Surgery
Real Life HoLEP case nº 15: trilobar prostate with narrow urethral lumen
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 involving a small-calibre urethra and a three-lobed prostate. The commentary discusses the development of the en-bloc technique, early apical release and preservation of the sphincter's mucosa. These features define the teaching focus described for the recording.
This is another case in the series, a man with a rather small-calibre urethra, and a trilobar prostate. I felt somewhat inspired and discussed several interesting aspects related to HoLEP and the development of the En-bloc technique with early apical liberation and sphincter's mucosa preservation.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- En bloc
I felt somewhat inspired and discussed several interesting aspects related to HoLEP and the development of the En-bloc technique with early apical liberation and sphincter's mucosa preservation.
- Early apical release
I felt somewhat inspired and discussed several interesting aspects related to HoLEP and the development of the En-bloc technique with early apical liberation and sphincter's mucosa preservation.
- Preservation of sphincter mucosa
I felt somewhat inspired and discussed several interesting aspects related to HoLEP and the development of the En-bloc technique with early apical liberation and sphincter's mucosa preservation.
- Narrow urethra
Real Life HoLEP case nº 15: trilobar prostate with narrow urethral lumen
Source checked: 2026-10-06.
Available transcript · English
Subtitles exported from the original-language YouTube Studio editor. Not clinically reviewed; source identity and timestamps verified, full audio coverage not verified.
They may contain transcription or translation errors; check the explanation in the video.
- so we're going to start with this man who is severely bothered by his symptoms despite taking an alpha blocker now Camelot is for power the Aretha is a little bit tight on the on the scope so I'm going to do a notice what is your throw to me it's a normal urethra but doesn't have the caliber to allow the scope comfortably so I'm going to do an ass mild what is your throat to me it's the OTC urethra tom is a device that makes a cut in the urethra until your name you see a 12 of walk it cuts the mucosa and that gives the urethra much better caliber from severe lotta huh this testimony mr. cheetah vs you saddle and aquatic on Instagram in CC mejor it's a conundrum in the quadrant I felt a deal at our mucho choice milady
- I thought I am poquito mas take a memo sir ring place Miwako demitasse in Africa getting off the optic icky but yes telecom on a pasta okay all right so hopefully so we have downgraded the scope also we are using a 24 French so I did notice your throat to me and now with the 24 you see the it's much easier so you won't cause any any forcing of the urethra that's the sphincter and that's the prostate which has a bulge here a middle lobe and there we go so we I'm going to introduce the fiber we will be starting in no time huh so Otis I think I used to work with Tony mundane in London I went there for a year to learn how to do with a plastic and reconstructive urology and he told me Otis is a good thing so I remember that
- I remember that and also there was a Spanish year oldest who inspired many of us [Music] who was recommending its use he was doing porp he used a nun plots sheath in the ladder to respect the dignity glance and he would also always say I don't have a high incidence of strictures because I used the OTC right at home and maybe you know the name that was dr. Valdivia is known internationally for his role in the development of supine percutaneous surgery for stones he was also a great receptionist he was able to respect very large glands and he would use this suprapubic Amplatz so he could resect and resect and the pieces of tissue would go would go into the bladder and out through the Amplatz sheath
- and I I followed his advice I think and I have to say that using the OTS liberally which means that whenever I find that there is some I'd say discrepancy between the size of the scope and the size of the urethra I think that you can really prevent post-operative strictures but but I say a mild Otis I mean I'm doing a very gentle let's say dilatation of the urethra so I open the Otis until it contacts with the wall I'm not doing a lot of pressure because I want to do a mucosal cut only retract the idea is that if I do a longitudinal lesion of the urethra this will not cause a stricture even if there is post presence bearing it will not heal scarring circumferentially like a stricture it will do a longitudinal scar on the interior part of the urethra so that's that's the
- idea whereas if you do traumatize the urethra with a very tight scope it's likely that the patient's going to have a circumferential tendency to to stricture okay I did a mechanical a little bit of mechanical dissection of the plane here you see that's the beautiful plane that's a beautiful plane that's the one we love to see but it is not always possible to see such a beautiful place plane sorry so this is the line of attack here you see that we went a little bit further down the plant on the plane but just by a millimeter so no worries there [Music] Here I am just following the white line as always we split the screen in two parts in the middle we have the line of attack in the upper part we can see the prostatic adenoma in the lower part we can see
