Abstract
Objective:
Training in holmium-laser enucleation of the prostate (HoLEP) is not ubiquitous in urological training programmes. We sought to investigate whether those who learn HoLEP at trainee (resident) level have similar outcomes to those who learn at consultant level.
Patients and Methods:
Consecutive patients undergoing HoLEP by mentorship-trained consultant surgeons and a trainee surgeon were compared to a control group of cases performed by an experienced HoLEP surgeon. Specimen weight, length of stay (LOS), stress incontinence outcomes and complication rate data were collected retrospectively for 30 HoLEP cases by each surgeon. All patients underwent follow-up after 3–6 months. Data were then compared between groups to assess for any differences in outcomes.
Results:
Specimen weight and prostate volume were greater (p < 0.001) in the control group but were similar between learners. There was no difference between rates of stress urinary incontinence (p = 0.928), complications (p = 0.561) or LOS (p = 0.124) between groups.
Conclusion:
Our data show comparable outcomes, regardless of the stage at which the surgeon trained in HoLEP. This demonstrates that learning as a trainee or a consultant is equally safe and effective, supporting the concept of HoLEP training starting from a more junior level.
Level of evidence:
This retrospective comparison study is level 4 evidence
Introduction
Benign prostatic hyperplasia (BPH) is a common condition affecting men. With an ageing population, there are an ever-rising number of patients who present with bothersome lower urinary tract symptoms (LUTSs). About 1 in 10 men will go on to require surgical treatment for their symptoms. 1
Holmium-laser enucleation of the prostate (HoLEP) is rapidly becoming the preferred surgical treatment option for BPH, particularly for patients with larger prostates (>80 cm3). HoLEP has been shown to be a safe, effective and durable option with low complication rates. 2
There is a steep learning curve associated with HoLEP. 3 Many surgeons learn at a consultant level, while learning during urological surgical training is not currently widespread. HoLEP requires longer training than standard transurethral resection and extensive previous experience with transurethral surgery is thought to be advantageous. 4 Challenges of HoLEP include the recognition of surgical planes and orientation of oneself with anatomical landmarks. 5
Although the existence of a learning curve is known, it is less clear how many cases are required for a surgeon to reach sufficient competency and the literature suggests this may be between 20 and 50 cases.6,7 There are impracticalities associated with urologists undergoing such vigorous training while working as a consultant, as time is taken away from covering usual clinical work. 5 Since HoLEP is becoming more prominent in the surgical management of BPH, it would seem appropriate for this to become part of the core urology training programme.
This study aims to explore whether there are clinically significant differences in the outcomes for patients undergoing HoLEP by a trainee or mentored consultant urologist.
Material and methods
A retrospective analysis was conducted to compare the learning journey of two mentor-trained consultant surgeons (surgeons 1 and 2) and one registrar (resident) trainee against a control group of cases performed by an experienced HoLEP surgeon. Data from the first 30 consecutive cases for each surgeon were gathered. Mentored surgeon 1 and the trainee surgeon were from the same hospital, whereas mentored surgeon 2 was from a different hospital. The experienced surgeon (control group) was mentored surgeon 1, recorded after performing 300 cases.
Cases were collected from mentored surgeon 1 (group A) from August 2014 to July 2015, mentored surgeon 2 (group B) from December 2022 to May 2023, trainee surgeon (group C) from October 2020 to February 2022 and the experienced surgeon (group D) from January 2020 to August 2020. All patients were followed up at 3–6 months. Regarding instruments, one hospital used a Lumenis VersaPulse 100W Holmium laser, and the other used a Cook Cyber Ho 150W Holmium laser. Both sites used a 550-μm laser fibre, Olympus endoscopic equipment and a Wolf Piranha morcellator.
