Surgery
3rd live En Bloc HoLEP case transmission during the InaSER Stream 2026 meeting in Bali, Indonesia
Dr. Fernando Gómez Sancha · ICUA
Dr. Fernando Gómez Sancha · YouTube
Language: English. YouTube audio metadata.
Surgical content for professionals. Contains footage of an operation.
Playback connects to YouTube. Your search query is not sent to the player.
About this video
The third and final live en-bloc HoLEP case from the InaSER Stream 2026 Masterclass in Bali, Indonesia. The description highlights commentary for urologists beginning to learn HoLEP. It does not specify a prostate measurement or particular operative complication for this case.
This is the last case of an En bloc HoLEP performed during the day of live surgery at the InaSER Stream 2026 Masterclass. It was probably the most beautiful case of the day, with a lot of interesting comments for those who are starting to learn to perform HoLEP. From here I would like to thank the organisers of the Masterclass for their kind invitation and hospitality, to the Sponsors of the meeting for making it possible! Always friends!
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- En bloc
3rd live En Bloc HoLEP case transmission during the InaSER Stream 2026 meeting in Bali, Indonesia
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.
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 Gomes Sancha and uh this is the last case of the session that took place in Bali, Indonesia. A patient with a 120 gram prostate and retention. I hope you enjoy it. Okay, so we ready to start? You think they're ready? So, let's come down. Yeah. You want to dim the light? Dim a little bit if you want. Maybe we can bring the camera a little bit closer to the patient. Okay. So as we come out you see we see the pillar of the sphincter. You see the pillar here. So this is this is the mark. Huh? This is the place. Thank you. So there is a very large very large uh adenoma. Huh. Here we have to come down and maybe take this
- towards the Verto Montanum. And here we have to go up now. here again down and towards the veru. This is how we mark the the white line. Now coming up up up up to see if we can connect anteriorly to the other side and come all the way down hereh again. Okay. So this is going to be our landmark. There's a lot of stones, stone cavities, stone crypts uh here. So we need to remove, we need to do a good twilelet of all that uh tissue there. Removing the stones, but not only the stones. You see this
- epithelium? We want to go under that to be able to remove it. We don't want to leave this uh mucosa of these cavities. We want to go below that if we can to to find a good plane. Let's see. Let's see if we can find a good entrance to the posterior plane. Let's see. That looks too much uh uh deep. No. So, we need to find a nice balance to develop a good uh space here that doesn't go too deep. But we want to remove all these scripts and stones. Huh. So let's see. This is the entry into the paracolicular space.
- This side here. You see here we were going deeper but we corrected very nicely. And now this is the development of the paracolicular space always moving slowly and doing long lines because we want to have a relatively uniform line. Uh if you start moving like this very short movements you get deeper in this place but the rest is not getting deeper. Uh so we get an irregular line. We want regular lines and that's why we try to work you know more in doing this longer longer lines of dissection. Now
- here again we have some little stones. Let's go all the way down to the bottom here to the floor of the paracolicular space. See if we can find a nice entry to this space in this side too and develop a nice opening here. That's too deep. Maybe this is better. So slowly progressing to develop this para paracolicular paracolicular space. I need to focus better. I think I need to focus a little bit closer now. Okay. And this is the paracolicular space in this side.
- I want to come down here. This will be the beginning of the lateral line then later. Okay. But now you see we have this space. We have the other space on the other side. And now we're going to connect by cutting on top of the verontanum. Here is where before in the previous case we found the ejaculatory ducts. In this case I think we are respecting the ejaculatory ducts. Let's see here. Now this is the connection between both spaces. And now I'm developing the posterior line of dissection. This is the posterior line going from side to side. I want to keep you see under under the adenoma and try to develop
- this posterior line as far as I can take it comfortably. As I said, the plane changes direction and sometimes it goes up very abruptly and it's not very easy to continue dissecting this this posterior plane. So, let's see how far can we take it. It's a very very nice looking plane. Huh. Sometimes when you treat a bigger prostate, you you think you're going to find more difficulty and actually you find a much better plane. So somehow the fact that it's bigger, it's compensated by the fact that the plane has better better quality. It's easier to recognize so you can progress a little bit faster.
- That was a nodule. H you can see the nodule. And then we are getting some bleeding from here. So I don't spend a lot of time trying to coagulate the bleeders that come from the adenoma because these will stop the moment we devascularize the original bleeder you know and spending a lot of time here trying to to stop these bleeders sometimes is counterproductive so mostly I don't worry about the bleeders that come from the arenoma mostly there are some exceptions here we see that the plane de develops very nicely again. So let's see how far can we take this plane successfully without deepening too much. You see here
- it's looking looking very very good and the quality of the plane is excellent. You can see the detachment. This would be what I call the beautiful plane. Huh? Sometimes we are able to see a beautiful plane like this. Sometimes we're not able and then we we discuss or we talk about a capsular plane. Huh? Capsular plane has these features that we discussed before. In this case, we can be very sure that this is a very good anatomical plane. Sadly, the fact that we see it in the posterior aspect doesn't mean that we're going to see it in the lateral or the anterior. Sometimes within the same case you can find areas where the plane is very good and then neighboring areas where the plane is really bad. So
- Mhm. It's most of the posterior plane. In this case, we were lucky to be able to develop more because if you if you're lucky, if you can enter this posterior plane and develop a lot of it. Normally, the operation gets uh quite faster because you have already done a lot. You see, if we go to the veru, you see most of the posterior plane has been dissected already. And now we're going to put the fiber upside down because we want to engage the lateral lateral lateral plane. So we come here. Initially we do a little bit of deepening on the on the white line. You see trying to deepen the the white line. This is already sphincter mucosa. So we want to stay there where we marked
- beforeh trying to deepen and trying to get some better access to and separation uh from from the aex and the and the sphincter. Now here we're going to try to enter the lateral plane. Let's see where where do we find it? Where do we find this lateral plane here coming up and down? Let's see. We can connect also this lateral plane that we are finding with the that's the beak of the scope. You see it's uh clashing with the tissue and making some trouble. My endoscope you see has this big it's u a little bit aggressive against the tissue. So, but here we are trying to
- develop the lateral line. Let's see if we find a nice lateral line here and we can connect it with the previous uh line of dissection that we had below. So, we are entering now a good plane that could be a little bit deep. So, we're going to correct uh to to see if we can find a plane that we can trust that makes us happy and uh it's a believable let's say lateral plane. Let's see here. It looks okay. So, we are starting the posterior part of the lateral plane trying to follow what we had already. You see connect this looks beautiful and it connects very well to the posterior plane that we had already developed here. Okay.
