Photoselective Vaporisation of the Prostate Using 80-W and 120

EUROPEAN UROLOGY 62 (2012) 315–323
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Review – Benign Prostatic Obstruction
Photoselective Vaporisation of the Prostate Using 80-W and
120-W Laser Versus Transurethral Resection of the Prostate
for Benign Prostatic Hyperplasia: A Systematic Review with
Meta-Analysis from 2002 to 2012
Isaac A. Thangasamy a, Venu Chalasani b, Alexander Bachmann c, Henry H. Woo d,*
a
c
Department of Surgery, Hornsby Ku-Ring-Gai Hospital, Sydney, Australia;
b
NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia;
d
Department of Urology, University of Basel, Basel, Switzerland; Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, Australia
Article info
Abstract
Article history:
Accepted April 24, 2012
Published online ahead of
print on May 4, 2012
Context: Photoselective vaporisation (PVP) of the prostate is being used increasingly
to treat symptomatic benign prostatic hyperplasia, due to the associated lower
morbidity. Holmium laser enucleation of the prostate was considered to be the
treatment with the highest evidence; however, evidence for PVP has dramatically
increased recently.
Objective: To conduct a systematic review and meta-analysis of level 1 evidence studies
to determine the effectiveness of PVP versus transurethral resection of the prostate
(TURP) for surgical treatment of benign prostatic hyperplasia. Outcomes reviewed
included perioperative data, complications, and functional outcomes.
Evidence acquisition: Biomedical databases from 2002 to 2012 and American Urological
Association and European Association of Urology conference proceedings from 2007 to
2011 were searched. Trials were included if they were randomised controlled trials, had
PVP as the intervention, and TURP as control. Meta-analysis was performed using a
random effects model.
Evidence synthesis: Nine trials were identified with 448 patients undergoing PVP (80 W
in five trials and 120 W in four trials) and 441 undergoing TURP. Catheterisation time
and length of stay were shorter in the PVP group by 1.91 d (95% confidence interval [CI],
1.47–2.35; p < 0.00001) and 2.13 d (95% CI, 1.78–2.48; p < 0.00001), respectively.
Operation time was shorter in the TURP group by 19.64 min (95% CI, 9.05–30.23;
p = 0.0003). Blood transfusion was significantly less likely in the PVP group (risk ratio:
0.16; 95% CI, 0.05–0.53; p = 0.003). There were no significant differences between PVP
and TURP when comparing other complications. Regarding functional outcomes, six
studies found no difference between PVP and TURP, two favoured TURP, and one
favoured PVP.
Conclusions: Perioperative outcomes of catheterisation time and length of hospital stay
were shorter with PVP, whereas operative time was longer with PVP. Postoperative
complications of blood transfusion and clot retention were significantly less likely with
PVP; no difference was noted in other complications. Overall, no difference was noted in
intermediate-term functional outcomes.
# 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords:
Benign prostatic hyperplasia
GreenLight
Laser therapy
Meta-analysis
Photoselective vaporisation
Prostatectomy
Randomised
Transurethral resection of
prostate
PVP
TURP
* Corresponding author. Sydney Adventist Hospital Clinical School, Suite 406, 185 Fox Valley Road,
Wahroonga, NSW, 2076, Australia. Tel. +61 2 9473 8765; Fax: +61 2 9473 8969.
E-mail address: [email protected] (H.H. Woo).
0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.eururo.2012.04.051
316
1.
EUROPEAN UROLOGY 62 (2012) 315–323
Introduction
Lower urinary tract symptoms (LUTs) in men are commonly
due to bladder outflow obstruction secondary to benign
prostatic hyperplasia (BPH) [1]. By the end of the seventh
decade, nearly 60% of the Baltimore Longitudinal Study of
Aging cohort had some degree of clinical BPH [2], and with
the aging male population, it can be expected to increase
[3]. Long-term complications of untreated bladder outflow
obstruction include detrusor failure, renal failure, recurrent
urinary tract infections, urinary retention, bladder diverticula, and bladder stones [4]. The most widely performed
surgical treatment for patients with moderate to severe
LUTS secondary to BPH has been transurethral resection of
the prostate (TURP). Recent guidelines also support the use
of TURP for the treatment of BPH [5,6]. However, there is
still significant morbidity associated with TURP, and the
retreatment rate after 5 yr is between 3% and 14% [7].
