Introduction: Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure. However, whether long surgical experience is able to improve peri- and post-operative outcomes is still unknown. We thus investigated results and complications after HoLEP performed by a highly experienced surgeon Methods: This is a single-institutional prospective study (NCT03583034) performed at a tertiary referral centre including 243 consecutive patients with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) treated with HoLEP by a single highly experienced surgeon (>1600 cases performed). Patients were assessed using validated questionnaires, PSA measurements and uroflowmetry at baseline and several follow-up dates. Intra- and postoperative complications were recorded and graded according to Clavien-Dindo (CD) classification. The Kaplan-Meier analysis estimated urinary continence (UC) (defined as no pad) and erectile function (EF) recovery rates. Logistic regression models assessed predictors of post-operative complications Results: Median(IQR) prostate volume (PV) was 87cc(60-115) with 146(59.8%) patients having a PV>80 cc and 78(32.1%) having an indwelling catheter at baseline. At 3-month follow-up, 219(90.1%) patients had a peak flow rate >20 ml/s, and 182(74.9%) had a null residual urine volume. Improvement in subjective symptoms as assessed with the IPSS was significant already at 1-month, and it was maintained until 12-month after surgery. UC recovery was slow with estimated rates of 68%(62-74%) at 1-month and 94%(91-97%) at 12-month post-HoLEP. Increased PV (HR 0.95; 95%CI: 0.91-0.99), incontinence at baseline (HR 0.45; 95%CI: 0.27-0.73) and a higher baseline IPSS (HR 0.97; 95%CI: 0.94-0.99) were predictors of worse UC recovery rates (all p<0.04). The EF recovery rates were 53%(46-61%) at 1-month and 85%(77-90%) at 12-month post-HoLEP. Post-operative complications were reported in 36(14.8%) patients during hospital stay [CD-2: 14(5.8%); CD-3: 1(0.4%)], in 34(14%) within one month post-discharge [CD-2: 17(6.9%); CD-3: 1(0.4%)] and in 10(4.1%) at later follow-up [CD-2: 3(1.2%); CD-3: 6(2.4%)]. Severe complications (CD=2) were more common in patients with indwelling catheter at baseline (OR:5.05;p=0.006) Conclusions: A highly experienced surgeon is commonly referred complex cases of LUTS due to BPE. Although HoLEP remains an effective procedure, it is not devoid of complications and sequelae even in the hands of a surgeon with more than 1600 procedures completed SOURCE OF Funding: No
