Evaluation of the Learning Curve for Holmium Laser Enucleation of the Prostate Using Multiple Outcome Measures

Objective To assess and quantify the surgical learning curve of holmium laser enucleation of the prostate (HoLEP) of a single surgeon. Methods A retrospective analysis of 253 consecutive cases performed by the same surgeon from 2006 to 2013 was conducted. Primary outcomes included enucleation ratio and morcellation efficiencies and complication rates. Three-month postoperative prostate-specific antigen values were used as secondary measures. Cases were divided into cohorts of 20 cases to assess changes in means analyzed through Analysis of Variance (ANOVA) tests. Scatter plots of cases with a best-fit line were drawn to analyze the learning curve. Results The mean age of patients across the cases was 69.21 years with an average transrectal ultrasound prostate volume of 95.84 cc. Enucleation ratio efficiency was significantly different between cohorts (P =.02) plateau after 50-60 cases conducted. Similarly, a significant difference is shown for morcellation efficiency (P =.01) with stabilization in performance after 60 cases. Complication rates decreased through the caseload but did not show a statistical difference (P =.62) or plateauing on the graph. Finally, no difference between 3-month postoperative prostate-specific antigen values was seen (P =.083); however, a learning curve of 50 cases was observed graphically. Conclusion Within our single-surgeon cohort, we experienced a learning curve of 40-60 cases for the HoLEP procedure. Large variability in performance late into the caseload demonstrates the technical difficulty of HoLEP. Owing to this, adjuncts to training such as simulation-based training may be of use for the new surgeon to shorten the initial phase of learning.