Stesura Seveso 297Archivio Italiano di Urologia e Andrologia 2020; 92, 4 ORIGINAL PAPER L. Cindolo and G. Ferrari do surgical tutorship for AMS and received honoraria for their tutorship. DOI: 10.4081/aiua.2020.4.297 INTRODUCTION Lower urinary tract symptoms (LUTS) are strongly associ- ated with ageing (1) and might be the most evident con- sequence of benign prostatic hyperplasia (LUTS/BPH). LUTS/BPH, when related to bladder outlet obstruction (BOO), are often caused by benign prostatic enlargement (BPE) (2). A surgical treatment is often necessary in LUTS/BPH patients who experience low efficacy of phar- macological therapies or want to discontinue these ther- apies (3). Moreover, some patients may have already progressed and/or experienced LUTS/BPH complica- tions, such as bladder diverticula or vesical calculi before surgery (4). Furthermore, since patients with LUTS/BPH are usually aged, other conditions such inguinal hernia may require supplementary surgical treatment (4). Nowadays, photoselective vaporization of the prostate (PVP) with GreenLight XPS 180 Watt laser (GL-180-W XPS) (American Medical Systems, Minnetonka, Minnesota, USA) is considered a valid alternative to TURP, thanks to its safe- ness and efficacy (5). Moreover, the GL-180-W XPS PVP guarantees an early discharge and limits the need for blood transfusion (6-8). Currently, little evidence on the safety, efficacy and feasibility of PVP with other concomi- tant procedures are available. This evidence derived most- ly from single center or case series reports (9, 10). The aim of this study is to evaluate the safety and feasi- bility of GL-180-W XPS PVP combined with other sur- gical procedures. Moreover, we aim to test the effect of simultaneous procedures on perioperative outcomes, functional outcomes and complication rates. MATERIALS AND METHODS Data on patients in whom PVP was performed to relieve LUTS/BPH symptoms were abstracted from a multi-insti- tutional database (2011-2016). Patients were stratified into two groups. In the first group, all patients who had PVP with a concomitant procedure during the same sur- gical session were included as cases. In the second group, Objectives: To explore the safety and feasi- bility of photo-selective vaporization of the prostate (PVP) with GreenLight XPS 180 Watt laser (GL-180- W XPS) combined with other surgical procedures. Material and methods: Data on patients in whom GL-180-W XPS was performed to relieve lower urinary tract symptoms/ benign prostatic hyperplasia (LUTS/BPH) symptoms were extracted from a multi-institutional database (2011-2016). Patients were stratified into two groups. In the first all patients who had GL-180-W XPS with a concomitant proce- dure during the same surgical session were included as cases while those who underwent GL-180-W XPS PVP only were included as control. Results: A total of 487 patients were included. Fifty-eight (11.9%) patients underwent concomitant procedures. Multivariable linear regression models failed to find an associ- ation between concomitant procedures and longer laser time (p = 0.4). Similarly, multivariable linear regression models failed to find an association between concomitant procedures and laser time even when the analyses were repeated and stratified into endoscopic (p = 0.6) and open/laparoscopic (p = 0.4) procedures. Multivariable logistic regression models failed to demonstrate any association between concomitant procedures and early complications (OR:1.39, CI: 0.379-2.44, p = 0.2), late complications (OR:1.84, CI:0.78-3.98; p = 0.1) and acute urinary retention (OR:1.84, CI:0.78-3.98; p = 0.1). When the analyses were repeated and the concomitant proce- dures