Age and Voiding Complications as a Function of Surgeon Experience with Holmium Laser Enucleation of the Prostate

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Background: Holmium Laser Enucleation of the Prostate (HoLEP) has received wide acclaim as treatment for bladder outlet obstruction with distinct advantages over other surgical approaches. Numerous studies have demonstrated a steep learning curve, suggesting a threshold of 20 cases. However, data on decreased complication rates with surgeon experience is limited. We assessed voiding complications by a single surgeon from fellowship-5 yrs in practice in a teaching institution with no previous laser prostate program. Urologists referred 100% of pts. Reviewed by Internal Review Board.
Methods: A retrospective chart review was performed of all pts undergoing HoLEP between March 2002-Feb 2007, which includes a 1.5 yr cessation of the program due to institutional employment arrangements. Incontinence was defined as ≥1 pad per day at any point post operatively, including stress and/or urge. All pts had ≥ 1 yr follow-up. Retention was defined as failed voiding trial or acute retention requiring catheterization within the first 3 weeks. The patients were divided into the first 22 cases (Group 1) and the last 22 cases (Group 2). In addition, pts were stratified by age <70 (Group A) and >70 (Group B). Statistical analyses included Pearson Chi-Square, Odds Ratio, and Mantel-Hazel tests.
Results: 67 men underwent HoLEP, mean age 66.9 years (SD=11.4). 46 (69%) had urodynamics prior to surgery: 91.3% obstructed; 8.7% equivocal. Overall, transient incontinence rates significantly decreased with surgeon experience: 59% to 22.7% for Groups 1 and 2, respectively (p=0.014; OR=2.6). Similarly, acute retention rates decreased: 27.3% to 4.5% (p=0.039; OR=6.0). Incontinence was not significantly different between the two age groups: 47.7% vs 56.5% for Groups A and B, respectively. However, retention was different: 15.9% vs 39.1% (p=0.034; OR=1.38). With surgeon experience, the younger age population showed improvement in both transient incontinence (66.7% vs 11.8%, p=0.002) and acute retention (25% vs 0, p=0.029). However, no significant improvement was shown in pts >70 yrs. Overall incontinence rate at one year was 10.4% regardless of patient age and surgeon experience. Patients on clean intermittent catheterization (CIC) pre-operatively had similar incontinence and retention rates as those not on CIC.
Conclusions: Overall incontinence and acute retention rates were acceptable given this complex patient population with challenging voiding, neurologic, and medical issues. Despite this, urinary complications after HoLEP clearly decrease with surgeon experience. It has been quoted that approximately 20-30 procedures are required to master the technique as regards operative time, total tissue resection and efficiency, but to our knowledge, this study is the first to prove that voiding complications are also decreased at the same threshold. All pts were treated in a teaching institution with resident involvement, which may have affected outcomes. Interestingly, the data supports the steep learning curve with the younger patient subset, but the same dramatic improvement in complication rate did not hold true for older patients. Further study of pts >70 yrs will likely show associations with medical co-morbidities and neurologic disease, compromising pt outcomes. This information suggests that for the new HoLEP practitioner, selecting younger, healthier patients during the learning curve is important.

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