In this episode we discuss Greenlight, a laser treatment for the urinary symptoms experienced by men due to an enlarged or obstructing prostate(BPH). In previous episodes we have covered a variety of other BPH treatment ranging from the historical gold standard (TURP) to minimally invasive surgical therapies (MIST) such as Rezum, Urolift, and iTind to more specialized treatments such as HoLEP and robotic simple prostatectomy. So how does Greenlight fit in to this spectrum of BPH treatments? How is the procedure performed? What are the risks and benefits? What is the recovery like? And, of course, how effective is it? To help us answer these questions, we are joined by a true expert.
Bilal Chughtai, MD
Dr. Bilal Chughtai is an Associate Professor of Urology at Cornell. He is also an Associate Attending Urologist at NewYork-Presbyterian Hospital. Dr. Chughtai specializes in Voiding Dysfunction, Female Urology, and Neurourology. Dr. Chughtai earned his medical degree at State University of New York at Stony Brook. He then completed his Residency in General Surgery and Urology at Albany Medical Center, followed by a Fellowship in Female Urology, Neurourology, and Voiding Dysfunction at Weill Cornell Medical Center and Memorial Sloan Kettering Cancer Center. Dr. Chughtai is also an active researcher. He has served as primary & co-investigator in numerous studies. He has published over 160 peer-reviewed articles, authored chapters and books, and has presented at numerous prestigious national meetings.
Better Man Clinics
GreenLight is a procedure using laser technology to treat the urinary symptoms associated with an enlarged prostate (BPH). With all the new procedures that have become available to treat BPH (like UroLift, Rezum, HoLEP etc), why is GreenLight still a viable treatment option for men with BPH?
Bilal Chughtai, MD
Greenlight is a technology that has been around since around 2012. The most recent iteration is the 180 watt laser. Since its introduction, there have been what I like to call micro-evolutions of changes (how you approach the pressure bag, the appropriate scopes to use, a variety of techniques of how you create incisions etc). and so it has improved over time. Some of the newer procedures that you mentioned are limited by the anatomy of the prostate (two lobe versus three lobes, high bladder neck, etc.), but when you talk about GreenLight, it’s really able to treat almost any prostatic anatomy and prostates of almost any size as well. So, in many ways, it’s a great tool to have in an armamentarium of how to address bladder outlet obstruction.
Better Man Clinics
You mentioned that GreenLight is a technique but you also mentioned that it is a specific type of laser. What is GreenLight? Is GreenLight just the laser that you are using or is GreenLight a whole series of techniques?
Bilal Chughtai, MD
GreenLight is the tool and it is the specific laser that you’re using. So, as we know, there are a multitude of lasers- Holmium laser, Thulium laser, and there’s the GreenLight laser. What makes Greenlight unique is that it is a 532 nanometer laser. That basically means that it is a chromophore for hemoglobin. That means that it really does target hemoglobin to help reduce bleeding. As such, it has a very unique laser property that other lasers like Holmium do not have. The other lasers can also address prostatic growth, but they’re not as hemostatic as a GreenLight.
Better Man Clinics
So, by targeting hemoglobin, which is a component of blood in the bloodstream, (and obviously within the blood vessels going through the prostate), Greenlight can actually neutralize those blood vessels easier and limit the amount of bleeding during the procedure ?
Bilal Chughtai, MD
Exactly. The prostate is a very highly vascular organ. As we know, if you cut into the prostate, it does bleed quite a bit which obscures visualization during the procedure. However, when you have a laser that’s a chromophore for that hemoglobin, it can help stop bleeding as you move along. So, therefore, it gives you good visualization and ensures that you’re staying within the correct anatomic planes.
Better Man Clinics
Most guys with BPH have been introduced to the concept of the TURP, or the colloquial “Roto Rooter”. The TURP procedure is often described as a hot knife or a hot ice cream scoop that scoops away the inner part of the prostate. In so doing, if we think of the prostate as a donut, the TURP scoops out the inner part and makes the donut hole larger. So, if TURP is a scooper, what is GreenLight? How is GreenLight different from a TURP?
