Veil sparing Holmium Laser Enculeation of the Prostate (Lobe by Lobe HoLEP)

Veil sparing HOLEP was performed in step manner approach abbreviated for sake of learning as (IT PAS ABCD). I, incision of the prostate from the deepest groove at the bladder neck till just lateral to the Veru Montanum. T, trough creation, it means widening the incision by incising underneath the 2 lateral lobes with slight pressure applied by the scope to have a wide channel allowing free flow of irrigant while doing apical dissection. This trough is similarly created if we have 2 deep grooves with prominent median lobe by enucleating median lobe first. P, plane development, this step is done by extending mucosal only incision laterally over the apical lateral bulge followed by blunt enucleation of the lateral lobe. A, apico-lateral dissection, it entails upward enucleation of the prostate apex till 3 O’clock position on the left and 9 O’clock position on the right. S, sphincter liberation or strip cutting, where the scope is rotated 180 degrees up with fiber facing 12 O’clock position and mucosal attachment of the adenoma is cut 1cm proximal to the veru (the adenoma should be stretched slightly towards the bladder neck) from 12 to 3 O’clock position on the left and from 12 to 9 O’clock position on the left. A, anterior dissection, where the adenoma is sharply dissected by cutting in arc-shape from the anterior commissure towards the previously developed apico-lateral plain. Anterior dissection in the distal one third of the prostate entails sharp cutting leaving a veil of tissue anteriorly where a capsular plain is poorly identifiable. Later a combined sharp and blunt dissection could easily develop a capsular plain that continues laterally. B, bladder neck dissection, once the bladder neck fibers are identified anteriorly, they were cut transversely by laser. C, c-shaped baso-lateral dissection, at this stage the scope is rotated in c-shaped manner from 12 to 4 O’clock positions on the left and from 12 to 8 O’clock positions on the right. In this step sharp laser dissection is used while applying pressure on the adenoma pushing it from lateral to medial. The rotating movements were repeated while withdrawing the scope inside the prostate fossa till joining the previously formed apico-lateral and basal capsular plains. D, detachment and flipping of the adenoma, the adenoma is lifted by the scope toward the bladder neck till we can flip it to the bladder with remaining basal bladder neck attachment cut by laser from lateral to medial till being completely detached to the bladder. #HOLEP #ANATOMICAL ENDOSCOPIC ENUCLEATION OF THE PROSTATE #enucleation #prostate #learning visit our website https://mansoura-endoacademy.com/ Review the original article https://www.minervamedica.it/en/journals/minerva-urology-nephrology/article.php?cod=R19Y2024N02A0210