Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns - Beyond the Abstract

Holmium laser enucleation of the prostate (HoLEP) has a well-established body of evidence demonstrating superior durability and reduced morbidity to other transurethral benign prostatic hyperplasia (BPH) surgeries, with some arguing that HoLEP should replace transurethral resection of the prostate (TURP) as the new gold standard. However, HoLEP has yet to gain widespread adoption in the United States. There are many possible reasons for this, perhaps most notably a steep learning curve.


We administered a survey to gain insight from fellowship-trained HoLEP surgeons as to their experience learning the procedure, the barriers they experienced adopting it into practice, and their current practice patterns. We found that only 12% of fellowships reported HoLEP as a component of training as of September 2019 (at the time this survey was administered). This percentage has increased since then, but in our opinion still remains low. As part of the study, respondents were asked to rank the level of difficulty of each step.  The most difficult steps were noted to be joining the anterior/posterior planes, encircling the lateral lobe to 12 o’clock, and the apical enucleation. The easiest steps included bladder neck incisions, equipment setup, and enucleating a median lobe (if present).

It was interesting to see the heterogeneity of HoLEP training experiences reported by the prior fellows. Observed cases ranged from 1 (4 respondents) to over 50 (4 respondents), while completing an entire HoLEP from start to finish ranging from 0 (6 respondents) to over 50 (4 respondents). While there is no question HoLEP has a steep learning curve, some other challenges of practicing this procedure, reported by our respondents include:

  • Educating the OR and floor nursing staff regarding perioperative patient care
  • Adequate HoLEP volume to maintain proficiency
  • Efficiency of the surgery
  • Compensation compared to other, less effective but faster and easier to perform outlet procedures
Overall we were encouraged to see that most fellows (75%) go on to incorporate this surgery into their practice, which is higher than a previously reported 50% incorporation rate of non-fellowship trained surgeons.  We hope that the lessons gained from our fellowship-trained HoLEP surgeons will provide better insight into both learning and teaching HoLEP, and how to reduce the barrier for more surgeons to incorporate this beneficial procedure into their practice.

Written by: Henry C Wright, MD, Donald Fedrigon, MD, Smita De, MD, PhD

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH

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