The surgical learning curve for endoscopic GreenLight™ laser enucleation of the prostate: an international multicentre study

Abstract

Objectives To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP). Subjects/Patients and Methods A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3‐month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement. Results In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P < 0.001), lower IOC rate (P < 0.001), higher 3‐month postoperative reduction in IPSS (P = 0.004), and higher probability of Pentafecta achievement (P < 0.001). The relationship between surgical experience and enucleation time/IOCs appeared as non‐linear, with a steep slope reduction within the first 100 cases and a plateau observed after 200 cases, whilst the IPSS improved rapidly early in the learning curve process and plateaued after ~100 procedures. Finally, there was a linear improvement in Pentafecta achievement, with a plateau observed after 270 cases. Conclusion Surgical experience has a significant impact on the perioperative outcomes for GreenLEP procedures. After adjusting for patient and prostate characteristics, plateau results were achieved after a long learning curve. A more intensely mentored and structured training schedule might allow quicker and safer adoption of the procedure.

Anatomical endoscopic enucleation of the prostate: The next gold standard? No! (or not yet!)

“…Perhaps the most important factor in the difficulty of implementing a new surgical technique is the learning curve (LC) (Naspro et al., 2017). An understanding of the LC is crucial to determine how much surgical experience is required to provide reproducible outcomes (Khene et al, 2020). In aEEP, the LC tends to be steep, and according to a recent analysis, 50–60 cases were required to effectively perform enucleation; and efficient morcellation was also reported after 60 cases (Hueber & Zorn, 2013; Jeon et al., 2019; Kampantais et al., 2018; Khene et al, 2020).…”

“…An understanding of the LC is crucial to determine how much surgical experience is required to provide reproducible outcomes (Khene et al, 2020). In aEEP, the LC tends to be steep, and according to a recent analysis, 50–60 cases were required to effectively perform enucleation; and efficient morcellation was also reported after 60 cases (Hueber & Zorn, 2013; Jeon et al., 2019; Kampantais et al., 2018; Khene et al, 2020). Some institutions have discontinued the technique due to complications encountered early in the LC (Shigemura et al., 2017).…”

En bloc GreenLight laser enucleation of the prostate (GreenLEP): An in‐depth look at the anatomical endoscopic enucleation of the prostate using a 532‐nm lithium triborate laser

“…In a large multicentre retrospective study ( n = 922) of the first patients treated with GreenLEP by six surgeons, the post‐operative complications reported by Khene et al were found in 6.18% of the cases (4.88% were minor complications and only 1.3% major complications). Regarding functional results, SUI at 3 months was observed in 5.75% (Khene et al, 2020).…”