Simulation and quantitative evaluation of three surgical techniques of endoscopic enucleation of prostate on a realistic phantom model.

Objective: To evaluate the impact of three different AEEP techniques on the training performance of novices using a realistic hydrogel prostate phantom model.

Material and methods: The experimental setup utilized realistic prostate phantom model provided by the Max Planck Institute for Intelligent Systems, Germany. For the enucleation, we utilized a new solid-state pulsed thulium laser (Thulio®, Dornier MedTech, Weßling, Germany). We explored three different AEEP techniques-bilobar, trilobar, and en-bloc-repeated ten times each, totaling 30 procedures.

Results: Median enucleation time was 9.5 min (range: 6-16), median laser time was 4.29 min (3.21-6.34), median total energy used was 25.8 kJ (19.4-38.1), and median number of laser pulses was 12.8 thousand (9.7-17). There were no significant differences in operation time, laser time, pulses, or joules among the en-bloc, two-lobe, and three-lobe techniques (p = 0.113, 0.143, 0.148, 0.141 respectively). Ultrasound evaluations showed the one-lobe technique to be superior in accuracy, smoothness, and circularity (p = 0.0002, 0.012, 0.00005 respectively) (Figs. 9, 10, 11), despite having the highest perforation rate, which was not statistically significant compared to other techniques (p = 1.4). The one-lobe technique's higher accuracy may increase the risk of perforation. In contrast, the three-lobe technique had the lowest perforation rate and removal efficiency due to its lower accuracy.

Conclusion: The en-bloc, bilobar, and trilobar enucleation techniques exhibited comparable operation times. The one-lobe method emerged as superior in terms of accuracy, smoothness, and circularity. However, it also presented the highest rate of perforation.