The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique

Holmium laser enucleation of the prostate (HoLEP) is currently considered a safe and effective therapeutic option for the treatment of adenomas of any size. Being considered difficult to learn and to teach, HoLEP is not as diffused as it would deserve. In 2011, we started performing HoLEP reproducing the traditional Gilling's technique. Case after case, we introduced alterations in the surgical approach, trying to overcome our difficulties and minimize our learning curve. We present a detailed step-by-step description of our modified HoLEP technique, developed in Torino, Italy, which we called en-bloc no-touch. The main steps of the en-bloc no-touch enucleation phase include: (1) the identification of the correct plane between adenoma and capsule only once, at the apex of the left lobe laterally to the veru montanum, extending the incision retrogradely towards the bladder at 5 o'clock; (2) the en-bloc enucleation of a horseshoe-like adenoma, sparing the 7 and 12 o'clock incisions; (3) the use of the beak of the endoscope, gently raising up the lobe from the capsular plane and creating a dihedral angle, crossed by connective bundles put in tension by this movement; and (4) the gradual no-touch lasing of such fibres, exploiting the effects of the plasma bubble at the tip of laser fibre, with no direct energy supply to the capsule. In our experience, the en-bloc no-touch technique has the potential to ease some difficult intraoperative steps and to improve the learning curve of HoLEP.