Dear Venusir,

Thanks for forwarding this interesting article for review. 

Holmium Laser Enucleation of Prostate (HoLEP) is fast gaining popularity as an alternative to standard Transurethral Resection of Prostate (TURP) in the surgical management of BPH. One of the main draw-back of HoLEP is steep learning curve. There are many articles published about Learning Curve (LC) of HoLEP. 

This article by a German Center has many good points for consideration. 

1. The center has an experienced HoLEP surgeon who started this program in September’16, quoted in article as Surgeon 1. Other surgeons who joined later as Novice surgeons were compared with Surgeon 1 who worked as mentor cum reference surgeon. This is considered as an ideal situation for assessing LC, as variables are compared with some reference point, instead of single surgeon comparing his own cases in past. 

2. Enucleation Time (Time taken for enucleation of adenoma) is usually recorded in majority of studies. Here, Enucleation ratio (amount of adenoma removed/Total Prostate Volume) is measured which is an important variable. Enucleation Speed (Time taken per gram of tissue removed in min/gm), Laser energy usage in kJ and weight of retrieved tissue are additional variables used. 

3. Combination of these variables, Enucleation Speed (min/gm) x Laser Energy (in kJ) per gram of tissue is calculated as HoLEP efficiency Score. HoLEP efficiency Score(HES)  is first of its kind variable used to evaluate learning curve in any studies published so far.

4. They have also divided their cases in four different groups like 1-40, 40-80, 80-120 and >120 cases to judge the improvement in their learning parameters. 

5. Increase in Enucleation Speed and reduction in Laser Energy usage for both novice surgeons over increasing case load are important findings of this study.  Enucleation Ratio remained same in all groups, which indicates that, novice surgeons took more time and used more energy initially but removed adenoma adequately. 

6. Complications (Grade 2 according to Clavien Dindo Classification) reduced for all surgeons over a period of time. They also studied various factors like presence of UTI,   patients with indwelling urethral catheter, history of Prostate Biospy, patients on anti-coagulants and previously diagnosed CaP, responsible for increase in post operative complications. 

According to me, there are several draw backs of this study which needs answers or readers’ attention. 

• Learning curve is important in surgical treatments as there is constant flow of new technologies and methods available for surgeon, each claiming its superiority. Measuring variables to study learning curve is important. There are two types of variables, one depicting surgical process like enucleation time, speed etc. and other variables measuring patient outcomes like improvement in symptoms and reduction of complications. This study elaborates only surgical process. There is no data about the outcomes measured like blood loss, re-operative rates, improvement in Qmax etc. No mention of SUI as that is the most feared complication of HoLEP especially for beginners. Clavien Dindo grade 2/3 complications are anyways rare in experienced hands in any surgical procedures. 

• If you look at the data carefully, especially Table 2, one may see that, Surgeon 2, who is supposed to be a novice surgeon, has better statistics than his mentor. It could be confounding factors like, surgeon’s previous experience, natural ability, less complex cases etc. which has led to this finding.

• There is no mention of exact method of mentoring. It is just casually mentioned as staged approach used.  Average volume of prostate is very high and for novice surgeons handling bigger prostates without getting lost in their planes and stuck in enucleation, ultimately handing over to his mentor etc has not been mentioned. Few patients were excluded from the study due to improper recording of operative findings. 

• Incidence of diagnosing Cancer Prostate is unusually high, even though average PSA value for that volume of prostate is very low.  Their argument of finding increased number of CaP is attributable to completeness of enucleation procedure looks improper. Significant and persistent reduction in PSA is more important finding for judging completeness of adenoma removal. 

• Increased rate of complications is mainly attributed to Cancer Prostate diagnosis which is very rare. Chronic Prostatitis leading to inflammatory reactions and obliteration of planes between adenoma and capsule is one of the main factors responsible for difficult enucleation. 

• If you look at the learning curve data, there is usually a plateou seen after certain number of cases. Here in this series, Surgeon 2 data, improvement is very fast and there is no plateou reached. This is bit unusual. He has done higher number of cases compared to his mentor (275 versus 181). Whether this was statistically significant or not, is doubtful. 

These are my observations and comments. I may be wrong in analyzing some of the findings.  But, HoLEP Efficiency Score (HES) looks useful concept as quantifying variable for evaluating two surgeons carrying out the same procedure or comparing two different techniques of enucleation procedure. 

Yours truly,

Dr. Ajay Bhandarkar. 

Vadodara.