Mastering HoLEP: Learning Curves and Perioperative Complications in Holmium Laser Enucleation of the Prostate

Abstract

Introduction:

Holmium laser enucleation of the prostate (HoLEP) is an established surgical technique for treating benign prostatic enlargement with bladder outlet obstruction. Although HoLEP offers advantages such as reduced hospital stays and lower complication rates compared with traditional transurethral resection of the prostate, it presents a steep learning curve for surgeons. The number of procedures required to achieve proficiency remains debated, with estimates differing widely. This study aims to analyze the HoLEP learning curve beyond 200 cases, evaluating perioperative efficiency and complication rates in high-volume surgeons.

Materials and Methods:

A retrospective analysis was conducted on 1724 HoLEP procedures performed between 2015 and 2022 by six surgeons, three of whom had performed over 200 cases each. Key parameters assessed included operative time, enucleation efficiency, energy use, and complication rates. Statistical analyses included univariate and multivariate regression models to identify predictors of postoperative complications and efficiency improvements.

Results:

The mean patient age was 70.48 years, with an average prostate volume of 93.43 g. The mean operative time was 80.68 minutes, with significant efficiency improvements correlating with increased surgeon experience (p < 0.001). Complication rates, including bleeding necessitating coagulation (4.7%) and urinary retention (9.3%), decreased significantly beyond 350 cases. Learning curves demonstrated a nonlinear reduction in complications and a continuous increase in surgical efficiency, with operative proficiency plateauing after approximately 350 procedures.

Conclusion:

Contrary to previous studies suggesting HoLEP proficiency after 50 to 60 cases, our findings indicate ongoing improvements beyond 200 cases, with stable complication rates achieved after 350 procedures. Structured mentorship programs and simulation-based training could facilitate faster learning and enhance patient outcomes.