Professional education
Lecture at the CAU (Confederación Americana de Urología) session during this year's AUA congress
Dr. Fernando Gómez Sancha · ICUA
Dr. Fernando Gómez Sancha · YouTube
Language: English. YouTube audio metadata.
Professional education. May contain surgical footage.
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About this video
A virtual lecture delivered during the Confederación Americana de Urología session of an American Urological Association meeting. The description explains the online setting of the congress. It does not name the lecture's clinical topic or report study findings, so those details cannot be supplied from the preserved text.
I recently gave this virtual lecture during the CAU session during the AUA (American Urological Association) virtual meeting. Sadly, we could not go to Las Vegas for the AUA this year, but the AUA pulled out an excellent virtual experience this year.
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Original title and description on YouTubeSource checked: 2026-10-06.
Available transcript · English
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- hello i am fernando gomez sanchez from madrid spain i would like to thank the cow as well as jorge gutierrez for the invitation to discuss prostate nucleation chromium thulium sodium fiber or green laser what is the best alternative these are my disclosures when when a patient is going to have an operation he normally wouldn't ask the doctor doctor what scalpel are you going to use to perform my operation more likely the patient would say who is going to do my operation what will he do what experience does he have and we are living in a time where the tool is becoming more important than the surgeon and i think that is probably wrong and i would rather be operated by a good surgeon with a lot of experience
- with uh i don't know maybe not my favorite tool uh rather than a some with without experience with a very good tool so this is just a reflection to start we have a plethora of options of laser consoles that promise to provide the best experience the best abilities to help us educate bph patients and i'm going to try to reflect about it if if you look at the literature most published studies are providing very low quality of evidence there's few direct randomized comparisons there's of course different variations of surgical technique many groups publish their initial experience and certainly expert opinion is the lowest quality of evidence available so let's try to discuss certain aspects that i think
- it's important for people to understand and let's see what we can do with all this we have the knowledge that the effect in prosthetic tissue of a laser is going to depend on its absorption coefficient in hemoglobin and water for example green light it's a high affinity for hemoglobin they can travel through water for meters whereas home and tubulium and lastly trillium fiber have a higher affinity for water and these are lasers that you can use for example within the urethra to break a very hard stone so this is going to reflect on the tissue effect we get when we do a nucleation a nucleation anatomical nucleation has demonstrated to be a safe established alternative to trp and simple prostatectomy and it can be
- performed with different tools bipolar energy monopolar different lasers we're discussing lasers today but apparently when you remove the whole adenoma we get the good durability the excellent recovery of the urinary function that patients experience and maybe the selection of the energy source for endoscopic nucleation is going to be a matter of choice let's start with green light you know that green light has as i said high affinity for hemoglobin it provides excellent hemostasis when it's used for vaporization and it's recommended for the treatment of bph especially in the treatment of high risk and anticoagulated patients there have been different generations of green light lasers there have been
- different types of fibers which has made the interpretation of literature even more difficult because some of the papers at the beginning do not reflect what you can get with a newer laser and it all gets a little bit confusing the truth is that vaporization was quite slow at the beginning it got better and better with the different generations of lasers providing the chance to do a better vaporization effort but still doing big lands was the challenge and we described a way to do an in blocking nucleation the three-lope classic technique with green light and with the green light fiber is not so not so nice as the unblock technique and um we used the side firing fiber the 2090 fiber special scope with plant tip
- for mechanical dissection and the settings of 80 watts for cutting and 20 watts for coagulation we used very little energy to perform this procedure and it requires more solution at the end the procedure starts by marking the white line this line that separates the apex of the adenoma from the sphincter and we saw that this strategy actually was very good to prevent post-operative temporary stress incontinence that has been observed with the classic treelop technique of a nucleation and that's because the the mucosa of the sphincter is preserved so it it's really taught us a lot about the anatomy and about the anatomy of the sphincter to perform this in blocking nucleation with green light there's a recent review from italy
- where there are some groups doing green lighting nucleation of the prostate with the published evidence and again this is another demonstration that when you do an anatomically nucleation irrespective of the tool you're going to have good results relatively fast procedures with a lot of tissue extracted 60 70 grams and very nice results and very low rate of incontinence this is a video showing the white line already marked and how the tip of the scope is used to develop the anatomical plane and following the interface between the capsule and the anoma surgical capsule and the abnormal and then the laser would be used for hemostasis and for cutting of the fibrous adherences between abnorma and capsule so
