Surgery
T&T Semilive surgery: Virtual Basket pulse modulation Holmium laser enucleation of the prostate
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 HoLEP case presented at the online Technology & Training in Endourology meeting organised by Cesare Scoffone and Cecilia Cracco. The description identifies the Quanta System Cyber Holmium 150 W laser with Virtual Basket pulse modulation. The recording was shared as a teaching case; the written source does not give a postoperative clinical assessment.
This is the case I presented at the recent meeting "Technology & Training in Endourology", organised by Cesare Scoffone and Cecilia Cracco. This year's meeting was fully online. It shows a HoLEP case performed with another Holmium laser that allows pulse modulation, the Quanta System Cyber Holmium 150 W laser, with the "Virtual Basket" pulse modulation. It is a nice teaching case as well. Hope you enjoy it.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- Virtual Basket
T&T Semilive surgery: Virtual Basket pulse modulation Holmium laser enucleation of the prostate
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.
- block hollap with early apical release this is fernando romet sancha i'm going to show semi-live case using the quanta system holmium 150 watt laser using the virtual basket pulse modulation setting at 2 joules uh 50 what's classical settings for home nucleation patient is a 70 sorry 67 year old man with bothersome luts who has been on dude dart for eight years with a normal psa and a prostate on ultrasound of 85 cubic centimeters so the procedure starts with a very careful cystoscopy trying to avoid bleeding and we're going to use a 550 nanometer reusable fiber from from this system here you can see this sphincter is a little bit sort of the apex is a little bit asymmetric and initially the procedure starts
- with the marking between the sphincter and the apex of the adenoma this is called this i call this a white line is a line that you demarcate as a surgeon there's no other anatomical clue about the sphincter than the sphincter itself so you have to look at the anatomy and decide where you're going to mark this white line that will guide you for the rest of the procedure initially i tried to make a circumferential line that goes over the very montanum or just cutting the mucosa and all around the adenoma to delineate the limit of of the operation from the beginning this is going to be the capsular localization maneuver on this side usually i like to do a little bit of this mechanical dissection
- at the edge but of course you have to make sure that you cut the attachments of the sphincter and the apex posteriorly first because this way you create some space that gives you some access to go in there and do again this maneuver on the other side so but always you know cutting these fibers you can you can enter the plane with energy dissection sometimes but in this occasion i thought it was a good idea to develop this plane both sides so we have a very clear anatomical reference or of with where the operation is starting this is the section of the frenulum of the varroa crossing the midline so we can have one single posterior plane once this space is developed i like to turn the fiber to put the
- fiber at 12 o'clock which is going to be my static fiber position during the operation i think keeping the fiber in this position throughout the procedure makes the procedure simpler you don't have to be moving the camera you don't have to be moving the fiber around and it makes the procedure more simple now this is the line of attack this is the line of attack it's going to be always in the center of the image so you have to position your scope center it with this line the line of attack so you can always see half of the screen width capsule and half of the screen with that normal working with this wide line of attack makes the procedure simpler and it helps you decide where the plane is when you cannot see
- where it is because the anatomy is not so clear so it's nice to have this uniform line and here you can observe the effect of this pulse modulation setting you know the holmium energy typically is absorbed by water so it doesn't reach very far but you can see that i'm using the fiber a little bit apart from the tissue and it's providing me with excellent dissection of the plane and at the same time it's providing me with an excellent first pass hemostasis this means that i can focus on the dissection of the plane and the anatomy i don't have to be worrying about fiber the rotation of the camera or keeping actively the hemostasis because this pulse modulation technology allows us to operate in better
- conditions this enhanced hormone laser energy that provides better cutting and better coagulation is helping to develop the plane with excellent visibility and of course making the operations faster one of the other things that i think is going to be facilitate by these lasers is the learning curve you know if you don't have to worry so much about bleeding during the operation learning this procedure seems to be easier we haven't got data yet but we have the clinical impression that teaching the procedure with this laser is much easier than with a normal hormone because whoever is using it at least can see properly and is not anxious with the control of hemostasis also of course this and block technique with early apical
- liberation has many advantages and one of them is the excellent irrigation this excellent irrigation of a very small space provides also very good visibility even when there is mucosal bleeding so whatever we did in the posterior aspect so the liberation of the posterior aspect of the apex we have to replicate now integerly so initially i'm going to do this cut which seems to be cutting on the adnoma you see i'm cutting on the adenoma i'm cutting i'm deepening the the white line that i did at the beginning and i do that to get more access so i can really look for the good plane and do the dissection of the apex but without causing excessive stress in the external sphincter so it's very important that this initial
