Surgery
Real life HoLEP case number 2: Redo case after GL vaporization 10 years ago
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
An en-bloc HoLEP reoperation ten years after GreenLight vaporisation performed at another centre. The description identifies the earlier procedure and the retreatment technique. It does not supply additional case measurements or postoperative outcomes.
Another video from this series. This one shows the En-bloc HoLEP technique in a Redo case after GreenLight vaporization 10 years ago in another centre.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- En bloc
This one shows the En-bloc HoLEP technique in a Redo case after GreenLight vaporization 10 years ago in another centre.
- Redo surgery
Real life HoLEP case number 2: Redo case after GL vaporization 10 years ago
- After GreenLight laser surgery
Real life HoLEP case number 2: Redo case after GL vaporization 10 years ago
Source checked: 2026-10-06.
Available transcript · English
Automatic YouTube captions, not clinically reviewed. Names, technical terms and numbers may contain errors. Check them against the video; complete audio coverage has not been verified.
They may contain transcription or translation errors; check the explanation in the video.
- so okay so here we are again preparing the next case watch your spelling out now balli that's just hilarious proxy to the white balance okay there we are let's see we can go in this man has a relatively something is not connected properly because I shouldn't be seeing the edge of the school
- mr. go in that's a small you see cops collar know how do you pull this what's going on there that's impossible yes Allah mister is where I start immediate stop it's broken that's why this very strange come on
- and I didn't want to go in without being charged by the intermedia the instrument was broken yeah that's very strange to be able to see the profiles Thomas Willis attached to to this one it seems
- to be broken right so see we see a lot of these colors here this cops colors you have to go in perfectly we are that's a cynic yeah it's interesting you know do me a favor let's cut through it
- it's the least or maybe no if he looks as if he has this is a redo case have the redo case you can see that this area it looks as if the resection was quite good this is the you all the other one we cannot see for the moment but there is a big let's say growth of tissue on the other side and I'm happy that we have this space because I'm going to show you how this all green lights ten years ago okay so he had this unique yeah so you can clearly see the sphincter limit here I'm going to mark
- the sphincter limits all around like we do in normal it's a initial case or is that you don't have any treatment before I'm going to try to mark the let's say the white line all around the prostate even in the areas where I think the resection was good enough okay I'm going to come this way this way this is like a butch a white line here of course I'm going to go inside this winter so trying to bring this this white line down well this is this is counterintuitive because
- it looks as if they did a very good work on that side no yeah okay but in my experience you have to do this because there's usually a lot of tissue behind even when it looks like a nice fossa huh a nice resection so again this is the rarer montano so I will cut on top of the barrel just as we do in a virgin case let's say and then we're going to try to follow let's say the same method the same intention the same method huh protocol yes the same step-by-step strategy huh so here we go in the plane you see
- that's the proper plane and I'm trying to to bring it to the other side more or less like this
- I'm going to cut this attachments on the FX so we don't damage the sphincter from 6 époque we see 2 to 3 here is where the obvious pop bulk of tissue is now
- you see as we develop the plane look at the variance here you're going to find that it's also tissue on the other side now I'm going to put a 5 or 12 and let's continue with the dissection this is how the plane is looking here line of attack this is the other side that's the white line the way we marked it it's absolutely attachments until let's say 9 o'clock
- right then it's not so good we are this is the anterior aspect also let's develop the posterior aspect a little bit more like we do in normal at stake places this is what I told you before sometimes when you're here in this kind of plane it's because it's very inflammatory or sometimes it's because you're going in the peripheral zone I don't know for sure let's see how can we develop this be careful stay close to the ANOVA
- let's see something like a good plan to me now let's see over here just last year it's always worth checking you know because in many cases we have seen that despite the look of a it's a well respected foster well there is a significant amount of BPH tissue behind and these patients what you want to do is to try to give them a definitive solution now you leave a tissue behind maybe after some years they will need to come back again so this is the posterior aspect and now we're going to focus on liberating the apical parts okay so this would be say the access to the to the
- plane this is still you know white line some tissue there let's see
- all right now we want to come up upwards towards this area here so no teapots here a little bit more horizontal these are always very interesting pieces the reading pieces still because you're never the same well they're always different and you always learn these pieces let's try to go up up you see
- that's an odd Nuala let's see that looks like a novel stay more eccentric it's no deal
- okay so here we are reaching let's say the 12 o clock line we did you see on the other side so try to connect this side so we are going here [Laughter] what easy cases with this law reading pieces I may be challenging from times but if you follow let's say the surgical
- principles you're going to be ok it's it's difficult to say where where is where is the the good plane let's follow and we can see for the moment then here for example is where transmit a lotta sound can tell you huh after a while or when you want to check if you we need a proper the obstruction helped you a lot but I think now we managed to release this inter almost completely from the
