From Focused Residency Training to Attending Practice: A Junior Attending's Experience with Greenlight Laser Enucleation of the Prostate (GreenLEP) on Large Prostates (>80cc)
Michael E. Rezaee, MD1, Christopher D. Ortengren, MD1, Alan Yaghoubian, MD2, Michael T. Grant, MD1.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: GreenLEP is a relatively new endoscopic technique for the treatment of symptomatic benign prostatic hyperplasia. The procedure consists of transurethral en-bloc excision of the transitional zone of the prostate gland using a combination of mechanical dissection with a rigid scope and the Greenlight laser. Advanced endoscopic enucleation procedures such as GreenLEP and Holmium laser enucleation of the prostate (HoLEP) can be viewed as minimally invasive alternatives to open or robotic assisted simple prostatectomy for the treatment of large glands (>80cc). Over the past two decades widespread adoption of HoLEP has been hampered by a significant learning curve and the procedure is disproportionally utilized by urologists with exposure in fellowship training or who learned the procedure after years of experience with transurethral resection. There is limited data suggesting GreenLEP may have a softer learning curve than HoLEP but little is known about patient and procedural outcomes associated with GreenLEP on large prostates (>80cc) after structured mentorship in residency training and the transition to attending practice
METHODS: A retrospective cohort study of patients with prostates >80cc who underwent GreenLEP with a single attending surgeon after structured mentorship during residency training (6 months in chief year, 18 cases) was conducted at two academic institutions between November 2017 and January 2020. Paired t-test was used to assess differences in International Prostate Symptom Score (IPSS), Quality of Life (QOL) due to urinary symptoms, and post void residual (PVR) 1 month after GreenLEP. Multiple linear regression was used to identify predictors of operative time. Generalized estimating equations were used to estimate the post procedural odds of stress urinary incontinence (SUI) as a logistic function of time and covariates.
RESULTS: A total of 73 patients were included with an average age of 68.9 years and estimated prostate volume of 147.8 cc (79-365cc, SD 53.5). Overall, patients who underwent GreenLEP experienced significant reductions in IPSS (22.4 vs. 6.4, p <0.001), QOL (4.5 vs. 1.4, p<0.001) and PVR (442.5 vs. 54.4 cc, p<0.001) at 1 month. An increasing number of cases performed was associated with decreasing operative time (β -0.76, p<0.001, Figure 1), while larger estimated prostate volume was positively associated with increasing operative time (β 0.56, p<0.001). Post procedural SUI was 15.3% at 1 month, and declined to 4.3% and 1.4% at 3 and 6 months, respectively. Age was the only variable associated with transient SUI (p=.04)
CONCLUSIONS: GreenLEP is a safe and effective surgical technique for prostates >80cc that can be successfully performed as a junior attending after structured mentorship during chief year. Significant improvements in IPPS, QOL, and PVR can be achieved 1 month after GreenLEP, while post procedural SUI is approximately 1.4% at 6 months. 
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