Faculty: Tevita Aho, MD, Chandler Dora, MD and Nicole Miller, MD

Moderator: Amy Krambeck, MD


Tevita Aho, MD

Tev moved from New Zealand to Cambridge University Hospitals NHS Foundation Trust (CUH), UK in 2003. During his training in Tauranga, NZ he spent a year learning HoLEP from the urologists who invented it (Peter Gilling & Mark Fraundorfer).

In 2004, Tev introduced HoLEP at CUH where it rapidly became, and remains, the gold standard surgical treatment for male LUTS/retention. CUH was one of the first UK centres to offer HoLEP.

Tev is the most experienced HoLEP surgeon in the UK (> 2,200 procedures). He is frequently invited to lecture on HoLEP in the UK and abroad and has convened annual HoLEP courses at CUH since 2005. He has demonstrated live laser prostate surgery (including the world’s first thulium laser enucleation of the prostate) at more than 30 conferences throughout the world. He also has experience with other BPH procedures including laser vaporisation, urolift, rezum and aquablation.

Tev was the founding President of the UK Holmium User Group (HUG). He designed and implemented the national HUG Training Programme for HoLEP (a model which is now used internationally),  and has mentored many surgeons in HoLEP.

Tev has been involved in HoLEP research from its earliest days, and has published and presented widely on the subject.

 

Chandler Dora, MD

Assistant Professor of Urology Mayo Clinic in Florida

Attended medical school University of Miami

Completed residency at Mayo Clinic in Rochester 2005

First HoLEP January 2011

Current practice is BPH and stone disease with emphasis on HoLEP.

 

Nicole Miller, MD

Dr. Nicole Miller currently holds the position of Professor of Urology at Vanderbilt University School of Medicine in Nashville, TN.  She joined the department in 2007.  She completed her M.D. degree at the University of Pittsburgh School of Medicine in 2000, and received her urology residency training at the University of Virginia.  Dr. Miller went on to complete a 2 year fellowship in Endourology and Minimally Invasive Surgery at the Indiana University School of Medicine under the mentorship of Dr. James E. Lingeman.  She specializes in the medical and surgical treatment of kidney stone disease as well as laser surgery for BPH.  Dr. Miller’s research interests include investigation of Randall’s plaque in the pathophysiology of nephrolithiasis, new laser technologies for kidney stone and BPH treatment, novel platforms for BPH surgery and investigation of pathophysiologic pathways for refractory BPH/LUTS.  She has been the major contributor of transition zone prostate tissues from men undergoing surgery for refractory BPH/LUTS as part of Vanderbilt University’s Biorepository in the Center for Benign Urologic Diseases (CBUD) and has co-authored work on this developing resource. She has served as course faculty member and moderator both nationally and internationally for the American Urological Association and Endourological Society in the area of surgical treatment of BPH and nephrolithiasis.  Dr. Miller is an Editorial Board Member for the Journal of Urology, Journal of Endourology and Director of the Minimally Invasive Surgery and Endourology Fellowship at Vanderbilt University Medical Center. She also served as a member of the AUA guidelines panel for the Surgical Management of Nephrolithiasis and AUA Leadership Class of 2017. 

 

Amy Krambeck, MD

Dr. Amy E. Krambeck is a Professor of Urology and Co-Director of the Division of Endourology at Northwestern Medicine in Chicago, Illinois. She graduated Summa cum laude from the University of Missouri-School of Medicine, completed her Urology residency at Mayo Clinic in Rochester, MN, and fellowship at the Kidney Stone Institute in Indianapolis, Indiana. Dr. Krambeck’s practice focuses on the metabolic and advanced surgical management of urinary stone disease and is a world renowned experience in Holmium Laser Enucleation of the Prostate (HoLEP). She has received several awards throughout her career including the Mayo Clinic Distinguished Fellow Award, the University of Missouri Outstanding Young Physician Award, the Indiana University Health Center Leadership Award, and the Arthur Smith Award for Excellence in Endourology. Dr. Krambeck is passionate about providing the highest quality of care with kindness and compassion.

 

Webinar Transcript

Dr. Amy Krambeck:

Hello. My name is Amy Krambeck, and I am professor of urology at Northwestern University in Chicago, Illinois, and welcome to the Endourology Society and Society of Urologic Robotic Surgeons Masterclasses in Endourology and Robotics webinars series. The Masterclass in Endourology and robotics series is a CME activity. The purpose of the activity is to provide our attendees an online program dedicated to surgical techniques in endourology and robotics. The target audience is physicians who specialize in endourology and robotics and all aspects of minimally invasive therapies. The objectives of the series are to identify specific examples of different technologies, the critical steps in the techniques, the differences in application and how to avoid and minimize complication.

Dr. Amy Krambeck:

As I stated before, this is accredited. After the webinar, you will receive a survey from Michelle Paoli, and it's important to complete this for your CME credit. Today's event is Overcoming the Enucleation Learning Curve; Which Educational Method is Best? I will be your host today, and we are joined by three excellent faculty physicians. The first physician is Dr. Dr. Chandler Dora. He is assistant professor of urology at Mayo clinic in Florida. He attended medical school in the University of Miami and completed his residency at Mayo Clinic in Rochester in 2005. He was actually my senior resident and he was wonderful. He did his first HoLEP in January of 2011, and he is 100% self-taught. It will be great to get his perspective.

Dr. Amy Krambeck:

His current practice is BPH and stone disease with an emphasis on HoLEP. Our second presenter will be Dr. Dr. Nicole Miller. She is professor of urology at Vanderbilt University School of Medicine in Nashville. She joined the department in 2007. She completed her medical degree at the University of Pittsburgh School of Medicine in 2000, and received her urology residency training at the University of Virginia. She did a two-year fellowship with Dr. Lindeman at Indiana University, and she specializes in the medical and surgical treatment of kidney stones as well as BPH. She's exceptionally well-known for her work in the field of BPH and stone disease, and she's an editorial board member for the Journal of Urology, Journal of Endourology, and director of the minimally invasive surgery and endourology fellowship at Vanderbilt.