- this was the the way to form green light nucleation a very nice operation but quite difficult when the plane was not uh easy and a patient with prostatitis sometimes uh with history of prostatitis it could be difficult to develop this plane also in this more glance the plane was not so properly developed and that's why in in my experience i i decided to switch to to polyp tullium yak the classic julium has shown to be a very good laser as well but it emits a continuous uh source of laser energy this this stream of energy uh provides the two laser with excellent cutting properties and very good hemostasis although it's not a very good laser for stones now there are some false lasers that can emit pulses and there
- are some papers where they can break certain types of stones but in general it was used for a nucleation and it has been recognized by the aua as a nice option to hollop and they are both recommended for the treatment of bph the initial technique described was the thulium vapor resection of the prostate so cuts were made into the prostate and little tips of tissue were taken out similar to trp a little bit slow procedure but a nice introduction for people to get used to to using the laser later on they started to try to replicate the classic three-lobe nucleation which was the two web that were thulium vapor education but the problem was to remain in the proper plane a very expert surgeon could do it
- but the laser energy dissection made it difficult so people would removed three theoretical lobes but they would probably leave bph tissue behind so it was not an anatomical technique whereas tulip the thulium laser nucleation with anatomical laser support with anatomical following of the plane described that thomas hermann has shown to be an excellent alternative to hole there is a mechanical dissection of the plane and the laser is used for coagulation as well as for cutting uh similar to what we did with the green light there are a number of uh important studies comparing thulep with durp with bipolar nucleation with open surgery there's uh some meta-analysis published and for example this paper
- uh which is published by the enthusiast of uh zulium uh they defend this this operation and this is a tool as an excellent tool that carries very little bleeding that it can also be used apparently in anticoagulant patients so if you look at how the tissue interacts with energy there is a nice cutting effect this is a surgery performed by an expert and also the hemostasis is good although there might be some carbonization of the tissue you see there is a need to do mechanical dissection to to find the proper plane because the laser itself cannot find the plane so it has to be the surgeon with this instrument which will mark the anatomical landmarks and then the laser will be used for cutting and
- coagulation so a nice option but there are as we will see other other alternatives the new sodium fiber laser is the new kid on the block it has a continuous or pulsed mode with a large range of energy frequency and pulse shape settings it provides uh apparently it's a very good tool for for for stones and of course companies always try to push their devices to to to as a useful tool for other procedures as well and this is how this laser initially was used for stones and then they explored its use for bph it has excellent cutting and hemostatic properties on prosthetic tissue similar to the current uh say classic tulum the laser generation mechanism is different than the the typical solid-state lasers where there
- is a laser medium that is excited by a flash lamp and two reflective mirrors and the optical resonator will give energy these these classic solid-state lesions that like the tullium classic tuning the classic holding are big boxes they produce a lot of heat and they need a big cooling system whereas the tooling fiber laser is going to use a fiber of silica with tullium elements that will be excited by a diet laser and the production of the laser energy is going to be within this fiber so there are smaller boxes they generate less heat they allow to use the smaller fibers and they have this super pulsed mode that seems to be very good to [Music] fragment no fragment but pulverize stones it's a young laser there's not so much
- evidence published for a nucleation they call it souffle sodium fiber laser nucleation of the prostate but whatever they gets published seems to be in the line of all the publications that refer to anatomic and nucleation so it's a good technique irrespective of the energy source and if you look at the video here you can see how the cutting properties are good the hemostasis is excellent but again the laser is not developing the plane it has to be the surgeon who describes who decides where the plane is taking place and despite some people say that there are some bubbles and there is some effect similar to what you would expect to see in holmen i think they are uh fooling themselves as i will explain
- later on during this presentation so if we go now to holmium we know the classic holmen laser but there's been a new revolution of voluminum the pulse modulation this pulse modulation consists on using two consecutive pulses and it improves the cutting and the coagulation properties of this laser provides an excellent first pass violation so when you dissect the plane the plane is coagulated so you don't need to do a lot of hemostasis which reflects in faster procedures and the quality of hemostasis has improved and that is allowing to do ambulatory follow-up which is quite an achievement because we can treat large glands in in patients who can then go home some hours later also the guidelines uh
