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Prospective Assessment Of Learning Curve Of Holmium Laser Enucleation Of The Prostate For Treatment Of Benign Prostatic Hyperplasia Using A Multidimensional Approach

A. Elshal, Hossam Nabeeh, Y. Eldemerdash, Ramy Mekkawy, M. Laymon, A. El-Assmy, A. El-Nahas
Published 2017 · Medicine

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Purpose: Despite being endorsed in most guidelines, wide adoption of holmium laser enucleation of the prostate is hindered by learning difficulties. We prospectively assessed the learning curve using a multidimensional approach. Materials and Methods: We prospectively report all perioperative safety and efficacy outcome measures as well as the need for reoperation and continence status. Case difficulty and learning curve characterization variables were considered, looking for predictors of different outcome measures. Our analysis included the first 313 procedures done by a total of 3 surgeons. Results: Prostate volume and the number of previously performed cases independently predicted operative and enucleation efficiency (mean ± SD 0.76 ± 0.36 and 1.2 ± 0.6 gm per minute, respectively). Both measures plateaued only after the first 40 procedures. The mean percent reduction in postoperative prostate specific antigen was 80% ± 19%. A significantly lower decrease was independently predicted by the transrectal ultrasound depiction of a grossly multinodular prostate (p = 0.000, R2 = 0.59). Perioperative safety measures showed significant improvement after the first and second 20 procedures apart from hospital stay and catheter time. Urinary incontinence was reported in 89 (28.5%), 26 (8.3%) and 7 cases (2.2%) at 1, 4 and 12 months, respectively. Only the number of previously performed cases predicted urinary incontinence at 1 month, which was significantly reduced following the first 20 procedures (plateau) (OR 0.99, 95% CI 0.98–0.999, p = 0.03). The I‐PSS (International Prostate Symptom Score) preoperative storage subdomain (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 number of previously performed cases (OR 0.97, 95% CI 0.98–0.999, p = 0.02) predicted urinary incontinence at 4 months, which was significantly reduced after the first and second 20 procedures. Persistent urinary incontinence at 12 months was significantly associated with fewer previously performed cases (median 60, range 0 to 211 vs 20, range 0 to 99, p = 0.04) with no plateauing through the curve. Conclusions: Plateauing through the learning curve of holmium laser enucleation of the prostate is a moving target. Looking at different outcome measures, different levels of experience are needed to reach the plateau. Preoperative prostate volume, the number of previously performed cases and case density are the main influential factors in the curve. Urinary incontinence is the most relevant clinical outcome that was significantly affected by learning, although its transient nature is assuring.
This paper references
Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases.
N. Seki (2003)
Symptom characteristics and the development of tolerance with time in patients with indwelling double‐pigtail ureteric stents
Irani (1999)
The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society.
P. Abrams (2003)
The Learning Curve for Holmium Laser Enucleation of the Prostate: A Single-Center Experience
Jungbum Bae (2010)
Enucleation is enucleation is enucleation is enucleation
T. Herrmann (2016)
Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP)
G. Robert (2016)
[Improvement of prostatic detaching blade for transurethral enucleation of benign prostatic hyperplasia].
Y. Hiraoka (1986)
Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH)
A. Elshal (2012)
Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: an inpatient cost analysis.
A. Salonia (2006)
Holmium laser enucleation of the prostate for treatment for large-sized benign prostate hyperplasia; is it a realistic endourologic alternative in developing country?
A. Elshal (2015)
Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve.
J. Placer (2009)
Thulium lasers
A Gross
Is there a way to predict stress urinary incontinence after holmium laser enucleation of the prostate?
Hazem M. Elmansy (2011)
GreenLight™ laser (XPS) photoselective vapo-enucleation versus holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic hyperplasia: a randomized controlled study.
A. Elshal (2015)
The relationship between the reproducibility of holmium laser enucleation of the prostate and prostate size over the learning curve
T. Haraguchi (2009)
EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction.
M. Oelke (2013)
Factors affecting the cost of airplanes
T. P. Wright (1936)
Prospective evaluation of the learning curve for holmium laser enucleation of the prostate.
H. Shah (2007)
Stress incontinence during the learning curve of holmium laser enucleation of the prostate.
L. Lerner (2010)
Enucleation ratio efficacy might be a better predictor to assess learning curve of holmium laser enucleation of the prostate.
C. Jeong (2012)
Assessment of the learning curves for photoselective vaporization of the prostate using GreenLight™ 180-Watt-XPS laser therapy: defining the intra-operative parameters within a prospective cohort
V. Misraï (2013)
Holmium laser enucleation of the prostate: the safety, efficacy, and learning experience in China.
Chuanjun Du (2008)
Predictor of de novo urinary incontinence following holmium laser enucleation of the prostate
M. Cho (2011)
A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update.
J. Cornu (2015)
Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve.
E. Elzayat (2007)
Should operations be regionalized? The empirical relation between surgical volume and mortality.
H. Luft (1979)
Learning curves in surgical practice
A. N. Hopper (2007)
Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence.
F. Endo (2010)
Evaluation of the Learning Curve for Holmium Laser Enucleation of the Prostate Using Multiple Outcome Measures.
O. Brunckhorst (2015)
Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia.
A. Krambeck (2013)
Guidelines on the Management of Male Lower Urinary Tract Symptoms ( LUTS ) , incl . Benign Prostatic Obstruction
M. Emberton (2012)
Holmium laser enucleation of the prostate can be taught: the first learning experience
A. El-Hakim (2002)
Holmium:YAG Laser Enucleation of the Prostate Combined with Mechanical Morcellation: Preliminary Results
M. Fraundorfer (1998)

