Introduction: Holmium laser enucleation of the prostate (HoLEP) has a steep learning curve, which limits widespread adoption. Objective metrics to define surgical proficiency, efficiency, and perceived workload remain underexplored outside academic institutions. This study aimed to characterize the learning curve of HoLEP from one single surgeon at an ambulatory surgical center. Methods: A total of 103 patients underwent HoLEP for BPH between March 2024 and August 2025. Surgical cases were stratified into 3 sequential groups of 34, 34, and 35 cases, respectively, based on operative chronology. Operative characteristics were compared across groups: enucleation time, laser energy, fluid use, and enucleation speed (enucleation time/specimen weight). Perceived workload was assessed using the NASA Task Load Index (NASA-TLX) to evaluate perceived workload across several “performance” domains (mental demand, physical demand, temporal demand, performance, effort, and frustration). Comparisons of outcome metrics were made for 90-day postoperative complications. Urinary continence outcomes were evaluated at 1 week, 1 month, and 3 months postoperatively. Univariable and multivariable multinomial logistic regression analyses were performed to examine associations between surgical characteristics and group classification. Results: Progressive improvement was observed in operative time, enucleation time, laser energy, total fluid, enucleation speed, and NASA TLX, as seen in Table 1 . No statistically significant associations were observed between group classification and 90-day postoperative complications or urinary continence outcomes at any follow-up interval. In multivariable multinomial logistic regression analysis, the NASA-TLX score (OR 0.83, 95% CI, 0.70–0.98, p = 0.02) remained an independent predictor of higher learning curve classification. ( Table 2 ). Table 1. Comparison of Baseline Characteristics among Surgical Category Groups Baseline characteristics 1st group ( N = 34) 2nd group ( N = 34) 3rd group ( N = 35) Age at surgery (yr) 71 (63.2–75.8) 70 (65.2–76.8) 70 (66.5–75) Had Urinary Retention, n (%) 12 (37.5%) 8 (24.2%) 15 (42.9%) Prior BPH Surgery, n (%)* 4 (11.8%) 2 (6.2%) 9 (34.6%) AC/AP, n (%) 14 (41.2%) 14 (45.2%) 11 (32.4%) BMI (kg/m²) 28.5 (25–31.8) 28.1 (24.8–30.6) 30.3 (27.3–32) ASA Class I/II/III, n (%) 1 (3%)/11 (33.3%)/21 (63.6%) 1 (2.9%)/17 (50%)/16 (47.1%) 0 (0%)/13 (37.1%)/22 (62.9%) HTN, n (%) 25 (73.5%) 20 (58.8%) 25 (71.4%) DM, n (%) 5 (15.6%) 8 (23.5%) 10 (28.6%) PSA (ng/mL)* 3.48 (1.61–5.68) 3.35 (2.71–5.55) 1.67 (0.75–4.52) PSAD (ng/mL/cc) 0.03 (0.03–0.07) 0.05 (0.03–0.09) 0.04 (0.02–0.06) Bold values indicate statistical significance at p < 0.05. Continuous variables are reported as medians with interquartile ranges. Categorical variables as n (%). Percentages and medians are based on non-missing data; denominators may vary slightly where values were missing. *Statistically significant difference between groups ( p < 0.05; Kruskal–Wallis test for continuous variables, chi-square test for categorical variables). Table 2. Comparison of Surgical Parameters among Surgical Category Groups Surgical parameters 1st group ( N = 34) 2nd group ( N = 34) 3rd group ( N = 35) Had previous urinary retention/Foley catheter 12 (35.3) 9 (25.7) 14 (41.2) Had anticoagulation/antiplatelet 14 (41.2) 15 (42.9) 10 (29.4) Prostate Size 71 (50–136) 71.8 (50–110) 50 (40–71.7) Estimated blood loss (mL) 50 (20–100) 50 (20–75) 35 (20–62.5) Operative Time* (min) 74 (59.5–93.5) 65 (49–82) 54 (42.7–68) Enucleation Time* (min) 46.5 (33.7–61.5) 35 (28–51) 34 (26–42) Hemostasis time (min) 6 (4–10) 6 (3–10) 3.5 (2–7) Specimen weight (g) 45.8 (28.2–77.7) 47.2 (24.3–100.5) 30.8 (16.7–42.7) Laser time (min) 28.8 (21.7–37.2) 24 (18–28) 22 (14.7–27) Laser Energy* (kJ) 162.4 (127.7–216.4) 134.2 (102.9–188.3) 124.2 (95.1–145.2) Morcellation time (min) 8 (3.5–15) 9 (4–12) 4.5 (2.7–8) Total Fluid* (L) 29 (21–42) 24 (18–30) 21 (18–28.5) Enucleation ratio (g/mL) 0.57 (0.49–0.76) 0.61 (0.43–0.83) 0.57 (0.39–0.72) Enucleation speed (g/min) 0.15 (0.10–0.20) 0.14 (0.10–0.23) 0.18 (0.11–0.26) Morcellation speed (g/min) 6.33 (4.9–9.94) 6.71 (4.33–9.18) 5.24 (3.7–7.8) NASA TLX* ( n = 25) 12.6 (9.8–22) ( n = 34) 9.3 (6.4–14.5) ( n = 19) 6.3 (5.3–11) Bold values indicate statistical significance at p < 0.05. Continuous variables reported as medians with interquartile range, and categorical variables are reported percentages. *Statistically significant differences between groups ( p < 0.05). Conclusions: Progressive reductions in operative time, energy use, and perceived workload signify quantifiable improvement over the first 100 cases in a community hospital, The NASA-TLX score remained independently associated with improvement in proficiency, outperforming traditional operative measures in defining the HoLEP learning curve.
