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BackTable / Urology / Article
GreenLight Laser Therapy: Surgical & Post-Operative Considerations
Quynh-Chi Dang • Oct 26, 2021 • 544 hits
GreenLight laser therapy is a minimally-invasive treatment for benign prostate hyperplasia (BPH). In this procedure, a laser fiber is inserted through a transurethral cystoscope and is used to enucleate excessive prostate tissue. Patients with large (>80 g) prostates are ideal candidates for GreenLight laser prostatectomy.
Urologist Dr. Francisco Gelpi shares his approach to GreenLight laser and other BPH procedures on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• While performing a cystoscopy during the initial BPH patient evaluation, prostate size, protuberant median lobes, and bilobar obstruction can guide decisions between surgical choices.
• Dr. Gelpi recommends GreenLight laser therapy for large (>80 g) prostates with very protuberant median lobes.
• Dr. Gelpi focuses on enucleating the median lobe and allows the lateral lobes to passively disarticulate. He recommends using a lower wattage (80 W) to minimize irritative symptoms and bleeding.
• Because GreenLight laser prostatectomy carries a risk of anejaculation, patient prioritization of ejaculation function should be discussed pre-operatively.
Table of Contents
(1) Deciding on a BPH Surgical Intervention
(2) Surgical Tips for GreenLight Laser Therapy
(3) Risk of Retrograde Ejaculation in GreenLight Laser Therapy
Deciding on a BPH Surgical Intervention
Dr. Francisco Gelpi emphasizes the importance of prostate anatomy when deciding on a BPH surgical intervention. While performing a cystoscopy during the initial BPH patient evaluation, he looks for specific anatomical features, such as prostate size, protuberant median lobes, and bilobar obstruction.
If the prostate is under 80 grams and only a bilobar obstruction is present, he prefers the UroLift because it provides instant patient relief and does not require a post-operative catheter. If the prostate is smaller or close to 80 grams and a median lobe is present, he evaluates its protuberance. For prostates with little to no protuberance, he prefers Rezum therapy. For larger prostates with a large protuberant lobe, he will choose GreenLight laser therapy.
[Dr. Jose Silva]
...So Paco, after you do the UroCuff, how do you decide whether to go with UroLift, GreenLight, or Rezum?
[Dr. Francisco Gelpi]
So again, it's a very involved conversation with the guy, right? I need to be very, very emphatic about the importance of setting expectations. So when you have these conversations, what is the priority for the patient? Is it just bladder health? Is it getting rid of the nasty side effects of the medication? Do they want to preserve their ability to ejaculate? Is it not that big of a deal for them? So there's a number of different layers to that conversation. In order to simplify it as much as possible, I ask myself during the cystoscopy: okay, does this guy have any sort of median lobe, or does he only have bilobar obstruction? Then, what is the size of this prostate?
I tackle, for instance, Rezum prostates that I know that are larger than what's supposed to be done, but I have the conversation with the patient. You explain to them that this might be pushing the envelope, but some are willing to give it a shot. Yeah, we might give it a couple more injections than we otherwise would have. But again, in order to simplify it, I normally think if it's bilobar and it's smaller than 80 grams, I typically prefer UroLift. I like the Urolift a lot because it's a very easy way of getting a patient to stop medications, leave the SC and be happy, not need a catheter, and basically start experiencing improvement of symptoms almost immediately.
If there is a median lobe, then it all depends on how protuberant that is. I've started doing some of these UroLifts with the median lobe, but my preferred option for the younger guy with a prostate smaller than 80 gram prostate is probably going to be Rezum. Now Rezum is interesting because I think it's a great tool, but you have to be very careful how you sell that procedure to the patient. You have to be clear about explaining that things are going to get worse before they get better. It’s likely that they will be uncomfortable for a number of weeks. The way I handle that is to let everyone go on anti-inflammatories, stool softeners, and keep a catheter for about a week.
