PVP is a laser procedure used to treat LUTS/BPH that operates at a wavelength of 532 nm and has evolved over time from 60/80 W (Nd:YAG passed through a potassium titanyl phosphate [KTP] crystal) to 120 W (using lithium triborate [LBO] to have a more collimated beam) to 180 W (increased power and a sturdier fiber). Unlike other laser wavelengths, this wavelength is particularly absorbed by hemoglobin so that there is less bleeding during surgery. There are numerous studies regarding PVP versus other BPH treatment modalities that have been published since the last Guideline. Despite progressively increased efficiency with the evolution of the 180 W PVP versus the 80 W PVP, PVP was consistently shown to take longer to perform than other modalities. A systematic review and meta-analysis by Liu et al. looking at 5 RCTs and 4 non-RCTs, included 1,525 patients and showed that PVP had a longer operative time (MD: 8.79 minutes; 95% CI: 1.28 to 16.30; P=0.02) than a TURP.285 Jovanovic et al.’s prospective RCT of 62 patients with a 180 W PVP also showed that the mean operating room time was significantly shorter for a TURP at 82±13 minutes versus a 180 W PVP operating room time of 92±18 minutes (p<0.01).286 Peng et al.’s 120 patient RCT between PVP and a PKRP/B-TURP showed PVP required a longer operative time than that of PKRP (56 minutes versus 41 minutes, respectively; P<0.01). Finally, a systematic review and random effects meta-analysis of 13 RCTs and 1,757 patients by Gill et al., also showed that PVP cases took 10 minutes (95% CI: 5 to 15; P<0.001) longer than a TURP.287 However, PVP has consistently shown to be associated with shorter duration of catheterization and shorter hospital stays. Liu et al. showed a shorter PVP catheterization time (MD: -0.95 days; 95% CI: -1.11 to -0.80; P<0.00001) and shorter hospital stay with PVP (MD: -1.72 days; 95% CI: -2.43 to -1.01; P<0.00001) versus TURP.285 Jovanovic et al. also showed that the average duration of catheterization was shorter for the PVP group (1.1±0.6 days versus 2.9±0.9 days; p<0.0001). The average hospital stay was also shorter for the PVP group compared to the TURP group (1.9±0.8 days versus 4.4±0.6 days; p<0.0001).286 Likewise, Peng et al. showed that PVP also needed shorter length of catheterization (2.4 days versus 3.5 days; P<0.01) and shorter length of hospital stay (3.5 days versus 5.1 days; P<0.01) versus PKRP.273 Finally, Gill et al. also showed that catheterization duration (MD: -1.3 days; 95% CI: -1.7 to -0.9; P<0.001) and hospital stay (MD: -2.1 days; 95% CI: -2.5 to -1.7; P<0.001) were both significantly shorter with PVP than TURP.287 PVP also showed to consistently have less blood loss than TURP. In Liu et al., patients treated with PVP had lower incidence of postoperative complications compared to TURP which included a significantly lower rate of transfusion (OR: 0.57; 95% CI: 0.37 to 0.89; P=0.01) and a significantly lower rate of clot retention (OR: 0.16; 95% CI: 0.06 to 0.43; P=0.0003).285 Gill et al. showed that PVP had fewer rates of bleeding-related complications, including clot retention, than TURP (RR: 0.12; 95% CI: 0.05 to 0.32; P<0.001) and fewer rates of transfusion compared to TURP (RR: 0.26; 95% CI: 0.12 to 0.58; P<0.001).287 Jovanovic et al. also showed no significant blood loss with the PVP procedure as opposed to the significant reduction in the hemoglobin levels in the TURP group compared with preoperative values. In fact, 19.4% of the TURP group needed a transfusion versus no patients in the PVP group.286 It should also be noted that two studies showed PVP to cause significantly more dysuria than TURP. Liu et al. showed dysuria (OR: 3.43; 95% CI: 1.86 to 6.33; P<0.0001) was significantly higher in PVP, possibly related to the energy source.285 In addition, a report by Wroclawski et al. showed that after BPH was treated with a PVP laser, the incidence of dysuria leading to emergency room visits was significantly higher than the incidence of dysuria related to emergency visits after a TURP.288 When assessing efficacy of PVP versus TURP, there is considerable evidence since the last Guideline showing they have similar efficacy. Thomas et al.’s 2-year outcomes of the GOLIATH trial showed maintenance of non-inferiority up to 2 years for the 180 W PVP versus TURP since the mean IPSS at 24-months remained at the lower, postoperative level (6.9 points in PVP versus 5.9 points in TURP; MD: 1.0 point; 95% CI: -0.5 to 2.5). Similarly, the mean Qmax remained at clinically higher levels in both treatment groups (21.6 mL/s in PVP versus 22.9 mL/s in TURP; MD: -1.3 mL/s; 95% CI: -4.0 to 1.4).289 In prostates <80 cc, Liu et al. assessed differences in outcomes between TURP and PVP. The six-month data showed a slight benefit of TURP over PVP in total IPSS, but no statistical difference in PVR, Qmax, and quality of life. Long-term data at 12, 24, and 60 months showed no statistically significant difference between the PVP and TURP groups with regards to IPSS, PVR , Qmax, and quality of life.285 It should also be noted that numerous other laser procedures have evolved for vaporization of the prostate including the use of holmium and thulium lasers, both having their own respective pros and cons involving different wavelengths. In addition, there have been different techniques employed with holmium, thulium, and PVP lasers. These techniques include straight vaporization as well as the micro-enucleation/holmium laser resection of the prostate (HOLRP) alternative technique of vaporizing the prostate into small prostate chips (much like with a TURP). This later technique can result in a more efficient removal of obstructing prostatic tissue. These laser techniques are operator-dependent but have been employed with a wide range of prostates.290 Finally, when comparing the availability of lasers, the Panel agreed that the 80 W PVP laser is less effective than the 120 W and 180 W PVP lasers and that, given the option, it is best to use the higher power PVP lasers. The Lee et al. study showed non-inferiority to the 80 W PVP laser versus the 120 W PVP laser with regards to all parameters aside from operating room time where median laser time was longer in the 80 W group (85 minutes versus 51 minutes; p<0.001) with a higher median energy utilized (253 kJ versus 210 kJ; p=0.001) despite an equivalent prostate volume.291 Still, operating room time aside, PVP with the 80 W laser had similar outcomes to TURP as noted in Mordasini et al., a 5-year RCT with 105 patients that compared an 80 W PVP laser group versus a TURP group which showed that after 5 years of follow-up, mean improvements in IPSS, PVR, and Qmax were similar in both groups. The retreatment rate was 14.3% in the 80 W PVP group versus 11.9% in the TURP group (P=0.9).292