- So again when I go up I stop here because if we come out you see this was a little bit deepening inside the inside the deepening inside the capsule. So we want to keep our plane let's say here we want to stay here coming up and down making a little bit more of the lateral line. You see developing a little bit more and connecting always finally to the posterior. Huh? So we have a line that follows all around the adenoma and takes us to the to the right place here. Everything we do looking downwards, everything we do down here is not aggressive to the sphincter. We're not p
- pushing the sphincter. We're not damaging the sphincter. So that's why I develop more because if you develop more the mobility of the adenoma increases and then you have much better exposure of of the rest here you see we want to go up uh let's see where we have our white line is here you see this is this is the white line that we marked I think here so we try to cut and connect you see the white line we're coming this way trying to protect this finger that we have above. Now let's see if we can continue towards 12:00 here. This is an access incision. There we go. Try to to get in the interface you see in the in the plane
- that we can usually find between capsule and adenoma. We want to be careful. We don't want to go there very lateral. Although we are probably here in a good place now we have to explore and we have to decide where we go. Of course we want to be safe but if you if you get into the adenoma because you want to be safe then you're going to be in trouble. So there's a balance. No you need to look for this balance and define the plane define the line. We want to have a line that uh is helping us is guiding us. There we go. This is also very nice looking uh beautiful plane. No, you see millimeter by millimeter. I want
- to progress very slowly in a very controlled way. So my endoscope moves slowly but there is continuous progress. Huh? Continuous progress. Here we're coming more anterior. So this lateral line. I wonder if the if if the camera could be a little bit more in front of me because especially not like this but more like in front of me. So rotate and and bring it to the head of the patient. Bring it to the head of the patient. Thank you. Thank you very much. Thank you. It's a little bit un uncomfortable sometimes to have the camera on the side. Okay. So, there we go. Trying to go up following this line and following the same principles. No, we progress. We do heostasis. We pay as we go. Here there's
- an area where we find some vessels. So, we need to control these vessels. We can do the helicopter movement going around the vessel to try to find there's a sound of water flowing. No. What is that? Is this water flowing? What is it? You hear it? It's like if it was raining outside or something. Clicking sound. Yeah. So, some vessels are very resistant. Huh? You You need to be ah air conditioning. Okay. Okay. Yeah. Yeah. Yeah. Okay. Okay. Hello. How How are you?
- So, here we are. Here we are. We're trying to ascend, you see. But here we need to be careful and cut the attachments of the apex with the sphincter. You see so that we are respecting the what happened. Ready. So we're slowly going up. You see trying to protect the the sphincter. This is now close to the 12:00 region here. So we are almost crossing over to the other side. So let's develop a little bit of the anterior plane here to see if we can get some descent opical descent. See going up here
- trying to release a little bit more anteriorly. Mhm. always mobilizing towards the bladder neck a little bit because we we want this detachment in in order to have some space. Huh. So before going to 12:00 I try to develop more of the lateral and anterior. There we are. It's a very good plane. Very nice. Up here you see we have a lot of exposure. Let's deal with these little vessels to see if we can keep a good demois as we go.
- And then as we come up here, let me focus a little bit closer. It's possible to push it backwards a little bit. Yeah, my head is I'm looking up. Too much but not more not possible. Mhm. Here we're clashing with the patient. Yeah. Okay. Some heistasis of the anterior. We have very good plane here, huh? Very beautiful plane. proate of the day. It's the most friendly prostate of the day. Yes. Yes. Uh so we need to this man uh is 76 and he has multiple
- myoma and he has had a catheter for 3 days apparently. Ah well blood thinners I mean if you're if you're treating an anti-coagulated patient you have to be very careful. The companies who sell try to sell you lasers. They tell you, "Oh, it's very safe. You can do you can do the operation without any any trouble. You don't need to stop anticoulagulation." But then when the patient bleeds, you call them, uh, come come and deal with the patient, you know, and they don't come, you know, to help you. So, in principle, you should be very careful. I think an anti-coagulated patient bleeds from the nose. He bleeds when he brushes his teeth. So if you do a big wound in the prostate, they they are bound to to
- to bleed a lot. So or there is a big risk that they will bleed. So I I I'd rather probably uh breach the patient with atrial fibrillation. I think the risk of leaving the patient without anti-coagulation is very low. But if you if you have a patient with a metallic cardiac valve, these ones they have to stay anti-coagulated. And these are the more challenging population because you need to stop the warerin and then you operate and then you start the infusion of uh heperin sodium and then you have to tailor how much anti-coagulation you give the patient because there's a fine balance. No, if you anti-coagulate the patient too much, he's going to bleed. If you don't antiquagulate him too much, the
- cardiac valve can be can be, you know, problematic. So, you need to be careful with the anti-coagulated patients who take uh uh new antiquagulant drugs. I tell them that they need to expect that they're going to be having hematia for a long time, usually low-grade hematuria, but maybe for a month. Huh? So, sometimes they call you, hey, I'm still bleeding, doctor. Is this normal? But for the atrial fibrillation patients, I'm very careful and I send them home with uh subcutaneous low molecular weight hepin you know and not not to the maximum dose. I want to keep them only a little anticoagulated so they feel safe and they are protected from their atrial fibrillation but short enough so that they don't bleed too much because otherwise it's a it's a pain. How long?
