Lasers in Medical Science (2023) 38:150

https://doi.org/10.1007/s10103-023-03781-7

REVIEW ARTICLE

Network meta‑analysis of the treatment safety and efficacy

of different energy systems in prostate vaporization
Kaiwen Xiao1 · Yucheng Ma1 · Zhumei Luo2 · Hong Li1 · Tao Jin1

Received: 17 May 2022 / Accepted: 20 April 2023

© The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature 2023

Abstract
Many clinical trials and meta-analyses have examined vaporization with different energy instruments has been recognized
by the American Urological Association (AUA) and the European Association of Urology (EAU) as a promising treat-
ment for benign prostate hyperplasia. However, there is still a lack of evidence for a network comparison between different
vaporization devices. The PubMed, Embase, Cochrane and Web of Science databases were searched to identify randomized
controlled trials (RCTs) of different energy systems for prostate vaporization. Pairwise and network meta-analyses (NMA)
were performed to analyze the outcome regarding surgery time, complications, short-term maximum urine flow rate (Qmax),
and long-term Qmax. The Stata software was used for paired meta-analysis. A Bayesian NMA model with ADDIS software
was applied to achieve the indirect comparison of different energy systems. Node-splitting analysis and inconsistency factors
were used to test inconsistency for closed-loop indirect comparison. Fifteen studies were included in this study, involving
three types of energy systems used in prostate vaporization: diode laser (wavelength: 980 nm, power: 200–300 W, mode:
continuous), green-light laser (wavelength: 532 nm, power: 80–180 W, mode: continuous), and bipolar plasma vaporization
(bipolar electrode, power: 270–280 W, mode: pulsed). In the conventional paired meta-analysis, significantly better short-
term efficacy was found in green light laser vaporization, while no significant difference was detected in other parameters.
According to the results of the NMA, a greenlight laser is recommended for prostate vaporization rather than the other two
systems. When considering operation time, overall complications, short-term Qmax, and long-term Qmax, there were no
significant differences among green-light laser vaporization, diode laser vaporization, and bipolar vaporization in BPH
treatment. However, according to the probability ranking and benefit-risk analysis results, the green-light laser might be the
best energy system for prostate vaporization in BPH treatment.

Keywords Diode laser · Greenlight laser · Prostate vaporization · Network meta-analysis

Introduction different kinds of therapies have been developed to relieve

Benign prostate hyperplasia (BPH) has become one of the
main causes of lower urinary tract symptoms (LUTs) with
the increasing aging of major developed countries [1]. Many
Kaiwen Xiao, Yucheng Ma, and Zhumei Luocontributed equally to
this work and should be considered the co-first author.
* Tao Jin
jintao97@scu.edu.cn
1
Department of Urology, Institute of Urology (Laboratory
of Reconstructive Urology), West China Hospital,
Sichuan University, Chengdu 610041, Sichuan,
People’s Republic of China
2
Chengdu Third People’s Hospital, Chengdu 610041, Sichuan,
People’s Republic of China
or treat LUTs induced by BPH. A series of drug therapies
represented by 5-alpha reductase inhibitors have been applied
on a large scale and have achieved good results [2]. When
drug therapy has difficulty controlling LUTs caused by BPH,
surgical intervention has become one of the main means to
solve the problem. At present, transurethral resection of the
prostate (TURP) is still the most commonly used surgical pro-
cedure for the surgical treatment of BPH, and in recent years,
there have been many new surgical methods for the treatment
of benign prostatic hyperplasia, such as enucleation and
vaporization [3]. Many clinical trials and meta-analyses have
examined vaporization with different energy instruments, and
vaporization has been recognized by the American Urological
Association (AUA) and the European Association of Urology
(EAU) as a promising treatment for BPH [4].

13
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150 Page 2 of 19
As a transurethral treatment of prostate-related diseases,
the vaporization technique gradually entered the field of
urology in the 1980s [5, 6]. After decades of development,
different kinds of energy devices, including green-light laser,
diode laser, and bipolar electrode, have been applied to pros-
tate vaporization procedures [7]. The bipolar electrode is
able to generate a constant layer of plasma field that, by
directly contacting the prostate tissue, enables it to vaporize
the limited prostate layer cells while glide over the tissue
without affecting the deep tissue [8]. The green-light laser,
potassium-titanyl-phosphate (KTP), and the lithium tribo-
rate (LBO) laser work at a wavelength of 532 nm, and its
energy can be absorbed mainly by hemoglobin, not water.
For diode laser, in the prostate vaporization field, the main
reported wavelength is 980 nm, which also exhibits satisfac-
tory efficacy and safety [7]. Currently, there have been many
published clinical trials comparing different vaporization
instruments, and there seem to be some significant safety
and efficacy differences among them in paired comparisons
conducted within randomized controlled trials (RCTs). Some
published meta-analyses also supported this [9]. However,
no published network meta-analysis has compared all three
main vaporization techniques in a unified indirect model.
Therefore, the purpose of this study was to use the
Bayesian network meta-analysis (NMA) method to pool
all published RCTs of different energy instruments in pros-
tate vaporization to evaluate the safety and efficacy of this
technique. We hypothesize that due to the difference in the
physical parameters of different energy output devices, laser
devices may exhibit superior safety and efficacy in prostate
vaporization compared to bipolar electrode.
Materials and methods
This study was performed in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines for NMA.
Two independent authors searched the PubMed, Embase,
Web of Science, and Cochrane Central Register of Con-
trolled Trials databases to identify relevant RCTs published
between January 1, 2010, and April 1, 2022. Detailed search
keywords included “vaporization” and “benign prostate
hyperplasia (BPH).” The article type was restricted to “ran-
domized controlled trial.” The reference lists of the included
articles were also manually screened.
The inclusion criteria followed the PICO criteria:
1. Patients: Patients with BPH requiring surgical intervention.
2. Intervention: One or more types of prostate vaporization
techniques should be included and compared in the pri-
mary studies. Combined techniques should be excluded.
13
Lasers in Medical Science (2023) 38:150
3. Comparators: Another type of prostate vaporization
technique. To maintain transitivity, only TURP surgery
was selected as an intermediate node in this analysis.
4. Outcomes: Surgery time, voiding parameters, and com-
plications should be reported in the eligible studies for
further pooling.
5. Study design: According to the NMA principles, only
multiple-arm RCTs could be included in the current
analysis.
Two independent authors extracted the data according to
a predefined unified standard and crosschecked their work.
The following data were extracted: first author name, the
year of publication, techniques compared, region of patients
studied, the sample size of each arm, detailed surgical proce-
dures, follow-up time point, and outcome information. The
study quality assessment was mainly performed with the
Cochrane risk-of-bias tool offered by the Review Manager
v5.4.1 software (Review Manager. Version 5.4.1 Copenha-
gen: The Nordic Cochrane Centre, The Cochrane Collabora-
tion, 2021).
Conventional paired meta-analysis was conducted with
the Revman v5.4.1 and ADDIS v1.6 software (ADDIS:
Aggregate Data Drug Information System, http://d​ rugis.o​ rg/​
addis, an open-source evidence-based drug-oriented strat-
egy decision support system). For continuous outcomes, the
mean difference was assessed and synthesized as the estima-
tion. The odds ratio (OR) was calculated for category vari-
ables (complications). Heterogeneity was mainly evaluated
with I2 in the current analysis. Since follow-up time points
were varied in different eligible studies, two time points
were selected to evaluate the short-term and long-term effi-
cacy. For comparison of short-term efficacy, 3 months after
the initial operation was chosen as the main time point. If the
corresponding follow-up information was not reported in an
included study, the closest time point was selected but could
not exceed 6 months after the operation. In the compari-
son of long-term efficacy, similar principles were applied.
Twelve months after the operation was set as the long-term
efficacy evaluation point in this study. Unlike the short-term
time point, follow-up data beyond 12 months after opera-
tion were not included in this analysis. Regarding data on
complications, we combined all reported complications to
evaluate the overall adverse event effect.
The NMA procedures were performed with the ADDIS
v1.16.8 and the “network” package in Stata v15.1 (Stata
version 15.1, https://​www.​stata.​com, Texas, USA) based
on the Bayesian random effects model. For both the direct
and indirect comparisons of the closed-loop network, the
consistency was evaluated by node-splitting analysis and
the inconsistency factor. If no significant inconsistency
(P > 0.05, 95% CI of median of inconsistency factor covered
0) was observed, a consistency model was applied for this
Lasers in Medical Science (2023) 38:150
NMA. To assess the degree of convergence of the model,
the potential scale reduction factor (PSRF) was computed.
The model was expected to have good convergence if the
PSRF was close to 1; then, the consistency model could be
used to acquire relatively stable results. In the current study,
the threshold of PRSF that was set at 1.02. ADDIS was also
applied for the estimation of the ranking probability of each
vaporization device for different results after operation as
well as the benefit analysis (based on the stochastic multic-
riteria acceptability analysis model).
Results
There were 323 potentially eligible studies identified in the
PubMed, Embase, Web of Science, and Cochrane Central
Register of Controlled Trials databases. After deleting 118
duplicates and 136 unrelated studies, 69 studies were sub-
jected to title screening. A total of 21 records were removed
because they did not offer relevant information. Fifteen stud-
ies were non-randomized controlled studies. After abstract
and full-text screening, 7 studies were excluded since they
discussed vapo-resection or vapo-enucleation techniques.
Three studies were excluded since we failed to identify the
exact TURP technique compared (bipolar or monopolar),
and seven studies were excluded because they were not
Fig. 1  The literature screening
flow chart
Page 3 of 19 150
related. One study was excluded since it analyzed the same
cohort as another study. The detailed flow chart is shown in
Fig. 1. According to the Cochrane risk of bias tool, the main
risks of bias were related to detection bias and attrition bias
(Fig. S1).
In the past 10 years, only 4 studies compared different
prostate vaporization techniques directly [10–13], while
the other included studies were focused on the comparison
between different vaporization techniques and TURP tech-
niques. Seven studies compared different vaporization tech-
niques with monopolar TURP [14–20]. Two studies com-
pared different vaporization techniques with bipolar TURP
[21, 22]. Two studies were three-arm trials [23, 24]. The
detailed basic characteristics of the 15 included studies are
displayed in Table 1.
NMAs were performed to compare different vaporization
techniques in terms of operation time, complications, short-
term efficacy (short-term Qmax), and long-term efficacy
(long-term Qmax). Figure 2 displays the network for four
outcomes. Each node represents one vaporization technique,
and connections between nodes represent published direct
comparisons. The size of the nodes and the thickness of the
connections varied according to the number of studies.
In the conventional paired meta-analysis stage, it was
found that green-light laser vaporization could lead to sig-
nificantly better short-term efficacy (MD: − 1.92, 95% CI:
13
 Table 1  Basic information of included studies
150

Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/ Comparisons Sample size Outcomes*
Qmax/IPSS

13
Capitán C 2011 Spain Inclusion criteria: Preoperative prostate volume: Greenlight-laser vaporization: 50 for 120 W green-light laser Operation time
International Prostate Symptom 51.29 ± 14.72 ml for green-light HPS 120 W laser vaporization and vaporization Postoperative complications
Score (IPSS) > 15 after failed laser vaporization; a 600um side-firing laser fiber 50 for TURP
Page 4 of 19

medical therapy 53.10 ± 13.75 ml for TURP; were used

Prostate volume < 80 ml on tran- Preoperative Qmax: Mono-polar TURP with 1.5%
srectal ultrasound 8.03 ± 3.14 ml/s for PVP; glycine irrigation
Maximum flow rate 3.88 ± 2.71 ml/s for TURP;
(Qmax) < 15 ml/s, and patient Preoperative total IPSS:
understanding and signed written 23.74 ± 5.24 for PVP
informed consent 23.52 ± 4.38 for TURP
Exclusion criteria:
Detrusor overactivity or hypocon-
tractility on urodynamic study
Urethral stricture
Prostate cancer
Previous prostate, bladder neck, or
urethral surgery
Those patients who had a prostate-
specific antigen PSA > 2.5 ng/ml
or an abnormal finding on digital
rectal examination underwent prior
ultrasound-guided prostate biopsy
Razzaghi MR 2014 Iran Inclusion criteria: Preoperative prostate volume: 1. 120 W 980 nm diode laser 35 for diode laser varipozation Operation time;
BPH refractory to medical treat- 50.6 ± 16.0 ml for diode laser vaporization with 600 mm side- 36 for TURP Postoperative complication
ment vaporization; fire fiber Qmax at 3rd month after operation
Recurrent urinary retention 64.7 ± 10.2 ml for TURP; 2. Monopolar TURP with manni-
Prostate volume of < 80 mL, Qmax Preoperative Qmax: tol/sorbitol solution irrigation
of ≤ 15 mL/s (under medical 9.63 ± 3.18 ml/s for diode laser
treatment), an IPSS of ≥ 15, and vaporization;
an IPSS-QoL of ≥ 3 8.41 ± 4.50 ml/s for TURP;
Exclusion criteria: Preoperative total IPSS:
Patients with prostate or bladder 22.6 ± 5.23 for diode laser vapori-
cancer histories, neurogenic zation;
bladder dysfunction, bladder 21.36 ± 4.81 for TURP;
stones, and urethral structures
Previous bladder, urethral, or pros-
tate surgery was excluded
Lasers in Medical Science
(2023) 38:150
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
Qmax/IPSS
Yee CH 2015 China Inclusion criteria:
Men, 50–75 years old with BPE
American Society of Anesthesiolo-
gists Class ≤ 2
Compliant patients
Activities of daily living independ-
ent or largely independent
Failed medical therapy with alpha-
blockers or 5-alpha reductase
inhibitors, with IPSS ≥ 18 and/or
Qmax ≤ 15 mL/s, urinary reten-
tion status
Exclusion criteria
Previous TURP or other forms of
surgical intervention for BPE
Patient confirmed to have carci-
noma of prostate
Patients with known neurogenic
bladder, bladder stone, or ure-
thral stricture
Skinner TAA​ 2017 Canada Inclusion criteria:
Age over 45, International Prostate
Symptom Score (IPSS) ≥ 12,
estimated prostate volume on
digital rectal exam (DRE) ≥ 30 cc
(as this is a real-life clinical
practice study, prostate size
and post-void residual were not
mandatory)
Exclusion criteria:
Patients with prior invasive inter-
vention for BPH, PSA > 10 ng/
ml, urinary retention, history of
prostate cancer, and documented
prostatitis within the past
3 months
Zhang SY 2012 China Inclusion criteria:
1. Patients with BPH with maxi-
mum flow rate < 10 ml/s, prostate
volume 25–125 ml
Exclusion criteria:
1.Serious comorbility
2. Previous history of prostate
surgery
3. History of prostate cancer
4. Abnormal digital rectal examina-
tion and prostate-specific antigen
(PSA) level > 4 ng/ml
13
Preoperative prostate volume:
57.2 ± 25.4 ml for bipolar plasma
vaporization
66.1 ± 30.2 ml for TURP
Preoperative Qmax:
8.8 ± 3.6 ml/s for bipolar plasma
vaporization
8.41 ± 4.50 ml/s for TURP
Preoperative total IPSS:
21.8 ± 7.0 for bipolar plasma
vaporization
21.5 ± 5.8 for TURP
Preoperative prostate volume:
47.8 ml for bipolar plasma
vaporization (without standard
deviation)
46.6 ml for diode laser vaporiza-
tion (without standard deviation)
Preoperative Qmax:
NR
Preoperative total IPSS:
22.6 for bipolar plasma vaporiza-
tion (without standard devia-
tion);
20.5 for diode laser vaporization
(without standard deviation);
Preoperative prostate volume:
59.0 ± 17.4 ml for bipolar plasma
vaporization
70.1 ± 28.8 ml for TURP
Preoperative Qmax:
4.5 ± 2.7 ml/s for bipolar plasma
vaporization
5.3 ± 2.6 ml/s for TURP
Preoperative total IPSS:
24.6 ± 4.7 for bipolar plasma
vaporization
27.3 ± 5.9 for TURP
Comparisons Sample size Outcomes*
In bipolar vaporization, vaporiza- 84 for bipolar vaporization Operation time
tion and coagulation were set at 84 for monopolar TURP Complication
280 W and 100 W, respectively Qmax at 3rd and 6th months after
Monopolar TURP used a 26-F operation
Lasers in Medical Science
continuous flow resectoscope.
The power settings were 120
W for cutting and 70 W for
coagulation
(2023) 38:150
Bipolar plasma vaporization of the 30 for bipolar plasma vaporization Complication
prostate; 25 for diode laser bipolar vapori-
Diode laser bipolar vaporization zation
Bipolar plasma vaporization con- 15 for bipolar plasma vaporization Operation time
ducted with Olympus USE-40 15 for mono-polar TURP Qmax 1 month after the operation
bipolar generator, “Button type”
vaporization resection electrode
and continuous saline lavage
TURP conducted with a 24F
continuous flow mono-polar
resectoscope. During the opera-
tion, mannitol solution lavage
was used
Page 5 of 19
150
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
Qmax/IPSS
13
Geavlete B 2015 Romania The inclusion criteria were
represented by prostate volume
over 80 mL, maximum flow rate
(Qmax) below 10 mL/s, IPSS
over 19, or urinary retention
imposing catheter indwelling.
The exclusion criteria consisted
of associated comorbidities
preventing BPH surgery, in
general, from being performed
(such as severe heart, respiratory,
hepatic, or renal failure, ongoing
anticoagulant therapy that could
not be stopped 7 days before the
intervention for cardiovascular
reasons, unstable angina, recent
stroke, or myocardial infarc-
tion), previous prostate surgery,
urethral strictures, and not
BPH-related voiding disorders.
If required, prostate cancer was
screened for and subsequently
ruled out by using TRUS-guided
biopsy
Ghobrial FK 2020 Egypt Inclusion criteria:
1. Patients’ age > 50 years, LUTS
secondary to BOO due to BPH
who failed medical treatment,
IPSS > 15 and, maximum urinary
flow rate (Qmax) < 15 ml/s with
at least 125 ml voided volume
or cases with AUR secondary
to BPH who failed trial of void-
ing on medical treatment and
TRUS estimated prostate size
(30–80 ml)
Exclusion criteria:
1. Patients with neurological disor-
ders or diagnosed prostate cancer
were excluded from the study
Cetinkaya M 2015 Turkey Inclusion criteria:
1. Patients with BPH refractory to
medical treatment, recurrent uri-
nary retention, prostate volume
of < 80 ml, Qmax of ≤ 15 ml/s,
IPSS of ≥ 15, and an IPSS-QoL
of ≥ 3
Exclusion criteria:
1. Patients with prostate or bladder
cancer histories, neurogenic
bladder dysfunction, bladder
stones, urethral strictures, or
previous bladder, urethral, or
prostate surgery were excluded
Preoperative prostate volume:
126.7 ± 33.1 ml for bipolar plasma
vaporization
121.8 ± 30.4 ml for TURP
Preoperative Qmax:
6.9 ± 1.8 ml/s for bipolar plasma
vaporization
6.4 ± 2.2 ml/s for TURP
Preoperative total IPSS:
24.4 ± 3.1 for bipolar plasma
vaporization
25.2 ± 3.2 for TURP
Preoperative prostate volume:
59.3 ± 13 ml for green-light laser
vaporization
55.9 ± 12.4 ml for bipolar plasma
vaporization
Preoperative Qmax:
9.5 ± 2.7 ml/s for green-light laser
vaporization
8.7 ± 3 ml/s for bipolar plasma
vaporization
Preoperative total IPSS:
23 ± 5.5 for green-light laser
vaporization
23 ± 5.94 for bipolar plasma
vaporization
Preoperative prostate volume:
50.6 ± 16.0 ml for diode laser
vaporization
54.8 ± 22.7 ml for mono-polar
TURP
Preoperative Qmax:
9.63 ± 3.18 ml/s for diode laser
vaporization
8.41 ± 4.50 ml/s for mono-polar
TURP
Preoperative IPSS:
22.6 ± 5.23 for diode laser vapori-
zation
21.36 ± 4.81 for mono-polar TURP
150
Comparisons Sample size Outcomes*
Bipolar plasma vaporization: 80 for bipolar plasma vaporization; Operation time;
Hemispherical-shaped button 80 for mono-polar TURP (detailed Qmax at 3rd and 12th months after
electrodes were used. No other patient number changed in the operation
Page 6 of 19
parameters were offered follow up)
Bipolar TURP:26F OES-Pro bipo-
lar resectoscope with 280–320
W energy supply for the cutting
mode and 160–180 W energy
supply for coagulation
Green-light laser vaporization:180 58 for green-light laser vaporiza- Operation time;
W system and side-firing fiber tion Complication;
were used 59 for bipolar plasma vaporization Qmax at 4th and 12th months after
Bipolar plasma vaporization: the operation
Olympus UES-40 surgmaster
generator and button electrode
(Olympus Europe, Hamburg,
Germany) using power of 280 W
for vaporization and 140 W for
coagulation were used
Diode laser vaporization: 36 for diode laser vaporization; Operation time
A 120-W diode laser system emit- 36 for mono-polar TURP Complication
ting at a wavelength of 980 nm Qmax at 3rd month after the opera-
Lasers in Medical Science
was used in diode laser vaporiza- tion
tion. The light is transmitted via
a flexible 600-mm side-fire fiber
to vaporize the tissue in a non-
contact mode
Mono-polar TURP
TURP was performed with the use
(2023) 38:150
of a standard mono-polar 26 F
resectoscope. Mannitol/sorbitol
solution was used for irrigation
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/ Comparisons Sample size Outcomes*
Qmax/IPSS

Lukacs B 2012 France Inclusion criteria:
IPSS > 12 and bother score ≥ 3,
(according to IPSS question 8);
Qmax < 12 ml/s (associated with
Preoperative prostate volume:
50.54 ± 16.53 ml for green-light
laser vaporization
50.11 ± 14.73 ml for mono-polar
Green-light laser vaporization
Green-light laser vaporization was
conducted with 120 W laser
system
69 for green-light laser vaporiza- Complication
tion Qmax at 3rd, 12th months after the
70 for mono-polar TURP operation
Lasers in Medical Science

a > 125-ml void) TURP Mono-polar TURP

Prostate volume between 25 and Preoperative Qmax: No detailed description in manu-
80 ml; 7.79 ± 2.75 ml/s for green-light script
Postvoid residual volume < 300 ml laser vaporization
Normal digital rectal examination 7.76 ± 2.64 ml/s for mono-polar
PSA < 4 ng/ml or negative prostate TURP
biopsy if PSA between 4 and
(2023) 38:150

