Evaluation of the learning curve for Thulium VapoEnucleation of the prostate (ThuVEP) using a mentor-based approach

Department of Urology, Asklepios Hospital Barmbek, Rübenkamp 220, 22291, Hamburg, Germany, .
World Journal of Urology (Impact Factor: 2.67). 06/2012; 31(5). DOI: 10.1007/s00345-012-0894-1
Source: PubMed


To evaluate the learning curve of Thulium:YAG VapoEnucleation of the prostate (ThuVEP) for patients with symptomatic benign prostatic obstruction (BPO) prospectively.

ThuVEP was performed using the 120 Watt 2 μm continuous wave Thulium:YAG laser. ThuVEP was done by a resident without experience in transurethral prostate surgery (A, n = 32), an experienced endourologist (B, n = 32), and an experienced surgeon in ThuVEP (C, n = 32), who served as the mentor for A/B. Patients were divided into consecutive subgroups of 8 patients to assess the impact of the learning curve on procedure outcome. Patient demographic, perioperative, and 12-month follow-up data were analysed.

ThuVEP was successfully completed in all patients. Enucleation efficiency (g/min) differed significantly between surgeon A (0.48 ± 0.3), B (0.7 ± 0.36), and C (1.4 ± 0.67) (p ≤ 0.001). Enucleation efficiency correlated significantly with the weight of resected tissue in surgeon A (r = 0.88), B (r = 0.73), and C (r = 0.79) (p < 0.001). ThuVEP was performed by surgeon A and B with reasonable enucleation, morcellation, and overall operation efficiency after 8-16 procedures. At 12-month follow-up, 68 (71 %) patients were available for review. IPSS, QoL, Qmax, PVR, PSA, and prostate volume improved significantly at follow-up (p ≤ 0.023). Mean PSA/prostate volume reduction was 81.95/74.5, 80.7/79.4, and 87.6/75.9 % in surgeon A, B, and C, respectively. Urethral stricture and bladder neck contracture developed 2 (A = 1, B = 1; 2.1 %) patients and 1 (C, 1 %) patient each, respectively.

ThuVEP can be performed with reasonable efficiency even during the initial learning course of the surgeon when closely mentored. Previous experience in the field of endourology is beneficial.

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    • "The procedure of Holmium laser enucleation of the prostate (HoLEP) has the advantage of complete anatomic enucleation of the prostate [1,2]; however, this procedure is technically difficult to perform and has a steep learning curve [3,4,5]. HoLEP requires blunt dissection between the prostatic adenoma and the capsule, with the beak of the resectoscope serving as the "surgeon's finger" during simple open prostatectomy. "
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    ABSTRACT: Purpose To identify the endoscopic vascular anatomy of the prostate during Holmium laser enucleation of the prostate (HoLEP), and analyze the clinical risk factors associated with significant arterial bleeding. Methods We identified 107 consecutive patients with benign prostatic hyperplasia who underwent HoLEP between September 2009 and August 2010, performed by a single surgeon (S.J.O.). Two independent reviewers reviewed the surgery video database and completed a prespecified form. The location of bleeding arteries was marked at the level of the bladder neck, proximal prostate, distal prostate, and verumontanum. Arterial bleeding was classified into one of three grades according to bleeding severity (grades 2 and 3 indicate significant bleeding). Results The mean prostate volume was 65.1±31.5 mL, and the mean prostate-specific antigen (PSA) level was 3.69±3.58 ng/mL. During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. The average number of bleeding arteries was 12.1±7.9 per procedure, and 1.93±1.20 per 10 mL of prostate volume. Multivariate analysis revealed that prostate volume and serum PSA were significant parameters for estimating the number of bleeding vessels. Conclusions During the HoLEP procedure, the most common locations of significant bleeders were the 2-5 and 7-10 o'clock positions in the proximal prostate. Prostate volume was associated with the number of bleeders. A careful approach to the capsular plane of the proximal prostate facilitates early hemostasis during the HoLEP procedure, especially with larger adenomas.
    International neurourology journal 09/2014; 18(3):138-44. DOI:10.5213/inj.2014.18.3.138 · 1.06 Impact Factor
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    ABSTRACT: BACKGROUND: Thulium vapoenucleation of the prostate (ThuVEP) has been introduced as a minimally invasive treatment for benign prostatic obstruction (BPO). OBJECTIVE: To analyze immediate outcomes and the institutional learning curve of ThuVEP, and to report its standardized complication rates, using the modified Clavien classification system (CCS) to grade perioperative complication rates. DESIGN, SETTINGS, AND PARTICIPANTS: A prospective evaluation of 1080 patients undergoing ThuVEP from January 2007 until May 2012 at our institution. INTERVENTION: ThuVEP was performed using the 2-μm, continuous-wave, thulium:yttrium-aluminum-garnet laser. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative status, surgical details, and immediate outcome were recorded for each patient. Perioperative complications were classified according to the modified CCS. RESULTS AND LIMITATIONS: Median prostate size was 51ml (interquartile range [IQR]: 36-78.7). Median operation time was 56min (IQR: 40-80), and median enucleation time was 32.5min (IQR: 22-50). Median catheterization time was 2 d (IQR: 2-2); median length of hospital stay was 4 d (IQR: 3-5). Median resected tissue weight was 30g (IQR: 16.00-51.25). Incidental carcinoma of the prostate was detected in 59 (5.5%) patients. Median maximum urinary flow rate (8.9 vs 18.4ml/s) and postvoid residual urine volume (120 vs 20ml) changed significantly (p<0.001). Minor complications occurred in 24.6% of the patients (Clavien 1: 20.8%; Clavien 2: 3.8%). Early reinterventions were necessary in 6.6% of the patients (Clavien 3a: 0.6%; Clavien 3b: 6%). One Clavien 4 complication occurred (0.09%). The overall complication rates decreased significantly over time due to decreasing Clavien 1, 2, and 3b events. The major limitations of the study are the prospective, unicentric study design, the lack of a control group, and that only short-term data were documented on morbidity and efficacy of the ThuVEP procedure. CONCLUSIONS: ThuVEP is a safe and effective procedure for the treatment of symptomatic BPO, with low perioperative morbidity.
    European Urology 12/2012; 63(5). DOI:10.1016/j.eururo.2012.11.048 · 13.94 Impact Factor
  • European Urology 01/2013; 63(5). DOI:10.1016/j.eururo.2013.01.024 · 13.94 Impact Factor
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