








































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Benign prostatic hyperplasia, holmium, laser 
surgery, learning curve, mentoring

See Acknowledgements. Received on June 23, 2022 
Accepted on July 31, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2023;4(1):11–18

DOI: 10.48083/UJCR1584

Implementing HoLEP in an Academic Department 
With Multiple Surgeons in Training: Mentoring Is  
the Key for Success

Clément Klein,1,2 Thibault Marquette,3 Grégoire Capon,1,2 Eric Alezra,1,2 Peggy Blanc,1,2  
Vincent Estrade,1,2  Jean-Christophe Bernhard,1,2 Franck Bladou,1,2 Grégoire Robert1,2

1 Department of Urology, Bordeaux Pellegrin University Hospital, Bordeaux, France  2 Department of Health Sciences, University of Bordeaux, Bordeaux, France  
3 Department of Urology, Centre Hospitalier de Dax Côte d’Argent, Dax, France

Abstract

Objective Holmium laser enucleation of the prostate (HoLEP) has been recommended for the surgical management 
of benign prostatic hyperplasia (BPH) in most of the international guidelines, regardless of prostatic volume. The 
main advantages reported by randomized clinical studies are reduced perioperative bleeding, catheterization time, 
and length of hospital stay, but this technique is also described as difficult to master with a steep learning curve. 
The objective of this study was to describe the clinical outcomes of HoLEP in the real-life setting of an academic 
department with multiple operators with no previous experience.

Methods A retrospective observational study was conducted including all consecutive cases performed in our 
department from April 2012 to October 2020. Over the study period, 31 different operators were involved. In April 
2012, 2 surgeons were trained by an experienced urologist. The 29 others learned the technique progressively with the 
help of the first 2 surgeons (surgical mentoring).

Results A total of 1259 patients were included. Preoperatively, the mean prostate volume and Qmax were 82.3 g 
and 9.4 mL/s, respectively. The mean operative time was 79.7 min. The intraoperative complication rate was 5.6% 
(n = 71), with the need for conversion being 0.6%. Postoperatively, the complication rate was 18.6% (n = 234). Surgeon’s 
experience reduced the perioperative complication rates (P = 0.01), operative time (P < 0.001), and length of hospital 
stay (P < 0.001), but the difference in blood transfusion rate was statistically non-significant (P = 0.3).

Conclusions Most of the 31 urologists in training were able to master HoLEP progressively, with good functional 
outcomes and acceptable complication rates. Supervision by trained urologists was critical for the safe dissemination 
of the technique in our department.

Introduction

Holmium laser enucleation of the prostate (HoLEP) is recommended by the main international guidelines for the 
surgical management of benign prostatic hyperplasia (BPH), regardless of prostate volume[1,2]. In addition to 
having been evaluated in several randomized controlled trials against monopolar transurethral resection of the 
prostate (mTURP) and open prostatectomy (OP), HoLEP has been shown to provide long-term functional outcomes 
(flowmetric and quality of life data) that ensure the durability of the improvement in urinary symptoms.

If the functional outcomes were more or less similar to those of mTURP[3,4] or OP[5,6], the main advantages 
of HoLEP were reduced perioperative bleeding, catheterization time, and length of hospital stay[7,8]. For all these 

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reasons, HoLEP has become a recommended surgi-
cal alternative to TURP and OP, regardless of prostate 
size. However, its steep learning curve has considerably 
slowed the spread of this technique since it was first 
described in 1998[9].

The objective of this retrospective study was to 
describe the clinical outcomes of HoLEP in the real-life 
setting of an academic department involving multiple 
operators who had no previous experience with HoLEP 
and limited experience in endoscopic surgery.

Materials and Methods
Study population
A single-center retrospective observational study was 
performed with consecutive patients who underwent 
HoLEP between April 2012 and October 2020 in a high-
volume center (180 to 200 HoLEP interventions per 
year). All procedures were performed by 31 different 
urologists. In April 2012, 2 surgeons were trained by an 
experienced urologist from another center and became 
expert surgeons in our academic hospital. Then each 
year, 3 to 4 new surgeons have learned the technique 
progressively, with the mentorship of the first 2 trained 
surgeons over a period of 2 years.

