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Background Bench and virtual reality nonbiological simulator models for anatomic endoscopic enucleation of the prostate (AEEP) surgery have been reported in the literature. These models are acceptable but have limited practical applications. Objective To validate a fresh-frozen human cadaver model for holmium AEEP training and assess its content validity. Design, setting, and participants Holmium AEEP operations on fresh-frozen cadavers performed by an experienced surgeon were recorded, and a video, including the main steps of the operation, was produced. Outcome measurements and statistical analysis The video and an accompanying questionnaire were subsequently distributed electronically to ESUT AEEP study group experts and associates (N = 32) for assessment of the AEEP training model. A ten-point Likert global rating scale was used to measure the content validity. Results and limitations A total of 26 answers were returned (81%). The experts agreed on the model’s suitability for AEEP training (mean Likert score: 8). According to the responses, “identifying anatomic structures and landmarks” was the most valuable aspect of the model in terms of AEEP training (median Likert score: 9). Conversely, the experts found the model’s ability, in terms of demonstrating laser and tissue reactions, to be weak (median Likert score: 6) Conclusions Based on the content validity assessment, the fresh-frozen cadaver-training model for laser AEEP seems to be a promising model for demonstrating and learning the correct prostate enucleation technique. Patient summary An increasing number of researchers have proposed that anatomic endoscopic enucleation of the prostate (AEEP) should replace transurethral resection of the prostate surgery and become the gold standard for treatment of bladder outlet obstruction due to benign prostatic hyperplasia. AEEP requires anatomic familiarity for enucleation, technical knowledge, and a solid training program before starting with the first cases. This is the first cadaver study to assess the content validity of a fresh-frozen human cadaver model for AEEP training., Take Home Message Anatomic endoscopic enucleation of the prostate (AEEP) has a steep learning curve and not become widespread due to the lack of a standardized training program. This is the first cadaver study validating a fresh-frozen human cadaver model for AEEP training

Background: Prostate size estimation is a valuable clinical measure widely utilized in urology. This study evaluated the accuracy of preoperative transabdominal ultrasound (TAUS) compared to radica...

Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and effective alternative procedure for the treatment of benign prostatic hyperplasia (BPH), especially in anticoagulated men. This descriptive analysis aims to characterize the current state of GL-PVP, pooling data from international centers. Data from 3627 patients who underwent GL-PVP with the XPS-180 W system in seven international centers performed by eight expert surgeons between 2011 and 2019 were retrospectively analyzed. Demographic, perioperative, and postoperative data were collected, including IPSS, QoL, Qmax, PVR, and PSA, and complications. At baseline, median age, prostate volume, PSA, and IPSS were 70 years (interquartile range 64–77), 64 (47–90), 3.1 ng/mL (1.8–6), and 22 (19–27), respectively. Median lasing and operative time were 34 (23–48) and 62 min (46–85), respectively. Median energy use was 250.0 kJ (168.4–367.9), with 92.6% of procedures being completed with one laser fiber. In 60.1% of cases, catheter was removed on postoperative day 1 with median length of 2 days. All-cause mortality within 30 days was 0.3%. Median PSA reduction at 3 months and 60 months compared to baseline was 43.9 and 46.4%, respectively (p

To compare the perioperative and functional outcomes between 180_W XPS GreenLight photoselective vaporization (PVP) and 532-nm GreenLight laser enucleation of the prostate (GreenLEP) in the surgical management of benign prostatic obstruction (BPO). Retrospective review of a prospectively maintained international database of patients managed with GreenLight laser surgery (PVP or GreenLEP) was performed. To adjust for potential baseline confounders, propensity-score matching (PSM) was applied at a ratio of 1:1 to compare the perioperative and functional outcomes between the groups. A total of 2,420 patients were included. 1,491 (61.6%) underwent PVP and 929 (38.4%) underwent GreenLEP. Before PSM analysis, patients in the vaporization group were older (p

Objective Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity. Methods A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification. Results There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77 ± 6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94 ± 56 mL, 301 ± 211 kJ, and 35 ± 21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2 ± 2.4 days and 2.4 ± 2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions. Conclusions This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

It has been shown that endoscopic enucleation of the prostate (EEP) allows for similar efficacy and safety, no matter what energy and type of instruments we use, but the length of learning may differ greatly. The aim of this systematic review is to verify if there is any significant difference between EEP methods in learning. We performed a systematic literature search in three databases and included only the articles containing their own data on the EEP learning curve assessment during the last 10 years. The primary endpoint was to determine the necessary experience needed to achieve a plateau. The secondary endpoints were to review methods used to evaluate a learning curve. The final sample included 17 articles, containing a total of 4615 EEPs performed by 76 surgeons, the most common method was HoLEP (9/17). The majority of articles studying HoLEP report a learning curve of experience level achievement in roughly 30–40 (min 20; max 60) cases. The studies of GreenLight laser showed high heterogeneity in the results with minimum of 20 cases and maximum of 150–200 cases. TUEB required roughly 40–50 cases to reach the plateau. Although EEP is considered challenging, it shows a steep learning curve with a plateau after 30–50 cases. Proper criteria are critical for accurate assessment of the learning curve. The Trifecta and Pentafecta criteria are currently the most appropriate method to evaluate EEP learning.

