Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.

PURPOSE: In a prospective manner we evaluated the learning experience of an endourologist inexperienced with holmium laser prostate enucleation and its impact on surgical outcome. We also reviewed the literature to document technical features of holmium laser prostate enucleation at different institutions. MATERIALS AND METHODS: Patient demographic, perioperative and followup data were analyzed. To assess the impact of the learning curve on postoperative outcome patients were divided into group 1--patients 1 to 50, group 2--51 to 100 and group 3--101 to 162. The effect of the learning curve and weight of resected tissue on enucleation and morcellation efficiency was studied. RESULTS: Holmium laser prostate enucleation was successfully completed in 93.82% of patients. Eight patients required conversion to transurethral prostate resection. Enucleation and morcellation efficiency was 0.49 and 2.75 gm per minute, respectively. Enucleation efficiency attained a plateau after 50 cases. Postoperative outcome was compared in the 3 patient groups. There was a higher incidence of capsular perforation and stenotic urethral complications in group 1. In the literature a mean of 57.09% of tissue (range -9.6 to 81.9%) was retrieved after holmium laser prostate enucleation and mean efficiency was 0.52 gm per minute (range -0.11 to 1.09). Efficiency increased proportionally with resected prostate weight. CONCLUSIONS: An endourologist inexperienced with holmium laser prostate enucleation can perform the procedure with reasonable efficiency after about 50 cases with an outcome comparable to that of experts, as described in the literature. During the learning curve conversion to transurethral prostate resection can be done without any harm to the patient.

A prospective, randomized trial evaluating the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy.

PURPOSE: We performed a prospective, randomized trial to assess the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy. MATERIALS AND METHODS: A total of 63 patients undergoing tubeless percutaneous nephrolithotomy were randomized to receive Tisseel vapor heated sealant at the end of the procedure. Fibrin sealant was instilled under direct vision in the nephrostomy tract at the end of the procedure. Patients younger than 14 years and those undergoing staged percutaneous nephrolithotomy or bilateral simultaneous percutaneous nephrolithotomy were excluded from study. Patients needing greater than 2 percutaneous tracts, those with significant bleeding or associated pyonephrosis and those with a residual stone burden were also excluded from study. The perioperative outcome in these patients (experimental group) was compared with the outcome in those undergoing tubeless percutaneous nephrolithotomy without fibrin sealant (control group). RESULTS: Fibrin sealant was instilled in 32 patients. There was no difference in the hematocrit decrease and blood transfusion requirement in the 2 groups. Patients in the experimental group experienced less postoperative pain and required less analgesia. They were discharged home 5 hours earlier than patients in the control group. However, this difference was not statistically significant. Complete stone clearance was achieved in 87.5% of patients in the experimental group and in 90.32% of controls. CONCLUSIONS: The instillation of Tisseel fibrin glue is safe for tubeless percutaneous nephrolithotomy. It is associated with less postoperative pain and a lower analgesic requirement. Additional prospective, randomized studies are required to better define its clinical role in the future.