Holmium laser enucleation of the prostate (HoLEP) is an effective surgical treatment for benign prostatic obstruction, but adoption remains limited by a demanding learning curve. Most learning-curve studies use surgeon-specific benchmarks, potentially overestimating proficiency. We evaluated HoLEP learning trajectories across multiple surgeons using a common expert benchmark to determine whether expert-level performance is achieved during routine training.
Prospectively collected data from 701 consecutive HoLEP procedures performed by seven surgeons between January 2022 and April 2026 were retrospectively analyzed. Surgeons represented different experience levels and training environments, including an expert surgeon, a mentored surgeon trained in a high-volume private center before transitioning to hospital practice, hospital-based trainees, and early learners. The primary outcome was enucleation efficiency (EE, g/min), calculated as enucleated tissue weight divided by enucleation time. Non-risk-adjusted cumulative sum (CUSUM) curves were generated for each surgeon using a common reference value: the mean EE of the final 100 procedures performed by the expert surgeon (3.40 g/min). Secondary outcomes included perioperative morbidity, catheterization time, length of stay, continence, and functional outcomes. The study was conducted in accordance with the Declaration of Helsinki, and ethics committee approval was waived according to local regulations.
Mean EE ranged from 0.62 to 2.75 g/min across surgeons. Progressive improvement was observed in all learning curves, with marked heterogeneity between surgeons and training pathways. When benchmarked against mature expert performance, none of the non-expert surgeons achieved sustained performance equivalent to the predefined expert reference. CUSUM curves generally maintained a positive trajectory, indicating ongoing technical optimization despite increasing operative experience. These findings contrasted with proficiency thresholds commonly reported using surgeon-specific benchmarks. Despite persistent differences in technical performance, perioperative outcomes remained acceptable. Mean catheterization time was 1.69 days and mean hospital stay was 1.25 days. Major complications (Clavien-Dindo ≥III) occurred in 1.1% of cases.
When evaluated against a common expert benchmark, HoLEP learning curves appear substantially longer than previously reported. Non-risk-adjusted CUSUM using mature expert-level performance as a reference provides a more demanding and clinically meaningful assessment of technical progression than surgeon-specific benchmarking. Technical mastery in HoLEP may therefore represent a continuous process extending beyond traditional proficiency thresholds.
