Safety of HoLEP Not Affected by Participation of Trainees

Indian Wells, California—There is a steep learning curve associated with the use of Holmium Laser Enucleation of the Prostate (HoLEP). HoLEP is an established surgical treatment for benign prostatic hyperplasia (BPH); however, the need for new endoscopic skills required has made the widespread adoption slow.

Haidar M. Abdul-Muhsin, MBChB, and colleagues recently conducted a study designed to systemically measure the impact of trainee participation on the perioperative and functional outcomes following HoLEP in a residency training setting. Dr. Abdul-Muhsin reported results of the study during a poster session at the 91st Annual Meeting of the Western Section of the American Urological Association. The poster was titled The Impact of Training on the Perioperative and Intermediate Functional Outcomes after Holmium Laser Enucleation of the Prostate.

The researchers stratified patients with BPH who underwent HoLEP at the Mayo Clinic, Phoenix, AZ, between January 2007, and January 2013, based on the trainees’ postgraduate level. The surgery was performed or supervised by a single endourology fellowship-trained urologist who was well beyond the learning curve for this surgery. Exclusion criteria were patients with prostate cancer, previous prostatic intervention, or concomitant urethral stricture disease.

Functional outcomes were assessed using a comprehensive validated questionnaire sent be an independent third party survey center. The questionnaire included Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society (ICSmaleSF) questionnaires.

There were three groups of patients: group 1 had no trainees participate in the surgery; group 2 had a senior trainee, defined as post-graduate year 4 or 5, perform the operation; and group 3 had a junior trainee, defined as post-graduate year 1, 2, or 3, perform the operation. Patient baseline characteristics, complications, and perioperative and postoperative outcomes were compared among the groups.

There were no differences among the groups in baseline clinical, urinary, and sexual function characteristics. Further, preoperative prostate size, prostate specific antigen, and uroflowmetry were comparable among the three groups. There were significant differences in overall operative time (P=.0186) and enucleation (P=.0047), with shorter operative time seen with more experienced operators. However, there were no differences in the morcellation time.

There were also no differences in the weight of the resected tissue, hemoglobin change, and incidence of blood transfusion. All patients had similar length of stay and duration of urinary catheter use postoperatively. There were no significant differences in complications, which were graded according to the Clavien-Dindo grading system.

Uroflowmetry was performed at 6 weeks postoperatively and every 3 months thereafter. There were no differences at any time point in the maximum flow rate, average flow rate, or post void residual. However, at 6 weeks, there was a difference in voided volume (P=.03).

Moreover, there were no differences in SHIM, IPSS, and ICS male VS among the groups. In an analysis of the incontinence scale, there was a significant difference among the groups: the highest score was seen in group 2.

“Trainee participation in HoLEP in a controlled training environment with an experiences mentor does not compromise the safety or the functional outcomes of the procedure. The overall sexual and functional outcomes are comparable. However cases performed by senior trainees may have higher incidence of storage symptoms,” the researchers concluded.


Source: Abdul-Muhsin HA, Tyson M, Nunez R, Stern KL, Humphreys MR. The impact of training on the perioperative and intermediate functional outcomes after Holmium laser enucleation of the prostate. Abstract of a poster presented at the 91st Annual Meeting of the Western Section of the American Urological Association, Indian Wells, California, October 25, 2015.