The GreenLight laser, an example of flexibility: Lessons learned from the Italian GreenLight Study Group

Among all the techniques used for the surgical treatment of benign prostatic obstruction (BPO), photoselective vaporization of the prostate (PVP) with the lithium triborate laser (LBO or GreenLight) stands out as the most versatile option.^[1]

The LBO laser operates at a wavelength of 532 nm, which produces its characteristic vivid green coloration. Its high affinity for hemoglobin within human tissues enables a remarkably strong coagulation effect. These physical properties, combined with the high-power settings commonly employed, make the LBO laser a unique technology among its peers, particularly well-suited for rapid, effective, and virtually bloodless prostate vaporization. Initially, the GreenLight laser was conceived as a viable alternative to transurethral resection of the prostate or other vaporization-enucleation techniques, such as thulium laser vapoenucleation.^[2] The original technique, or “standard” vaporization, relied on the concept of centrifugal ablation of benign prostatic hyperplasia tissue, progressing from the urethral lumen toward the prostate capsule.^[3] The outcomes of PVP confirmed its defining features of safety, efficacy, and versatility.^[4]

First, the GreenLight PVP showed noninferiority to the standard transurethral resection of the prostate in its capacity to relieve lower urinary tract symptoms and restore micturition-related quality of life, both in randomized controlled trials and real-life settings.^[3] Moreover, the use of the GreenLight technology rapidly expanded beyond standard prostate volumes and routine BPO patients to more complex scenarios.^[4] For instance, in elderly BPO patients, the GreenLight PVP proved not only highly effective but also free from an increased risk of surgical complications.^[5] Similarly, PVP has achieved excellent results in patients undergoing chronic anticoagulation therapy, owing to its powerful hemostatic effects.^[2] Finally, the GreenLight technology allows urologists to successfully manage challenging cases, such as patients with severe cardiologic comorbidities or those with complicated BPO conditions requiring combined treatments, such as synchronous diverticula repair. The remarkable versatility of PVP has earned it the reputation of being suitable for virtually every prostate, patient condition, and surgeon.^[6]

Nevertheless, the GreenLight PVP has faced some criticism: the high-power settings of the vaporization could lead to abnormal tissue degradation, potentially resulting in the accumulation of toxic byproducts and an increased incidence of postoperative irritative symptoms.^[3,7] Additionally, the nonradical nature of prostate cavitation, compared with enucleation, may contribute to higher recurrence rates.^[8] In both cases, surgical expertise could play a critical role. Appropriate handling of the vaporization ensures the correct distribution of laser energy to the tissue, minimizes accidental capsular perforations, and improves the durability of functional outcomes. Nonetheless, prostate volume remains one of the toughest limitations to overcome. Despite using a perfect vaporization technique, larger prostate volumes inevitably result in longer operative times, higher energy doses, and an increased risk of symptoms relapse.^[4,8] Under pressure to address larger prostates, the GreenLight procedure underwent an evolution, shifting from the original centrifugal vaporization to more “advanced” techniques.^[9] The so-called “anatomical” GreenLight PVP is a perfect example of a new concept of prostate vapoenucleation, and it has been widely adopted by members of the Italian GreenLight Study Group. Anatomical PVP combines enucleation and vaporization; the adenoma is detached by blunt dissection at the apex and posteriorly to the bladder neck and subsequently vaporized in situ, whereas the lateral lobes are vaporized in the classic centrifugal direction. Compared with standard vaporization, anatomical PVP allows for the creation of an optimal central channel, even in the presence of a significant median lobe. However, anatomical PVP did not show superiority over standard vaporization in terms of postoperative functional outcomes or surgical complications. The lack of randomized controlled trials has limited its international recognition and adoption. Additionally, the GreenLight laser was used for the anatomical enucleation of the prostate, the so-called GreenLEP. In this case, enucleation is obtained entirely through blunt dissection, whereas laser energy is used to divide strong adhesions or ensure perfect hemostatic control, and the procedure concludes with morcellation.^[9] Finally, the GreenLight technology enables the exploration of the ultimate frontiers of benign prostatic hyperplasia surgery: its versatility and excellent hemostatic control allow the creation of atypical vaporization templates, such as those designed to preserve antegrade ejaculation.^[10]

Whether used for standard vaporization, anatomical vaporization, or enucleation procedures, the GreenLight laser’s versatility is testified by the personal nuances that each urologist can bring to their surgical practice, according to their preferences and expertise. Efficacy and safety, combined with flexibility and innovation, underscore the potential of GreenLight PVP. Although much is already known about this technology, it is easy to envision that a new era of “advanced” GreenLight procedures is just beginning.

Acknowledgments

None.

Statement of ethics

Not applicable.

Conflicts of interest statement

PD received speaking honoraria from Boston Scientific Corporation. No conflict of interest has been declared by the other authors.

Funding source

None.

Author contributions

MS: Writing of the manuscript;

PD: Critical review of the manuscript;

PG: Critical review of the manuscript.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.