competing financial interests exist. Runtime of video: 10 mins