The GreenLight procedure can be performed in a hospital outpatient center or an office-based surgical facility. Typically no overnight stay is required. However, in some cases when a patient travels a long distance, has other medical conditions to consider or is in frail conditions, an overnight stay may be recommended.

The GreenLight HPS® procedure follows these steps. Caution: This information is for general educational purposes only. Refer to the procedure videos for more detailed instructions on this procedure.

Step 1: Insert Cystoscope

Insert the cystoscope with a visual obturator into the urethra using atraumatic technique and perform a preliminary cystoscopic examination, advancing the cystoscope all the way into the bladder. Blind insertion of the cystoscope without the visual obturator can cause trauma to the prostatic urethra that may result in bleeding.

Step 2: Identify Uterteral Orifices

Visually confirm location and condition of both uerteral orifices and retract the cystoscope back into the urethra.

Step 3: Vaporization of the Median Lobe

Begin the procedure with the median lobe at the bladder neck. Sweep the fiber so that it delivers laser energy between the 5 and 7 o'clock positions, keeping the fiber moving at all times. Maintain a working distance of 3mm from the targeted tissue. Adjust sweeping speed to maximize vaporization efficiency. Consider titrating the laser power until the desired tissue effect is achieved. The default setting of the laser is 80 Watts vaporization and 20 Watts coagulation. The laser can be adjusted in 10 Watt increments. For smaller or vascular glands, lasing is recommended at powers less than 80 Watts, followed by tissue evaluation. Do not adjust the power of the laser until its effect on the tissue has been evaluated. Continue lasing tissue at the bladder neck until capsular fibers are visualized. Continue tissue removal by retracting the cystoscope gradually toward the verumontanum, continuing to sweep the fiber left to right, vaporizing down to the level of the capsular fibers, until the verumontanum has been reached.

Step 4: Vaporization of the Lateral Lobes

Rotate the cystoscope 90 degrees while keeping the video camera on a fixed vertical plane. Begin lasing tissue at the bladder neck, sweeping the entire length of the lateral lobe from top to bottom. Again, systematically lase down to the capsular fibers, working from the bladder neck to the verumontanum. Once the entire lobe has been reduced, rotate the cystoscope 180 degrees to the contra-lateral lobe while keeping the video camera on the same fixed vertical plane. Return the cystoscope to the bladder neck and repeat the same technique, working from the bladder neck towards the verumontanum, lasing down to capsular fibers.

Step 5: Vaporization of Anterior Tissue

Once the lateral lobes have been removed, rotate the cystoscope upside down so that the telescope is looking at the 12 o'clock position. Keep the video camera at its original fixed vertical plane. Begin lasing at the bladder neck and rotate the fiber left to right, Again, systematically lase down to the capsular fibers, carefully working down toward the apical tissue.

Note: It is very important to protect the verumontanum and the external sphincter from backward scatter or direct contact with the laser beam.

Step 6: Confirm Endpoint

Retract the cystoscope to the verumontanum and look toward the bladder neck. Confirm a TURP-like cavity. The prostatic fossa will appear somewhat "ragged" as small strands of glandular tissue will project loosely from the walls of the cavity. These miniscule remnants do not have to be removed as they will gradually slough-off over the course of several weeks and should not cause the patient to experience any negative symptoms.

Step 7: Check for Bleeders

Turn off the inflow and outflow valves of the cystoscope. Check the prostate carefully for bleeders in the same manner as following a TURP. If bleeders are found, turn the inflow back on and coagulate the tissue surrounding the bleeders. Note: Do not fire the laser beam directly on a bleeder, instead coagulate the tissue surrounding the bleeder. Fill the bladder with saline and remove the cystoscope. Drain the bladder and check the flow and the color of the outgoing fluid.

The decision to place a Foley catheter post procedure is dependant on individual physician preference as well as the condition of each patient. Factors to consider are:

• Type of anesthesia used;
• Bladder condition or function;
• Post operative bleeding;
• Length of procedure;
• Time of day the procedure was performed and
• Distance the patient traveled for the procedure.

Post Procedure Care

As this is an endourological procedure, a post-op antibiotic is generally recommended. Urinary analgesics should be considered for those who were experiencing irritative voiding symptoms pre-procedure, or if the physician has had to coagulate extensively during the procedure.

Systemic analgesics are generally not necessary following an HPS treatment, but may be considered for patients with generalized pain or those having difficulty tolerating a catheter. In addition, the following types of medications may be prescribed at the physician's discretion:

• Anti-spasmodic; anticholinergic medications;
• Non-steroidal anti-inflammatory drugs; and
• Stool softeners

Patients should be counseled that BPH does not solely affect the prostate, but affects bladder function as well, as the bladder works harder to expel urine through the narrowed prostatic urethra. Following removal of the obstructing adenoma, the patient may initially experience more severe urgency symptoms until the bladder adjusts to the obstruction having been removed.

Advise the patient to avoid strenuous activity, including all sexual activity and exercise for three weeks following the procedure. Patients may return to normal, non-strenuous, activities (including driving) within two to three days.

Patients should be advised that they may experience intermittent episodes of initial or terminal hematuria, dysuria, frequency, and urgency for the first few weeks postoperatively. This is especially true of patients who complained of significant irritative symptoms pre-procedure, or who may have a previously undiagnosed overactive bladder.