DOI: 10.1177/08927790261500971 ISSN: 0892-7790

NASA-TLX Reveals Cognitive Workload Across the HoLEP Learning Curve from Our First 100 Cases

Raviraj Rege, Victor Sandoval, Carl Ceraolo, Rajat Jain, Scott Quarrier, Nitin Sharma
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Introduction:

Holmium laser enucleation of the prostate (HoLEP) has a steep learning curve, which limits widespread adoption. Objective metrics to define surgical proficiency, efficiency, and perceived workload remain underexplored outside academic institutions. This study aimed to characterize the learning curve of HoLEP from one single surgeon at an ambulatory surgical center.

Methods:

A total of 103 patients underwent HoLEP for BPH between March 2024 and August 2025. Surgical cases were stratified into 3 sequential groups of 34, 34, and 35 cases, respectively, based on operative chronology. Operative characteristics were compared across groups: enucleation time, laser energy, fluid use, and enucleation speed (enucleation time/specimen weight). Perceived workload was assessed using the NASA Task Load Index (NASA-TLX) to evaluate perceived workload across several “performance” domains (mental demand, physical demand, temporal demand, performance, effort, and frustration). Comparisons of outcome metrics were made for 90-day postoperative complications. Urinary continence outcomes were evaluated at 1 week, 1 month, and 3 months postoperatively. Univariable and multivariable multinomial logistic regression analyses were performed to examine associations between surgical characteristics and group classification.

Results:

Progressive improvement was observed in operative time, enucleation time, laser energy, total fluid, enucleation speed, and NASA TLX, as seen in Table 1

. No statistically significant associations were observed between group classification and 90-day postoperative complications or urinary continence outcomes at any follow-up interval. In multivariable multinomial logistic regression analysis, the NASA-TLX score (OR 0.83, 95% CI, 0.70–0.98, p = 0.02) remained an independent predictor of higher learning curve classification. ( Table 2
).

Table 1.

Comparison of Baseline Characteristics among Surgical Category Groups

Baseline characteristics
1st group ( N = 34)
2nd group ( N = 34) 3rd group ( N = 35)
Age at surgery (yr)
71 (63.2–75.8) 70 (65.2–76.8) 70 (66.5–75)
Had Urinary Retention, n (%)
12 (37.5%) 8 (24.2%) 15 (42.9%)
Prior BPH Surgery, n (%)*
4 (11.8%) 2 (6.2%) 9 (34.6%)
AC/AP, n (%)
14 (41.2%) 14 (45.2%) 11 (32.4%)
BMI (kg/m²)
28.5 (25–31.8) 28.1 (24.8–30.6) 30.3 (27.3–32)
ASA Class I/II/III, n (%)
1 (3%)/11 (33.3%)/21 (63.6%) 1 (2.9%)/17 (50%)/16 (47.1%) 0 (0%)/13 (37.1%)/22 (62.9%)
HTN, n (%)
25 (73.5%) 20 (58.8%) 25 (71.4%)
DM, n (%)
5 (15.6%) 8 (23.5%) 10 (28.6%)
PSA (ng/mL)*
3.48 (1.61–5.68) 3.35 (2.71–5.55) 1.67 (0.75–4.52)
PSAD (ng/mL/cc)
0.03 (0.03–0.07) 0.05 (0.03–0.09) 0.04 (0.02–0.06)

Bold values indicate statistical significance at p < 0.05.

Continuous variables are reported as medians with interquartile ranges. Categorical variables as n (%). Percentages and medians are based on non-missing data; denominators may vary slightly where values were missing.

*Statistically significant difference between groups ( p < 0.05; Kruskal–Wallis test for continuous variables, chi-square test for categorical variables).

Table 2.

Comparison of Surgical Parameters among Surgical Category Groups

Surgical parameters
1st group ( N = 34)
2nd group ( N = 34) 3rd group ( N = 35)
Had previous urinary retention/Foley catheter
12 (35.3)
9 (25.7) 14 (41.2)
Had anticoagulation/antiplatelet
14 (41.2) 15 (42.9) 10 (29.4)
Prostate Size
71 (50–136) 71.8 (50–110) 50 (40–71.7)
Estimated blood loss (mL)
50 (20–100) 50 (20–75) 35 (20–62.5)
Operative Time* (min)
74 (59.5–93.5) 65 (49–82) 54 (42.7–68)
Enucleation Time* (min)
46.5 (33.7–61.5) 35 (28–51) 34 (26–42)
Hemostasis time (min)
6 (4–10) 6 (3–10) 3.5 (2–7)
Specimen weight (g)
45.8 (28.2–77.7) 47.2 (24.3–100.5) 30.8 (16.7–42.7)
Laser time (min)
28.8 (21.7–37.2) 24 (18–28) 22 (14.7–27)
Laser Energy* (kJ)
162.4 (127.7–216.4) 134.2 (102.9–188.3) 124.2 (95.1–145.2)
Morcellation time (min)
8 (3.5–15) 9 (4–12) 4.5 (2.7–8)
Total Fluid* (L)
29 (21–42) 24 (18–30) 21 (18–28.5)
Enucleation ratio (g/mL)
0.57 (0.49–0.76) 0.61 (0.43–0.83) 0.57 (0.39–0.72)
Enucleation speed (g/min)
0.15 (0.10–0.20) 0.14 (0.10–0.23) 0.18 (0.11–0.26)
Morcellation speed (g/min)
6.33 (4.9–9.94) 6.71 (4.33–9.18) 5.24 (3.7–7.8)
NASA TLX*
( n = 25) 12.6 (9.8–22) ( n = 34) 9.3 (6.4–14.5) ( n = 19) 6.3 (5.3–11)

Bold values indicate statistical significance at p < 0.05.

Continuous variables reported as medians with interquartile range, and categorical variables are reported percentages.

*Statistically significant differences between groups ( p < 0.05).

Conclusions:

Progressive reductions in operative time, energy use, and perceived workload signify quantifiable improvement over the first 100 cases in a community hospital, The NASA-TLX score remained independently associated with improvement in proficiency, outperforming traditional operative measures in defining the HoLEP learning curve.

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