Surgery
Live surgical transmission to the PUA (Philippines Urological Association) Global Summit
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 live HoLEP transmitted from Hill Clinic in Sofia, Bulgaria, to the Philippine Urological Association Global Summit. The description identifies the rods and cones platform used for the transmission and states that this recording is in English. It does not provide a case-specific prostate measurement or outcome.
I transmited a live surgical case from the Hill Clinic in Sofia, Bulgaria, to the PUA Global Summit. We used the rods and cones platform and I managed to get the recording. I am uploading it here to show a HoLEP in English.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
No clinical case details have been extracted for this video.
Original title and description on YouTubeSource 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.
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.
- raction. So I think uh we have probably 1 hour allocated. We are already about 15 minutes late. So I'll try to show you as much as we can about this operation. I'm going to use the magneetto uh laser from quant system. My settings are uh 2 jewels. And uh here you can see the pillar of the sphincter. Huh. So this is actually apex apex apex and this is sphincter. So I'm going to mark here and then on the other side I have the same view of the sphincter and the apex. So I'm going to mark here. You see? Now we're going to take this up towards uh 12:00 to connect anteriorly. And then I'm going to bring this down. I'm going to bring this down down down to uh mark the [clears throat] limit between the apex and the adenoma. Look at the ver. Sometimes the
- ver is quite high compared to the real location of the interface between the adenoma the aex of the adenoma and the sphincter. Huh. So we have to come all the way back here. Luckily, we have very good visibility. So, we can deepen slightly more uh to make our life easier later.
- We can make a nice nice and sound uh incision. And now we will go to look for the plane parallel to the verontanum. I'm going to the floor of the verontanum and I'm going to do this movements from the midline towards the side you see to enter this nucleation plane. I'd like to say hello to my friends from the Philippines. Uh I hope you're having a good congress and I'm sorry that I couldn't be there. I was actually committed to be here but then we came up with the idea of uh trying to transmit a case. I hope you can see it very well. Let's see this is the ver again on the other side. This is my white line. So this is the aical limit. And now you see the idea is to come down here to follow the the floor of the verontanum here to enter the plane the anatomical
- plane between adenoma and capsule. All right. So I I usually think of the of the prostate as if it was a box. Okay. So we're going to talk about the posterior plane. Posterior plane of the box. Then we will have two lateral planes and then we will have an anterior plane. You see this would be the plane. Let's say the plane and this is the line of dissection. So every plane is going to have its own line of dissection. And so we will have four planes posterior, lateral, lateral and anterior.
- And we will have also four lines posterior, lateral, lateral, and anterior. Huh. The lines of course I want them to be connected because the line is going to behave uh like uh my GPS. You see it will give me orientation. It will let me know where I am. You see this is already getting deep.
- Okay. So I'm going to to try to stop. I cannot go. You see I'm trying to develop the posterior plane but there's a lot of prostate above and also there are some lateral fixations here. So uh basically I don't I don't have much space to enter. So I'm going to turn my fiber to 12:00 and I think if you if you want to ask questions we cannot talk but you can write them down. So uh Paulo here will uh relay them to me. Okay. So now what I'm doing here is I'm deepening a little bit the initial uh white line that we did. My intention is to start the development of the lateral plane. You see here I am going now up and down. This would be the initiation of the lateral plane and the lateral line. And I as I said the lines have to be connected. So I'm going
- to connect the lateral line with the posterior line here. Okay. [snorts] This is the way to keep uh a line that is going to serve us as an orientation. This is actually the edge of the dissection. And you can see that I'm know only doing the posterior aspect of the lateral plane here. Only the posterior. Why? Because if I come out, you see there is still attachments here.
- There's still aical attachments. In the past when uh people were doing the thrielope technique and the classic encircling maneuver, they would go all the way up tearing tearing this tissue, breaking this tissue with the endoscope and then that resulted in a breakage of the mucosa of the sphincter that uh gave rise to this 12:00 mucosal flap. I call it the infamous uh 12:00 mucosal flap because you know there are no flaps of mucosa in the human anatomy. If you see a flap of mucosa most likely is because you have ripped the mucosa from the sphincter and that's why people had patients had a lot of uh early stress incontinents. So here again you see I'm I am um continuing my dissection continuing my lateral line. Let's take care of the little vessels. And
- now as we go up, you see again I go out to the to the aical part. This is my white line here. I'm going to continue deepening initially this uh white line. I call this incisions for axis.