Bilal Chughtai, MD
I actually use the same analogy for a TURP. I describe it like a hot ice cream scoop or a hot loop. In contrast, I describe Greenlight as more of an instrument that sculpts the inside of the prostate by vaporizing the tissue or converting that tissue into a gas. So what you’re doing is this: I point the laser at the tissue, and I physically remove that tissue by converting it into a gas. By doing so, you’re creating a space or enlarging that doughnut hole. You are sculpting that doughnut hole to be larger. Basically, the laser is able to very precisely remove that tissue.
Better Man Clinics
Is GreenLight consider a MIST (Minimally Invasive Surgical Therapy) procedure like Rezum or UroLift?
Bilal Chughtai, MD
BPH therapies come in two categories. There are procedures that are designed to alter tissue without actually destroying it. In other words, you’re not actively removing that tissue. UroLift and Rezum fall into this category. With these procedure, you are either compressing the tissue or putting steam into the tissue so that tissue shrinks. The other category includes the truly ablative procedures such as TURP, GreenLight, and Aquablation. With these procedures, you are physically making a hole in that doughnut, and you’re making it far larger. In terms of invasiveness, I would say that TURP, GreenLight, and Aquablation are probably pretty similar. When you talk about MIST, you’re going to be talking about UroLift, Rezum, and probably iTIND now, which reshape the inside of the urethra. But, in some ways, I feel like iTIND almost falls under another category called ”True MIST”. It’s a term coined by one of my colleagues, Dr. Elterman. With iTIND, we’re talking about a procedure similar to cardiac stenting. You see a blockage and you place a type of stent to relieve it. There are a bunch of stents that have come out including Butterfly, iTIND, Zenflow, and Proverum. So there’s a slew of these technologies that have come out that are designed to be temporary and almost reversible. That is a third category that is starting to pan out as well.
Better Man Clinics
Is there an ideal candidate for GreenLight or is it really for all comers?
Bilal Chughtai, MD
I think you really have to decide what is the risk benefit ratio? That is where we get to shared decision making. So when we get to share decision making, I think there are a couple of things that really pan out for GreenLight. I think those benefits include durability, bleeding risk and the removal of tissue. GreenLight has a huge benefit there. I think the other area where GreenLight has an advantage is for anyone on anticoagulation. Urologists have all had the same experiences with TURPs: you might have a case that looks pretty good as you’re finishing up, but all of a sudden, it can get pretty red as that patient gets into the recovery room. If you add on anticoagulation on top of that, the urine can get really red and patients may need catheters and transfusions. In contrast, its in these situations that GreenLight really shines. I think GreenLight also has an advantage when it comes to anatomy. I have performed the say GreenLight procedure for prostates as small as 30 grams and as large as 250 grams. So, I think, it’s able to really address a variety of prostate sizes. Now, there are limitations to the technology. I do think that as you get into larger prostates, you will probably see a higher retreatment rate because GreenLight is not going to be as thorough as a simple prostatectomy. But at the same time, it’s going to be a lot less invasive than a simple prostatectomy. These are discussions I typically have with patients when considering GreenLight versus other prostate procedures: ejaculatory function, durability, and level of invasiveness. Those three factors really play a role in determining who is a good candidate for GreenLight. I think another factor consider is that some urologists are attracted to technologies that are brand new while others are more data driven. I have seen some patients who ask, “What procedure have you performed the most? What procedure do you have the most experience with?” I think that’s where Greenlight really shines, because most urologists have extensive experience with it, especially given the fact that it is a technology we’ve been using since 2012. As a result, we’ve got a good cohort to follow and record data on.
Better Man Clinics
You mentioned anticoagulation. Do patients who are on blood thinners have them stop it for a period of time before GreenLight or can they just stay on them through the surgery?
Bilal Chughtai, MD
If I’m able to stop anticoagulation, I will. Of course, I’m still doing this under the guidance of their cardiologist, neurologist, or primary care doctor. But if I’m not able to stop it, I’ll warn the patient that there is always a chance that we might get into some bleeding and may have to stop the procedure. However, there is a good chance we will remove all the prostate tissue we need to despite keeping them on anticoagulation. I’ve done plenty of green lights on anticoagulation.
Better Man Clinics
Is there anybody who absolutely cannot or should not get GreenLight therapy for BPH?