In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE). A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion. For small–medium prostates (30–80 mL), Aquablation’s main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80–150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern. The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

The BPH surgical armamentarium is composed of a rapidly expanding number of technologies and techniques. These include greenlight photovaporization of the prostate (PVP), greenlight enucleation of the prostate (GreenLEP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP) and, more recently, the aquablation procedure. To the best of our knowledge, no direct comparison in operative time has been performed. Data for this study were pooled from five sources. For aquablation, patient-level data from four studies of the aquablation procedure were provided by the device manufacturer as well as from a high-volume commercial user. PVP, GreenLEP, HoLEP, and ThuLEP were performed by high-volume, experienced experts. Endpoints included total operative time, resection time, and proportion of total operative time for resection. General linear models were used to evaluate the relationship between prostate volume (or other continuous predictors) and procedure time. Total procedure time was related to prostate size. Except for the small prostate size range (size 40 cc.

To compare the perioperative outcomes associated with laser enucleation of the prostate (LEP) and transurethral resection of the prostate (TURP) using a national database. The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent TURP or LEP from 2008 to 2016. Baseline demographics, comorbidities, and predisposition to bleeding were compared between TURP and LEP. The 30-day perioperative outcomes including operative time, length of hospital stay (LOS), return to the operating room (OR), bleeding requiring transfusion, and organ system-specific complications were compared between the procedures. A multivariate logistic regression analysis was performed, adjusting for the type of surgery and other covariates. The series included 37,577 TURP and 2869 LEP procedures. While TURP was associated with a shorter operative time (55.20 ± 37.80 min) than LEP (102.80 ± 62.30 min), the latter was associated with a shorter hospital stay (1.29 ± 2.73 days) than TURP (2.05 ± 5.20 days). Compared to TURP, LEP had 0.52 (0.47–0.58) times the odds of a LOS > 1 day and 0.67 (0.54–0.83) times the odds of developing urinary tract infections. Nevertheless, no difference was found for other postoperative complications, need for transfusion, and return to OR. Real-life data from a large national database confirmed that LEP is a safe and reproducible procedure to treat benign prostatic obstruction. Compared to TURP, LEP was associated with a lower rate of infectious complications and a shorter LOS at the expense of an increased operative time.

We sought to characterize the adjusted outcomes of GreenLight photoselective vaporization of the prostate (PVP) in high-medical-risk (HMR) patients using data from the largest international database.Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. Eligible study participants underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019. HMR patients were defined as patients with ASA III or greater and were compared to non-HMR patients. Analyses were adjusted for patient age and prostate volume.In the HMR group, patients on average were older and had smaller prostates than the non-HMR control group. Compared to non-HMR patients, transfusions occurred more frequently (2.6% vs. 0.14%, p 0.01) and the odds of readmission were elevated [OR 2.0, (95% CI 1.4-2.8, p 0.01)] among HMR patients. Twelve months postoperatively, HMR patients experience greater improvement in QoL than the control group [+ 0.54 (95% CI 0.07-1.0, p = 0.02)]. PVR also decreased 93.1 ml more in HMR than in non-HMR patients after 12 months (95% CI 33.6-152.6, p 0.01).We found that GreenLight PVP is safe and effective in improving functional outcomes in higher-risk patients with severe systemic disease compared to their lower-risk counterparts. Though absolute risks remain low, GreenLight PVP is associated with higher odds of transfusion and readmission in the high-risk cohort. The findings of our study reaffirm current guidelines that propose PVP as a viable treatment option for HMR patients.

Purpose To evaluate changes in global perioperative data of GreenLight-XPS 180-Watt photo-selective vaporization of the prostate (GL-XPS) of the Global Greenlight Group (GGG) database. Methods 3441 men, who underwent GL-XPS for symptomatic BPH between 2011 and 2019 at seven high volume international centers, were included. Primary outcome measurements were operative time (OT; min), effective laser time (LT; min of OT), as well as intraoperative and postoperative adverse events (AEs), all analyzed by year of surgery (2011–2019) and prostate volume (PV) group ( 150 ml). Results The median age was 70 years (interquartile range 64–77), the median PV was 64 ml (IQR 47–90). The OT and LT slightly increased but stayed highly efficient all in all. Median OT was 60 min (IQR 45–83) and LT was 33 min (IQR 23–46). Median energy use was 253 kJ (IQR 170–375) with an energy density of 3.94 kJ/ml (IQR 2.94–5.02). The relative probability of perioperative AEs decreased by 17% each year (p p = 0.007). The early postoperative complications (within 30 days after surgery) decreased significantly from 48.8% (n = 106) in 2011 to 24.7% (n = 20) in 2019 (p > 0.001). Conclusion These findings from the GGG demonstrate significant improvement secondary to growing experience with GL-XPS between 2011 and 2019 in intraoperative AEs, including transfusions, and postoperative AEs. While staying highly efficient in OT and LT of GL-XPS within a 9-year period of experience.