- And they let us see where is the plane wanting to go. You see? So my line was here. But now I'm following the proper anatomical plane going up further up. Let me focus slightly better to see if we can come all the way towards 12:00. Okay. So reflecting on enucleation, you see I came with this idea that I came up with this idea that every time we release the capsule from the adenoma, we gain some mobility of the adenoma. Okay. Initially the adenoma is going to be fixed to the to the capsule and uh as we release the adoma from the capsule what we gain is a lot of mobility. The adenoma is mobile. We can push it towards the midline and then what we give we get better access. You see so this is a sequence that is very important. we liberate the
- plane, we gain mobility. And this mobility gives us access to areas where before we didn't have access. Okay? So here, as you can see, I'm doing very, very wide movements and I dissect when I go up and I dissect when I go down. You see, some people at the beginning will do movements like this and then go up again and then again dissect a little bit. But then of course these people are going to take twice as much as I'm going to take for this operation because I use all the time uh from the operation. I try to minimize the pausing time. Okay. So here you see I'm coming up every time we release more uh capsule from the adenoma we get more mobility. And now you can see that I'm starting the anterior line of dissection. You see anterior line. Now if we come back, this
- is the 12:00 fibers. I'm going to show you the stringers mucosa here. And now this is the other side. So I'm going to start now going from 6:00 again on this side towards 12:00. Initially I do this incision for access deepening the white line and then I'm trying to find the lateral plane. You see the camera always has to align itself with the line of dissection. So the camera has to give us um a little view. We can see we can we should always see a little bit of the capsule and a bit a little bit of the adenoma. Okay. So here we are. Look at the amazing effect of this laser. It does separate the tissue and it provides with very good first pass coagulation which means that we can focus more on the dissection. And we don't need to focus on keeping the hemoasis as we had to do with
- the classic commiums. This is a connection between the lateral line that I'm starting to develop in this side and the posterior line that we had already started developing before. Okay. So you see now we have a very nice line of dissection. This was the deepening. So later on we will go a little bit further up. You see I'm marking now the the the the path that we will follow. Okay. So we don't go too deep there later on. And now you see coming up. The objective of course is to do the early aical release which means that we're going to liberate the apex from the sphincter early in the operation. But as you can see the early aical release has a very very thorough preparation. We need to we need to dissect the plane. We need to gain mobility of the apex of the adenoma in
- order to be able to reach uh access to the two elbow clock area where the most remote place is. Uh I always think of the prostate as if it was a palace. I mean if you if you've visited some palace in Europe probably everywhere palaces are the same. You enter a room and in this room there is a door at the other end of the room and when you open that open that door you enter another room you know and then that room also has another door at the end. If you open that door you go to another room you know. So this is similar we gain mobility we gain detachment and the detachment is going to give us access to a new place where we can gain more detachment and that's how we progress. The lines of dissection, these lines of dissection are paramount because they allow you to
- get orientation. Huh? This is like the breadcrumbs from Hansel and Gretel. Huh. When they were uh uh going to the forest. Okay. So, this is my white line here. This is my white line. I see a little bit of BPH tissue here. So, I'm going to take it a little bit further back.
- But you see I do these incisions for access initially trying to deepen this uh white line and then as we move inside 2 or 3 mm we can then uh start to see where is the plane going. H and we can try to continue our ascending dissection of the apex of the adenoma. You see coming up. Always looking for the capsular plane. Always looking for a capsular plane. A capsular plane is a plane that looks mostly white. It's a plane that looks very fibrous. It looks uniform. Uniform smooth in the surface. So not not bumpy. Huh? If you see the plane uh if you see bumps on the plane, it probably means that you're not following a very good capsular plane. So, and also as you can see, Professor Sancha, we have a question. We have a question. We have a question from Professor Russo.
