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180 W XPS GreenLight laser vaporization of the prostate in high surgical risk patients: 48-month safety and efficacy results for patients with ASA score of 3 or greater
Naren Nimmagadda, MD, Bo Wu, MD, Mahdi Zangi, MD, MPH, Shahin Tabatabaei, MD.
Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: The objective of this study was to compare the safety, efficacy and durability of 180 W XPS GreenLight photoselective vaporization of the prostate (PVP) in high surgical risk patients relative to those with lower risk. Current studies evaluating surgical risk and PVP are limited by smaller cohorts and/or older, low power lasers. The GOLIATH trial established PVP using the 180 W laser as comparable to TURP, however, patients’ surgical risk was not included, limiting its validity in deciding who should undergo PVP.
METHODS: All patients who underwent PVP for uncomplicated lower urinary tract symptoms (LUTs) secondary to benign prostatic hypertrophy (BPH) between 2010 and 2014 by a single surgeon at a tertiary referral center were retrospectively reviewed. 496 patients were identified and stratified according to their American Society of Anesthesiologists (ASA) score; 34.3% of patients were classified as “high risk” (ASA score of 3 or greater) and 65.7% of patients were classified as “low risk” (ASA score less than 3).
RESULTS: “High risk” patients were significantly older at baseline and a significantly higher percentage was anticoagulated; no other significant differences in baseline characteristics were noted. The mean age of the cohort was 70.7 years with a mean preoperative prostate volume of 83.4 mL and mean postoperative follow-up time of 17.5 months. There were no significant differences in procedural time, lasing time or laser energy delivered between the surgical risk groups (mean 48.3 ± 33.7 min, 30.8 ± 20.9 min and 251.9 ± 186.3 KJ, respectively). On multivariate analysis, only prostate volume of 80 mL or greater influenced hospital lengths of stay while both prostate volume and the presence of a urinary catheter at the time of surgery impacted duration of catheterization. Significant improvements in Qmax, PVR, IPSS and QoL were seen after PVP in both surgical risk groups relative to baseline at all follow-up time points. "High risk" status was a significant determinant only in postoperative improvement in Qmax at a mean follow-up of 17.5 months and Clavien grade 1 complications within 1 month. No differences were seen in the occurrence of Clavien grade 2 and 3 complications during the follow-up period in either surgical risk group nor were there any Clavien grade 4 or 5 complications in the 1 month period after surgery. The overall rate of operative reintervention was 4.44%.
CONCLUSIONS: PVP using the 180 W system is well tolerated in high surgical risk patients and efforts should be made to perform a comprehensive vaporization. This is evidenced by comparable procedure times, lasing time and laser energy delivered and absence of any significant difference in major postoperative complications. Preoperative prostate volume and presence of a urinary catheter at the time of surgery are better predictors of the immediate postoperative outcomes of duration of hospital stay and catheterization. High surgical risk patients benefit significantly from PVP as suggested by similar functional outcomes to patients with less medical comorbidities in up to 48 months of follow-up. Surgical risk classification alone should not be used to bar patients from PVP.
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