Common trend: move to enucleation—Is there a case for GreenLight enucleation? Development and description of the technique

Abstract

BackgroundTransurethral laser prostatectomy has evolved as a viable alternative for the management of benign prostate enlargement. Since the renaissance of laser prostatectomy with the advent of the holmium:yttrium–aluminum–garnet laser in the 1990s, various lasers and subsequent procedures have been introduced. These techniques can be categorized as vaporizing, resecting, and enucleating approaches. Photoselective vaporization of the prostate (PVP) is dominated by high-power lithium triborate (LBO) crystal lasers (GreenLight XPS). The mainstay of this technique is for the treatment of small to medium prostate volumes whereas enucleating techniques, such as holmium laser enucleation of the prostate and thulium enucleation of the prostate, focus on large-volume glands. In order to perspectively “delimit” LBO into the field of large-volume prostates, we developed LBO en bloc enucleation to render it as a competing transurethral enucleating approach.Materials and methodsWe present a detailed stepwise progressive technique developed in Madrid, Spain, for the complete removal of the transitional zone by vapoenucleation. The steps include exposition of the prostatic capsule by PVP toward the peripheral zone, thereby identifying the anatomical limits of enucleation. Subsequently, the transitional zone is excised in a single bloc and morcellated after its placement into the bladder.Conclusion This new GreenLight en bloc enucleation technique allows to treat larger prostates than those previously treated with the PVP technique.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement

“…In addition, it should be emphasized that the concept of anatomical enucleation being a widely energy-free technique can be performed with any kind of energy for hemostasis and not only thulium laser. Accordingly, variations of anatomical transurethral enucleation have been developed with other energy sources such as GreenLight laser (GreenLEP) [13]. Still, thulium laser appears as an excellent energy source for retrograde anatomical enucleation of the prostate as it offers a clear and bloodless incision through prostatic tissue necessary in the initial steps of the operation when incision at 5 and 7 o'clock of bladder neck is performed.…”

Enucleation is enucleation is enucleation is enucleation

“…ThuVEP focuses on the favorable vaporization effect of continuous-wave lasers to perform a fast, effective and safe enucleation, whereas ThuLEP focuses on almost blunt mechanical enucleation using the laser only for dissection of adherences and mucosa. The latter on anatomy focusing approach was mimicked by other continuous-wave lasers (LBO/"Greenlight" and 980 nm diode laser) that had not been found suitable for enucleation at the initial point of the discussion [5,6].…”

“…followed in 2004 [2], then later in the end of the 2000s all other transurethral laser-based enucleation techniques: Tm:YAG Vapoenucleation (ThuVEP) [3], transurethral anatomical enucleation with Tm:YAG Support (ThuLEP) [4], diode laser enucleation of the prostate (DiLEP) [5] and finally Lithium-Borate "Greenlight" enucleation of the prostate (GreenLEP) [6] appeared on the market to finally replace open prostatectomy (OP) and TURP. It took Thulium:YAG as the challenger to initiate a discussion about the impact of laser in transurethral enucleation.…”

Comparison of Patients Undergoing PVP Versus TURP for LUTS/BPH

“…Kuntz et al demonstrated equivalent functional outcomes between HoLEP and open simple prostatectomy with 5-year follow-up for prostates over 100 grams [39]. A novel enucleation technique was recently reported by Gomez et al that utilizes the Greenlight laser [40]. However, enucleation techniques are not as commonly performed as other minimally invasive procedures, possibly due to a longer learning curve [41,42] and the requirement of a tissue morcellator to remove the large volume of adenoma.…”