Holmium Laser Enucleation of the Prostate: A Description of the Fundamental Skills

Introduction: In the landscape of surgical options for the treatment of benign prostatic hyperplasia (BPH), holmium laser enucleation of the prostate (HoLEP) has risen to the top. Despite its many advantages, HoLEP has not been widely adopted in the United States.1 Its slow adoption is multifactorial, largely because of its inherent difficulty and learning curve.2–4 The difficulty of learning HoLEP arises from the acquisition of fundamental surgical skills, grasping the steps of the procedure, and perseverance through challenging cases. The acquisition of surgical skills encompasses a complex interplay between motor and technical skills, both of which are refined over time with practice and feedback.5 Many have addressed the steps of HoLEP and other laser enucleation modalities; however, there is a paucity of resources directly addressing the fundamental skills required for surgical proficiency. Here we aim to address this gap within the literature. We aim to characterize and describe the fundamental skills of HoLEP and utilize video supplements to demonstrate these skills. Materials and Methods: We retrospectively reviewed surgical videos of two experts (M.R.H and S.M.C) performing HoLEPs. Examples of novice surgeons performing HoLEP were included for comparison. The fundamental skills of HoLEP were characterized from these videos. Surgical videos were obtained and used with patient consent. Our technique for HoLEP has previously been described.6,7 Results: We identified five fundamental skills for HoLEP: these include capsule identification, blunt dissection, laser dissection, joining planes, and hemostasis. There is a lack of resources highlighting the skills required to obtain proficiency when performing HoLEP. Checklists are helpful in learning the sequences of specific techniques but miss the mark when evaluating the core skills required to complete steps. Global domains or skills are more effective in evaluating proficiency, as they allow surgeons to be rated and discuss progress outside of the constraints of a specific technique. Conclusions: HoLEP is an effective and durable option for the surgical management of BPH. It has a steep learning curve and has suffered from slow adoption, in part, because of its inherent difficulty. Here we aim to characterize and describe the fundamental skills required for obtaining surgical proficiency. These include capsule identification, blunt dissection, laser dissection, joining planes, and hemostasis. Our study adds to the current bank of available educational resources by specifically identifying the skills needed for proficiency. This brief overview can provide learners and their mentors a framework for structured feedback. Furthermore, these may lay the groundwork for future metrics used to evaluate HoLEP practitioners. No competing financial interests exist. Runtime of video: 7 mins 48 secs Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.