Surgery
Real life HoLEP case 45: 200 gram prostate with a tendency to bleed, dealt with MAGNETO
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 in a 200 gram prostate with persistent intraoperative bleeding, using the Magneto laser. The description focuses on the surgeon's experience of longer holmium pulses and coagulation during this case. It does not supply a controlled comparison or measured postoperative safety outcomes.
Hi again, it has been a while since I posted videos, but here I am to show you the new Magneto laser in action, and how it was so helpful to deal with a patient with a big gland who bled all the time. This is a new addition to our armamentarium that promises to be a leap forward in surgeon comfort and patient safety due to the enhanced coagulation properties that the new Magneto settings allow. Basically, Magneto allows for longer pulses (similar to Thulium and TFL lasers) to be emitted with a Holmium laser. This enhances coagulation for enucleation and allows for dusting if you treat stones, that was not possible before.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- MAGNETO
Real life HoLEP case 45: 200 gram prostate with a tendency to bleed, dealt with MAGNETO
- Documented bleeding
Real life HoLEP case 45: 200 gram prostate with a tendency to bleed, dealt with MAGNETO
- 200 g
Real life HoLEP case 45: 200 gram prostate with a tendency to bleed, dealt with MAGNETO
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.
- Hello, this is Fernando Gomez Sancha again. It's been a while since I didn't post a video. And that is because I felt that all my knowledge is already on the videos that I already published.
- Of course, in this case I want to show you the new Magneto laser in action. You know that Magneto is a new laser console that allows to use the pulse modulation settings that we already had with the this cyber holmium laser.
- So, we we use virtual basket for dissection. But then you can have this Magneto setting that emits longer pulses, longer pulses similar to thulium and thulium fiber pulses. So, now in the same machine we have the ability to use the former holmium settings, but also we have this Magneto effect or Magneto setting that has nothing to do with magnetism. It's just a commercial name.
- But it allows to emit longer pulses of holmium, which is quite new and quite unusual because as we know the the the pulses emitted from holmium laser up to now were quite short. And that produced the excellent opening of the plane that we love for holmium enucleation.
- With this uh virtual basket setting the pulse modulated double bubble we could get enhanced dissection and coagulation at the same time. And this is the setting I'm using at 2 J and 50 Hz as I usually do for dissection, but I'm going to use the Magneto setting for hemostasis. So, in this machine you can emit pulses that have a length of I think up to 2,000 microseconds, which is much more than the previous longest pulse duration, which was 1,100 microseconds. So, the the pulses of Magneto are much longer.
- You can use the Magneto settings with combinations of energy energy and um frequency that will be less than 32 W. So, it's going to be an enhancement in the ability of this laser to treat stones.
- And but it's going to be a great enhancement and I think my my my personal impression is that this is going to be very very relevant. And it's going to be an addition that will make us surgeons much more comfortable with what we are doing because we will have much improved coagulation. Okay, this this is a bleeder coming from the adenoma. These are notoriously difficult to coagulate, so I never almost never pay attention to them. So, I gave it a try here.
- Even with Magneto and it didn't stop, but you will see you will see because this case is special in the sense that it was a very demanding case. This this man had a catheter. He was on refractory urinary retention.
- And his prostate was over 200 g of volume as determined by MRI and ultrasound. So, it was quite a big prostate. He had a very high blood pressure during the operation. So, it was at 170 um systolic pressure which couldn't be lowered by the anesthesiologist. They tried several strategies and he kept this this very high blood pressure and it was a very very bloody, you know, very very bleeding prostate in the sense that despite using virtual basket for dissection, you will see that when we return to the dissected um area there is a tendency to bleed.
- So, I was really really happy that I could have the the Magneto setting to coagulate at I think it was 1 J and 30 30 Hz setting. Of course, with the with the Magneto setting turned on for coagulation, okay?
- So, here you can see this is the usual technique that you have seen many times in in my other videos where I tried to do an early apical release trying to protect the sphincter mucosa.
- So, I started by marking the white line as I usually do. And then I started developing the entry into the posterior plane in one side of the veru and the other side. Then I communicated both planes in the midline and this is the development of the posterior plane.
- So, here you can see this is virtual basket in action trying to develop the posterior plane. You can see there's blood in the medium, which is not so common, not so usual and this is because of this special characteristics of this patient, very very hard, very large prostate and this uh you know, probably this this very very high blood pressure during the operation and of course big prostates come with bigger vessels also. So, sometimes we'll have the experience that we find larger vessels and more complicated um hemostasis to to be carried out.
- Especially prior to morcellation because you have a big fossa. You have um to to have very good hemostasis because it's going to be a little bit longer morcellation. So, it's a double challenge, the size the tendency to bleed and the need to to get uh very very good coagulation. In this in this case the total operative time was 115 minutes. So, you see that despite the the big size of the prostate if you are able to work slowly, carefully, but consistently and keep the laser activated and keep uh dissecting, you know, keep dissecting even if you go slow, if you're constant if you don't stop too much, then you will be able to to progress. So, uh I will You see this is the coagulation setting from Magneto now.
- So, I experienced it. Normally when I when I operate with virtual basket, there's very little need for me to use the coagulation pedal. That's because virtual basket generally gives us a very very good coagulation.