Basic patient demographics were recorded. Pre-operative prostate volumes were calculated from different imaging modalities including magnetic resonance imaging (MRI), computed tomography (CT) and Transrectal or Transabdominal Ultrasonography. Specimen weight was recorded by the pathology laboratory. We equated the percentage prostate volume removed by assuming 1 cm3 of prostate volume was equivalent to 1 g of tissue resected. This enabled calculation of the percentage of prostate tissue removed as an indicator of the completeness of resection.
Outcomes assessed included postoperative complications, length of stay (LOS) and incidence of stress urinary incontinence (SUI) at 3–6 months. Cases of SUI were defined as patients having to use more than one pad a day; patients using pads for safety were excluded. A retrospective review of electronic patient records was conducted to confirm the absence of any long-term complications and record histological findings. Complications were graded using the Clavien-Dindo classification. 8
Training
Mentored surgeon 1 initially attended a formal training course on HoLEP, following which he received mentorship for the first 10 cases from an experienced HoLEP surgeon. Mentored surgeon 2 and the trainee surgeon were mentored initially by the experienced surgeon prior to achieving independence. This involved simulation practice and then a modular approach with dual operating so proficiency could be demonstrated in each step of the procedure. This was followed by direct continuous observation until it was agreed that the learner was competent to operate independently.
Statistical analysis
Mean specimen weights, prostate volumes and median length of stay were compared using the analysis of variance test (ANOVA). The Kruskal–Wallis test was used to compare the estimated proportion of overall prostate volume removed between the four groups. A chi-squared test assessed for any statistical significance in complications and SUI rates between groups.
Results
The mean ages of the patients for groups A, B, C and D were 68.2 years (range = 47–81 years), 70.5 years (range = 56–89 years), 73.6 years (range = 65–84 years) and 72 years (range = 56–88 years), respectively.
The mean specimen weight in group D was 102.57 g (34–222 g) and was greater than the other three groups (see Table 1). Group A’s mean specimen weight was 45.47 g (2–129 g), group B’s was 64.09 (11–128 g) and group C’s was 63.33 (4–198 g). There was a statistically significant difference in mean specimen weight between group D and the three learning groups (A, B and C) (p < 0.001).
Specimen Weights and Prostate Volumes from each Case Series.
Mean prostate volume was greatest in group D at 145.77 cm3 (75–243 cm3) compared with group A at 88.83 cm3 (20–250 cm3), group B at 92.21 cm3 (50–146 cm3) and group C at 96.10 cm3 (46–306 cm3) (see Table 1). There was a statistically significant difference between group D’s mean prostate volume and the other groups (p < 0.001). There was also a statistically significant difference between the mean percentage of prostate resected between the groups (p = 0.0022) with group B and group D having the highest mean percentage of prostate resected at 69.32% and 69.55%, respectively.
There was no statistical difference in early complication rates between the groups (p = 0.561) (see Table 2). Groups A and D had a complication rate of 16.67%, group B 10% and group C 6.67%. Group D had five reported complications including return to theatre for bleeding (Clavien-Dindo 3b) and urethral stricture requiring optical urethrotomy at 6 months (Clavien-Dindo 3b). One patient was admitted with haematuria and required irrigation and a blood transfusion (Clavien-Dindo 2). Two patients had significant lower urinary tract infection postoperatively (Clavien-Dindo 2). Group A also had five complications including a prolonged admission with pneumonia requiring an 11-day hospital stay and one significant lower urinary tract infection (both Clavien-Dindo 2). Two patients went into delayed acute urinary retention following a trial without a catheter, and one patient had a morcellator-related superficial bladder mucosal injury not requiring further treatment (Clavien-Dindo 1). Group B had three complications, including return to theatre for bleeding (Clavien-Dindo 3b), a bulbar urethral stricture (Clavien-Dindo 3a) and one significant lower urinary tract infection (Clavien-Dindo 2). Group C had two complications of postoperative bleeding and clot retention not requiring return to theatre (Clavien-Dindo 1).
Complication Rate, LOS and Stress Urinary Incontinence Rate from each Case Series Group.
