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Article of the week: A randomized trial comparing bipolar TUVP with GreenLight laser PVP for treatment of small to moderate benign prostatic obstruction

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a podcast prepared by one of our Resident podcasters; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years 

Fady K. Ghobrial, Ahmed Shoma, Ahmed M. Elshal, Mahmoud Laymon, Nasr El-Tabey, Adel Nabeeh and Ahmed A. Shokeir

Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Abstract

Objective

To test the non‐inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia‐related lower urinary tract symptoms in a randomized trial.

Methods

Eligible patients with prostate volumes of 30–80 mL were randomly allocated to GL‐PVP (n = 58) or bipolar TUVP (n = 61). Non‐inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri‐operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post‐void residual urine volume) and sexual (International Index of Erectile Function‐15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources‐related costs of both procedures were recorded and compared.

Results

Baseline and peri‐operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL‐PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval −0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25–99)% and 65.9 (50–99)% (P = 0.006) after GL‐PVP, and 32.1 (28.6–89.7)% and 39.3 (68.8–90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL‐PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL‐PVP procedure after 24 months (P = 0.01).

Conclusions

In terms of symptom control, bipolar TUVP was not inferior to GL‐PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL‐PVP compared with bipolar TUVP is an important concern.

Image courtesy of BJUI Knowledge

Editorial: Vaporization is vaporization, but not at any cost…

The paper by Ghobrial et al. [1] confirms that bipolar electrocautery vaporization is more cost‐effective than GreenLight Laser vaporization, as the two techniques are equally effective but GreenLight vaporization is more costly in the smaller prostates being studied.

Underpinning the analysis was a well‐conducted randomized controlled trial, showing equivalent peri‐operative and postoperative measures with the two procedures and no difference in the primary endpoint of IPSS reduction at 2 years. The two techniques were performed in a similar manner and were equally efficient and safe as expected.

Philosophically, the clinical results are both unsurprising and expected, and confirm the long‐held belief that the energy source employed for vaporization and, for that matter, enucleation, is of secondary concern compared to the skill and dedication of the operator. The technique in either case should result in comparable efficacy, leaving cost‐effectiveness to be an important way to help both urologists and administrators discriminate between them.

Although the costs are not necessarily going to be comparable with those in other jurisdictions, this will apply equally to both treatments and this study therefore represents an excellent attempt to cost both procedures, removing equivalent costs. Importantly, this assessment included the costs of both readmissions and interventions over the full 24‐month period. This captures the bulk of the important complications after these types of procedures and adds to the validity of the findings.

The big difference between the costs of the two treatments being studied is, of course, ‘capital equipment including maintenance’. The single‐use fibre model rather than the cost of the machine has been the mainstay for the profitability of laser companies since the inception of laser prostatectomy. The maintenance contract has been a further cost, which is always underestimated. Reusability of the laser fibres is one way of diminishing per‐procedure costs, but is only consistently possible for Holmium end‐fire fibres [2]. The fact that the authors estimate of these costs was a ‘case share in 5‐year budget plan’ also suggests that the true cost of the use of the GreenLight laser is underestimated.

With the burgeoning number of new techniques and technologies for the treatment of BPH emerging, and new treatment paradigms being proposed, let alone the increasingly negative focus on medical waste [3] and the increasing use of single‐use disposable handpieces/tubing/drapes/fibres, articles such as this are timely. A standardized methodology for assessing the cost‐effectiveness of treatments for BPH is needed and should be an essential part of pivotal studies and therefore the regulatory approval processes.

by Peter Gilling

 

References

  1. Ghobrial FKShoma AElshal AM et al. A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years. BJU Int2020124144– 52
  2. Fraundorfer MRGilling PJKennett KMDunton NGHolmium laser resection of the prostate is more cost effective than transurethral resection of the prostate: results of a randomized prospective study. Urology 200157454– 8
  3. Rose EDModlin DMCiampa MLMangieri CWFaler BJBandera BCEvaluation of operative waste in a military medical center: analysis of operating room cost and waste during surgical cases. Am Surg. 201985717– 20

 

Residents’ podcast: A randomized trial comparing bipolar TUVP with GreenLight laser PVP for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years

Maria Uloko is a Urology Resident at the University of Minnesota Hospital.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years

Abstract

Objective

To test the non‐inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia‐related lower urinary tract symptoms in a randomized trial.

