Step-by-step anatomical photovaporization of the prostate using 180-W XPS greenlight laser: optimizing functional outcomes through energy modulation

BACKGROUND: The surgical management of patients with benign prostatic hyperplasia (BPH) has considerably evolved through recent years. Nonetheless, benefits and harms of several laser procedures are still to be determined. The study aimed to report perioperative and early functional results of patients treated with anatomical photo vaporization of the prostate (aPVP). METHODS: Data from consecutive patients treated with aPVP by using a 180-W XPS GreenLight laser were prospectively collected in a single tertiary center between 2020 and 2023. The surgical procedure was divided into a modular step-by-step fashion. Patients were asked to complete self-administered questionnaires at baseline and during follow-up visits. RESULTS: Overall, 176 consecutive patients were enrolled. Median age was 65 [interquartile range (IQR) 63-72] years. The baseline median prostate volume was 61.2 (IQR 52.5-71.0) mL, and the median max flow rate (Qmax) was 9.3 (IQR 7.8-11.5) mL/s. Median preoperative International Prostate Symptom Score (IPSS) was 25 (IQR 22-29). Overall, the median operative time was 42 (IQR 31-47) minutes with a median energy/mL of tissue delivered of 2447 kJ/mL. At 3 month-evaluation, significant improvements were observed, with a median Qmax of 28 (IQR: 24-32) mL/s and a median IPSS reduction of 15 (IQR: 11-18) points. A strong inverse correlation was identified between energy delivery during initial procedural steps and the severity of postoperative storage symptoms (all p < 0.05), underscoring the importance of precise energy modulation. Multivariate analysis identified increased prostate volume (odds ratio [OR]: 1.02; 95% confidence interval [CI] 1.01-1.11; p = 0.001) and higher prostate width-to-length ratio (OR: 1.28; 95% CI 1.04-1.78; p = 0.03) as independent predictors of increased energy requirements. CONCLUSIONS: aPVP with 180-W XPS GreenLight laser is a safe and effective technique showing worthy early functional results. The limitation of the energy delivered in some key phases of the procedure may be associated with a significant reduction in postoperative irritative symptoms. The shape and dimensions of the prostate also play a critical role in determining the total energy required for complete adenoma removal.