This paper is referenced by
Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate
Bernd Rosenhammer (2020)
The complications of the HoLEP learning curve. A systematic review
F. A. Castañeda (2020)
Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial.
A. Elshal (2018)
A systematic review and meta-analysis of efficacy and safety following holmium laser enucleation of prostate and transurethral resection of prostate for benign prostatic hyperplasia.
Jian Zhong (2019)
Safety and efficacy using a low-powered holmium laser for enucleation of the prostate (HoLEP): 12-month results from a prospective low-power HoLEP series
B. Becker (2017)
Surgical Treatment: Enucleation of the Prostate
R. Catterwell (2018)
The effect of prostatic tissue density on the perioperative outcomes of Holmium laser enucleation of prostate (HoLEP): a pilot study
E. Kaya (2019)
Surgical Options for the Enlarged, Obstructing, Benign Prostate.
J. Parsons (2017)
Holmium Laser Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia: a Safe and Effective Treatment Option in our Elderly Patients
Bristol B. Whiles (2019)
Predictors of Postoperative Urinary Incontinence After Holmium Laser Enucleation of the Prostate: 12 Months Follow-Up.
L. Cornwell (2019)
Treatment of Benign Prostatic Hyperplasia with Tm:YAG Laser
S. Shoji (2017)
GreenLight Laser photoselective vapo-enucleation of the prostate with front-firing emission versus plasmakinetic resection of the prostate for benign prostate hyperplasia.
Xiangming Cheng (2020)
Assessing the Learning Curve of Holmium Laser Enucleation of Prostate (HoLEP). A Systematic Review.
S. Kampantais (2018)
Holmium laser enucleation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia
N. Sathianathen (2019)
Complications of anatomical endoscopic enucleation of the prostate
Y. Wei (2020)
‘Top-Down’ holmium laser enucleation of the prostate. Report of initial cases performed by a single surgeon
A. Hodhod (2020)
Combination of Thulium Laser Incision and Bipolar Resection Offers Higher Resection Velocity than Bipolar Resection Alone in Large Prostates.
K. C. Huang (2018)
The surgical learning curve for endoscopic GreenLight™ laser enucleation of the prostate: an international multicentre study
Zine-Eddine Khene (2019)
Análisis de las complicaciones en el aprendizaje del HoLEP: revisión sistemática
F. A. Castañeda (2020)
Systematic review of the endoscopic enucleation of the prostate learning curve
D. Enikeev (2020)
The New American Urological Association Benign Prostatic Hyperplasia Clinical Guidelines: 2019 Update
R. Dornbier (2020)
Does Surgeon Experience Affect Operative Time, Adverse Events and Continence Outcomes in Holmium Laser Enucleation of the Prostate? A Review of More Than 1,000 Cases
K. Shigemura (2017)
Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo‐enucleation of the prostate for treatment of large benign prostate obstruction: 3‐years outcomes
A. Elshal (2020)
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