- Okay. What is the basic energy and frequency setting used? Okay. So the settings of the laser I'm using a double pulse called uh virtual basket. You know it's similar to Moses. It's a double bubble double pulse. And [snorts] the advantage of this pulse is that it has two two little pulses one after the other. So the first pulse is going to give me uh a nice bubble a nice separation of the plane and the second pulse is going to reach the take the energy further so I can get very good simultaneous coagulation. I use two jewels and 50 hertz. But you see I'm going to show you something when I get rid of these bleeders. Let me get this control of these bleeders.
- Um they're a little bit how do you say um reluctant to stop bleeding? Let me check. So I wanted to explain. So I'm using two jewels and 50 Hz. Okay. But you see if I am far away from the tissue and I fire, there's no effect at all. If I get a little bit closer, we will get hemostasis. You see? And if I get even closer, we will get dissection disruption. If I touch the tissue, I will make a hole. Okay. So the settings and I, as I said, I use this virtual basket setting with 2J jewels and 50 Hz. The settings are not going to determine uh the effect of the laser in the tissue. It's the surgeon. You see this is a 12:00 tissue. Now we can see the plane here. We can see the plane on the other side there. You see? So now I I need to
- connect point A with point B here. Just cross over and end the early aical release. This means that now the sphincter is totally totally separated from the from the prostatic tissue. And here I have to look for the uppermost plane uppermost plane trying to get as anterior as I can. Okay. to to try to to define and and respect uh that's BPH tissue there. So, we need to go further up. You see, I want to try to find the most anterior possible uh [clears throat] plane. So, I need to go, it's looking a little bit messy, but you see, I don't want to settle for the less aggressive plane and leave BPH tissue there. So I'm trying to define an anterior line that uh is true and capsular. So as [clears throat] I said the settings is only one one one one part.
- The settings will determine how the energy comes out from the fiber. But it is the surgeon who has to decide how the energy is going to reach the tissue. You see? So I I I I like the example of of you know you you walk in Paris and you see a man drawing a portrait in the street and you tell the man what what pencil are you using you know and the man says uh well I'm I'm using a 2B pencil would you like to try you know and he was doing an amazing an amazing portrait and then you sit down and you try to replicate what he was doing and you realize that your drawing is really bad. You know, the pencil is the same. The settings are the same, but of course the the painter, the the artist knows how to make the most of these energy settings. You know what I mean?
- his his his pen uh allows for different effects on the paper depending on how much pressure you put on the pen depending on on on how much you angle the pen when you when you when you draw you know so he gets all these effects and he understands what kinds what kinds of effects he can get from the pen here you see I'm trying to remove all this all this tissue from above sometimes it's quite high and uh Maybe otherwise at the end we will be able to see if there is any residual tissue.
- Okay. So this is now our anterior line. You see I have a posterior line. I have an anterior line and uh you know the surgeon as the artist has uh different ways of of manipulating the energy. For example, we have discussed one of the factors that influences the effect on the tissue and that's the working distance. Here I want coagulation. So if I get a little bit separated sometimes I can get proper coagulation. You see I have to wait a little. If I get closer though the tissue will start to be disrupted as you can see. No. So there's a very fine very fine tuning of the working distance that the surgeon has to decide. But also if you think about it, I move the fiber.
- So the movement is important. If I move the fiber 1 cm in 1 second and I fire 50 pulses in 1 second, I know that I'm going to fire 50 pulses in 1 cm. But if I fire uh with the same uh frequency I fire I move at two 2 cmters per second and this is the entry into the bladder. Okay. Here I found the the bladder anteriorly professor I am anterior. Yes we have we have two more questions. Two more questions. Go ahead. Go ahead. Yeah. The first one is how will you differentiate anatomical and surgical capsule and what is your target on your on your dissection? What is my target?
- Okay. So the question is how do I differentiate the plane? Well, yes. You see, with this with these uh modern lasers that have so very very good heostasis, we lose a little bit the possibility of seeing the the beautiful plane that we saw before or the beautiful plane that you see when you do mechanical dissection because you see the energy is very heostatic. So, it all gets white.