Photoselective vaporisation of the prostate (PVP) is a
side-firing laser prostatectomy and has been commercially
available for the last 10 yr, in the form of an 80-W laser
initially, then a 120-W laser, and currently a 180-W laser.
The technique has been refined during these 10 yr as the
technology has improved. The 532-nm wavelength laser
passes through a fluid medium and is absorbed by
haemoglobin, leading to better coagulation during vaporisation [8]. PVP has already been shown to be an efficient
and safe alternative to TURP in anticoagulated patients
[9,10]. It has no risks of transurethral resection (TUR)
syndrome because the irrigation used is saline rather than
glycine. The ablative and coagulative characteristics of
PVP are at a virtual optimum. PVP presents several
potential advantages over TURP including reduced bleeding, absence of TUR syndrome, and shorter duration of
hospitalisation [9–12] due to its safety profile. Thus PVP
offers the promise of a minimally invasive alternative to
standard care whilst providing similar efficacy with reduced
risk of complications.
There have been nine randomised controlled trials
(RCTs) of PVP compared with TURP, the current standard
of care [13–21]. To date there have been six reviews of
randomised data [22–27]; however, these have not included all of the recently published data. The objective of this
analytic study was to conduct a systematic review and
meta-analysis of level 1 evidence studies to determine the
safety and efficacy of PVP versus TURP for surgical
treatment of LUTS secondary to BPH. Outcomes reviewed
included perioperative data, short- and long-term complications, and functional outcomes.
2.
Evidence acquisition
2.1.
Study criteria
All randomised controlled studies of patients treated
surgically for symptomatic LUTS using PVP and TURP were
included in this systematic review. A minimum follow-up of
6 mo was required for the control (TURP) and interventional
arm (PVP). The intervention studied was PVP, which
was performed with either an 80-W laser or a 120-W
laser. Due to the absence of sufficient RCTs and direct
comparative studies between 80-W and 120-W lasers,
these were considered to be similar interventions, and
results were combined as such. Studies that used a hybrid
laser technique (eg, both side-firing and end-firing lasers)
or experimental laser <80 W in the intervention arm were
excluded.
2.2.
Search strategy
RCTs were identified by searching the electronic databases
of EMBASE, Medline, and the Cochrane Central Register of
Controlled Trials (2002 to February 2012). There were no
language restrictions. The medical subject headings and
keywords used for the Medline search included, but were
not limited to, prostatectomy, transurethral resection of the
prostate, laser surgery, photoselective vaporisation, and
GreenLight. The search strategy was modified as required
for each electronic database. Attempts were made to
identify unpublished trials by searching the annual conference proceedings of the American Urological Association
and the European Association of Urology for the last 5 yr
(2007–2011). In addition, the reference lists of selected
articles were checked for any additional studies.
2.3.
Selection of trials, data extraction, and methodological
quality assessment
Trials were selected based on meeting the prespecified
inclusion criteria. Abstracts identified were deemed eligible
after independent review by two authors. The full-text
article was retrieved for any trial that appeared to meet the
inclusion criteria. Data were independently extracted by
two reviewers and entered into an Excel spreadsheet
according to the prespecified outcome measures. Authors of
all trials were contacted to obtain missing data. Authors
who responded are listed in the acknowledgements section.
An assessment of methodological quality was made
according to the Jadad scale. This scale assesses the criteria
of randomisation, sequence generation, blinding, withdrawals, and dropouts [28].
2.4.
Outcome measures
The outcomes assessed included perioperative variables
and both efficacy and safety measures. The perioperative
variables assessed were operative time, catheterisation
time, and duration of hospitalisation. Safety outcome
measures assessed were blood transfusions, TUR syndrome,
clot retention, urinary retention, infection, macroscopic
bleeding, unplanned readmission, unplanned reoperation,
and bladder neck contracture or meatal stenosis or urethral
stricture. For efficacy, the outcomes assessed were maximum flow rates (Qmax), symptom scores (International
Prostate Symptom Score [IPSS]), and postvoid residual
volume (PVR). These outcome measures were analysed at
12-mo follow-up and compared with baseline data.
EUROPEAN UROLOGY 62 (2012) 315–323
2.5.
Statistical analysis
Statistical analysis was performed using RevMan v.5.1.4.