- First pass coagulation, so we get very nice hemostasis as we go. But of course, occasionally you have to insist in in hemostasis. This is now the ascension ascension in the lateral plane trying to cut the apical attachments first.
- And then progress towards the bladder neck a little bit because if we don't mobilize the apex we don't get access, we don't get space enough to reach the anterior part without, you know, tensioning the sphincter. So, here as you see I come back to the apex gain some access by cutting the apical attachments and then I try to progress towards the bladder neck to gain mobility mobility. Okay, so normally as I said virtual basket gives you very good cutting and dissection properties and uh coagulation as well.
- But of course, when we encounter bigger vessels or when we encounter that we are taking a relatively deep plane or you know, in this in this very large prostates often the the plane is very thin, you know, the capsule is very thin because it has been distended too much. So, we get very very big adenoma and very thin capsule. Often you can go a little deeper and then find that the surface is has a much bigger tendency to to bleed. Okay, so here we are. This is the apex. You can see there's some nodules at the apex.
- So, even when we are at the level of the white line, we we want to remove these nodules. We don't want to leave BPH nodules remaining hanging from the apical area. So, here what I'm doing is one more time coming to the apex trying to cut the apical attachments and then try to continue the ascending dissection Often these nodules, you know, get on the way. They don't let you see. It's a little bit cumbersome, but it's it's not a big deal. Trying to go up and trying to make sure that we take the most uh peripheral route. So, we don't cut through the adenoma at the anterior apex and leave anterior tissue there. So, again as you can see I'm trying to mobilize mobilize and at the same time, I'm trying to
- have a line of dissection that I can easily recognize. So, you see I work a lot on making sure that the line that we bring from below, from the posterior aspect, continues, you know, it's it's uh it's communicated, it's continued by going down again, you see, and trying to check that the line is a uniform line. It's super important to carry uniform lines.
- I think this is all virtual basket, no need to change to Magneto. Normally, and this is because of uh the economy of the procedure. You don't want to, you know, stop and start when you can keep lasing.
- Uh And if it's efficient, if it's uh you know, it coagulates the tissue enough, it it's probably better than stopping and starting. So, we will use Magneto, for example. This is probably now Magneto because I thought oh, that was a a little vessel.
- And um also, when you when you see that there's bleeding in the area, sometimes you have to stop a little and look for uh the bleeders. Here, this is the 12:00 region, you know, when I did the white beginning, I didn't connect at 12:00 because at the time I had to force too much to get there, and you know, my feeling is that the sphincter in the first moments of the operation is a little bit more um tense, that that has more more tone than when you have already been operating there for a while. So, uh often, if I cannot reach the 12:00 without forcing, and uh for the same reason, for the same reason, you could see that I didn't enter the bladder at the beginning because often, if you want to force the entry to
- the bladder, you will see that the sphincter splits at 12:00. So, you're going to damage uh the sphincter. And um that's why I I try not to force the sphincter. Uh but of course, after some time operating, you you feel that the the sphincter has given a little bit.
- The tone is less, it's more relaxed, and you can reach without needing to do much much force. So, again, here we are trying to make sure that we have a nice line that connects uh you know, that the lateral line of dissection is clearly visible.
- Here, I was seeing that there's adenomatous tissue anteriorly that is a little bit difficult to reach. This prostate was very tall, you know, the And how do you say that with the patient lying down?
- The posterior anterior diameter was quite quite long. So, but there I am trying to improve things, trying to move slowly. I am let's say more careful when I do very large prostates with hemostasis, of course.
- Uh with a smaller prostate, you can be a little bit more dynamic in the dissection because if there is a remaining bleeder or something, you can al- always, you know, go back and and coagulate, but uh in many cases, we can move forward a little bit uh faster, but in the large prostates, I tend to be very very careful and try to move slowly uh because I want to make sure that I don't have many vessels bleeding at the same time. So, you see, and this was a very highly vascularized prostate.
- And you've been there. I mean, if you do HoLEP, you can see that sometimes the prostates are quite challenging. As I usually say, the prostate is a formidable enemy, and um despite having a good laser, despite having a lot of experience, uh sometimes we are still challenged by the difficulty of these of these cases, okay? So, that was at 12:00. I think it was enough to start the ascending dissection on the other side, and you can see that there's some clot formation uh where we haven't been working and irrigating.
- So, there is a tendency to bleed, and that is uh making things slightly more difficult, okay? So, this is the up and down movement I do to enter the lateral plane. I don't go up very much because I don't want to stress the sphincter.
- And uh of course, I come out to try to deepen the white line a little bit. This is white line. So, I'm going to cut these attachments between the sphincter and the apex of the prostate to try to make sure that I preserve the sphincter uh as perfectly as I can. And you see, I like to do the the white line at the beginning because I think often, in in cases like this that are slightly more difficult, you you have difficulty to to distinguishing where is the apical limit of the operation. And if you have a white line, you can recognize much easier where the limits of of the operation and not make mistakes there, okay? So, this is now lateral plane development. You see that I like to do wide movements, so the fiber goes up
- and down, but not in a short distance, but I try to you know, move and do long movements that will make sure that the line that I'm drawing uh with my uh laser on on the prostate is more or less uniform and and continuous and is going to help me um guide my my dissection, is going to help me recognize the limit between the the prostate and the adenoma.