stratified into endoscopic and open/laparoscopic ones, they yielded virtually the same results. Conclusions: GL-180-W XPS PVP could be safely performed in concomitant endoscopic or open/laparoscopic surgery. These results should be taken into consideration in the counseling of the patient who might choose to undergo simultaneous proce- dures. KEY WORDS: GreenLight laser; Concomitant procedures; LUTS/BPH; Simultaneous surgery. Submitted 24 March 2020; Accepted 21 August 2020 The safety and feasibility of the simultaneous use of 180-W GreenLight laser for prostate vaporization during concomitant surgery Summary Roberto Castellucci 1, Michele Marchioni 2, Giuseppe Fasolis 3, Francesco Varvello 3, Pasquale Ditonno 4, Gaetano Di Rienzo 4, Francesco Greco 5, Vincenzo Maria Altieri 5, Antonio Frattini 6, Giovanni Ferrari 7, Luigi Schips 2, Luca Cindolo 8 1 Department of Urology ASL Abruzzo 2 Chieti, Italy; 2 Department of Urology, SS Annunziata Hospital, “G. D’Annunzio” University, Chieti, Italy; 3 Department of Urology, “S. Lazzaro” Hospital, Alba, Italy; 4 Department of Emergency and Organ Transplantation, Urology and Andrology Unit II, University of Bari, Bari, Italy; 5 Department of Urology, Humanitas “Gavazzeni”, Bergamo, Italy; 6 Department of Urology, “Ercole Franchini” Hospital, Montecchio Emilia, Italy; 7 Department of Urology, “Hesperia” Hospital, Modena, Italy; 8 Department of Urology, Private Hospital Villa Stuart, Rome, Italy. Castellucci_Stesura Seveso 14/12/20 20:34 Pagina 297 Archivio Italiano di Urologia e Andrologia 2020; 92, 4 R. Castellucci, M. Marchioni, G. Fasolis, F. Varvello, P. Ditonno, G. Di Rienzo, F. Greco, V.M. Altieri, A. Frattini, G. Ferrari, L. Schips, L. Cindolo 298 all patients who underwent only simple PVP were includ- ed as controls. PVP procedures were performed according to the techniques previously described by Gomez-Sancha and following the surgeons’ preferences (11). The characteristics of patients collected at the time of sur- gery were age, LUTS/BPH drug therapy, antiplatelet/anti- coagulant therapy, ASA score. Moreover, prostate volume, PSA levels, International Prostate Symptom Score (IPSS), maximum urinary flow (Qmax) and indwelling catheter history before surgery were recorded. Intra- and peri- operative data, including anesthesia type, laser time, ener- gy used, catheterization time and postoperative stay were noted. The laser time referred only to the time from the beginning to the end of laser prostate vaporization. All the patients underwent an outpatient clinic visit at least after 3 months and then annually. During the follow-up visit, IPSS, Qmax, and PSA levels were recorded. The Patient Global Impression of Improvement (PGI-I) was evaluated with the PGI-I scale (12). Complications were collected and classified as early (within 30 post-operative days) or late (after 90 days). Early complications were clas- sified according to the Clavien-Dindo system (13, 14). Our study has been reported in line with the STROCCS criteria (15). Written informed consent was obtained from all subjects and for this study ethical committee approval was given. Statistical analysis Descriptive statistics relied on median and interquartile ranges for qualitative covariates and on count and percent- ages (%) for categorical variables. Differences between groups were assessed with the chi-square test for categori- cal variables and the Mann-Whitney U test for continuous variables. Three sets of analyses were performed. First, multivariable linear regression models examined the effect of concomitant procedures on the laser time. Second, sep- arate multivariable logistic regression models tested the effect of