Urology Video Journal (Dec 2020)
Thulium laser enucleation of the prostate: A standardized 10-step approach for surgeons-in-training
Abstract
Introduction and Objective: Endoscopic enucleation of the prostate has been established as a reliable option with superior outcomes for men with benign prostatic hyperplasia. However, despite guidelines endorsement, endoscopic enucleation is not widely adopted. The procedure has been traditionally perceived as technically demanding with a steep learning curve. Herein, we describe a standardized 10-step approach to Thulium Laser Enucleation of the Prostate (ThuLEP) dividing the procedure into discrete reproducible steps. Methods: A standardized 10-step approach was adopted for ThuLEP training in our residency program. The ten steps are detailed in the presented video, namely: (1) bladder neck incision, (2) widening the working channel, (3) distal mucosal incision, (4) development of the enucleation plane, (5) enucleation of the adenoma from 6-4 o'clock, (6) early sphincter release, (7) lateral dissection of the adenoma, (8) crossing over the anterior commissure, (9) incising the anterior commissure, and (10) final anterior dissection.Following each procedure, residents completed a proficiency score assessment questionnaire which evaluated their perception to safely and autonomously perform each of the ten steps. For each step, total number of attempts, number of trainees who achieved basic proficiency or higher, and median number of attempts to achieve basic evaluation were evaluated. Morcellation times were recorded for each case and correlated with the learning curve. Results: A total of 13 residents reported self-evaluation scores for 87 cases. Median age was 67 years Mean prostate size was 108± 59.97 grams. Each step performance was rated on a scale of 1 to 5, with basic proficiency (defined as the ability to complete the step with bare minimum proficiency and with occasional direction) identified as proficiency score of 3 or higher. Residents scored highest for steps 1 and 3, with 13 residents achieving basic proficiency with a median of 5 trials. Step 6 was perceived as the most difficult, with 5 residents achieving basic proficiency in a median of 10 trials. Steps 5, 8 and 9 were similar in difficulty, with 8 residents achieving basic proficiency at a median of 9 trials. Morcellation time was 13 ± 9.24 minutes. Mean morcellation efficiency was 5.37 gm/minute and didn't change with progressing number of cases. Conclusion: Thulium laser enucleation of the prostate can be divided into 10 simplified reproducible steps. This break up facilitates training and allows for more accurate assessment of performance metrics.