Where possible, meta-analysis was performed to generate
summary statistics. For continuous outcomes, the weighted
mean difference was calculated, along with the 95%
confidence interval (CI) and p value. For binary outcomes,
a summary risk ratio (RR) and its 95% CI were calculated.
Statistical significance was defined as p < 0.05. A random
effects model was used because significant heterogeneity
was expected. Trial heterogeneity was assessed by visual
inspection of forest plots, and statistical heterogeneity
was assessed by chi-square tests and the I2 statistic. Due
to inconsistent data reporting, meta-analysis was not
possible for all studies, especially when analysing functional
outcomes.
3.
Evidence synthesis
Nine trials, with a total of 889 patients, were included in this
systematic review (Fig. 1). Table 1 summarises the
characteristics of the included studies. The median sample
size was 100 patients (range: 20–155). The duration of
follow-up varied from 6 to 36 mo. The technology used
317
for PVP included both the 80-W laser (five trials) and the
120-W laser (four trials). No RCT utilising the recently
launched XPS laser setting was found in the literature search.
Two trials included only patients with larger prostates
[20,21].
Formal critical appraisal using the Jadad scores (Table 2)
suggested that the risk of bias was low in four studies,
moderate in two studies, and high in three studies.
3.1.
Perioperative outcomes
Perioperative outcomes are summarised in Table 3. Operative time was shorter in the TURP group by 19.64 min (95%
CI, 9.05–30.23; p = 0.0003) for all included studies;
however, catheterisation time and length of hospital stay
were shorter in the PVP group, for all included studies, by
1.91 d (95% CI, 1.47–2.35; p < 0.00001) and 2.13 d (95% CI,
1.78–2.48; p < 0.00001), respectively.
3.2.
Postoperative complications
Table 4 lists the postoperative complications analysed. In
the PVP groups, there was no incidence of TUR syndrome,
and only one patient required a blood transfusion (RR: 0.16;
[(Fig._1)TD$IG]
Fig. 1 – Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram. AUA = American Urological Association; EAU = European
Association of Urology; RCT = randomised controlled trial.
318
EUROPEAN UROLOGY 62 (2012) 315–323
Table 1 – Characteristics of included studies
Author
n
Laser
Mean prostate volume, ml (SD)
PVP
Al-Ansari et al. [16]
Bouchier-Hayes et al. [17]
Capitán et al. [15]
Horasanli et al. [20]
Lukacs et al. [13]
Pereira-Correia et al. [14]
Sarica and Altay [21]
Schwartz et al. [18]
Skolarikos et al. [19]
120
119
100
76
139
20
60
100
155
120
80
120
80
120
120
80
80
80
W
W
W
W
W
W
W
W
W
61.8
38.8
51.3
86.1
50.5
43.4
89.1
32.0
NR
Follow-up, mo
TURP
(22.0)
(NR)
(14.7)
(8.8)
(16.5)
(NR)
(4.0)
(NR)
60.3
33.4
53.1
88.0
50.1
47.0
91.8
36.0
NR
(20.0)
(NR)
(13.8)
(9.2)
(14.8)
(NR)
(3.6)
(NR)
36
12
24
6
12
24
12
11
12
NR = not reported.
Table 2 – Jadad score
Author
Al-Ansari et al. [16]
Bouchier-Hayes et al. [17]
Capitán et al. [15]
Horasanli et al. [20]
Lukacs et al. [13]
Pereira-Correia et al. [14]
Sarica and Altay [21]
Schwartz et al. [18]
Skolarikos et al. [19]
Study
design
Design
of RCT
Adequate sequence
generation
Blinding
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
NR
Equivalence
NR
NR
Noninferiority
NR
NR
NR
NR
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
Yes
No
Withdrawals and
dropouts described
Overall Jadad
score
Yes
Yes
Yes
No
Yes
No
No
No
No
3
3
3
1
3
2
1
2
1
NR = not reported.
Table 3 – Perioperative outcomes
Outcome
Operation time, min
Catheterisation time, d
Length of hospital stay, d
PVP, n
TURP, n
259
303
253
Mean difference
T
252
293
243
19.64
1.91 P
2.13 P
95% CI
p value
9.05–30.23
1.47–2.35
1.78–2.48
0.0003
<0.00001
<0.00001
PVP = photoselective vaporisation of the prostate; TURP = transurethral resection of the prostate.