Methods

Eligible patients with prostate volumes of 30–80 mL were randomly allocated to GL‐PVP (n = 58) or bipolar TUVP (n = 61). Non‐inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri‐operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post‐void residual urine volume) and sexual (International Index of Erectile Function‐15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources‐related costs of both procedures were recorded and compared.

Results

Baseline and peri‐operative variables were similar in the two groups. At 1, 4, 12 and 24 months, 117, 116, 99 and 96 patients, respectively, were evaluable. Regarding urinary outcome measures, there was no significant difference between the groups. The mean ± sd IPSS at 1 and 2 years was 7.1 ± 3 and 7.9 ± 2.9 (P = 0.8), respectively, after GL‐PVP and 6.3 ± 3.1 and 7.2 ± 2.8, respectively, after bipolar TUVP (P = 0.31). At 24 months, the mean difference in IPSS was 0.7 (95% confidence interval −0.6 to 2.3; P = 0.6). The median (range) postoperative PSA reduction was 64.7 (25–99)% and 65.9 (50–99)% (P = 0.006) after GL‐PVP, and 32.1 (28.6–89.7)% and 39.3 (68.8–90.5)% (P = 0.005) after bipolar TUVP, at 1 and 2 years, respectively. After 2 years, retreatment for recurrent bladder outlet obstruction was reported in eight (13.8%) and 10 (16.4%) patients in the GL‐PVP and bipolar TUVP groups, respectively (P = 0.8). The mean estimated cost per bipolar TUVP procedure was significantly lower than per GL‐PVP procedure after 24 months (P = 0.01).

Conclusions

In terms of symptom control, bipolar TUVP was not inferior to GL‐PVP at 2 years. Durability of the outcome needs to be tracked. The greater cost of GL‐PVP compared with bipolar TUVP is an important concern.

 

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Article of the week: Multicentre international experience of 532‐nm laser PVP with GreenLight XPS in men with very large prostates

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

Roger Valdivieso*, Pierre‐Alain Hueber*, Malek Meskawi*, Eric Belleville*, Khaled Ajib*, Franck Bruyere, Alexis E. Te, Bilal Chughtai, Dean Elterman§, Vincent Misraiand Kevin C. Zorn*

 

*Division of Urology, Centre Hospitalier de lUniversite de Montreal (CHUM), Montreal, QC, Canada, Department of Urology, CHU, Tours, France, Department of Urology, Cornell University, New York, NY, USA, §Department of Urology, University of Toronto, Toronto, ON, Canada, and Department of Urology, Clinique Pasteur, Toulousse, France

Abstract

Objectives

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Methods

Retrospective analysis of a prospectively maintained multicentre database was performed to select a subgroup of patients with very large prostates (volume ≥200 mL) treated with the GreenLight XPS laser. A subgroup of patients with prostate volumes 100–200 mL was used for comparison. International Prostate Symptom Score, maximum urinary flow rate, postvoid residual urine volume and prostate‐specific antigen levels were measured at 6, 12, 24, 36 and 48 months. Durability was evaluated using benign prostatic hyperplasia re‐treatment rate at 12, 24 and 36 months. Additionally, complications were recorded using Clavien–Dindo classification.

Results

A total of 33 patients (38%) had prostates ≥200 mL. Baseline characteristics were similar between patients with prostates ≥200 mL and those with prostates 100–200 mL. Patients with very large prostates (≥200 mL) had longer operating times (129 vs 93 min), less energy delivered, a greater number of fibres used (3 vs 2) and a higher conversion rate to transurethral resection of the prostate (16% vs 4%). In terms of complications and functional outcomes, we did not find any differences between the groups. Retreatment rate was also comparable.

Conclusions

Our results show that PVP GreenLight XPS‐180W is an acceptable technique for very large prostates (≥200 mL); however, operating times, energy delivery, fibres used and conversion to TURP are a concern in this particular subgroup. This should be used for patient counselling and surgery planning.

 

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