Half of men aged60 years will develop benign prostatic hyperplasia (BPH) with 40% of these men having moderate-to-severe lower urinary tract symptoms (LUTS). There is limited knowledge on a head-to-head comparison of prostatic urethral lift (UroLift) and convective water vapor ablation (Rezum) for the treatment of LUTS secondary to BPH. We sought to compare randomized controlled trials with 3-year clinical outcome data.After a thorough literature search, two multicenter sham-controlled double-blind randomized trials for UroLift and Rezum were identified and compared. Both studies had similar designs, baseline characteristics, reported outcomes, and low risks of bias.Rezum and UroLift resulted in significant improvement of International Prostate Symptom Score (IPSS) at 3 months (51.4% and 49.9%, respectively) and 50% reduction of IPSS Quality of Life that was durable across all time points. At 24 and 36 months, there was a statistically significant difference in IPSS between groups, favoring Rezum (-11.2 ± 7.3 versus -9.13 ± 7.62, p = 0.04, and -11.0 ± 7.1 versus -8.83 ± 7.41, p = 0.04, respectively). While Rezum had greater improvement in Qmax at 3 months (6.4 ± 7.2 versus 4.29 ± 5.16, p0.01), there was no difference in improvement from 12-36 months between treatments. Only UroLift experienced improvements of Men's Sexual Health Questionnaire- Ejaculatory Dysfunction (MSHQ-EjD) function from baseline and was better than Rezum at all time points (p0.01). Rezum failed to significantly reduce the MSHQ-EjD bother at 3 months, while UroLift demonstrated a significant reduction of 27.56% (p0.01). Both systems offered equal improvements in the bother score by 12-36 months. Surgical re-treatment rates favored Rezum over Urolift (4.4% vs. 10.7%, respectively).Rezum achieved a greater improvement in symptom relief compared to UroLift. Improvement in ejaculatory dysfunction in patients treated with UroLift was greater than Rezum.

INTRODUCTION AND OBJECTIVE: Prostate tissue resection for patients with lower urinary tract symptoms (LUTS) remains the most effective means to provide symptomatic improvement. Many studies have evaluated the bleeding complication profile post-operatively for TURP and report a range up to 7% of patients requiring a blood transfusion, but with typical limitations in treating prostates up to 80mL in size. For larger prostates (>80mL), open prostatectomy and Holmium laser enucleation of the prostate (HOLEP) are the global reference standard surgical options with reported transfusion rates up to 24% and 4%, respectively. The Aquablation procedure is a new, impressively fast, resective BPH surgical alternative harnessing image guidance, high velocity waterjet, and robotic standardized execution, with a rapid learning curve. While several techniques for hemostasis following Aquablation have been utilized, the optimal strategy has not been fully vetted across different prostate sizes. METHODS: The current commercial AQUABEAM robot that performs Aquablation Therapy was first used in 2014. Since then numerous clinical studies have been conducted in various countries; Australia, Canada, Germany, India, Lebanon, Spain, New Zealand, United Kingdom, and the United States. All of the clinical trial data since 2014 have been pooled with the early commercial procedures from France, Germany, and Spain. The objective is to determine if athermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volume sizes. RESULTS: 801 patients were treated with Aquablation Therapy from 2014 to early 2019. The average prostate volume was 67mL ± 33mL (range 20-280mL) where 31 (3.9%) transfusions were reported. The largest contributing factor to transfusion risk was prostate size and method of traction. There was an increasing risk of transfusions in larger prostates when robust traction using a catheter tensioning device without cautery ranging from 0.8% to 7.8% in prostates ranging from 20mL to 280mL. However, when standard traction (taping the catheter to the leg, gauze knot synched up to the meatus, or no traction at all) was used and where the surgeon performed bladder neck cautery only when necessary, the risk of transfusion 1.4% to 2.5% in prostates ranging from 20mL to 280mL. CONCLUSIONS: While the athermal subgroup with robust traction with a catheter tension device had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion is reduced to a 1.9% across all prostate sizes.

Background Aquablation has emerged as a novel ablative therapy combining image guidance and robotics for targeted waterjet adenoma resection. Objective To describe a standardised technique of aquablation in the treatment of benign prostatic obstruction (BPO), and to report the perioperative and 1-yr functional outcomes obtained by multiple surgeons with no previous experience of the technique. Design, setting, and participants Between September 2017 and January 2018, patients referred to three different urological centres for BPO surgical management were prospectively enrolled to undergo an aquablation procedure. Surgical procedure Aquablation was performed using the Aquabeam system (Procept BioRobotics, Redwood Shores, CA, USA) that combines transrectal prostatic image guidance and robotics bespoke tissue resection with a high-pressure saline jet. The surgeon defines the area of treatment, and the resection is executed automatically. Measurements The primary endpoint was the change in total International Prostate Symptom Score (IPSS) score at 6 and 12 mo. Functional outcomes were assessed at 1, 3, 6, and 12 mo with IPSS, International Index of Erectile Function (IIEF)-15, Sexual Health Inventory for Men, and Male Sexual Health Questionnaire questionnaires and uroflowmetry. Results and limitations Thirty patients were enrolled in the study. The median operative time and resection time were 30.5 (24–35) and 4 (3.1–4.9) min, respectively. The median catheterisation time was 43 (23–49) h. The median hospitalisation stay was 2 (2–4) d. The IPSS score improved to 3 (1–6) at the 6 mo, with a mean change of 15.6 points (95% confidence interval 13–18.2). IPSS improvements persisted at month 12. The maximum urinary flow rate improved to 20.4 (17–26) ml/s at 12 mo. The 6-mo rates of Clavien-Dindo grade 2 and 3 events were 13.3%. There were no reports of incontinence or de novo erectile dysfunction. Postoperative de novo ejaculatory dysfunction was observed in 26.7% of patients. Conclusions This clinical registry confirmed that aquablation was feasible, safe, and effective, and provided immediate good functional results and similar outcomes to those of prior studies despite the lack of surgeons’ previous experience with the technique. Patient summary Aquablation is feasible, safe, and reproducible with promising outcomes for treating benign prostatic enlargement.