- I I I asked him to keep on heperin for two two weeks. Two weeks. Yeah. Yeah. I mean, there's always someone who tells you this story, you know, we had this patient who was anti-coagulated, very high risk, and he had a 400 gram prostate. And I did the operation under full anti-coagulation, and it went very well, and there was no problem. you know, it's it's a possibility, but I think you're risking a lot when you do that, you know, and I think if you can be careful and and the power to uh [sighs] it doesn't really matter too much because these these lasers coagulate very well, but there is a wound, you know, and the wound is uh every time you go to to pass uh to to to defecate, you know, you're going to
- push, you're going to strain, and then the the the the the wound is squeezed you know and then there's bleeding and so be very careful I think be very careful it's interesting after many years working with the same internists you know initially they were very prone to take the patients back to anticoagulation as soon as possible because they were thinking on the cardiac risk they know the atrial fibrillation risk the trombotic risk the but then when they saw how patients bled afterwards, you know, so they got more cautious. No, so it's nice to develop some collaboration with your internists and intensivists and anesthetists. So you look at the patient uh from different angles. No. And then try to see what is the highest risk for the patient. Of course, the bleeding risk is
- always significant because if they start bleeding, you know, they get anemia, they get problems, they get taken back to the operating room to remove a bladder tamponate, you know. So, here we're coming up. You see, I don't want to come continue going up here because here I have a limitation and and if I continue, I will break this. And often when you break this, you break the mucosa of the sphincter. So, you here you see we're almost reaching the other side now. So, we go from 6 to 12 trying to get a rendevu at at 12. Huh? Try to connect with the other side at 12. We want to go all as as eccentric as we can. So we make sure that we don't leave uh adenomatus tissue up there. So we
- this is like a BPH nodule here and I want to take it out. Let's see. You see here there is some BPH tissue. So we we need to go outside. You see in this case the targeting has to go more capsular. When you see a nodule and you see that you didn't take the right plane, you have to go more eccentric, more outside, you see, to to remove the nodule uh with the rest of the adenoma. Let's see if we can gradually get closer towards 12:00 and then we will be able to connect here. Here we have connected but I want to check at the apex. I want to check if we have connected at the apex level. Let's see. Because this is sometimes you can cross from one side and cross from
- the other, but still when you come here at 12:00, there's still an attachment. You see? And this is what you want to cut with the laser. You don't want to break it with the endoscope because when you break with the endoscope, this pulls from the area of the sphincter. And now that we can really connect both planes anteriorly at the apex, we're quite happy now that the aex has been released completely. No. And now we just have to go around. Let's get Let's not Sorry. Sometimes Yeah, sometimes the the fiber breaks. Let me see. Hold this fiber for a moment. Now, how do I do this? Because I don't want to get the camera wet. It's going to get wet. Let's see. We'll clean it before we continue. Sorry. That's the fiber.
- Yeah. The moment you change your instruments and you change your it's a little bit more more challenging. Okay. Let's um clean clean a little bit the with No, no. Clean, clean, clean. Come on. Clean. Thank you. Thank you. Thank you. Thank you very much. Okay, here's the fiber again. So, make sure that I have enough fiber. There we are. Are we ready? Thank you. Going to see if I can improve the heistasis here a little bit. Let's see if we find some vessels. This is the coagulation setting. All the time you spend coagulating is well spent because
- in any case you're going to have to do it later. So one of the interesting aspects of the homeium fiber is that the fiber tip gets so much you know so many explosions near the tip that it starts uh cracking you know and then when when you have uh cracks on the surface of the tip of the fiber the water gets between the cracks you see and then of course with all this energy the the fiber tends to break. So initially it gets degraded. So the quality of the quartz the quality is not so good and then you start feeling that the the effect of the laser is not so good. You know when you talk to the engineers they give you a microscope.
