Last updated: March 2026
Every urology department in the world should be able to offer endoscopic enucleation to its patients. This is the conviction that has driven my dedication to training for over 15 years. The technique is not easy, but it is teachable and reproducible — and the data prove it.
If you are a urologist who wants to incorporate en bloc HoLEP into your practice, or if you already enucleate and want to refine your technique, this article explains the training options we offer at ICUA and the learning curve data you should know before you begin.
The HoLEP learning curve: what the data say
The learning curve has historically been the main argument against adopting HoLEP. "It's too difficult", "you need 50 cases to become competent", "I don't have enough volume". I have heard these objections hundreds of times. Let us look at what the data actually show.
In a comparative learning curve study, the en bloc enucleation technique showed a shorter curve than the classic three-lobe technique: 14–30 cases versus 22–40 cases to achieve competence, with shorter operative times despite enucleating somewhat larger prostates (Peyronnet, 2017).
An independent study of 500 consecutive cases using the en bloc technique (Wenk et al., World J Urol 2024) demonstrated that, with structured training, the learning curve is significantly shorter than traditionally attributed to HoLEP. A study with beginners (Li et al., 2023) confirmed that the technique is feasible from the earliest cases when adequate mentorship is provided.
The key is not individual talent — it is structured training, clear anatomical principles, and sufficient case volume under supervision.
The ICUA Training Programme
Since 2007, we have received over 600 visiting urologists from more than 60 countries at ICUA. Our training programme operates at several levels, adapted to each surgeon's experience and needs.
Operating theatre observership — Madrid
This is the foundational experience. The visiting urologist spends an afternoon in our operating theatre at Clínica CEMTRO, where we schedule five operations with varied cases: different prostate sizes, patients with prior treatment, prostates after TURP, after UroLift, and so on.
The goal is not merely to demonstrate the technique — it is to inspire. For the visitor to see a well-practised team executing the operation with fluency, to understand the principles (early apical release, sphincteric mucosa preservation, incision-free dissection) and to leave with a clear objective to implement at their own hospital.
Traditionally, after the surgical session we go to dinner together. It is an opportunity to talk, get to know each other better, and understand the specific challenges each surgeon faces in adopting the technique in their environment.
Operating theatre observership — Hill Clinic, Sofia (Bulgaria)
My collaboration with the Hill Clinic in Sofia has been a true school of learning and a teaching centre where many urologists who are now international figures in the field began their enucleation experience. It is another site where visiting urologists can observe the technique in a high-volume setting.
On-site proctoring at your hospital
For surgeons who have completed the observership and want to implement the technique, we offer on-site proctoring: I travel to your hospital and accompany you through your first cases. Having an experienced surgeon alongside you during the initial procedures drastically shortens the learning curve and increases patient safety.
I have provided proctoring at hospitals across Europe, Latin America, Asia, the Middle East, and Africa. Every hospital is different — equipment, surgical team, patient mix — and adapting the training to the specific environment is an essential part of the process.
Video-based training and remote consultation
For surgeons who are already enucleating and have questions about specific cases or wish to improve particular technical aspects, we offer video consultation. We can review surgical videos together, discuss strategies for complex cases, and troubleshoot technical problems in a personalised way.
The manual: a complementary resource
In 2026, I published the Manual de HoLEP en Bloque (ISBN 978-84-09-81888-4), a 352-page book born precisely from the questions and challenges that visitors raise in the operating theatre. It is not an evidence-based manual in the classical sense — it is an experience-based manual reflecting the thought process of a surgeon obsessed with simplifying the procedure to make it reproducible and teachable.
The manual covers everything from anatomical fundamentals to complex situations (previously operated prostates, catheterised patients, incidental cancer, associated stricture), with detailed step-by-step illustrations. If the reader finds a useful detail or adopts any of the ideas reflected within, it will have been worthwhile.
+600 surgeons trained across 60+ countries
Our visitor database includes more than 600
urologists from over 60 countries who have gone through our training programme since 2007. Many of them now perform enucleation routinely at their centres, and several have published their own results — confirming that the technique is reproducible in the hands of appropriately trained surgeons, with outcomes comparable to ours.
This global network of surgeons trained in our technique also benefits patients: when a patient from another country contacts me, I can often refer them to a colleague trained at their own city who performs the technique with proven competence.
For urologists who wish to refer patients
If you are a urologist and have a patient who needs enucleation but you do not have the technique or the equipment at your centre, you can refer them to ICUA. We commit to keeping you informed throughout the process and to returning the patient to your care with a comprehensive report. We work in collaboration, not in competition.
Contact us to arrange your visit or request information about proctoring.
📞 +34 91 435 28 44 · ✉ icua@icua.es
Coordination: Vanesa Cuadros · vcr@icua.es
Scientific references
- Saitta G, Becerra JEA, Del Álamo JF, Gómez Sancha F, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
- Wenk MJ, Hartung FO, Egen L, Netsch C, Kosiba M, Grüne B, Herrmann J. The long-term learning curve of HoLEP in the en-bloc technique: a single surgeon series of 500 consecutive cases. World J Urol. 2024;42:436. PubMed
- Li S, et al. En bloc HoLEP: feasibility for beginners. BMC Urol. 2023;23:56. PMC
- Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
- Gómez Sancha F, et al. Manual de HoLEP en Bloque. ISBN 978-84-09-81888-4. 2026. 352 pages.