Favours TURP.
P
Favours PVP.
T
Table 4 – Postoperative complications
Outcome
Blood transfusion
TUR syndrome
Clot retention
Urinary retention
Infection
Macroscopic haematuria
Unplanned readmission
Unplanned reoperation
Meatal stenosis, or urethral stricture, or bladder neck contracture
TUR = transurethral resection.
Effect estimate <1 favours photoselective vaporisation of the prostate.
*
p value = 0.003.
y
p value = 0.0003.
No. of
studies
7
4
2
4
3
4
3
6
5
No. of
participants
716
405
229
421
312
455
345
651
492
No. of events
PVP
TURP
1
0
3
13
11
16
9
25
14
25
6
23
13
11
28
16
12
20
Effect of estimate risk
ratio (95% CI)
0.16
0.20
0.14
0.88
1.00
0.72
0.55
1.87
0.65
(0.05–0.53)*
(0.03–1.14)
(0.05–0.40)y
(0.30–2.56)
(0.25–4.02
(0.23–2.25)
(0.25–1.24
(0.65–5.39)
(0.33–1.31)
319
EUROPEAN UROLOGY 62 (2012) 315–323
[(Fig._2)TD$IG]
Fig. 2 – Blood transfusions. CI = confidence interval; M-H = Mantel-Haenszel [test]; PVP = photoselective vaporisation of the prostate; TURP = transurethral
resection of the prostate.
[(Fig._3)TD$IG]
PVP
Study or Subgroup
TURP
Mean Difference
Mean [ml/s] SD [ml/s] Total Mean [ml/s] SD [ml/s] Total Weight
Bouchier-Hayes 2010
Capitan 2011
Skolarikos 2008
Mean Difference
IV, Random, 95% CI [ml/s]
18.6
8.2
46
19.37
8.67
39
25.3%
–0.77 [-4.38, 2.84]
22.53
7.96
50
22.55
7.93
50
29.3%
–0.02 [-3.13, 3.09]
18.3
5.78
80
15.42
3.68
75
45.3%
2.88 [1.36, 4.40]
164 100.0%
1.10 [–1.38, 3.59]
Total (95% CI)
176
Heterogeneity: Tau² = 2.94; Chi² = 5.17, df = 2 (p = 0.08); I² = 61%
IV, Random, 95% CI [ml/s]
–20
Test for overall effect: Z = 0.87 (p = 0.38)
–10
0
10
20
Favours TURP Favours PVP
Fig. 3 – Maximum flow rate. CI = confidence interval; PVP = photoselective vaporisation of the prostate; SD = standard deviation; TURP = transurethral
resection of the prostate.
95% CI, 0.05–0.53; p = 0.003) (Fig. 2). Furthermore, fewer
patients experienced clot retention in the PVP group (RR:
0.14; 95% CI, 0.05–0.40; p = 0.0003). No differences were
noted in urinary retention, infection, macroscopic haematuria, unplanned readmissions, unplanned reoperations, or
the composite end point of meatal stenosis or urethral
stricture or bladder neck contracture.
and 4). Sufficient data were not available to conduct a metaanalysis on PVR data. Overall, seven of nine studies found no
differences in urinary flow rates (Qmax) and symptom scores
(IPSS) at final follow-up; two studies favoured TURP (Table
5a and 5b). One study showed a significantly lower PVR in
the PVP group at final follow-up (Table 5c).
3.4.
3.3.
Discussion
Functional outcomes
Because not all studies reported 12-mo data sufficiently to
perform a meta-analysis, only three studies were included;
no differences were noted in Qmax and IPSS scores (Figs. 3
Meta-analysis of the randomised data evaluating PVP versus
TURP found that PVP has a more desirable perioperative
profile. Length of catheterisation was markedly shorter in
the PVP group. Hospital stay was also shorter following PVP.
