Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach.

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, R = 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.