- both in america and europe recognize uh that hollap has level one evidence it's durable it's safe even in anticoagulated patients it's cost effective because it allows to use to be used for for stones as well and it's recommended for the treatment of bph of any size i'm going to explain the concept of big power because this is the main difference between the hormium and the two counterparts big power is the instantaneous power of a single pulse so if you emit a pulse of a very high energy of 10 000 watts for 100 microseconds you're going to be emitting one watt you know the rest of the second is going to be empty without pulse but the one watt is the average power so what happens if we emit this pulse differently we emit a
- 2000 watt power but only for 500 microseconds so the rest of the second is going to be empty but the pulse characteristics are going to be different we will still be using one lot and this is what marks the difference between home impulses and two impulses home pulses have an enormously big uh or can have an enormously big big power whereas thorium uh has a different way of producing these pulses and they don't reach this uh very powerful big power so this is the homing working area it's very different from the thulium working area as you can see all both sodium and tulum fiber lasers do not reach this big power of the pulses of home and as you know when you you produce one of these pulses there's
- going to be a sudden heating of the water and the water will go over 100 degrees and this super hot water will have to change very fast and it does it violently and it produces a cavitation bubble and a pressure wave [Music] with a photo acoustic effect that's why we can hear the blasts and it produces a pressure wave this pressure wave is going to allow us to dissect the prosthetic tissue you have different effects volume laser if you're too far it doesn't do anything the mechanical the pressure wave is going to dissect the plane if you get a little bit closer you can get both effects coagulation and mechanical but this was a little bit difficult with the classic hollow and then of course if you get closer to the
- tissue this disruption of the tissue is going to produce a cutting effect so you see we have different uh kinds of tools for the job holmium is going to allow us to dissect the plane uh to peel the plane properly following the anatomical plane where studium and tuning fiber are going to be a little bit more tricky to do this this dissection as i said the experience of the surgeon will compensate for this but uh it's interesting to know and if you look at the two commercially available pulse modulated homing bases we will use the virtual basket from quantum system which has two consecutive pulses as you can see first pulse and the second pulse will travel through the first one allowing the energy to reach a little
- bit further and also with moses 2.0 which has been optimized for bph tissue there's a first pulse and then a second pulse that travels far away and also prevents the fiber from being degraded during the procedure so it's very interesting new effects what is the advantage of pulse modulation we're going to have an excellent dissection of the anatomical plane if you spray the energy in the interface in the line of dissection you're going to see how the plane opens very beautiful but then the energy is going to reach enough to provide an improved first pass hemistasis these enhanced cutting properties and enhance first pass coagulation are going to result in better visibility faster procedures increase safety and i think
- because we haven't proven it yet it it will make learning hollop much easier because the visibility is better there's less less bleeding and it also very interestingly allows to use very small scopes there have been a number of publications already both with moses and virtual basket and they both seem to highlight the positive feedback that we we get with this laser this is the mosses in action and as you can see when you go against the line of dissection it opens up the plane beautifully and it provides a nice coagulation nice first pass regulation of the prosthetic capsule this means that you're going to be able to dissect concentrate on the dissection of the plane and you will not need to be um
- about keeping hemostasis during the procedure sorry i'm going to try to pass yeah this is uh the experience we have published as an abstract during this congress and you can see that we were able to remove 56 grams of tissue in average of 32 minutes for nucleation and more solution time we had very little complications very little bleeding very little catheterization and we were able to increase our ablation rate when we compared it to classic call it almost double our ablation rate to four grams per minute and reduce the hemostat time in in about five minutes sorry i missed a slide and this is the experience with virtual musket which is uh similar uh we treated prosthetics with an average size of 80 grams and surgical
- time of 40 minutes also with little in the way of complications and very nice very nice results so in conclusion endoscopic nucleation and atomic endoscopic nucleation of prostate is feasible safe and reproducible different energy sources green light green light is a versatile tool for bph if you master both vaporization and nucleation you can do ejaculation protection so it's an interesting tool uh thulium and tullium fiber are excellent cutting and coagulating tools so if you are skilled and you can perform nucleation you can perfectly do a nucleation with these lasers and then holmium and especially the pulse modulated lasers are an excellent dissecting tool so it will be up to you to decide which one is going to be your
- surgical knife for a nucleation i think endoscopic nucleation is the natural evolution of turp into something better more complete more definitive more anatomical and it should be widely adopted and there is now technical and surgical technique improvements that make it more attractive than ever and i am happy there is some question thank you very much for your attention all the best