- And I I am understanding that this is an integral um part of being able to operate all the time. So, many surgeons need to stop and go back like I'm doing now to see, to understand, but most of the times, I have I have learned that if I carry these very very nicely drawn lines on on the capsule and the limit with the adenoma, I can um keep on working, and I don't need to go back to look, and I don't need to stop so often, which is helping in the in the speed of the operation. No, I'm not trying to run, but of course, I want to be efficient with with time, and uh I I will see. Here, for example, I was also not sure if not sure if I was going up all that I needed, all, you know, as much as I needed. Sometimes, you fear that you are
- cutting through the adenoma apically, and uh so, I decided to do a little bit more liberation, you know, which is al- always good because then you have better access and better understanding of of the planes.
- So, here again, coming up and down. You see that I tailor the speed of movement um depending on the response of the tissue. And in some moments, you can progress a little bit faster. Sometimes, you you need to be very slow if you want to have a uh a better hemostasis. No, but you will see that you know, the man had a very high blood pressure, and it it is a much more bloody operation than usual. And I have to say that I felt very very safe uh having the re- uh the ability to to use Magneto to go through the bleeding areas and and get proper hemostasis. Now, you you will see that several times, I will need to I will need to resort to Magneto. Here, when we come back again, you see that there is also a little bit
- of clot formation. That's the 12:00 incision. But uh there was some apical tissue, and it was not so not so easy to know if I was on the right uh anterior plane. In these cases, when, for example, you are quite happy with uh height of of the plane that you have achieved, and you're quite happy that there's no adenomatous um remnants in one in one side, you can try to let's say take the dissection from the good side towards the less clear side, like I'm doing now. So, I'm I'm coming back to to to the good side and try to see You see, that looks like nodular, so we need to go even further up.
- So, we want to remove all this apical anterior tissue. So, it it does I never hesitate hesitate to re-explore or to deepen a little bit the dissection line if I feel that I am leaving tissue behind.
- Uh if if when you deepen your incision you find that you're getting too deep, of course you can always go back to the previous steps. But here you see I was a little bit struggling to to get all as much anterior as I needed to be. So you need you need to keep the face and you need to do these long movements trying to connect the lines.
- And you know lately I'm telling everybody who comes to watch operations with me that with with HoLEP often the information you need is not on the screen, you know, it's it's not all of it.
- Because some people think if I am I don't know, I'm I'm guiding my movements because I am of what I am seeing in the screen and it's not completely true. Uh you have to look at the screen but you have to keep in your mind the 3D anatomy of of the prostate.
- You have to remember what you saw, you know, some minutes ago. You have to remember the degree of development of the plane that you had, you know, on the other side. And so of course the information in the screen is very very important but often you have to let's say also imagine a little bit to try to understand uh you know, what's going on.
- And also of course we have a knowledge of prostate anatomy that um we get from watching, you know, MRI studies from previous surgeries. So you have to combine all of this, you know, the information on the screen that mostly confirms what you're suspecting, what you think you're doing, let's say.
- And um and try to advance. Here you see a little discrepancy in the plane. So with the plane we took from the left side of the patient towards the right was a little bit uh deeper than than the plane that we were carrying from right to left of the patient. And uh here as always I'm trying to make sure that the lines connect, that the the line that I was carrying on the lateral plane, you know, is connecting to the posterior.
- So I think the apex is already released. Uh you know, we call it apex early apex release. Which of course is not an immediate apical release because we want to let's say prepare things so that we can do the early apical release with the lessening the the stress to the to the sphincter as much as possible.
- So probably I was using magneto in some some of these coagulation moves but I think we're going to have a lot of a lot more of that later. And here we are now progressing to develop the anterior line.
- This is still natural line, you see I'm trying to do uniform a uniform line. I'm trying to draw with my fiber like an artist, you know, that is doing a drawing. And um of course trying to keep a good hemostasis during the during the procedure.
- It's interesting to watch the videos after surgery because you might remember the operation in a certain way and then when you watch the video you find that things that you didn't see probably during the operation not because your attention was somewhere else.
- And I I remember that I was thinking wow, this is a difficult case. Uh because of the bleeding but now it doesn't look so bad to me. Uh you will see that there's bleeding often, you know, tendency to bleed, many vessels. Probably now we're getting to see that and that's the magneto in action. You see we that's the magneto in in action. The longer pulses of the magneto are similar to those of a stolium laser of a tool or a thulium fiber laser.
- So these these these pulses are quite long. And that we know that enhances hemostasis. My colleagues in in my hospital are quite who do stones are quite impressed by the ability of this setting to produce very fine dust with very very low retro pulsion. So the initial the initial experience both for for me as an enucleator and for my colleagues as stone breakers is very very positive. So we are quite happy.
- We have to see if we can gather some data and start publishing or you know, getting more objective comparisons, you know, as as we were uh with with with previous settings, you know, normal coagulation with long pulse or the bubble blast setting that other people uh is using for coagulation.
- But uh as I said, my feeling was that I had a consistent way to stop the bleeding. A little bit more consistent and more trustworthy. For example, here this is magneto. I was also curious to see how it behaved with bigger vessels.
