Benign prostatic hyperplasia (BPH) is one of the most common conditions treated by urologists. As the surgical management of BPH has evolved, there is increasing demand for less invasive and more definitive treatment options. Endoscopic prostate enucleation has gained popularity due to its favorable risk profile and ability to treat a wide range of prostate sizes including large glands traditionally managed with open or laparoscopic surgery, sometimes on an outpatient basis. Various enucleation techniques have been described including holmium laser enucleation of the prostate (HoLEP) as well as similar approaches using Greenlight laser (GreenLEP) and thulium laser (ThuLEP), among others.

Unfortunately, steep learning curves for these techniques have limited adoption by many urologists who often favor transurethral resection (TURP) or photoselective vaporization (PVP). Excluding enucleation procedures, GreenLight PVP is the most commonly performed laser prostate procedure in the US, and most urologists coming out of training are comfortable with the platform. With this being considered, we feel GreenLEP to be relatively easier to teach to urologists who are not experienced with enucleation, particularly if they use GreenLight in their practice already. We recently described a simplified GreenLEP technique which allowed for a lobe-by-lobe approach to learning enucleation.

In this series, we present our experience with 108 patients using this technique. Primary outcomes were urinary flow rate (uroflow) and PVR. Secondary outcomes included international prostate symptom score (IPSS) and PSA change. These outcomes were measured up to three years with a mean follow up of 10.2 months. At three months, statistically significant improvements were noted in max flow rate (237%), average flow (227%) and these changes remained durable through two years. Statistically significant improvements were also noted at 3 months in international prostate symptom score (IPSS, -64%), post-void residual (-83%) and PSA change (-77%). Rates of adverse events and complications were comparable to other published enucleation studies.

Overall, our simplified GreenLEP technique showed favorable results with an acceptable adverse event and complication profile. Our experience in teaching this technique to over 50 urologists leads us to believe it is more easily adopted than other methods, particularly for those who are experienced with GreenLight. Further investigation is needed with large scale randomized studies comparing specific enucleation techniques against one another and against TURP in order to determine optimal treatment modalities.

Written by: Petar Bajic, MD, Rush University Medical Center, Chicago, Illinois, Twitter: @PBajicMD and Edward Karpman, MD, Co-Medical Director, Men’s Health Program, El Camino Hospital, Mountain View, California, Twitter: @EKarpmanMD

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