A Journey of Skills—Theory and Practice of a Multi-Modal Learning Approach to Holmium Laser Prostatectomy

Abstract

Introduction: Holmium Laser enucleation of the prostate (HoLEP) is an effective treatment, yet the learning curve is considered difficult. We propose the trimodal approach of Holmium Laser ablation (HoLAP), then ablation with resection (HoLARP) and finally enucleation (HoLEP) during the development of surgical competence. Methods: A centre experienced in Holmium Laser (HoL) prostatectomy evaluated ablation techniques in prostates less than 50cc as a training modality. Prospective data were collected and outcomes compared with controls who had HoLEP. Subsequently a HoL prostatectomy service was introduced to a new centre and evaluated prospectively during the initial experience of two surgeons mentored by another trained in the trimodal staged approach. Results: Outcomes following HoLAP were comparable to HoLEP in prostate volumes under 50 cm 3 . The new HoL service was evaluated over 6 months. 70 cases were carried out, 42 HoLAP and 28 HoLEP. Outcomes were compared prospectively with 30 TURPs by another surgeon. A decrease in catheterisation time and hospital stay was noted in the laser group. Conclusion:The staged progression from HoLAP, then HOLARP and finally to HOLEP with morcellation appears a safe and reproducible way to introduce HoL prostatectomy into standard urological practice.

Holmium laser enucleation of the prostate: a review of the clinical trial evidence

“…In the UK there is a structured training and mentoring programme, which includes HoLEP courses and masterclasses, as well as HoLEP simulation on a realistic prostate model. This has led to more widespread uptake than in other countries and with support the learning curve has been shortened [Kastner et al 2010]. Trainees often find HoLEP easier than TURP due to improved intraoperative vision from reduced bleeding, so the long learning curve for HoLEP appears to be largely a myth [Ahmed et al 2010].…”

“…In the UK there is a structured training and mentoring programme, which includes HoLEP courses and masterclasses, as well as HoLEP simulation on a realistic prostate model. This has led to more widespread uptake than in other countries and with support the learning curve has been shortened [Kastner et al . 2010].…”