Green Light Photo Vaporization of the Prostate Versus Minimal Invasive Surgical Techniques (MIST): A Patient-Centered Shared Decision Making Approach

Abstract

Background Benign prostatic hyperplasia (BPH) is a highly prevalent cause of lower urinary tract symptoms (LUTS) in the aging male population. Photoselective vaporization of the prostate (PVP) and minimally invasive surgical treatments (MISTs) are established surgical alternatives to traditional resection, each with distinct mechanisms of action and clinical profiles. Objective The study aims to compare the perioperative parameters and functional outcomes of PVP versus MISTs in patients with moderate-to-severe LUTS secondary to BPH. Methods This was a retrospective observational cohort study conducted at a single tertiary center, including patients treated between October 2023 and January 2026. Ethics approval was obtained from the Research Ethics Committee at King’s College Hospital NHS Foundation Trust, London, UK (approval reference number: 25/LO/8780); the requirement for individual written consent was waived given the retrospective, fully anonymized nature of the data. After removal of duplicate and incomplete records, 99 patients treated with PVP and 64 patients treated with MIST (water vapor thermal therapy (WVTT), n=58; prostatic urethral lift (PUL), n=5; temporarily implanted nitinol device (i-TIND), n=1) were analyzed. Baseline and three-month postoperative maximum urinary flow rate (Q-max), post-void residual volume (PVR), and International Prostate Symptom Score (IPSS) were compared within each cohort using paired-samples t-tests (available-case analysis, restricted to patients with both baseline and follow-up values recorded), and between cohorts using Welch's independent-samples t-test on change scores. Results Both cohorts showed statistically significant within-group improvement across all evaluated parameters. In the PVP cohort, Q-max improved by a mean of 6.55 ml/s (n=24, 95% CI 2.54-10.57, p=0.003), PVR decreased by 222.6 ml (n=28, 95% CI −356.1 to −89.2, p=0.002), and IPSS decreased by 8.13 points (n=15, 95% CI −15.83 to −0.43, p=0.040). In the MIST cohort, Q-max improved by 3.74 ml/s (n=33, 95% CI 1.17-6.30, p=0.006), PVR decreased by 68.9 ml (n=42, 95% CI −97.3 to −40.5, p<0.001), and IPSS decreased by 11.65 points (n=23, 95% CI −15.40 to −7.90, p<0.001). Direct between-group comparison of change scores showed a significantly greater reduction in PVR with PVP (difference of −153.7 ml, p = 0.028) but no significant between-group difference in Q-max change (p = 0.231) or IPSS change (p = 0.391). Mean baseline prostate volume was larger in the PVP group (61.6 vs. 50.0 cc, p < 0.001). Conclusions Both PVP and MIST produced statistically significant improvement in urinary flow, post-void residual volume, and symptom burden at three months. PVP demonstrated a significantly greater reduction in PVR, consistent with more complete anatomical resolution of obstruction, but showed no significant advantage over MIST in Q-max or IPSS improvement in this cohort. Treatment selection should be individualized to patient priorities, procedural setting, and anticipated recovery profile, rather than assuming uniform PVP superiority across all functional domains. Larger prospective studies with complete outcome capture are needed, including evaluation of sexual function, which was not assessed in this cohort.