That was one of my mistakes at the beginning. I probably left it for a little shorter than I should have. So but once you start re-visiting and refining those things, you can explain to them and they're fine. And then anything larger than that, in particular, if there's a large protuberant median lobe, it's likely going to be a GreenLight, unless it's someone that is open to the option of robotic simple prostatectomy. I normally reserve for robotic prostatectomies for prostates with very, very large intravesical median lobes. You can just get the procedure done so much quicker than being there for a while with the GreenLight. So that's it in a nutshell, how I kind of think and navigate these things.
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Surgical Tips for GreenLight Laser Therapy
Dr. Gelpi explains his GreenLight prostatectomy procedure technique: First, he makes two channels at the 5:00 and 7:00 positions in the median lobe and connects the two incisions. In this step, he uses 80W, as using a higher energy setting could cause irritative symptoms. After he focuses on enucleating the median lobe with the laser, he makes 11:00 and 1:00 incisions in the lateral lobes and allows the tissue to disarticulate passively. He exercises extra caution around the vicinity of the trigone and the verumontanum of the bladder.
[Dr. Jose Silva]
And when you do the GreenLight, are you doing the channels at five and seven, and then going down to the verumontanum and then resecting the median lobe and then lateral lobes?
[Dr. Francisco Gelpi]
So I do something that you probably haven't seen. It's kind of like using the HoLEP technique where you would create these channels at five and seven. And then I connect those and I enucleate that middle portion with the beak of the scope. And then after I leave that tissue hanging, I blast it with 180 and I mean, again, prostate from today, perfect example. 170 grams, most of it was a median lobe, and the procedure took me 15, 16 minutes because most of what I do is concentrate on that median lobe, enucleate using the scope as if it was my finger. And then by the time you're done there's stuff on the sides, yes, you shave it off, but you don't have to be overly aggressive. Once you've done that, those incisions which mimic the transurethral incisions of the prostate. And then when you take that valve like mechanism of the median lobe, I mean, those guys are going to pee like a champ.
[Dr. Jose Silva]
And you go down to the channels in 150 and then 180 to the middle?
[Dr. Francisco Gelpi]
Actually, no. I do my channels with 80 because I am very, very cognizant of the irritated symptoms they can get when you mess up the bladder neck and anything in the vicinity of the trigone. I would make the channels with 80. I connect them with 80--and that's the part probably that's the hardest to explain in something like this which is not visual. But once you are able to disarticulate that piece of tissue--I mean, this thing, if you're in the right place and the right layer, this thing just peels off, just like when you're doing an open simple prostatectomy, right?
And then I just allow that tissue to sit there and I aim away from the floor of the prostate so that I'm not causing any of that burning, and that tissue in the middle just disappears. It's pretty cool.
[Dr. Jose Silva]
Wow, well, that's very impressive. 15 to 16 minutes for 170 grams.
[Dr. Francisco Gelpi]
I pick the guy up because I know that most of it is a median lobe and that's what I'm going to have to work on hard, right. So if you have a guy that's 170 g and it's all lateral lobes, you're going to be there until tomorrow.
[Dr. Jose Silva]
...And in terms of the GreenLight, you mentioned the lateral lobes. So how far up do you go? Sometimes I run into trouble when I start going towards the lateral lobe, but if there are very tall lateral lobes, you go in the middle and then the top part falls like a roof or a ceiling.
[Dr. Francisco Gelpi]
So that's where the HoLEP technique is very helpful for me, right? Because when we did HoLEPs, at least the way that I learned it at Jefferson, we would originally do our five and seven incisions for the median lobe. And then you would make a 1:00 and an 11:00 incision on the sides. And then when you follow that, the lateral tissue just falls or plops down. And I use that to my advantage because as I mentioned before, now I'm not super worried about having to remove all that stuff. So I want to lower it and shave it enough so that I create a good channel, but not really trying to get into that meat of the prostate at the five and seven where you know you're probably going to get into some bleeding.
I typically always leave all the tissue in the vicinity of the verumontanum for the end, and I normally lower the energy there. Again, because if you get in the right spot, I mean, it's perfect. But if you mess up some of that deeper tissue, it's going to start bleeding. And yeah, instead of just eyeballing it, just find that edge of the lobe which is usually at 1 and 11, and once you get there, it just plops down.