- And you can see that the long pulse is allowing for excellent excellent excellent coagulation of of the bleeders. There we go. A little more for you. But my subjective idea was that this is an improvement. So maybe we are starting to see the the holy grail, you know, which was the perfect tool for for for enucleation, you know, when we had the single pulse holmiums, you know, there was complaints about the quality of hemostasis or first pass hemostasis after holmium.
- When we got um thulium lasers for enucleation, we thought wow, cutting and hemostasis is very good. But we lost the ability of dissecting the pulse thanks to these uh wonderful holmium pulses that generate a pressure wave that opens the plane.
- Uh so there have always been drawbacks to to every laser and advantages, of course. Uh you know, virtual basket, Moses, very nice double pulse. Some people perceived that the punch off of the dissection was a little bit less.
- Here again this is all magneto, I think. I'm going through the bloody area anteriorly. And laterally, you see here's where the prostatic arteries often come in. So I was using the magneto to try to And And here in the big prostate I'm I'm spending more time during hemostasis during the enucleation because I want I want to to to progress safely and you see often when you go back to the areas that you dissected before, you can see that there's red coloring the surface.
- And some probably little or not so little bleeders that you have to go through and this is all magneto. This is all magneto, you see that it is providing a very nice very nice hemostasis.
- And also, you know, we get very easily to this anterior part now that we are have our endoscope on top of the adenoma. So we are able to push it down a little bit. And this brings this anterior aspect even the bladder neck very close to to where we are. We don't need to tilt the endoscope too much to get to that place because we're bringing down the adenoma.
- When you push the adenoma in the bladder later on you will feel that it is much more difficult to reach up there because you don't no longer have this this uh advantage to be able to push the adenoma downwards.
- And you see when you enter when we enter the other side, we see again that clots are forming. So there's some bleeding in the area. And we have to go you know, and be quite thorough with with coagulation before progressing with the operation.
- Usually I say that this is time well spent because now we have the advantage of having a very fast flow of of the water between adenoma and capsule. You know, it's a very very narrow space between adenoma and capsule.
- So, the irrigation is very very efficient. This is what I I I I refer to as a laminar flow of the water that we get when we are working between capsule and adenoma when the adenoma is still present in the fossa.
- You see, we get very good visibility. But if you if you finish the enucleation and disregard all these vessels often you you know, you push the adenoma in the bladder and then the visibility is much worse because there are several vessels at the same time and because we lose this laminar flow and we get a more chaotic flow inside the fossa. So, the ability to to wash and also the the water coming out sometimes brings in some blood coming from another place.
- So, at the end the visibility is not so good. So, you can see that I perceived in this case that there was a higher tendency to bleed. I I've never been sure if the blood pressure is so important to you know, for the bleeding.
- Many many surgeons say so like you know, it was very bloody because the patient had a very high blood pressure. I'm not sure if it's so so important, but well, probably it it it is a little.
- But here there was a conjunction of factors, no? A big prostate and a high blood pressure, big vessels probably I don't know, inflammation that that could justify you know, more more bleeding.
- So, here I am continuing now. You saw that we entered the bladder. You saw that um we dissected laterally now. I'm trying to progress. That there the plane is a little bit thin. So, in these cases we have to keep the fiber closer to the adenoma to try to progress without deepening deeper or deepening the the going deeper.
- And uh also at the same time trying to carry a line that we can recognize and we can follow. So, here I was getting the fiber closer to the side of the adenoma to try to progress in the dissection.
- Often when you find that it is difficult to continue with the dissection because there's not so much space, you know, you feel the weight of the adenoma on top of the endoscope, you know, you find that there is difficulty with access.
- This is a matter of surgical strategy. You have to release more in other in other parts of of the prostate because when you release the the attachments, the mobility of the apical part of the prostate that has been you know, released from the capsule gets better and better. The prostate is mobilized better.
- And this mobilization will give you better access. So, sometimes especially in the very large glands, you know, with with an en bloc approach you need to be strategic and understand that if you don't release from you know mostly circumferentially, you know, if you don't release the attachments, there will be areas that are more difficult to to access. And again here I'm using the magneto.
- You see because I see that the surface of the capsule is getting red again, which means that probably there are tiny little veins bleeding. And I want to be as thorough as I can to because then of course we have the challenge of morcellation and in order to reach that moment with with good visibility you have no other possibility. Here you have to work your way, try to progress. I want to I want to push the operation forward and that's why you don't stop. And that's why doing large glands is difficult for beginners at the the beginning because you need to have the skill to work mostly continuously, you know, to avoid doing a lot of pausing time. You need to have have the orientation and the knowledge
- or the experience or the you know, to be able to work in a little bit more challenging conditions. You know, here I think for a moment I suspected there was a bleeder at the bladder neck opening, bladder neck mucosa.
- The middle lobe is medial to that and here I want to check also the position of the UO. It was quite lateral on the other side here, right? I didn't see it very well. So, let's do a little bit more dissection and maybe more hemostasis before we can go back and it is helpful to know where is one UO because you imagine that the other UO is more or less situated symmetrically.
- But as you saw, I didn't enter the bladder in this case. As I said before, trying to protect the sphincter. So, this is the moment to enter and and see the the UO and try to avoid damaging it.