- So basically we need to change the definition of plane. You know instead of looking for a beautiful plane we're going to look for um as I say a capsular plane. Let me see if I can control this this bleeder. It's not so it's not so easy. Let's see. Let's get to the depth of the so basically my definition of a surgical plane of a capsular plane is a plane that is uh mostly white uh mostly white. The adenoma is more yellow in color. The surface has to be smooth. You see smooth more or less smooth surface not bumpy. It has to have fibers on the surface. And of course it's uh it's coherent you see when you look at the plane it looks like we are in the same depth you know in the correct depth it looks very good
- um I call this coherence so the plane has to be coherent when you go from the side to the anterior to the posterior it has to look like an empty orange and then there is another factor the plane shouldn't be perforated so if you start perforating ating you you have to correct your aiming. You see when we do this dissection actually going from the apex towards the bladder neck it is it is a little bit like driving a car you know let me see if I can explain myself here we have for example the the plane the line of dissection so when we are driving with our car you know if you get too close to the outer part of the road that you're going to get out you need to you know change your direction. You need to get closer to the center of the road. So here
- is the same. I am aiming my laser to try to stay inside of the capsule. Uh if I see for example here it looks a little bit deep. In the next pass I'm going to go closer to the adenoma. And I was talking about the artist and about the surgeon. You know that I told you that the surgeon has to u decide what is the working distance uh how far from the tissue you are firing. You have to decide how fast you're moving because if you move too fast like you know three uh cm/s then you will only fire 15 pulses in in 1 cm you see. So basically you want to have enough pulses to get good hemoasis. So if you run too much the hemoasis will suffer. Okay. And then there's the third factor that the surgeon has to let's say modulate how the energy is going to reach
- the tissue is going to be the targeting. Exactly. Where do you target the laser? Okay. So there are three theoretical places where we can target the laser. Uh if this is the line of dissection here, I can fire against the line of dissection. In this case, you see the capsular is very perpendicular to the fiber. So I need to target in this case I need to target closer to the side of the adenoma.
- Okay? This way the energy will stay in the adenoma and will get away from the capsule. Okay. So and then the fourth factor the fourth factor and that will finish uh the explanation about how the surgeon can modulate the energy uh how how the energy reaches the tissue because as we said the settings only determine how the energy comes out from the fiber. Uh the other factor is how do you use your endoscope. You see if you work like this very far from the line of dissection it's very difficult to dissect. You need to get close. You need to get traction on the tissue. A little bit of traction and counter traction so that you expose the line of dissection with your endoscope and you generate a little bit of uh traction because this this endoscope
- can be used as a pusher or as a um an aid you see to to aid you with the uh dissection of of the adenoma. There are more questions I believe. No. Yeah. Yeah. Let me know. Yeah. Yeah. Okay. I don't hope I'm asking answering the the questions. Yeah. Some more questions, Professor Sanchez. The first one is in learning and block resection, do you need to go through mastering two lobe or three lobe techniques before you're qualified to do in block? Okay. The question is, do you need to learn two two block two loes or three loes before you learn in block? Okay. So when I teach to people, you know, that work with me, for example, I teach them and block right away. I think and block is rather easy. You have a way to ensure that the patient is going to be all right. So what I do
- is I do the aical release myself first and then I let the beginner do the rest of the operation. Okay? I try to explain all these subtleties about where to fire, you know, the aiming and so on.
- But of course some [clears throat] people say you know I would like to learn and block but my teacher only knows two loaves. And I said of course uh you have to learn what your teacher can teach you. You know it doesn't make sense that your teacher is going to try to teach you uh and block if he doesn't know how to do it. You know what I mean? But in block uh there are some papers out showing that it's uh probably easier to learn than than three lobe. Uh because people think that when they see the three-lobe and they see the middle lobe uh dissection, they think that the the initial step of the three-loop technique just cutting a five and seven and removing the middle lobe seems very simple and it is very simple. But of course uh the rest
- of the operation is much more difficult. So again, my advice would be learn the technique that your teacher can teach you because once you know the anatomy, once you know the basics, once you know how to how to use the energy properly, you're going to be able to to try other approaches.
- More questions? Yes, we have more questions. The first one is how do you deal with large morsel resistant prostates if you encounter them? Oh, how do you feel if you encounter large prostate that is difficult to morulate? Yeah. How how you feel very you feel very sad, huh? Because it's going to be a tough tough u tough situation.