concomitant procedures on the rates of early com- plications, late complications and acute urinary retention. Third, all the analyses were repeated after using a different coding that stratified the concomitant procedures into endoscopic versus open/laparoscopic ones. All the multi- variable models were adjusted for age and prostate volume. All statistical tests were two-sided. The level of signifi- cance was set at p < 0.05. Analyses were performed using the R software environment for statistical computing and graphics (version 3.4.3; http://www.r-project.org/). RESULTS Preoperative and post-operative descriptive analyses In total 487 patients were included. Out of them 58 (11.9%) underwent a PVP and a concomitant procedure during the same anesthesia. Twenty-nine endoscopic and 29 open/laparoscopic concomitant procedures were per- formed (Table 1). Patients who underwent concomitant procedures had a more frequent history of an indwelling catheter (36.2 vs. 21.2%, p = 0.02). Moreover, patients with concomitant procedure were more frequently treat- ed for LUTS/BPH symptoms (31 vs. 18.4%, p = 0.02) (Table 2). Patients who underwent PVP in association with Overall PVP PVP + Concomitant p-value (n = 487) (n = 429) procedures (n = 58) Preoperative parameters Age, years 70 (64-76) 70 (64-77) 70.5 (65.2-76) 0.8 Follow-up duration, months 17 (11-23,5) 18 (11-24.6) 14.5 (8-19.8) < 0.001 Prostate volume, mL (missing = 3) 60 (43.8-80) 60 (45-80) 52 (40-74) 0.05 PSA, ng/mL (missing = 58) 2.7 (1.3-4.5) 2,7 (1.3-1.4) 2.5 (1-5.1) 0.7 Qmax, mL/s (missing = 116) 8 (6-10) 8 (6,1-10) 7.6 (6.3-10) 0.2 IPSS (missing = 118) 25 (21-28) 25 (21-28) 26 (20.5-33.5) 0.05 ASA score 0.05 1-2 259 (53.2) 220 (51.3) 39 (67.2) 3-4 93 (19.1) 83 (19.3) 10 (17.2) Unknown 135 (27.7) 126 (29.4) 9 (15.5) History of catheterization 112 (23) 91 (21.2) 21 (36.2) 0.02 BPH therapy 0.02 5-ARI 15 (3.1) 12 (2.8) 3 (5.2) Alfa-blocker 236 (48.5) 207 (48.3) 29 (50) Combination therapy 139 (28.5) 131 (30.5) 8 (13.8) None 97 (19.9) 79 (18.4) 18 (31) Table 1. Concomitant procedures. Table 2. Demographic and clinical characteristics of patients before photo-selective vaporization of the prostate stratified according to the surgical procedure (PVP vs PVP + concomitant procedures). Quantitative variables are reported as median and interquartile ranges (IQR). Qualitative variables are reported as count and percentages (%). Concomitant procedure Numbers of procedures Kind of surgery Vescical lithotripsy 13 Endoscopic Internal Urethrotomy 8 Endoscopic TURB 5 Endoscopic Vescical botulinum 3 Endoscopic Inguinal hernia repair 24 Laparoscopic/open Colecistectomy 2 Laparoscopic/open Hydrocelectomy 2 Laparoscopic/open Laparoscopic bladder diverticulectomy 1 Laparoscopic/open other endoscopic procedures were more frequently diag- nosed with smaller prostate glands (median volume 50.0 vs. 60.0 mL; p = 0.020) and had more frequently an his- tory of indwelling catheter (41.4 vs. 21.2%, p = 0.012 (Supplementary Table 1). After the surgery, significant statistical differences were found for the indwelling catheter time which was longer in patients who underwent concomitant procedures (2 vs. 1 day, p = 0.006). Moreover, the DIPSS was slightly wider for patients who underwent concomitant procedures (-20 vs. -18, p = 0.03) than in those who underwent simple PVP (Table 3). No differences between the two groups were found in terms of an early and late complication rate (p = 0.3 and p = 0.07 respectively) (Table 3). Acute urinary retention occurred in 8.4 and 15.5 patients after simple PVP and PVP with concomitant procedure, respectively (p = 0.1). DUFM was not statistically signifi- cant different between two groups (p = 0.4). Most of the patients (56.7%) had no complications at all; among patients with complications the wide majority was graded as Clavien-Dindo I (40.7%) (Tables 3, 4). Consistently we found no statistically significant differences in terms of Castellucci_Stesura Seveso 14/12/20 20:34 Pagina 298 main postoperative outcomes when PVP patients were compared to those who had PVP in association with other endoscopic procedures (Supplementary Table 2). Multivariable linear regression models Multivariable linear regression models failed to find an association between concomitant procedures and longer laser time (coefficient 1.59, -1.90 to 5.08; p = 0.4). Similarly, multivariable linear regression models failed to find an association between concomitant procedures and 299Archivio Italiano di Urologia e Andrologia 2020; 92, 4 Green Light laser and concomitant surgery Table 3. Demographic and clinical characteristics of patients during and after photoselective vaporization of the prostate stratified according to the surgical procedure (PVP vs PVP + concomitant procedures). Quantitative variables are reported as median and interquartile ranges (IQR). Qualitative variables are reported as count and percentages (%). Supplementary Table 1. Demographic and clinical characteristics of patients before photoselective vaporization of the prostate stratified according to the surgical procedure (PVP vs PVP + other endoscopic procedures). Quantitative variables are reported as median and interquartile ranges (IQR). Qualitative variables are reported as count and percentages (%). PVP PVP + Other endoscopic p-value (n = 429) procedures (n = 29) Age, years 70.0 (64.0, 77.0) 72.0 (67.0, 76.0) 0.546 Prostate volume, mL 60.0 (45.0, 80.0) 50.0 (35.0, 67.2) 0.020 PSA, ng/mL 2.7 (1.3, 4.4) 1.4 (1.0, 3.6) 0.133 Qmax, mL/s 8.0 (6.1, 10.0) 8.6 (7.0, 11.0) 0.573 IPSS 25.0 (21.0, 28.0) 23.0 (20.0, 30.0) 0.954 ASA score 0.477 - 1-2 220 (51.3%) 17 (58.6%) - 3-4 83 (19.3%) 3 (10.3%) - Unknown 126 (29.4%) 9 (31.0%) History of catheterization 91 (21.2%) 12 (41.4%) 0.012 BPH therapy 0.163 - 5-ARI 12 (2.8%) 3 (10.3%) - Alfa-blocker 207 (48.3%) 14 (48.3%) - Combination therapy 131 (30.5%) 8 (27.6%) - None 79 (18.4%) 4 (13.8%) Supplementary Table 2. Demographic and clinical characteristics of patients during and after photoselective vaporization of the prostate stratified according to the surgical procedure (PVP vs PVP + other endoscopic procedures). Quantitative variables are reported as median and interquartile ranges (IQR). Qualitative variables are reported as count and percentages (%). PVP PVP + Other endoscopic procedures p-value (n = 429) (n = 29) Laser time (min) 27.0 (18.0, 38.2) 20.5 (17.0, 33.5) 0.250 Energy used (Kj) 247.1 (157.1, 360.0) 193.0 (148.8, 337.7) 0.442 Discharge day 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) 0.838 Catheter removal day 1.0 (1.0, 2.0) 2.0 (1.0, 3.0) 0.079 Δ PSA, ng/mL -1.3 (-2.9, -0.2) -0.7 (-1.8, -0.3) 0.207 Δ Qmax, mL/s 11.0 (7.0, 14.0) 8.2 (1.8, 12.8) 0.076 Δ IPSS -18.0 (-23.0, -14.0) -16.0 (-25.0, -13.0) 0.691 Acute urinary retention 36 (8.4%) 5 (17.2%) 0.106 Late complications 73 (17.0%) 8 (27.6%) 0.149 Early complication 182 (42.4%) 12 (41.4%) 0.912 Satisfaction 0.617 Not satisfied 16 (3.7%) 2 (6.9%) Satisfied 388 (90.4%) 26 (89.7%) Unknown 25 (5.8%) 1 (3.4%) Clavien-Dindo classification 0.356 0 247 (57.6%) 17 (58.6%) 1 170 (39.6%) 11 (37.9%) 2 2 (0.5%) 0 (0.0%) 3a 2 (0.5%) 1 (3.4%) 4a 8 (1.9%) 0 (0.0%) Overall PVP PVP + Concomitant p-value (n = 487) (n = 429) procedures (n = 58) Peri- and post-operative features Laser time (min) (missing = 26) 27 (18-37) 27 (18-38.2) 25 (18.4-34.2) 0.6 Energy used (Kj) (missing = 