A surgeon was considered an expert when he or 
she had performed at least 50 successful procedures as 
defined in the study by Robert et al.[10]: a combination 
of complete enucleation and morcellation, within less 
than 90 min, without any conversion to TURP, with 
acceptable stress and difficulty.

At the start, mentoring began with the observation of 
approximately 10 procedures carried out by an expert, 
followed by 10 HoLEP performed by the trainee itself 
under the supervision of the expert surgeon. Then, the 
trainee performed HoLEP autonomously, starting with 
easy cases (prostate volume 50 g to 80 g, no anticoag-
ulant therapy) and progressively undertaking more 
complicated cases. At the end of their 2-year training, 
the operators had performed between 20 and 40 proce-
dures on their own.

All included patients received oral and written infor-
mation explaining the principles of the procedure and 
its main complications and provided consent for data 

collection and analysis. This study was approved by  
the local ethics committee before data extraction and 
analysis.

HoLEP: equipment, technique, and follow-up
The procedure was performed in the operating room 
under general anesthesia or spinal anesthesia.

The equipment used included a 100 W holmium:YAG 
laser generator (LUMENIS), with a 550 m fiber, a 
26 Fr resectoscope, and a Versacut morcellator (KARL 
STORZ).

The surgical technique of enucleation has evolved over 
the last 8 years from the original technique described by 
Gilling in "two or three lobes"[11] to a so-called "en bloc" 
technique[12].

At the end of the surgery, a 2-way bladder catheter 
was placed with continuous saline irrigation for a few 
hours. The bladder catheter was usually removed the 
next morning in the urology department or at home if 
the patient was already discharged.

Postoperative follow-up also evolved over time. 
During the first 3 years, follow-up check-ups were 
scheduled at 3, 6, 12, and 24 months postoperatively. 
Subsequently, follow-up was done only 3 months post-
operatively.

Statistical analyses
Data analysis was performed using R software (version 
4.0.0). The significance level was set at 0.05 for all 
statistical tests, and P-values were 2-sided. Continuous 
variables were reported as means and standard 
deviations (SDs) or medians and interquartile ranges 
(IQRs), whereas categorical variables were reported as 
frequencies and proportions. Student t test and Mann-
Whitney U test were used for continuous variables. 
The chi-square test and Fisher exact test were used for 
categorical variables.

Results
During the study period, 1174 patients were operated on 
by 31 different urologists. Preoperative characteristics 
are described in Table 1. The mean age was 70.7 ± 8.6 
years. At the time of preoperative consultation, the rate 
of AUR was 27.7% (n = 326), and 27.9% (n = 320) of the 
patients had an indwelling urinary catheter at the time 
of surgery. At the time of surgery, 78.9% of patients 
(n = 926) received at least 1 drug treatment indicated for 
lower urinary tract symptoms (LUTS), and a previous 
history of surgical treatment for LUTS/BPH was 
retrieved in 49 (4.1%) patients.

Perioperative data are reported in Table 2. The over-
all perioperative complication rate was 6%, and 8 (0.7%) 
procedures required conversion (7 to TURP and 1 to 

Abbreviations 
BPH benign prostatic hyperplasia
HoLEP holmium laser enucleation of the prostate 
mTURP monopolar transurethral resection of the prostate
OP open prostatectomy
UI urinary incontinence

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OP). A total of 330 patients (28.2%) had a day-case proce-
dure (LOS < 12 h according to the French requirements 
for day-case procedures).

Regarding surgeon experience, the peri- and post-
operative complication rates were lower in the hands 
of experienced surgeons (Table 3 and Supplementary 
Online Appendix S1). The same applies to the operative 
time, but not blood transfusion rates.