- The only the only cases that I see that are big prostates and they're very hard is the prostate cancer patients. When you when you have to do a a prostate cancer patient, uh the tissue can be extremely hard. Okay. So [snorts] basically in those cases sometimes I do I do leave the adinoma attached to the bladder neck at 6:00 and use a rectocope to morcellate the tissue. So I resect the tissue. I'll I'll show you exactly how I do it in a moment. Um otherwise most of the times I would say prostates are easy to morelate but as you know prostatic uh BPH benign prostatic hyperplacia is a nodular disease and some of the nodules. Now look at what I'm going to do here.
- I'm going to lift the prostate a little bit. You see? So I'm going to put the prostate here. Maybe it's a little bit early to do that. Let me check one thing. This is the UO here. So, what I'm going to do is to cut the bladder neck a little bit more here to make the pedicle much uh much thinner and also to protect the UO. Okay. So, we know that the UO is uh around here somewhere. We saw it a moment ago on the right. On the right. No, here. Okay. Now we have this limit. So we know that the UO is quite far. But as I said you you you first elevate the adenoma and then you try to push it into the bladder very gently. Okay. This is the tilting of the adnoma. This is the prostatic urethra in
- the midline in contact with the bladder neck which means that there has been a rotation. Look at the space we have now. We have a lot of space. So now we can finish uh this side much much uh happier.
- So as I said if you leave the prostate attached uh at 6:00 with a pedicle like this you see now I will push it inside uh the bladder completely. I think it will go you see completely. Now this situation uh the adenoma is fixed or the prostate cancer adenoma is fixed and then you can go with a reccoscope and resect everything uh very fast there is no bleeding so that could be an option for morcellation also for those of you who don't have a morsul a morcellator it could be an alternative the problem is that morcellating a very very large I don't see here is a okay okay so here also you see we are going to be careful We don't want to hit the UO. So I'm going to mark a little bit here so that we don't get close to to the UO. They see the inucation is finished. I think it
- took us 20 20 minutes 25 minutes maybe. Uh so you see that and block enucleation can be very fast. So it's really worth learning this procedure I think. It has many many advantages over two loes or but of course it's very difficult to say scientifically you know which one is better and uh then there is uh how do you say expert opinion and expert opinion as you know is the lowest form of of um evidence [snorts] there is you see that we left a little bit of fluffy material here but there's not much uh serious significant adenoma here so I'm going to do some heistasis and we will move on to to morcellation. Huh? Did we come out? Did we come out? One second. One second. You see the sphincter is perfectly preserved and the mucosa is going all the way to the white
- line that I marked. So I am quite satisfied with the sphincter mucosal preservation. Yes. More questions. Yeah. What is your technique to preserve retrograde ejaculation? Ah, what is the technique I use to preserve ejaculation? Okay, so ejaculation preservation, I have to say in my opinion, has not been brought to us by troubled patients who cannot ejaculate, you know, and are very sad. Um, you see, there are support groups for patients in the world. There are more than 100,000 support groups for patients, you know, alcoholics, uh, diabetic people, uh, people with cancer, uh, people who were circumcised when they were born and nobody asked them permission.
- You know, you find support groups for everything, but I was not able to find one support group in the world for patients who are troubled by retrograde ejaculation. So in my opinion this is coming from the industry you know the industry makes a lot of money selling euro lifts selling resum selling accoation selling all these uh let's say less efficient techniques to treat the the BPH uh like like homemium in my opinion a nucleation of the prostate is a true operation it really solves the problem for the patient it generates happy patients and um I don't think we should let's say of course it's always good to learn more no and to investigate and to see if there would be a way to keep the good uh results of a nucleation if if the patients could even ejaculate it would
- be great but in my opinion when you preserve an uh aical tissue to try to preserve ejaculation you risk uh retreatment, you risk uh uh having worse results, you risk uh not to deobstract the patient completely. So I'm a little bit reluctant to try to modify a nucleation to preserve ejaculation.
- Okay. So there are some publications uh some people uh I think from Korea published they could preserve ejaculation in 40 40 45%. Now David Ao from Oxford is saying that you need to leave uh epical tissue and leave like a keyhole and um but you see this patient is totally unobstructed.
