180W-LBO GreenLight XPS laser vaporization for benign prostatic hyperplasia: our experience with current markers of surgical proficiency for durable and reproducible outcomes

Introduction: This study aims at analyzing the impact of reaching current markers of proficiency on intra and postoperative clinical outcomes of laser vaporization with 180W GreenLight XPS in the treatment of benign prostatic hyperplasia. Materials and methods: A retrospective analysis was conducted on a prospectively collected database of 328 consecutive patients who underwent photoselective vaporization of the prostate (PVP) using Greenlight XPS performed by a single experienced laser surgeon. A logarithmic model was used to evaluate the case number to attain benchmark criteria for durable treatment. We compared clinical outcomes before and after current markers of proficiency, defined as either an energy density of 414/cm3 or a 6 month prostate-specific antigen (PSA) drop of 50%, were attained. Results: Energy delivered per prostate volume increased significantly with experience. The published benchmark values of 4kJ/cm(3) and 6 month PSA drop of 50% were attained after 190 and 155 cases, respectively. There were no significant differences between groups in intraoperative complications or postoperative functional outcomes. However, the number of Clavien-Dindo category I adverse events significantly decreased with experience. Sub-analysis evaluating prostate volumes 80 cm(3) and > 80 cm(3) demonstrated comparable clinical outcomes before and after technical proficiency. Conclusion: In our experience, the case volume required to achieve consistent reference values related to durable clinical outcomes and surgical proficiency was > 150 cases. However, desirable clinical outcomes were attained before reaching current markers of proficiency, regardless of preoperative prostate size. This suggests that current thresholds of technical proficiency may not be a good predictor of satisfying clinical outcomes.