Bilal Chughtai, MD
One group who should not have GreenLight are patients who are not willing to tolerate any ejaculatory dysfunction because with GreenLight, there is a chance of ejaculatory dysfunction. I think the second group who should avoid GreenLight would be those men who’ve had previous radiation. It seems like once that blood supply changes to the prostate, that healing that occurs after radiation can be quite challenging after GreenLight.
Better Man Clinics
What are the risks of ejaculatory dysfunction or retrograde ejaculation after GreenLight?
Bilal Chughtai, MD
Yeah, so when it comes to preserving ejaculatory function, I would have a discussion about the benefit of iTind, Urolift and Rezum. iTind and UroLift have close to a 0% chance of ejaculatory dysfunction. The risk with Rezum is close to 6%. Now, with GreenLight, there are a variety of techniques, including an ejaculatory sparing technique that we’ve described. We have had ejaculatory dysfunction rates as low as 10% in this cohort of patient undergoing the ejaculatory sparing GreenLight technique. But for most men, if we’re doing a traditional GreenLight, I would say that the rates of ejaculatory dysfunction are about 30% – meaning either a complete loss of the ejaculate or, at least, some dropping off of the ejaculate volume.
Better Man Clinics
How do those rates of ejaculatory dysfunction with GreenLight compare to those with TURP?
Bilal Chughtai, MD
The risk of ejaculatory dysfunction after TURP is around 30 to 50% as well, which is fairly high. I would say that the risk of ejaculatory dysfunction for GreenLight and TURP is probably pretty close, but it really depends on the technique you’re using for both.
Better Man Clinics
What techniques using GreenLight can decrease that risk of retrograde ejaculation?
Bilal Chughtai, MD
Traditionally, we’ve been taught that it’s the bladder neck that really preserves ejaculation. But I think what we’ve learned from the technology of Aquablation is that preserving the structures right around the ejaculatory ducts can preserve ejaculation probably close to 90% of the time. Now, there is a caveat, which is that we’re looking at a three-dimensional donut in two dimensions. So, what can happen, especially with larger prostates, is that you can sometimes leave a little bit too much apical tissue (around that area of the ejaculatory ducts), and those patients may not have the same response in terms of the clinical improvement, because you’re leaving a little bit too much tissue behind. So typically, my goal is to preserve the “urethral skin” or the mucosa of the area but I want to try to remove all the bothersome adenoma if I can.
Better Man Clinics
What are the risks of the GreenLight procedure?
Bilal Chughtai, MD
I think classically you want to talk about bleeding. There is a three to 4% risk of bleeding, but the risk of transfusion is pretty low. Bleeding can lead to a prolonged catheter time. There is also a risk of urinary tract infection which for most patients is 3 to 4%. For some patients, like those with indwelling catheters, the risk of urinary tract infection may be higher. The risk of incontinence is fairly low. In other words, when it comes to stress incontinence, the risk is probably less than 1%. That is based on our own data. If you look at the literature, the risk of incontinence is probably around 1%. The risk of erectile dysfunction is not going to change through one of these procedures.
Better Man Clinics
Why is the risk of of erectile dysfunction with GreenLight minimal or non existent given the traditional concerns of erectile dysfunction with prostate surgery?
Bilal Chughtai, MD
For a lot of patients, there’s always a family member or close friend who has had some type of prostate surgery. The problem is that when use the term prostate surgery, there’s there’s always a bit of a blur between cancer and benign surgery. When it comes to cancer surgery, there is a risk of erectile dysfunction and incontinence. But we know that when it comes to benign prostate surgery, you’re far away from those nerves that control erections and, so, the risk of erectile dysfunction is fairly low.
Better Man Clinics
How do the risks of GreenLight compare to those of TURP?
Bilal Chughtai, MD
With the modern TURP, like the modern bipolar TURP, the risk factors are probably pretty similar when it comes to risk of infection. The chances of having new onset urinary urgency and frequency are also pretty equivalent for the two procedures. Also, the rates of continence are pretty similar. I think the biggest advantage of GreenLight probably lies within bleeding and the recovery time. You are healing faster because you’re dealing with less bleeding. As a result, your healing time, time out of the hospital, and time to the removal of the catheter is probably faster with GreenLight.