Dr. Amy Krambeck:

Welcome, Nicole. I look forward to your talk. Our third presenter's Tev Aho. Tev moved from New Zealand to Cambridge University Hospital in NHS Foundation Trust in the UK in 2003. During training in New Zealand, he spent a year learning from the godfather of HoLEP, Dr. Peter Gilling. Tev is the first and most experienced HoLEP surgeon in the UK. He's performed over 2,000 procedures, and he was the founding president of the UK Holmium User Group, or HUG. This group is used to implement training for HoLEP and it's used throughout Europe, and I think that Tev will bring an interesting perspective on a different way to teach enucleation as it's been widely adopted throughout the European nations. Welcome all, and we will get started with Dr. Dora's talk on self-taught HoLEP.

Dr. Chandler Dora:

First of all, I'd like to thank the Journal of Endourology for hosting this event, and Dr. Krambeck for inviting me to be on the panel. I have fond memories of working with Dr. Krambeck back in residency and we've kept in touch since then. I'd also like to thank the attendees for taking time out of their busy schedule to listen to our presentations. As Dr. Krambeck said, I'm Dr. Chandler Dora. I started doing HoLEP back in January of 2011. I actually started with holmium laser ablation of the prostate, and I used that to become familiar with the wavelength and how it interacted with the tissues, and then I started branching out and making incisions and doing poor man's enucleations with the ablation.

Dr. Chandler Dora:

Eventually I became intrigued with HoLEP and I requested an observership at Indiana University for a day where I observed two cases. I then scheduled two cases of my own and requested a proctor, and Dr. Akhil Das from Thomas Jefferson University came and proctored me for my first two cases. After that, I took the training wheels off and I started doing HoLEP. I was in private practice until 2018, and now I work here at Mayo Clinic, Florida. I'm actually not in that nice atrium you see behind me, but I'm in a little cubicle here in this building. Disclosure, I have done some speaking and conducted some observerships for Lumenis. The objective today is to give the self-taught learner of HoLEP encouragement and strategies to overcome the learning curve.

Dr. Chandler Dora:

The question is what are the methods of learning HoLEP? The title of this webinar is Overcoming the Enucleation Learning Curve; Which Method is Best? I will go ahead and concede to my fellow panelists that the fellowship method is best. There's no doubt about it. One or two year immersion in HoLEP would be the best way to prepare the learner for success in HoLEP, including complex anatomy and more advanced cases. Fellowship and mini fellowship allow for hands-on participation in surgery by the mentor and the mentee. Also, the fellow is able to participate in the preoperative evaluation, surgery, and postoperative care and longitudinal fellowship over the course of a year or two, which is ideal. But if that's the only path to learning HoLEP, we exclude the majority of urologists who did not elect a fellowship immediately after residency.

Dr. Chandler Dora:

Shouldn't the patients of those existing practitioners benefit from having HoLEP in their community? Other paths include proctoring where the teacher observes but cannot intervene, observerships which are [inaudible 00:06:53] or what I jokingly call the monastic approach, which is what I did where you read about HoLEP, watch videos, and then eventually just start implementing it into your practice on live patients. What does the literature tell us about learning HoLEP? There was a systematic review which looked at 24 cases on the HoLEP learning curve and establish the learning curve as 25 cases in a structured mentorship and 50 cases in a non-mentored environment. But interestingly, one of the parameters that they looked at in that study was whether there was a mentor present.

Dr. Chandler Dora:

In roughly half of those studies, there was no mentor presence. That leads me to conclude that there are quite a few people out there that are learning through self-taught means. But my sense is that it's distinctly unusual in the US to learn HoLEP outside of a fellowship setting. Why is self-taught HoLEP so unusual in the US? I'll get to that in a moment. If you are learning HoLEP through self-taught means, what benchmarks can you use to determine if you're progressing along your learning curve or have achieved proficiency? I like this trifecta concept that's been promoted in a paper by Peyronett et al. If you can perform a HoLEP consistently in 90 minutes or less, including the enucleation and morcellation, and you can complete four consecutive cases without converting to TURP, then you are proficient.

Dr. Chandler Dora:

I also looked, when I was learning, at my own enucleation ratios, which I think is very important. I knew if I had a man who had 100 ml prostate and I get the pathology report back and it only shows 20 grams, that I whiffed on some tissue and did a subtotal enucleation. I also wanted to emphasize that it's amazing how many men come in with an MRI because they've recently undergone evaluation for elevated PSA or prostate biopsy that turned out to be benign. You can leverage that information. I'd encourage you to leverage that information. A lot of the imaging software that comes along with the disc, you can use to calculate a surface area of each slice, the transition zone only.

Dr. Chandler Dora:

Then you can multiply that by a slice thickness and add those together and get an exact transition zone volume. Really, your enucleation ratio, if you're looking at just the transitions zone volumes, should almost be one-to-one. For barriers to self-taught implementation, I wanted to focus mainly on what I think is probably the most significant barrier to self-taught learning in the US, and that is medical legal. Credentialing and professional liability coverage in the US is very specific to facilities and is not transferable. Even if a urologist here in Jacksonville down the street wanted to learn HoLEP, I cannot touch the patient or the scope if I think that the learner is proceeding in an incorrect plane or getting into trouble.

Dr. Chandler Dora:

I believe this creates a huge barrier to disseminating new techniques and doesn't necessarily accomplish its intended role of protecting the patient. Other more minor barriers would be equipment purchase, institutional inertia or historical inertia for other types of BPH procedures. Sometimes the personnel in the room is so accustomed to one particular procedure like TURP that they're resistant to learning new things. The other thing is obviously patient volume. How do you overcome this? The medical legal barriers are difficult to overcome. You have to have fairly steely nerves as a proctor to teach someone HoLEP without having the ability to physically intervene if you think they're getting into trouble. For equipment, I would make use of your vendors.