- So, again this is posterior line dissection. You see that we are slowly advancing but I'm not insisting for example posteriorly because I want to liberate on the sides as well. But now I'm taking the advantage that I got in terms of mobility and access and I'm dissecting the posterior area a little bit more.
- I'm trying to connect the posterior to the lateral, always trying to connect the lines to make sure that we have a good orientation system. This is like my GPS, you know, these lines help me understand what's happening and help me orient myself and here we are improving but of course the the capsule sometimes is quite thin in this area. So, you have to point your laser closer to the adenoma so that the energy cuts the attachments between adenoma and capsule but doesn't penetrate too much.
- So, it's a 37 minutes now into the into the operation. We are progressing, you know. In smaller prostate probably we would be finishing now, but you know, longer prostates mean and and bigger prostates mean longer lines of dissection, a little bit more time and often more need to to stop to do to do hemostasis, you know, it there's a lot of variation. There's a lot of variation.
- Here again we are reaching the the bladder neck. You see, I want to come from the bladder neck downwards to connect with the posterior aspect and you can see it's a very very long prostate, very very large.
- I think probably we took out about 200 g. I haven't received the pathology report yet, but and um but the the the the bucket was full of tissue which is an indication that it was a very very large very large gland.
- Okay, so slowly progressing, you know, a little bit more bleeding than usual. Trying to recognize the UO again. And there it is. There's like 1 and 1/2 or 2 cm distance and again we go back with magneto to try to get a more solid hemostasis of the dissected areas.
- In this case virtual basket was not enough to dissect and coagulate at the same time for the reasons that I mentioned. You know, we see variability. Sometimes we do large prostates and they're a joy to make because the plane is so nice, so easy to develop and there's so little bleeding.
- And some other times, you know, we see that there's variability and it is very nice. And I remember, you know, when I started using Moses and virtual basket that I already felt much better equipped to do very large prostates than with a classic holmium. So, I started feeling that it was it was an advantage because of the improved hemostasis. So, I really now have the same feeling.
- You see there's a an area there that is a little bit difficult to access where the endoscope jumps, you know, when you go from side to side and yeah, we have to continue, continue releasing, continue mobilizing.
- Continue following the lines, connecting the lines. And uh you have to have a lot of faith that the case will come to a nice ending. You have to trust the tech and the technique. You have to trust that things are going to go well and we have spoken before a lot about the attitude.
- You know, the attitude of the enucleation surgeon must be very relaxed, very technical. You know, you you will deal with the problems that you find on your way as they come, but not with anxiety, not with fear, but with a technical mentality. We can see what's going on and then we will take the right decision to handle the situation. Here you see my line or the shape maybe of the prostate is not perfectly uniform.
- It's not like a billiard ball, you know, the prostate has sometimes funny shapes. That I suspect is an ejaculatory duct. You see that little white uh cylinder there. And here I'm trying to dissect even, you know, 1 or 2 mm of dissection depth with each pass is it's a joy because the more you mobilize, the more you see, the better access you have, but you see, it seems that we have some kind of step there that is not so easy to reach.
- My advice is uh of course, try try to improve, but if you get stuck in in these situations, if you get stuck in an area and you cannot you cannot you know, continue, you cannot gain too much advancement, then of course, you have to go somewhere else and continue the dissection where you can.
- Because mobilizing other spots will help you um access this better later on. So, don't get stuck, don't get desperate. Just try to gain millimeters, gain millimeters. And if you cannot progress here, go somewhere else. That is the middle lobe pocket area, so we are now under the middle lobe and uh it is this side that seems to be a little bit more sticky and a little bit more difficult to access with this jump of the cystoscope. You see, I cannot see very well what's going on down there and I feel the weight of of the adenoma on my endoscope when I try to reach there. So, let's go somewhere else.
- Continue because I think also in the in the large glands, you know, some some people say you cannot do en bloc in large glands because the transverse diameter of the prostate is much bigger than the transverse diameter of the bladder neck.
- But here we use a a nice trick and this is to you see, to try to connect the posterior plane with the bladder neck. See that we have detached nearly all the attachment of this lobe to the bladder neck so that we have a nice uh view here, for example, of the bladder.
- You see, we we try to cut all these attachments and cut the bladder neck going downwards. Let's see where we get. Here. You see, coming towards the midline. And then that is going to help us luxate or mobilize or tilt this side of the adenoma into the bladder. This is trial number one which failed.
- And I'm pushing really gently until I can luxate. You see, I can push and here I'm back with Magneto to check. But you see that the the lobe, the left lobe of the patient has already been tilted into the bladder.
- So, you see, by applying a rotational movement uh we can initially tilt one lobe. And this is going to generate an improvement in the access to the lower aspect of the adenoma because we will have more space now.
- But again, this is Magneto trying to get a good hemostasis in a in a challenging case where you know, there's a it's a huge tendency to bleed. And you know, the situation is a little bit tricky and difficult.
- Also, of course, the surface we have to cover is is bigger. This is like a an orange this prostate. Okay, there's not so much clot formation there, but you see now we can get to see the jump that we couldn't see before because the mobilization of the adenoma, the gentle mobilization of the adenoma has allowed me to gain more space and to see this area and detach it very easily.