10 ng/ml for patients < 75 yr of

age or with life expectancy > 10
y
Exclusion criteria:
Patients with urinary catheter
before intervention
Active urinary tract infection
Impaired renal function
Unstable cardiac or pulmonary
disease
Bladder disease or neurologic dis-
ease affecting bladder function
Altered urinary sphincter function,
urethral stricture, bladder neck
stenosis, active hematuria, or
bladder stones
History of prostate or urethral
surgery
Anorectal disease
Anticoagulation therapy that
cannot be stopped or replaced
without risk for the patient
Antiaggregant therapy that cannot
be stopped without risk for the
patient
Severe coagulopathy
ASA score > 3
Patient unable to complete ques-
tionnaires or having no medical
insurance
Page 7 of 19
150

13
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
13
Chiang PH 2010 China Inclusion criteria:
1. Patients with maximum flow
rate less than 15 ml/s and
moderate to severe lower urinary
tract symptoms as defined by
IPSS ≥ 10. Urodynamic studies
including pressure-flow studies
were preformed only for patients
where pre-operative assessments
raised suspicions of an underly-
ing neurogenic bladder
Exclusion criteria:
1. Patients with neurogenic blad-
der, prostate cancer, prostate
volume ≤ 25 ml, or previous
urethral surgery were excluded
from this analysis
150
Comparisons Sample size Outcomes*
Qmax/IPSS
Preoperative prostate volume: Green-light laser vaporization: 84 for green-light laser vaporiza- Operation time
Reported without standard devia- GreenLight HPS laser procedure tion Complication
tion performed with using 60 W of 55 for diode laser vaporization Qmax at 1st, 12th month after the
Page 8 of 19
Preoperative Qmax: power. The lateral lobes were operation
5.5 ± 5.4 ml/s for diode laser vaporized bilaterally at first.
vaporization After the working space from
4.3 ± 4.5 ml/s for green-light laser bladder neck to verumontanum
vaporization was created, the power setting
Preoperative IPSS: was increased to 80 W, 100 W,
20.1 ± 5.2 for diode laser vaporiza- and finally to 120 W to widen
tion; the cavity. The middle lobe, if
21.6 ± 5.6 for green-light laser present, was vaporized after
vaporization completing the lateral lobe
vaporization. To control bleed-
ing when it occurred, the coagu-
lation mode setting was used in
which the power was reduced to
20–30 W, while the laser beam
was directed around rather than
directly at the bleeder. The fiber
was introduced through a 23-F
continuous flow cystoscope.
Normal saline (0.9% saline solu-
tion) was used as an irrigant;
Diode laser vaporization:
A maximum power of 200 W was
used for the procedure with the
Diolas LFD 980 nm diode laser
(Limmer Laser GmbH, Berlin,
Germany). Generally, the power
setting used at the start of the
procedure was 150 W. After
an initial working space was
created, the power setting was
increased to 200 W. The apex
and anterior region was vapor-
ized at an output power of 150
W. When bleeding occurred, the
laser beam was directed straight
at the bleeder without decreasing
the power setting. The fiber was
introduced through a Wolf 24F
Lasers in Medical Science
continuous flow cystoscope
(2023) 38:150
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/ Comparisons Sample size Outcomes*
Qmax/IPSS

Kumar N** 2018 India Inclusion criteria: Preoperative prostate volume: NR 60 for mono-polar TURP Complication
1. Patients with age ≥ 50 years, 52.20 ± 15.93 ml for mono-polar 57 for bipolar TURP Qmax at 12th month after the
IPSS > 7, prostate volume: > 20 TURP 58 for green-light laser vaporiza- operation
and < 80 ml, and maximum flow 50.26 ± 16.50 ml for bipolar TURP tion
Lasers in Medical Science

rate (Qmax) < 15 ml/s were 52.79 ± 16.13 ml for green-light

included in the study laser vaporization
Exclusion criteria: Preoperative Qmax:
1. Patients with history of prostate, 7.00 ± 1.97 ml/s for mono-polar
bladder, urethral surgery, spinal TURP
surgery, spinal trauma, neuro- 7.05 ± 1.87 ml/s for bipolar TURP
logic disease, postvoid residual 6.68 ± 2.00 ml/s for green-light
(2023) 38:150

urine (PVRU) > 300 ml, indwell- laser vaporization

ing Foley catheter for chronic Preoperative IPSS:
retention (PVRU > 300 ml), a 20.71 ± 2.68 for mono-polar TURP
diagnosis of carcinoma of the 19.76 ± 2.78 for bipolar TURP
prostate, carcinoma of the blad- 20.05 ± 2.75 for green-light laser
der, urethral stricture, patients vaporization
receiving antiplatelet drugs in
whom drugs could not be safely
stopped perioperatively, and
patients who did not give written
informed consent were excluded
from the study
Page 9 of 19
150