5) 246.6 247.1 (157.1-360) 242.4 (169.0-336.1) 0.7 Discharge day 2 (1-2) 2 (1-2) 2 (1-2) 0.7 Catheter removal day 1 (1-2) 1 (1-2) 2 (1-2,8) 0.006 Δ PSA, ng/mL -1.3 (-3 to -0.3) -1.3 (-2.9 to -0.2) -1.1 (-3.0 to -0.5) 0.5 Δ Qmax, mL/s 11 (7-14) 11 (7-14) 12.6 (8.6-13.7) 0.4 Δ IPSS -18 (-24 to -14) -18 (-23 to -24) -20 (-27.5 to -14) 0.03 Acute urinary retention 45 (9.2) 36 (8.4) 9 (15.5) 0.1 Late complications 89 (18.3) 73 (17) 16 (27.6) 0.07 Early complication 211 (43.3) 182 (42.4) 29 (50) 0.3 Satisfaction 0.5 Not satisfied 20 (4.1) 16 (3.7) 4 (6.9) Satisfied 439 (90.1) 388 (90.4) 51 (87.9) Unknown 28 (5.7) 25 (5.8) 3 (5.2) Clavien-Dindo classification 0.4 0 276 (56.7) 247 (57.6) 29 (50) 1 198 (40.7) 170 (39.6) 28 (48.3) 2 2 (0.4) 2 (0.5) 0 (0) 3a 3 (0.6) 2 (0.5) 1 (1.7) 4a 8 (1.6) 8 (1.9) 0 (0) Table 4. Early and late complications according to the surgical procedure (PVP vs PVP + concomitant procedures). Qualitative variables are reported as count and percentages (%). Early complications Overall PVP PVP + Concomitant procedures Fever (< 38°C) 13 (2.7) 12 (2.8) 1 (1.7) Fever (≥ 38°C) 15 (3.1) 11 (2.6) 4 (6.9) Burning urination 74 (15.2) 61 (14.2) 13 (22.4) Bladder tenesmus 37 (7.6) 32 (7.5) 5 (8.6) Urge 42 (8.6) 36 (8.4) 6 (10.3) Urge incontinence 47 (9.7) 37 (8.6) 10 (17.2) Stress incontinence 36 (7.4) 30 (7) 6 (10.3) Capsule perforation 6 (1.2) 5 (1.2) 1 (1.7) Hematuria 16 (3.3) 16 (3.7) 0 (0) Acute urinary retention 45 (9.2) 36 (8.4) 9 (15.5) Urinary tract infections 7 (1.4) 7 (1.6) 0 (0) Blood transfusion 3 (0.6) 3 (0.7) 0 (0) Cardiovascular acute event 13 (2.7) 13 (3) 0 (0) Minor cardiovascular event 5 (1) 5 (1.2) 0 (0) Major acute cardiovascular event 8 (1.6) 8 (1.9) 0 (0) Late complications Urethral stenosis 14 (2.9) 11 (2.6) 3 (5.2) Bladder neck contracture 18 (3.7) 14 (3.3) 4 (6.9) Prostatic fossa sclerosis 8 (1.6) 8 (1.9) 0 (0) Urinary stress incontinence 27 (5.5) 23 (5.4) 4 (6.9) Re-intervention 10 (2.1) 7 (1.6) 3 (5.2) Persistent irritative symptoms 28 (5.7) 22 (5.1) 6 (10.3) Urethral stenosis 14 (2.9) 11 (2.6) 3 (5.2) Bladder neck contracture 18 (3.7) 14 (3.3) 4 (6.9) Castellucci_Stesura Seveso 14/12/20 20:34 Pagina 299 Archivio Italiano di Urologia e Andrologia 2020; 92, 4 R. Castellucci, M. Marchioni, G. Fasolis, F. Varvello, P. Ditonno, G. Di Rienzo, F. Greco, V.M. Altieri, A. Frattini, G. Ferrari, L. Schips, L. Cindolo 300 laser time even when the analyses were repeated and the concomitant procedures stratified into endoscopic (coef- ficient 1.21, -3.50 to 5.92, p = 0.6) and open/laparo- scopic (coefficient 1.99, -2.88 to 6.85, p = 0.4) ones. Multivariable logistic regression models Multivariable logistic regression models failed to demon- strate any association between concomitant procedures and early complications (OR: 1.39, CI: 0.38-2.44, p = 0.2), late complications (OR: 1.84, CI: 0.78-3.98; p = 0.1) and acute urinary retention (OR: 1.84, CI: 0.78-3.98; p = 0.1). When the analyses were repeated and the concomitant procedures were stratified into endoscopic and open/laparoscopic ones, they yielded virtually the same results (Table 5). DISCUSSION We hypothesized that PVP combined with other surgical procedures is feasible and safe. To test our hypothesis, we compared functional and surgical outcomes of patients who underwent PVP combined with other surgical proce- dures, with those who underwent PVP only. Data were abstracted from a large multi-institutional database. Our analyses showed several important findings. First, the proportion of patients with a history of catheter- ization was higher in the concomitant procedure group compared to the standard procedure group (36.2 vs. 21.2%). However, the proportion of