- You can look at the cut. You give they give you a special cutting device and they tell you you have to check the quality of the cut with this microscope. Okay? So you do that the first time but then Olivier Traxxer in his laboratory showed that the fiber degrades very fast. So after three minutes the quality of the cut you did is lost. So the quality of the beam coming out of the fiber is much less. So the truth is we cannot stop the operation every 3 minutes to do a cut with a microscope you know check that everything's okay and then come back to the operation because we would spend two or three times you know more time cutting the fiber and checking the fiber than operating no so most of the times
- we have to operate with a fiber that is not giving us the best possible beam you know so the only moment when I stop to cut the fiber is when I feel that it's not working well. You know, most of the times even with a not so perfect beam, with a not so perfect fiber, you can get the work done. You see, when you when you try to dissect the plane, it dissects. When you try to coagulate, it coagulates. So, you keep going. But then if you use a low power laser because these high power fibers when they get very degraded they start breaking up. So sometimes you see that the tip breaks you know and it refreshes itself. Okay that's the thing I want to ask you about
- no power inocation. Well, when when you use a low power laser, the thing is that the fiber gets degraded, degraded, degraded to a point where it's totally opaque, you know, and as you're using low power, it doesn't tend to break by itself. You know what I mean? So many times you think ah I'm not able to dissect, I'm not able to quagle it, you know, because the quality of the tip is very bad. So you need to cut it manually. Okay? So for example, if you use a low power laser, you need to tell your nurses to cut the fiber before every case. Don't give it to you used like that and degrade it like that because it's going to be very bad. No, mostly it's not uh it's in the beginning from the surgery.
- Mostly. Yes. Yes. But if if you feel if you feel that uh the the the the beam is degrading, you know, and you don't see very well anymore and like that, then of course it's a good idea to to get it out for a moment and cut it. No, I I don't use a low power. Say again. Hello open the bladder neck avoid neck contraction after the fall. Yeah. So, how do you avoid bladder neck contraction? What do you do to avoid bladder neck contraction? I don't know. Do you know? I mean, what do you do to avoid bladder neck contraction? How do you avoid it? So, you never see you never see bladder
- neck contraction. Yeah. I've seen one uh uh not using the volume that maybe I have too small opening. Is it correct or Well, my my feeling my feeling is that we don't know. We don't know exactly what causes bladder neck contraure. You know, some people think if you're too aggressive there's more risk. Some people think if you're not so aggressive then there's risk. I don't know. I don't know what causes bladder neck contraure. You know, normally I open the bladder neck widely. I open widely but uh because I cannot be sure what is the factor that you know I I think nobody knows what causes uh bladder neck contraure. People
- have opinions you know but uh we don't have certainty and u I keep seeing bladder neck contraurs mostly after 90 days after the operation but sometimes I get to see the bladder neck contractors later on after a longer period of time there's a bleeder and I cannot see where it is I want to stop it so yeah I open the bladder bladder neck, trying to follow the curve of the bladder neck, trying to follow the the curve of the fibers. You know, some people talk about preserving the bladder neck, but I for me it's a very silly concept because how do you know? I mean, where is the landmark to preserve? When do you preserve and when you don't preserve, you know, I I am not sure.
- What is the landmark of the how wide? Well, you you see as there is no landmark, I cannot tell you exactly how wide. You know what I mean? You have to follow you have to follow the anatomy more or less. Of course, you don't want to get out and see fat all around the bladder neck. You know what I mean? There's no need to be excessively aggressive. um but there is no clear landmark of where where to you know where to stop or where to open. So basically what I do is I come to the bladder neck and I follow this direction of these fibers mostly huh trying to go around the adenoma and trying to you know judge I don't want to see the fat I don't want to see that I
- leave BPH tissue trying to to find the edge of the adenoma no on the capsule um the rest is uh I don't know it's it's opinion it's not science um we don't know if bladder neck contraure happens when we're too aggressive or when we are too little aggressive. For example, um this lady Amy Rambeck from the states published a paper saying that after a nucleation, she does a bladder neck um incision. Yeah. So when she does this bladder neck incision, she she she's being quite aggressive, I think. And uh she says that she gets less uh bladder neck strictures but I don't know. I wouldn't I wouldn't know really. I
- I feel that probably we don't know. Uh I don't see the UOO. I don't see the UO. Maybe it's here. Huh. So this is the UO. We need to we need to prepare the bladder neck a little bit better so that we leave this uh prepared to signal that we are medial to the to the urethral orifice. Let's see if I show you how I do. This is lateral uh plane. I'm pushing the arenoma here towards the side towards the middle. Okay. Trying to get in here. see if I can see the location of the UO here and see if I can mark a line that goes let's say medial uh to the UO. So we can set the landmark for later. There many ways to do this but I want
- now that I see the UO now that I see that it's here I want to go medial to that you see and leave this mark this way when we come back later we know that if we stick to this edge you know the the UO is going to be safe because this is more medial than the UO okay now for some reason we're not seeing very well and there seems to be some bleeder still going on. I I don't know where is it. Maybe it's below. Let's see. I I was thinking it might be anterior. Now, once we get in here, we see very well
- water. No, now we have water. Okay. So here is the posterior aspect here. I also like to keep the fiber at 12:00 but I need to be careful with the beak of of the endoscope down here. So here let's see if I can follow this posterior line of dissection. Let's see trying to come. This is this is purely posterior plane and let's see what happens when we go towards the lateral here. You see we are progressing posterly. I told you before that we were able to at the beginning of the operation to progress a lot towards the bladder neck. So now this is making our life much easier. Now you see when the
- prostate lets you do the posterior plane uh very very well from the beginning then the operation is very fast because most of the posterior work is done already you see. So we have a very beautiful nice plane posterly and we're getting now very close to the to the bladder neck here. [clears throat] This is posterior. Let's see how it goes when we go lateral here. Huh? You see it? We still have some attachments. So, let's work our way up to see if we can reach the bladder neck from here, which would mean that we are uh reaching the moment when we have only a pedicle at 6:00 and the adnoma is hanging from there. And then often we can tilt the
- adnoma into the bladder which will give us much more space. And then we can check heostasis and probably finish the enucleation. I my feeling is that we progress quite fast in this case. As you see, I don't run. I try to go slowly. You see, I try to go slowly. I try to do long movements of the scope from side to side. So, we get more or less uniform lines of dissection. You see, I don't I don't mind. I don't want to run. I want to be consistent and and I want to work all the time. you you won't see me stopping for a long time. Many people at the beginning, you know, they need to have orientation. So, they stop a lot. They check where they are. They check the veru. They check
- everything, you see. But here, the fact that I've been looking after these lines of dissection and that I'm following them gives me a lot of confidence of where an orientation know where I am. I know where I am and uh that's helpful. to continue with the dissection. Let's see where is the bladder neck up here. No, we want to see here. This is like middle lobe here. This is bladder neck on the other side. We didn't cut so much. So in this case the bladder neck we didn't touch it in this side. Sorry. So let's cut the bladder neck coming down. You see then downwards bladder neck.