13
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
13
Kumar A** 2013 India Inclusion criteria":
1. Patients with age ≥ 50 years,
IPSS > 7, prostate volume: > 20
and < 80 ml, and maximum flow
rate (Qmax) < 15 ml/s were
included in the study
Exclusion criteria:
1. Patients with history of
prostate, bladder, urethral
surgery, spinal surgery,
spinal trauma, neurologic
disease, postvoid residual urine
(PVRU) > 300 mL, indwell-
ing Foley catheter for chronic
retention (PVRU > 300 mL), a
diagnosis of carcinoma of the
prostate, carcinoma of the blad-
der, urethral stricture, patients
receiving antiplatelet drugs in
whom drugs could not be safely
stopped perioperatively, and
patients who did not give written
informed consent were excluded
from the study
Qmax/IPSS
Preoperative prostate volume:
52.20 ± 15.93 ml for mono-polar
TURP
50.26 ± 16.50 ml for bipolar TURP
52.79 ± 16.13 ml for green-light
laser vaporization
Preoperative Qmax:
7.00 ± 1.97 ml/s for mono-polar
TURP
7.05 ± 1.87 ml/s for bipolar TURP
6.68 ± 2.00 ml/s for green-light
laser vaporization
Preoperative IPSS:
20.71 ± 2.68 for mono-polar TURP
19.76 ± 2.78 for bipolar TURP
20.05 ± 2.75 for green-light laser
vaporization
150
Comparisons Sample size Outcomes*
Mono-polar TURP: 60 for mono-polar TURP Operation time
Monopolar TURP was performed 57 for bipolar TURP Qmax at 3rd month after the opera-
using a 26-F continuous flow 58 for green-light laser vaporiza- tion
resectoscope. 30-degree lens, tion
Page 10 of 19
standard tungsten cutting wire
loop, and 1.5% glycine as irrigant.
Power setting used was 160 W for
cutting and 80W for coagulation.
The resection was carried down to
the surgical capsule with the distal
limit being the verumontanum
Bipolar TURP:
Bipolar TURP was performed using
a 26F continuous flow resecto-
scope. The Gyrus ACMI plas-
makinetic system was used for
the procedure. A 30-degree lens
and 0.9% saline as irrigant were
used for the procedure. Power set-
tings used were 180 W for cutting
and 90W for coagulation. As with
monopolar TURP, the resection
was carried down to the surgical
capsule with the distal limit being
the verumontanum
Green-light laser vaporization:
For PVP by GreenLight laser, a
23-F continuous flow laserscope,
30-degree lens, 0.9% sodium
chloride as irrigant, and a
600-μm, 70-degree side firing
GreenLight laser fiber having a
wavelength of 532 nm was used.
Prostatic tissue was vapor-
ized up to the surgical capsule
with the distal limit being the
verumontanum until a wide
TURPlike cavity was made,
and an unobstructed view of the
bladder from the verumontanum
was achieved. For vaporization,
the laser fiber was moved in a
Lasers in Medical Science
paint brush fashion keeping the
fiber in close contact with the
prostatic tissue. Coagulation, if
required, was achieved by the
power setting of 30 W
(2023) 38:150
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
Qmax/IPSS
Kobayashi T 2021 Japan Inclusion criteria:
1.IPSS total score ≥ 8
2.QOL index ≥ 2
3.prostate volume ≥ 20 ml
Exclusion criteria:
1.An established neurogenic lower
urinary tract dysfunction
2.Organic illness with bladder out-
let obstruction other than BPH
(e.g., bladder neck contracture or
urethral stricture)
3.Undergone a surgical procedure
for BPH
4. A prostate cancer. In case of an
elevated PSA level or an abnor-
mal digital rectal examination,
ultrasonography-guided prostate
biopsy was performed to exclude
prostate cancer. The use of anti-
coagulants or indwelling urinary
catheters/clean intermittent cath-
eterization for urinary retention
was not a criterion for exclusion
owing to the high incidence in
our aging population
Abdelwahab O 2019 Saudi Arabia Inclusion criteria:
1. Patients with BPH with
Q-max < 10 ml/s, IPSS > 18,
and prostate volume > 40 g were
included in this analysis
Exclusion criteria:
1. Patients with active urinary tract
infection, coagulopathy, neuro-
genic bladder, prostate volume
above 80 g, PSA above 4 ng/ml
or abnormal DRE, previous ure-
thral stricture or urethral surgery,
presence of bladder stones, or
renal impairment were excluded
from this analysis
13
Preoperative prostate volume:
47.2 ± 25.7 ml for green-light laser
vaporization
46.9 ± 33.7 ml for diode laser
vaporization
Preoperative Qmax:
11.8 ± 6.6 ml/l for green-light laser
vaporization
8.2 ± 4.5 ml/l for diode laser
vaporization
Preoperative IPSS:
19.4 ± 7.7 ml for green-light laser
vaporization
19.0 ± 7.8 ml for diode laser
vaporization
Preoperative prostate volume:
59.4 ± 13.9 ml for bipolar vaporiza- was set to coagulation at 150 W
tion
58.2 ± 12.5 ml for bipolar TURP
Preoperative Qmax:
9.01 ± 4.1 ml/s for bipolar vapori-
zation
8.1 ± 7.7 ml/s for bipolar TURP
Preoperative IPSS:
19.1 ± 1.2 for bipolar vaporization
19.9 ± 1.4 for bipolar TURP
Comparisons Sample size Outcomes*
Green-light laser vaporization 62 for green-light laser vaporiza- Operation time
was performed using a 120-W tion Complication
GreenLight HPS laser (532 nm) 55 for diode laser vaporization Qmax at 3rd and 12th months after
system with a side-firing fiber the operation
Lasers in Medical Science
(tip outer diameter of 1.8 mm)
and a peak power of 100 to
120 W
Diode laser vaporization was
performed using a 300-W diode
laser (980 nm) system with a
large twister fiber (end-firing
(2023) 38:150
contact type) and a peak power
of 50 to 200 W
Laser vaporization was started
at the median lobe from the
bladder neck to the verumon-
tanum, followed by the lateral
lobes. The power was controlled
within 80 W (PVP) and 120 W
(CVP) near the external urethral
sphincter
The Olympus bipolar generator 45 for bipolar vaporization Operation time
44 for bipolar TURP Complication
and cutting at 270 W, doing the Qmax at 3rd and 9th months after
standard technique of bipolar the operation
resection and vaporization in
both groups
Page 11 of 19
150
 Table 1  (continued)
Author Year Country Patients inclusion/exclusion criteria Preoperative prostate volume/
Qmax/IPSS
13
Purkait B 2017 India Inclusion criteria:
1. Patients with BPH leading to
refractory urinary retention,
recurrent urinary tract infections,
lower urinary tracts symptoms
(LUTS) refractory to medical
treatment, renal insufficiency,
bladder stones, and recurrent
hematuria were included in this
analysis
Exclusion criteria:
1. Patients with history of prostate,
bladder, urethral, spinal surgery
or spinal trauma, hypocontractile
bladder on urodynamic study
(UDS), diagnoses of prostate
carcinoma, carcinoma of the
bladder, urethral stricture, and
patients who did not give consent
for the study were excluded from
this analysis
TURP transurethral resection of the prostate, PVP photoselective vaporization of prostate, IPSS International Prostate Symptom Score, Qmax maximum flow rate, PSA prostate-specific antigen,
LUTS lower urinary tracts symptoms, UDS urodynamic study
*
Four main outcomes were pooled in this analysis to evaluate: operation time was used to evaluate operation difficulty; complication was used to evaluate safety; Qmax as a subjective indicator
was used to evaluate efficacy
**
These two studies were based on a same trial, but Kumar N’s study reported long-term results and Kumar A’s study reported short-term results
Preoperative prostate volume:
70.3 ± 15.5 ml for green-light laser
vaporization
69.6 ± 16.35 ml for mono-polar
TURP
Preoperative Qmax:
8.5 ± 2.7 ml/s for green-light laser
vaporization
8.3 ± 2.4 ml/s for mono-polar
TURP
Preoperative IPSS:
26.1 ± 4.8 for green-light laser
vaporization
25.9 ± 5.2 for mono-polar TURP
150
Comparisons Sample size Outcomes*
