Thulium fibre laser endoscopic enucleation of the prostate (THUFLEP) learning curve assessment: A retrospective analysis of the experience of a single surgeon

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Abstract
Objectives: To assess the learning curve of thulium fibre laser enucleation of the prostate (THUFLEP). Patients and methods: We conducted a retrospective study including the first 111 patients treated with THUFLEP by a single surgeon. The operator had no prior experience in prostate enucleation and performed the first two procedures under the supervision of an expert. Initial 68 cases were performed using the three‐lobe technique, and the later cases were done as en bloc enucleation with early apex release ( n = 43). The learning curve was analysed in terms of temporal changes in the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs) and achievement of pentafecta (enucleation + morcellation <90 min, a complete enucleation without complications and stress urinary incontinence at 3 months) in four consecutive patients. Results: A total of 111 consecutive patients were included, with a mean age of 71.5 years (SD = 10.8), a mean total PSA of 7.9 ng/ml (SD = 8.4) and a mean prostate volume of 99.1 cc (SD = 35.9). The mean enucleation and morcellation times were 65.9 min (SD = 36.2) and 15.5 min (SD = 13.5), respectively. There were 13 postoperative complications (11.7%), and only one required reoperation for clot evacuation. The pentafecta was achieved in 66 patients (59.5%) and was reached in four consecutive patients after the 38th case. Operative time reached a plateau after approximately 60 procedures. The average enucleation efficiency was 1.1 g/min (SD = 0.7), and the plateau had not yet been reached after 111 patients. Conclusions: In our experience, we observed a learning curve of 40–60 cases for THUFLEP. This plateau was reached after a relatively long learning curve; a more structured and supervised training programme may help improve these learning curves. Lastly, the complication rate was low from the beginning of the surgical experience, and the pentafecta was achieved in more than half of the patients.

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