The authors are addressing an important issue facing urologists doing holmium laser enucleation of the prostate early in their experience to prevent the early and temporary stress urinary incontinence that could be encountered and could last for a few weeks to a few months. They suggest that this technique could shorten the steep learning curve, remains to be seen. The idea of starting the enucleation anteriorly is reminiscent of the Nesbitt technique of transurethral resection of the prostate that was quite popular. The major difference, however, is that during the TURP we are constantly removing tissue and opening up a space to work in. With enucleation however we need to constantly retract the adenoma as it is being enucleated. We normally retract the adenoma with the tip of the instrument while the laser fiber is separating the adenoma from the capsule. In the anteroposterior technique you need to displace the adenoma downwards as you are dissecting with the instrument reversed. That is not a big problem anteriorly but becomes more difficult as we come down toward the 6 o'clock position. Another slight disadvantage is the fact that the plane between the adenoma and the capsule is not as easy to find anteriorly as it is posteriorly, where the major bulk of the adenoma is located. To overcome this problem we proposed in a recent video article published in the BJUI February 2010 1 Baazeem A. Elmansy H. Elhilali M. Holmium laser enucleation of the prostate: modified technical aspects. BJU Int. 2010; 105: 584-585 Crossref PubMed Scopus (38) Google Scholar that when we dissect the lateral lobe from 5 to 12 o'clock we cross the midline to the other side to facilitate the identification of the plane of dissection when we start the midline incision at 12 from underneath, whereby the 2 incisions would always meet, avoiding some of the problems described in having the planes not meeting at the same depth. Anteroposterior Dissection HoLEP: A Modification to Prevent Transient Stress Urinary IncontinenceUrologyVol. 76Issue 6PreviewThe prevalence of transient stress urinary incontinence (SUI) after HoLEP has been reported to be as high as 44%. Anteroposterior dissection HoLEP was newly developed to protect the urethral sphincter and therefore lower the incidence rate of SUI. This study was conducted to determine the SUI incidence rate after anteroposterior dissection HoLEP. Full-Text PDF ReplyUrologyVol. 76Issue 6PreviewAlthough the cystoscopic movements in our anteroposterior dissection HoLEP is similar to the Nesbitt technique of TURP, as Dr. Elhilali indicated, it emulates the finger movements of the open prostatectomy. Once the tip of the cystoscope finds the plane between the adenoma and the surgical capsule, the tip can be moved from the upper edge of the adenoma to the anterior bottom, regardless of the prostate size. Furthermore, this little space is thought to help the cystoscope shaft tear the urethral mucosa off the sphincteric ring in an appropriate manner. Full-Text PDF