Holmium Laser Enucleation of the Prostate (HoLEP): Our Experience with the Learning Curve and the Development of the ‘En-Bloc No-Touch’ Technique

Background: Holmium laser enucleation of the prostate (HoLEP) is a safe and effective therapeuticoption in patients suffering from benign prostatic hyperplasia (BPH) of any size. In spite of its excellent and durable outcomes, HoLEP is gaining widespread acceptance very slowly, since it is perceived as requiring significant endoscopic skill and having a steep learning curve. Here we present our 4-year experience with this technique after more than 200 cases, describing our learning curve with the traditional three-lobe technique of Gilling, and its progressive modification into the so-called ‘en-bloc no-touch’ technique. Methods: From January 2011 to December 2014, 200 consecutive patients diagnosed with symptomatic and obstructive BPH underwent HoLEP in our department. Demographic and clinical data were prospectively collected. Age, total operating time, enucleation time and efficiency, morcellation time, energy employed, adenoma weight, hospital stay, and complications were recorded. Results: The HoLEP learning curve in our department included an initial 1-year experience with the traditional technique of Gilling, and its progressive modification with the development of the socalled ‘en-bloc no-touch’ approach, subsequently standardised step by step. At the beginning of the learning curve short time intervals between the procedures are relevant for faster learning. With time and experience, adenomas of all sizes are treated, with significantly shorter total operating and enucleation times, significantly increased enucleation efficiency, decreased use of energy (meaning fewer postoperative voiding symptoms), and fewer complications. Morcellation time is more devicedependent than surgeon-dependent, and is also influenced by the composition of the adenomatous tissue. Conclusion: The ‘en-bloc no-touch’ technique seems to simplify the procedure, making it easier to teach and to learn. HoLEP safety and efficacy are improved by increasing experience, as expected, but apparently also by the application of our modified and standardised procedure.