Comparison of enucleation efficiency of HoLEP with the early apical release ‘En Bloc’ technique between the learning curve period and after becoming proficient in HoLEP

Objective: To compare prostate enucleation efficiency using Holmium laser (HoLEP) with the early apical release ‘En Bloc’ technique between a learning curve and experienced group and to evaluate factors required to ensure proficiency. Materials and Methods: A retrospective analysis was conducted on 120 patients diagnosed with benign prostatic hyperplasia (BPH) who underwent En Bloc HoLEP with early apical release by a single surgeon (CL) at Thammasat University Hospital between January 2019 and December 2023. The primary outcome was a comparison of enucleation efficiency (EE). EE was calculated by dividing the weight of enucleated prostatic tissue (g) by the enucleation time (min). Secondary outcomes were hematocrit (Hct) change, one-month postoperative maximum urine flow rate (Qmax), International Prostate Symptom Score (IPSS) reduction, catheter time (CT; day), length of hospital stay (LOS; day), morcellation efficiency (ME; calculate by dividing enucleated tissue weight (grams) by the morcellation time) and post-operative stress urinary incontinence (SUI) occurrence. The 120 cases were divided into a learning curve group of 60 cases and an experienced group of 60 cases. Mean EE & ME, post-operative Hct change, IPSS reduction, Qmax, CT, LOS and post-operative SUI were compared. Results: The median (IQR) prostate weight in the learning curve group vs the experienced group was 66 (50.5-101) g vs 69 (50-95) g. Demographic and clinical data differed significantly between groups. Mean EE was significantly different between the learning curve group vs the experienced group (0.76 g/min vs 0.92 g/min (p = 0.021), respectively) after experience of 60 cases. Mean CT and LOS were decreased in the experienced group. Mean ME improved slightly but was not statistically significant. Conclusion: The number of cases required to become proficient at the early apical released En Bloc technique of HoLEP is 60 cases.