Presented by: Sai Vangala MD
Northern Ontario School of Medicine

Introduction

Holmium laser enucleation of the prostate (HoLEP) is known to have a steep learning curve. The top-down technique was introduced to lessen the number of procedures required to master HoLEP. The objective of our study was to present the experiences of two successive clinical fellows with the top-down HoLEP learning curve and to compare the fellows’ performance with their supervisor.

Materials

We conducted a prospective study of 40 patients that underwent top-down HoLEP performed by two successive clinical fellows at our institution from September 2020 to July 2022. Prior to data collection, each fellow observed three top-down HoLEP procedures and assisted with seven additional cases before independently performing top-down HoLEP under supervision. We collected data from each fellow’s first 20 consecutive top-down HoLEP procedures. All patients included in the study had a prostate size >80 g. The learners’ cases were grouped according to chronological order (Cases 1-10 and 11-20). The primary outcome was defined as the number of cases before the clinical fellow could independently complete all steps of top-down HoLEP without any major intraoperative complications. The secondary outcomes included the intraoperative and postoperative outcomes of both groups. The 40 cumulative cases of the clinical fellows were then compared to 148 procedures performed by their supervisor in terms of efficiency, outcomes, and complications.

Results

,

There were no significant differences in baseline patient demographics for both clinical fellows. Each learner performed the first 20 cases independently without needing the supervisor to intervene. There were no major intraoperative complications recorded and no statistically significant differences in intraoperative and postoperative outcomes between fellows’ cases (Table 1). There was a statistically significant difference between the fellows and their supervisor in terms of operative efficiency and enucleation efficiency (p=0.000). We did not find a significant difference between the fellows and the supervisor regarding intraoperative complications, major postoperative complications, or postoperative subjective and objective parameters.

Conclusion

Top-down HoLEP shows promising and reproducible results in shortening the HoLEP learning curve. Further comparative and multi-institutional studies with additional learners are needed to verify our preliminary findings.

Funding

None

Co-Authors

Hazem Elmansy,
Northern Ontario School of Medicine

Abdulrahman Alkandari,
Northern Ontario School of Medicine

Moustafa Fathy,
Northern Ontario School of Medicine

Parsa Nikoufar,
Northern Ontario School of Medicine

Loay Abbas,
Northern Ontario School of Medicine

Prashidhi Pathak,
Northern Ontario School of Medicine

Amr Hodhod,
Northern Ontario School of Medicine

Walid Shahrour,
Northern Ontario School of Medicine