Prospective assessment of Learning curve of Holmium Laser Enucleation of the Prostate (HoLEP) for treatment of Benign Prostate Hyperplasia (BPH) using multidimensional approach

Despite being endorsed in most of the guidelines, yet wide adoption of Holmium laser enucleation of the prostate (HoLEP) is hindered by learning difficulties. Herein, we prospectively assess its learning curve using multidimensional approach.

Prospective reporting of all perioperative safety and efficacy outcome measures as well as need for reoperation and continence status was performed. Case difficulty (CD) and learning curve characterization (LCC) variables were considered looking for predictors of different outcome measures. Analysis included the first 313 procedures done by 3 surgeons.

Prostate volume and NPPCs (number of previously performed cases) independently predicted operative and enucleation efficiency (0.76+0.36 and 1.2+0.6 gm/min respectively). Both measures showed plateauing only after 1(st) 40 procedures. Mean percent reduction of postoperative PSA was 80+19% and significantly lower reduction was independently predicted by TRUS depicted GMP (Grossly multinodular prostate) P=0.000 and R(2)=0.59. Perioperative safety measures showed significant improvement after the 1(st) and 2(nd) twenty procedures apart from hospital stay and catheter time. UI (urinary incontinence) was reported in 89 (28.5%), 26 (8.3%) and 7 (2.2%) at one, 4 and 12 months respectively. Only NPPCs [OR 0.99, 95%CI 0.98:0.999, P=0.03] predicted UI at one month that was significantly reduced following the first twenty procedures (plateau). Preoperative storage subdomain of IPSS [OR 0.7, 95%CI 0.4:0.9, P=0.04], case density [OR 0.3, 95%CI 0.2:0.6, P=0.01] and NPPCs [OR 0.97, 95%CI 0.98:0.999, P=0.02] predicted UI at four months that was significantly reduced following the first and second twenty procedures. Persistent UI at 12 months was significantly associated with less NPPCs [60 (0-211) vs. 20 (0-99), P=0.04] with no plateauing through the curve.

Plateauing through the learning curve of HoLEP is a moving target. Looking at different outcome measures, different levels of experience are needed to reach plateau. Preoperative prostate volume, number of previously performed cases and case density are the main influential factors in the curve. UI is the most relevant clinical outcome that was significantly affected by learning however its transient nature is assuring.

The Journal of urology. 2016 Nov 04 [Epub ahead of print]

Ahmed M Elshal, Hossam Nabeeh, Yasser Eldemerdash, Ramy Mekkawy, Mahmoud Laymon, Ahmed El-Assmy, Ahmed R El-Nahas