patients not pharma- cologically treated was also higher in the concomitant pro- cedure compared to the standard procedure (31.0 vs. 18.4%). This finding is of interest because suggests that patients undergoing concomitant procedures could be less compliant to chronic treatments or physicians less prone to prescribe medications in those who are candidate to combination surgery with an history of indwelling catheter. It is worth of consideration the fact that in patients with a history of an indwelling catheter, the use of an alpha-blocker reduces the risk of acute retention after catheter removal (16). Moreover, the use of combination therapy in LUTS/BPH patients reduces the risk of compli- cations (17). Taken together these observations suggest that it might be of importance for more complex patients, such as those candidates for concomitant procedures, to continue or start LUTS/BPH therapy in order to reduce the risk of complications after surgery. Unfortunately, the granularity of our dataset do not allow to specifically investigate this hypothesis, thus larger and prospective studies investigating the effect of LUTS/BPH treatment in concomitant procedure candidates are warrant. Second, in a multivariable linear regression model no sta- tistically significant differences were found in laser time between the concomitant procedure and standard proce- dure groups. We relied on this parameter as a surrogate of surgical difficulties that may occur when more than one procedure is performed. Indeed, when concomitant pro- cedures are performed before the PVP, especially for endo- scopic treatments (i.e. vesical lithotripsy or internal ure- throtomy), bleeding or access difficulties are always a pos- sibility. Moreover, it is worth of consideration that in our study the two groups (simple PVP and concomitant pro- cedure) had similar prostate size. In consequence, our findings suggest that the most important predictor of laser time is the prostate size. Thus, physicians should not worry to perform concomitant procedures, that do not affect the effectiveness of PVP. The latter is confirmed again by our results, which also showed no detrimental effect of concomitant procedures on overall early compli- cations, late complications or acute urinary retention in multivariable logistic regression models. Results were vir- tually the same even when all the multivariable models were adjusted to the different nature of concomitant sur- gical procedures (standard, endoscopic and laparoscop- ic/open) in specific analyses. Our findings suggest that PVP performance is not affected by other surgical procedures. Such evidence is clinically meaningful considering that almost 10% of patients need more than one treatment, according to our series. This finding corroborates those of smaller and/or more histori- cal series. Patel et al. in a smaller single institutional series (N = 372, 38 underwent concomitant procedures) also showed no enucleation and morcellation time differences in patients who underwent HOLEP with concomitant pro- cedures (4). Similarly, the feasibility of GL-180-W PVP in combination with various other procedures was shown in small series or case reports (9, 10, 18, 19). More specifically, De la Torre et al. explored the feasibility of Green Light laser 80 or 120 W prostate vaporization and bladder lithotripsy with holmium laser in 19 patients. The authors showed that there was a significant improvement in terms of Qmax, post-micturition residual volume, and IPSS after surgery with no intra- o post-operative compli- cations (10). In a similar study Hora et al. reported no peri- or post-operative complications in 8 patients who under- went