Holmium Laser Enucleation of the Prostate Simulation: Analysis of Realism and Level of Difficulty by Holmium Laser Enucleation of the Prostate-naïve Urologists

Abstract Objective To evaluate the opinion of Holmium laser enucleation of the prostate (HoLEP)-naive urologists about a surgical simulator and the level of difficulty at each step. Materials and Methods We evaluated 40 HoLEP-naive urologists in a course involving 4 steps: lecture introducing Holmium laser basics and technique; live surgery; video explaining prostate enucleation using simulators; and simulator trial. A survey was applied to evaluate content validity and face validity of the simulator. Subjects also ranked the level of difficulty of each surgical step. Results All urologists agreed on the importance of a validated HoLEP simulator in training; 95% agreed that simulation-based training is essential for patient safety. The mean rate of face validity of all analyzed components was 8.4 (8.1-9.0). Instrumentation was considered the most realistic component, followed by laser-tissue interaction. Positioning the fiber and bladder neck incisions (BNIs) at 5 and 7-o'clock were the easiest steps. Detaching the median lobe from the bladder neck, BNI at 12, dividing the mucosal bridge distally, and joining the upper and lower incisions were the most difficult steps. Residents found more difficulty in joining the BNIs distally (3.6 vs 2.4, P  = .006) and in dividing the mucosal bridge distally (4.0 vs 3.0, P  = .038) when compared to specialists. Conclusion HoLEP-naive urologists found this simulator useful and important for patient safety. Most components were considered realistic. Simulation was able to reproduce the levels of difficulty usually found in real life cases. The level of expertise may influence the learning process of some steps.