Surgery
Real-life HoLEP 19: Modified three-lobe HoLEP technique to avoid early stress incontinence
Dr. Fernando Gómez Sancha · ICUA
Dr. Fernando Gómez Sancha · YouTube
Language: English. YouTube audio metadata.
Surgical content for professionals. Contains footage of an operation.
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About this video
A live HoLEP teaching case showing a modified three-lobe technique and the white-line concept for protection of the external sphincter's mucosa. The stated objective is to reduce early stress incontinence; the description does not report a measured continence result. The session was transmitted from ICUA–Clínica CEMTRO with participants from Germany and Brazil.
This is a video of a live transmission we carried out last week from our operating room at ICUA-Clínica CEMTRO, sponsored by Richard Wolf, with participants from Germany and Brasil. It shows how to use the concept of the "white line" to achieve an excellent external sphincter's mucosa protection which helps to avoid early stress incontinence after HoLEP surgery. There is very good advice in this video if you perform AEEP with three-lobe or two-lobe techniques. I hope it helps.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- Three-lobe technique
Real-life HoLEP 19: Modified three-lobe HoLEP technique to avoid early stress incontinence
- Preservation of sphincter mucosa
It shows how to use the concept of the "white line" to achieve an excellent external sphincter's mucosa protection which helps to avoid early stress incontinence after HoLEP surgery. There is very good advice in this video if you perform AEEP with three-lobe or two-lobe techniques. I hope it helps.
Source checked: 2026-10-06.
Available transcript · English
Automatic YouTube captions, not clinically reviewed. Names, technical terms and numbers may contain errors.
Selected spellings of enucleation, morcellation and holmium terms have been edited. This is not a full audio or clinical review; the original captions remain the source.
They may contain transcription or translation errors; check the explanation in the video.
- i did a lot of green light vaporizations in the past and with green light it was possible to do the operation almost alone huh but with hollop you need a lot of help you need a lot of help maybe you can show them that we have the most later prepared in the here and of course the surgeon is going to perform the operation but the support of the nursing staff is it's very important maybe last hour okay so we're going to we're going to change to the endoscopic image i think if if the quality is not good enough you tell me sometimes we can focus uh a little bit better so okay so if you're if you're watching here we are approaching the sphincter area and i think it's very important to protect this
- this sphincter area here we can recognize the very montanum and we can recognize the edge of the sphincter here and as i said this is not especially large land it's a little bit enlarged but not not too too enlarged let's have a look the o's are relatively close relatively close to the to the bladder neck trabeculated bladder this is the edema from the catheter and i'm going to introduce the laser fiber huh i'm going to work with a holmium laser at uh my my favorite setting is to use two joules and frequency that can be 40 50 depending on the on the machine you use all right so typically when we did the original uh let's say three load technique we would start doing incisions in the bladder neck
- straight ahead but i'm going to recommend you to come down here and mark the limits of the sphincter you see this is what i call the white line and it will serve us as a reference during the procedure all right so you don't want to get lost so you want to mark this this white line all around the center and down to the apical area and i you will see how helpful it is later on to do the apical dissection and what i'm trying to achieve with this is i'm trying to achieve a protection of the mucosa of the sphincter you see i want to protect i don't want to be far away from the sphincter i want to be relatively close but sometimes you know one or two millimeters is not such a relevant difference okay
- so this would be the white line i also like to prepare a little bit the posterior fibers here so basically what i'm doing is i'm cutting the attachment of the apical prostate with the sphincter you see in the lower part near the vero montanum and i will do the same thing on the other side and you see why this is important in a moment huh so this is the initial preparation you know that the plane is is very easy to find near the vera montanum so you can you can put your scope here and push you see to do a little bit of mechanical dissection you can push a little bit to the side until the the plane is more or less revealed okay you see that plane so this is the advantage of the wolf let's say instrument