- epics there is still some attachment apparently here the interior it's a plane okay
- it's not partial good huh I think we're able now to see the Antonia plane now we do our dissection so one of the things that conditions what we're doing with this operation is that we are using receptor scopes or sister spots that were let's say designed for T or P which means that PRP you shouldíve have a central cavity and then the the scope is moving let's say inside that cavity not oh so the orifice is for drainage of the irrigation fluid are around the tip but
- here we are working on a very very restricted space you know sometimes the irrigation is compromised by the design of the endoscope you know because the the space is not enough on the orifices to drainage are a little bit compromised by the walls of the prostate or by the sphincter closing on there so sometimes we have a little bit it's a compromised visibility we are discussing we're not companies to produce let's say to design all instruments specifically for this approach in the block approach so maybe where they inflow and outflow could go in the tip or closer to the tip you know what I mean you see now we are following the circumferential plane we haven't
- seen a proper plane but we haven't seen I'd say structures that tell you if you're going out of the capsule for the moment so we are probably in the right plane off of a nucleation where we're coming upwards this is the interior tissue here maybe if you look at the tissue you see that this is the cavity we have known we are finding that there is still some tissue around here maybe we can remove what this plane is a little bit strange no it's very spongy I don't know how to describe it
- maybe bustling with previous treatment well sometimes BPH is like that no you have a lot of you say small validations that's what we are seeing here we are reaching until you li see we keep a good disability and that's that's really important because you can in progress and you can judge if you are too deep in the caption or not here again I'm trying
- to bring the plane of dissection a little bit downwards now because we are we have surpassed the equator of the prostate and now we need to go a little bit further down to try to look for the bladder neck if you are let's say dissecting and you don't get to see the bladder neck and you're afraid to continue you know because at the beginning of your experience you find it scary let's say - you are afraid maybe if I cut here I will go and let's say auntie New York Tina prostate no another one into the bladder there's one trick you can use the trick is very simple what you do is you go again inside the to study urethra you know to have a look and you make a 12 o'clock incision all
- right see that because then then of course you will be able to connect let's say this space with the the other space all right because it's very close if you cut there you're going to end up here this is what I try Here I am looking and yeah there we are you see so we are removing all the tissue that is remaining
- it's blutter Nick beautiful case I love this business they're much more fun than it's a virgin prostate yes because this always well know it's always fun of course you have to be careful now here we don't know for sure if we are deep or not you see over there is looking that's like a big vessel maybe yeah let me careful as long as we are inside the prostate it doesn't matter sometimes you can take a little bit of the virtual zone with you or a
- little bit of the central zone as well the prostate with you and as long as you don't perforate you see it's it's very very alternately so to be careful but we can enjoy it see if I can come from above like this stay close to the Noma no if you are in doubt you know you go a little bit that's a big vessel and it's a fun thing you see let's see you leave it there for the moment maybe we have to talk a little later
- yeah this is bladder neck it's not so very interesting you know when you get a lot of next feature after TRP many times you're tempted to do a bladder neck incision but also many times there's residual tissue so I'm often doing an improper nucleation of the residual tissue which also lets say a new clay it's the strictured bladder neck you know what I mean and so I remove the residual tissue with the bladder neck that's a little bit scary this one now so I'm notify from from the distance to
- see if I can get some energy to travel a bit more otherwise yeah we got it at the end oh yeah also when you're doing a let's say post TRP or sometimes some areas and very fibrous because of the previous inflammatory let's say insult no you can find that it's not easy to develop Leonor there it's not a good plane so going around the ANOVA gives you very important anatomical clues know where you are more or less what you're doing
- that looks like possibly seminal disappointment so this happens sometimes all you see the similar base but it doesn't seem to matter very much maybe we are in the central zone after all you know it looks like seminal vesicle but maybe it is not the seminal vesicle just the it's a ejaculatory or the differential appeal how do you call it's the dilated you know initial part of the vas deferens inside the prostate it's possibly telling us you need to go a little bit further up to find a good plane here we have to be careful and stay very close to the Adama huh let's
- see if we can release the lateral lateral plane and even better so we have better information where we are want to stay up you don't want to go there we want to stay up just leave there that's flimsy capsule there and try to stay close to the end normal to cut the attachments of the Annamma to the cut zone without damaging the capsule it's one of the major when you say teachings you can take back home with you all right staying close to the Anoma when on the angle of dissection changes no here this is a nodule this is a nodule I want to take it out I'm going to come here I'm going to close to the no do
