HoLEP is an option for the surgical management of BPH and it’s an alternative treatment to TURP or open surgery according to EAU GuideLines. One of the main advantages of HoLEP is that reduces intraoperative and post-operative bleeding, leading to a lower transfusion rate, shorter hospitalization, and less catheterization .
This kind of enucleation is performed with the Ho:YAG laser, which is a pulsed system with a wavelength of about 2.1 µm obtaining tissue coagulation and necrosis limited to a depth of 0.3–0.4 mm while also providing a hemostatic effect . Nowadays, Ho:YAG laser is used also for stone lithotripsy, during which, the impact of the energy against the stone can cause its migration from the ureter to the renal cavity or from one calyx to another. To prevent this phenomenon, anti-retropulsion devices have been engineered, like the “Virtual Basket” mode, which is a result in pulse modulation during holmium laser lithotripsy in which the laser creates an initial bubble with the first part of its energy, and then it discharges the remaining energy once the bubble is formed so that it can pass through the formed vapor channel. In this study, we report the results of our intra and early postoperative outcomes of the application of Virtual Basket to HoLEP (VB-HoLEP) confronted to the conventional technique; we also studied the 6 months of follow-up of these patients.
Vizziello et al firstly reported their in vitro experience regarding the use of Virtual Basket in stone phantom lithotripsy . The authors concluded that this mode was associated with significantly fewer events of stone migrations and a better target stability during the procedure. Another study  investigated this emission mode in the treatment of ureteric and renal stones. In particular, it was reported that when compared with regular mode, Virtual Basket Technology was associated with significantly less retropulsion and lower fragmentation time and total procedural time, with no significant differences in total emitted energy.
Based on these studies, this mode may grant a smoother effect not only on stones but also on soft tissues, resulting in less trauma and thus bleedings. The displacement of water medium occurred with the first pulse should further impact the overall energy transmission of laser energy to the tissues, which the second pulse withstanding a lower medium attenuation.
Because of its double pulse pattern, we further hypothesize that the use of Virtual Basket during HoLEP may result in a first energy portion creating an initial separation of prostatic tissues and the remaining energy being discharged through the engraving to further extend the incision and clot the bleeding vessels. Indeed, because the laser second pulse travels through the vapor tunnel created by the first pulse, a lower attenuation should occur, so that a stronger tissue reaction (sealing and/or incision) should develop. This system with emission of energy with two pulses fired with little time in between” seems however to allow faster and more immediate coagulation which reduces bleeding, the risk anemia and, so, the operative time. Indeed, as reported in our results, compared with HoLEP, VB-HoLEP had faster operative time (57.33 ± 29.71 vs 42.99 ± 18.51 minutes, P = 0.04) and resulted in less hemoglobin decrease (2.54 vs 1.12 g/dL, P = .003). Although bleeding risk of BPO surgery using HoLEP is less than in other older procedures, the risk of bleeding remains. Some studies report a risk of severe hemorrhage in 5.2% of patients and a risk of bladder tamponade that required cystoscopy and evacuation of blood clots in 2.3% . In some Centers, to reduce the risk of bleeding in the early post-operative time, surgeons use a bipolar resectoscope to obtain prostatic loggia coagulation. This lengthens the operating time and thus increases the risk of anesthesiologic complications. In our experience, the use of Virtual Basket could improve the coagulation with the laser allowing to omit the use of the bipolar and reduce the morcellation time thanks to a good endoscopic vision without remaining bleeding.
Moreover, HoLEP has been proven safe and effective in anticoagulated patients. The hemostatic efficacy of this kind of laser let HoLEP to be effective and safer than other BPH treatment on patients who take anticoagulant agents. Specifically, the low depth of penetration of the holmium laser limits eschar formation which can contribute to delayed bleeding seen with other BPH procedures . The use of VB-HoLEP, thanks to its observed better coagulation capability, could further reduce the risk of bleeding in this kind of patients .
The comparison between HoLEP and VB-HoLEP during the 6 months of follow-up did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS.
Urinary incontinence (UI) is one of the most worrying postoperative complications. Postoperative UI occurred in about 20% of patients and most of them recovered in the first year. The operative time is the first risk factor: the longer the resectoscope remains for enucleation in the urethra, the higher the possibility of sphincter damage. Some studies stated that high prostate volume, a conspicuous reduction in postoperative PSA and diabetes mellitus are significant risk factors for stress UI . Various authors have suggested that postoperative incontinence is a symptomatic urge due to the damage of the fossa or it’s linked to the presence of urinary tract infection, BPH-related detrusor instability, or prostatic capsule thermal injury associated to laser exposure . Another risk factor for UI is the presence of a large prostatic fossa created after the removal of adenoma, because it leads to urine trapping and leakage with stress maneuvers . In our experience, VB-HoLEP reduces the risk of UI, maybe because it cut the mucosa better thus significantly reducing the traction forces on the urethra.
Moreover, the long learning curve is the major negative factor that hinders widespread use of this procedure to date . The inexperience of the Surgeon elevates the risk of bleeding and UI after HoLEP because of long operation time, frequent intraoperative complications and inadequate enucleation.
Because the use of VB-HoLEP proved to reduce the operative time in our experience, we speculate that the risk of UI may be reduced with this technique. Also reducing the bleeding and improving the quality of the endoscopic vision, the use of VB-HoLEP may reduce the learning curve. These aspects may be verified in some other multicentric studies.
Together with the long learning curve associated with enucleation technique reported above, the cost associated with the purchase of high power laser platforms has probably represented another factor hindering the spreading of laser enucleation. However, the possibility to use VB technology also with reusable fibers and on medium power platforms might help in fostering the spreading of HoLEP in upcoming years. Indeed, the non-inferiority of low-power HoLEP with respect to high power HoLEP has been investigated [18, 19]. For instance, Elshal et al compared 50W and 100W power HoLEP techniques, reaching comparable improvement in IPSS, Qmax, median reduction in PSA with similar perioperative and late postoperative complications .
There is a growing interest for new pulse modulation technologies which can potentially enhance lithotripsy effectiveness and which have been recently launched on the market [9, 20, 21]. However, so far the potential advantages of these modulations have been mainly explored in stone application, whereas little has been reported regarding the effect of these pulse modulations on soft tissue treatments. One exception consists in study of Large, who shared his experience with Moses™ technology in HoLEP ; he report that the use of this modality resulted in increased OR efficiency and hemostasis regardless of prostate size when compared to standard HoLEP. Both his study and ours suggest that advance pulse modulation by Ho:YAG laser can result in increased hemostatic effect.
To our knowledge, this is the first study describing the use of Virtual Basket in HoLEP, and one of the few ones reporting the use of advanced Ho:YAG pulse modulation for soft tissue applications. Further investigations by other Centers are needed in order to corroborate the findings of our study.
Limitations of this study are linked to the fact that all the procedures were not done by one only skilled surgeon. Another limitation is represented by the fact that hemostasis effectiveness was judged only based on the hemoglobin drop. Potentially, a recording of the time needed for hemostasis (for example the time with the right pedal pushed) may have represented an additional comparison term to corroborate our outcomes regarding the hemostatic capabilities. Furthermore, this study dealt with the use of a single emission settings as mentioned above.