title: Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP).
abstract: OBJECTIVE
  To describe the step-by-step learning curve of the holmium laser enucleation of the prostate (HoLEP) surgical technique.
  
  
  METHODS
  A prospective, multicentre observational study was conducted, involving surgeons experienced in transurethral resection of the prostate and open prostatectomy but never having performed HoLEP. The main judgment criterion was the ability of the surgeon to perform four consecutive successful procedures, defined by the following: complete enucleation and morcellation within <90 min, without any conversion to standard transurethral resection of the prostate (TURP), with acceptable stress, and with acceptable difficulty (evaluated by Likert scales). Each surgeon included 20 consecutive cases.
  
  
  RESULTS
  Of nine centres, three abandoned HoLEP before the end of the study due to complications, and one was excluded for treating patients off protocol. Only one centre achieved the main judgment criterion of four consecutive successful HoLEP procedures. Overall, the procedures were successfully performed in 43.6% of cases. Reasons for unsuccessful procedures were mainly operative time >90 min (n = 51), followed by conversion to TURP (n = 14), incomplete morcellation (n = 8), significant stress (n = 9), or difficulty (n = 14) during HoLEP. Ignoring operating time, 64% of procedures were successful and four out of five centres did four consecutive successful cases. Of the five centres that completed the study, four chose to continue HoLEP.
  
  
  CONCLUSIONS
  Even in a prospective training structure, HoLEP has a steep learning curve exceeding 20 cases, with almost half of our centres choosing to abandon or not to continue with the technique. Operating time and difficulty of the enucleation seem the most important problems for a beginner. A more intensely mentored and structured mentorship programme might allow safer adoption of the procedure.
authors.affiliation: Service d'Urologie, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France.
authors.forename: Grégoire
authors.initials: G
authors.lastname: Robert
authors.affiliation: Service d'Urologie, Hôpital Tenon, Université Paris-6, Paris, France.
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Cornu
authors.affiliation: Service d'Urologie, Centre Hospitalier du Pays d'Aix, Aix-en-Provence, Provence, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Fourmarier
authors.affiliation: Service d'Urologie, NHC, Strasbourg, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Saussine
authors.affiliation: Service de Chirurgie Urologique, Hôpital Dupuytren, CHU de Limoges, Limoges, France.
authors.forename: Aurélien
authors.initials: A
authors.lastname: Descazeaud
authors.affiliation: Service d'Urologie, CHU d'Angers, Angers, France.
authors.forename: Abdel-Rahmène
authors.initials: AR
authors.lastname: Azzouzi
authors.affiliation: Clinical Research Unit, Lariboisière-Fernand Widal Hospital, University Paris Diderot, Paris, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Vicaut
authors.affiliation: Service d'Urologie, Hôpital Tenon, Université Paris-6, Paris, France.
authors.forename: Bertrand
authors.initials: B
authors.lastname: Lukacs
mesh_terms: D000328:Adult; D000368:Aged; D004502:Education, Medical, Continuing; D006801:Humans; D053685:Laser Therapy; D053844:Lasers, Solid-State; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011446:Prospective Studies; D011469:Prostatic Diseases / Q000601:surgery*; D020728:Transurethral Resection of Prostate / Q000193:education
keywords: HoLEP; enucleation; holmium; learning curve; prospective study; prostate