- So you see there's no clear landmark of the blad neck. There's no clear way to say I preserved it or I you know was very aggressive. So you have to do what you feel it's right and then hope for the best. Yeah, you don't want to undermine the bladder neck if you can. Sometimes it happens, you know, but uh I have no water now. Open the water. Open the water. One of the waters have to be open. Don't close the flow. Thank you. You cannot leave me without irrigation. You know when you change one of the waters has to be open. Thank you. Okay.
- Well, you see MIP is a very nice proposal because we have lasers now that are very heostatic. So maybe you don't need a lot of irrigation to to do this is the U hereh. So in this case also we are going to come let's say medial to the UO and we will leave a mark here. So MIP is very interesting but uh you know I think it it uh promises less trauma for the urethra. It promises that, but I'm not sure because for example, when I talk to Filipe Figero, the guy that invented all this, he tells me that he can only do three cases in one night, in one day. No, he's an experienced surgeon, he does three cases because I think when he uses
- this low, sorry, the low caliber endoscopes, it takes longer for him to do to do the operation, you know, it takes longer. So that means that uh probably you're changing a smaller instrument you know for a longer operative time. So for a longer urethral time. Okay. So there has been no proper study looking at the incidence of of of strictures. No. And uh I think it's a proposal. It's very interesting. I think for some patients it could be lifesaving because the urethra sometimes is so tiny that let's clean the camera for a moment because it's getting wet and we're not seeing well on this one too. Thank you. Thank you very much. Okay. So, [clears throat] you know,
- so I like the idea. I like the idea, but I think it might it's similar to the proposal of the mini perk. You know, mini perk was uh really fashionable for some time. No, then they went ultra mini perk and the sizes were very very very small. But then some people started saying well we're struggling you know with this so small small instruments so maybe these are good instruments for some cases where we don't need so many you know so so so big instrument but then for the difficult cases I will still use the the normal caliber no so initially there is this enthusiasm and then over time people are more judicious you know and they they they rethink it uh what they're going to
- do. So I think it's it's a good idea. the the instruments uh propose uh new design features that are interesting because you see HOIP or enucleation in general has not been of interest for companies uh producing instruments because it was a niche treatment you know so for them it was not uh worth investing in design or engineering ideas you know what I mean so we have been using modif ified rectocopes for enucleation for a long time. Here there's a little bit of tissue here. Let's see. Sometimes if there's a little bit of tissue, you can try to vaporize it, you know, if it's difficult to to remove it. So
- I I I like the I like the idea of of MIP. I think uh it's nice to have them these instruments in your armamentarium if you do HOL. I haven't bought them yet because they only have a trigger version and I hate the trigger, you know. I don't like the trigger. Can I get the patient coming to me? I still have bunch of Okay. Yeah. Sorry. I got some disconnected uh stuff here. Let me see. The water should come like that. Yeah. Okay. This is the And I want to get rid of this little piece of clot from the tip. And now it got wet again here. This came out. Let's clean.
- Okay. Still wet in the region. Let's see if we can do some some little heistasis here. The U was uh nearby here. This is one. This is this side. And that's the other side. I think here. So they are both safe. Now let's check the hemoasis. But I think the enucleation went really well. We had a very nice plane almost all around the prostate. So it was very friendly. As you said, we need to find out where is the where the bleeding is coming from. Let's see. I'm investigating here. We will check the mucosa later. It's a big fossa. It's a broad fossa. You see it's it's quite large. And
- we need to find where is the bleeding coming from.
