Comment to “Analysis of predictive factors of success for prostate photovaporization in BPH by greenlight laser”

Gómez-Sancha, F.

doi:10.1016/j.acuroe.2012.05.014

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There is a statistically significant improvement between the mean preoperative Qmax and the controls at 3, 6, 9, and 12 months after the surgery (p<0.001)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Miralles, J.L. Palmero, M. Ramírez-Backhaus, J.M. Osca, A. Benedicto" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Miralles" ] 1 => array:2 [ "nombre" => "J.L." "apellidos" => "Palmero" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Ramírez-Backhaus" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Osca" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Benedicto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480612001088" "doi" => "10.1016/j.acuro.2012.03.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480612001088?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578613000310?idApp=UINPBA00004N" "url" => "/21735786/0000003700000001/v1_201306251136/S2173578613000310/v1_201306251136/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "Commentary" "titulo" => "Comment to “Analysis of predictive factors of success for prostate photovaporization in BPH by greenlight laser”" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "25" "paginaFinal" => "26" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "F. Gómez-Sancha" "autores" => array:1 [ 0 => array:3 [ "nombre" => "F." "apellidos" => "Gómez-Sancha" "email" => array:1 [ 0 => "fgomsan@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Instituto de Cirugía Urológica Avanzada, Madrid, Spain" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentario a: «Análisis de factores predictivos de éxito para la fotovaporización próstatica en HBP mediante láser verde»" ] ] "textoCompleto" => "The search for a minimally invasive alternative to the transurethral resection of the prostate and open prostatectomy has recently culminated in the use of different types of lasers. The prostate enucleation with Holmium laser (2140nm) has proved to be an excellent choice to conventional techniques, but its spread has been limited by its great technical complexity. The photovaporization by greenlight laser (532nm) has been consolidating as a safe and effective option for the treatment of BPH, and it is now accepted as a surgical treatment option in the latest guidelines of the EAU<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and the AUA.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> There are 9 randomized trials comparing it to the TUR and a meta-analysis thereof will be published shortly, so we can no longer say that there is no scientific evidence that supports it.Since the introduction of the greenlight laser in 2003, there have been two developments: one in technology, with three successive generations of lasers, of 80, 120, and 180W, with better vaporization capacity and improved safety and efficiency in each generation; another in the anatomical knowledge and surgical technique. At the time of release of this laser in the U.S. market, it was essential to the manufacturer that this procedure could be performed in the urologists’ offices, with sedation and local anesthesia, as done in this way, the reimbursement for the urologist by American insurance companies would be very substantial, and so, urologists would welcome it with open arms. That is why, a mere adenoma tunneling was promoted, with good short-term but unconvincing results to most European urologists, more concerned about the durability of the procedure. The idea that it was an easy technique to learn, with virtually no learning curve, was also falsely promoted.Today, thanks to current technology and new knowledge, it is perfectly possible to perform a total vaporization of the adenoma localization using the capsular location technique and intraoperative transrectal ultrasound scan.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> It is also possible to perform a transurethral enucleation of the adenoma followed by intravesical morcellation in large prostates.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> These techniques are unfortunately still little known.This logical evolution in technology and technique resembles that occurred in the years following the introduction of the transurethral resection of the prostate and, undoubtedly, will help to progressively improve the efficiency and reduce the morbidity of this form of treatment, as a greater “culture” or a deeper knowledge on the use of lasers for the treatment of BPH among urologists becomes widespread.The authors of this article have retrospectively reviewed their series of 179 patients treated over a period of 3 years and a half with two different lasers (80 and 120W), not evenly distributed among 9 surgeons. They operated on patients with medium-sized prostates. They arbitrarily define the success of the intervention as the absence of reconversion to TUR, the subjective improvement of the patient, and the absence of reintervention. They subsequently conducted a univariate and multivariate analysis to identify factors significantly associated with thus defined success. They conclude that the surgeon's experience is a success factor.This article<a class="elsevierStyleCrossRef" href="#bib0035">5</a> reflects the learning curve of 9 different surgeons who divided 179 cases. The most expert surgeon in the group accumulated 65 cases and the least experienced surgeon managed only 3 cases.Honestly