- He will not ejaculate but he will be well for the rest of his life. So I don't do ejaculation preserving hole. I do bladder neck incision in younger patients who need to preserve ejaculation.
- uh bladder neck incision. If there is a middle lobe, I will remove the middle lobe. And if you stay 1 cm above the verontanum and remove the the tissue here, sometimes they pee much better. Let's moreate. Uh can we have silence in the operating room? Thank you.
- One one more question. Fernando, go ahead. Yeah. for patients with large intrarostatic protrusion in which sometimes you cannot see the ureeral orifice during dissection. What technique to do in order to avoid damaging the orififices? Okay, [laughter] I mean you you have to be careful in these patients. You see how I was dissecting the bladder neck until 4:00 more or less and then I went in to look for the uos and then I marked a line uh on the a cut on the on the bladder neck in order to to um prevent the damage. I think uh it's it might be difficult at the beginning for people who are beginning but normally it's not the end of the world. If you come from the sides at 4:00 and 8:00, you always see the UOS and you can always draw a line with your laser that will
- uh mark the way to follow without hitting the UOS. Also, if you heat the UO with a homemium laser, normally typically you shouldn't do anything. Just keep an eye on the kidney, but it's very unlikely that there will be dilation of of the kidney posteriorly. So I think uh this approach the Enblo approach is quite universal. You can use it for all cases. Redo cases, big prostates, huge prostates. Uh as you have seen when I tilt the prostate, I tilt one lobe first very carefully and uh then you you have to follow the same rotational movement to push the enoma into the bladder so that the bladder the prostate enters the bladder sideways you know not not uh frontally. And this way even in the very large prostates you can always nearly always um uh flip the adenoma into
- the bladder. So and the uos I mean sometimes they're they're hidden. They're not visible. I don't mind not to see the uos uh when I do the initial systocopy. I never force to see them if they are occult by a big middle lobe. But then I come to see them when I'm uh cutting the bladder neck. When I go to 4:00, I stop my bladder neck cut, you know, descending towards six. I go inside and I try to see them. And in that situation, they're always visible. Always visible. Some groups uh in Russia, they don't care about the UOS. They don't even look for them. You know, they do the enucleation and they know if they hit the U nothing will happen, which is a little bit risky, I think. Um let's say we should be careful now if we can. Do I have water? Yeah,
- water is good. Yes. So this is the upside down uh morcellation. I like it very much. You see it helps you um because the adenoma tends to float up during morcellation and uh if you are up there you know the contact is going to be a little bit better. Also the adenoma is between the mouth of the morcellator and the bladder. So this is the preferred uh way to morcellate in Asia and Japan and um I use it very often. I use both both ways the normal 6:00 uh position of the morcellator and as I was telling you before you see I developed these lines of dissection connected the posterior to the lateral the lateral to the anterior to have a reference an anatomical reference. These lines allow me to operate continuously without needing to stop to have panoramic views, without needing
- to stop to to see where I am. And with morcellation also, you want to go in and you want to morelate very fast and you want to finish very fast because you see we did a good hemoasis, but there will be some veins in the capsule that might start bleeding. If you think about it, we are sucking water out from the bladder. So sometimes the moment we suck 50 100 ml from the bladder, the pressure is going to drop to zero. So then these little bleeders will start bleeding again. Okay.
