The en bloc method is feasible for beginners learning to perform holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate (HoLEP) is a new alternative method for the treatment of benign prostatic hyperplasia (BPH); however, most surgeons are hesitant to use this new technique due to its steep learning curve. Notably, most beginners start with the traditional multi-incisional method rather than the en bloc method. Thus, we sought to explore the feasibility of beginners adopting the en bloc method in HoLEP.

A clinical development project was established at Department of Urology, Affiliated Nantong Rehabilitation Hospital of Nantong University in December 2019 to promote HoLEP. The study included 1st 132 consecutive patients treated by a single surgeon between January and December 2020. The overall pre-, peri-, and post-operative metrics were documented and evaluated. The 132 patients were divided into Group A (1st 50 patients) and Group B (the following 82 patients), and these two groups were compared to each other.

No conversion of operative methods occurred. The major significant differences between Groups A and B related to the enucleation time and enucleation efficiency. We found that 20-30 procedures needed to be performed for the surgeon to become relatively comfortable with the en bloc method. Further, skill improvement was continuous but tended to stabilize with case accumulation. The main short-term complications observed in the hospital and 30 days post-operatively included acute urinary retention, urinary tract infection, transient incontinence, and gross hematuria. In the 18-month follow-up period, the complications consisted of urethral stricture and bladder-neck contracture, which required endoscopic urethrotomy or bladder-neck incisions.

The en bloc HoLEP provided a significantly improved voiding with low complications and recurrence, and this technique could feasibly be adopted to teach beginners.