- need to review all the anterior because we want to morillate in peace. No. And you have seen how in both cases that we did today the morcellation uh visibility during morcellation was decaying very fast. So unless you do very very good hemostasis you're not going to get very good visibility. We went to see the second patient and the urine was quite clear. So we're happy. So sometimes at the end of morcellation it looks as if it's bleeding but it's more like there's an accumulation of blood in the fossa and when we put the catheter you know it bleeds for 2 minutes and then it stops. Let's see. You see it's a very very
- capsular plane very very capsular uh depth of dissection. Let's see if we find the the vessel. There's something here. You see, sometimes also when you come close with the endoscope, you do a little bit of pressure, the bleeding stops and then when you go to somewhere else, you start bleeding again. So sometimes it's a little bit tricky. If we don't get good visibility, happy visibility, then we we will enter with the rectocope to get additional hemoasis. No, [sighs] no, it's it's better. I don't know. I think we stopped the the bleeder and most of the most of the most of the coagulation we did during
- the procedure was uh helping us to get uh better visibility. It's just a huge fossa. Huh. Huge fora. We need to clean again the camera. Vision is okay. This is feeling well. Which one? Ah, air conditioning is making noises. You know, with I don't know. I'm extremely sensitive to noises in the operating room. My wife always says, "I wouldn't ever work with you." You know, [laughter] she's an orthopedic surgeon. She says, "I would never work with you." That's what everyone said to
- Yes. Okay. No. And my nurses uh how do I say this? After they know me because I get angry sometimes in the operating room when they talk and like that but they know that when I leave the operating room I already forgot about it. So they they are quite uh see the there's a tendency to to to bleed to don't see very well where it's coming from maybe from here the epical part even more aical it's pretty good huh pretty good hemostasis If you still have something going, you know, it's going to compromise your visibility during
- morcellation. And of course, it's a big prostate, so morcellation will take some time. And if you lose uh you know, if the visibility decays, then you have to stop and go back to coagulate. So, it's better to spend a little bit of time here trying to get it right.
- Well, you can you can you can get close. I mean, you see this laser has very little penetration depth. So you know [clears throat] some people say when I work near the sphincter I lower the power because what has happened is that people had incontinents uh stress incontinents after the operation and they tried to explain why it happened. So I heard this German professor say you know big big pro patients with big prostates they have let's clean the camera again they have cleaned properly. Yeah, they have um no need to use the sphincter because the prostate is so big that the co-opting loes are going to give the patient continent. So basically the sphincter is hypoactive and when you do
- a prostatectomy the sphincter is not trained and that's why patients have stressing continents. Maybe 30% of my patients with big prostates they have uh stress incontinence. No, he said and then I said to him, so why is it that my patients with big prostates have only you know 5% incontinence rate you know so probably sometimes we need we we try to give explanation to what we see but they are really hypothesis you know it's not scientific it's not the truth you know what I mean so [clears throat] there's many false uh statements like that some people say I use low power close to the sphincter because I high power near the sphincter is what causes incontinents. But then I use high power all the all the time near the
- sphincter and we get very good continent results. Some people say I leave 1 cm of tissue uh at 12:00 near the sphincter because this protects continents but I don't leave it and I get very good continents. So you know what I mean there's a lot of and that's a problem. you know this this field BPH studies are very low quality and you cannot extrapolate uh all the conclusions that people make in their studies because um probably it's not it's not there's it's not possible to extrapolate no the studies are not powered enough sometimes I see papers like where they try to determine the risk factors uh for incontinents after HOPE. No. And they say, okay, in our series being diabetic, being fat,
- having a very large prostate, they're risk factors for for incontinence. But then when I see the surgeon who published the paper operate, I think, well, the main the main risk factor is the the surgeon, you know. So many times you cannot extrapolate this these papers and you shouldn't believe that every paper you read about in nucleation is the truth. So you have to read between the lines sometimes. Pedal pedal pedal pedal for more solation. Where is the pedal? Give it to me. Thank you. These things have to be automatic. Huh? There we go. So now we focus properly. Let's start with the moreellulation again. Which are the settings? You know 750. There's no suction. There's no suction. Suction is not working.
- It's it's on and off. Huh? It was closed. Now it's open. Okay. Hey, hey, hey, hey, hey. The patient's moving. The bladder is distended. We waited a little bit. The bladder is a little bit distended. Yes, we have two hertz you think? Yes. Thank you. Thank you. Okay. Ready? So again for morcellation now we go to the we go to the bladder neck area here. I lower my hands. So the tip of the morsel goes up. And now we want to morcellate. Morcellate morcellate non-stop if we can. And I want to put the blade a little bit inside. So I can see the tissue in the
- upper part of the image. And we can see the blade in the lower part. And we can see that in both sides of the blade there is a black triangle. Huh? This black triangle is telling me that I'm far away from from the bladder. Let's see. This is a theory. You know, we we try to h this is a basic uh idea. Water is running I hope. Yes. Thank you. So let's see how long it takes to bring the tissue out. I think the hemoasis was quite good, quite solid.