- Of course, when I do the pushing of the lobe into the bladder, I don't push very hard because if you have attachments here, often you can pull from these attachments and you could break the capsule by trying to force the entry of one of the lobes into the bladder. So, you have to liberate as far as you can go, then mobilize one lobe very very gently.
- If it doesn't go, don't push, try to dissect a little bit more and then you see here, now we are nearing the the completion of the enucleation and this is now 46 minutes. But again, you know, I know that it is better to do the hemostasis when there's still a significant amount of prostate inside the fossa because we benefit from this better flow. You see, and sometimes we find the bleeders that are causing the trouble.
- And here I'm doing a systematic coagulation with uh the longer pulse. You can see the beautiful hemostatic effect of of this setting when we um had already passed with a with a virtual basket. So, very very nice feeling of having a reliable tool for for for coagulation and I felt very well equipped to do a challenging case because uh before, you know, often I would resort if I needed to to to to get in with a resectoscope and and do a rollerball coagulation prior to morcellation when I couldn't get a good hemostasis, but you will see that despite you know, being a big surface and you know, needing a lot of time to to do hemostasis to cover all these surface, the reliability of of the hemostasis is
- quite quite impressive and uh but you need you need to spend the time that you need to spend, you know, each case has his own. But I would say in in a degree of difficulty uh this was a difficult this was a difficult case. And the tendency to bleed of the patient was was not so I wasn't so so happy with with the the way that things were going.
- But then of course, having this ability to coagulate really really helped and made me feel very very very safe. Of course, you have to keep your um emotions down, you know, you have to be a Vulcan a Vulcan.
- A Star Trek Vulcan, you know, you have to be very logical and very uh dispassionate or that's it. There it is. Okay, so there's time and now this is now 48 49 minutes of of enucleation time for this huge prostate and um now again I will spend more time doing coagulation, but until I can see well enough to start the the morcellation. So, but I was so happy with my new, you know, toy and testing the ability of of this new setting to improve our experience.
- And I thought it was relevant enough to bring you this um to bring you this this video, no, to to to to to publish it. I got a message from one urologist from South America who had been watching cases with me and he said, "Well, you know, we we're thinking to buy a 60-W laser and a cheap morcellator." And and I told him, "You know, try to get the best equipment you can get because when you face difficult cases like this, working with, you know, substandard or I I don't know how to say without being offensive, no, um working with a laser that doesn't really give you the the the best uh features, no, to to face this uh challenging cases is is is a pain, you know, and maybe this operation that took 1 hour and a 15
- minutes could take much longer. So, at the end, my feeling is when you when you start doing HoLEP, especially if you can get good outcomes, low uh incontinence rates, you know, you're going to have very very happy patients, not only not only after 6 months, but uh but uh postoperatively, you know, the great majority of patients are very happy.
- They can pee very well, they keep they hold their urine, and they they leave that with a big relief because they heard about the chance of having incontinence, and then they send you patients, they send you a lot of patients, and you're going to operate progressively more and more.
- Your numbers are going to grow. Uh I don't know if I can say exponentially, but but if if you are going to start doing HoLEP and you think that, I don't know, I do 30 cases a year or of TURP or 40 or 50, the likelihood is that you're going to very fast double that number doing HoLEP, and it's going to grow and grow and grow every year. So, you if you're going to how do you say uh finance the the laser, and that's the sphincter, it looks very good.
- It looks very good uh sphincteric preservation. The patient was continent postoperatively, so I was very happy, too, because in this in this uh big prostates, you know, there's probably there's a little bit higher chance of stress incontinence uh postoperatively because of the amount of and the degree of of of of the movements you have to do, hm?
- So, here I was trying to go through all the surface. Remember, the patient had this high blood pressure and tendency to bleed, so I I was trying to be patient. Here, I think the patient was like uh coughing or something, not coughing, but making abdominal abdominal strain, and uh I think for some time, he was uh having nausea or something.
- And I was impressed when the anesthetist gave him alcohol to smell. I didn't know that, but apparently, when the patient gets a little bit nauseous, if you give him alcohol to smell, uh things seem to be a little bit better, maybe because you remember the good times drinking with your friends or something.
- No, but jokes apart, um you see, the patient was not giving us a lot of uh It was difficult, huh? It was difficult, it was a challenging case, and then he started having this nausea and movements.
- So, it's it's difficult to to work. Luckily, the he stopped, and we were able to morcellate very very nicely. Also, the morcellation was excellent. So, the behavior of the morcellator was really really good, and we could take a lot of tissue in a very short time.
- So, probably getting more than 10 g per minute, which is not always the case, huh? Sometimes, the prostatic tissue is uh soft, sometimes the prostatic tissue is a little bit harder, sometimes the morcellator is operating at full efficiency for some reason.
- The suction is very good, and one thing that I heard from from the Piranha system is that it doesn't work well in very high places, like uh I was invited to go to Bogota in the near future, and uh I couldn't They told me, "You cannot use the Piranha there because the atmospheric pressure is very low because this Bogota is very high uh over the sea level, so And here, I decided it was worth trying to start the morcellator, the morcellation.