Dr. Chandler Dora:

You can demo lasers, you can demo the morcellator, and the vendors are typically very good about instructing the room personnel on how to use them. Absolute case numbers are important for learning curve, that 25 to 50 number, but the time in between cases is important as well, which has been written about by Dr. Lerner and others. To accumulate sufficient cases over reasonable timeframe, you may have to abandon other modalities that you currently like. If you're doing a green light here and a bipolar chirp there, and then maybe this guy is good for HoLEP, you're probably not going to have the volume to get off the learning curve. I do have a pick list of instruments with the item numbers from my set that I can email to anybody who's interested.

Dr. Chandler Dora:

A word on the morcellator, the morcellator is a pretty temperamental piece of equipment. It's an excellent piece of equipment. It's an improvement on prior iterations, but it is very temperamental. I also have an atlas on troubleshooting the morcellator with lots of pictures that I can email you if you're interested in that as well. Everybody always wants to know about complications that patients suffer on the learning curve, which is understandable. I would say to you don't be afraid to convert to a bipolar TURP or simple prostatectomy if the patient's anatomy or your skill level dictates. I say bipolar because if the tissue is mostly or completely enucleated or you're struggling with morcellation and the tissue is no longer grounded, then using a monopolar loop is not useful in that situation, and bipolar does become useful there.

Dr. Chandler Dora:

Also, a word about body habitus, just be aware of the man when he come in the exam room and he stands up and towers over you, and then you shake his hand and his hand wraps around yours twice. Be aware of that situation. If their BMI's over 30 and their trust volume is over 125, I typically will include on the consent possible open cystotomy or possible perineurium arthrotomy. Because sometimes you do run into instrument length issues with some of these huge patients with very long prostatic urethras, and it's good to be consented for a fallback plan. Also, expect some bring backs and clot evacuations and some subtotal enucleations or disappointing enucleations ratios while you're learning.

Dr. Chandler Dora:

Subtotal enucleations, which you'll certainly have I'm sure if you're self-learning, typically do very well with avoiding, but the procedure will just not be as durable. A word on anticoagulation. I know that Dr. Miller has published some favorable studies on HoLEP and anticoagulation, and even our guidelines mentioned doing HoLEP on anticoagulation. But I would avoid this certainly when you are learning. I even try to avoid it now as a self-proclaimed expert. Aspirin, yes. Perhaps I'll do a HoLEP on aspirin if necessary. Plavix, never. If they've had a stent, I wait six to 18 months dictated by the cardiologist. In the direct oral anticoagulants, I would not do a HoLEP on that medication.

Dr. Chandler Dora:

Occasionally, I'll have to bridge someone if they have a mechanical heart valve. But those patients are also fraught with danger as far as transfusion, bring backs, clot evacuations. I have quite a few patients who are on a [inaudible 00:15:32] ban or other direct oral anticoagulants for atrial fibrillation. I talk with them about their stroke risk in accordance with their CHADS-VASc score in consult with the cardiologist. It's not uncommon in my experience for a patient on these medicines not to be able to reliably go back on them for several weeks after their surgery due to the large raw surfaces in the prostate after HoLEP.

Dr. Chandler Dora:

It's not unusual for them to have to start and stop these medications several times during their recovery. I'd be very cautious, particularly if you're a self-taught learner and you're on your learning curve about doing any of these procedures on anticoagulation. Catheter insertions do occur for various reasons, especially with smaller prostates. We remove all the catheters on postoperative day number one. Since we've been using the MOSES-enabled software, the catheter reinsertion rates have gone down quite a bit because of the enhanced hemostasis. But expect a catheter reinsertion rate of maybe 5% or less. As far as preoperative counseling, I generally focus on setting their expectations regarding incontinence, and also I make sure to reinforce that they will have retrograde or [inaudible 00:16:57] ejaculation.

Dr. Chandler Dora:

I try to use common terminology for that. I rarely have patients complain about that as long as they know about it ahead of time. Which always leads to the question, how much leakage will I have? From the patient. I get asked that a lot. Let's talk about briefly of that incontinence. Predictive tools are lacking. What we do know is that men who are incontinent coming into surgery are more likely to be incontinent after surgery, which seems logical. Men tend to fall into a retentive phenotype where they have hesitancy slow stream retention or an irritative phenotype nocturia urgency urge incontinence. The latter patients will have more postoperative incontinence. Another study with a large number patients tout surgeon experience as a predictor.

Dr. Chandler Dora:

If they need numbers, for me, I tell them at the three month visit, probably about 10% will still be wearing some kind of a security or safety pad that they don't have to change out. If you fast forward to about a year, that's about 2% of patients will have some kind of bothersome leakage. Just anecdotally, my experience is in line with the literature and that patients with a retentive picture tend to leak less than patients with an irritative picture. I've also noticed, which I haven't seen in the literature, that these patients with a very acute urethra prostatic or urethral vesicle angle, where you have to torque way down to get up over the prostate and into the bladder, it tends to be more difficult to access their anterior atypical tissue, and that may portend a delayed recovery of continence.

Dr. Chandler Dora:

That's just something I've noticed anecdotally. Seeing the patient back too early can give anxiety for the patient and the urologist. I remember talking to Dr. Krambeck a few years ago, and she had switched from seeing them at three months to seeing them at four months, just for that reason, because there is additional recovery that occurs between months three and four that can sometimes make that visit easier, and I don't know what you're currently doing now.

Dr. Amy Krambeck:

Yeah, I agree 100%. I think if you see them back too early, their expectations are very high early.

