Presented by: Dan gralnek MD
Univ Wisconsin Madison

Introduction

INTRODUCTION AND OBJECTIVE:  Holmium Laser Enucleation of the Prostate (HOLEP) is a well-established treatment of BPH in any size prostate.  Despite well-established HOLEP efficacy and AUA BPH Guideline endorsement, adoption rate remains low and an alleged steep learning curve is often cited as an obstacle to more widespread use in surgical management of BPH.  Access to training for HOLEP is limited with few residents and fellows nationwide finishing their training ready to perform HOLEP independently.  At our institution, HOLEP is performed at a high volume with >400 HOLEP procedures year.  We witnessed a pattern of trainee learning and competence such that several residents had taken HOLEP skills learned in residency and successfully transitioned to independent practice.  We aim to assess trainee performance improvement objectively as they progress through our curriculum to better understand the resident and fellow learning curve for HOLEP.  Our primary objective is to determine the number of training cases required to independently complete prostate enucleation of <100g gland in 90 minutes or less. 

Materials

METHODS:  After institutional review board approval, two HOLEP surgeons identified the technical steps required to reach HOLEP proficiency.  A step-wise approach to surgical teaching was defined as the University of Wisconsin HOLEP training curriculum (Table).  A rubric was developed for the trainee and attending surgeon to be completed throughout the study duration.  Study duration was set at one academic year (June 2021-June 2022).  De-identified procedure information was prospectively collected including prostate size, imaging modality, total procedure duration, enucleation time, morcellation time, specimen weight, and intra-op/immediate post-op complications.  Trainee performance evaluations documented Objective Structured Assessment of Technical Skills (OSATS) and Global Rating Scale (GRS) measurements as each resident progressed through the curriculum.  A total of 201 evaluations were collected from trainees (57) and attendings (144). 

Results

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RESULTS:  Evaluations were completed by two attendings (DG and CM) and a total of 14 trainees.  Number of HOLEP cases recorded by each PGY-level include PGY-1 (1), PGY-2 (20), PGY-3 (11), PGY-4 (173), PGY-5 (48), and PGY-6 (49).  A total of 7 trainees reached the primary objective of independent enucleation of <100g gland in <90 minutes including 3/3 PGY-4, 3/3 PGY-5, and 1/1 PGY-6.  Number of cases to reach objective of full HOLEP was noted to average 31 (range 19-44). 

Conclusion

Conclusion: Using a progressive step wise standardized program, resident education in performing HOLEP surgery was successful in all residents during the study period. An average of 31 cases was required for independence

Funding

an educational grant was extended through Lumenis for the study