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Re: Evaluation of the Learning Curve for Thulium VapoEnucleation of the Prostate (ThuVEP) Using a Mentor-Based Approach
BENIGN PROSTATIC HYPERPLASIA
610
can be problematic. This pilot study was designed to determine if a virtual reality exercise component could be successfully added to more traditional pelvic floor muscle exercises in a group of older women with mixed urinary incontinence. Following 2 pretreatment evaluations a total of 24 women were enrolled in structured weekly group treatment sessions during a course of 12 weeks. Therapy included traditional pelvic floor muscle exercises taught and supervised by a physiotherapist, and a virtual reality component that used video based dance games that combined movement and prompted pelvic floor muscle contractions. Overall program compliance was 91%, and 92% of patients completed the home exercise assignments. Patient satisfaction was also high, with 91% satisfied and a mean appreciation score of 9.8 on a 10-point scale. Continence outcomes were statistically improved compared to baseline. A limitation of the study was lack of a control group doing pelvic floor exercises without the virtual reality dance component, although the authors compared their results to historical publications of traditional behavioral therapies. It will be interesting to see if this type of unique training method improves long-term compliance and efficacy. Tomas L. Griebling, MD, MPH
Benign Prostatic Hyperplasia Re: Evaluation of the Learning Curve for Thulium VapoEnucleation of the Prostate (ThuVEP) Using a Mentor-Based Approach C. Netsch, T. Bach, T. R. Herrmann, O. Neubauer and A. J. Gross Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany World J Urol 2013; 31: 1231e1238.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.040 available at http://jurology.com/ Editorial Comment: Those of us involved in residency teaching often wonder how many cases a resident must do before being competent. The question is fraught with problems, primarily because the definition of competent is sometimes hard to determine. Moreover, certain techniques that are predominantly technology based (ie robotic prostatectomy) vs tactile (ie cystoscopy, passing a trochar needle in a sling procedure) may have different criteria. Finally, in an era when residents often do not “do” the case, but rather observe or assist, the numbers of cases required are even more difficult to ascertain. In this report the authors attempt to define the number of cases required to attain competency using ThuVEP in 1) a resident who had previously performed fewer than 10 transurethral prostatectomies (TURPs) and 2) a senior urologist with an experience of more than 500 TURPs. An expert in ThuVEP mentored both physicians. The authors report that competency could be achieved in 8 to 16 cases in both cohorts. There are a number of concerns with this particular study, including patient and urology selection bias. Moreover, having someone watch over you during a case, even if you are performing it, does not necessarily constitute competence. One can only really learn to drive without the instructor in the passenger seat. Finally, my own observation is that it takes many more cases for urologists to become competent in performing TURP, regardless of technique. Having done well over 3,000 TURPs, I am still learning! I suspect that this study was done partly to help market ThuVEP as an easily learned and adaptable technique. I would strongly recommend being a lot more wary, realistic and prudent. Steven A. Kaplan, MD
Re: Which Laser Works Best for Benign Prostatic Hyperplasia? A. A. Kahokehr and P. J. Gilling Department of Urology, Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand Curr Urol Rep 2013; 14: 614e619.
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
611
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.041 available at http://jurology.com/ Editorial Comment: One would guess that the answer would vary depending on whom you asked. Each of the laser technologies has its advocates/proponents. The senior author has been a leading researcher in using the holmium:YAG laser. At least 2 long-term studies (more than 7 years) using holmium:YAG have been published, and in general holmium:YAG has the most robust data set. Nevertheless, there does not appear to be an obvious “go to” laser at this time. Selection is based more on personal preference, patient comorbidities and availability of equipment. Moreover, at the end of the day let us look at the current landscape. In the United States it appears that electrovaporization of the prostate, particularly using bipolar technology, is making a comeback, and I would expect it to soon and consistently overtake lasers as the preferred method to perform transurethral removal of tissue. Finally, due to the need for morcellators in some iterations of holmium technology, one has to be cautious, especially considering the warnings about using them in gynecologic cases. While it may not be a direct extrapolation, one has to wonder where the regulatory issues may finally land. As stated many times, pick a technology you like, stick to it and master it! Steven A. Kaplan, MD
Suggested Reading Elmansy HM, Kotb A and Elhilali MM: Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol 2011; 186: 1972.
