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Laser Photoselective Vaporization and En-bloc Enucleation of Prostate with Morcellation: The First U.S. Experience
Kai Li, MD, Mahdi Zangi, MD, MPH, Bo Wu, MD, Shahin Tabatabaei, MD.
Massachusetts General Hospital, Boston, MA, USA.

Introduction:
Optimal endoscopic management of prostates greater than 80g in size is unclear. Holmium laser enucleation of prostate (HoLEP) is the most well-studied laser enucleation technique with encouraging short and long-term outcomes. The procedure however has a steep learning curve and has not been widely adopted by Urologists. We introduce laser photoselective vaporization and enucleation of prostate (PVEP) with prostate morcellation as an alternative to HoLEP, with improved reproducibility and versatility. PVEP differs from HoLEP in that the green light laser has better hemostatic properties than holmium laser in prostate tissue. There is improved preservation of tissue plans and the ability to combine vaporization with enucleation allows for more versatility. The side firing mechanism improves ergonomics and tissue handling. In this first U.S. case series, we introduce our surgical technique of en bloc Green light enucleation and morcellation along with short-term results.
Methods:
Data from 40 patients who underwent PVEP from 9/2014 to 2/2016 was analyzed retrospectively. Median age of patients was 71.5±8.08. 32.5% of patients had ASA score ≥ 3. 37.5% of patients were on aspirin, 5% on coumadin, and 5% on plavix. Median prostate size was 174.6 ±105.9 (67 to 570 ml). Mean preoperative IPSS was 23±9.3.
Surgical Technique: 26 Fr Wolf™ resectoscope is used to locate ureteral orifices, verumontanum, and rhabdosphincter. The prostate apical mucosa is incised with laser vaporization anteriorly and carried posteriorly bilaterally. Mucosal incisions are made lateral to the verumontanum and is extended distally until it meets the apical incision. We start enucleation using blunt dissection with the resectoscope sheath. Dissection in the proper plane is ensured with easy separation along the glossy surgical capsule. Dissection is carried out circumferentially around each lobe from distal to proximal until reaching the bladder neck. Attachments are freed along the way with vaporization as necessary. Hemostasis is achieved with laser coagulation. Once the prostate is freed from all attachments circumferentially, it is pushed into the bladder. We used Wolf Piranha™ morcellator to morcellate the prostate adenoma inside the bladder.
Results:
Median energy: 106.1 KJ; procedure time: 154 min ±55.1; estimated blood loss: 34 cc ±29.3. There were no intra-operative complications including capsular perforation, bladder wall injury, ureteral orifice injury. Hospital stay: 1.93 days ±1.72 (60% of patients stayed only one night). Post-operative complications included early clot retention (7.5%) and early temporary stress incontinence (10%). There was no incidence of urethral stricture or delayed/prolonged hematuria. In 2 months, median IPSS improved from 23 to 5, quality of life from 3 to 1, post void residual from 100 mL to 25 mL, and max flow rate from 6.85 mL/sec to 22.8 mL/sec (p<0.01).
Conclusions:
PVEP is a promising endoscopic management option for large prostates. PVEP was successfully used in prostate sizes up to 570g with low hospital stays and morbidity along with early improvement in IPSS and high patient satisfaction. Further studies are necessary to confirm the results of this study


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