Presented by: Gregory Lacy II MD, FACS
Yale New Hven Hospital

Introduction

Holmium laser enucleation of the prostate (HoLEP) is an effective treatment for benign prostatic hyperplasia, but by most accounts, has a steep learning curve. We report the experience of a non-Fellowship trained single surgeon’s initial experience of more than 400 holmium laser enucleation of the prostate procedures at a single institution. 

Materials

From April 2019 to February 2022 holmium laser enucleation of the prostate was performed on more than 400 patients. An institutional review board approved database was used to analyze the experience.

Results

,

In the first 400 patients (mean age 68.3 years), 381 patients underwent standard (N=138) or en-bloc (N=243) HoLEP procedures. As the surgeon’s experience rose, average pathology volume increased (p=.035) and overall operation time decreased (p<.001). Mean hospital stay also decreased from the first 100 patients to the last 100 (p<.001). 6-month incontinence rates decreased from 10.8% (first 100 patients) to 5.5% (patients 301-400) as the surgeon gained experience. When reviewing complications, there was not a significant difference in hematuria, UTIs, or urinary retention complications as the case numbers grew. When stratifying incontinence outcomes across various prostate sizes we identified significant decline in 3- and 6-month incontinence rate from second to third quartile of cases for 50-100g prostates and 100+g prostates (p<0.005, 11.2% to 6.3% and 10.8% to 5.0% from first to fourth quartile in 50-100g and 100g+ cases respectively). This decline in incontinence was not present in smaller sized prostates.   

Conclusion

Holmium laser enucleation of the prostate can be implemented safely in the practice of community urologists despite a lack of specific procedural training in residency or Fellowship, in a properly supported environment. Improved operative efficiency, lower complication rates, and incontinence values can be expected as procedural case volume increase even as prostate volume and case complexity increase, with the adoption of the en-bloc enucleation technique.

Funding

None

Lead Authors

Daniel Kellner, MD
Yale New Haven Hospital