laparoscopic bladder diverticulectomy and Green Light Laser HPS 120 W or XPS 180 W vaporization of prostate in one operative session (19). Taken together, our study as well as those previously discussed, show the feasi- bility of laser surgery and more specifically of GL-180-W PVP concomitantly with other procedures (9, 10, 18-20). Third, despite the fact that preoperative IPSS was similar in a concomitant procedure compared to the standard, ∆IPSS was wider in the concomitant procedure compared to the standard procedure (-20 vs. -18). This finding corroborates the results of previous investigators that showed a larger improvement in terms of IPSS in patients who underwent Table 5. Multivariable logistic regression (adjusted for prostate volume and patient age), concomitant procedures endoscopic and other vs. standard. Outcomes Odds ratio (95% confidence interval) Univariable p-value Multivariable p-value Early complications Standard Reference Reference Endoscopic 0.96 (0.44-2.04) 0.9 0.99 (0.45-2.16) 0.9 Laparoscopic/open 1.92 (0.90-4.22) 0.09 1.91 (0.89-4.21) 0.09 Late complications Standard Reference Reference Endoscopic 1.86 (0.75-4.21) 0.15 1.95 (0.77-4.49) 0.1 Laparoscopic/Open 1.86 (0.75-4.21) 0.15 1.85 (0.75-4.20) 0.2 Acute urinary retention Standard Reference Reference Endoscopic 2.27 (0.73-5.89) 0.1 1.91 (0.60-5.11) 0.2 Laparoscopic/open 1.75 (0.49-4.81) 0.3 1.76 (0.49-4.97) 0.3 Castellucci_Stesura Seveso 14/12/20 20:34 Pagina 300 301Archivio Italiano di Urologia e Andrologia 2020; 92, 4 Green Light laser and concomitant surgery a concomitant procedure compared to a standard proce- dure (4). This finding is a novelty in the field of GL-180- W XPS PVP. Indeed, to the best of our knowledge no previous studies have investigated functional outcomes after GL-180-W XPS PVP with concomitant not urologi- cal surgical procedures. For example, De la Torre et al. related the use of Green Light laser 80 or 120 W prostate vaporization and bladder lithotripsy with holmium laser, Hora et al. Green Light Laser HPS 120 W or XPS 180 W with bladder diverticulectomy and Cindolo et al related the feasibility of GL-180-W XPSPVP associated to robot- assisted laparoscopic diverticulectomy (9, 10, 19). It might be hypothesized that in patients with concomi- tant pathological conditions the relief from multiple comorbidities may exert a positive effect also on IPSS, which is wider than in patients with LUTS/BPH only. Nevertheless, this study has several limitations. The major limitations are related to its retrospective study and the fact that non-randomized design and different surgical experience could not be controlled in the ana- lytic phase. 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Correspondence Roberto Castellucci, MD - roberto.castellucci@gmail.com Via Nazionale Adriatica nord 99 - Pescara (Italy) Michele Marchioni, MD - mic.marchioni@gmail.com Luigi Schips, MD - luigischips@hotmail.com Via dei Vestini 1 - Chieti, Italy Giuseppe Fasolis, MD - info@poliambulatoriosanpaolo.it Francesco Varvello, MD - segreteria@francescovarvello.it C.so Entoria 16 - Alba, Italy Pasquale Ditonno, MD - ditonno@urologia.uniba.it C.so V. Emanuele II, Bari- Italy Gaetano Di Rienzo, MD - dirienzo@urologia.uniba.it Via Lucera 4 Bari - Italy Francesco Greco, MD - francesco.greco@gavazzeni.it Vincenzo Maria Altieri, MD - vmaltieri@alice.it Via Gavazzeni 1 - Bergamo, Italy Antonio Frattini, MD - antoniofrattini@gmail.com Via Donatori di Sangue - Guastalla, Italy Giovanni Ferrari, MD - gferrari@hesperia.it Via Arquà 80 - Modena, Italy Luca Cindolo, MD - lucacindolo@virgilio.it Via Trionfale 5952 - Roma, Italy Castellucci_Stesura Seveso 14/12/20 20:34 Pagina 301