Regarding other factors that may influence perioper-
ative outcomes, the perioperative complication rate was 
higher in patients on antiplatelet therapy. The operative 
time was higher among patients with prostatic weight 
≥ 100 g, anticoagulant therapy, and preoperative urinary 
catheters. Anticoagulant and antiplatelet therapy and 
preoperative urinary catheterization increased the post-
operative complication rate. The blood transfusion rate 
was higher in patients with prostatic weight ≥  100  g, 
anticoagulant therapy and preoperative urinary cath-

FIGURE 1.  
Evolution of functional outcomes between preoperative and 3, 6, 12, and 24-month follow-up visits

IPSS: International Prostate Symptom Score; IPSS-Q8 : question 8 of the IPSS; PSA : prostate-specific antigen; Qmax: maximum urinary flow rate;  
PVR: post-voiding residual urinary volume; IIEF-5: 5-items International Index of Erectile Function; ns = P > 0.05; = P < 0.001; = P < 0.0001

0.0

2.5

5.0

7.5

10.0

12.5
IPSS-Q8IPSS

0

10

20

30

40

50

3 mo
nths

6 mo
nths

12 m
onth

s
24 m

onth
s

Preo
pera

tive

PSA Qmax

0

10

20

30

40

50

3 mo
nths

6 mo
nths

12 m
onth

s
24 m

onth
s

Preo
pera

tive

0

10

20

30

40
nsns

nsns
nsns

nsns

3 mo
nths

6 mo
nths

12 m
onth

s
24 m

onth
s

Preo
pera

tive
3 mo

nths
6 mo

nths
12 m

onth
s
24 m

onth
s

Preo
pera

tive

IIEF5

0

20

40

60

80

3 mo
nths

6 mo
nths

12 m
onth

s
24 m

onth
s

Preo
pera

tive

PVR

0

200

600

400

800

3 mo
nths

6 mo
nths

12 m
onth

s
24 m

onth
s

Preo
pera

tive

eterization. The LOS was higher in the anticoagulant, 
antiplatelet and urinary derivation catheter groups.

Concerning functional results (Figure 1 and Supple-
mentary Online Appendix S2), there was a significant 
improvement in Qmax (+14.2 mL/s) (P < 0.001) and IPSS 
(-14 points) (P < 0.001) at 6 months. These results were 
maintained over time since the median IPSS at 3 years 
was 4, an improvement of 15 points. Regarding sexual 
function, the mean IIEF5 score at 6 months was 12 ± 8.2 
and appeared to remain stable over time.

The rate of urinary incontinence (stress and urgency) 
requiring protection was 11.6% at 3 months and 3.8% at 
6 months.

Discussion
As noted, several RCTs have proven the superiority of 
HoLEP over mTURP and OP regarding perioperative 
bleeding, duration of catheterization, and length of 

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TABLE 1. 

Preoperative characteristics of the study population 

Preoperative data n = 1174 Values

Age, years 1174 70.7 ± 8.6

BMI (kg/m2) 1081 26.3 ± 4.1

ASA score 1113 2 [2–2]

Antiplatelet therapy

1174

310 (26.4)

Monotherapy 282 (90.9)

Bitherapy 28 (9)

Curative anticoagulant therapy

1174

141 (12)

Vitamin K antagonists 84 (60)

New oral anti-coagulants 54 (38.6)

Low molecular weight heparins 2 (1.4)

BPH complications (≥ 1 complication)

1174

510 (43.4)

AUR 326 (27.7) 

Infection 173 (14.7)

Bladder stones 27 (2.3) 

BPH treatment (≥ 1 oral treatment) 926 (78.9)

Alpha blocker

1174

850 (91.6)

5ARI 219 (23.6)

Phytotherapy 240 (25.8)

PDE5I 16 (1.7)

Monotherapy 496 (53.6)

Bitherapy 404 (43.6)

Tritherapy 26 (2.8)

History of BPH surgery

1174

49 (4.1)

TURP 28 (57.1)

OP 4 (8.1)

Greenlight 6 (12.2)

HoLEP 6 (12.2)

PAE 3 (6.1)

Urolift 2 (4.1)

Prostatic weight (g) 1056 84.5 ± 43.5

PSA (ng/mL) 916 6.8 ± 9.4

Qmax (mL /min) 635 9.5 ± 4.6

PVR (mL) 631 150.5 ± 188.4

IPSS 626 19 [13–23]

IPSS Question 8 699 5 [4–6]

IIEF5 459 13.7 ± 8.3

Indwelling urinary catheter at  
the time of surgery

1143 320 (27.9)

Values expressed as mean (SD), median [interquartile range] or n (%).
BMI: body mass index; ASA: American Society of Anesthesiologists;  
BPH: benign prostatic hyperplasia; AUR: acute urinary retention;  
PAE: prostate artery embolization.