- the capsule the Fiber goes in about a third of the screen maybe this is my favorite let's say working situation I put the fiber 1204 because I think it helps performing a very comfortable a new creation and I keep in there for almost all the operation I just did the original white line using the fiber at 6 o'clock because it's more difficult to go up there to the fiber of 12 o'clock and here you can see the white line we developed the posterior space and you can see now that the apex has been liberated from the sea there's some bleeding coming from here we can stop that there's a little bit of bleeding for bleeding mainly huh so now to to to release the interior parts I'm going to do my incision here on the prostate on the prostate following the white
- line trying to try to cut the fibers that are joining the apex to the sphincter and then once this is done I don't mind cutting here you see a little bit because it gives me access gives me access and it releases the sphincter from the apex so we can then follow the proper plane to develop the right plane and release the effects from the posterior to anterior huh so I'm coming up up up of course here you want to come out and see what's going on here again it's better to cut a little bit under the sphincter you see cutting here under the sink are very horizontally up here because I want proper access first so now when we have access we can gradually separate the sphincter from the apical tissue then we're going to look for the for the good plane anteriorly
- so this is the ascending dissection from one side you can try to beautify it a little bit more that they make it more perfect by going a little bit deeper inside up here and this is what we call the early ethical liberation to me there are two important factors to protect the sphincter and to prevent post-operative incontinence and that is one two preserve the mucosa of the sphincter and to to liberate the effects as soon as possible in the operation because this will limit the amount of traction that the sphincter is going to have so here again this is the line of a white line here I'm cutting on the tissue following that white line deepening a little bit into the ED Noma I don't mind you see because
- this is the sphincter this is our Noma I'm just separating those separating those so I have for better access to the rest of the the plane now we see the fact that I did this path allows me to enter there with comfort without putting traction on the sphincter or its Mikasa there we go again the thing you might find these videos live with a repetitive in the sense that I'm repeating this same let's say ideas once and again but I think it's important to watch many cases before trying to do it on your own it's important to see how it works in different prostates and it's important to see how claims not always look the same I would say that many times you don't so here you see we are under the sphincter and this is a nodule so
- I'm going to cut initially here to separate I keep horizontal you see this is fibers at 12 o´clock and as we enter in a deeper let's say layer then it's easier to do to follow the plane and it's also safer for the sphincter huh which is what we want to preserve at all costs recently I saw a Twitter comment by Felipe figueiredo Felipe is a Brazilian neurologist and he's very very keen and very let's say obsessed with polyp as we are all are and I have to say that he he does a lot of work reading papers and remembering them and bringing them out I think he is a brilliant star from Brazil and he was saying that there was some Chinese or oriental let's say paper highlighting how it's very important to preserve some of the interior tissue
- at the apex four continents he was referring to this article and saying why don't they translate this very important articles well I have to say I don't preserve any amount of tissue and clearly at the epochs right at least I don't try to I have excellent continents so I think there's a lot a lot of things that we think or we defend or we express about Halep and what we think about it that is not really scientific guides based on experts it's a opinion and you know that expert opinion is the lowest rate of quality of evidence scientific evidence so it's probably just an opinion now we have to take it that way so one important thing I think when you do these operations and in general in life we have to listen to experts
- but of course you have to make up your own mind with your own experience and what you what do you think of course an expert usually knows a lot but the experience doesn't mean that he's always right but his ideas are always right also I have to say that there are different kinds of experts some experts are experts because they are operating loads of patience every day every week very high volume you know these are the let's say surgical experts these are guys who are very well respected by other colleagues because they have developed the quality of I mean when they operates they simplify things there you can see things very clearly you you can see how they anticipate problems and so they it's it's a total joy to watch them operate and
- of course they have a lot to offer in the sense that their surgical experience is based on many mistakes you know they say that an expert is someone who has committed all impossible mistakes and they have learned by repetition and this is one kind of experts and and then there are other experts that probably base their expertise on the fact that they get invited to congress's they get to publish some studies they get some prestige because this or that or they're very good speakers or they know the literature very well and they can quote and say the most important papers and so they are respected because of that but still there is a big degree of disagreement between experts in certain aspects so and everything we say now if I consider myself
