En-bloc HoLEP training and learning curve challenges: a multi-generational survey study.

Background
Initial training of Holmium Laser Enucleation of the Prostate (HoLEP) often favored the 3- or 2-lobe techniques, as the en-bloc approach was considered most technically demanding. In recent years, the en-bloc method has become increasingly standardized. This survey aimed to evaluate the subjective perception of primary en-bloc HoLEP training within a structured mentorship network in Switzerland, to identify procedural steps perceived as particularly demanding and to determine whether trainees continue to apply the technique in independent practice.
Materials and methods
Swiss Urologists trained directly by a single surgeon in en-bloc HoLEP, as well as those further down the teaching line, were surveyed. An online questionnaire covered demographics, prior experience, learning curve, surgical technique, and experiences with proctoring others.
Results
Nineteen (100%) urologists responded, 70% had successfully completed formal proctoring at the time of the survey. In total, 2,201 procedures were performed (range 12–950 procedures per surgeon). The majority of participants have completed at least 50 other transurethral prostate procedures beforehand. Prostate volumes of 50–90 ml were considered ideal for learning. Among those who reached confidence, 63% felt confident after fewer than 30 cases. All participants continued using the en-bloc technique. Key benefits reported included single-plane identification, better orientation and visibility, and shorter operative time. Common challenges included apical release, maintaining plane continuity, and final detachment into the bladder. Six participants now act as proctors, spreading the technique to the next generations.
Conclusion
Structured one-on-one mentorship appears to support the introduction and sustained adoption of en-bloc HoLEP. While this survey reflects subjective perceptions rather than objective operative outcomes, complete technique retention within the cohort suggests high acceptance. Several procedural steps were perceived as technically demanding and may warrant focused attention in structured proctoring programs.