Trauma, and Genital and Urethral Reconstruction Re: Transcorporal Artificial Urinary Sphincter Implantation as a Salvage Surgical Procedure for Challenging Cases of Male Stress Urinary Incontinence: Surgical Technique and Functional Outcomes in a Contemporary Series L. Wiedemann, J. N. Cornu, E. Haab, L. Peyrat, S. Beley, X. Cathelineau and F. Haab ^ pitaux de Paris, Pierre et Marie Curie Faculty Department of Urology, Groupe Hospitalo-Universitaire EST, Tenon Hospital, Assistance Publique-Ho of Medicine, University Paris VI, Paris, France BJU Int 2013; 112: 1163e1168.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.046 available at http://jurology.com/ Editorial Comment: It is nice to see a report on transcorporeal artificial urinary sphincter outcomesdonly a few studies have appeared since the inception of this technique more than 10 years ago. We have had a favorable experience with this salvage technique in dozens of high risk patients. Of the 23 patients in this series from Paris most had failed a prior anti-incontinence procedure, or had a frail urethra after radiation or previous stricture treatment. This clean, well written prospective study contributes nicely to the literature. Included is an observation that 5 of 6 potent patients retained potency after the transcorporeal procedure. In my experience it is rare to find potent patients who are candidates for this procedure, since we tend to reserve it for salvage patients who have usually been impotent and incontinent for many years. Outcomes indicated that less than half of these patients attained dry status, and 4 of 23 (17%) reported using 2 to 3 pads daily. I suspect that this was due to a rather large median cuff size (5 cm)dwe almost always use a 4 cm cuff for transcorporeal procedures. On the other hand, no cuff erosions are reported, so perhaps we are seeing a trade-off of having a few more patients with persistent stress urinary incontinence but fewer erosions. Allen F. Morey, MD
610
can be problematic. This pilot study was designed to determine if a virtual reality exercise component could be successfully added to more traditional pelvic floor muscle exercises in a group of older women with mixed urinary incontinence. Following 2 pretreatment evaluations a total of 24 women were enrolled in structured weekly group treatment sessions during a course of 12 weeks. Therapy included traditional pelvic floor muscle exercises taught and supervised by a physiotherapist, and a virtual reality component that used video based dance games that combined movement and prompted pelvic floor muscle contractions. Overall program compliance was 91%, and 92% of patients completed the home exercise assignments. Patient satisfaction was also high, with 91% satisfied and a mean appreciation score of 9.8 on a 10-point scale. Continence outcomes were statistically improved compared to baseline. A limitation of the study was lack of a control group doing pelvic floor exercises without the virtual reality dance component, although the authors compared their results to historical publications of traditional behavioral therapies. It will be interesting to see if this type of unique training method improves long-term compliance and efficacy. Tomas L. Griebling, MD, MPH
Benign Prostatic Hyperplasia Re: Evaluation of the Learning Curve for Thulium VapoEnucleation of the Prostate (ThuVEP) Using a Mentor-Based Approach C. Netsch, T. Bach, T. R. Herrmann, O. Neubauer and A. J. Gross Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany World J Urol 2013; 31: 1231e1238.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.040 available at http://jurology.com/ Editorial Comment: Those of us involved in residency teaching often wonder how many cases a resident must do before being competent. The question is fraught with problems, primarily because the definition of competent is sometimes hard to determine. Moreover, certain techniques that are predominantly technology based (ie robotic prostatectomy) vs tactile (ie cystoscopy, passing a trochar needle in a sling procedure) may have different criteria. Finally, in an era when residents often do not “do” the case, but rather observe or assist, the numbers of cases required are even more difficult to ascertain. In this report the authors attempt to define the number of cases required to attain competency using ThuVEP in 1) a resident who had previously performed fewer than 10 transurethral prostatectomies (TURPs) and 2) a senior urologist with an experience of more than 500 TURPs. An expert in ThuVEP mentored both physicians. The authors report that competency could be achieved in 8 to 16 cases in both cohorts. There are a number of concerns with this particular study, including patient and urology selection bias. Moreover, having someone watch over you during a case, even if you are performing it, does not necessarily constitute competence. One can only really learn to drive without the instructor in the passenger seat. Finally, my own observation is that it takes many more cases for urologists to become competent in performing TURP, regardless of technique. Having done well over 3,000 TURPs, I am still learning! I suspect that this study was done partly to help market ThuVEP as an easily learned and adaptable technique. I would strongly recommend being a lot more wary, realistic and prudent. Steven A. Kaplan, MD
Re: Which Laser Works Best for Benign Prostatic Hyperplasia? A. A. Kahokehr and P. J. Gilling Department of Urology, Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand Curr Urol Rep 2013; 14: 614e619.