- that allows you to do this and you see when i put the instrument against the tissue i still can see the tissue with some other instruments when you contact the tip of the scope with the tissue you cannot see the tissue because the telescope is touching the tissue so here we are okay so at the beginning of the procedure we already know where is the plane okay and now we can go if you are if you prefer uh to do a three lobe technique and we can choose to do incisions so let's start for example in this side i'm going to start making an incision to carry out these incisions i would recommend you to try to make a v you know the letter b the letter b sorry it has a pointy edge and stay in this pointy edge
- to deepen the incision and to make only one incision i wouldn't like to see two three four five incisions just one incision and my my recommendation is not to go all the way down at the beginning because you see the prostate is a little bit long and if you stay in the bladder neck and you if you deepen the incision in the bladder neck first you see you stay here a little bit let's go in and see where is the uo the o is there more or less so what's going to happen is that we are only going to do like half of the incision half of the incision the depth is going to be let's say reaching the bladder neck fibers reaching the bladder neck fibers here you see and when i want to continue with my incision
- it gets it is already much shorter you know so basically when you do this incision in two in two parts the initial part the bladder neck part and then you continue downwards what is what you are achieving is that you are making a simpler incision sometimes especially when you are starting so initially you do the upper parts you know the proximal parts and then you try to connect and you try to bring this incision down downwards downwards downwards downwards uh to where the plane is huh you see we already have the plane here so [Music] here we have to continue you know one of the mysteries of this operation was when to stop with the incision and i have to say that the mystery has been let's say
- much more easy now when we can see the plane already here you see so instead of following the incision and trying to reach the level of the capsule without really being able to tell where is the capsule what we're going to do is let's see where is the v of the incision here what we're going to do what we're going to try to do is to bring the plane from from below so here is the good plane so i'm going to continue with this incision from below you see this is good plane good plane you can see the good plane here and then we can bring this depth upwards all right and then it's much more intuitive and much more simple all right these are tips and tricks that i picked up on the way although you have to say again
- hello i cannot hear you very well but i see someone has joined the conversation okay so you see initially we have we have achieved to do an incision that goes from the bladder neck towards the plane here huh here's the vero montanum where is it here you see so by localizing the plane at the beginning of the operation now we know where the plane is coming another tip is to cut a little bit uh the bladder neck towards the midline all right so here once you have completed your incision if you cut a little bit towards the midline like this then the nucleation of the middle lobe is going to be much simpler all right so let's go to the other side let's start the other incision so instead of going all the way down
- down down i'm going to stay here i can hear your voice but i cannot understand [Music] someone is talking brazilian i think [Music] maybe if if you don't hear me maybe you can write your questions in the chat and then they will relay them to me okay so this is the second incision all right i'm coming towards the uo more or less in the direction of the uo and initially i'm doing the incision only in the proximal part okay because this way i can simplify simplify a little bit when i want to continue the incision so now from here to here you see it's a very short it's a very short way huh so it makes [Music] life much easier if we can do the incision in two in two parts let's come up here try to get inside the incision and then
- bring it down down down to try to connect here and there will be a point where we will find the plane that we developed near the very montanum which is around here you see this is capsule huh so again we will bring the incision upwards to the depth of the capsule huh that's that's a way for someone who has no not a lot of experience to know where the limit of the capsule is more or less okay so we keep on our incision this is the original bladder neck incision now i can come a little bit further down further up you see and this way we can get to a depth that looks like the capsule you see if you have the need to do it you can do a little bit of mechanical dissection just by connecting with the capsule and
- pushing up to find the proper plane alright so let's continue with our incision there we are coming up coming up coming up towards the bladder neck all right so this incision more or less is a it's completed i wouldn't go you know very deep at the beginning because we can correct also the depth when we see how how it's going again this is ladder neck and i'm going to do what i did in the other side which is to cut here towards the midline all right why is this important because it's going to simplify the middle lower nucleation all right so it's just a little nick this is the uo here we are and now we go down to the room so now we have you see the plane in one side the plane in the other side