[(Fig._4)TD$IG]
PVP
Study or Subgroup
Mean
TURP
SD Total Mean
Mean Difference
SD Total Weight
Bouchier-Hayes 2010
8.86
46 10.91
9.38
39
5.7%
–2.05 [–5.72, 1.62]
Capitan 2011
8.11 4.07
50
4.03
50
30.5%
–0.50 [–2.09, 1.09]
Skolarikos 2008
9.32 4.07
80
10 2.828
75
63.8%
–0.68 [–1.78, 0.42]
164 100.0%
– 0.70 [–1.58, 0.17]
Total (95% CI)
7.6
176
8.61
Heterogeneity: Tau² = 0.00; Chi² = 0.58, df = 2 ( p = 0.75); I² = 0%
Test for overall effect: Z = 1.57 (p = 0.12)
Mean Difference
IV, Random, 95% CI
IV, Random, 95% CI
–10
–5
0
5
10
Favours PVP Favours TURP
Fig. 4 – International Prostate Symptom Score. CI = confidence interval; PVP = photoselective vaporisation of the prostate; SD = standard deviation;
TURP = transurethral resection of the prostate.
320
EUROPEAN UROLOGY 62 (2012) 315–323
Table 5 – Systematic review of functional outcomes: (a) maximum flow rate; (b) International Prostate Symptom Score; (c) postvoiding
residual volume
a.
Author
Follow-up, mo
Mean QMax, ml/s
PVP
Al-Ansari et al. [16]
Bouchier-Hayes et al. [17]
Capitán et al. [15]
Horasanli et al. [20]
Lukacs et al. [13]
Pereira-Correia et al. [14]
Sarica and Altay [21]
Schwartz et al. [18]
Skolarikos et al. [19]
36
12
24
6
12
24
12
11
12
TURP
p
Baseline
F/U
Baseline
F/U
6.9
8.8
8.0
8.6
7.8
10.0
17.2
18.6
18.9
13.3
16.7
20.5
6.4
8.9
3.9
9.2
7.8
6.4
19.9
19.4
22.0
20.7
16.8
18.6
19.0
18.3
9.3
NR
NR
9.3
NR
NR
22.0
15.4
NS
0.49
0.66
0.02T
0.71
0.38
ST
NS
0.12
b.
Author
Follow-up, mo
Mean IPSS score
PVP
Baseline
Al-Ansari et al. [16]
Bouchier-Hayes et al. [17]
Capitán et al. [15]
Horasanli et al. [20]
Lukacs et al. [13]*
Pereira-Correia et al. [14]
Sarica and Altay [21]
Schwartz et al. [18]
Skolarikos et al. [19]
36
12
24
6
12
24
12
11
12
TURP
F/U
27
25
24
19
22
22
Baseline
11
8
8
13
6
7
28
25
23
20
20
25
5
9
21
NR
NR
19
NR
p
F/U
9
10
8
6
5
6
NR
4
10
NS
0.12
0.48
0.01T
0.49
0.70
ST
NS
0.34
c.
Author
Follow-up, mo
Mean PVR volume, ml
PVP
Al-Ansari et al. [16]
Bouchier-Hayes et al. [17]
Capitán et al. [15]
Horasanli et al. [20]
Lukacs et al. [13]
Pereira-Correia et al. [14]
Sarica and Altay [21]
Schwartz et al. [18]
Skolarikos et al. [19]
36
12
24
6
12
24
12
11
12
TURP
p
Baseline
F/U
Baseline
F/U
53.2
129.2
11.0
22.3
57.0
111.3
10.0
17.9
78.9
0.0
4.0
176.9
75.0
177.0
20.0
27.0
120.0
NR
NR
183.0
89.5
150.0
NR
NR
120.0
NR
22.9
7.0
6.0
NR
20.0
50.4
NS
0.24
NR
0.01T
0.75
0.81
NR
NS
0.03P
F/U = follow-up; IPSS = International Prostate Symptom Score; PVP = photoselective vaporisation of the prostate; PVR = postvoid residual; NR = not reported;
NS = Not significant (p value not reported); TURP = transurethral resection of the prostate.
T
= Favours TURP.
P
= Favours PVP.
T
S = Statistically significant in favour of TURP (p value not reported).
* Reported as median not mean.
The economic advantages of a shorter hospital stay should be
evaluated in conjunction with the longer operative time and
overall costs of the laser. Operation time was almost 20 min
longer in the PVP group. This is likely to shorten with
increased experience and confidence in the manual handling
of the technology.
