Today, more and more surgeons want to learn HoLEP so they can deliver better outcomes while avoiding more invasive, higher-risk procedures. At the same time, patients with BPH read about HoLEP and search for surgeons who perform HoLEP, thus creating a high demand for more HoLEP education.

By the end of my residency, I knew I wanted to learn HoLEP because of the robust and exciting literature and my experience seeing the smiling faces of patients after being treated with HoLEP by senior surgeons. I also knew I wanted an academic career that involved cutting-edge research. I chose to train at Indiana University with surgeons who are at the forefront of HoLEP and stone treatment: Drs. Amy Krambeck, Marcelino Rivera, and Tim Large. If you’re considering a fellowship in advanced procedures for urology, I hope my observations from working with great surgeons and mentors can help.

The HoLEP learning curve is comfortable.

HoLEP’s learning curve is not much different from any surgery. HoLEP does not have more steps than other endoscopic or robotic procedures, so surgeons only require enough repetition to feel comfortable doing it. MOSES technology in HoLEP has demonstrated a reduction in bleeding¹, which may assist shortening the learning curve. HoLEP is the gold-standard, definitive treatment for BPH — a “Swiss Army knife” solution for patients with a huge range of medical histories, comorbidities and prostate sizes—and it affords plenty of research opportunities.

Cutting-edge technologies mean research opportunities.

One of the benefits of fellowship was gaining experiences with new technology and publishing those experiences. I was able to participate in multiple HoLEP studies, some of which were possible due to improvements from MOSES technology in procedural hemostasis.² One demonstrated an 87% success rate for same-day dismissal with HoLEP.³ Additionally, in a small cohort of patients, we were able to successfully remove catheters on 90% of patients after HoLEP utilizing MOSES.⁴

MOSES makes stone surgery notably easier.

Using a 120-watt MOSES laser in fellowship, I was able to dust stones more efficiently because the energy delivery of the pulse modulation reduced the number of times that the stone bounced around compared with standard pulse.⁵ This is not an approach I was very familiar with prior to fellowship, but one I plan to use in practice.

Fellowship is an effective way to learn HoLEP—but not the only one.

With advanced training in my fellowship, I was able to get very good at performing HoLEP, but there are other ways to learn, including self-teaching and programs offered by Lumenis. For me, it was invaluable to have mentors who have performed a lot of HoLEPs and seen everything. In the future, HoLEP may be taught during residency, but not every hospital has the volume of BPH cases to become proficient.

Exposure to technology during training is good preparation for the future.

Now that patients are seeking out not only surgeries, but also technology, exposure to cutting-edge technology, like MOSES will give me a competitive edge. I’m joining the University of Minnesota to build upon a BPH and stone practice with a colleague. I feel confident starting my new position with the ability to deliver effective patient care, carry out research that pushes the envelope, and train the next generation of surgeons in HoLEP and stone treatment with MOSES.

1. Kavoussi NK, Nimmagadda N, Robles J, et al. MOSES Technology for Holmium Laser Enucleation of the Prostate: A Prospective Double-Blind Randomized Controlled Trial. J Urol. 2021 Jul;206(1):104-108.
2. Nevo A, Faraj KS, Cheney SM, 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.
3. Agarwal DK, Large T, Tong Y, et al. Same Day Discharge is a Successful Approach for the Majority of Patients Undergoing Holmium Laser Enucleation of the Prostate. Eur Urol Focus. 2021 Jan 4;S2405-4569(20)30320-5.
4. Agarwal DK, Rivera ME, Nottingham CU, et al. Catheter Removal on the Same Day of Holmium Laser Enucleation of the Prostate: Outcomes of a Pilot Study. Urology. 2020 Dec;146:225-229.
5. Ibrahim A, Badaan S, Elhilali MM, et al. Moses technology in a stone simulator. Can Urol Assoc J. 2018 Apr; 12(4): 127–130.

The below urology blog article is written in collaboration with Dr. Deepak K. Agarwal based on his own experience through fellowship training.
*Risk information and laser safety label are available at Lumenis website, operator’s manual and brochure.