European Urology

Benign Prostatic Hyperplasia

Urology, and probably general surgery, is being overwhelmed by new technologies. These new technologies gain momentum in part due to the patients themselves. Internet access and frequent publication in newspapers for the general public about new surgical instruments prompt patients to request the use of these new techniques by their surgeons. Sometimes these techniques significantly improve surgical results, but most often, these techniques are used before significant results are published.

Transurethral resection of the prostate (TURP) is an old technique that has been proven, yet the threat exists that it will be supplanted by new technologies. The situation is the same for open prostatectomy, which remains the gold standard for surgical treatment of large adenomas of the prostate.

The laser emerged in the early 1990s in the treatment of lower urinary tract symptoms, with initial mixed results [1]. Gradually, the laser sources have improved, and the GreenLight laser (AMS, Minnetonka, MN, USA) has been one of the first to show promising results.

It is with enthusiasm that we started using this technique with very satisfactory results, including less morbidity than TURP and reduced hospital stays.

In our work with cardiovascular disease patients on anticoagulants, the laser completely supplanted TURP. Anaesthesiologists are now pushing us to use laser techniques on these patients, and that is the reason that we have many patients with high American Society of Anaesthesiologists scores in our study. Reading other published studies, we expect to refine the indications, and we have a track record with the results of our study.

Although patients with normal erectile function who require surgical treatment of benign prostatic hyperplasia are not the majority, we will continue to use the GreenLight laser, with a caveat for patients with completely normal sexual function.

Given our results regarding functional urinary symptoms and complications associated with this technique, we will continue more than ever to use the GreenLight laser on patients taking anticoagulants or those with large prostates and comorbidities.

In this issue, Dr. Reich, one of the leaders of GreenLight use in the world, wrote an editorial regarding our study [2]. He has published many studies about the GreenLight laser and has never showed erectile dysfunction after photoselective vaporization of the prostate (PVP) [3], and [4]. We agree with Dr. Reich that the definition of erectile function is unclear. The use of the five-item version of the International Index of Erectile Function (IIEF) has the merit of being simple, rapid, and noninvasive [5]. This score can thus be compared between centres and between countries because it has been validated in several languages. Alas, only taking into account the IIEF or open questions does not reflect the status of ejaculation.

Finally, with the results of this study, we are able to refine the best indications for prostate GreenLight laser treatment, giving arguments to the practitioner who is pushed by his or her anaesthesia team or by the patient himself to use this technique.

The number of indications for PVP with the GreenLight laser may decrease only slightly because it is increasingly essential for patients in our practice with drug-eluting stents or those taking antiplatelet aggregation therapy.

Despite the apparent ease of movement, PVP has a steep learning curve, and we need a larger population and a study powerful enough to clarify the impact of this technology on erectile function. The surgeon who performed all of the PVP procedures did a fellowship in one of the major departments involved in GreenLight use in the world [6], and [7]; we can guess that the impact of PVP at the beginning of the learning curve would be greater.

As addressed by Dr. Damiano and Dr. Autorino, we used one of the highest energy levels published [8]. We initially thought that the higher the energy we used, the better the functional results we would have. It was a mistake. As published recently, with lower energy levels, the postoperative flow rate can be satisfactory [7]. Nevertheless, we wait for longer follow-up to confirm that low energy uses are enough to remove enough prostate tissue to have long-term good results. Hermanns et al did not give any demonstration about tissue damage and laser fibre deterioration but showed that loss of power output during PVP was significant [9]. We do not agree with Dr. Damiano about the correlation between erectile dysfunction and energy used. We were not able to show any significant difference with different energy ratio, but correlation between energy levels and urgency rate seems clear. It is currently impossible to incriminate dispersion of energy because we had about 30% of patients with urgency the first postoperative month with quite the same level of energy used for all the population. We need more data to identify patients who will suffer from urgency or erectile dysfunction, and our study gave a track. Furthermore, in our study, patients who suffered from postoperative erectile dysfunction were not those who suffered from urgency. As Dr. Damiano said, we need larger studies to confirm our findings, and maybe high-volume centres should merge data to give clear and significant guidance for identifying patients who should have PVP.