Green-light laser vaporization: 60 for green-light laser vaporiza- Operation time
A 120-W green-light laser high- tion Complication
performance system was used. 57 for mono-polar TURP Qmax at 12th month after the
A 30-degree lens and an irrigant operation
Page 12 of 19
0.9% sodium chloride were used.
A 600-μm fiber and 70-degree
side firing laser fiber emitting
green light at 532 nm were
employed. At first, the median
lobe (if present) and then the
lateral lobes were lased in a
symmetrical manner. Tissue was
vaporized down to the prostatic
capsule until an unobstructed
view of the trigone and a
TURP like cavity was obtained.
Vaporization was achieved by
moving the laser fiber slowly
and constantly in a “paint brush
fashion” taking care to keep the
fiber in “near contact” with the
prostatic tissue. If any bleeding
vessels were encountered during
vaporization, coagulation was
accomplished by defocusing the
laser fiber (increasing working
distance to 3–4 mm) or by
reducing the power setting
Mono-polar TURP:
TURP was performed in the stand-
ard manner using 30-degree lens
and 26 F continuous irrigation
resectoscope sheaths. All TURP
procedure was done using
monopolar cautery and tungsten
cutting wire loop at a setting of
160 W current for cutting and
80 W current for coagulation. A
0.5% glycine solution was used
as the irrigating fluid. The resec-
tion was carried down to the
surgical capsule from bladder
Lasers in Medical Science
neck up to the verumontanum
(2023) 38:150
Lasers in Medical Science (2023) 38:150
3.58, − 0.26, P = 0.02, I2 = 0%). Since only four studies
offered direct comparisons, not all pairs had direct results,
and no other significant result was detected (Table 2).
Before conducting NMA, it was crucial to test inconsistency
between direct comparison results and indirect comparison
results. In the operation time, NMA comparison, no sig-
nificant inconsistency was detected based on inconsistency
factor calculation and node-splitting analysis (Table S1,
operation time; the 95% CI of the median of inconsistency
factors in all cycles covered 0; Table 3, operation time; all P
values were larger than 0.05). Similar results were found in
the complication, short-term efficacy, and long-term efficacy
NMA comparisons (Table S1; Table 3); therefore, NMAs
based on the consistency model were stable and robust. In
the operation time, indirect comparison, no significant dif-
ference was detected among the three included vaporization
techniques (bipolar vaporization, green-light laser vaporiza-
tion, diode laser vaporization; Table 4), and similar results
were also obtained in the complication comparison, short-
term efficacy, and long efficacy comparisons (Table 4).
Although there was no significant difference between
the safety and efficacy of the three vaporization techniques,
further probability ranking based on existing data is still of
practical significance for guiding clinical work. In the oper-
ation time, probability ranking, green-light laser vaporiza-
tion might be the best technique for shorter operation times
(Fig. 3A). In the postoperative complication probability rank-
ing, green-light laser vaporization might be the best technique
to avoid postoperative complications. In the short-term and
long-term Qmax probability ranking, the green-light laser
might also be the best technique to obtain the best short-term
efficacy among the three included vaporization techniques.
Benefit-risk analysis is another useful method to compre-
hensively rank different treatments based on more than one
outcome comparison [25]. In this analysis, the SMAA model
was used for benefit-risk analysis [26]. When considering all
complications, short-term efficacy, and long-term efficacy
outcomes among the three vaporization techniques, green-
light laser vaporization may still be the best technique to
obtain a benefit-risk balancing outcome (Fig. 4).
Discussion
In this NMA, based on all currently published clinical tri-
als, we found that when considering operation time, over-
all complications, short-term Qmax, and long-term Qmax,
there were no significant differences among green-light laser
vaporization, diode laser vaporization, and bipolar vaporiza-
tion in BPH treatment. According to the probability ranking
and benefit-risk analysis results, the green-light laser might
be the best energy instrument for prostate vaporization in
BPH treatment.
Page 13 of 19 150
Photoselective vaporization of the prostate (VP) involving
the green-light laser was first introduced in 1998 [27]. Dur-
ing vaporization, with a wavelength of 532 nm, the optical
tissue penetration was not deep (± 0.8 mm), which led to
excellent perioperative hemostasis. Three specifications of
greenlight laser equipment have been widely used in VP:
80 W, 120 W, and 180 W [11, 28, 29]. Since 2002, the early
clinical outcomes, including safety and efficacy of the 80-W
greenlight KTP laser system, have been proven. Then, in
2006, a new greenlight HPS laser system with an output
frequency of 120 W was introduced. In 2011, this system
was upgraded to 180 W (greenlight XPS), as it involved
a new pulsed coagulation feature (12 Hz, 5–40 W), and
the hemostatic properties were also improved, especially
for oversized prostates. Although these systems exhibited
similar efficacy and safety, discrepancies still exist. It has
been reported that compared with the 80-W or 120-W laser
system, the 180-W system showed some benefits in shorter
operation time, catheterization time, shorter recovery time,
and better intraoperative visibility [29].
Different forms of diode lasers with various wavelengths,
including 940 nm, 980 nm, or 1470 nm, have been applied
for surgical management of the prostate. In diode laser
vaporization, a 980-nm-wavelength system is mainly used,
as it can provide simultaneous absorption in both water and
hemoglobin, leading to favorable hemostasis and tissue abla-
tion. The physical nature of the diode laser may be the expla-
nation for the Qmax advantages in the early stage compared
with bipolar devices. However, another diode laser system
with a 1470-nm wavelength may exhibit better efficacy.
Wezel et al. and Seitz et al. demonstrated that the necrotic
areas induced by the 1470-nm diode laser were more super-
ficial than those induced by the 980-nm diode laser [30],
but the depth was sufficient to seal the blood vessels in most
prostate tissues. When the penetration depth increases, the
risk of reaching the substructures also increases. On the
basis of maintaining effectiveness, as the depth decreases,
the risk of reaching the substructures also decreases, so that
complications, for instance, irritative symptoms, erectile
dysfunction, and urinary incontinence, could be avoided.
In the direct perioperative efficacy comparison of laser
devices in enlarged prostate vaporization, the wavelength of
the diode laser is close to the water or hemoglobin absorp-
tion peak; water and hemoglobin are the main absorbing
substance which comprises over two-thirds of the prostate,
thus resulting in a high energy absorption rate and instan-
taneous tissue vaporization. Unlike other types of lasers,
the green light laser with 532 nm wavelength can be easily
absorbed by the hemoglobin in the prostate tissue, but not by
water. During vaporization, the high-power laser energy can
be immediately absorbed into the blood, which produces an
excellent vascular sealing effect. Therefore, in the prostate
tissue with abundant blood supply, the green laser has the
13
150 Page 14 of 19 Lasers in Medical Science (2023) 38:150