- an expert everything we say I think has to be questioned let's say for the sake of keeping a scientific mind and also you have to let's say take the advice that works well for you huh so I'm not convinced that this preserving the interior tissue near the sphincter I mean some people who do the preload technique they make an incision at 12 o clock but they start the incision one or two centimetres inside in order to preserve that tissue I am not convinced that that's the key to to post-apartheid continents immediate continents and the rate of post-operative stress incontinence sir okay so here I'm having a little bit of trouble let's say connecting both sides there must be some tissue up here that I'm not able to cut
- at the moment so here you have to be patient as long as we are in the white region we see we are in the right white region so it's safe the sphincter is way back okay so as I said some people think this piece of tissue and literally this piece of BPH tissue has to be it's a respected and clearly near the sphincter in my opinion that's not necessary and I believe that it's more important to preserve the mucosa also you know it is difficult to it's difficult to negate your training you know if you had a mentor who was your teacher and you talk to you this is important this is important this is important it's difficult for you to say a question that you know so many people just inherit inherits their knowledge and they
- defend that because this is what they learned this is what they do and they probably never question that anymore so why why why did I let's say think that the in block approach was good or better well I started in a different way than most polyp surgeons I started by doing green light green light a new creation I was to live it frustrated by green light by ization and I wanted to give a better let's say service to my patients trying to remove the the adenoma down to the surgical capsule and we developed the anatomic vaporization initially but then we moved on to more and more hybrid cases where we will nucleate the middle lobe and then rise a lot for looks and then they we moved on to the greenland relighting nucleation of the prostate and to me
- the most striking thing was that with remap doing an early apical liberation and block technique we didn't get incontinence post practically it was very low rate of incontinence so I I started believing that this was really important to to liberate the epics early so the mucosa you can if you watch the greenlight videos in my channel you can see how beautifully the apex is developed very early in the operation and then of course I thought this was a definite advantage and I thought that you could only do that with sight firing fiber but then learning Halep because I thought if you want to be a good expert you need to know I mean use different energy sources and get to know more I started doing Halep and then I thought maybe
- I can do the the in block approach as well there was someone who published video on the EU there was someone some oriental guy who published a Lin block technique so everything is invented before you know by the time we get there but I try to apply the same principle of liberating the epics early on and of course this white line idea marking the epics and then release minimum cosa early I think it's it was very very important I I thought maybe there is no way to do this apical liberation with a straight firing fiber but the truth is I learned how to do that and I think these cuts that we do in the epics to liberate the epics from the sinker I think they are very very important to deliberate the the sphincter and respected beautifully
- so so that's the original of all these then we studied our experience with Holland home human block you compare this to Greenland and we saw that we have even less in continents with holoband block because of course when you do green leap you have to do a mechanical dissection of the plane all around the capsule and that probably means more traction and I think that's probably the cause for for a longer let's say we had higher rates of post-operative stress incontinence with Greenup and a little bit of longer lasting so we decided to move to do this and block early optical release home IAM a nucleation and you see now most operations in this prostate is estimated as sixty six sixty grams it looks a little bit bigger to me
- but all these operations with a little bit of experience take you 40 45 minutes 30 minutes 20 minutes it's very fast operation it's very safe as you can see there's very little drama involved today we have scheduled five cases in the afternoon session so you can do many cases in a short time these patients will have their catheter removed tomorrow morning it's now 7 p.m. here in Madrid and tomorrow morning at about 80 so in 12 hours I will be removed and patients are able to go home the next morning now when we use Moses I think we could shorten that we are planning to do a study of a day case only me nucleation in patients with with BBH because the hem estas is we achieve with Moses is slightly more reliable and patients do