Objective: Our objective was to characterize the safety and efficacy of the 180 W XPS-GreenLight laser in men with lower urinary tract symptoms secondary to a small volume benign prostatic hyperplasia (BPH). Methods: A retrospective analysis was performed for all patients who underwent 180 W XPS-laser photoselective vaporization of the prostate (PVP) vaporization of the prostate between 2012 and 2016 at two-tertiary medical centers. Data collection included baseline comorbidities, disease-specific quality of life scores, maximum urinary flow rate (Qmax), postvoid residual (PVR), complications, prostate volume and prostate-specific antigen (PSA). The secondary endpoints were the incidence of intraoperative and postoperative adverse events. Complications were stratified using the Clavien-Dindo grading system up to 90 days after surgery. Results: Mean age of men was 67.8 years old, with a mean body mass index of 29.7 kg/m2. Mean prostate volume as measured by transrectal ultrasound was 29 mL. Anticoagulation use was 47% and urinary retention with catheter at time of surgery was 17%. Mean hospital stay and catheter time were 0.5 days. Median follow-up time was 6 months with the longest duration of follow-up being 22.5 months (interquartile range, 3–22.5 months). The International Prostate Symptom Score improved from 22.8 ± 7.0 at baseline to 10.7 ± 7.4 (p

Background The learning curve for photoselective vaporisation of the prostate (PVP) has never been assessed accurately. Objective To compare 180-W GreenLight XPS PVP learning curves for three surgeons with different levels of surgical experience and different institutional backgrounds. Design, setting, and participants A multicentre retrospective study of the first patients treated with PVP by three operators in three different centres ( n =152 in group 1, n =112 in group 2, n =101 in group 3) was conducted. Surgeon 1 had performed >600 PVP procedures (120-W GreenLight HPS laser) since 2007, while surgeons 2 and 3 had no previous experience with GreenLight PVP. Surgeon 1 mainly treats both benign prostatic hyperplasia (BPH) and urologic oncology, surgeon 2 primarily focuses on urologic oncology, and surgeon 3 mostly treats BPH. Surgeon experience was analysed as a continuous variable in terms of consecutive procedures performed. Intervention PVP using a 180-W GreenLight XPS laser. Outcome measurements and statistical analysis The learning curve was analysed in terms of changes over time for the following variables: operative time, the vaporisation time/operative time ratio, and the energy delivered/prostate volume ratio. The primary endpoint was a trifecta of (1) energy delivered >5kJ/ml of prostate, (2) vaporisation time/operative time ratio of 66–80%, and (3) no postoperative complications. Results and limitations Patient baseline characteristics differed significantly among the centres in terms of age, prostate volume, and International Prostate Symptom Score (IPSS). Most perioperative outcomes favoured group 1 over group 3 over group 2. Functional outcomes, such as a decrease in IPSS at 1 mo for the first 50 patients (−15 vs −13.6 vs −13.3; p 0.0001) and an increase in maximum flow at 1 mo for the first 50 patients (+14.2 vs. +7 vs. +9.4; p 0.0001), favoured group 1 over group 3 over group 2. The trifecta achievement rate was significantly higher in group 3 over group 1 over group 2 (26.7% vs 14.4% vs 5.4%; p 0.0001). In multivariate analysis adjusting for age, American Society of Anesthesiologists score, and preoperative prostate volume, the only factors predictive of trifecta achievement were surgeon experience ( p p Conclusions More than 100 PVP procedures were required to reach an intraoperative parameter plateau regardless of surgeon expertise and institutional background. Both surgeon background and expertise seemed to influence perioperative outcomes during the GreenLight XPS PVP learning curve. Patient summary Both surgeon background and expertise seem to influence perioperative outcomes during the learning curve when using a GreenLight XPS laser for photoselective vaporisation of the prostate.

The following video Atlas summary reviews all technical elements of the standardized setup, robotic execution, aquablation procedure, and hemostasis for efficient rapid benign prostate hyperplasia treatment.

Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database. Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score. A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22–10.23; p