- So there it is. Uh it's usually more educational to see the smaller cases, you know, because when we have a 50 60 g prostate, we can discuss the steps of the operation much better. It's much more clear. But also, I think people want to see the big prostates know and see how they're done and the problems you find. But in my experience, the teaching cases are better, you know, between 60 and 80 or something like that. No, no, it's it's okay. I'm not I'm not uh worried about doing large prostates but I'm you see the teaching teaching experience is because and that's why you have to see many many cases because maybe for
- someone who has seen today's session he saw the first case bled quite a lot so we had to do a lot of hemostasis then we had to enter with the rectocope then the second case went a little bit better I And this case was nicer in terms of dissection. But people can have the feeling that this is a very difficult procedure. And um you see it's only when you see many many cases when you see the easier cases as well when you see that we can do a 50 gram pro in 20 minutes when you get a more balanced view you know. So don't don't settle for just watching very very small number of cases because and also what happens in Bulgaria and
- the people from from Bali who had visited me in Bulgaria and from I'm from Jakarta you know they they will tell you that after watching 20 25 cases you you get a much balanced view you understand that the steps of the operation are logical. you understand that the principles how to use the energy to coagulate to dissect how to uh the fact that when I use the energy to dissect it's a very very soft energy so if I start penetrating into the capsule I have time to correct you know and so we don't perforate so they they understand the methodology they understand the the steps and they they they are able to see the simplicity
- that lays behind the apparent complexity. No, here the suction is not so good. Let's see. And the camera is getting wet again. Let's clean the camera because once the humidity enters there, it's difficult to clean outside also. Thank you. Thank you. So, we we want to have Well, I I work with only one inflow, only one inflow. But um my recommendation when you start is to have two inflows as I was saying before because you want to make sure that you don't suck too much water out. You see the the hyperlastic tissue has nodules. Some of these nodules are very hard. So
- the morcellator is going to eat the soft tissue before you know and then the hardest tissue is usually left for the end because the morcellator logically eats the softer softer tissue much easier. So when it gets to very hard tissue it doesn't chew it properly. So at the end you have the toughest at the end you have the lowest visibility you have the toughest pieces. So morcellation is tricky in that sense. No, when you're more tired at the end of the procedure, you get harder pieces of tissue, you get lower visibility. So, it gets uh a little bit tricky. No. So, I use only one inflow because after a lot of experience, I like the simplicity of not having to put another
- two bags and another line, you know, to to irrigate. But I think for the beginners, it's safer to use two inflows. uh with uh so two lines entering water trying to keep the bladder full all the time. If you think about it, we we are talking about the decay of visibility because there are little veins that are bleeding. You see when you start morcellating the heart tissue at the end of the procedure, the visibility is already low, but the heart tissue is less elastic. So when you try to suck it into the mouth of the morcellator, it doesn't feel it. it doesn't fill the mouth. Here the tissue goes inside the mouth. So there's very little water coming out. And uh sometimes when we have very efficient morcellation, we can see that we took out
- a lot of tissue and the bucket didn't ever feel didn't even fill completely. Okay, we didn't have to stop to change it. So the thing is that um I lost my track track of what I was going to say. Sorry. No. Uh the idea, yes, the idea is when you're trying to morulate harder tissue, the tissue is less elastic. It doesn't cover the mouth of the morcellator so well. So you suck more water. When you suck more water, maybe the bladder drops a little bit the pressure inside the bladder. You know the and then what happens? This is the upside down morcellation. Now we have enough space to enter this. This sometimes improves the connection, the contact. Okay. But what I was trying to say is that when you
- have difficult morcellation at the end of the hardest tissue, you tend to suck more water out. So the the bladder is not full, the pressure goes down, the bleeding gets worse, you know. So it's like a vicious cycle. So yeah, you need to be careful with morcellation. And uh that's why initially I think it's better to have two inflows uh in with experience many times we can you know compensate you see when you find when you find hard tissue it's difficult to morillate let's see I love simplicity I went to London to visit one guy doing hole and he had several screens he had uh a morcellator
- He had a machine to heat the inflow. So to Okay, let's change let's change. He had a pump to put pressure inside to bring it out. And um at the end it was like a cockpit of an airplane, you know, very very complicated. And I like the simplicity of a small table, a small number of instruments in the operating room. So, I like to have one only one inflow because it's simpler. Okay, let me know when it's ready.
- Well, I'd like to take the opportunity to thank everybody for the for the session. The anesthetist team is amazing. Um, the nurses are amazing and um maybe I'm not so amazing myself. [laughter] No, but I I thank you because I I get very I get I get very anxious. I get very anxious when when there are people talk in the operating room and I get a little bit nasty and like that. But then it's very nice to be operating with a silent, you know, operating room and do you demand silence in your operating room? Do you I I put music. You put music. The problem I found with
- music is that uh it's very difficult to choose music that everybody likes. So sometimes it's for you. Yeah. Yeah. I mean if that if that's the case then but you know I I got my nurses complaining doctor your music is not nice. You know we want to hear different things and then the anesthetist sometimes doesn't like the music. So at the end there's no I tried wearing um earbuds, you know, but then you cannot communicate with your team. It's not safe. So it's it's not easy unless you're a tyrant, you know, like him. Okay, we will need to clean in a moment because we are losing visibility. You see how how wet it gets? It's amazing. Where's this water coming from?
