Enucleated Weight/Enucleation Time, Is It Appropriate for Estimating Enucleation Skills for Holmium Laser Enucleation of the Prostate? A Consideration of Energy Consumption

Abstract

PurposeTo date, the parameters for evaluating enucleation efficiency have only considered enucleation time, although operators simultaneously consume both time and energy during holmium laser enucleation of the prostate. This study was undertaken to find a better way of assessing enucleation skills, considering both enucleation time and consumed energy.Materials and MethodsOne hundred (n=100) consecutive patients who underwent holmium laser enucleation of the prostate from April 2012 to April 2014 by a single surgeon were enrolled. Ten groups of 10 consecutive cases were used to analyze the parameters of enucleation efficiency.ResultsThe mean enucleation time, consumed energy, and enucleated weight were 41.3±19.2 minutes, 66.2±36.0 kJ, and 26.6±21.8 g, respectively. Concerning learning curves, like enucleation time-efficacy (=enucleated weight/enucleation time), enucleation energy-efficacy (=enucleated weight/consumed energy) also had an increasing tendency. Enucleation ratio efficacy (=enucleated weight/transitional zone volume/enucleation time) plateaued after 30 cases. However, enucleation time-energy-efficacy (=enucleated weight/enucleation time/consumed energy) continued to increase after 30 cases and plateaued at 61 to 70 cases. Furthermore, one-way analysis of variance showed that group means for enucleation time-energy-efficacy (F=3.560, p=0.001) were significantly different, but that those of enucleation ratio efficacy (F=1.931, p=0.057) were not.ConclusionsWhen both time and energy were considered, enucleation skills continued to improve even after 30 cases and plateaued at 61 to 70 cases. Therefore, we propose that enucleation time-energy-efficacy should be used as a more appropriate parameter than enucleation ratio efficacy for evaluating enucleation skills.

Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate

“…Furthermore, laser energy outcome measures have been evaluated in prior studies, and a reduction of laser time and energy usage was observed with growing experience [11,17,20,22,23]. Our data underline these findings, showing a continuous improvement for both novice surgeons which was present even beyond case 120.…”

“…In the past years, several studies have been published investigating the learnability of HoLEP, and a recent review estimated 50 procedures to achieve a stable outcome, which could decrease to approximately 25 in case of a structured training. In these studies, various endpoints were applied to describe the learning curve, such as enucleation and morcellation efficiency, postoperative complications, functional outcome, postoperative prostate-specific antigen (PSA) decrease, lack of conversion to TURP, and laser energy application [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Further parameters may influence the learning curve, including patient-related factors potentially complicating the procedure.…”

Second to fourth digit ratio and lung function (forced vital capacity): predictors of maximum urinary flow rate after holmium laser enucleation of the prostate

“…It is clear that HoLEP is a surgical treatment for relatively large BPH. However, HoLEP surgery is not the only method for treating enlargement of the prostate more than 100 g. In published studies, the prostate size in the HoLEP group was over 100 g in comparisons with open prostatectomy (Kuntz & Lehrich, ; Naspro et al ., ), but in almost all HoLEP studies the prostate size is similar to the present study (about 50–70 g) (Kuntz et al ., ; Montorsi et al ., ; Westenberg et al ., ; Bae et al ., ; Kwon et al ., ; Nam et al ., ; Hur et al ., ; Kim et al ., ).…”

Surgical training for anatomical endoscopic enucleation of the prostate

“…What is considered ‘small’ and ‘big’ is largely based on expert opinion only, but perhaps a moderately enlarged prostate gland (30 to 80 g in size) has a good balance of benefits and it is likely to represent where the sweet spot is. The case selection of the published studies may have implied consensus on the ‘best case’ for AEEP. Looking into the studies investigating the learning curve of AEEP, the average prostate volume ranged from 51.6 to 92 g (Bae, Oh, & Paick, 2010; Jeong et al, 2012; Kim et al., 2018; Placer et al., 2009; Shah et al., 2007). This range of prostate volume appears to be safe at least in terms of the complication profile. Operative time must be taken into account in AEEP especially when the procedure has to be completed within a reasonable operative time under spinal anaesthesia.…”

“…This range of prostate volume appears to be safe at least in terms of the complication profile. Operative time must be taken into account in AEEP especially when the procedure has to be completed within a reasonable operative time under spinal anaesthesia. In the studies investigating the learning curve of AEEP (Bae et al., 2010; Jeong et al, 2012; Kim et al., 2018; Placer et al., 2009; Shah et al., 2007), the average enucleation efficiency ranged from 0.32 to 1.0 g/min. Assuming an enucleation efficiency of 0.6 g/min, a 90 g prostate is pretty much the maximum size that a beginner should start with, in order to complete the procedure within an acceptable time of anaesthesia.…”