TABLE 2. 

Perioperative characteristics of the study population 

Perioperative outcomes n = 1174 Values

Surgical technique
1174 1174 (100)

Complete prostatic enucleation

Hospitalization

1174

1174 (100)

Conventional 841 (71.8)

Day-case 330 (28.2)

Perioperative complications

1174

71 (6)

Capsular perforation 23 (32.4)

Bladder injury 15 (21.1)

Other  
(Equipment failure. Ureteral meat coagulation  
significant bleeding. Negative input-output) 

33 (46.5)

Conversion

1174

8 (0.7)

TURP 7 (87.5)

OP 1 (12.5)

Operative time (min) 1079 83.2 ± 40.9

Irrigation (L) 882 27.6 ± 14.7

Delivered energy (kJ) 997 105.7 ± 63.6

Resected weight (g) 1151 50.1 ± 36.6

Postoperative outcomes n Values

Postoperative complications

1174

227 (19.3)

Clavien-Dindo 1–2 207 (91.2)

Clavien-Dindo ≥ 3 20 (8.8)

Blood transfusion 1174 52 (4.4)

Postoperative lengths of hospital 
stay (excl. the day before surgery) 1148 1.6 ± 3.1

Values expressed as mean (SD) or n (%).

hospital stay, but its steep learning curve has slowed its 
widespread adoption over the last decade[6–8].

In our cohort, the mean LOS (1.6 nights after surgery) 
was similar to that reported in major meta-analyses 
of randomized clinical studies (1.1 to 2.4 nights after 
surgery)[3,7]. Our results confirm that, in a non-
selected patient population operated on by a high 
number of surgeons with or without experience in the 
technique, the reduction of hospital stay remains a clear 
advantage of the HoLEP technique. Nonetheless, we 
observed a significantly longer hospital stay for patients 
of inexperienced surgeons (2.1 versus 1 for experts; 
P  <  0.001) that was balanced by a high proportion of 
day-case surgeries (28.2%) performed mainly by expert 
surgeons.

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Significant perioperative bleeding resulting in post-
operative blood transfusions was observed in 4.4% of 
patients in our cohort. This transfusion rate is higher 
than the one reported in meta-analyses of randomized 
studies. Indeed, in a meta-analysis of 4 randomized 
trials comparing HoLEP to TURP, Tan et al. reported a 
0% transfusion rate[3]. This difference may be explained 
by strict patient selection in RCTs often excluding 
patients receiving anticoagulant therapy. The percent-
age of patients undergoing antiplatelet or anticoagulant 
therapy was not specified in this meta-analysis.

In a recent multicenter study that investigated factors 
influencing perioperative blood loss after HoLEP, the 
transfusion rate was 5%[13]. In this study, 26.4% and 

TABLE 3.

Perioperative outcomes depending on surgical experience, prostatic weight, anticoagulant therapy, 
antiplatelet therapy and indwelling urinary catheter

Overall 
cohort

Surgeon 
experience
expert vs 

 in-training

Prostatic weight
≥ 100 g vs < 100 g

Anticoagulant 
therapy

Yes vs No

Antiplatelet 
therapy

Yes vs No

Indwelling urinary 
catheter

Yes vs No

n = 1174
Expert
n = 511

P -valuea ≥ 100 g
n = 313

P -valueb Yes
n = 141

P -valuec Yes
n = 310

P -valued Yes
n = 320

P -valuee

Perioperative  
complications

71 (6) 21 (4.2) 0.01 24 (7.6) 0.2 7 (5) 0.5 29 (9.3) 0.004 25 (7.8) 0.1

Operative  
time (min)