PVP was shown to have a better safety profile. TUR
syndrome is completely removed from the list of complications of PVP because the fluid medium used is saline
rather than glycine. Patients in the PVP group were 84% less
likely to require blood transfusion in the immediate
postoperative period. Fewer incidents of clot retention
were reported in the PVP group. A potential advantage of
PVP over TURP is the ability to undergo surgery despite
anticoagulation or antiplatelet agents due to the substantially lower risk of bleeding [8–10,12]. This can be
attributed to the coagulative properties of the 532-nm
laser. At a cellular level, laser energy is delivered through
saline and absorbed by haemoglobin inside prostatic
tissue. The rapid heating of intracellular water allows
EUROPEAN UROLOGY 62 (2012) 315–323
photothermal vaporisation. Due to the short optical penetration of the 532-nm beam, laser power is confined to a
superficial layer of prostatic tissue [29]. In terms of urinary
retention, infection, macroscopic haematuria, unplanned
readmission, unplanned reoperation, or the composite end
point of meatal stenosis or urethral stricture or bladder neck
contracture, no differences were noted between PVP and
TURP at 12-mo follow-up.
Only three studies were able to be included in the metaanalysis of functional outcomes, which demonstrated no
significant difference between the two interventions at
12 mo. Seven RCTs reported no statistically significant
difference in functional outcomes between PVP and TURP at
final follow-up [13–19]. However, these studies do show an
improvement within each treatment arm in terms of Qmax
and IPSS. One study showed a statistically significant lower
PVR in the PVP group; however, this is of minimal or no
clinical significance (27.0 ml with PVP vs 50.4 ml with
TURP). Average prostate volume in these studies ranged
from 32 ml to 60 ml.
Two RCTs report a significant difference in functional
outcomes in favour of TURP at final follow-up [20,21].
Horasanli et al. and Sarica and Altay both reported
significantly inferior Qmax, IPSS, and PVRs following PVP
[20,21]. It must be noted that these two studies assessed
PVP versus TURP in larger prostates, >70 ml and 80 g,
respectively, and utilised the 80-W laser. Horasanli et al.
reported that the prostate volume reduction was significantly lower in the PVP group. Reoperation rate within
6 mo of PVP was 17.9% [20]. It has been suggested that lack
of experience and proper technique led to poor outcomes in
the Horasanli et al. study [30]. However, the level of
training and experience with PVP amongst operators in this
study is unknown. Although there have been case series
reporting favourable outcomes following PVP on much
larger glands (>100 ml) [31–33], no randomised data exist
for PVP versus TURP for larger prostates.
The rapidly developing nature of the technology has
meant that most of the evidence regarding efficiency and
morbidity has come from short- to midterm prospective
nonrandomised studies [10,11,34–42]. The laser fibre was
initially commercialised as an 80-W laser, was subsequently
improved to the 120-W laser, and then to the current laser at
180 W. These improvements have led to reduced operating
times due to increased vaporisation with the higher powered
devices. There have been systematic reviews of TURP versus
alternative minimally invasive techniques; however, these
reviews do not include most of the recently published RCTs
comparing commercially available PVP and TURP in their
analysis [22–27]. All have suggested that PVP is a promising
alternative to TURP but have stated the need for further
research including multicentre randomised trials. This metaanalysis combines data from nine recent RCTs and has shown
that PVP is a reasonable alternative to TURP with regard to
short-term perioperative outcomes. There is a clear reduction
in perioperative morbidity and complications when PVP is
utilised compared with TURP. Further long-term follow-up
(such as 5-yr follow-up data) is needed for functional
outcomes.
321
It is prudent to consider the cost effectiveness of new and
developing surgical therapies. Using a Markov model to
consider future care pathways, it has been shown that
transurethral vaporisation of the prostate is less costly than
TURP [43]. This is further supported by the demonstrated
decrease in hospital stay. However, further cost analysis is
required, taking into account associated morbidity, followup requirements, PVP training costs, and utility function.
Only then can a meaningful conclusion regarding economic
benefits and their impact on health budgets be made.
This study is limited by the paucity of long-term data,
heterogeneity of available data, and the lack of randomised
trials for the currently available 180-W laser. Data reporting
was inconsistent and hence data pooling was not always
possible, especially for reporting functional outcomes. All
authors were contacted and requested to provide nonpublished data to facilitate greater and more in-depth
meta-analysis. Only one author provided extra data that
limited meta-analysis, especially for functional outcomes.