- these modules have to be removed you see they they grow in the castle many times and they leave a footprint so the capsule becomes very very thin oh look how thin you know but I I try to take them out always even if I leave a very thin capsule behind some reason now we are descending the or the irrigation pressure and like that then we understand in the fossa but when when the pressure goes down this is going to contract and many times we do interpretive ultrasound or postpartum ultrasound and we see that there's not nearly no extra session of urine so we remove the catheter the next day in Puglia and we don't keep the catheter longer we see this kind of thin capsular
- layer they're close together normal folks in the Anoma all the time you see here we are in the bladder neck so we are quite happy there let's see over here that's bladder neck but you see there's still some tissue here I'm going to try to follow this this way it's quite fibers here due to the previous operation
- it's a beautiful case I love this business I really have a lot of fun and enjoyment having to do this we do cases it always reminds me how important it is to try to provide the patient with a complete clearance of their normal fashion now is to preserve in circulation and I think for those patients who are it's a very keen on reciting interpolation it's perfectly reasonable but of course they have to accept that they will have a higher retreatin rate so if a man doesn't care about the declination I think the best service you can give him is to remove the whole adenoma and prevent its
- further growth and solve its near dying problems forever also it's true that as a holic surgeon or an endoscopic nucleation surgeon you get used to the excellent results you know functional results excellent loads total emptying of the bladder very low pH says post apparently so it becomes harder and harder for you to compromise when we see these patients ten years after their new creations and they still as smooth as they were the first day and they're very happy and they tell you it's the best thing I did in my life so as I said when when a patient is really keen on steel
- ejaculating then you can try to trade durability for definition preservation but otherwise I think we shouldn't let ourselves let's say be influenced by industries interests now with all these new options for vph that mildly improved the patient situation in terms of your dynamic improvement symptomatic improvement but for serving Appalachians there's a lot of discussion going on about that there's very strong proponents of
- preserving in Appalachian at all costs but my experience many older patients do not really care so much anymore about this and they would happily let's say except I resolve that lets them sleep at night properly have a nice flow and see properly stop the urgency and the material there we are the last touch mints and see whether you always good
- you see we are giving the patient a new bladder neck you know what I mean and there is the bladder neck structure and residual fragments this is an excellent option as well well that's the fossa this is the sphincter we managed to preserve the mucosal on this things are on the sphincter it's a little bit of lovely tissue but not so relevant I think let's do some viruses see it was very scary at the beginning but now we can see that it's not so bad looks like he'll be deep in the peripheral or so on but that's about it a good massage evening
- nice interior teaching removal small irregularity you think that the fiber measures 0.5 millimeters it's this is a two millimeter a three millimeter let's say receive your fragment but let's take it out because most likely these fragments will fall off later on and the patient will be a little scared he sees that being passed this is a little bit retro wrote right off but we are good I think okay let's modulate we are presenting
- this year our video on reading thesis putting both in the near you anyway it's a beautiful technique and I'm pretty sure this man will not come back because of prostate tissue you know regrowth so it's probably a definitive solution for him simple hopefully he has to make you can go home and after the second operation have a final resolution of his urinary symptoms in common no but the patients are more and more
- accessing videos in YouTube and things so they are very knowledgeable about about the options you know now they discuss with you what kind of laser are you going to use with me and why the Internet is let's say giving them a lot of information but sometimes also miss information that's why we are here now to try to help them decide what to do also you know when I want to ejaculate in a patient who has for example young patient with a middle lobe we can do an
- indication of the middle lobe and reserve the ejaculatory ducts by staying you know 5 or 10 millimeters cranial to the very montana these patients find improvement in their urinary symptoms and they nearly always preserve inoculation so that's why you know I had a tool that allows me to tailor the treatment for the individual I feel much better doing that for example than doing a your left and leaving staples inside the prostate Sagan offer for a small middle of yeah you can do you can do that you can remove the middle lobe you can remove actually you can remove the
- bladder neck as long as you preserve the apical tissue the patient is going to ejaculate so you can also do education presentation with all ammonium or green light I would realize you can perfect me let's save a prize the amount of tissue you want it's like a sculpture you know you can this is a very interesting study by Burton Newkirk's a French surgeon he was doing voiding cystoscopy yeah so he was doing a cystoscopy with a flexible instrument he was asking the patient to pee and he would stay at the very Montanan looking up to see how the prostate behaved during migration so many times you could tell where the obstructive problem was you know so
- sometimes you could see the middle lobe folding and coming into the prostatic fossa and you could tell if I cut here the patient is not going to be attracted you know but he was frightened icing this let's say preoperative voiding cystoscopy to find out what is the cause for the obstruction of the patient well okay I think we finished down the bladder is simply that's why we see a little bit of bleeding there we are so many times we do also learn incisions in patients were young and they preserve ejaculation let me put the thing