To evaluate the safety and efficacy of the 180-W Greenlight XPS laser system for the treatment of high risk patients with benign prostatic hyperplasia (BPH) and assess patient’s satisfaction with the treatment.

Retrospectively we reviewed medical charts of 44 high risk patients who underwent Photo-Selective Vaporization of the Prostate (PVP) with the 180W-XPS Green Light laser system (Boston Scientific, Boston, MA, U.S.) performed by a single surgeon between November 2013 and December 2016 with minimum of 1 year follow up. 
High Risk patients are those who has at least one of the following: Patients on anticoagulant therapy, urinary retention on catheter, and/ or prostate size larger than 100 ml.
Preoperative data (demographic data ,medical history ,Prostate size, pre op Urodynamic study , pre op serum creatinine and Hemoglobin level ,Uroflowmetry if possible), Intraoperative data (Operation time ,laser energy used ,lasing time) and  post-operative date ( Follow Up uroflowmetry, post void residual measurement ,day of catheter removal , discharge day ) were all recorded and reviewed. Patient satisfaction was assessed using two questions: 1. are you satisfied regarding lower urinary symptoms post-surgery (answer from 1 to 10) (1 unsatisfied at all, 10 full satisfied), 2.If the patient will advise others for this procedure.

44 charts were reviewed and included in the study. Age range 55-88 years with mean 69.9 years. All patients had at least one high risk factor and other factors as follow: 30 patients with urinary retention, 12 patients with IHD on anticoagulant therapy, prostate size was 40 -250 ml with mean 111.5 ml, 20 patients prostate size <100 ml, 24 patient ≥100 ml. 6 Patients had renal impairment, 2 had bladder stone, and 4 had history of transurethral resection of prostate. 6 patients with hematuria, 11 patients with recurrent UTI, 6 patients with urinary incontinence, and 29 patients with other lower urinary tract symptoms.29 patients underwent Urodynamic study which showed Bladder outflow obstruction in 24 patients, phasic Detrusor over activity in 4 patients, 3 patients with hypo contractile bladder, and 5 with impaired compliance.
 Surgery duration 30 -120 minutes with mean 72.9 minutes ± 28.2, Energy in Joule 44000-470000 with mean 230705, laser time 9-75 minutes with mean 32 +-14.8.

 1 patient required ICU post OP due to chest infection, 1 required Blood transfusions 2 day post op, 3 developed UTI during follow up and 1 urethral stricture. Hgb and serum Creatinine were comparable pre and post op with no statistical difference. 26 patients were discharged on the 2nd post op day and 18 patients on 3rd post op day. Mean maximum flow pre op 9.7 ml/sec and mean max flow post op (3, 6, and 12 months post op) 13.1 ml /sec (statistically significant by repeated measure ANOVA; P value <0.05). In patients with prostate size <100 ml, 18/20 (90%) were fully satisfied. All patients will advise others for this procedure. In patients with prostate size ≥100ml, 19/24 (79.2%) were fully satisfied, 2 were not satisfied and 3 did not answer the questionnaire.

BPH patients with high risk including larger size prostate, patients on anticoagulant therapy and urinary retention represent a challenge to urology surgeon with the gold standard surgery (TURP). Green light laser using 180 XPS machine demonstrated an excellent efficacy in low risk patients but few studies looked at efficacy of 180 XPS in high risk patient. This is the first study from Saudi Arabia that looked at local experience with 180 XPS machine in treating high risk patients with BPH. Results showed that 180 XPS Green light laser was an effective method to treat patients with high risk with minimal complications. Procedure was with a reasonable timing ( mean 72.9 minutes with lasing time mean 32 minutes which represent 44% utilization time ). Looking at relatively big size prostates group (mean of 111.5 ml), the operative time was very good. The maximum flow rate was statistically significant with minimal residual and over all high patients’ satisfaction represent the efficacy of the therapy in such patients.

Photo-Selective Vaporization of the Prostate (PVP) with the 180W-XPS Green Light laser system is an effective and safe modality of treatment in high risk patients with BPH whatever size of prostate is. Prospective randomized controlled studies with higher number of patients are needed to further confirm such results.