Fig. 2  Network comparing the different energy systems in prostate vaporization. A comparison network for surgery time). B Comparison net-
work for complications. C Comparison network for short-term efficacy. D Comparison network for short-term efficacy

Table 2  Conventional paired meta-analysis between different laser systems and bipolar vaporization results based on random-effects model. The
direction of comparison is comparator vs. treatment

Operation time Complications

Treatment Comparator MD (95%CI) P I2 Treatment Comparator OR (95%CI) P I2
Green-light laser Bipolar vaporiza- − 3.50 (− 14.36, 0.52 / Green-light laser Bipolar vaporiza- 0.60 (0.29, 1.24) 0.17 /
vaporization tion 7.36) vaporization tion
Diode laser No direct com- / / Diode laser 0.71 (0.23, 2.15) 0.55 /
vaporization parison vaporization
Diode laser Green-light laser 1.05 (− 6.25, 8.34) 0.78 0% Diode laser Green-light laser 1.95 (0.69, 5.52) 0.21 78%
vaporization vaporization vaporization vaporization
Short-term Qmax Long-term Qmax
Treatment Comparator MD (95%CI) P I2 Treatment Comparator MD (95%CI) P I2
Green-light laser Bipolar vaporiza- − 1.01 (− 4.88, 0.61 / Green-light laser Bipolar vaporiza- 1.41 (− 10.71, 0.82 /
vaporization tion 2.86) vaporization tion 13.53)
Diode laser No direct com- / / Diode laser No direct com- / /
vaporization parison vaporization parison
Diode laser Green-light laser − 1.92 0.02 0% Diode laser Green-light laser − 2.42 (− 4.90, 0.06 0%
vaporization vaporization (3.58, − 0.26) vaporization vaporization 0.06)

SMD standardized mean difference, OR odds ratio, CI confidential interval, Qmax maximum urine flow rate

13
Lasers in Medical Science (2023) 38:150 Page 15 of 19 150

Table 3  Inconsistency between direct and indirect comparison tested by node-splitting analysis
Comparison Direct effect (95%CI) Indirect effect (95%CI) Overall (95%CI) P