- and we're going to cut on top of the veyro to try to connect both planes like a smile i'm going to smile from one side to the other side here we can try to use a little bit of the mechanical dissection or we can use the energy from the laser beam you see if you if you want to dissect also you have to position yourself down here and make very very gentle pushes to find where we are to find where we want to be and to follow the the right plane huh so we connect from one side to the other side and continue with this dissection very gentle always so you don't want to go deep in the prostate also sometimes i like this this plane is a little bit flimsy so i'm going to put my fiber at 12 o'clock and i'm going to
- connect you see with energy because otherwise we're going to go a little bit deep there huh i'm going to try to connect from side to side from side to side let's see trying to stay a little bit further up so we are very sure that we are in the right plane in the in the in contact with the capsule all right so from side to side you see and the way we did these incisions uh and the way we cut the bladder neck at the beginning we're going to leave a very small pedicle you see and the middle lobe is going to detach very very fast all right there we are and that's the end of the middle lobe [Music] that is the end of the middle up here maybe i will bring my fiber back again to six o'clock this is
- this is personal preference and many people always keep the fiber at six some people rotate the fiber i like to keep it either at six or twelve so this this would be a relatively simple way to do the middle lobe education now you see now that we are finding this edge here and not over there because we cut already this ladder neck at the beginning so it's quite easy now to to finalize this that's completely free completely free and a little push there we are huh so that's the middle lobe area here we went a little bit into the capsule but not nothing to to really to worry about let's uh do some hemostasis but i think it's pretty good here and now of course if we go back you see this is a small identity
- maybe yeah so the next step is going to be to go to the 12 o'clock area to do the 12 o'clock incision but of course if you remember we already marked here at 12 o'clock you see this is the 12 o'clock mark here is the white line from the other side all right so now we perfectly know where is 12 o'clock where is the limit of the sphincter so we're not going to make mistakes there huh so i'm going to come here under the 12 o'clock region and i'm going to make a small cut that i'm going to bring towards my limit here again 12 o'clock bladder neck region and i will do this incision again [Music] until we see some fibers a capsular fibers anteriorly are a little bit more easy to to distinguish now you can see the
- aspect of the of the fibers crossing from one side to the other they're usually quite bright shiny shiny shiny fibers all right so here i would say there's another trick and the other trick is when you are here on the bladder neck let's cut a little bit towards the side all right if you do this you're going to make your life easier for later it's very similar to what we did in the middle of region so here we come to the 12 o'clock region near the capsule you see and we bring our incision a little bit towards the side okay [Music] so this is our 12 o'clock 12 o'clock incision here and also if we come down down down down we can come out almost come out we can see the sphincter here you see on the white
- line the white line remarked so the next thing i'm going to try to do is to continue cutting over the white line so this is a white line as i marked it and then try to connect this white line all the way up when you come up here you have to continue horizontally because we want to go and connect connect with the 12 o'clock region you see let's try to do this this this dissection coming from below here you see coming up coming up coming up take your time take your time you can do this in one pass or you can do it in 30 passes it doesn't matter huh and then when you come towards 12 o'clock we have to join join with the incision we made before huh so here and this is the most difficult part of the operation here
- always the epical liberation but here you see this is a 12 o'clock incision we made and now we can come around you see we can come around the apex we come out again now you see this is apical tissue we can follow the line all the way up here huh so now we're going to try to release this lobe following this plane my advice is that you try to use the energy let the energy do the work and move a little bit dynamically from side to side don't stay too long in the same spot because you don't want to deepen in the capsule you don't want to go very deep let's see that looks like tissue [Music] but you you want to also make very wide lines like this you see going from side to side keeping oriented keeping oriented this