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
611
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.041 available at http://jurology.com/ Editorial Comment: One would guess that the answer would vary depending on whom you asked. Each of the laser technologies has its advocates/proponents. The senior author has been a leading researcher in using the holmium:YAG laser. At least 2 long-term studies (more than 7 years) using holmium:YAG have been published, and in general holmium:YAG has the most robust data set. Nevertheless, there does not appear to be an obvious “go to” laser at this time. Selection is based more on personal preference, patient comorbidities and availability of equipment. Moreover, at the end of the day let us look at the current landscape. In the United States it appears that electrovaporization of the prostate, particularly using bipolar technology, is making a comeback, and I would expect it to soon and consistently overtake lasers as the preferred method to perform transurethral removal of tissue. Finally, due to the need for morcellators in some iterations of holmium technology, one has to be cautious, especially considering the warnings about using them in gynecologic cases. While it may not be a direct extrapolation, one has to wonder where the regulatory issues may finally land. As stated many times, pick a technology you like, stick to it and master it! Steven A. Kaplan, MD
Suggested Reading Elmansy HM, Kotb A and Elhilali MM: Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol 2011; 186: 1972.
Trauma, and Genital and Urethral Reconstruction Re: Transcorporal Artificial Urinary Sphincter Implantation as a Salvage Surgical Procedure for Challenging Cases of Male Stress Urinary Incontinence: Surgical Technique and Functional Outcomes in a Contemporary Series L. Wiedemann, J. N. Cornu, E. Haab, L. Peyrat, S. Beley, X. Cathelineau and F. Haab ^ pitaux de Paris, Pierre et Marie Curie Faculty Department of Urology, Groupe Hospitalo-Universitaire EST, Tenon Hospital, Assistance Publique-Ho of Medicine, University Paris VI, Paris, France BJU Int 2013; 112: 1163e1168.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.11.046 available at http://jurology.com/ Editorial Comment: It is nice to see a report on transcorporeal artificial urinary sphincter outcomesdonly a few studies have appeared since the inception of this technique more than 10 years ago. We have had a favorable experience with this salvage technique in dozens of high risk patients. Of the 23 patients in this series from Paris most had failed a prior anti-incontinence procedure, or had a frail urethra after radiation or previous stricture treatment. This clean, well written prospective study contributes nicely to the literature. Included is an observation that 5 of 6 potent patients retained potency after the transcorporeal procedure. In my experience it is rare to find potent patients who are candidates for this procedure, since we tend to reserve it for salvage patients who have usually been impotent and incontinent for many years. Outcomes indicated that less than half of these patients attained dry status, and 4 of 23 (17%) reported using 2 to 3 pads daily. I suspect that this was due to a rather large median cuff size (5 cm)dwe almost always use a 4 cm cuff for transcorporeal procedures. On the other hand, no cuff erosions are reported, so perhaps we are seeing a trade-off of having a few more patients with persistent stress urinary incontinence but fewer erosions. Allen F. Morey, MD