Initial Experience of Thulium Fiber Laser (TFL) for Anatomic Endoscopic Enucleation of the Prostate (AEEP): Insights

on the Early Phase of Learning Curve from the First 12 Cases at a Provincial Tertiary Training Center in Northern
Mindanao, and its implications on the viability of TFL as training tool for AEEP in Residency Training

Raul Martin Brien C. Andutan M.D.

Northern Mindanao Medical Center

Key words:

Thulium Fiber Laser; Anatomic Endoscopic Enucleation of the Prostate; Learning Curve

Introduction:

We present our initial experience of Thulium Fiber Laser (TFL) for Anatomic Endoscopic Enucleation of the
Prostate (AEEP) in a provincial tertiary training center in Northern Mindanao from January to May 2024. Of the to-
tal of 12 cases done, 7 were done by an expert on Anatomic Endoscopic Enucleation of the Prostate (AEEP) with
over 2000 cases done, and 5 cases were done by urology consultants assisted by residents, all of whom had no
prior experience in AEEP, with only TURP competency as the requirement. With the objective of incorporating
AEEP as a core competency in the residency training program, this is an initial review comparing the complication
rates of the expert (Expert Group) to that of urologists who had no prior AEEP experience on the Early Phase of
their learning curve (Novice Group), defined as the surgeon’s 1st and/or 2nd case of AEEP, based on operative time
(enucleation + morcellation time), combined enucleation + morcellation efficiency (grams/min), post-operative de-
crease in Hemoglobin, blood transfusion and post-operative complications with a definition of Clavien-Dindo classi-
fication score of 2 or higher, incidence of TUR syndrome, post-operative decrease in serum sodium, number of
post-operative days before discharge and functional outcomes (mean post-operative IPSS improvement).

Materials and Methods:

We analyzed retrospectively the data from 12 patients who underwent AEEP in one tertiary training cen -
ter, regardless of prostate volume, catheter status, or symptom severity. 7 cases were done by an expert on AEEP
(Expert Group), and 5 cases were done by urologists who had no prior experience with AEEP (Novice Group). The
Thulium Fiber Laser machine used was an EMS Laser Clast Thulium TFL machine (500 Watts) (EMS, Nyon, Suisse),
the diameter of the laser fiber used was 550 μm, and a morcellator machine was used (Hawk, China). We collected
the following preoperative characteristics (age, pre-op IPSS score, prostate size, pre-op Hemoglobin, pre-op serum
sodium) intra-operative metrics (operative time, blood transfusion) and post-operative metrics (post-op hemoglo-
bin, post-op sodium) and complications (defined as grade 2 or higher according to the Clavien-Dindo Classification
of Complications), number of post-op days prior to discharge, post-operative IPSS after 2 weeks, and compared the
data between the two groups (Expert Group versus Novice Group).

Results:

The study included 12 patients with an average age of 72.9 years. The average prostate size for the expert
group was 80.4 grams while that of the novice group was 82.8 grams. There was a significant difference in the av-
erage operative time (enuclation + morcellation time) for the expert which was 70.85 mins compared to that of the
novice group which was 194 mins (3 hours and 14 mins). This translates to a combined enucleation + morcellation
efficiency for the expert group of 1.135 grams/min, compared to 0.42 grams/min for the novice group, a 270%
higher efficiency on the expert group. Despite the significant difference in the operative time and combined enu-
cleation + morcellation efficiency of 2.7 times between the groups, there was no significant difference in the com-
plication rates with one complication on the expert group (Clavien Dindo IV-A with the patient requiring post-op
ICU monitoring), and one on the novice group (Clavien Dindo II-A requiring blood transfusion). There was also no
incidence of TUR syndrome on both groups, and the post operative sodium levels was insignificant in the novice
group with a net change of +2, which may be attributed to the institutional protocol of administration of 20mg
furosemide every 60 mins of enucleation. There was however a significant difference in the blood loss with an av-
erage of 1.86g/dl on the novice group with one patient in the novice group requiring blood transfusion, none re -
quiring transfusion in the expert group. Comparison of the number of post-operative days before discharge (3.28
days on expert group vs 3.2 days on novice group) and as well the International Prostate Symptom Score improve-
ment mean score with 19.1 for the expert group and 18.2 for the novice group showed no significant difference be-
tween the groups.

Previous studies show that compared to TURP, Thulium Fiber Laser Enucleation of the Prostate (THUFLEP)
has a significant advantage in terms of mean blood loss (1.01 g/dl for THUFLEP versus 1.8 g/dl for TURP) (Enikeev
et al, 2019). In our case on the Early Phase of Learning Curve for THUFLEP, the mean blood loss in the Early Phase
of the Learning Curve was 1.86g/dl per case which is not significantly different compared to the TURP mean blood
loss of 1.8 g/dl (Enikeev et al, 2019). Another study shows lower hemoglobin decrease in TFL compared to HOLEP
(0.5 g/dl vs. 0.9g/dl) (Peteinaris et al, 2024), with experimental studies comparing TFL and Ho:YAG showing deeper
ablation and coagulation zones with TFL, likely translating into superior cutting and coagulation abilities (Enikeev et
al, 2023). Also the serum sodium decrease in this pervious studies showed a significant difference in favor of THU -
FLEP (1.1mmol/L for THUFLEP vs 4.1 mmol/L for TURP) (Enikeev et al., 2019). In the early phase of learning curve of
THUFLEP, our study shows that there was no net decrease of serum sodium, due to the feasibility of using saline as
the irrigation medium for TFL, resulting in lower rates of systemic fluid absorption compared to sterile water, de-
laying the onset of dilutional hyponatremia, which is a significant advantage over TURP even compared to the early
phase of learning curve in THUFLEP.

Conclusions:

Based on the results on the Early Phase of Learning Curve in TFL for AEEP, the preliminary data shows that
despite the significant difference of 2.7x in the operative time (enucleation + morcellation time) and also 2.7x in
the combined enucleation + morcellation efficiency (1.135 grams/min versus 0.42 grams/min) between the expert
and the novice groups, there was no significant difference in intra-operative complication rates, post operative
serum sodium levels, number of post operative days prior to discharge and functional outcomes (mean IPSS im-
provement). This preliminary data may suggest that Thulium Fiber Laser is a safe and effective tool that can be uti-
lized in residency training as the modality of choice for achieving competency in AEEP, with only TURP competency
as the preliminary requirement. Further studies with larger cohorts and extended follow-up periods to assess long-
term functional outcomes in correlation with learning curve and the required volume of cases needed to achieve
competency in AEEP in residency training is warranted, in preparation for the inclusion of AEEP as an additional
core competency in urology residency training, as the technology is becoming more readily available in the coun-
try.