Holmium laser enucleation of the prostate (HoLEP) with MOSES has become the premier therapy for BPH. To my experience, the relief in obstructive symptoms is unparalleled, as is the ability to make patients independent of medications and urologic care.1,2 There are many ways to learn HoLEP—traditional fellowship, “mini fellowship,” proctoring, observership, and monastic learning are all effective. If you want to learn HoLEP within your busy schedule, it can be self-taught. Here’s how to make it a success.

Get Prepared

In my experience of learning HoLEP on my own, it helps to reflect on the barriers to self-taught HoLEP. First, you may not have all the necessary equipment, including a Lumenis holmium laser with MOSES technology, a morcellator, and specialized instruments. Assuming there is money in the budget, is there resistance from the administration or historical adherence to TURP? Pick lists containing the instruments needed for HoLEP are available from the scope manufacturers or HoLEP centers of excellence on request.  The cystoscopic equipment is not exceedingly expensive, and your institution may already have many of the common components. You also have the option to rent laser equipment and a morcellator or trial them on a per-case basis.

Patient volume is another consideration because you need to have repetition over a short time to become proficient. A recent study showed that the HoLEP learning curve was 50 cases when HoLEP was self-taught.3 You may need to abandon other modalities for a time to ensure you get enough cases over a concentrated period of time.

Lumenis offers you training with the MOSES HoLEP University, a comprehensive educational online platform, or with dedicated MOSES Mastery courses. In addition, Lumenis can help connect you with high-volume centers for live observation of HoLEP.

Finally, if you want to assist other surgeons or have them assist you, take the time to verify that you have practitioners with privileges in your system currently doing HoLEP with whom you can partner. Many high-quality videos are also available online demonstrating different enucleation techniques. Videos featuring simultaneous views of the camera and surgeon’s hand movements are particularly useful.

Get Started

“As a self-taught HoLEP, you need to work through the learning curve, but you’ll be proficient in a few months, and your patients will be the biggest beneficiaries of your effort”.

HoLEP is indicated for prostates of all sizes.4 For your first cases, select patients with a 60-80ml prostate with well-defined surgical capsule, no prior BPH procedures, no finasteride, and no anticoagulation or antiplatelets. Avoid very small prostates initially to avoid a poorly defined surgical capsule and bladder neck contracture issues.

With preparation, enucleation can typically be completed on initial attempts, but err on the side of caution with incomplete resection of adenoma if necessary—you can always take out more prostate, but you can’t put back the sphincter if you get aggressive. I also recommend that you have a contingency plan in case the HoLEP can’t be proceeded. For example, if the morcellator fails, you can switch to bi-polar TURP to remove the enucleated adenoma. Through Lumenis, you can invite a proctor to your hospital to watch one or two cases, while helping the OR staff get up to speed on equipment assembly and troubleshooting (typically proctors cannot assist with the surgery unless credentialed and insured at a particular facility).

During the HoLEP learning curve, expect an occasional disappointing enucleation ratio (specimen weight/prostate volume). Enucleation ratios should improve with experience and ultimately be reflected by 3-month PSA averaging 0.6 or lower.

To set patients’ expectations and minimize phone calls, tell them to expect transient incontinence during recovery. The majority of this leakage is urge in nature due to bladder instability triggered by raw surfaces in the prostate and a profoundly reduced outlet resistance. Resolution of incontinence typically depends on rate of re-epithelialization and pre-existing bladder instability. I don’t see patients back until at least 3 months post-op to minimize discussion of symptoms that will ultimately subside spontaneously. If bothersome leakage exists at that visit, I will continue to follow the patient at quarterly intervals and begin to employ adjuncts such as overactive bladder medicines and pelvic floor physical therapy.

For your own growth, be sure to engage with the community of urologists doing HoLEP through the literature, which can offer you benchmarks for comparison, as well as through outreach to established practitioners whom can answer your questions. Professional meetings and Lumenis courses offer more chances of engagement. Keep notes about your cases and, if possible, take videos to review later.

How will you know when you are proficient at HoLEP? In a recent retrospective study, the authors defined HoLEP competence as completing enucleation and morcellation in under 90 minutes and performing four consecutive cases without converting to TURP or open surgery.5 In my experience, it is recommended  to achieve an enucleation ratio (specimen weight/preoperative TRUS volume) of 50% for prostates under 80ml, with a higher ratio at higher TRUS volumes (approaching 90% for very large prostates). As you get better at using preoperative MRI to calculate the transition zone volume, your enucleation ratio can approach 100%.

As a self-taught HoLEP, you need to work through the learning curve, but you’ll be proficient in a few months, and your patients will be the biggest beneficiaries of your effort.

  1. Ibrahim A, Alharbi M, Elhilali MM, Aubé M, Carrier S. 18 Years of Holmium Laser Enucleation of the Prostate: A Single Center Experience. J Urol. 2019 Oct;202(4):795-800.
  2. Humphreys MR et al. Holmium laser enucleation of the prostate using Moses 2.0 vs non-Moses: a randomised controlled trial. BJU Int. 2021 May;127(5):553-559. doi: 10.1111/bju.15265
  3. Kampantais S, et al. Urology. 2018 Oct;120:9-22. 2. Peyronnet B, et al. World J Urol. 2017 Jun;35(6):973-983.
  4. EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2021. ISBN 978-94-92671-13-4.
  5. Robert G, Cornu JN, Fourmarier M, Saussine C, Descazeaud A, Azzouzi AR, Vicaut E, Lukacs B. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP). BJU Int. 2016 Mar;117(3):495-9.

 

*Risk information and laser safety label are available at Lumenis website, operator’s manual and brochure.

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