Dr. Chandler Dora:

It gives you anxiety because you're worried that they're not going to make a full recovery either. My routine is that I contact patients with their pathology report a few days after the surgery to capture any immediate complications, catheter reinsertion, other issues they might be having. Then I see them back at three months with a flow, a PVR and a new baseline PSA. Certainly, I get a lot of portal messages. I try to dutifully respond to those but I try not to get too caught up in a patient's complaints or leakage in the first few weeks. Time will take care of the majority of this. The final irritative side effects typically subside between months three and four when the final re-epithelialization happens. I've had occasion to scope a lot of post-HoLEP patients for various reasons.

Dr. Chandler Dora:

As long as there even small areas of granulation tissue or areas that are not re-epithelialized, the patient typically will have some bladder spasticity and some of this urgency stuff still going on. Complete re-epithelialization typically takes about four months. In conclusion, HoLEP can be self-taught. I've done it. There's special about me. It's probably a little harder in the US. Patients will be very grateful if you implement this into your practice as the relief of obstruction with HoLEP is unparalleled, as is the ability to get them off medications and to become independent of a urologist. But you have to dedicate yourself to it and expect a learning curve. Thank you. This is my email address, if anybody needs to screenshot it, if they have any questions or they'd like the items that I described before. Thank you.

Dr. Amy Krambeck:

That was a great talk, Chandler. A couple of questions came through while you were speaking, and I'll ask them before we move on to Dr. Miller. What are your preferred settings for HoLEP in? Did you use lower settings when you first started and then have ramped up, or have you always used these settings?

Dr. Chandler Dora:

I've gone the opposite direction. Actually, I started off higher at a 50 Hertz and two Watts or two joule, and then I read your paper on the MOSES and I read the methodology what settings you used, and I started using a 40 and two for the non-apical areas, and then I started using 20 and two for the apex. I found that that lower setting actually enables a much more methodical slow dissection around the apex, and I feel like it's better for the trainees because things tend to move a little slower and it really pops open those planes. I've actually gone from 100, when I first started, down now to 80 and 40.

Dr. Amy Krambeck:

Yeah. I like that 80 just because of how it opens up the plane. I agree. Another question was, would you recommend a certain technique for someone who is self-taught?

Dr. Chandler Dora:

That's a good question. I use a single incision technique for just about everything. I just make one incision. I think if somebody has a very discrete pedunculated median lobe, then a two incision makes sense, but you end up spending a lot of time on the median lobe, and then the end result is you've only enucleated maybe a third of the tissue, and you still have a lot to go. I would advocate a single incision.

Dr. Amy Krambeck:

Perfect. Well, thank you very much, and we'll have more questions at the end, but I think we'll move on-

Dr. Chandler Dora:

Thank you.

Dr. Amy Krambeck:

... to Dr. Miller now.

Dr. Nicole Miller:

I'm so excited to be here and to join you all. Thanks to Endourology Society for the opportunity. Our distinguished panelists, Dr. Dora and Dr. Aho, and of course, my good friend, Dr. Krambeck. We've been at this for a long time, so I appreciate to join everyone. Then one other thing, I wanted to thank is Michelle Paoli, who really makes this happen behind the scenes. Work so tirelessly. Thank you so much. I'm going to be taking the position that fellowship training is best. I really appreciated Dr. Dora's presentation because I will say that we keep it all in the family. My brother is a urologist who's a few years older than me, and he is actually self-taught in HoLEP. While we learned by different techniques, I think we both do a fantastic job in offering this to patients.

Dr. Nicole Miller:

Here are my disclosures just briefly. I think we need to discuss the whole adoption of HoLEP, because the nagging question is we had level one randomized controlled trial data as extremely robust suggesting that laser enucleation should be the gold standard for prostate treatment. However, the issue is why is it so poorly adopted, especially here in the United States? What is most commonly cited is the steep learning curve. One of my fellows Dr. [inaudible 00:24:59] and I looked at Medicare's claim data from the United States, and looked at the number of poll cases that are being done between 2008 and 2014. While we solve, the number of cases sharply rose over time. When we looked at how people have accounted for the number of overall BPH cases, it was only 4% in 2014.

Dr. Nicole Miller:

When we looked at updating those numbers for 2018, it was up to 7%, but that's still considerably low for something that has such robust evidence to support. This is just looking at a map of centers that were doing HoLEP in 2008, the bigger the circle, the more cases that were being done. Then again, in 2011, 2014, read in the map here are centers that were continuing to do the procedure between 2011 and 2014, suggesting that there was continued preservation of offering HoLEP to these patients. My answer to the nagging question is that a learning curve is really only part of it. It's the part that we're here to talk about today, but I don't want us to forget that, particularly United States, the reimbursement system is completely flawed.

Dr. Nicole Miller:

We're not compensated commensurate with the skill that is required to do this operation. There are definitely issues around marketing technique, and particularly here in the states, I think there's a lot of competing robotic technology. But since we're here to talk about the learning curve, and I do think it's important, I will move on to discuss what I think the challenges are in terms of learning laser enucleation. It definitely requires a greater appreciation of 3D concepts. One of the things Dr Dora had said was that that angle between the prostate and the bladder neck, particularly at the adenomas growth under the bladder neck can be very challenging. The operation requires a very complex group of endoscopic movements with simultaneous use of the beak of the scope for retraction, as well as utilizing the laser for enucleation.

Dr. Nicole Miller:

I'm going to show you a little later just how extreme the angles can be sometimes to get around these large prostates, and that will be unlike anything that you're trained to do in residency. It's really quite a special skillset. In addition, we know that prostate anatomy is variable, not just the size of the prostate can differ patient to patient, but how vascular the prostate is. When we see multinodular BPH, and we're thinking about enucleation, we definitely can see that you can have enucleation planes that are going between nodules and that just increases the technical complexity. Here's a summary of learning curve studies. I think Dr. Dora well-defined the learning curve.

