title: Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve.
abstract: OBJECTIVE
  To analyze the self-learning curve of a single surgeon with holmium laser enucleation of the prostate and to evaluate the safety, effectiveness, and outcome of the procedure after 2 years of experience.
  
  
  METHODS
  The data from the first 125 patients who underwent holmium laser enucleation of the prostate were retrospectively analyzed. The patients were assessed preoperatively and at 1, 3, 12, and 24 months postoperatively. The patient evaluations included serum prostate-specific antigen measurement, peak urinary flow rate determination, postvoid residual volume measurement, and symptom scores. To assess the effect of the learning curve on the perioperative data and complications, the patients were divided into subgroups of 25 consecutive patients.
  
  
  RESULTS
  The mean patient age was 71.4 years. The average prostate volume was 75.8 mL, and the mean weight of the enucleated tissue was 46.7 g. The average operative time was 109.8 minutes. The operative times and enucleation and morcellation efficiency rates improved significantly during the learning process. The mean hemoglobin loss was 1.7 g/dL. The median catheter time and hospital stay was 44 and 30 hours, respectively. Compared with baseline, at 1 year postoperatively, the median postvoid residual urine volume had declined by 99 mL, the mean peak urinary flow rate had increased by 19 mL/s, and the mean American Urological Association symptom score had decreased by 16.5 points. All changes observed were significant and regardless of the prostate size. Persistent stress urinary incontinence (4.8%) occurred with the first enucleations of large-size prostates. Other complications included bladder neck contracture (4%) in small-size prostates and bulbar urethra stricture (1.6%).
  
  
  CONCLUSIONS
  Holmium laser enucleation of the prostate is a safe, reproducible and effective surgical modality. Case selection is necessary to avoid the morbidity associated with the first stages of the self-taught learning curve, mainly urinary incontinence.
authors.affiliation: Servei d'Urologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain. jplacersantos@gmail.com
authors.forename: José
authors.initials: J
authors.lastname: Placer
authors.forename: Antoni
authors.initials: A
authors.lastname: Gelabert-Mas
authors.forename: Felip
authors.initials: F
authors.lastname: Vallmanya
authors.forename: Josep M
authors.initials: JM
authors.lastname: Manresa
authors.forename: Violeta
authors.initials: V
authors.lastname: Menéndez
authors.forename: Ramón
authors.initials: R
authors.lastname: Cortadellas
authors.forename: Octavio
authors.initials: O
authors.lastname: Arango
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D015331:Cohort Studies; D006801:Humans; D053685:Laser Therapy / Q000009:adverse effects / Q000379:methods*; D053844:Lasers, Solid-State; D007858:Learning; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D010818:Practice Patterns, Physicians'; D011470:Prostatic Hyperplasia / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D001748:Urinary Bladder Neck Obstruction / Q000209:etiology* / Q000601:surgery*