- So the visibility is going to decay uh throughout the morcellation process. So you you want to go in you want to morcellate as fast as possible in order to keep uh good visibility because you see as I was saying before the BPH nodules sometimes are very stro okay they don't have a lot of glandular components if you think about it glands are empty they're hollow and they they behave like spongy tissue you know they're it's like a sponge there's cavities inside. So glandular nodules are quite soft. But then also we have stromal nodules. You know stromal nodules are like fibramas. Fibramas are going to make morcellation very difficult. So typically when we morelate it's like when you eat a peach you know uh the the teeth of the morcellator are able to eat the soft meat
- you know the soft part but when you reach the very hard nodules uh it's not able to chew the tissue. So normally the piece that you have at the end of the morcellation is the hardest and uh at the end of morcellation usually the visibility is the worst visibility. We have to change. Okay, change the morulator. So we will change for a moment. We took out already a lot of tissue. But you see if you look in the fossa, there is already uh little bit of blood and uh the visibility is not perfect. So the idea is that uh we want to we want to finish as fast as possible. And at the end of the operation sometimes we get these hard nodules. We call them the beach balls. They're very hard. Also, they're less elastic. You know, if if I if I turn off the the suction from the I
- don't know if I can turn it off here. Yeah. If I turn off the suction, I'm turning off the suction and try to morcellate. Look what happens. No, no, it's okay, Luba. Look what happens. You see, if there's no suction, there's no attraction of the piece. So, we need to do suction. When we do suction, you see the piece gets into the mouth of the morcellator and then the rotation of the blades will eat little pieces of tissue. So [clears throat] when you when you have elastic tissue when it's soft, the tissue is going to block the the the the mouth. And during morcellation, there won't be much water coming out only a little bit. Huh? there will be water coming out, tissue coming out but not too much water. So we can we can we can be assured that uh the bladder is not
- getting empty. uh if you see good attachment of the tissue like we see now when you cannot see the mouth of the morcellator that means that there's not much tissue coming out not much water coming out okay so basically what I try to do is I try to work with the morcellator with the blade well inside the bladder and I'll tell you why because if you work like this you see because you're very shy you're very afraid of hitting the bladder wall you What happens is the tissue blocks the view.
- You don't see anything but tissue. But when you work with the blades a little bit more inside like that, you can see that on the sides of the of the blade there are two little black triangles. These triangles look black because the light is hitting the arenoma. It's reflecting with high intensity and then the camera sensitivity uh adjusts. So we don't see the bladder pink. We see it black. Okay.
- But we see the bladder black because we are far away from it. If we get closer to the bladder, you see we start seeing pink color. Huh? So basically if I drop my hands to elevate the blade a little bit. I push it inside the bladder enough so I can see this this uh black triangles on both sides. I know that I'm in a safe morcellation position. Let me try to bring this into the fossa because you see the tissue at the end is harder and uh when I morcellate inside the fossa it doesn't go away so much. It cannot go very far away. You can see that the visibility has uh decreased a little bit because there is a little bit of blood blood in the fossa and now I'm flushing all this blood around. But you see that the piece is coming to me. I'm able to morcellate in a safe safe position.
- So I I would like to Yeah, there's more question. Yeah. Yeah. Question. Yeah. Uh what tips can you share to shorten the learning curve for new lab surgeons? Okay, I'll tell you a story. They're asking me what tips can I share to shorten the learning curve for new users. I I'll tell you the story of my colleague here Dr. Gf you know he was helping me for thousands of cases for several years. He was a little bit shy to to learn to to enucleate at the beginning but then one day he said I want to learn you know he had been with me in innumerable uh sessions you know trying to well helping me and learning about the procedure. So I said, "Okay, prepare a couple of cases. I will assist you." He sat down to do the case and I was impressed. He was able to do it perfectly. He just
- needed two indications from me uh during the uh cases he was able to finish and this is all the training he got. You see, so the guy was able to do a nucleation uh from the very beginning because he knew what to do. He had already uh a lot of experience about how the procedure is done. Uh what is the give me a catheter what is the you know the steps of the operation. He understood very well the use of the energy. So if you want to learn my advice would be go to a center where they do a lot of cases. See many cases. Try to see 30 40 50 cases rather than two and three you know because if you see many cases you will understand the procedure and enucleation is not difficult to carry out enucleation [clears throat] is difficult to understand okay so watch many videos watch my
- videos in YouTube um and try to try to understand get to know the instruments very well get to know the the laser physics And uh that will shorten your learning curve. Of course, you want to do many cases in a short time. If you do one case a month, it's very difficult to learn. So, you need to do three or four cases per week. That will speed up. Huh. And of course, uh look for a good teacher. Don't try to learn on your own. No. Do we have the main camera now? Yes. Okay. So, I'm happy to answer more questions. I don't know if we have more time. It's about 1 hour now. [clears throat] Um, no questions at the moment. No questions anymore. Okay. So, I hope you enjoyed the transmission. Uh, I'm sorry I cannot be there. I have a lot of friends in uh,
- Philippines and I wish to see you soon, maybe next year. Um, and uh, I hope you enjoyed the session. All the best to all of you.