title: 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.
abstract: BACKGROUND
  The aim of this study was to determine the learning curve for thulium laser enucleation of the prostate (ThuLEP) for two surgeons with different levels of urological endoscopic experience.
  
  
  METHODS
  From June 2012 to August 2013, ThuLEP was performed on 100 patients in our institution. We present the results of a prospective evaluation during which we analyzed data related to the learning curves for two surgeons of different levels of experience.
  
  
  RESULTS
  The prostatic adenoma volumes ranged from 30 to 130 mL (average 61.2 mL). Surgeons A and B performed 48 and 52 operations, respectively. Six months after surgery, all patients were evaluated with the International Prostate Symptom Score questionnaire, uroflowmetry, and prostate-specific antigen test. Introduced in 2010, ThuLEP consists of blunt enucleation of the prostatic apex and lobes using the sheath of the resectoscope. This maneuver allows clearer visualization of the enucleation plane and precise identification of the prostatic capsule. These conditions permit total resection of the prostatic adenoma and coagulation of small penetrating vessels, thereby reducing the laser emission time. Most of the complications in this series were encountered during morcellation, which in some cases was performed under poor vision because of venous bleeding due to surgical perforation of the capsule during enucleation.
  
  
  CONCLUSIONS
  Based on this analysis, we concluded that it is feasible for laser-naive urologists with endoscopic experience to learn to perform ThuLEP without tutoring. Those statements still require further validation in larger multicentric study cohort by several surgeon. The main novelty during the learning process was the use of a simulator that faithfully reproduced all of the surgical steps in prostates of various shapes and volumes.
authors.affiliation: Department of Urology, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. giovannisaredi@yahoo.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Saredi
authors.affiliation: Department of Urology, University of Modena e Reggio Emilia, viale Borri, 57, 21100, Varese, Modena, Italy. gmo.pirola@gmail.com.
authors.forename: Giacomo Maria
authors.initials: GM
authors.lastname: Pirola
authors.affiliation: Department of Urology, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. a.pacchetti.90@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Pacchetti
authors.affiliation: Department of Urology, Ospedale di Circolo di Busto Arsizio, Saronno, Italy. jalovis@hotmail.com.
authors.forename: Jon Alexander
authors.initials: JA
authors.lastname: Lovisolo
authors.affiliation: Department of Surgery, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. medici.urologia@ospedale.varese.it.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Borroni
authors.affiliation: Department of Statistics, Bicocca University, Milan, Italy. sembeninifederico@alice.it.
authors.forename: Federico
authors.initials: F
authors.lastname: Sembenini
authors.affiliation: Department of Urology, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. Albertomario.marconi@ospedale.varese.it.
authors.forename: Alberto Mario
authors.initials: AM
authors.lastname: Marconi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D015331:Cohort Studies; D005500:Follow-Up Studies; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011446:Prospective Studies; D011470:Prostatic Hyperplasia / Q000473:pathology / Q000601:surgery*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery; D012044:Regression Analysis; D018570:Risk Assessment; D013932:Thulium; D020728:Transurethral Resection of Prostate / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D013932:Thulium