En-block Anatomical Endoscopic Enucleation of the Prostate with the use of a hybrid Tm:YAG laser (HTLEP)

I. K. Goumas, E Ventimiglia

This video illustrates a standardized technique for anatomical endoscopic enucleation of the prostate (AEEP) using the Revolix HTL™ 150-W hybrid thulium laser in combination with a 550-µm reusable laser fiber, a 26-Ch continuous-flow resectoscope, and the Piranha™ morcellator. The hybrid thulium platform provides both pulsed and continuous-wave emission, allowing fine-tuning of energy delivery (up to 150 W and 300 Hz, with variable pulse peak power and duration) to optimize tissue dissection and hemostasis. In our protocol, enucleation is performed at 100 W, 50 Hz, and 100% effect in pulsed mode, whereas coagulation of bleeding vessels is achieved with 5 W in continuous-wave mode.

The procedure begins at the prostatic apex. After identifying the verumontanum and external sphincter, an initial incision is made lateral to the verumontanum at the base of the lateral lobes. This incision is extended superiorly to release the mucosa. The right and left incisions are then joined anterior to the verumontanum, establishing the initial mucosal boundary."

The surgical capsule is identified through a combination of laser energy and gentle mechanical leverage using the endoscope tip. We maintain a symmetric dissection to ensure anatomical orientation. The inferior aspect of the lateral lobes is progressively enucleated, utilizing circular movements to follow the contour of the surgical capsule.

To complete the apical release, the sphincteric mucosa is incised at the 12 o’clock position. This incision is carried out in an oblique, caudal direction to merge with the previous lateral incisions. Dissection proceeds by precisely incising the anterior apical adenomatous tissue to maintain the correct surgical plane symmetrically across both lobes.

Once the apex is fully liberated, dissection proceeds from the anterior aspect toward the bladder neck. We follow the circumferential curvature of the adenoma, maintaining a strict capsular plane. As we approach the bladder neck, the transverse fibers become visible. The bladder neck is then incised, allowing entry into the bladder lumen.

The final enucleation proceeds in a 'top-down' fashion. The adenoma is detached from the capsule and displaced medially. This maneuver facilitates access to the base of the adenoma, allowing for thinning of the pedicle while strictly adhering to the steep curvature of the posterior capsule near the bladder neck. Finally, the adenoma is pedunculated and completely released into the bladder.

Leveraging the perfect balance of wavelength and peak power, this highly versatile laser allows seamless transition between pulsed and continuous wave modes, resulting in precise dissection and excellent hemostasis.

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