AUA2023: REFLECTIONS BPH Hands-on Course Recap: Innovative Models, Surgical Technologies, and Experienced Faculty

By: Mark A. Assmus, MD, University of Calgary, Alberta, Canada; Amy E. Krambeck, MD, Northwestern University, Chicago, Illinois | Posted on: 20 Jul 2023

Figure 1. Four prostate models utilized during benign prostatic hyperplasia hands-on course at the 2023 AUA Annual Meeting. Stations included thulium laser enucleation of the prostate (A), robotic water-jet treatment (B), morcellation (C), and holmium laser enucleation of the prostate (D).

This year’s AUA Annual Meeting in Chicago featured 7 diverse hands-on skills training courses, including “Surgical Management of Benign Prostatic Hyperplasia (BPH),” directed by Drs Amy Krambeck and Mark Assmus. In an effort to fill an AUA-identified gap in ablative and minimally invasive surgical training for BPH, this course combined novel integration of 3D-printed prostate models with endourological technologies and knowledgeable faculty. This 3-hour course provided over 50 participants with valuable didactic lectures and exposure to 4 categories of small-group hands-on stations led by 14 urologists from across North America.

Figure 2. 3D-printed prostate gel models depicting laser enucleation plane between medial prostate adenoma and lateral capsule (A), proximal penile urethra (B), and verumontanum with proximal bladder neck (C).

The didactic program measured objective pre- and posttest evaluation of the participants with respect to indications, equipment, surgical steps, and complications associated with AUA guideline–recommended BPH treatments.1 Lectures from Amy Krambeck, MD, Naeem Bhojani, MD, Joel Funk, MD, and Deepak Agarwal, MD, focused on large-gland evaluation, robotic water-jet treatment (RWT), holmium laser enucleation of the prostate, thulium laser enucleation of the prostate, and prostate morcellation.

To reinforce the didactic program, the hands-on component of the course successfully led participants through four 30-minute stations including RWT (Aquablation), holmium laser enucleation of the prostate, thulium laser enucleation of the prostate, and prostate morcellation. Each station sought to provide a wide range of exposure, incorporating numerous prostate models (Figure 1), multiple lasers (spanning energy source type and industry vendors) as well as morcellators. For example, each participant had the opportunity to directly compare morcellator A to morcellator B in an ex vivo model using prostate surrogate bull testicles within a urinary bladder (tunica vaginalis and spermatic cord removed as previously described).2 Faculty proctors successfully demonstrated and then evaluated participants with respect to morcellator setting understanding, scope setup, the safe handling of the morcellator, and troubleshooting the devices.

Similarly, participants were able to compare how different laser energies (holmium and thulium) interact with the prostate models. The surgical steps for multiple enucleation techniques were concurrently taught across the 6 enucleation stations (3 holmium, 3 thulium). Meanwhile, at the RWT station, participants received personal experience with placement of the urethral scope, robotic arm, and ultrasound probe. This was followed by outlining ablation zones on the monitor. To visualize and physically examine the prostatic urethral–ablating effect of the Aquablation water-jet treatments, treatment within an apple was performed.

As was recently highlighted by Deyirmendjian et al, despite prostate enucleation techniques demonstrating durable, safe, and effective outcomes for the past 20 years, training barriers and historically “steep learning curves” have only recently become targets of training-focused research, spurred on by the rapid evolution of 3D-printed models.3,4 This is illustrated by the use of several prostate gel inserts which allowed participants to landmark critical surgical anatomy, visualize distinct planes between prostate adenoma and capsule, and experience the physical scope force and technical movements required to combine lasering with blunt dissection in order to enucleate (Figure 2). As a subspecialty of urology that prides itself on surgical technology innovation and adoption, prioritizing the development of fast and cost-effective 3D-printed tissue models for future endourological research and training will be valuable. This will continue to support hands-on courses and improve safe access to training for motivated surgeons.

Beyond the didactic and technical hands-on experience, this BPH surgical skills course also encouraged international networking and both constructive clinical and research discussions among the participants and faculty. At the conclusion of the course, the skills and connections that were developed will serve as a springboard for subsequent productive collaboration to improve BPH care.

Support: None.

Conflict of Interest: Dr Mark Assmus has no conflicts of interest to disclose. Dr Amy Krambeck is a consultant for Boston Scientific, Karl Sotrz, Uroprene, and Virtuoso Surgical, and is a board member for Sonomotion.

  1. Lerner LB, McVary KT, Barry MJ, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline part II—surgical evaluation and treatment. J Urol. 2021;206(4):818-826.
  2. Lee MS, Assmus M, Cooley L, Li E, Large T, Krambeck AE. Ex vivo comparison of efficiency, safety, and surgeon satisfaction in four commercial morcellators. J Endourol. 2022;36(4):514-521.
  3. Deyirmendjian C, Nguyen D-D, Andonian S, et al. Simulation-based prostate enucleation training: initial experience using 3D-printed organ phantoms. Can Urol Assoc J. 2022;16(12):409-416.
  4. Assmus MA. 3D-printing better urologists?. Can Urol Assoc J. 2022;16(12):417.