Operation time
Bipolar vaporization, green-light laser vaporization 1.32 (− 10.93, 13.92) 0.04 (− 3.39, 3.70) 0.11 (− 3.15, 3.70) 0.85
Bipolar vaporization, bipolar TURP 0.06 (− 2.82, 2.94) 0.31 (− 5.35, 6.12) 0.49 (− 1.83, 2.96) 0.93
Bipolar vaporization, monopolar TURP − 0.56 (− 4.08, 3.29) − 0.59 (− 5.62, 4.71) − 0.22 (− 2.79, 2.79) 0.98
Green-light laser vaporization, bipolar TURP 0.40 (− 4.59, 5.45) 0.16 (− 4.33, 4.37) 0.37 (− 2.96, 3.69) 0.94
Green-light laser vaporization, diode laser vaporization vapori- − 2.50 (− 6.67, 1.51) − 2.20 (− 7.61, 3.37) − 2.38 (− 5.53, 0.85) 0.91
zation
Green-light laser vaporization, monopolar TURP − 0.23 (− 3.17, 2.62) − 0.44 (− 4.70, 3.82) − 0.30 (− 2.74, 2.15) 0.93
Bipolar TURP, monopolar TURP − 0.88 (− 4.08, 2.13) 1.36 (− 2.40, 5.21) − 0.68 (− 3.34, 2.14) 0.31
Diode laser vaporization vaporization, monopolar TURP 1.85 (− 2.87, 6.60) 2.26 (− 2.69, 7.20) 2.07 (− 1.26, 5.39) 0.91
Complication
Bipolar vaporization, green-light laser vaporization − 0.52 (− 2.25, 1.23) − 0.17 (− 1.40, 0.92) − 0.27 (− 1.26, 0.59) 0.70
Bipolar vaporization, bipolar TURP − 0.14 (− 2.02, 1.14) 0.08 (− 1.92, 1.98) − 0.20 (− 1.48, 0.73) 0.85
Bipolar vaporization, diode laser vaporization vaporization − 0.37 (− 2.26, 1.57) 0.22 (− 1.17, 1.46) 0.06 (− 1.02, 1.05) 0.59
Bipolar vaporization, monopolar TURP 1.07 (− 0.16, 2.31) 0.32 (− 1.06, 1.56) 0.64 (− 0.29, 1.43) 0.33
Green-light laser vaporization, bipolar TURP 0.15 (− 1.70, 1.97) − 0.10 (− 1.90, 1.27) 0.07 (− 1.15, 1.04) 0.81
Green-light laser vaporization, diode laser vaporization vapori- 0.68 (− 0.50, 1.84) − 0.18 (− 1.47, 1.15) 0.33 (− 0.54, 1.21) 0.30
zation
Green-light laser vaporization, monopolar TURP 0.65 (− 0.15, 1.45) 1.46 (0.34, 2.58) 0.91 (0.18, 1.60) 0.20
Bipolar TURP, monopolar TURP 0.84 (− 0.26, 1.86) 0.42 (− 0.70, 1.80) 0.84 (− 0.06, 1.91) 0.56
Diode laser vaporization vaporization, monopolar TURP 0.90 (− 0.50, 2.33) 0.32 (− 0.92, 1.53) 0.57 (− 0.35, 1.45) 0.50
Post-operative short-term Qmax
Bipolar vaporization, Green-light laser vaporization 1.06 (− 4.65, 6.83) − 0.47 (− 3.95, 3.08) − 0.09 (− 3.06, 2.99) 0.64
Bipolar vaporization, bipolar TURP − 0.15 (− 3.02, 2.87) − 0.80 (− 6.01, 4.57) 0.00 (− 2.30, 2.44) 0.82
Bipolar vaporization, monopolar TURP − 2.00 (− 5.06, 1.04) − 0.51 (− 5.03, 4.04) − 1.18 (− 3.51, 1.27) 0.56
Green-light laser vaporization, bipolar TURP 0.35 (− 4.51, 5.18) 0.26 (− 3.76, 4.36) 0.11 (− 3.02, 3.19) 0.99
Green-light laser vaporization, diode laser vaporization vapori- − 1.98 (− 5.66, 1.57) − 2.09 (− 6.82, 2.41) − 2.00 (− 4.76, 0.70) 0.97
zation
Green-light laser vaporization, monopolar TURP − 0.71 (− 4.14, 2.84) − 1.37 (− 4.88, 2.07) − 1.08 (− 3.55, 1.42) 0.77
Bipolar TURP, monopolar TURP − 0.54 (− 3.67, 2.68) − 0.98 (− 4.57, 2.48) − 1.19 (− 3.76, 1.50) 0.84
Diode laser vaporization vaporization, monopolar TURP 0.96 (− 2.43, 4.51) 0.88 (− 3.89, 5.61) 0.94 (− 1.71, 3.59) 0.97
Post-operative long-term Qmax
Bipolar vaporization, Green-light laser vaporization 1.32 (− 10.93, 13.92) 0.04 (− 3.39, 3.70) 0.11 (− 3.15, 3.70) 0.85
Bipolar vaporization, bipolar TURP 0.06 (− 2.82, 2.94) 0.31 (− 5.35, 6.12) 0.49 (− 1.83, 2.96) 0.93
Bipolar vaporization, monopolar TURP − 0.56 (− 4.08, 3.29) − 0.59 (− 5.62, 4.71) − 0.22 (− 2.79, 2.79) 0.98
Green-light laser vaporization, bipolar TURP 0.40 (− 4.59, 5.45) 0.16 (− 4.33, 4.37) 0.37 (− 2.96, 3.69) 0.94
Green-light laser vaporization, diode laser vaporization vapori- − 2.50 (− 6.67, 1.51) − 2.20 (− 7.61, 3.37) − 2.38 (− 5.53, 0.85) 0.91
zation
Green-light laser vaporization, monopolar TURP − 0.23 (− 3.17, 2.62) − 0.44 (− 4.70, 3.82) − 0.30 (− 2.74, 2.15) 0.93
Bipolar TURP, monopolar TURP − 0.88 (− 4.08, 2.13) 1.36 (− 2.40, 5.21) − 0.68 (− 3.34, 2.14) 0.31
Diode laser vaporization vaporization, monopolar TURP 1.85 (− 2.87, 6.60) 2.26 (− 2.69, 7.20) 2.07 (− 1.26, 5.39) 0.91

advantages of good hemostatic effect, but a relatively long
operative time is required. However, studies have demon-
strated that green light laser systems with 180 W exhibited
shorter operation time compared with green light systems
with 120 W or 80 W, suggesting benefits in less operation
risk for especially elderly high-risk patients [31].
In the comparison of voiding parameters, both laser
devices exhibited significant improvement. However, in
a recently published meta-analysis that compared green-
light light vaporization with the HPS system and 980-nm
diode laser vaporization, the pooled results showed better
IPSS and Qmax with the greenlight laser. Green-light laser
vaporization may exhibit more potential benefits in terms of
primary voiding parameters than diode laser vaporization
with a side-firing noncontact fiber, demonstrating possible
minor damage to the muscle layer and nerves of the external

13
150 Page 16 of 19 Lasers in Medical Science (2023) 38:150

Table 4  NMA results based on included studies

Operation time, MD (95%CI)