Follow-up beyond 1 yr had a high attrition rate, and
adequate analysis of follow-up after 12 mo was not
possible due to small sample sizes. Only two studies
blinded study personnel. Variable surgical experience with
laser technology of the surgeons participating in the
studies also had an impact on some outcomes. Separate
data analysis of the 80-W and 120-W laser was difficult due
to the paucity of available data. Hence despite the wellknown shortcomings and subsequent improvements to the
laser, these have been considered as a similar intervention
for the purpose of meta-analysis. To overcome these
deficiencies in the literature, further multicentre randomised studies must be carried out with sound methodology
and long-term follow-up. More studies are also required to
determine the effect of variations in power settings and
laser wavelength on outcomes.
4.
Conclusions
We have identified nine randomised trials utilising the 80-W
or 120-W laser that compared PVP with TURP. Perioperative
outcomes of catheterisation time and length of hospital stay
were shorter with PVP; operative time was longer with PVP.
Postoperative complications of blood transfusion and clot
retention were significantly less likely with PVP, and no
difference was noted in the complications of urinary
retention, infection, bleeding, unplanned readmission, unplanned reoperation, or TUR syndrome. No difference was
noted in the intermediate term with regard to functional
outcomes, although heterogeneous reporting of results
limited formal meta-analysis for functional outcomes. The
study is limited by heterogeneous reporting of data, lack of
data for the 180-W laser, and a high attrition rate beyond 1-yr
follow-up.
Author contributions: Henry H. Woo had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Thangasamy, Chalasani, Woo.
Acquisition of data: Thangasamy, Chalasani, Woo.
322
EUROPEAN UROLOGY 62 (2012) 315–323
Analysis and interpretation of data: Thangasamy, Chalasani, Woo.
Drafting of the manuscript: Thangasamy, Chalasani, Bachmann, Woo.
Critical revision of the manuscript for important intellectual content:
Thangasamy, Chalasani, Bachmann, Woo.
[12] Ruszat R, Wyler S, Forster, et al. Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing
oral anticoagulation. Eur Urol 2007;51:1031–41.
[13] Lukacs B, Loeffler J, Bruyere F, et al. Photoselective vaporization of
Statistical analysis: Chalasani.
the prostate with GreenLight 120-W laser compared with mono-
Obtaining funding: None.
polar transurethral resection of the prostate: a multicentre ran-
Administrative, technical, or material support: Chalasani, Woo.
Supervision: Woo.
Other (specify): None.
domized controlled trial. Eur Urol 2012;61:1165–73.
[14] Pereira-Correia JA, de Moraes Sousa KD, Santos JB, et al. GreenLight
HPSTM 120-W laser vaporization vs transurethral resection of the
prostate (<60 mL): a 2-year randomized double-blind prospective
Financial disclosures: Henry H. Woo certifies that all conflicts of interest,
including specific financial interests and relationships and affiliations
relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents filed,
received, or pending), are the following: Alexander Bachmann and Henry
H. Woo are advisory board members of American Medical Systems. The
other authors have nothing to disclose.
Funding/Support and role of the sponsor: None.
urodynamic investigation. Br J Urol. In press. http://dx.doi.org/
10.1111/j.1464-410X.2011.10878.x.
[15] Capitán C, Blázquez C, Martin MD, Hernández V, de la Peña E,
Llorente C. GreenLight HPS 120-W laser vaporization versus transurethral resection of the prostate for the treatment of lower
urinary tract symptoms due to benign prostatic hyperplasia: a
randomized clinical trial with 2-year follow-up. Eur Urol 2011;60:
734–49.
[16] Al-Ansari A, Younes N, Sampige VP. GreenLight HPS 120-W laser
vaporization versus transurethral resection of the prostate for
Acknowledgement statement: The authors thank Dr. Carlos Capitán,
Department of Urology, Hospital Universitario Fundacion Alcorcon,
Universidad Rey Juan Carlos, Madrid, Spain, for contributing additional
data for analysis.
treatment of benign prostatic hyperplasia: a randomized clinical
trial with midterm follow-up. Eur Urol 2010;58:349–55.
[17] Bouchier-Hayes DM, Van Appledorn S, Bugeja P, Crowe H,
Challacombe B, Costello AJ. A randomized trial of photoselective
vaporization of the prostate using the 80-W potassium-titanyl-
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