The median LOS was one day for all groups except group B, which had a median LOS of zero days. There was no statistically significant difference between the 4 groups (p = 0.124). The greatest LOS was 12 days in the group D; this was due to a prolonged admission with haematuria, requiring multiple blood transfusions, prior to an emergency HoLEP. In total, 60% of group B were day cases, with 13.33% for the group D, 36.67% for group C and 0% for group A.
SUI rates of the 111 of 120 patients assessable at 3–6 months were 3.70% (group D), 6.61% (groups A and B) and 8.33% (group C). There was no statistically significant difference between the groups (p = 0.928), suggesting that trainees have comparable results to consultant learners.
Discussion
Meaning of the study
The use of laser within the urinary tract is now considered the gold standard for upper tract stones and the management of larger benign prostate disease. 9 Although the ideal laser type and energy settings for prostate enucleation remain variable, it is evident that while trainees use the laser routinely for stone treatments from an early stage, they have limited experience with its use in HoLEP. 10 This may be because of a perceived increased risk of potential complications, although this is not borne out in our study. Since HoLEP is not yet considered a core training skill, many newly established consultants have not had the opportunity to learn the technique and may not feel comfortable or competent to mentor their trainees.
It is important to know whether it is safe and appropriate for trainees to be taught HoLEP as a core surgical skill at a stage when they might not yet have had the benefit and experience of performing numerous endoscopic procedures.
We have demonstrated that with appropriate training and mentorship, there was no difference between the learning journeys of the consultants and the trainee. Likewise, there was a very similar overall percentage volume of prostate resected across the groups. Importantly, HoLEP is an anatomical procedure, so even during the learning curve, significant tissue volumes are enucleated.
Comparison of this study with other studies on HoLEP learning curves
Group D had very similar mean prostate volumes and mean specimen weights compared with other studies looking at HoLEP outcomes. Elzayat and Elhilal 11 conducted a retrospective analysis of 225 consecutive patients undergoing HoLEP over a 7-year period. They found a mean prostate volume of 126 cm3 and mean specimen weight of 86.5 g which compare favourably to group D.
There was no statistically significant difference in complication rates between the different groups. This suggests that training at the trainee level is safe and results in comparable outcomes with consultant learners. The complication rates in this study were comparable to larger volume studies. Capogrosso et al. looked at rates and predictors of complications following HoLEP at a high-volume centre and retrospectively analysed data from 284 patients undergoing a HoLEP over a 2-year period, and they found a 28.6% complication rate at 12 months post-operatively. 12 This study observed a much lower complication rate in all groups, ranging from 6.67% to 16.67%. Although the sample size is smaller, this does suggest that trainees are able to achieve comparable outcomes to consultant learners without having an increased complication rate. Capogrosso et al. also had a mean prostate volume of 87 cm3. Given that the mean prostate volumes in all groups in this study were greater and yet the complication rates were less, this suggests that a larger prostate volume does not necessarily equate to a higher complication rate, providing sensible limits are observed.
There was no statistically significant difference between all four groups when comparing median LOS. Mentored surgeon 2 had the shortest mean LOS and his learning case series is the most recent. This may be due to variation in pathways and facilities at the different hospitals. The experienced surgeon group had the greatest mean LOS. The cause of this was the inclusion of a patient operated on during an emergency admission with haematuria rather than a routine, elective case. HoLEP is now considered a safe day case procedure in many cases, hence the decreased LOS in the more recent learning series. However, other factors including larger prostate volumes, patient comorbidities and social needs must be taken into consideration. 13 Lee et al. 14 conducted a study including 210 patients undergoing HoLEP and concluded that the two most significant factors affecting feasibility and safety of a day case procedure were prostate volume and morning theatre lists. They reported a 35.3% day case rate which was very comparable to the trainee surgeon in this study. The control group had the greatest mean prostate volume, impacting their mean LOS, as these patients are more likely to require an overnight admission for irrigation and monitoring. Laser equipment and morcellation technology have advanced over the study period which will have influenced operating time and further facilitated day-case surgery. Two patients from the experienced surgeon group were done as an emergency during an inpatient stay (LOS of 11 and 12 days) significantly impacting the mean LOS, although the median length of stay was similar to the other groups.