Bipolar vaporization 6.85 (− 10.69, 24.55) − 8.37 (− 23.91, 7.22) 8.65 (− 12.79, 30.98) 2.29 (− 12.18, 17.61)
− 6.85 (− 24.55, 10.69) Green-light laser vaporization − 15.22 (− 34.20, 3.77) 1.74 (− 15.42, 19.60) − 4.62 (− 18.25, 9.64)
8.37 (− 7.22, 23.91) 15.22 (− 3.77, 34.20) bipolar TURP 16.92 (− 5.60, 40.36) 10.60 (− 5.88, 27.97)
− 8.65 (− 30.98, 12.79) − 1.74 (− 19.60, 15.42) − 16.92 (− 40.36, 5.60) Diode laser vaporization − 6.32 (− 23.43, 10.71)
− 2.29 (− 17.61, 12.18) 4.62 (− 9.64, 18.25) − 10.60 (− 27.97, 5.88) 6.32 (− 10.71, 23.43) Monopolar TURP
Complication, RR (95%CI)
Bipolar vaporization 0.76 (0.28, 1.81) 0.82 (0.23, 2.07) 1.06 (0.36, 2.87) 1.89 (0.75, 4.17)
1.31 (0.55, 3.51) Green-light laser vaporization 1.07 (0.32, 2.83) 1.39 (0.58, 3.37) 2.49 (1.20, 4.95)
1.22 (0.48, 4.38) 0.93 (0.35, 3.17) bipolar TURP 1.31 (0.42, 5.05) 2.32 (0.94, 6.73)
0.94 (0.35, 2.76) 0.72 (0.30, 1.71) 0.76 (0.20, 2.39) Diode laser vaporization 1.77 (0.70, 4.27)
0.53 (0.24, 1.34) 0.40 (0.20, 0.83) 0.43 (0.15, 1.07) 0.57 (0.23, 1.42) Monopolar TURP
Short-term Qmax, MD (95%CI)
Bipolar vaporization − 0.09 (− 3.06, 2.99) 0.00 (− 2.30, 2.44) − 2.12 (− 5.48, 1.35) − 1.18 (− 3.51, 1.27)
0.09 (− 2.99, 3.06) Green-light laser vaporization 0.11 (− 3.02, 3.19) − 2.00 (− 4.76, 0.70) − 1.08 (− 3.55, 1.42)
− 0.00 (− 2.44, 2.30) − 0.11 (− 3.19, 3.02) bipolar TURP − 2.10 (− 5.58, 1.46) − 1.19 (− 3.76, 1.50)
2.12 (− 1.35, 5.48) 2.00 (− 0.70, 4.76) 2.10 (− 1.46, 5.58) Diode laser vaporization 0.94 (− 1.71, 3.59)
1.18 (− 1.27, 3.51) 1.08 (− 1.42, 3.55) 1.19 (− 1.50, 3.76) − 0.94 (− 3.59, 1.71) Monopolar TURP
Long-term Qmax, MD (95%CI)
Bipolar vaporization 0.11 (− 3.15, 3.70) 0.49 (− 1.83, 2.96) − 2.27 (− 6.38, 2.01) − 0.22 (− 2.79, 2.79)
− 0.11 (− 3.70, 3.15) Green-light laser vaporization 0.37 (− 2.96, 3.69) − 2.38 (− 5.53, 0.85) − 0.30 (− 2.74, 2.15)
− 0.49 (− 2.96, 1.83) − 0.37 (− 3.69, 2.96) bipolar TURP − 2.73 (− 6.90, 1.40) − 0.68 (− 3.34, 2.14)
2.27 (− 2.01, 6.38) 2.38 (− 0.85, 5.53) 2.73 (− 1.40, 6.90) Diode laser vaporization 2.07 (− 1.26, 5.39)
0.22 (− 2.79, 2.79) 0.30 (− 2.15, 2.74) 0.68 (− 2.14, 3.34) − 2.07 (− 5.39, 1.26) Monopolar TURP

SMD standardized mean difference, OR odds ratio, CI confidential interval, PVR post-void residual, IPSS International Prostate Symptom Score,
Qmax maximum urine flow rate

sphincter [32]. The development of the Twister™ diode laser
system may provide solution for this problem. This device
uses the end-firing fiber and is working in contact mode
which not only decreases coagulation zone compared with
the noncontact fiber but also provides magnificent ablation
and hemostasis to prostatic tissue with satisfactory clinical
outcomes [33]. However, more clinical trials are required to
confirm the results.
It is widely accepted that during interventions for BPH,
the thermal penetration damage of different types of devices
is an important problem that should be carefully considered.
In general, the deeper the thermal penetration depth of the
tissue, the more severe the damage to the remaining part of
the prostate may be and may even cause dysfunction. Energy
absorption is the most essential part of the laser-tissue or
electrode-tissue interaction processes, and the heat energy
converted by the lasers or electrodes can cause an increase
in the temperature of the target tissue and produce either
coagulation or vaporization. Based on the data of previously
published studies, under the condition of a satisfactory cura-
tive effect, the depth of thermal penetration of the green-
light laser was less than 1 mm [34]; however, a significantly
deeper necrotic zone (approximately 4 mm) was observed in
the application of the 980-nm diode laser [30]. In regard to
the plasma-kinetic electrode or bipolar electrode, due to the
modification of bipolar devices, when vaporizing the surface
of the tissue, the temperature is relatively low (40 ~ 70 °C)
and a solidified layer of 1 ~ 3 mm is formed in the wound
[35]. This evidence also supports the conclusion of the cur-
rent study that the greenlight laser might be the best energy
device for prostate vaporization in BPH treatment.
Better control of the energy spot size and higher wiping
speed are recommended to achieve a smooth surface of the
wound. To avoid severe complications such as uncontrolla-
ble bleeding or capsule perforation, it is important to avert
persistent vaporization on a small area of the prostate tis-
sue. In this respect, laser devices may exhibit more benefits
than electrode devices. Due to the physical characteristics
of greenlight lasers as well as diode lasers, the blood vessels
of prostate tissue are blocked immediately, thus significantly
minimizing bleeding and enhancing the clarity of vision.
Blinded vaporization under blurred vision may cause tissues
to attach to the tip of the fiber or loop, further decreasing the
energy delivery efficacy and reducing equipment service life.
The pooled results were almost consistent with our ini-
tial hypothesis. However, there are still some limitations
in this analysis that we should mention. First, considering
the rapid development of transurethral prostate hyperplasia

13
Lasers in Medical Science (2023) 38:150 Page 17 of 19 150

Fig. 3  Ranking probability of each energy system in prostate vaporization. A Comparison of surgery time. B Comparison of complications. C
Comparison of short-term efficacy. D Comparison of short-term efficacy

Fig. 4  Benefit and risk analysis

based on complications and
efficacy

surgery in the last decade, when conducting this study, we in this study, mono-polar TURP and bipolar TURP were
only included studies published from 2010 to the present, included in NMA as intermediate nodes, but we only
which may have missed some candidate studies. Second, included clinical trials comparing two types of TURP and

13
 150 Page 18 of 19
vaporization techniques. A large number of studies directly
comparing mono-polar TURP and bipolar TURP were not
included, which may impair the precision of the compari-
son results between mono-polar TURP and bipolar TURP,
thereby affecting the accuracy of the comparison network.
Third, as only a small number of randomized controlled tri-
als were qualified in each comparison of different vaporiza-
tion devices in the quantitative analyses, the pooled results
should be interpreted carefully, and such a small number of
included trials and sample sizes were unable to make strong
conclusions. Thus, well-designed and high-quality multi-
center long-term RCTs with large sample sizes are required
to validate our findings.
Conclusion
Significantly better short-term efficacy was observed in
the green-light laser vaporization group compared with the
diode laser vaporization group in the conventional paired
meta-analysis stage. However, only four studies offered
direct comparisons; thus, we conducted the NMA com-
parisons. We found no significant difference in the indirect
comparisons of the operation time, short-term efficacy,
long-term efficacy, and complications among the vaporiza-
tion devices. Nevertheless, through the probability ranking
analyses and benefit-risk analyses, green-light laser vapori-
zation of the prostate might be the best energy system for
prostate vaporization in BPH treatment.
Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 10103-0​ 23-0​ 3781-7.
Author contribution Conception and design: TJ; administrative sup-
port: TJ; provision of study materials or patients: YM, KX; collection
and assembly of data: YM, KX; data analysis and interpretation: YM,
KX, ZL; manuscript writing: all authors; final approval of manuscript:
all authors; manuscript revision: KX, HL.
Data availability The data that support the findings of this study are
available from the corresponding author upon reasonable request.
Declarations
Conflict of interest The authors declare no competing interests.
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