Descazeaud A, Robert G, Lebdai S et al (2011) Impact of oral anticoagulation on morbidity of transurethral resection of the prostate. World J Urol 29:211–216. https://doi.org/10.1007/s00345-010-0561-3 CAS Article PubMed Google Scholar Cornu J-N, Ahyai S, Bachmann A et al (2015) A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. Eur Urol 67:1066–1096. https://doi.org/10.1016/j.eururo.2014.06.017 Article PubMed Google Scholar Hashim H, Worthington J, Abrams P et al (2020) Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trial. Lancet 396:50–61. https://doi.org/10.1016/S0140-6736(20)30537-7 Article PubMed PubMed Central Google Scholar Xia S-J, Zhuo J, Sun X-W et al (2008) Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol 53:382–390. https://doi.org/10.1016/j.eururo.2007.05.019 Article PubMed Google Scholar Gratzke C, Bachmann A, Descazeaud A et al (2015) EAU guidelines on the assessment of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 67:1099–1109. https://doi.org/10.1016/j.eururo.2014.12.038 Article PubMed Google Scholar Worthington J, Taylor H, Abrams P et al (2017) A randomised controlled trial to determine the clinical and cost effectiveness of thulium laser transurethral vaporesection of the prostate (ThuVARP) versus transurethral resection of the prostate (TURP) in the National Health Service (NHS)—the UNBLOCS trial: a study protocol for a randomised controlled trial. Trials 18:179. https://doi.org/10.1186/s13063-017-1916-5 Article PubMed PubMed Central Google Scholar Stone BV, Shoag J, Halpern JA et al (2017) Prostate size, nocturia and the digital rectal examination: a cohort study of 30 500 men. BJU Int 119:298–304. https://doi.org/10.1111/bju.13613 CAS Article PubMed Google Scholar Krijthe BP, Kunst A, Benjamin EJ et al (2013) Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J 34:2746–2751. https://doi.org/10.1093/eurheartj/eht280 Article PubMed PubMed Central Google Scholar Download references Department of Urology, Clinique Pasteur, 31300, Toulouse, France Vincent Misrai Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria Benjamin Pradere Department of Urology, University Hospital of Tours, Tours, France Benjamin Pradere You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar VM: project development, manuscript writing. BP: manuscript writing and reviewing. Correspondence to Vincent Misrai. Vincent Misrai and Benjamin Pradere have nothing to disclose. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions Misrai, V., Pradere, B. Transurethral laser ablation of the prostate: from “which technique does better” to “what patient benefits the most” the real challenge in contemporary surgery. World J Urol (2020). https://doi.org/10.1007/s00345-020-03455-x Download citation Received: 04 September 2020 Accepted: 10 September 2020 Published: 21 September 2020 DOI: https://doi.org/10.1007/s00345-020-03455-x

INTRODUCTION Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. EVIDENCE ACQUISITION A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. EVIDENCE SYNTHESIS Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. CONCLUSIONS En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.

INTRODUCTION AND OBJECTIVE:Transurethral resection of the prostate (TURP) is the gold standard for surgical treatment of benign prostatic obstruction (BPO). Over the last decades, laser enucleation...

INTRODUCTION AND OBJECTIVE:Amongst the surgical treatment modalities available, Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and ef...

INTRODUCTION AND OBJECTIVE:Aquablation is a novel and minimally invasive alternative to transurethral resection of the prostate for treating lower urinary tract symptoms (LUTS) secondary to benign ...

GreenLight laser enucleation of the prostate (GreenLEP) is an alternative endoscopic enucleation of the prostate (EEP) technique for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). GreenLEP is an 'en bloc' EEP technique to remove the transitional zone tissue in one piece. The procedure is a combination of laser enucleation and blunt gentle mechanical dissection using the tip of the resectoscope. The advantage of mechanical dissection is that it allows for better visualisation of the capsule and in some cases makes the dissection a little faster. This procedure is performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180 W generator, AMS), a 2090 side-firing fibre and a Piranha™ morcellator (Richard Wolf GmbH). We offer a review of the evolution of the technique including the most important technical aspects, complications, advantages/disadvantages, tips and tricks and a visual step by step guide to perform the GreenLEP technique. GreenLEP is one of the latest energy sources reported in the armamentarium of EEP techniques for the treatment of BPO. GreenLEP has previously demonstrated its feasibility, safety and similar short- to mid-term functional outcomes compared to surgical gold standards in the literature.

To examine the complications and functional outcomes of high-risk patients on antithrombotic therapy (ATT) treated with photoselective vaporization of the prostate (PVP) using the Greenlight (GL) XPS-180 system.A retrospective analysis of prospectively maintained institutional database was performed. Men with symptomatic LUTS related to BPH were treated with 523-nm GL PVP using the XPS-180 W system. They were stratified according to ATT status: group 1 (control group), group 2 (acetylsalicylic acid), group 3 (antiplatelet agents other than acetylsalicylic acid) and group 4 (anticoagulation agents). Postoperative adverse events at 30- and 90-days were prospectively recorded. Complications were stratified according to the Clavien-Dindo classification. Additionally, functional outcomes (IPSS, Qmax and PVR) were analyzed up to 48 months of follow-up after surgery. Multivariable logistic regression analyses were used to predict the effect of ATT on serious bleeding-associated complications that was defined as the sum of patients with hematuria Clavien grade ≥ 2, patients requiring transfusions and patient with postoperative hemoglobin drop ≥ 15 g/dl.274 (63%), 87 (21%), 24 (6%) and 37 (9%) patients were included in groups 1, 2, 3 and 4, respectively. Patients on antiplatelet (group 3) and anticoagulant medication (group 4) were older (median age 60 vs. 68 vs. 77 vs. 76 years, p 0.001) and had more comorbidities (ASA 3-4: 9.5 vs. 27.6 vs. 66.7 vs. 64.9%; p 0.001) than their counterparts. The overall 30-day complications rates were 31, 28.7, 45.8 and 45.9% of patients included in groups 1, 2, 3 and 4, respectively (p = 0.4). Hematuria Clavien 1 events (p 0.001), readmissions rates (p = 0.02), length of post-operative hospital stay (p 0.001) and catheterization time (p 0.001) were significantly higher in patients on antiplatelet and anticoagulation medication. In multivariable analyses, ATT status was not a predictor of serious bleeding events after surgery (p 0.5). Finally, functional outcomes were significantly improved accross the four groups.GL PVP is safe and effective in treating high-risk patients on ATT. Although serious bleeding complications are rare and equivalent with non-high-risk patients, patients on antiplatelet and anticoagulation medication should be counseled on the increased risk of minor bleeding events and readmissions rates at 30 days after surgery.