described late morbidity in this series of patients with 15 reinterventions, 7 due to incomplete treatment (a typical problem of the lack of experience), 5 due to neck sclerosis (higher than in the rest of the published literature, probably reflecting an inappropriate use of technology), and 2 cases of incontinence on minimum effort that requires the implantation of artificial sphincter, constitute, in my view, a painful price for the introduction of a new technology, which in theory is minimally aggressive, in a Urology Department.The successful adoption of this technology goes through proper and progressive training, based on several steps: first, the acquisition of a solid knowledge of the physical basis of the use of this laser, essential and mandatory for any surgeon, who should know what is at hand; second, the apprentice should see several surgical procedures and understand the dynamics of these interventions; third, we should exploit the use of surgical simulators (there is already an excellent simulator manufactured by American Medical Systems<a class="elsevierStyleCrossRef" href="#bib0030">6</a>); fourth, the apprentice should be observed by an expert trainer who can take on and solve the intraoperative problems and complete the treatment when necessary, and who must decide when the apprentice can operate independently; and fifth, once the apprentice is independent, they must consolidate their learning curve performing many cases in little time. It is important that the prostate size is small-medium during the learning curve.I believe that in a Urology Department, one or two urologists who amply consolidate their surgical capacity and then are able to teach their colleagues to perform the procedure safely, being able to redirect a difficult case and ensure a good surgical outcome, thus avoiding that the patient suffers the learning curve, should accumulate the initial experience." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-Sancha F. Comentario a: «Análisis de factores predictivos de éxito para la fotovaporización prostática en HBP mediante láser verde». Actas Urol Esp. 2013;37:25–6." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EAU guidelines on laser technologies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.R.W. Herrmann" 1 => "E.N. Liatsikos" 2 => "U. Nagele" 3 => "O. Traxer" 4 => "A.S. Merseburger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2012.01.010" "Revista" => array:6 [ "tituloSerie" => "Eur Urol" "fecha" => "2012" "volumen" => "61" "paginaInicial" => "783" "paginaFinal" => "795" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22285403" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on AUA guideline on the management of benign prostatic hyperplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.T. McVary" 1 => "C.G. Roehrborn" 2 => "A.L. Avins" 3 => "M.J. Barry" 4 => "R.C. Bruskewitz" 5 => "R.F. 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Schmidt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/end.2010.0550" "Revista" => array:6 [ "tituloSerie" => "J Endourol" "fecha" => "2011" "volumen" => "25" "paginaInicial" => "1199" "paginaFinal" => "1201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21612434" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0035" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de factores predictivos de éxito para la fotovaporización próstatica en HBP mediante láser verde" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Miralles" 1 => "J.L. Palmero" 2 => "M. Ramírez-Backhaus" 3 => "J.M. Osca" 4 => "A. Benedicto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2012.03.004" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "20" "paginaFinal" => "24" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22728021" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laser surgery simulation platform: toward full-procedure training and rehearsal for benign prostatic hyperplasia (BPH) therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Shen" 1 => "V. Konchada" 2 => "N. Zhang" 3 => "S. Jain" 4 => "X. Zhou" 5 => "D. Burke" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Stud Health Technol Inform" "fecha" => "2011" "volumen" => "163" "paginaInicial" => "574" "paginaFinal" => "580" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21335859" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003700000001/v1_201306251136/S2173578613000322/v1_201306251136/en/main.assets" "Apartado" => array:4 [ "identificador" => "6274" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003700000001/v1_201306251136/S2173578613000322/v1_201306251136/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578613000322?idApp=UINPBA00004N"]

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Actas Urológicas Españolas is an international journal dedicated to urological diseases and renal transplant. It has been the official publication of the Spanish Urology Association since 1974 and of the American Urology Confederation since 2008. Its articles cover all aspects related to urology. Actas Urológicas Españolas, governed by the peer review system (double blinded), is published online in Spanish and English. Consequently, manuscripts may be sent in Spanish or English and bidirectional free cost translation will be provided. It has high visibility and accessibility and is found in the most important data bases, Medline/Pubmed, Emabase, JCR, Ïndice Médico Español, Índice bibliográfico Español en Ciencias de la Salud (IBECS), Cuiden, Dialnet, Hinari, Scopus, Google Scholar.

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