Purpose: Bladder neck contracture (BNC) following anatomical endoscopic enucleation of the prostate (AEEP) occurs in approximately 3% of cases and carries high recurrence rates after standard endoscopic management. The Optilume drug-coated balloon (DCB) delivers paclitaxel at dilation but has not been reported for post-enucleation BNC. We describe the first such series following pulsed thulium laser enucleation of the prostate (p-ThuLEP). Patients and Methods: We retrospectively reviewed 10 consecutive patients with cystoscopically confirmed BNC after p-ThuLEP at a single high-volume center (IRB 2425566-1). All underwent laser enucleation of bladder neck scar followed by Optilume DCB dilation. Data were abstracted from the electronic health record. Results: Median age was 74 years (range 59–89). Median pre-p-ThuLEP prostate volume was 80 cc (range 36–100, n = 8). BNC presented at a median of 5.8 months after p-ThuLEP (range 2.7–12.0). A 36F balloon was used in nine patients and a 26F balloon in one, at 8 to 11 atm for 5 minutes. At a median follow-up of 5.2 months (range 0.9–15.1), no patient required reintervention (0% recurrence). Cystoscopy, performed in 5 of 10 on clinical indication, showed a patent bladder neck in all. Median post-procedure Qmax was 14.1 mL/s ( n = 7), and post-void residual was 23.5 mL ( n = 10). Thirty-day complications after Optilume occurred in two patients (20%), both Clavien–Dindo Grade II: gross hematuria with clot retention managed by continuous bladder irrigation and urinary tract infection. Conclusions: Optilume DCB following laser enucleation of post-p-ThuLEP BNC appears safe and feasible with encouraging short-term patency. Median follow-up (5.2 months) is shorter than the median interval to BNC presentation (5.8 months); thus, these short-term data do not establish durability. To the best of the authors’ knowledge, this is the first report of Optilume DCB outcomes for BNC specifically following AEEP. A prospective cohort trial with longer follow-up is warranted.
Introduction: Accurate assessment of stone burden is essential for clinical decision-making in urolithiasis. Although stone volume is considered a more accurate representation of stone burden than maximal diameter, most clinical practice continues to rely on linear measurements. The extent to which volumetric assessment is used in daily practice remains unclear. Therefore, this study aimed to evaluate current global practices in stone burden assessment and identify factors associated with the adoption of volumetric measurement. Materials and Methods: An international cross-sectional survey was conducted among practicing urologists. The questionnaire was distributed electronically to members of the Endourological Society, the European Association of Urology Endourology Section, and national urological societies across Latin America, Africa, and Oceania. The survey assessed preferred methods for stone burden measurement, perceived barriers to volumetric assessment, and willingness to adopt automated measurement tools. Multivariable logistic regression analysis was performed to identify predictors of volumetric measurement use. Results: A total of 252 urologists participated in the survey. Respondents were distributed across South America (32.9%), Europe (25.4%), North America (21.0%), Asia (9.9%), Central America (5.2%), Africa (5.2%), and Oceania (0.4%). Most respondents relied primarily on maximal stone diameter for clinical decision-making, although 51.6% reported incorporating volumetric assessment selectively depending on the clinical scenario. In multivariable analysis, perceived feasibility of volumetric assessment was the strongest predictor of volumetric measurement use (odds ratio [OR] 3.95, 95% Confidence Interval [CI] 2.28–6.86; p < 0.001), followed by academic practice (OR 1.87, 95% CI 1.03–3.38; p = 0.040). Fellowship training and years in practice were not independently associated with volumetric adoption. Conclusions: Despite increasing evidence supporting volumetric assessment, its use in routine clinical practice remains limited worldwide. Improving feasibility through automated or integrated measurement tools may facilitate broader adoption.