- not need post-operative irrigation and probably we can take the catheter out they can go home we have this situation where we operate mainly the afternoons so we would have to change our day schedule to operate in the morning to be able to discharge the patients later on during the day it's been done in America and there are more and more centers publishing their day case polyp experience so I think it's a big big big step forward provided by Moses okay there we are that's the Noma which is now very mobile as you can see let's see we can something happen that it moved that's the bladder neck over there so let's do this posterior dissection until we get to the bladder neck here we have to get close to the enema as I always say to release [Music]
- and well to me I think it's been a very interesting journey where as I said my background was different from other surgeons many many excellent surgeons learned the three three lobe technique and performed it beautifully never question it but I think the principles of block a nucleation our solids are very good you know you see a lot of centers publishing their new technique and their new experience and with a very funny name sometimes this is our technique this is the way I do it but I think here we're talking about something more how would I say more universal I think the concept of starting by liberating the sphincter first I think it's a very valid valid concept the concept of having excellent irrigation
- during the operation because we are irrigating a restricted space is very solid it's very solid so I think despite this hasn't maybe received enough attention for the moment I think the message is strong and the more more people are learning learning this approach and the more they do it the more enthusiastic they are about it also I have to say that in block approach is an approach that you can do with any source of energy so you can do here I'm pushing the Annamma into the bladder initially one lobe and then the other lobe so I try to flip the Anoma you see here here's their Noma now going in the bladder hanging from this small pedicle at six o'clock so as I said [Music] I think this is a it's a step forward in the evolution
- of polyp it's been facilitated by a different view or different angle to a new creation and there it is I think this is knowledge that everybody can use and can apply of course not everybody will follow exactly the same steps and that's okay because you develop your own preference your own comfort with different approaches and maneuvers but I think this block approach has real merit you know you can you can discuss if one low or too low or thrill of technique is good or not but I think my personal view is that this is possibly superior to all those techniques in the sense that it's solidly I mean the the rationale is solid and the results are solid as well and I'm trying to showcase this in the videos the
- apical eyes section can be tricky sometimes but systemically we can get very good vamos a motel up a very good clinical result a very good clearance of the Anoma good hemostasis good view fast operations and fast recoveries of the patient's neck okay Lefevre okay so we're going to get ready this 24 French endoscope allows me to second puppy talk about a star meadow eventers allows me to use the Morse later as well see we see properly yes now I'll change the lights and I will connect the water this is a richer walled endoscope and it doesn't have the shark let's say connectors is the old model but in 24 French size more appropriate for patients with tighter urethra so now I'm this thing in the bladder Wilde I introduced the most lighter blades better neck so now
- we are in position and initially you see there must be some water going in the pipes and when they are full of water then the suction from the bass in the modulator is transmitted to the tip of a scope and illustrates the tissue against the the blades [Music] so the motivation can take place very fast this is another amazing development of endoscopic a new creation of the prostate I remember watching Malaysian was a pain would last one hour or more now we can do more solution in minutes which is a total game changer in endoscopic nucleation of the prostate because it transforms innovation into a simple procedure as I said we do five cases today which is extremely efficient and because these procedures take 30 2014 it's depending on the complexity allow
- for very fast change of patients they go home tomorrow morning the hospital is quite happy because the revenue from the hospital comes mainly from the use of the operating theater so they they don't like operations where patients have to stay for a long time in the hospital using a bed which is in in our country is paid much worse than the operating room so we have happy patients happy nurses in the words because they these patients do not bleed they do not you know complicate their lives with dk materials and the need to call for the specialists like that which was what happened when we did TRP we have happiness statists I recently posted a photo in Instagram of our operating room and the anisa T's was not
- in the photo and someone wanted that out that's because he's probably sitting somewhere reading a newspaper because he's so confident that the patient's going to be okay [Music] there we are that's the end of it and this is the end of the operation let's see there's a piece here it's a small piece but it would have struck the catheter there we go you see there's there's no interior tissue we just respected the sphincter so I hope you enjoyed if you watched all this you must be a very patient person and I hope I didn't bore you so much thank you very much ok