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Martinez-Salas ADJ, Garcia-Rivera OU, Reyna-Blanco I, Jimenez-Garcia AD, Rosas-Hernandez H. Adequate Mentorship Program for Holmium Laser Enucleation of the Prostate (HoLEP) Leads to Satisfactory Short-Term Outcomes in the Early Learning Curve of Young Urologists: First-Year Outcomes of a Newly Established Mentorship Training in Mexico. Cureus 2023; 15:e41756. [PMID: 37575804 PMCID: PMC10416137 DOI: 10.7759/cureus.41756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate (HoLEP) has been recommended by international guidelines as an alternative to transurethral resection of the prostate (TURP). HoLEP's learning curve and the lack of adequate mentorship remains an obstacle for the worldwide adoption of this technique. Objective To report the first-year learning curve of a newly established mentorship program in young urologists without any previous HoLEP experience. Methods We report a cohort of patients with BPH, with prostate size ≥70 grams, treated with HoLEP, analyzed for perioperative data and complications, and short-term postoperative complications and functional outcomes, at three and six months after surgery. Results A total of 47 patients were managed with HoLEP. Mean total operative time was 149.8 ± 42.9 minutes. We experienced five (10.6%) intraoperative complications, including one intravesical resection of the prostate with bipolar energy, three conversions to TURP and one conversion to open prostatectomy. We experienced four postoperative complications, all of them Clavien-Dindo ≤2. Median International Prostate Symptom Score (IPSS) decrease at six months was -17 points from baseline. Mean post-void residual volume and prostate-specific antigen significantly decreased by the third postoperative month. Multiple linear regression showed that prostate size is directly related to increased surgical time during the early learning curve. Discussion Our experience adequately reflects the importance of HoLEP mentorship in young urologists seeking training in this technique. Both surgeons had perioperative and postoperative outcomes deemed satisfactory based on previously published learning curves. Conclusions HoLEP is a technically difficult procedure, however, adequate mentorship leads to satisfying short-term outcomes since the early stages of the learning curve in young urologists with no previous training on this technique.
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Affiliation(s)
| | - Oscar Uriel Garcia-Rivera
- Urology, Centro Medico Nacional 20 de Noviembre Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, MEX
| | - Irving Reyna-Blanco
- Urology, Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) Tlahuac "Dra. Matilde Petra Montoya Lafragua", Mexico City, MEX
| | - Aldo Daniel Jimenez-Garcia
- Urology, Hospital General Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) Tlahuac "Dra. Matilde Petra Montoya Lafragua", Mexico City, MEX
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Kim YH, Kwon SY, Jun EH, Choi ST, Park SJ, Kim Y. Comparison of epidural, spinal, and saddle block for holmium laser enucleation of prostate (HoLEP): A prospective randomized, comparative study. Medicine (Baltimore) 2021; 100:e27534. [PMID: 34678887 PMCID: PMC8542140 DOI: 10.1097/md.0000000000027534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostate hypertrophy. The aim of the present study was to compare regional anesthesia methods for HoLEP operation and to determine the optimal technique. METHODS Sixty patients with American Society of Anesthesiologists scores of I-III were randomly allocated into 3 groups. Patients in group E received an epidural block with 75 mg of bupivacaine plus 50 μg of fentanyl. In group S, 15 mg of bupivacaine and 50 μg fentanyl were used for spinal anesthesia. In group SA, patients received saddle block with 15 mg of bupivacaine and 50 μg of fentanyl. RESULTS Time to T10 dermatome block and to maximal level block were longest in group E (P < .05), and maximal sensorial block level was higher in group E than group SA (P < .05). There was a significant difference in postoperative motor block, but no difference in systolic blood pressure and heart rate. CONCLUSION Among 3 techniques, saddle block might be preferable in HoLEP because an adequate sensorial level was achieved with lower motor block and stable hemodynamics.