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.

Introduction: Transurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH). However, photoselective vaporization of the prostate (PVP) has gained widespread global acceptance in national guidelines as a safe and effective alternative option. Nevertheless, further evidence is required to assess the durability of Greenlight PVP. Herein, we report our five years of PVP experience with the Greenlight 180W XPS laser system.Methods: A retrospective analysis was conducted on a prospectively gathered database of 370 consecutively included patients who underwent PVP using Greenlight XPS-180 W laser system (Boston Scientific, Boston, MA, U.S.) performed by a single experienced laser surgeon between 2011 and 2016. Preoperative characteristics, intervention parameters, postoperative functional, uroflowmetry outcomes, and complications were collected. Outcomes are reported over a period of five years.Results: Mean age was 68 years, with a mean prostate volume of 78.8 cc (95% confidence interval [CI] 70.9–78.7]). The mean followup was 59.4 months (55.4–63.5). Mean energy, operative time, and energy/cc were 270.2 kJ (255.2–285.2), 62.7 minutes (59.6–65.7), and 3.7 kJ/cc (3.6–3.9), respectively. Compared to preoperative values, International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) parameters were significantly improved and sustained over the five postoperative years. Of note, only 66 patients (out of 370) had a complete five-year followup. Prostate-specific antigen (PSA) reached nadir at one year, with a drop of 67% from the mean preoperative value of 6.2 ng/mL. Mean IPSS nadir was reached at three years, with a drop of 80.4% (-21.1 points). Similarly, mean quality of life (QoL) score dropped by 82.8% after three years (preoperative mean of 4.7). With respect to mean Qmax, there was an increase by 72.7% (+14.7 mL/s) at one year, reaching the value of 19.9 mL/s. Moreover, mean PVR was 32.8 mL at four years compared to 345 mL preoperatively. At five years followup, PSA, IPSS, QoL, and PVR dropped by 59.7% (3.7 ng/mL), 75.2% (19.7 points), 78.72% (3.7 points), and 84.4% (291.3 mL), respectively. Qmax increased by 12.9 mL/s. Clavien complication rates were low, with bladder neck stenosis observed in seven (1.6%) men. During the five-year followup, only four patients (1%) required BPH surgical re-intervention.Conclusions: This is the first long-term reporting of Greenlight XPS- 180W laser system. In experienced hands, the observed outcomes appear to demonstrate that Greenlight XPS-180 W laser system is safe, efficacious, and durable for the treatment of bladder outlet obstruction (BOO) secondary to BPH.

This study sought to compare perioperative outcomes and morbidities for open simple prostatectomy (OSP) and endoscopic green laser enucleation of the prostate (GreenLEP). In a single department, all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and all consecutive patients undergoing GreenLEP between July 2013 and January 2017 were prospectively enrolled. Perioperative data, information regarding early postoperative complications for up to 6 months and outcomes were collected and retrospectively compared. Overall, 204 patients were enrolled in each group. The baseline characteristics of patients in both groups were comparable. Intraoperative time was significantly longer for the OSP group than for the GreenLEP group (67 versus 60 min; p

International audience; PURPOSE:To evaluate perioperative cost related to surgical treatments of benign prostatic obstruction (BPO): photoselective vaporization of the prostate (pvp), holmium/thullium laser enucleation (HoLEP/ThuLEP), transurethral resection of the prostate (TURP) and open prostatectomy (OP).MATERIAL AND METHODS:We retrospectively collected data from 237 patients who consecutively underwent a surgical treatment for BPH between January 2012 and June 2013 at nine institutions in France. An economic simulation model was constructed to estimate the cost of hospitalization related to surgical procedure from the hospital perspective and a cost minimization analysis was performed.RESULTS:TURP, OP, HoLEP/ThuLEP and PVP were performed in 99 (42%), 23 (10%), 64 (27%) and 51 (21%) patients, respectively. For men with prostate size

Introduction: In light of the recent Canadian Urological Association (CUA) and other urological association (America Urological Association, European Association of Urology) recommendations for the treatment of benign prostate hyperplasia (BPH) with lower urinary tract symptoms (LUTS), open simple prostatectomy (OSP) remains the recommended approach for large prostates with measured volumes over 80 cc.1 We sought to assess the current state of OSP and other BPH surgical training across Canadian urology residency programs and the use of guideline-recommended imagery prior to BPH surgery. Methods: A survey was distributed among Canadian urology program directors in June 2019. We identified the various surgical modalities available for the treatment of BPH offered by each program and obtained the annual number of OSP performed at each academic residency program. Additionally, we evaluated if preoperative transrectal ultrasound (TRUS) of the prostate was routinely performed to obtain the prostate volume during patient counselling as recommended by 2018 CUA guidelines. Results: All 13 program directors from the Canadian urology programs responded to our survey. OSP and monopolar transurethral resection of the prostate (TURP) remain the most common across programs and are practiced in all centers. Greenlight photo-vaporization, bipolar TURP, holmium laser enucleation of the prostate and robot-assisted simple prostatectomy were practiced in 76.8%, 69.2%, 23.1%, and 23.1% of centers, respectively. The mean number of OSP per academic training program was 4.7 cases annually. Moreover, only five (38%) academic centers routinely performed a preoperative TRUS to evaluate prostate volume for BPH counselling. Conclusions: Although recognized and referenced as the BPH gold standard for the treatment of prostates over 80 cc, Canadian urology trainees’ annual OSP exposure remains extremely limited. Considering the degree of importance given (category A) to the direct observation (of a minimum of five) of this intervention during residency training in the new Royal College's practice guidelines, it may be unrealistic to reach these national standards considering the annual case OSP volumes in Canadian academic urology faculties.