Better Man Clinics
What is the recovery process like after a GreenLight procedure?
Bilal Chughtai, MD
The difference between Greenlight versus TURP is that you’re going to be out of the hospital faster, you’re going to have a catheter in for a shorter period of time, you’re going to have less bleeding, so you’re going to feel better faster. However, at the same time, there’s going to be some irritative voiding symptoms that can persist. So, in other words, for the first couple weeks, it can still be that the urine isn’t perfectly clear, and you may have to take something like Flomax or other alpha blockers, because of the smooth muscle that’s there in the area that we’re ablating. So, you may still have some of those symptoms, which can be controlled fairly easily with medications. And that’s typically why we have you on an alpha blocker like Flomax for the first two weeks after the procedure. You can probably imagine that, given the fact that you’re ablating some tissue, you’re going to have some burning with urination. However, that burning usually only lasts for the first couple days as well. The irritative voiding symptoms are really what prolong your recovery. But, for the most part, I think it’s a fairly quick recovery. The other part about it is that you’re going to be doing a lot less of the whole clot evacuation procedures because you’re having less bleeding as well. So, it’s really just dealing with a short period of irritative voiding symptoms, probably for the first couple weeks after the procedure.
Better Man Clinics
What kind of results do you typically see with Greenlight therapy for BPH?
Bilal Chughtai, MD
When we look at Greenlight, the durability is probably the biggest question because you’re worried that, if you’re not actually removing tissue, you may have a little bit of regrowth and you eventually have to remove more tissue. That is the biggest question that comes up. However, when we look at 10 years after surgery, we see that 80 to 90% of patients have good durability. They still have a nice urinary flow and quality of life. I think that a big part of this is selecting good candidates for GreenLight. There is an index called the Abrams Griffiths index, which is basically looking at how well your bladder is squeezing. On that scale, if you’re over a score of 40, you have a really good chance of having a good outcome with Greenlight. I think that really plays a role as well as your bladder capacity. If you have a good bladder capacity and good bladder contractility, you’re probably going to be a good candidate for Greenlight. Those are some of the factors that I think really play a role in terms of having good durability with GreenLight. But the fact is that, overall, if you’re a good candidate, you’re going to have a really good chance of having a long lasting outcome with this procedure.
Better Man Clinics
Do you find that Greenlight is effective for a wide range of prostate sizes or are there certain prostate sizes for which it seems to be more effective?
Bilal Chughtai, MD
GreenLight works better on prostates that are under 100 grams. I would say that you start to see a little bit more of a retreatment rate as you get over 100 grams. These retreatment rates are probably fairly similar to what you would see with UroLift, where some patients do retreat in that second year or third year. So, there is a higher retreatment rate that exists with the larger prostates, but it’s certainly not as high as you would see with some of the other techniques.
Better Man Clinics
What type of evaluation does a guy need to go through to see if he would be a good candidate for GreenLight?
Bilal Chughtai, MD
If you want to try pills, supplements, or natural remedies, we won’t do any workup initially. If progress isn’t made or frustration sets in, we’ll discuss the role of procedures. For procedures, I usually perform a Cystoscopy, a tiny camera inside the penis, to examine the prostatic anatomy. I also do a transrectal ultrasound to determine prostate size and non-invasive urodynamics like a Uroflow and PVR. Some patients may need additional urodynamic tests for a clear diagnosis before any procedure. After the workup, we discuss a couple of procedures based on their specific needs and preferences.
Better Man Clinics
Is there any preparation that is required before GreenLight surgery?
Bilal Chughtai, MD
Prior to the procedure, I usually have patients see their primary care doctor to ensure no other health issues are present. Since we perform the procedure under general or spinal anesthesia, we want to make sure they can tolerate it well.
Better Man Clinics
Is a bowel prep or fasting required before the GreenLight procedure?
Bilal Chughtai, MD
Since GreenLight requires anesthesia, patients need to fast the night before, but there’s no specific bowel prep for these procedures.
Better Man Clinics
How long does the GreenLight procedure take to perform?