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Affiliation(s)
- Young Hoon Kim
- Department of Anesthesiology and pain medicine, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
| | - So Young Kwon
- Department of Anesthesiology and pain medicine, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
| | - Eun Hwa Jun
- Department of Anesthesiology and pain medicine, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
| | - Seung Tae Choi
- Department of Anesthesiology and pain medicine, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
| | - Seong Jin Park
- Department of Anesthesiology and pain medicine, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
| | - Yumi Kim
- Department of Anesthesiology and pain medicine, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Republic of Korea
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Allameh F, Razzaghi M, Abedi AR, Dadpour M. The Learning Curves for Laser Application in Urology Procedures: Review of the Literature. J Lasers Med Sci 2020; 11:S8-S15. [PMID: 33995963 DOI: 10.34172/jlms.2020.s2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Currently, a laser is a popular technology in urological surgeries. The important laserrelated issue is the time when a surgeon reaches an acceptable level of safety and efficacy using laser technology. Methods: In this review, we aimed to assess the learning curves of three types of surgeries in urology, including photoselective vaporization of the prostate (PVP), holmium laser enucleation of the prostate (HoLEP) and retrograde intra-renal surgeries (RIRSs). Here, we searched Medline, Web of Science, Google Scholar, EMBASE, and Scopus for such keywords as Urology, laser, laser vaporization, prostate, nephrolithiasis, benign prostatic hyperplasia (BPH), and learning curve. Results: We evaluated 14 studies about PVP, 17 about RIRS, and 29 studies about HoLEP. Also, we separately discussed the learning curves of these three kinds of surgeries in detail. Conclusion: All the urologists, even expert surgeons, should attend a formal training course and have a skilled tutor present at their first cases.
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Affiliation(s)
- Farzad Allameh
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghi
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Center of Excellence in Training Laser Application in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Reza Abedi
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Dadpour
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Rosenhammer B, Schönhärl M, Mayr R, Schnabel MJ, Burger M, Eichelberg C. Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate. Urol Int 2020; 104:914-922. [PMID: 32877914 PMCID: PMC7845428 DOI: 10.1159/000510135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While holmium laser enucleation of the prostate (HoLEP) is accepted as safe and efficient, a long learning curve is considered the main reason for its slow adoption in clinical practice. So far, no standardized and easy-to-use parameter has been implemented to measure surgical experience or efficiency which could be useful for training and quality control purposes. The aim of the present study was to evaluate the learning curves of 2 HoLEP beginners and to identify applicable efficiency outcome measures as well as potentially complicating factors in performing HoLEP. PATIENTS AND METHODS A total of 594 patients treated by HoLEP between September 2016 and May 2019 were enrolled. The procedures were initially performed by 1 HoLEP expert (reference surgeon); over time, 2 further surgeons were trained. Baseline characteristics, enucleation weight, morcellation and enucleation time, laser energy usage, and postoperative results were recorded prospectively. The learning curves of the 2 novices were analyzed and compared to the reference surgeon. Logistic regression analyses were performed to identify predictors for postoperative grade ≥2 complications. RESULTS Median enucleation ratio and complication rates did not significantly alter along the learning curves. Median enucleation speed and laser energy application of the 2 novices significantly improved with growing experience. Combining these variables, we introduced the "HoLEP efficiency score" (HES) which demonstrated the most appropriate value to reflect the surgical experience and efficiency. The median HES for the reference surgeon was 82.8 min kJ/g. For the 2 novices, a drop from 130 and 124.4 min kJ/g by -57 and -30%, respectively, was observed. Among several tested clinical parameters, the presence of prostate cancer (p = 0.047) and the surgical caseload (p < 0.001) influenced the HES. On multivariable logistic regression, American Society of Anesthesiologists score and prostate cancer were independent predictors for grade ≥2 complications (p = 0.002, odds ratio [OR] 2.042 and p = 0.038, OR 1.940). CONCLUSION We introduce the HES as an objective and measurable tool to quantify surgical efficiency. In clinical practice, the HES may find application in training and quality control purposes as well as in comparing surgical modifications and hardware. Patients with prostate cancer seem to be more challenging cases and have a higher risk for complications, and may preferably be treated by experienced surgeons.
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Affiliation(s)
- Bernd Rosenhammer
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany,
| | - Maximilian Schönhärl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Roman Mayr
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Marco J Schnabel
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Christian Eichelberg
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
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Agreda Castañeda F, Buisan Rueda Ó, Areal Calama J. The complications of the HoLEP learning curve. A systematic review. Actas Urol Esp 2020; 44:1-8. [PMID: 31822354 DOI: 10.1016/j.acuro.2019.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Holmium laser enucleation of the prostate (HoLEP) could have better outcomes with decreased complication rates if compared to traditional techniques (transurethral resection and open prostatectomy) for the surgical relief of bladder outlet obstruction. Despite this, its use has not been implemented in the urology community, probably due to the high complication rates of the HoLEP learning curve (HoLC). OBJECTIVE To conduct a systematic review of the complication rates in HoLC and compare these with those of traditional techniques. EVIDENCE ACQUISITION a systematic literature search was performed in MedLine and Embase using the search terms «HoLEP» and «holmium laser enucleation». We identified 680 records and selected 15 studies following PRISMA criteria. EVIDENCE SYNTHESIS 1705 cases in the learning curves of 59 surgeons were analyzed. Most of the studies do not report complications in a standardized way. Intraoperative complication rates are low and usually without long-term impact. Postoperative complication rates are limited and show improvement with practice. The complication rates in the HoLC are similar or lower to those reported by traditional techniques. CONCLUSION Complication rates in HoLC are not higher than those reported by traditional techniques. HoLEP learning should not be delayed for fear of increasing complications or their severity.