- incision allows to dissect this relatively complex anatomical space you know the limit anterior limit of the sphincter and the apex with a little bit more easy and especially more safe conditions because by cutting these attachments of the sphincter and the apex initially we get better access and of course we can work safeguarding the sphincter's mucosa we have realized that the problem with classic hollop techniques that would dissect the adenoma without looking at the sphincter without looking after the sphincter would often cause a de-epithelization of the external sphincter which could cause early postoperative stress incontinence now with this careful early apical liberation and sphincter's causal preservation
- we see that stress incontinence is a very rare occurrence even in patients with large clouds this is a 12 o'clock limit we hadn't marked all the way up to 12 o'clock and here we can see that if we continue dissecting the lobe uh the classical way maybe this little curtain that we can see there often cosa would become much larger and would de-epithelialize the external sphincter so it's important to keep on the see that's the sphincter surface that's a sphincter's mucosa and it's important to avoid the generation of this curtain of mucosa that means that the mucosa has a split has broken and is leaving the sphincter probably intact in terms of the the muscle fibers of the sphincter but without the mucosal lining
- that is responsible for providing a perfect seal for post-partum continents so here we're coming up on the other side i like to connect the planes so when i'm doing the lateral dissection of the apex i like to connect it to the posterior plane we did before this is going to make things much easier later and then as we come up you have to be very conscious of the position of the sphincter and when you ascend in this dissection you have to start cutting more horizontally it's very important to cut these fibers so we can take the line of attack a little bit more proximal further from the sphincter and then once we have separated this apical anterior attachments to the sphincter we can then focus in following the right plane
- looking for the best most eccentric plane that will allow us to remove the whole anoma doing these incisions doesn't mean that you're going to leave any significant amount of tissue attached to the to the sphincter so these technological advancements the pulse modulation that we have seen initially with the moses holmium system from from luminesce and now with this virtual basket setting from quanta systems is changing everything you know it makes the holmium cut much better and become much similar to the cutting properties of thulium so this laser cuts the very hard tissue the very fibrous tissue like the 12 o'clock fibers of the sphincter much faster with excellent hemostasis and these are the two features that the
- hormone the modern volume systems are now acquiring the ability to cut much better on the ability to coagulate much better so before when i was using julium lasers and green light lasers for nucleation i was always missing the property of the holmium laser that provides this ability to dissect the plane following the anatomical route and now with this enhanced [Music] cutting i don't miss the tulum or the green light because of their properties so i think holmium has been now enriched with properties that we liked from tulium and greenlight and this excellent coagulation excellent first pass violation which means that as we dissect the coagulation is is already quite solid quite good is an excellent feature that makes
- the our everyday life much much better one of the things that i have liked from this special console it's a little bit bulky it's quite big and uh not especially let's say fancy in terms of design but it's a big box but it it provides a very silent operation and i think the lack of noise in the operating room is is really really a big joy we are used to to have a very big noise in the in the very high you know noise in the operating room with other lasers even low power lasers sometimes are very noisy but this unit is excellent in that respect so i think it's going to be competitive in the sense that we can reuse the fiber in the sense that uh it's very silent and the tissue effect seems to be excellent i
- have done now a number of cases with this laser and i like it a lot because it allows me to carry out this circumferential dissection of the adenoma without having to worry so much for the bleeding of course there's always cases special cases where there can be a little bit of bleeding because the vessels are too big or the prostate is very vascularized or i don't know the patient has a high blood pressure during the operation and it tends to bleed a little bit more but in principle the quality of hemostasis has been very much improved with this pulse modulation advances in the generators and the new generators of holmium laser so as you can see this operation also needs a laser that can withstand
- continuous operation you can see that i hardly ever stop working you know this is why these procedures are very fast not only because the holmium pulse modulation makes the procedure faster because but because and block uh and block holyp is a very fast procedure you don't have to lose time making incisions in the prostate you right away go to the plane and right away start to develop the plane and then the pausing time the time that you are actually not lazing is very very very little time during the operation so most of the operation you have to fire the laser and i i really like to be able to work like this continuously seeing how i can improve the situation every minute you know things are getting better and
- better as we go here we have a circumferential line of attack you see the camera is centered on the line of attack all the time but we have to take into account that the direction of the plane is not always the same so initially the plane is looking let's say towards the lateral sides towards the posterior and towards the interior because the planes are opening up let's say the angles are opening up because we are dissecting a spherical structure or pseudospherical structure in this moment in the operation you see the bladder neck for example is not going down anymore you know the direction of the dissection is changing and we can go around the adenoma but we have to be very careful where we aim the laser so it doesn't