- And we did the change of instrument, hoping that uh I had done enough hemostasis. Sometimes, this this this decisions influence how the operation goes in the sense that if you can go in and do morcellation all right, uh it's fast, but you might regret, let's say, not doing additional hemostasis. But I I was quite impressed with this Magneto, and I thought, "You know, there's a big fossa, there's some clots already, and I don't think I can I can make the hemostasis uh better than this." Or or well, I thought it was enough, and then I I entered with the morcellator.
- I got uh a reference of the bladder neck. I positioned the morcellator blade about 2 cm over the bladder neck, which uh is what I call the safety position, and then started the morcellation. Initially, I saw some red. You know, I was not completely sure that we could progress safely with this uh morcellation of a very large piece.
- But I was happy to see that the contact of the tissue with the morcellator blade was quite good. This usually means that there's a lot of tissue going out and not so much water. So, you can keep morcellating knowing that the that the bladder is is still distended, no?
- As you many of you know, I I use only what one inflow with my equipment. Uh but of course, this is uh based on on a lot of experience, and uh I do that because I want to try to make the procedure very simple, and it's a little bit cumbersome to have a second inflow with another two bags.
- But uh I have to say that sometimes I do, sometimes I decide to have an extra irrigation line. In this case, it was not uh necessary. Of course, if you're tackling a case like this for the first time, it might make sense to go in with a roller ball, you know, doing the best possible coagulation you can get prior to morcellation because you need, let's say, nearly perfect um visibility to morcellate. Uh I In this case, you know, the visibility is is just good enough, it's not uh perfect.
- You see, there is a problem with the cameras because uh as you can see, the light inside directly into the adenoma reflects a very bright uh light. So, the camera system adapts to this brightness, and in contrast, the lower part of the of the image is very dark. So, we cannot see we can see the black triangles natural to the to the blade in both sides. To me, that is a sign of tranquility. I mean, I am of safety. I I know that I'm not close to the bladder because I see black.
- But it would be much better if you if we could see uh the bladder wall, if you if you could have detail, which probably we would have if the was this this very bright light, you know, in the upper part.
- So, I I I It would be interesting to discuss with the companies if they could do, you know, split the screen in two parts, the anterior part and the posterior part, and probably do individual light adjustments, so we could see the bright adenoma on top, but we could also see the bladder through these lateral triangles. You know, just an idea.
- And there we are, progressing with morcellation. Um You see why I insist so much in this technical mentality and passionless, you know, Vulcan uh attitude to enucleation because I think that you need to reach the morcellation phase when you're still fresh. You know, if you have if you are stressed during the operation when you reach the morcellation phase, it's going to be you're going to be very tired.
- And here is where you want to be 100% looking at the screen and uh be ready to stop morcellation if something happens, you know, and prevent uh bladder mucosal perforation and etc. You have to keep all your senses to the task, you know, focused on the task and this needs uh sometimes in in cases like this, you know, it was like 15 to 20 minutes of of morcellation.
- So, you need to to remain fully uh focused on what you're doing. And if you're very tired, uh it's going to be difficult to perform properly. So, enucleation phase should be joyful, you know, relaxed technical, you know, if you have a challenge it doesn't mean that you cannot mm surpass it, you know, the challenges are there to be tackled technically.
- And so, when you get to morcellation, you're quite relaxed and happy not tired and then you can uh focus all your attention in in in the morcellation. But, uh to summarize my feeling with this new magneto development, I think it is a I I love engineers. I think they're so clever and the way they think and the way they put this new developments in in in our hands, you know, it's amazing and I think uh it's wonderful that their job is going to benefit so many people in the world and and this to me is a similar let's say breakthrough or improvement as the improvement I felt we had when we started using Moses and virtual basket, you know, pulse modulation.
- Um and from what I hear, you know, because I think the the hearts of the stone surgeons was a little bit uh split. Some stone surgeons liked uh TFL, but they still thought that holmium was a better choice for harder stones and probably bigger stones and so, they had a uh split heart and now they can have uh in the same machine, they can have settings that allow them to to go from, you know, very powerful fragmenting of the stone to to dusting.
- So, I think it's a very very relevant uh step forward. Of course, these things we need to see publications. Probably the the how do you say that? The general results of enucleation are already very good with um any of the, you know, commercially available lasers today.
- And, you know, proving very significant differences is going to be challenging because we already have very very happy, you know, very good results, very happy patients. But, you know, when you notice the difference of of having a better tool is when you when you work intensively like, you know, we do five or six HoLEPs uh in our sessions and the fact that you can move through the case relatively fast even when it's difficult, you know, when you have these reliable uh hemostatic properties.
- Uh I think it's a great thing, you know, because you can work efficiently and you know, in this particular session we did a a radical prostatectomy with an extended lymphadenectomy.
- That took about 2 hours and then we did this case and three more cases of HoLEP. So, um typically the other cases were relatively small glands, 50-60 g and they took probably 25 minutes each or something.
- So, we we have a very very energetic team of nurses that allow us to do a very fast change cleaning and starting again, you know, so we we we can run these lists and there is where you notice uh how technology helps you, you know, a faster morcellation uh like we are getting with with Piranha compared to other morcellators.