Dr. Nicole Miller:

We think, based on the systematic review of over 5,000 patients in 24 studies, a learning curve is between 25 and 50 cases. I would make the argument that a learning curve is reduced when you have fellowship training. Let's talk about one study that looked at the learning curve. This was a multicenter prospective evaluation, included nine centers, and these surgeons had experience in TURP and open prostatectomy, but not in HoLEP. Their training involved attending a course and been given a booklet describing the operation. They were then instructed by an expert with mentoring for first two cases only, and then they were expected to complete 20 consecutive cases with the main outcome being essentially the trifecta that Dr. Dora explained, the ability of the surgeon to successfully complete four consecutive procedures each in less than 90 minutes with acceptable stress and difficulty.

Dr. Nicole Miller:

Here are the results. Five centers completed the study, 100 patients being included. Four surgeon stopped performing the procedure in less than three patients. Only one surgeon achieved the primary outcome, and less than half procedures were successful. This would make it seem as if this can't be learned and that the procedure can not be learned and that this can be a very daunting learning curve. In comparison, there is a study that was just published in the Journal of Endourology in 2020, which was looking at surgeons that had fellowship training. This was a cumulative sum analysis of resection speed and resected ratio, comparing the learning curves of HoLEP and TURP. Two beginner surgeons who were fellowship-trained, one surgeon performing TURP, and one surgeon performing HoLEP.

Dr. Nicole Miller:

They looked at resection speed, defined as the grams per minute resected, and the resected ratio meaning the volume of resected tissue per the transitional zone volume. The main prostate size in this study, or what we would like to see in the learning curve, 57 CCS for the TURP and 65 CCS for the HoLEP. In terms of results, both surgeons achieved competency and resection speed, but it was actually faster in the HoLEP surgeon, 12 cases versus 23 cases. The HoLEP surgeon achieved competency in terms of resection ratio with a greater ratio in 12 cases, which is five cases in the TURP surgeon. The conclusion of this study was that HoLEP was not more difficult than TURP in terms of the learning curve if you had fellowship training.

Dr. Nicole Miller:

Dr. Dora explained nicely that what we care about are outcomes, and how does the learning curve effect outcomes. This is a study published in the Journal of Urology in 2017 that looked at 39 surgeons that had a differing HoLEP experience, from a minimum of one to five cases to over 100 cases. When you had increased experience, there was decrease in surgical times, decreased nucleation times and improve urinary incontinence. In fact, if you had greater than 20 case experience, this has significantly impacted the continence ratios. There have been other studies that have looked at continence and the learning curve. In a prospective evaluation of the first 313 cases that were performed by three surgeons, they found that the number of prior cases significantly impacted the rate of urinary incontinence at both four and 12 months with us seeing a decrease at the 20th case, and then a plateau at about the 40th case.

Dr. Nicole Miller:

There's a separate study looking at duration between cases suggesting that if you had greater than five weeks between HoLEP cases, that there was an associate odds ratio of 4.69 for stress urinary incontinence at three months. This goes to, again, what Dr. Dora already said is that we need to do a high volume of cases and we need to stack these cases. What do I think are the main benefits of fellowship training? Well, some of these are obviously intuitive. We're able to offer a high volume and a high density of cases. We can teach this in a step wise fashion so that you do not feel the pressure of completing the whole operation in one setting. Because of the high volume of cases, you're going to naturally have a variability of prostate size, configuration, vascularity, all the things that I said that make this operation more challenging. I think we all appreciate that getting feedback in real time has major benefits for learning.

Dr. Nicole Miller:

I think what my fellows would say is the idea of having stress around any operation is for the most part taken away from them because the stress and pressures of time and what I call crossing the finish line, which is finishing the case safely in a reasonable amount of time, is really left to the mentor, the person that is there teaching. The stress is all mine, I like to say. Then because we do have a high volume of cases, we really do have state-of-the-art tools, and I'm going to talk about that a little bit. What have I specifically personally learned about teaching? This is my 14th year teaching HoLEP trainees, and I think, as has been said previously, we really need to break the operation down to steps at difficulty. I'm certain that Dr. Aho will talk about this more specifically, but this is a table from one of his publications.

Dr. Nicole Miller:

Just giving a level of difficulty rating for the different parts of the steps. I think joining the anterior and posterior enucleation planes around the lobe is one of the most difficult steps, and I think we tend to teach that later. For my residents and fellows, I usually start them with a median lobe, as Dr. Dora said, only when there really is one present. I don't try to make one when there isn't one there, because that's actually makes the difficulty increase. I also like the fellows to do the second side before they do the first side, because when there's more room in the prosthetic [inaudible 00:34:24] after the first lateral lobe has been removed, they can get countertraction easier and have a little more room to work. I also pay a lot of attention to hand dominance. I teach my fellows who are right-handed to hold the camera with the left-hand and manipulate the scope with the right hand.

Dr. Nicole Miller:

When they work on the patient's left side, all of their movements are in a clockwise direction and it's very intuitive for them. When they are going to move on to do the first side, I have them work on the patient's left side first. In a fellowship training program, we are really able to allow the skills to be adopted based on prostate size as well. We all know that the smaller prostate and the really big prostate are going to be more difficult. So we start with the moderate size prostate. The 50 to 80 CC prostate in my opinion works very well to begin learning this technique. I'm going to show you what I call the hand over hand technique or the hand guiding technique. I think Dr. Dora said already, when we go proctor these cases, if you can't put your hands on the telescope or you can't put your hands on the trainees' hands or the learners' hands, it can be very hard for them to feel what it's supposed to feel like to do a certain move in the operation.

Dr. Nicole Miller:

This is what I call hand over hand technique. This is one of my fellows. I essentially have my hands over top of his. We are trying to isolate the mucosal strip to divide it, and this is a particularly difficult move, I think, because you have to maneuver the scope and there's a quite a bit of angularity of the other scope that's required. He can safely feel that movement with my hands over his, and it's more effective in my opinion teaching that than simply pointing to a screen. Now, I will disclose that you should get permission to put your hands over someone else's hands before you do that. But for the most part, I've gotten good feedback about that teaching technique. I want to take just a minute to talk about technology because I think that we can give all the tools in a tool set, but the tools in the tool box are just as important.