The trainee’s case series spanned the longest period of nearly 18 months. This could be related to multiple different demands during training along with on-call service provision commitments, so opportunities for theatre training may have been more infrequent. When learning a new technique, it is often helpful to be practising these skills on a frequent basis to reinforce technique and improve efficiency. However, the longer time period has not impacted the complication rates or LOS, as these results are all very comparable with the other groups.
There was no statistically significant difference in SUI rates between groups, reinforcing no significant difference in functional outcomes for trainee versus consultant learners. The data were impacted by 7.5% of patients being lost to follow-up, influenced by the COVID-19 pandemic effect on appointment cancellations and subsequent loss to follow-up. The British Association of Urological Surgeons specify a 2–10% risk of developing temporary short-term loss of urinary control which is in keeping with our data. 15 SUI tends to improve over time, so the improvement in symptoms is unknown in this study since there is no follow-up data after 6 months.
The number of cases required for a surgeon to be proficient and competent in HoLEP varies between previous studies. Elshal et al. 16 describe the plateau of the learning curve as being a ‘moving target’ depending on different amounts of previous experience but are also influenced by preoperative prostate volume. Kampantais et al. 6 conducted a systematic review of 24 studies assessing the learning curve of HoLEP and found that the learning curve requires somewhere between 25 and 50 cases, with faster progress being achieved with a structured mentorship programme. They also suggested that surgeons should be selective with their patient group and aim to operate on smaller prostate volumes while still in their learning curve (<80 cm3).
In a subjective analysis of senior residents in their new mentorship training curriculum, Chavali et al. 7 reported their suggested learning curve of around 25 cases and that residents felt that HoLEP training should be incorporated into residency training. Although a small study which did not look at specific surgical or patient outcomes, it did highlight that trainees felt able to perform HoLEP independently as part of their practice, after structured mentorship during their specialist training.
Strengths and limitations of the study
Our study highlights that HoLEP proficiency and good clinical outcomes can be developed equally safely by a mentored trainee or consultant learner and should therefore become part of the core trainee skillset. Limitations of this study include the small sample size, long time span of the different groups, dual-site surgery with differing equipment and loss of some patients to follow-up. There was no standardised imaging technique for prostate volume, so statistical analysis depended on estimations using whatever subjective preoperative imaging modality had been performed, although with a similar distribution of imaging techniques in each group.
Areas of future research
Further studies to evaluate the optimal curriculum to shorten the learning curve may help inform HoLEP training.
Conclusion
With appropriate supervision and mentorship, trainees can achieve comparable outcomes and safety profiles to both mentored consultant learners and experienced HoLEP surgeons. Providing that there is appropriate case selection and consultant supervision, there is no reason why HoLEP should not be incorporated into training programmes for urological trainees.
Footnotes
Acknowledgements
None relevant.
Conflicting interests
The authors declare that there is no conflict of interest.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Ethical considerations
The study has been registered with Salisbury District Hospital Audit Department – Urlgy/SE/2025-26/02.
Informed consent
Patients gave full written consent prior to their surgery including information leaflets regarding the procedure.
Consent to participate
Not applicable.
Consent for publication
Not applicable.
Data availability statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Guarantor
M.J. is the guarantor for this research.
Contributorship
All authors were involved in the concept of the study and development of the protocol. P.C. wrote the first draft of the manuscript. P.C. and T.P. collected and analysed all data. T.J., J.M., J.B. and M.J. were consultants, trainees and experienced surgeons. B.S. reviewed the manuscript drafts. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
