Live demos of prostate procedure found safe

San Francisco-Performing green laser enucleation of the prostate with a live audience does not result in more complications, researchers say.

The finding could ease concerns about the live demonstrations of surgical procedures, said Vincent Misrai, MD, a urologic surgeon at Clinique Pasteur in Toulouse, France. He presented the research at the AUA annual meeting in San Francisco.

Surgeons often demonstrate procedures, including green laser enucleation of the prostate, in front of students or other surgeons who are trying to learn the procedure. But some worry about patient safety.

"It puts pressure on the surgeon," Dr. Misrai told Urology Times. "When you do the case, you speak, and while you speak, you lose time.”

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Green laser enucleation of the prostate, first described in 2013, provides a good opportunity to study this effect because of the interest in live demonstrations and because of the demands of the procedure.

"When you proceed to the morcellation, it has to be done with clear vision and a trained scrub team to avoid complications such as bladder injuries," Dr. Misrai explained.

To test the risk of complications with and without an audience, Dr. Misrai and his colleagues retrospectively reviewed the records of 126 patients who underwent a green laser enucleation at Clinique Pasteur between June 2015 and January 2017.

Of these, 37 procedures were performed during 17 live case demonstrations, including video of an endoscopic view and an external view of the operating room, with a median of three attendees.

The surgeon discussed each step of the procedure and responded to questions from the attendees, some of whom were in the theater while other attendees were in another room. The procedures were conducted according to European Association of Urology policy.

The baseline ages, comorbidities, and body mass indices of the 37 patients who underwent surgery in live case demonstrations were similar to those of the 89 patients treated under standard conditions.

The prostatic volume, antiplatelet or oral anticoagulation medication use, International Prostate Symptom Score (IPSS), Qmax, and rate of indwelling catheter use were also similar in both groups.

During the procedure, the total energy used, morcellation time, and catheterization time were similar as well. Operative time was slightly longer, but the difference was not statistically significant.

Next: How complication rates comparedHow complication rates compared

The complication rate was 18.9% in the live case demonstrations and 24.7% in the standard procedures. The rates were also similar when the complications were broken down by severity using the Clavien-Dindo Classification system.

In the live case demonstrations, there were four cases of acute urinary retention, four cases of hematuria, and one case of urinary tract infection.

In the standard condition group, there were seven cases of acute urinary retention, three cases of hematuria, one case of fever, one case of pain, three cases of urinary tract infection, two cases of other infection, one case of hematuria with recatheterization, and four cases of endoscopic clot removal.

There were no statistically significant differences between the two groups at 1 month, 3 months, or 6 months of follow-up.

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At 1 month, the IPSS was 8 in both groups. The residual prostate volume was 20 mL in the live case group and 25 mL in the standard condition group. The rate of urinary incontinence was 16.2% in the live case group and 13.5% in the standard condition group.

At 6 months, the IPSS was 4 in both groups. PSA was 0.5 ng/dL in the live case group and 0.6 ng/dL in the standard condition group. None of the patients had urinary incontinence. The rate of unplanned readmissions was 8.1% in the live case group versus 17.9% in the standard condition group.

Dr. Misrai pointed out that he carried out the procedures in his own operating theater.

"It is less difficult than when you are in another theater with teams you don't know," he said.

Nevertheless, he said, doing this study reassured him that his teaching wasn't harming his patients.

"Every surgeon involved in surgical workshop programs should do the same evaluation to make sure of patient safety," he said.