Dr. Nicole Miller:

I'm showing you a regular laser pulse here with a single bubble, and then I'm showing you MOSES pulse modulation specifically for BPH. We have an initial laser pulse that separates the fluid and then the remainder of the bubble, the second bubble can reach the target. What we're demonstrating in this video is that we're getting better energy transmission to the target. Dr. Dora had already alluded to this, but what we see clinically is an improvement in hemostasis. We just completed a prospective, double-blind randomized controlled trial evaluating MOSES pulse modulation looking specifically at hemostasis time as our primary outcome. What we were able to show is that we were able to save 23 minutes per case and that was recognized predominantly in hemostasis time. I'm going to show you a video of that hopefully.

Dr. Nicole Miller:

On this side of the screen, you're seeing a traditional holmium laser for hemostasis coagulation at the end of the case after the integration has been completed, versus the MOSES on this side. Hopefully what we're trying to convey here is that you can see when you apply the MOSES pulse modulation, the energy is transmitted over a larger surface area. You can imagine if you're trying to get hemostasis, this can really be beneficial because you can spread over a larger area faster. The other thing I would say specifically, in regards to MOSES pulse modulation, is it has had a huge impact on the way I manage patients. This is now a day case for us. I used to bring patients into the hospital overnight for a continuous bladder irrigation. Now that is an extremely rare event. There hasn't really been anything in my experience that has made such a drastic change in doing a case of enucleation since this improved laser technology.

Dr. Nicole Miller:

In conclusion, the learning curve, we know is about 25 to 50 cases. I would make the argument that fellowship training allows us to be on the lower end of the learning curve at about 25 cases. I feel like our fellows after training can go out. They have a very low rate of conversion to TUR. I think their postoperative complications are less. We know that patient selection is key. As I've mentioned, in fellowship training allows us to give the extremes of size and be able to stack cases and have the variability that you would like to see before you have to go out and do cases on your own. We can teach the case in a step-wise fashion, which I really think is best. We give the fellows the opportunity to use the latest technology. I just want to say I'm a firm believer in clinical fellowship programs, the ones that are offered by the Endourology Society. We do offer one here at Vanderbilt. I'm the fellowship director. Anyone who would be interested in a fellowship with us, please contact me. Thank you so much for your attention.

Dr. Amy Krambeck:

It was a fantastic talk, Nicole. I actually learned a few things in there on learning curve that I was not aware of. I agree with you 100%. I think that the newer technology makes it easier to train, and I think it's easier to learn. The same question came through for you that came through for Dr. Dora, which was, do you believe that any of the newer techniques like in-block or two-cut or single-cut is more beneficial for training or easier to learn?

Dr. Nicole Miller:

I have definitely played around with the technique somewhat, all of them. I think I was first to try adopting top down. I found that actually I do a lot more blunt enucleation, and then I have more cleanup to do as far as controlling the bleeding. I really try to stay to two-lobe technique as much as possible for the same reasons Dr. Dora said, where it's time consuming, if there is no median lobe, not to take it as a medium lobe. For teaching purposes specifically, I find it's much easier to do one lobe at a time.

Dr. Amy Krambeck:

Perfect. Perfect. Then just one more quick question before we move on is do you think the lack of a HoLEP packet makes it difficult for the fellows to move on and start at their new institution because they're having to coordinate all the different companies to get there? Is there any advice on how to do that?

Dr. Nicole Miller:

Oh gosh. Yes. I think that the answer that is 100%, yes. What we try to do within a few months of our fellows leaving us, most of them already have jobs lined up and so they're communicating in their privileges. We do the same thing. We give a pick list of all of the things you're going to need for the operating room. We have a nice laminated card system that goes through some morcellator troubleshooting tips. I agree with Dr. Dora, that can be one of the more frustrating pieces of equipment, because it does have some areas where you have to troubleshoot it a bit. I think as much as we can prepare them, a packet is a fantastic idea. I don't think we have to date put together something so formal as that, but I think it's a fantastic suggestion.

Dr. Amy Krambeck:

Wonderful. Well, thank you so much, and it was highly knowledgeable, so thank you. Then we'll have our final speaker, Dr. Aho, and he will be talking about his unique training program that he has developed.

Dr. Tevita Aho:

Hi, everybody. Thanks very much for the introduction. It's a great privilege and pleasure to be joining you from London, is where I'm at at the moment in the UK. It's a great day. This morning, I did three HoLEPs. They were all over 100 CCS, and then I had a gentleman with a bladder full of bladder stones. There were about seven of them. It's just got better because we've now got this webinar to learn about how to overcome the HoLEP learning curve. Now, I'm going to concentrate on describing what we've developed in the UK in terms of a structured mentorship program. I have to agree that a fellowship program is ideal to learn a HoLEP in, but if you are already out in consultant practice and you've got no option to join a fellowship program, then a structured mentorship program, if there's one available, is I think probably just as good.

Dr. Tevita Aho:

Here are my disclosures. What's a learning curve anyway? Well, learning curves were first described by TP Wright in 1936. This was in the context of aviation. Now, as we all know, to begin with, when you're learning a complex activity like a HoLEP or learning to fly a plane, there's usually quite a slow beginning or there can be. We often refer to a steep learning curve as a bad thing, but in actual fact, what we want is a steep learning curve. We want a steep acceleration in our learning, and we want to be able to reach proficiency as quickly and as safely as possible, particularly in the context of surgery. What we are trying to do with our HoLEP training program is to steepen the learning curve, actually from the beginning, so that we don't have a slow beginning for people, and we get them to a point of proficiency as early as possible.