- is going to be the lower aspect you see so let the energy do the work of developing the plane if you are in doubt remember that you can use the tip of the scope but if you have a good visibility if you have a good progression if you have good hemostasis then it becomes relatively simple it's a piece of cake huh here we're coming let's see if we can go all the way towards the 12 o'clock incision we made you see we want to release everything here there we go and there's a nodule here so we have to take it out [Music] this one here coming up coming down it's really a very simple movement trying to follow the capsular plane some prostates show you the way very clearly some others are a little bit
- more difficult but you have to judge when you are dissecting the plane you have to judge if you can go a little bit deeper if you can correct or not if you're going too deep you know sometimes the plane will tell you exactly where where to go sometimes it's a little bit more difficult huh so but if you are patient and if you're careful there shouldn't be any major problem major accident or anything so here we're coming towards again towards 12 o'clock you see this is a 12 o'clock incision we made 12 o'clock coming around again 12 o'clock [Music] following the contour off of the capsule letting the plane dissect for you and coming all the way around towards the other side so now the lateral lobe
- is touching very nicely it's better to try to carry a single perfect line of attack perfect plane but sometimes it's not easy so you have to adapt to what you're finding this looks like a very good plane you see it's the touching very nicely with the energy also it's important i think to make a good hemostasis as you go so here i'm coming down down down this is maybe a little bit deep and i want to keep the line a little bit higher so as long as you don't go too far you see you can correct and nothing really happens you don't want to go very very deep in one place because you were not careful and that's why i like to to move the fiber from side to side so i don't allow it to stay too long in the same spot
- deepening huh deepening the incisions so here again classic technique three log technique but you saw that we developed the apical plane we separated the sphincter from the apex before starting the dissection in the classical technique you actually dissect the lateral lobe and you leave the apex for the end that's why i think the apex suffers a little bit more with the classic uh approach and that might explain the post-operative stress incontinence we simply do not see foster predistress in continents only only very very very rarely huh so here is 12 o'clock of course there comes a moment when we are going to find the bladder neck itself you see so in this in this moment when we come to the
- bladder neck we have to cut the bladder neck also circumferentially but here the plane is touching very nicely very nicely let's see where we are this is nice i don't know how good is the quality of the image you're seeing i'm trying to record the whole procedure so we can send in the whole procedure in better quality if you want and then maybe the representatives from richer wolf can give it to you huh so this would be bladder neck already you see here so i'm coming down coming down coming down and coming around huh coming around trying to follow the lateral plane [Music] all the way up let's see this is the lower aspect this is the plane that was a little bit deep and so we are nearly nearly finishing here
- [Music] so again we are approaching the the bladder neck here you see this is bladder neck now so we have to cut the bladder neck circumferentially also around the enoma and try to find you see the nice plane as i told you before i'm usually like to do more the block technique and i have a lot of videos in youtube so if you look in my channel in youtube by my name you will be able to see procedures like this but with the other technique but i have to i i have to agree that the classic technique is quite well known look at this look at the apex you see the sphincters mucosa is perfectly preserved we preserved everything and this is the important aspect okay so now we have the other lobe we have
- the other lobe this is 12 o'clock and we have the white line you see this is a little bit of the sphincter here our white line was was here you see so i'm going to deepen a little bit this cut in the white line and i'm going to follow the contour of the sphincter from below towards the anterior part i'd rather do it with a fiber at 12 o'clock so here you see i'm coming up a little bit and staying here what i want to do is i want to reach the anterior aspect from below like that you see carefully coming up but instead of going all the way here i could go much more deep here you see this is the classical way and then come up without looking at the sphincter i want to look at the sphincter first you see
- here i know the tissue is white so we've been there before so there's no danger for the sphincter huh and here i'm coming upwards towards 12 o'clock coming upwards and already connecting with the 12 o'clock incision i made before let's come here almost almost there almost there almost there over there okay then you see now i have done the optical release the apical release this is coming towards let's say 12 o'clock 12 o'clock i want to reach this point you see the 12 o'clock area here and i want to follow the circumference the the contour of the capsule you see to remove all the tissue around huh there's a bleeder there but let's see so again apex and we're going to replicate exactly what we