To analyse the accuracy of high preoperative PSA levels for predicting transitional zone incidental PCa (TZ-PCa) in men with very large prostates.Perioperative data from 375 consecutive patients who underwent endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction between July 2013 and December 2018 were retrospectively reviewed. Patients were stratified into three groups according to the preoperative PSA level: low-PSA ( 4 ng/mL), intermediate-PSA (4 ≤ PSA 10 ng/mL) and high-PSA (≥ 10 ng/mL). Men in each group were propensity score matched by age, 5α-reductase inhibitor (5-ARI) use, prostate volume and mpMRI. The TZ-PCa incidence rate was retrospectively compared by preoperative PSA level in a propensity score model including all predetermined variables.Age, prostate volume, 5-ARI use were similar between patient groups. The median PSA levels in the low-, intermediate- and high-PSA groups were 3 [2.3; 3.4], 6.6 [5.3; 8.1] and 12.7 [11; 16.7] ng/mL, respectively. The median prostate volume was 100 grams in all groups (108, 105 and 120 cc, respectively). The T1a-Gleason 6 incidental TZ-PCa rate was statistically comparable between the three groups (3.4, 5.1 and 8.6% in the low-, intermediate- and high-PSA groups, respectively). The detection rate of clinically significant TZ-PCa was low for preoperative PSA levels 4 ng/mL (1.7%); with no difference between the intermediate- and high-PSA groups.In men with large glands, the clinically significant incidental TZ-PCa detection rate was similar regardless of the preoperative PSA level stratum. Such details may help with patient counselling during BPH surgical management.

INTRODUCTION AND OBJECTIVES:The number of cases needed to become proficient in Green Light endoscopic enucleation of the prostate (GreenLEP) is the subject of continuous debate. The aim of this stu...

ObjectivesTo evaluate functional outcomes following Aquablation in various prostate volume and anatomical subgroups.DesignA meta-analysis with individual patient data undergoing Aquablation therapy from four prospective, global, clinical studies that have been conducted with Aquablation; WATER, WATER II, FRANCAIS WATER and OPEN WATER.SettingAustralia, Canada, Lebanon, Germany, New Zealand, UK and the USA.Participants425 men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with 1-year follow-up.InterventionsAquablation therapy is an ultrasound guided, robotically executed waterjet ablative procedure for the prostate.Main outcome measuresThe analyses focus International Prostate Symptom Score (IPSS), uroflowmetry, postoperative Incontinence Severity Index (ISI) and surgical retreatment.Results425 men with prostates ranging in size from 20 to 150 mL underwent Aquablation therapy. The outcomes from the seven questions in the IPSS questionnaire were grouped by the following; prostates 4, and regardless of prostate size, showed a reduction in incontinence during patient follow-up. Surgical retreatment due to BPH symptoms occurred in 0.7% (95% CI 0.1%–2.0%).ConclusionsAcross a variety of prostate anatomies, Aquablation therapy showed remarkable functional improvements following the index procedure. Additionally, men with moderate to severe LUTS/BPH and overactive bladder resulting in urge incontinence showed a reduction in incontinence symptoms postprocedure.

OBJECTIVES To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP). SUBJECTS/PATIENTS AND METHODS A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3-month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement. RESULTS In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P

Resume Introduction Un cancer actif est un facteur de risque connu de maladie thromboembolique veineuse (MTEV). La survenue de MTEV est la seconde cause de deces en cancerologie. En onco-urologie, certains cancers sont associes a un risque accru de MTEV. Le but de ce travail etait de proposer une mise au point sur l’epidemiologie et la prise en charge des MTEV en onco-urologie. Materiels et methodes Une revue systematique de la base de donnees PubMed® via la methode PRISMA a ete effectuee a l’aide des mots cles suivants : « neoplasm », « venous thromboembolism », « prophylaxis », « pulmonary embolism », « urology ». Les articles originaux ont ete inclus en priorisant : meta-analyses, revues de la litterature, essais randomises controles et etudes de cohorte de bon niveau de preuve. Seules les publications en langue anglaise ou francaise ont ete retenues. Resultats L’incidence des evenements thromboemboliques (ETE) etait plus importante en cas de carcinome a cellule renale (3,5 %/an). En cas de traitement chirurgical, la chirurgie la plus a risque d’ETE etait la cystectomie (2,6 a 11,6 %). La chimiotherapie etait a elle seule un facteur de risque important en augmentant le risque de survenue d’ETE par six. L’hormonotherapie augmentait egalement ce risque, par le biais de l’hypogonadisme induit. Le traitement curatif des MTEV lies cancer devait se faire via l’administration d’une heparine de bas poids moleculaire (HBPM). L’instauration d’un traitement prophylactique n’etait pas systematique chez les patients diagnostiques avec un cancer urologique. Conclusion La comprehension des differents mecanismes impliques dans la survenue d’ETE chez ces patients a permis d’optimiser la prise en charge notamment des patients avec un cancer urologique. En effet, la frequence des evenements thromboemboliques est probablement sous-estimee par les urologues dans la pratique clinique.