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Sapetti J, Sakat J, Saad E, Zerbib M, Belas O, Doru-Pop C, Peyromaure M, Delongchamps N. Incontinence urinaire après énucléation endoscopique de la prostate au laser Holmium : fréquence, évolution, et facteurs prédictifs de survenue. Prog Urol 2019; 29:101-107. [DOI: 10.1016/j.purol.2018.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/07/2018] [Accepted: 12/12/2018] [Indexed: 11/24/2022]
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Kampantais S, Dimopoulos P, Tasleem A, Acher P, Gordon K, Young A. Assessing the Learning Curve of Holmium Laser Enucleation of Prostate (HoLEP). A Systematic Review. Urology 2018; 120:9-22. [PMID: 30403609 DOI: 10.1016/j.urology.2018.06.012] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/27/2018] [Accepted: 06/07/2018] [Indexed: 11/17/2022]
Abstract
We systematically assessed the learning curve of Holmium laser enucleation of the prostate using the available literature to identify, as our primary outcome, the average number of cases required to reach competency. A computerized search of PubMed and Scopus for articles published from inception through to January 2018 was performed including 24 studies with a total of 5173 patients. Even though different outcome measures require varying case-loads to reach a plateau, Holmium laser enucleation of prostate has an acceptable learning curve with a proposed figure approximating 25-50 cases, with a structured mentorship programme aiding for faster progress.
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Affiliation(s)
- Spyridon Kampantais
- Department of Urology, Southend University Hospital, Southend on Sea, United Kingdom.
| | - Panagiotis Dimopoulos
- Department of Urology, Southend University Hospital, Southend on Sea, United Kingdom
| | - Ali Tasleem
- Department of Urology, The Royal London Hospital, Whitechapel, London, United Kingdom
| | - Peter Acher
- Department of Urology, Southend University Hospital, Southend on Sea, United Kingdom
| | - Karen Gordon
- Department of Urology, Southend University Hospital, Southend on Sea, United Kingdom
| | - Anthony Young
- Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, United Kingdom
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Campos-Juanatey F, Portillo Martín J, Gómez Illanes R, Velarde Ramos L. Nontraumatic posterior urethral stenosis. Actas Urol Esp 2017; 41:1-10. [PMID: 27133545 DOI: 10.1016/j.acuro.2016.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 03/28/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Posterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes. OBJECTIVES To identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures. ACQUISITION OF EVIDENCE Review of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included. SYNTHESIS OF EVIDENCE Posterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters. CONCLUSIONS Non-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.
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Benign prostatic hyperplasia and lower urinary tract symptoms. A review of current evidence. Actas Urol Esp 2016; 40:288-94. [PMID: 26823069 DOI: 10.1016/j.acuro.2015.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 02/07/2023]
Abstract
CONTEXT The treatment of benign prostatic hyperplasia (BPH) is changing due to a greater understanding of the disease and the development of the functional concept of lower urinary tract symptoms (LUTS). OBJECTIVES To describe the current state of BPH and the diagnosis and treatment of LUTS. ACQUISITION OF EVIDENCE We summarise the issues presented and debated by a group of expert urologists during the First UROVI Congress, sponsored by the Spanish Urological Association. SUMMARY OF THE EVIDENCE LUTS encompasses filling, voiding and postvoiding symptoms that affect patients' quality of life. The aetiological diagnosis is an important element in starting the most ideal treatment. For this reason, new alternative therapies (both pharmacological and surgical) are needed to help individually address the symptoms in the various patient profiles. There is now a new combination of drugs (6mg of solifenacin and 0.4mg of the tamsulosin oral controlled absorption system) for treating moderate to severe filling symptoms and emptying symptoms associated with BPH in patients who do not respond to monotherapy. Furthermore, new surgical techniques that are increasingly less invasive help provide surgical options for older patients and those with high comorbidity. CONCLUSIONS The availability of drugs that can act on the various LUTS helps integrate the pathophysiological paradigm into the functional one, providing more appropriate treatment for our patients.
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