Dr. Tevita Aho:

Of course, the learning curve doesn't finish when you reach proficiency. What you really want to aim for, if you're motivated to do this, is to become an expert. If you can become an expert, you can then pass your knowledge on, and that's what we're trying to achieve with our mentorship program, is to develop not just proficient HoLEP surgeons, but surgeons who are comfortable enough to go out and teach the technique to other trainees or to trainees, but also to other consultants. Now, there are some common misconceptions about the HoLEP learning curve, and a number of these have been mentioned already. In my opinion, a lot of these things are actually not realistic, but they're common excuses for why HoLEP has not done more in a more widespread fashion throughout the world. A lot of people think that the HoLEP learning curve is worse than TURP and it's more difficult to learn than TURP.

Dr. Tevita Aho:

I would disagree with that, in the context of a mentorship program. A lot of people describe it as being long and slow and painful, this HoLEP learning curve. Again, it doesn't have to be, and I'll explain what can be done to alter that and actually make it enjoyable, hopefully. People think that there's a significant chance of causing urinary incontinence during the learning curve. That does not have to be the case at all. In fact, we need to protect our patients. That's the key thing in all this. I'll mention a couple of little tips about ways to approach the apical tissue near the external sphincter. It's been said that only a few enthusiasts can do it well and get good outcomes.

Dr. Tevita Aho:

I think that [inaudible 00:46:19], Dr. Miller, [inaudible 00:46:20] the USA suggest otherwise. There's a growing number of dots on that map of HoLEP centers. It's not just a few people around the world that do this, and it's often used as the reason that HoLEP hasn't become more widespread. But there may be some truth in that. We formed a Holmium User Group back in March in 2007 in the UK, and we formed it at a time when we had about six HoLEP surgeons here that were motivated and willing to go out and train other consultants to proficiency in the HoLEP. The idea was that we were going to do this to allow them to establish other training centers throughout the UK. At any one time, we've had usually between six and eight different mentors. We've mentored more than 50 consultants now throughout the UK.

Dr. Tevita Aho:

Our policy has been to only mentor one or two consultants per hospital so that we can ... There's no point in mentoring somebody and then all their colleagues line up behind them and expect us to mentor them as well. We want to mentor the first person and get them to a level where they can then train their colleagues locally. Now, what we've found is that, over the years, more than 80% of consultant mentees have successfully established new HoLEP practices and most have gone on to train residents and other consultants. What are the basic ingredients? Going back to aviation again, the first step is the classroom. I mean, there's always going to be some theory, following on with simulation. Now that hasn't been mentioned yet. There are actually some simulators available for HoLEP and I'll come to those shortly.

Dr. Tevita Aho:

Then thirdly, the third part, main part about a structured training program here is mentorship, where we actually are able to more easily than in the US go to another consultants or another surgeon center, and we can actually relatively easily be hands-on to help them along the way. I know that's not possible in all settings. When we're speaking specifically about HoLEP, we tend, with our program, to start with a course where we talk about theory of HoLEP, the steps for each technique. We often bolt on to these courses a workshop, a hands-on workshop, using the simulation. Then we would suggest that people who've been to these conferences or training courses come along to an experts OR so you can see as many cases as possible.

Dr. Tevita Aho:

Now, I know that's very difficult in the COVID climate that we're all under, the COVID shadow that we're under at the moment, but a lot of this can actually be done online. There's a lot of resource and cases, [inaudible 00:49:16] cases available online to watch, and watching an expert operate is really, really important in your learning and overcoming your learning curve as quickly as possible. Then in the final components of the HoLEP program is for the mentor to actually go to the mentees' hospital and to join them and help them in their first few cases. Let's break down all these components individually. The classroom, what goes on in our courses? Well, we explain and we demonstrate three-lobe, two-lobe and en bloc techniques step-by-step, and it's really important to break these procedures down into individual steps to help you understand what's actually going on.

Dr. Tevita Aho:

It's very important to, when you're watching somebody operate, try to predict what the next step is so you can really get these into your minds as fully as possible. These courses that we run normally lasts for a day and a half. We have five live cases, usually a small prostate, medium prostate, large, and very large. We show, as I said, the en-bloc technique and a typical classic three-lobe technique. I'm not sure that one is better than the other or easier than the other to learn. What my approach now is to show people these techniques and ask them which way makes more sense to them. Whichever one makes more sense to them, that's the one that we should be training them on. We also cover tips and tricks in terms of setting up a HoLEP service.

Dr. Tevita Aho:

We cover things like instrumentation, what's required, the OR layout, how to prepare your team. It's not just the surgeon that goes through a learning curve. It's the anesthetist, it's the nurses in the OR, the nurses who look after our patients on the ward as well. We covered post-operative pathways, day stay pathways for HoLEP, 23 hour pathways. We summarize the theory, the published evidence for HoLEP, the main advantages of it, why bother in the first place? There's a lot of level 1b evidence to support it. Very importantly, we cover how to avoid and to deal with complications. We also include a laser core of knowledge course that talks about laser physics in the UK. It's necessary to do this sort of course before you can even use a laser, clinically. Now, if we move on to simulation and what's available, this is a wet model.

Dr. Tevita Aho:

It's an actual insert here that is put into a box that you can see down in the bottom left-hand corner. The beauty about this simulation model is that you're using the actual laser and you're using the actual instruments that you would use in real life. I'll just show you a quick video here. This is what it looks like, endoscopically, this model. It actually has an enucleation plane. When we're starting to nucleate here, you go through the mucosal ... Well, what is supposed to be? Mucosa? Then, as you get a bit deeper in, the model becomes a bit white. You see some white tissue that looks relatively close, I have to say, to the real thing. Then you see a bit of a pink color, which is where the capsule is.

