Several authors have reported comparison studies between TURP and HoLEP.[13–21] Gilling et al. reported outcomes at 1, 2, and 7 years after HoLEP or TURP.[13–15] They demonstrated that there was no difference in postoperative urodynamic results between TURP and HOLEP. However, they reported that HoLEP was superior to TURP in duration of catheterization and the duration of hospital stay. The results of several prospective and randomized trials are reported.[17–20] Authors of prospective and randomized trials have reported that HoLEP is superior to TURP in duration of catheterization and hospital stays. In addition, they have demonstrated that TURP is superior to HoLEP in operative time. Several authors have suggested that there was no difference in postoperative urodynamic results between HoLEP and TURP,[17, 19] while others argue that HoLEP is slightly superior to TURP in this aspect.[18, 20] Procedures in previous reports about the comparison between TURP and HoLEP were performed mostly by experts who have extensive experience of transurethral surgery. To the best of our knowledge, there is no comparative study of learning curves between TURP and HoLEP. For this reason, the predictive factor that is useful for young beginner urologists who agonize about selecting a surgical modality before performing surgical treatment for BPH should be identified.
Preoperative IPSS has been known as one of the predictors for favorable outcome in BPH patients who were treated using TURP.[22–24] Hakenberg et al. and Chang et al. reported that patients showing severe preoperative IPSS obtained a greater improvement in postoperative IPSS than patients showing mild preoperative IPSS. A preoperative IPSS value of 17 is the cut-off value for the prediction of favorable postoperative outcome.[23, 24] However, preoperative IPSS was not an independent predictor of favorable outcomes after TURP in these studies because they did not perform multivariate analysis. Moreover, these studies had a limitation in that they arbitrarily defined significant symptomatic postoperative improvement as a decrease of 10 or more symptom score points. Bruskewitz et al. also reported that preoperative IPSS could be one of the predictors for favorable outcome after TURP.[22] However, they also performed a multivariate analysis.
The authors identified that preoperative IPSS was a statistically significant independent predictor for favorable outcomes after surgical treatment in BPH unlike in previous reports, and that surgical modality is not an important factor for the improvement of lower urinary tract symptoms after surgical treatment in BPH. Especially, this report can be useful for beginner urologists who do not overcome the learning curve of surgical treatment for BPH, because this study was based on the experiences of young beginner urologists.
HoLEP is known as having a steep learning curve, and several studies have reported on this subject.[6–11] By comparing outcomes in HoLEP that were performed by an unexperienced urologist and by a urologist with extensive experience with transurethral surgery, El-Hakim et al. suggested that extensive experience with transurethral surgery is a prerequisite for the success of HoLEP.[8] Shah et al. reported that an urologist inexperienced with HoLEP could perform the procedure with reasonable efficiency after 50 cases; their prospective study was based on the experiences of a surgeon who has performed transurethral surgery in 150 cases.[11] Bae et al. also reported that they reached a stable enucleation and a morcellation efficiency state after 30 cases and 20 cases, respectively.[6] Meanwhile, Brunckhorst et al. reported that they experienced a learning curve of 40–60 cases for the HoLEP procedure in their retrospective study, which was based on the experiences of a surgeon who performed transurethral surgery in 500 cases.[7] A recently published report demonstrated that 20 cases are probably sufficient to give the surgeon the impetus to continue with the technique,[10] and Elshal et al. suggested that preoperative prostate volume, the number of previously performed cases, and case density are the main influential factors in the learning curve.[9]
Nevertheless, the authors indicate that young beginner urologists should concentrate their attention on the severity of symptoms rather than on the selection of surgical modality when they consider surgical treatment, such as HoLEP or TURP, for patients who have lower urinary tract symptoms. In addition, since the preoperative IPSS is more of an independent predictor than the surgical modality for improvement after surgical treatment for BPH, the authors recommend that it is unnecessary to hesitate to perform HoLEP just due to its steep learning curve.
This report has the limitation that this study was designed retrospectively and the number of included patients was relatively small. However, the authors judge that the scale of this study, which was performed in 40 patients who were treated with HoLEP or TURP is sufficient for evaluating initial experience because a learning curve of 20–60 cases was shown to be necessary for learning the HoLEP procedure through previously published reports.
The results that are reported in the current study need to be confirmed and validated by analyzing data from a prospective study.