[Dr. Jose Silva]
Sometimes you're torquing the cystoscope a lot. You don't know how much torque you're going to put in it. You're very, very high on the prostate, an area that maybe visually you're not seeing anything--it's just water flowing. And sometimes it's really hard to say where you're at if you don't know the area. In your case, because maybe you had that exposure to the HoLEP, you know--but you never go that high when doing TURPs, for example.
[Dr. Francisco Gelpi]
Exactly. I just happened to have the benefit of learning HoLEP and figuring out how you want to disarticulate it. And the reason you do so is because it puts you in that plane that minimizes bleeding. But like anything else, there's 100 ways to skin a cat. This is what makes sense to me. I've managed to turn it into a way that I can do it with a number of these guys and feel comfortable that the guys are going to go home, and I'm minimizing risk, and so forth. And yeah, I mean, am I always kind of trying to learn and improve the technique? Absolutely. I mean, you keep learning little tricks here and there.
Risk of Retrograde Ejaculation in GreenLight Laser Therapy
Although GreenLight laser prostatectomy is a minimally invasive procedure, it carries a high risk of retrograde ejaculation after prostate surgery. Dr. Gelpi and Dr. Silva both agree that before embarking on a BPH surgical treatment, urologists should engage patients in a transparent discussion about their post-operative priorities. For men who prioritize anterograde ejaculation preservation, a less aggressive approach can be explored.
[Dr. Francisco Gelpi]
Now that you mention the whole sexual side effects, that was a big part of me getting involved in things that I had never done. Again, when you and I trained, there was no HoLEP or Rezum.
[Dr. Jose Silva]
GreenLight had just started.
[Dr. Francisco Gelpi]
It had just started but the energy was not that good. And again, I trained with literally zero GreenLights. But one thing I was going to say is that I had a very uncomfortable situation with a patient a couple years ago. This guy was young, maybe 55. He comes in with a full-blown urinary retention. So I scoped him and found a massive median lobe. I don't recall now the size of his prostate, but it was closer to 100 or 120 grams. And we talked about the options. I did a GreenLight. The guy comes back, and he's peeing like a champ. And then he comes for his post-op, I think, three months later and basically accuses me of stealing his manhood. So I sit down with him and I'm like, what are you talking about? He said, “Yeah, I'm not ejaculating.” And I said, “Are you not experiencing the pleasure associated with it?” And he tells me that he’s not seeing the white stuff.
And I sat down with him and I told him that we had talked about it. He said I mentioned it, but he didn't know it was going to be like that. And it got heated and he almost punched me--it turned into something very aggressive, right? I had to fire the guy from the practice and whatnot, but it was sort of an experience that I had to learn from. Now when guys come in, sometimes they ask me why I’m spending so much time talking to them about these sexual side effects. And it's because it's a reality. I mean, these things can happen. And I have guys who I tell, “If ejaculation is the most important thing for you, then we're definitely not going to take the most aggressive approach.” And again, with a heavy Hispanic population, that’s definitely part of their manhood.
It sort of seems almost like something to laugh about, but it's a very important part of the way that I conduct my business. And that's how I looked into these other alternatives at the beginning.
[Dr. Jose Silva]
And that's exactly right. I had a patient in the same scenario. He had a Foley catheter, and I did a GreenLight. At that time, I wasn't doing a Rezum or a UroLift, but he's been great. But yeah, he came back because he was worried about ejaculating. I had to tell him that it wasn’t going to come back. He started crying, and I said, “Are you trying to have kids?” But yeah, we sometimes think about just the obstruction and really don't think about other effects. Now with all these new tools, ejaculation preservation is possible, and for younger patients, it's great. I mean, you don't even have to worry about that as long as they fit.
Podcast Contributors
Dr. Francisco Gelpi
Dr. Francisco Gelpi is a private practice Urologist in Houston, Texas.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 25). Ep. 14 – Patient Selection for GreenLight & Other BPH Treatments [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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