Bilal Chughtai, MD
Generally, it takes about an hour, including anesthesia time and getting them out of the operating room. For very large prostates, it may take up to an hour and a half.
Better Man Clinics
What actually happens during a GreenLight procedure?
Bilal Chughtai, MD
Once the patient is under anesthesia, we put his legs into stirrups to access the prostatic urethra. We then use a rigid telescope into the penis. The telescope has a small laser unit within it to precisely target and remove obstructing prostate tissue. I map out the anatomy and remove as much tissue as possible. Following removal, we ensure no bleeding, and place a catheter to aid healing. The catheter is usually removed the next morning.
Better Man Clinics
Do most patients stay in the hospital overnight after the GreenLight procedure?
Bilal Chughtai, MD
It depends on their comfort with the catheter. If they are uncomfortable, I recommend staying overnight. Otherwise, they can come to my office the next day for catheter removal.
Better Man Clinics
Catheter removal is a concern for many. Is it painful to have the catheter removed after a GreenLight procedure?
Bilal Chughtai, MD
The penis is a sensitive organ. Also, catheters we need to place postoperatively are typically a little bit larger than the ones that we place regularly. So, as a result, removing it can be a little uncomfortable. We do our best to add numbing jelly to the tip of the penis and try to make it as comfortable as possible. Once a catheter is removed, there will be some urinary urgency, frequency, and burning as well as a little bit of blood in the urine for a few weeks as they heal.
Better Man Clinics
Does any leakage of urine occur after the catheter is removed following a GreenLight procedure?
Bilal Chughtai, MD
When the catheter is removed, some leakage may occur initially, but it usually resolves as the sphincter strengthens after a couple of weeks. Persistent stress incontinence is uncommon (less than 1%).
Better Man Clinics
How long should patients refrain from sexual activity after the GreenLight procedure?
Bilal Chughtai, MD:
Usually, about a month, as an orgasm can cause muscles around the prostate to squeeze.
Better Man Clinics
What restrictions should patients expect post-procedure after GreenLight?
Bilal Chughtai, MD
Most patients could probably go back to their normal activities, such as walking, going up and down stairs, pretty much right away. Just expect to urinate frequently and the urge to urinate may be a little bit unpredictable. That could last for about a month or so but, at the two-week mark, they should have a dramatic improvement.
Better Man Clinics
When can guys return to work after a GreenLight procedure?
Bilal Chughtai, MD
It depends on what kind of work they do but most can return to normal activities after two weeks. Driving may be uncomfortable, so breaks are recommended. Avoiding bike riding is also suggested as pressure on the perineum from the seat can make it uncomfortable.
Better Man Clinics
How long until patients achieve complete recovery?
Bilal Chughtai, MD
Complete recovery may take up to three months, with significant improvement by the six-week mark. The time to recovery also depends on underlying bladder dysfunction. I would say that probably you get an 85% recovery at the six-week mark and a probably 95 or 99% recovery at the three-month mark.
Better Man Clinics
Many patients are on medications for the prostate before the GreenLight procedure. How do you handle medications post-procedure?
Bilal Chughtai, MD
I typically stop most prostate medications around the six-week mark, depending on symptom improvement. Five alpha-reductase inhibitors (Proscar, Avodart etc) may be continued for men with larger prostates to reduce the risk of retreatment.
Better Man Clinics
What is the risk of needing another treatment or going back on medication after GreenLight?
Bilal Chughtai, MD
Surgical retreatment rates are around 5% at five years. While there’s no direct head-to-head comparison with other procedures, Greenlight’s durability is comparable, if not slightly better as compared to the MIST procedures like UroLift and Rezum.
Better Man Clinics
Do all urologists perform GreenLight, and is there a recommended number of cases for proficiency?
Bilal Chughtai, MD
Not all urologists perform GreenLight, but many do. Proficiency usually develops after around 20 to 25 cases, although the specific anatomy and complexity of the case can influence the learning curve.
Better Man Clinics
Are there questions patients should ask their surgeons before agreeing to Greenlight?
Bilal Chughtai, MD
Patients can ask about the surgeon’s experience with ejaculation sparing procedures, the techniques used, and the incidence of ejaculatory dysfunction in their practice.