Dr. Tevita Aho:

The only downside of this is it's quite labor intensive to set up, and it's a bit messy. It gets quite wet because you're actually using saline. You're using the exact same kit that you would use for an actual HoLEP. It's a bit expensive as well. These are not very widely available, unfortunately. There's also a virtual reality simulator available, which is not bad at all. It's literally a plug and play thing. It comes in a little, almost like a briefcase, the screen, and it is incredibly easy to set up. A group of us from the UK looked at this in terms of the validity of it, and we found ... we did establish that it was a valid way to learn HoLEP. The really important step is to observe an expert. Now, once again, pre-COVID, we used to get people coming in into our OR to watch an all day operating this, where we get through as many cases as possible to show them.

Dr. Tevita Aho:

But this also can be done, I think, online with three videos. Now, you'll see here that the procedure, which is highlighted here in blue, is only one of a very long list of things that we would suggest that people be aware of and soak up while they're in our OR. It's a good practice to bring a nurse with as well because there's a lot of nursing tips and tricks to learn. The things to pay attention to would be the OR layout, the instrumentation again, the laser and morcellator set up, common troubleshooting tips on the actual machinery that we're using, the procedure, of course, but then there's the peri-operative management, the consent. How's the consent taken? People are often interested in our actual consent forms and our information sheets, which we're happy to share with other colleagues.

Dr. Tevita Aho:

Antibiotics, catheter type, how much fluid you put in a catheter balloon. Do you use CBI? If so, how do you manage that post-operatively? What is the actual post-operative care pathway? A lot of things that you can learn when you go to visit an expert. Then I'll also say, watch as many cases as possible. Now, there's lots of HoLEP training videos available on YouTube to anybody. The AIS channel also has a number of largely [inaudible 00:54:57] HoLEP cases, en bloc, two-lobe, three-lobe techniques. It's all out there. Choose which technique that you'd prefer to start with. It makes more sense to you, and watch as many of these procedures as possible is my advice. The other thing that we do is we break down the procedure into various steps, which has already been mentioned by Dr. Miller. This is just an example of that. Just helps you think about ... It gives you a framework to think about what's actually going on.

Dr. Tevita Aho:

There's two schools of thought in terms of protecting the external sphincter. There's late apical release. That was the sphincter pre-op. This is after I've done an en bloc enucleation. But as you can see up here on the roof, there's a couple of narrow bridges of tissue that we have to divide. The key is to come back out through the sphincter, go back in so you can see the two edges of this bridge, and then to very carefully divide it across the bridge. Now, the second school of thought is to do an early apical release. Again, it doesn't really matter which one of these you choose, but do the one that actually makes more sense to you, or the one that you think you'd be able to do more easier. What this involves is identifying the arch of this thing, going just inside it towards the bladder neck, and then cutting basically or scoring with the laser along this red dotted line to release the mucosal sleeve so that you can get into the plane without putting traction against the tissue when you're pushing it up towards the bladder.

Dr. Tevita Aho:

These are surgical models for morcellation. Morcellation is one of the first things that I teach to other consultants or trainees because it's technically extremely easy. But there are rules for safe morcellation. It's worth taking a shot of this, one slide for morcellation. These are the five rules for safe morcellation. If you stick to these five rules, you can't essentially go wrong. I won't go through them all just in the interest of time, but they're there. There was a video about morcellation tips and tricks, very comprehensive that a group of us have published, that looks at both the oscillating morcellators and the reciprocating morcellator as well. I'll just leave that for your reference. Why consider mentorship? Remember, mentorship is the final part of our training program here in the UK.

Dr. Tevita Aho:

While it can be frightening, if you're learning to [inaudible 00:57:23], you don't really want to be in that situation. It's always a lot more comfortable if you have an expert with you, and you might even enjoy the experience, hopefully. What does mentorship involve? There's a bit of preparation. There's information from the mentee that we're after. We want to know what sort of camera you use, what brand of instruments do you use, so that we can send you an appropriate mentor who's also comfortable with these pieces of equipment. Before the visits, we ask the mentee to arrange for three sets of HoLEP instruments to be available, and enough fibers and morcellator blades.

Dr. Tevita Aho:

These are usually provided by industry, by the vendors. Ensure you've got the correct laser socket in your OR, because we've had situations where we've gone to mentor somebody and we can't even plug the laser in because there's no socket in the OR. Clearly, that's quite important. These are things that you often don't even think about until we're actually there and then it really messes things up big time. Ensure that your team has fulfilled your local appropriate laser safety measures, complete the local requirements for a mentor to visit obviously. Select appropriate cases, we'll come to that shortly, and make sure you get informed consent from the patients so they know that you are having a mentored operating list.

Dr. Amy Krambeck:

It was a fantastic presentation. There's so many great questions. Wonderful tips and tricks for the audience and many great questions. You all three did a fantastic job. Do you think that the wet model is commercially available? The simulation model, Dr. Aho?

Dr. Tevita Aho:

Yeah, it definitely is available. I'm not sure about everywhere in the world, but it certainly is available. A lot of the industry partners have bought these simulators and they will be able to provide them often. In Europe, Lumenis and Boston Scientific both have them.

Dr. Amy Krambeck:

Okay, wonderful. Thank you all for joining us today. I want you to remind you of the next webinars series. It's January 22nd, What is Focal Therapy? The faculty will be John Ward, Dr. Ehdaie, Valerio, and moderators, Dr. Polascik and Barrett. This will be a great presentation on focal therapy. Again, you will receive CME credit. You'll get a survey from Michelle Paoli and indicate which seminar you attended. You will get a CME certification, so fill out the evaluation questionnaire at the end of the seminar. We encourage everyone who is not already a member to join the Endourology Society. Your membership dues provide you with many member benefits, including the full online text of Journal of Endourology, Video Urology and Case Reports. So please go to the endourology website. Don't forget to say the date, the WCET in 2021, September 21st through 25th in Hamburg, Germany. Thank you all, and thank you all for joining us today. Bye-bye.