Editorial Comment on: “Mind the Gaps: Adoption and Underutilization of Holmium Laser Enucleation of the Prostate in the United States from 2008 to 2014” by Robles et al.

There has long been shared sentiment among holmium laser enucleation of the prostate (HoLEP) surgeons that the procedure is generally underutilized in the United States. To date, this has been difficult to quantify; however, in the accompanying article, Robles et al. provide objective evidence to support this belief. ¹ Using a 100% Medicare claims database, the authors found that HoLEP accounted for just 4% of all benign prostatic hypertrophy (BPH) surgical treatments in 2014 with over 50% of U.S. states having fewer than one site where more than 10 HoLEPs were being performed annually. In their discussion, they point to a steep learning curve and a lack of training opportunities as possible reasons to explain the relatively low utilization. While the data they provide are new, recognition of these barriers is not. In fact, in an editorial from nearly a decade ago entitled, “Holmium Laser Enucleation of the Prostate—If Not Now, When?” Dr. James Lingeman highlighted many of the same issues and called the lack of HoLEP adoption despite superior outcomes “perplexing and disappointing.” ²

If HoLEP was going to challenge TURP as the true gold standard for BPH management on the basis of technique alone, it would have happened already. Perhaps it is time that the HoLEP community shift from trying to convince other surgeons that HoLEP CAN be taught to the fact that HoLEP SHOULD be taught. The reason to learn HoLEP is not because it is easy, but because it is an excellent surgery that has stood the test of time and is supported by an abundance of data. It is because it is versatile, appropriate for nearly any size prostate, and can be performed in medically complex patients on anticoagulants. ³

Perhaps the single greatest reason to learn and offer HoLEP though is the long-term durability of this procedure. Unfortunately, durability of symptom relief and retreatments are all too often ignored when discussing or studying BPH surgery. ⁴ Enucleation differs from alternative BPH therapies by achieving a relatively complete removal of the obstructing transition zone adenoma, making it less likely to grow back. This is supported by the unparalleled reduction in prostate specific antigen after enucleation ⁵ and is underscored by data from McGill University where patients undergoing HoLEP had only a 1% rate of retreatment for residual adenoma at a mean of over 7 years. ⁶ These authors also demonstrated outstanding functional voiding parameters among a cohort of 132 men followed beyond 10 years. ⁶ Further, improvement in functional voiding parameters were almost entirely preserved among a cohort of 132 men followed beyond ten years from surgery. ⁷ Alternative BPH surgical treatments on the other hand have a greater potential for failure. ³ Anderson et al. published data from the 2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) showing that there were a greater number of TURP's performed for adenoma regrowth that year than primary HoLEPs. ⁸

Over the past decade, data supporting HoLEP as a superior treatment for BPH has grown but the limitations in adoption remain. It is reasonable to believe that if the procedure is ever going to gain wider favor there needs to be an easier way to learn it. Perhaps the answer will come from industry. Increasing recognition that enucleation can be performed with a variety of energies has led to development of more tools and new techniques for this purpose such as bipolar, thulium, and greenlight enucleation. Similarly, there are efforts to improve holmium laser technology for this purpose. ⁹ While promising, there is limited data comparing the learning curves of these various new approaches compared to traditional HoLEP.

Alternatively, perhaps what is lacking most is a compelling reason to overcome the learning curve in the first place. As discussed in the manuscript, the difference in reimbursement between a HoLEP and TURP is relatively modest with no disincentives for BPH retreatment in the existing fee-for-service model of U.S. healthcare. One is left to wonder whether the definitive and durable outcomes associated with HoLEP become more appealing to surgeons as rising health costs, bundled payments, and resource limitations become more common in the coming years. Perhaps then, it will become more apparent that HoLEP not only holds the “moral” high ground as Dr. Lingeman referred to it in 2011, ² but the “fiscally responsible” high ground as well.