- Um so, all these details count and that's why when they ask me for advice, I say, you know, steal the money, get the money however you can. Spend a little bit risk a little bit more and of course, uh get the good tools because you might be starting with a low-powered laser, you know, 60 watts or something.
- But, you're going to suffer much more especially in the in the difficult cases and um I think this is a this is an operation that needs some maximal technology, you know, you want the best tools that you can find to to perform these operations because uh sometimes they put you to to to test, you know.
- And um I don't know if there's anything else I can tell you about uh magneto. Um it's it's interesting, you know, I think uh Chester Cavone is doing low power you know, 30 watt uh enucleation with magneto setting.
- Which to me would be similar to doing uh probably low power enucleation with thulium. Everything is is feasible and possible, huh? I have chosen to stick to virtual basket 250 to 250 hertz and magneto just for for coagulation.
- And I think it's going to be a killer killer combination. And um So, I I hope you enjoy the video again and uh I I thank the feedback many people write me and tell me that these videos have been helpful and this uh of course keeps me motivated to to continue adding information. I I think that I'm very repetitive because uh I use the same arguments and and uh mostly we we go over and over again over the same thing, but it's interesting that uh I get visitors that come come with me to to sessions where we do 25 or 30 cases in in 4 days and they tell me that this is a much better experience that than just watching the videos because they see the operative room, they see my hands as I manipulate the endoscope
- and they get a lot a lot of tips, you know, that uh the videos cannot easily show or convey, you know, so but uh still I think it's probably nice for people who are interested in holmium and improving to to see the real life cases that we face and um and uh you will agree with me that the morcellation efficiency was really good.
- Uh the the prostate never leaves the the mouth of the morcellator, so we we're able to take a lot of tissue in in one go. I had to do a change, I think, of the canister of the buckets of of water for a moment. So, probably we will be stopping before we finish, but um we took out a lot of tissue in the first go and then we we had to finish the the morcellation.
- So, what is clear to me now is that uh there's a huge interest in HoLEP. Many many hospitals want to adopt it want to do it. There's a huge uh interest in learning. Many young people are seeing an opportunity in in performing HoLEP and many people who work privately, they they see a big opportunity to adopt a technology that is going to drive a lot of patients and a lot of success.
- But, of course, it is important to have attention to detail and learn how to avoid the important uh problems, the important complications because in our center, this is a very very straightforward operation that we do quite fast.
- Patients go home the next day without a catheter. Um you know, some centers are doing ambulatory surgery. Um When when you go to experience centers, you can see that this is a you see here the morcellation was losing a little bit of its um mm efficiency. Sometimes the the pipes are blocked with tissue and you get less suction and less efficiency, so a certain moment I think we stopped before completing the morcellation. So, I if I see that the this is wonderful engagement of the adenoma is getting worse and worse, it might mean that the basket for the tissue is full, and the transmission of the vacuum to the tip of the morcellator is less less efficient.
- So, as I said, I think if if you if you do HoLEP, for example, and you get a lot of incontinence postoperatively, you have to re-evaluate what you're doing. You have to you have to try to do it better. You have to try to revisit how do you deal with the apex.
- Because I tell you we have very very low rates, and um many people are trying to do early apical release. Many people are trying to do mucosal uh sphincter mucosa protection. This is the moment of the change. You see that there's no activity because they're changing the both both the the tissue um basket and the and the bucket.
- And now we will get improved suction, but you can see the hemostasis is very stable. We don't see more blood than at the beginning. It's not perfect because it's a big fossa, and probably there is an oozing in the fossa, but we we can see. We can see, and we can perform a very fast uh morcellation of a big big big piece.
- And um so, I'm losing I'm losing my my what I wanted to say before I'm getting old, I think. But it was related to Yeah, more more people trying to learn. Yes, if if you have bad results, because I see we did a collaborative effort to report, you know, data retrospective registry, and when you see this this paper, um you see that the the advantages of early apical release are there, but they're not so evident, but I think it is because of the variability. Many people try to do early apical release, but maybe they don't liberate enough.
- Uh they don't mobilize enough to do a very respectful very respectful liberation of the apex. I recently saw two two papers from the group of Humphreys in the US, where one they they have better results of continence, and with an early apical release strategy.
- And also they have described a grading system. They look at the sphincter at the end of the procedure, and they give it grade zero when the mucosa is perfectly covering the sphincter all around, grade three when it's quite damaged. And they have seen a correlation in the in the with with the aspect of the sphincter at the end. If if you if you finish the operation and you see a very beautifully epithelialized sphincter, the chances that this patient is going to be continent are very very high, which is something we have observed, but they did a paper on I think nearly 100 patients.
- So, I think more and more we are understanding that this is a useful approach, and that it can minimize the rate of postoperative stress incontinence. And um so, it's nice that you can evaluate your own results, and if you get, you know, 10% 15% incontinence rate, there's definitely something that has to be improved, and then it might be worth that you look at these videos and try to, you know, make your own conclusions and try to change some things, especially um you know, handling the the cystoscope very carefully. There's a small clot you see on the fossa forming, and this is But I'm quite happy. I'm quite happy because it was a very very stressful case, very high blood pressure, big prostate,
- and we could finalize it in a very short time. Thank you for your attention again, and all the best to everybody. Let's hope this year will bring us a lot of happiness.