Thulium laser has been proven to be safe and effective, with no significant differences concerning functional outcomes and perioperative complications.2–6 Learning curve is a main concern when approaching a new technique. Enucleation and morcellation are the two main surgical steps, each related to some possible complications. Compared to holmium laser enucleation of the prostate (HoLEP), evidence in the literature on the learning curve for Thulium laser enucleation of the prostate (ThuLEP) is scarce, with some authors assessing that from 15 to 30 cases are needed for an experienced endourologist to reach proficiency.7,8
In our study patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. All procedures were carried out by the same surgeon, who had experience with TURP but not in ThuLEP or HoLEP. No simulators were used. An experienced surgeon was present in the operating room to give suggestions. According to our results, a statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload.
Our study should encourage urologists to embrace ThuLEP. A relatively limited number of cases is needed to significantly improve enucleation and morcellation skills, taking into account the high prevalence of BPH and the high number of patients who need surgical treatment. Moreover, the complication rate is acceptable from the very beginning of the learning curve.
Written by: Davide Perri, MD, Urologist, Division of Urology, Sant'Anna Hospital, Via Ravona 20, 22042, San Fermo della Battaglia, Italy
References:
- Gratzke C, Bachmann A, Descazeaud A, Drake MJ, Madersbacher S, Mamoulakis C, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol 2015;67:1099–109.
- Wani MM, Sriprasad S, Bhat T, Madaan S. Is Thulium laser enucleation of prostate an alternative to Holmium and TURP surgeries - A systematic review? Turk J Urol 2020;46:419–26.
- Huang S-W, Tsai C-Y, Tseng C-S, Shih M-C, Yeh Y-C, Chien K-L, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ 2019;367:l5919.
- Zhang Y, Yuan P, Ma D, Gao X, Wei C, Liu Z, et al. Efficacy and safety of enucleation vs. resection of prostate for treatment of benign prostatic hyperplasia: a meta-analysis of randomized controlled trials. Prostate Cancer Prostatic Dis 2019;22:493–508.
- Hartung FO, Kowalewski K-F, von Hardenberg J, Worst TS, Kriegmair MC, Nuhn P, et al. Holmium Versus Thulium Laser Enucleation of the Prostate: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur Urol Focus 2022;8:545–54.
- Zhang F, Shao Q, Herrmann TRW, Tian Y, Zhang Y. Thulium laser versus holmium laser transurethral enucleation of the prostate: 18-month follow-up data of a single center. Urology 2012;79:869–74.
- Zuo C, Yang KL, Li ZC, Gu YM, Diao YZ, Meng XB, et al. ["Double Grooves-Double Rings" technique of transurethral Thulium laser enucleation of the prostate: learning curve of single surgeon]. Zhonghua Yi Xue Za Zhi 2023;103:1563–7.
- Saredi G, Pirola GM, Pacchetti A, Lovisolo JA, Borroni G, Sembenini F, et al. Evaluation of the learning curve for thulium laser enucleation of the prostate with the aid of a simulator tool but without tutoring: comparison of two surgeons with different levels of endoscopic experience. BMC Urol 2015;15:49.