Lower urinary tract symptoms related to benign prostatic obstruction (BPO) are frequent in men aged > 50 years. Based on the use of innovative medical devices, a number of transurethral ablative techniques have recently been developed for the surgical treatment of BPO. In recent years, GreenLight photoselective vaporization of the prostate (PVP) has been considered as a non-inferior alternative to transurethral resection of the prostate. The GreenLight PVP is usually considered as an interesting surgical option for patients treated via oral anticoagulants (OACs) with regard to its haemostatic properties. The aim of this study was to assess the impact of maintaining OAC treatment in patients undergoing PVP. This study is a multicentre, open-label, randomized controlled trial (RCT) designed to show the non-inferiority of PVP surgery in patients with BPO treated with OACs. This study is designed to enrol 386 OAC-treated patients (treated with vitamin K antagonists and direct oral anticoagulants) who are undergoing PVP for BPO. Patients will be randomized (1:1) to either maintain or stop OAC treatment during the perioperative course. The intervention group will maintain OAC treatment until the day before surgery and resume OAC treatment the day after surgery, whereas the control group will stop OAC treatment (with or without low-molecular-weight heparin bridging therapy) according to the anaesthesia guidelines. The primary outcome of interest to be assessed is the 30-day complications rate according to the Clavien-Dindo classification. The secondary endpoint will examine the 30-day rate of haemorrhagic and thrombotic events. This study will provide 80% power to show non-inferiority, defined as not worse than a 10% (non-inferiority margin) inferior change in the proportion of patients with good outcomes (Clavien-Dindo score

This study sought to compare the incidental prostate cancer (iPCa) detection rate between pathological specimens from green laser enucleation of the prostate (GreenLEP) and open simple prostatectomy (OSP). In two institutions, the charts of all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and the data of all consecutive patients who underwent GreenLEP with tissue morcellation between July 2013 and January 2018 were also collected. Preoperative demographics and pathological findings were recorded. iPCa detection rate was retrospectively compared between the GreenLEP and OSP groups in a propensity score model, including all predetermined variables: Age, preoperative PSA level and prostate volume. Of 738 patients, 402 were included in the propensity-score matching analysis, and they were equally distributed among groups. The overall iPCa detection rates were similar in both groups (9.9% vs. 8.5%; p = 0.73), and there were no statistically significant differences in terms of tumour stage, Gleason score or the rate of clinically significant iPCa, although the number of cassettes analysed was significantly higher in the morcellation group than in the OSP group. No predictive factors for iPCa were identified. The results of the present study suggest that the mechanical morcellation of large glands had no influence on iPCa detection. Compared with a specimen from standard OSP, a large morcellated tissue sample allows adequate pathological evaluation and does not alter a pathologist’s ability to detect iPCa.

Background Live surgery remains controversial. Although it may improve surgical training and accelerate the dissemination of technical steps of surgical procedures, controversy exists regarding patient safety in live surgery. Objective To compare the perioperative outcomes of "en bloc" green laser enucleation of the prostate (GreenLEP) performed in workshops during live case demonstration (LCD) and in standard conditions (SCs). Design, setting, and participants Between June 2015 and January 2017, all consecutive patients who underwent GreenLEP for benign prostatic obstruction performed by a single surgeon were prospectively enrolled. Perioperative data and early postoperative complications according to Clavien–Dindo classification were collected. Workshop programmes started locally according to the European Association of Urology policy on live surgical events in June 2015 to enrol small groups of urologists in the GreenLEP technique. Intervention Endoscopic enucleation of the prostate using a GreenLight fibre. Outcome measurements and statistical analysis Outcomes were compared between the LCD and SC groups. Results and limitations Of the 126 performed procedures, 37 were performed live during 17 LCDs with a median attendee number of 3. The patients' baseline characteristics were similar in both groups. Intraoperative parameters were comparable: total energy of 62 [53; 77] versus 56kJ [44; 69] ( p =0.068), operative time of 61 [53; 71] versus 55min [45; 66] ( p =0.1), and morcellating time of 3 [3; 5] versus 4min [2; 6] ( p =0.82) in the LCD versus SC group. The catheterisation time (2d [1; 2]) and length of hospital stay (2d [2; 3]) were similar. The overall complication rate was comparable in the LCD (18.9%) and SC (24.7%) groups ( p =0.64). Preoperative parameters significantly improved from baseline without any significant differences between the two groups. Limitations included a small number of attendees/workshop, and case selections were made by the surgeon himself. Conclusions GreenLEP was safe and provided satisfactory functional outcomes in both conditions. From this preliminary study, it seems that LCD did not jeopardise the surgeon's skill or technique. Similar studies are required to further assess patient safety and outcomes associated with live surgical events. Patient summary According to the surgeon expertise, endoscopic enucleation of the prostate performed during live case demonstration provided similar functional outcomes to that performed in standard condition and could therefore be considered a safe potential educational tool.