- penetrate in the capsule and for that we have to work against the line of attack but keep the fiber a little bit on the side of the adnoma you see so you have to fire against the line of attack but on the side of the adenoma to try to correct this uh planes that are not straight the fiber is straight but we have to dissect these planes that are not straight at all so the way to adapt to the change in direction of the plane is to change the aiming initially we were aiming right at the line of attack now we are aiming a little bit closer to the adenoma all right so here we're trying to dissect downwards and pushing the enoma a little bit down we can reach the bladder neck integerly there is a steep change of the direction
- of the fibers you see above we have circular fibers but now we see vertical fibers and this means that we are reaching the bladder neck interiorly now we are with our scope placed above the anterior commissure between the anoma and the capsule entering the bladder integerly i think this is the safest entry point and i have to say it's rather constant to be able to see this uh change in the direction of the fibers which is paragnomically you know a sign that we are going to enter the bladder neck so there's no mistakes there of course i've done a lot of cases with this technique and i feel very happy and familiarized with it for those surgeons who haven't done it yet i recommend them to watch the videos that i have
- posted online in youtube to to try to learn uh the steps and tips and tricks to develop uh the skills to be able to do this procedure fast and easy and if you have a post-operative stress incontinence even when it's temporary you have to know that this approach changes that completely you will forget about uh incontinence in the post-operative period here in this uh in this drawing i'm trying to depict the changing plane that i was mentioning and how you see the fiber has to stay very close to the adenoma in order not to perforate the capsule and not to get with your dissection behind the trigon of course it's nicer you know especially when it's a difficult plane sometimes it's very easy uh you can always try to connect
- the sides you know you can connect the sides with the posterior aspect so go from lateral to medial because we know very well where is the plane laterally and we can progress towards the midline and below the middle lobe to try to do a progressive dissection careful dissection that doesn't perforate that part of the of of the prostate so this is the posterior aspect we are about to finalize the nucleation of the prostate there's only now an attachment at the bladder neck posteriorly and because all the anterior aspect of the ladder neck has been already cut and dissected here we're coming up towards the more anterior aspects laterally you can see that the behavior of the laser is amazing nowadays we can
- finish these cases you know for an 80 gram prostate i think the total operative time in this man was something like 35 minutes so it's really a fast procedure we can progress faster and faster with experience and it really makes this procedure extremely attractive you know we leave the catheter typically overnight and take the catheter the next day but there are already studies with pulse modulation that show that this procedure can be performed in an ambulatory setting in a number of patients in selected cases so i think the paradigm of hollap is changing it's been here for quite a while but there have been not only changes in technique you know and a better understanding of the anatomy of the apex and the center
- on how to protect continence in the post-operative period but also technological advances that make this procedure even more attractive and i believe it is making this procedure much easier to learn so that's uh well it doesn't mean that you don't have to work you know for this procedure so here you can see how the bladder neck is being cut lower and lower until we can get under the middle lobe you see under the middle lobe and we can leave the anoma hanging from the bladder neck at six o'clock we will be able to flip the adnoma into the ladder at some time i have found that even in very large glands it's usually possible to flip the adenoma by flipping one side first and then the other side
- you know making a rotational movement of the adenoma to to try to squeeze it into the bladder that's the other side here also we're trying to connect the bladder neck with our dissection the posterior plane with the lateral plane and incise the the bladder neck fibers following the circumference of the of the bladder neck and it is really a pleasure to work with a laser that is now i think approaching very fast this this goal or this tremped tool that would allow us to do a nucleation focusing on the anatomy only and providing excellent means to cut and coagulate and also an explosive effect in the tip of the fiber that separates the plane following the anatomic route you know following the path of least
- resistance and allowing for an anatomical dissection that makes us feel that we are in the right plane all the time we are removing the whole adenoma and we can be pretty sure that the patient is going to have an excellent clinical result we can do these operations typically under one hour and [Music] patients go home without a catheter after a few hours and go back to their normal life after two or three days so it's really i think the best procedure available for the long term resolution of uh lower urinary tract symptoms due to bph that's the end of the procedure there's always some attachments that have to be freed at the end and uh now it's the time to try to flip the ednoma you see that
- the capsule is is uh very nice very anatomic and there's uh nearly no bleeding i just maybe minor bleeders that usually happen at the bladder neck that's the uo and we had this little piece of tissue hanging there near the uo and we have to avoid of course damaging it and here mucosa very close to this thing too was very close to the uo was peeled off but both yours looked absolutely um healthy so no no problem there and the nucleation was finished the good hemostasis means that you can move on almost straight ahead when you finish your nucleation you change the morcellation and then of course the advances in morcellation have also allowed us to do very fast musculation i'm only showing the end because there's
- no time but uh here you can see how the fossa remains without bleeding and there is an excellent preservation of the sphincteric mucosa that will provide immediate continence for the patient