The learning curve for holmium laser enucleation of the prostate: a single center analysis of surgical and functional outcomes.

BACKGROUND

To report the surgical and functional outcomes of the HoLEP surgical program implemented at a high-volume tertiary referral center and to estimate the learning curve (LC) duration for this surgical procedure.

METHODS

Data of all consecutive patients undergoing HoLEP at the University of Verona between June 2022 and April 2024 were retrieved from a prospectively maintained institutional database of patients undergoing BPH surgical treatment. The primary endpoint was functional outcomes evaluation during the surgeons' LC. The secondary endpoint was to define the surgical LC for HoLEP. A multivariable test of means was carried out to compare functional outcomes at different time points. After adjusting for potential confounders (age, preoperative pharmacotherapy, and prostate volume), multivariable linear regression models were fitted to evaluate the effect of experience on operative time (OT) and enucleation efficiency. To assess LCs for HoLEP surgery, the non-risk-adjusted CUSUM method was used.

RESULTS

A statistically significant improvement in IPSS score, delta% IPSS score, IPSS-QoL score and delta% IPSS-QoL score was observed over the study period. Furthermore, the incidence of irritative symptoms (p<0.001) and stress incontinence (p=0.01) significantly decreased over time, with a 12-month incidence of 8.4% and 9.5%, respectively. A statistically significant association between experience and both OT and enucleation efficiency was observed at multivariable linear regression analysis. The CUSUM chart for OT and enucleation efficiency showed a steep initial upward/downward trend of ˜50 cases each, and a plateau until ˜100 procedures are reached, where the breakpoint is recognized for both variables, and where the CUSUM curve goes below the LOWESS curve in the corresponding O-E CUSUM plot.

CONCLUSIONS

HoLEP represents an effective treatment for BPH, demonstrating significant improvement in BPH-related symptoms over the study period, despite the considerable LC of ˜50 cases associated with the procedure.