- condensates. But you see in this case the visibility is not decaying. Huh? We are having very good very good visibility. But you can think I mean this man goes to the room with a catheter. Tomorrow morning we do this protocol. Wash the bladder. Wash the fossa. Remove the balloon. Wash the fossa. put 300 in the bladder, remove the catheter and then he will stand up and pee a first time. Then we give them ferosimid fosid 20 milligrams. So in two hours they pee three times, four times and then we discharge them because we tell them that it's normal to find some blood in the urine. I tell
- them, you know, if you put one drop in a glass full of urine, the the the glass gets like rosé wine. If you put two drops, it's like red wine. If you put three drops, it's like blood. So they they learn that this is not a worry. They didn't lose blood during the operation. So the deposit is full, you know. So we tell them all these stories so they can go home. Usually I send them with an anti-inflammatory drug, some gastric protection and I use an antibiotic uh with lowd dose antibiotic for a week because these guys have the possibility of developing or kites and and stuff like that which is very painful and I don't know the the the
- preventive medicine guys know or the the the antibiotic guys from the hospital from the public hospitals they say probably don't use antibiotics postoperatively but they don't have to see the patients later with orchitis and and problems. So I give them lowd dose antibiotics for a week. You see the tissue is getting harder. Let's try to get on top and see if we can get better contact and uh then I see them in the clinic after a month. You know some patients think why after a month? Because if they come after you know 10 days for example they still bleed a little bit they still feel some pain so it's a very uh boring uh consultation you know they complain so much so we prefer to tell them what
- is normal and when to consult so after a month they're much happier so I don't spend so much time with them trying to explain the same thing over and over again you know what I mean So sorry the pedal is rotating so I have difficulty finding it. We don't what? Ah uroflowometry. Yes. Normally we have we have in our clinic we have an ultrasound machine and we have a flowometer. So we tell the patients to come with a blood test uh already so we can see how they're doing if there's any urine infection or normally the PSA has gone down quite a
- bit normally it should remain below one after hole and actually if it goes over one you have to suspect that the patient has a prostate cancer so maybe there's some papers saying that if if they have a PSA over one after a nucleation they have a 90% chance of having prostate cancer which is a problem sometimes because these patients uh sometimes we discharge them no we say okay you're peeing well you're feeling well have a yearly PSA with your GP and then they go to the GP and they see PSA 3 and they say okay it's within normal limits go home and the guy has a big cancer so you need to tell them in the discharge report your PSA should be lower than one uh if it's higher than
- one come to see us, we would do an MRI and biopsy probably. So you see the tissue is getting harder, huh, at the end. So it's much more difficult to morillate. What else? Um, this is an operation that produces happy patients. The basket. Yeah, you have to change it with the Please do change the water on the basket. Also test the water. We're nearly finishing. Huh? It's uh two minutes hopefully. There's some clot. You see the clot forming in the fossa. The blood falls by gravity in the fossa. You see and at the end we have some layer of blood here.
- It's impossible not to have it. And if if you put a catheter probably it happens. So that's why we have to wash out at the end. Let me know with your array. But you see this is a nodular nu nodules. You see? So this is the hard tissue. These are the beach balls. Huh? Ready? Okay.
- I didn't hear you. You need to speak loud. Loud loud. Yeah. Sorry. Uh what happen if the is not working? Do you leave the for several days? Um well, it depends. If it's if it's a small piece of tissue, you can go in with our rectocope. You bring this tissue into the fossa and you try to resect it into smaller pieces inside the fossa. This is what I do. If it is a you know of course if you want to be serious about uh hole you should have a backup for everything. So we have two lasers, we have two morcellators, we have two of everything, you know, because it's very, how do you say it's not nice to tell the patient, I'm sorry, the morulator broke. We have to do a second stage, you know.
- So there is a very cheap morcellator uh from Quanta system. It's it's the handpiece. It has uh no cable, you know. It's a rechargeable handpiece that uh so we have this costs like €8,000. So we have it as a backup, you know, we have a of course we have two piranas, we have um and then we have this quantulator. So but if if you're going to do hundreds of patients, I think it pays off to have maybe a second lower power laser that would allow you to finish the case if the laser breaks down. Um normally when these lasers break down sometimes you can work at lower power sometimes it tells you I cannot work at uh full power but I can still work at 60
- watts. So often you can you can finish no the operation only it's very strange that the laser machine will break the morsel later can man malfunction and resecting a very long a very big piece like this uh from the beginning free floating in the bladder is quite difficult and risky. So if you don't have any other you know better option maybe it's it's safer to stop and come back another day when the morator is ready. But uh if the piece is not so large then maybe you can take it into the fossa and then try to resect it then. But this is very tedious and very very it makes the procedure ugly you know. So it's it's interesting h because in in Bulgaria we do it in a very small
- clinic. It has 11 beds in five rooms or six rooms and it has only one operating room and we can do 25 30 one weekend we did 45 cases. So HOL can be done in in very small places if the surgeon knows how to do it if the team is properly trained but then it's very sensitive to the quality of the instruments you use. So even if you work in a small center, you should have good instruments because that's that's when you can succeed with HOL. No, if you try to do HOL with a low power laser, bad instruments, you reuse the blades all the time. Many times, you know, at the end it's it's a nightmare. So you need to to use good equipment and good instruments to to make the most of it.
- No, but it moration went well. I think it it took it took a reasonable amount of time. It was not too slow. I I think with a with a single use blade, we we double the efficiency. It's much much faster, but uh it was not so painful. So sometimes probably in medicine and surgery maybe you don't need I don't know a certain forceps for closing the skin you know or if you need to do stitches in the skin maybe using bad forceps is not uh making a lot of difference no but if you're doing transplant maybe you need uh pot scissors you know that are fine and expensive
- so you want to use the money properly and and spend where it's needed. No. And with HOLIP, I think you need to have good equipment because even a very very good surgeon can look bad if if you have a bad morcellator or or a bad instrument or a bad laser. There you are. There's some little pieces in the fossa. These are coming along very well. Let's remove the clots that formed in the bottom. You see here the little pieces are coming to me. Here we can remove the little cloth and check that there are no more pieces. Uh okay, that's probably nothing. Let's put
- a catheter. Look at the sphincter. You see, we managed to protect the sphincter really well. So this patient will pee very well and will hold the urine very well. Good. Thank you very much. Now we need to close [applause] question. How you will take out the next day. Yes. I I already described the protocol to you. We wash we wash the bladder. We take down the balloon. We wash the fossa and then we remove the catheter after filling the bladder so the patient can have a first void very fast and then we give them fossimate 20 milligrams. This is a protocol to remove the catheter.
- You were sleeping there and you didn't listen to me. Okay, great. So good. We're ready. Thank you very much. H well well done. Well done.