83.2 ± 
40.9

71.4 ± 
34.3

< 0.001
103.9 ± 

44.3
< 0.001

88.8 ± 
42.8

0.03
81.3 ± 
40.2

0.3
96.5 ± 
45.5

< 0.001

Resected  
weight (g)

50.1 ± 
36.6

51.4 ±
35.8

0.2
83.4 ± 
44.5

< 0.001
51.3 ± 
34.8

0.7
44.6 ± 
32.6

0.002
65.8 ± 
46.9

< 0.001

Resected  
percentage  
(%)

60.8 ± 
25.4

62.4 ± 
23.8

0.07

Postoperative 
complications

227 
(19.3)

82 (16) 0.01 65 (20.7) 0.5 42 (29.8) < 0.001 85 (27.4) < 0.001 97 (30.3) < 0.001

Blood  
transfusion

52 (4.4) 19 (3.7) 0.3 23 (7.3) 0.001 15 (10.6) < 0.001 19 (6.1) 0.08 30 (9.3) < 0.001

Length of  
hospital stay

1.6 ± 3.1 1 ± 2.4 < 0.001 1.5 ± 1.9 0.8 3.3 ± 6.8 < 0.001 1.8 ± 2.2 0.05 2.4 ± 4.6 < 0.001

Values expressed as mean (SD), median [interquartile range] or n (%).
a P-value vs. in training; b P-value vs. < 100g; c P-value vs. no anticoagulant; d P-value vs. no antiplatelet; e P-value vs. no indwelling catheter

12% of patients were on antiplatelet and anticoagulant 
therapy, respectively. These results are very close to ours, 
considering that we also included 25.9% and 11.5% of 
patients undergoing antiplatelet and anticoagulant ther-
apy, respectively. Regarding perioperative bleeding and 
transfusion rates, our results also confirm the safety of 
the HoLEP technique performed by a high number of 
surgeons, with and without experience, in a non-selected 
population of patients.

The short-term (3 to 6 months) and long-term 
(>  5  years) functional outcomes of HoLEP have been 
widely described in the literature. Meta-analyses 
comparing HoLEP with TURP or OP found no differ-
ence between the techniques for flowmetric data (Qmax 
and RPM) or IPSS.

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In our study, we observed a 14- to 16-point decrease 
in IPSS at 3 and 6 months, respectively. Similarly, Qmax 
was improved by 13.4 to 14.2 mL/s at 3 and 6 months, 
respectively.

The HoLEP technique performed by a high number of 
surgeons, with and without experience, in a non-selected 
population of patients produced results similar to those 
reported in meta-analyses. In RCTs, the improvement 
in IPSS varied between 16 and 20 points at 6-month 
follow-up, and Qmax varied from 14 to 18 mL/s[14–16].

Even when follow-up after 6 months was avail-
able for a minority of patients, the improvement in 
IPSS remained stable over time in our cohort, with a 
median IPSS of 4 at 3-year follow-up, similar to the score 
reported in other publications with longer follow-up 
periods[4,17,18].

Urinary incontinence (UI) (stress or urgency) is the 
main functional complication described after HoLEP, 
with a rate varying from 4% to 17% at 3 months[19–22] 
and from 4% to 5% at 6 months[20–22]. The defini-
tion of UI in our study was based on the International 
Continence Society (ICS) definition: "the complaint of 
any involuntary loss of urine from the urethra"[23]. The 
results observed in our series at 3 months are slightly 
higher than those observed in the literature, with a UI 
rate of 22.9%. However, the results at 6 months (6.4%) 
are consistent with those described in the previously 
cited studies.

There is a chance that the higher rate of UI at  
3 months observed in our series could be explained by 
the high number of inexperienced surgeons involved, 
as the impact of the surgeon's experience on the rate 
of UI has been reported in several studies in recent 
years[21,22,24].

