Does Prostate Median Lobe Really Matter for GreenLight HPS Laser Photovaporization of the Prostate

Benign prostatic hyperplasia (BPH) is a common pathology in elderly patients, inducing lower urinary tract symptoms. The treatment of BPH is first a medical option, then a surgical treatment, either by endoscopy or open surgery. We here report a case of GreenLight HPS™ laser photovaporization (PV) with an impaired maintenance of median lobe postoperatively, unimportant on functional results. A 68-year-old man presented with lower urinary tract symptoms in the last 2 years, treated first by medicine with good response. On digital rectal examination, the enlarged prostate was homogeneous and regular. International Prostate Symptom Score (IPSS) was 30/35, Incontinence Quality of Life (iQol) 6/6, and International Index of Erectile Function 5 14/25 with regular sexual activity. Transrectal ultrasound (TRUS) reported BPH of 62 g with a median lobe of 6 g protruding into the bladder. At uroflowmetry, maximum urinary flow rate (Q_max) was 8 mL/s for 90 cc void volume and 20 cc postvoid residual. After failure of medical treatment, we offered a surgical treatment option by laser therapy using the 180W XPS GreenLight™. At 1-month follow-up, functional outcomes were improved with a Q_max of 11 mL/s, postvoiding residual volume 0 cc, IPSS 12/35, and iQol 2/6. At 3-month follow-up, outcomes still improved, although the TRUS reported a prostate volume of 30 g with a persistent median lobe. Impaired maintenance of median lobe after GreenLight laser PV does not seem to affect functional results. This case report opens the way for a new therapeutic strategy for patients according to their prostate anatomy. A randomized clinical trial could be done about surgical treatment for patient BPH according to prostate volume and anatomy.