- did from the other side [Music] i cannot hear you very well i hear someone speaking but i cannot hear you very well okay so there we are you see coming down down down and trying to connect [Music] ah okay i'm using 240 now huh 240 so 80 watts 240 it's perfect for for a nucleation you can do 250 to 60 depending on the machine you have i i really think you can work with low power but you know low power makes the procedure a little bit more difficult i think if you're going to start your experience my recommendation would be to use a little bit higher power because higher power provides a little bit better coagulation i think and especially when you're going to do very large glance i i prefer to use
- a little bit higher power not i mean we can work with the energy settings that go from 30 36 watts you know like uh 2 15 218 220 you can do the operation with uh surprisingly low energy but you have to work in a good uh in a good setting in a good situation something that is comfortable for you you see here for example the capsule looks a little bit thinner so i'm going to correct a little bit you see the the direction of the dissection so you have to judge during the operation you have to judge how deep you're going and how deep you want to go and just keep on the edge keep on the good on the good plane and really it's not so it's not such a difficult operation now we are about to finish the the
- nucleation phase and uh you see this this this energy allows me to develop the plane very safely and also to deposit some energy on the on the tissue so it provides reasonably good hemostasis of course we will check for hemostasis at the end but i think [Music] it's nice to have a little bit more power than what the consoles the low power consoles can give you you know if you have a 50 watt laser many times you can only work at 40 or 30 36 continuously you know these lasers do not uh support continuous lacing like we are doing one of the nice things that you you have seen is that i don't stop almost ah i stopped only to to to change from lobes but you see my action or with the laser is almost continuously
- that's why we can complete these procedures relatively fast you know you only stop strategically but stopping is the rare thing during the operation most of the operation the laser is activated so if if you buy a very low power console i think it can be a problem sometimes they don't help you they they stop you have to re-initiate unlike that so i would say you want more than 60 watts i think yes questions oh this is a 30 degree lens huh i think you can also work with 12 but this is our this is what we usually do a 30 degree lens what we usually use huh and you see we are completing now the dissection of the lateral lobe you know what happening the lateral lobe is pushing forward you see so we are
- getting to see the the bladder neck and i can go all around all around the bladder neck like this coming up towards the limit so really a piece of cake operation i think also for those of you who don't do hollab yet i i would say there's nothing so rewarding us to do hollap you know the patients are super happy these are the happiest patients i i see yeah the the the patients that undergo a whole new manipulation so there we are i think the inauguration is finished this is still a small bridge uh sorry my water inflow came out my water inflow came out that's why the visibility samuel say okay so here we are again and now of course we have to spend two or three minutes uh checking for for bleeders huh if we see any
- bleeder we have to stop it because before more selection we want to have a good visibility that's capsular you can tell very nicely um so before we finish i'm going to show you uh the transrectal ultrasound image off and let's look at the sphincter again you see this is perfect mucosal preservation and this is perfect mucosal preservation you see this is the sphincter huh so to me this is the most important uh aspect protecting the sphincter so the patient will be very well tomorrow morning i will remo here is the 5 p.m 5 p.m so the patient will keep a catheter and tomorrow morning we'll take it out and send him home [Music] and uh here is the uo which is safe here's the other uo and i think we're going to prepare for
- more selection i don't see major bleeders let's see anteriorly okay this is anterior yeah there's some small bleeders it's a little bit irregular here if you want to to complete let's say the removal of a little bit of tissue that was left behind you can perfectly do it at the end this is the trimming trimming phase sometimes you have very beautiful planes and sometimes there's some cling ons some little fragments of tissue that are hanging so you can just take them out while you check your hemostasis and i think this is it i think this is it beautiful so let's move on now to to marsulation let's move on to more solution i'm going to ask my nurse to help me and this coordination is very important i don't