In a multicenter retrospective study including 39 
surgeons and 1113 patients, Shigemura et al. evaluated 
how surgeon experience affected outcomes including 
continence after HoLEP[22]. The surgeon's experience 
(from 20 procedures) was associated with a significantly 
reduced the rate of UI at 3 months, as the more expe-
rienced surgeon paid more attention to the prostatic 
apex than an operator at the beginning of his or her 
training. This threshold is also described in the study 
of Houssin et al., in which the UI rate at 3 months was 
significantly lower in multivariate analysis for surgeons 
who had performed 20 procedures[21]. Similar results 
were reported in the prospective study by Elshal et 
al., in which they reported the functional results 
and the various perioperative and remote complica-
tions of the first 313 HoLEP procedures performed by  
3 surgeons. The rate of UI at 3 months decreased signifi-
cantly (8.7% vs. 23.3%) after the surgeon had completed  
20 procedures[24].

In our experience, only 4 patients (0.3%) with 
persistent UI required surgical management. Although 
these results should be interpreted with caution because 
of the limited data available and the relatively short 
follow-up (26 months), the literature review also shows a 
rate of surgical treatment for persistent UI under 1%[25].

One of the obstacles to the diffusion of the HoLEP 
technique over the last decade was said to be its long 
and steep learning curve. It has been clearly demon-
strated that HoLEP requires significant experience and 
endoscopic skills, and the advantages of the technique 
increase with the experience of the surgeon[18,26].

Our series also confirmed that the surgeon's expe-
rience plays a role in terms of perioperative results 
(perioperative complications, transfusion rate, and LOS) 
and in terms of remote functional results. However, 
even though results were better for expert surgeons, 
our cohort, with a high proportion of novice opera-
tors (< 30 surgeries) confirmed clinical results close to 
those published in RCTs. Conversion to mTURP or OP 
was necessary in only 0.7% of cases (n = 8), and major 
complications requiring re-intervention (Clavien-Dindo 
≥ 3) were seen in only 20 patients (8.8%).

Structured mentoring and supervision by an expert 
surgeon were critical in our experience, as previously 
described by Peter Gilling. The inventor of the technique 
divided the learning curve in 2 phases: a "mentoring" 
phase and a consolidation phase[27].

The importance of support at the beginning of the 
experience has already been underlined in a previous 
publication by our group[10]. In a prospective multi-
center observational study without structured mento-
ring during the early phase of the learning curve, we 
looked at the success of the procedures. Successful 
completion was defined as enucleation and morcellation 
in less than 90 min without conversion to TURP. One 
out of 3 surgeons included in this study dropped out 
before the twentieth procedure. The remaining surgeons 
were able to complete the procedure in only 44% of the 
cases according to the criteria mentioned above.

Apart from the biases linked to the retrospective 
nature of this work, its main limitation is the large 
number of patients lost to follow-up after the 6-month 
visit, which did not allow us to evaluate the long-term 
results of our cohort.

The main strength of this study is the representa-
tiveness of the results in a non-selected population of 
patients with multiple surgeons (real-life setting) reflect-
ing what could be expected when implementing the 
HoLEP technique in other urology departments.

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Conclusion
With 1174 patients and 31 urologists involved in a 
retrospective analysis of our experience, we were able to 
confirm that HoLEP can be progressively mastered by 
most urologists in training over a 2-year period, with 
good functional outcomes and acceptable complication 
rates close to those reported in previously published 
RCTs. In our experience, supervision of trainees by 
expert surgeons seemed to be critical for the safe 
adoption of the technique.

Acknowledgements
Author Disclosure
C. Klein, T. Marquette, G. Capon, E. Alezra, JC. 
Bernhard, P. Blanc, V. Estrade, F. Bladou : no competing 
interests.

G. Robert: HoLEP proctor for EDAP/TMS.

Author Contributions
C.K.: Data collection, data analysis, article writing. T.M.: 
Data collection, data analysis. G.C.: Critical revision of 
the article for important intellectual content. E.A.: Data 
collection. P.B: Data collection. V.E: Data collection. 
J.C.B.: Critical revision of the article for important 
intellectual content. F.B: Critical revision of the article 
for important intellectual content. G.R.: Protocol 
development, data analysis, article writing.

17SIUJ.ORG SIUJ  •  Volume 4, Number 1  •  January 2023

Implementing HoLEP in an Academic Department With Multiple Surgeons in Training: Mentoring Is the Key for Success

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ORIGINAL RESEARCH

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