- know if you can see the the external view this is a small final [Music] bit of tissue okay now it's completely free you can have mucosal bleeders you know at the edge of the mucosa sometimes you can get some mucosal bleeders that will obscure the visibility but now [Music] we are starting the the transaction ultrasound so i can show you the trans-rectal mobile pata [Music] okay it's calibrating [Music] so you can see this is the endoscopic uh sorry the trans-rectal ultrasound view of what we have done this is the cavity and the prostate huh and this is the longitudinal view huh you see we removed uh all the adenoma anatomically respecting the sphincter okay so let's marcel it now so first of all take the fiber out
- laser and stand by and we're going to change the instrument you can understand that uh through the channel of the systoscope we cannot introduce the morcellation blades so we have to change the instrument we have to change for a nephroscope or a more scope and we'll do a fast change so we don't decompress the bladder so my nurse is helping me this is what i meant about the teamwork and now we have the nephroscope view and i'm introducing the more the piranium oscillator okay so very important you never rotate the musculature like that okay can we see the uh [Music] [Music] never rotate the morcellator always looking up always looking up come to a point so near the bladder neck here for example
- where you see the bladder and use the suction pedal and then take the tip of the most later upwards and then activate the musculation okay so i will repeat this as many times as i need until also very important don't don't use them oscillator very close to the lens this is a bad idea take it in at least you should you should see the richer wolf logo and then because if you if you have the this view if you have this view no more vienna reflection is not very good let's see why but you see when you push the the tip of the most later blade inside what happens is that you can see on the sides let's see we start engaging the piece better now for some reason this morcellation is not so comfortable let
- me get comfortable okay so [Music] typically when the suction is good the the piece should engage very good now it's better here you see that uh when i'm more selecting i can see two triangles around the blade at each side of the blade there's a black triangle that means that i am looking at the bladder through these small triangles if i bring them oscillation here i only see adenoma and blade you see but if i keep it here i can have more perspective why is that important well if you get close to the bladder you see it starts looking pink you don't want to activate the blades here because i can see the pink in my triangle huh i i want to work with two black triangles around the the piece and i have to say that the
- best uh the best improvement in in uh mostly in technology for hollap has been the the the wolf uh fast most later blades huh you know this is uh amazing because even when the musculation is not optimal now i think it's like 80 percent it's not it's not perfect uh even when the morcellation is not so fast because of a lack of suction or something it takes the tissue away very fast so we measured our morcellation efficiency after many cases and it's about 10 grams per minute on average 10 or 11 grams per minute on average that means that you can morcellate a 100 gram adenoma in 10 minutes so it has shortened up a lot the the the duration of these operations i don't know how long did it take to do this one
- of course this is a a teaching video a teaching operation so it takes a little bit longer than usual but as i said you can look for my youtube channel to check for other operations and you will see that it's not unusual that we can do 60 grams in 20 25 minutes 100 grams in 35 40 minutes something like that so actually when we do a session that goes from 3 p.m to 9 p.m every day we can schedule up to 5 cases sometimes of course when we're going to do the monster prostates like 200 grams then we maybe do three or four cases but if we do regular sized prostates 100 grams 80 grams 90 grams often we can do five cases in one evening in one afternoon and there you can see the more slation is working very well
- we had a nice hemostasis so we still can't see very well the importance of a fast motivation is also because when you start the morcellation the visibility is good the water there's no proper washout and so the visibility can degrade huh so every minute the visibility will be a little bit worse okay one thing we can do if if the tissue is going away is we can come to the fossa and try to morcillate inside the fossa this is an advanced trick as you see now that the piece of tissue is clashing with the walls of the fossa and i'm keeping my morse later totally still i don't move it i'm not getting anywhere close to the to the walls of the fossa but we were able to mostly the piece inside the fossa very nicely this is very safe
- let's say for the bladder and this is also a way to keep the piece engaged to the morse later blade huh okay so let's see we have any other piece in the bladder you see how visibility is degrading so we were lucky that we had a fast moscellator to to to do the job there we are catheter