Professional education
MiLEP, The evolution of instrumentation for EEP, by Dr Felipe Figueiredo
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 talk by Dr Felipe Figueiredo on MiLEP and the evolution of instruments for endoscopic enucleation of the prostate. The introduction discusses the adaptation of older resectoscopes and the development of instruments intended for enucleation. This is a presentation about instrumentation, without a numerical comparison of clinical outcomes in the written description.
When you think about it, our instruments for endoscopic enucleation are adapted from old resectoscopes. Some adaptations have been better than others. Up to recently, the worldwide uptake of enucleation has been negligible for manufacturing companies deciding to invest in a proper engineering effort to design an instrument that meets all our needs as enucleators. Dr Felipe Figueiredo is a Brazilian enucleation expert who has pushed hard to improve our instruments. He is an avid reader, knows the relevant literature exceptionally well, and has contributed significantly to the democratization of enucleation, trying to improve outcomes and ultimately benefit patients. He has described an ingenious technique to obtain long bladder mucosal flaps for urethroplasty with laser and regularly travels worldwide to lecture and spread interest in enucleation. I hope you enjoy his talk!
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- MiLEP
MiLEP, The evolution of instrumentation for EEP, by Dr Felipe Figueiredo
Source checked: 2026-10-06.
Available transcript · English
Automatic YouTube captions, not clinically reviewed. Names, technical terms and numbers may contain errors.
They may contain transcription or translation errors; check the explanation in the video.
- so this is Philipe Figo from kashes Brazil I was invited by Dr Fernando Gomez sanha to present a lecture about the evolution of instrumentation in endoscopic nucleation of the prostate MIP minimally invasive laser nucleation of the prostate I have dedicated the last few years of my career to BPH treat treatment and all my my patients are treated with this New Concept that is the miniaturization of the endoscopes to perform holip I work in pompea hospital in the enlarged prostate Institute in Brazil and I would like to thank Dr Fernando for his efforts for the WID spread adoption of HB worldwide I believe this YouTube channel is one of the most complete uh video source for those who want to learn the technique with many
- tips and tricks and dozens of of surgeries and Fernando had played this major role in the adoption of the hup worldwide that we have seen the last five years and I'm really happy with this invitation my disclosures I have assisted in the development of these smaller Scopes by RZ medicine technique which is a German manufacturer and I run holip courses in my hospital for Quant system so the the most successful endoscope that we have seen is the glazes rectoscope from 1975 it's continuous flow so before that you had to stop your resection to empty the bladder every few seconds and it's rotatable so you can rotate the working element without rotating the outer sheet and is widely adopted worldwide but originally the
- endoscopes in 1938 were made originally made in two sizes 28 French and 33 French and it was abandoned because of the amount of Ural trauma and strictor many patients had to do a perenial otomy to be able to pass it and Nesbit was the first to propose a reduction in the caliber of the endoscopes to reduce Ural trauma so he proposed to reduce from 28 to 26 and 24 depending on the side of the prostate so we have a smaller sheath and a small Loop to treat smaller glands but it was intermittent flow and non rotatable then the glasses proposed to add a second layer another sheath outside and this would allow with this extra sheath to a continuous flow and you don't need to stop your reection to empty the bladder and he also proposed
- two sizes 28 French and 25 French for modal glands and then this new concept of continuous flow is the POS ability to have the irrigation through the Lumin of the inner sheet and in the outer sheet there was a small holes that would allow the fluid to go between the sheets and go out in the second stop [ __ ] and the initial paper described to add suction to the outflow so you could reduce the the pressure inside of the bladder and that way reduce the absorption of the irrigation with monopolar that could cause hypon the modern sheets are available also in this single sheet with a 24 French sheet and loop and 27 French for larger slices and The Continuous Flow is the most adopted is available with 26 French
- sheet but using a 24 French Loop in the inner sheet and 28 French outro sheet and 27 French Loop which is not pop in Brazil and Europe but in some part of the world like in the US they still use a lot the 28 FR sheets both for trp and for H it and the this difference of the fixed inner sheet is that when you rotate the working element you have to rotate everything so you have this rotation of friction in the urra and this New Concept of the rotatable allow you to rotate the working element and the Alor sheet is fixed so you don't have this this friction in the rra and reduce the rro trauma Peter Gilly in 1998 was the first to describe holip but he used the same 26 French sheet from TP but with the
- laser you don't have the loop and you may burn the ceramic tip so this is one of the problems you may touch the ceramic tip with the laser and break it and he proposed not to use the working element but a laser bridge and a catheter so this bridge is different from the cystoscopy Bridge because it's longer it fits the rectoscope and then in the tip you had a metallic tip with a ring that would stabilize a ceter a laser ceter this is still used in some countries that were Pioneer after Peter Gilling like in the US and in in UK in London but it's only available with a fixed inner sheet it's from car stores the evolution of the system is the possibility to have a bridge with a laser channel so you don't need a
- catheter anymore and later on we had the [ __ ] laser working element that would have the same handling of the standard working element but with the laser Channel and this allow you to adjust the working distance of the fiber this is very popular in in Europe and this is my favorite too but some some doctors like Fernando likes still likes the bridge and the channel because you have less instruments that allow you to rotate without hitting the legs but this is personal preference and both work very well but these two systems allow you to work with the ceramic tip without burning it because it's stabilize the fibers very well and then we had this new concept of the blunt nucleation that fando proposed with the
- green lip and later on Thomas hermer with tulip and we use the the ceramic the the tip of the rectoscope as the finger in open pomy and if you have a blunt a larger metallic tip it reduce the risk of of Perforating with this blunt movements and Richard wolf has this blunt metallic tip for green LA and even for for hoip but I want to show you a real life case when I was starting in 2017 I started in 2015 and this was a young male 58y old with a 60 G prostate and I was starting my holip but he had a very tight membran ofra I tried to negotiate but it was difficult I didn't want to create trauma so I step back and what should we do in such cases that happen really frequently so in this case one option is to adjust
- the rra to the instrument so we can have these metallic dilators in Brazil we call it Ben in the US VOR SS and with this dilation we create this circumferential trauma that can create a circumfer scar and after the metallic dilation you can see there was some degree of trauma especially in the in the membran of VRA and it was still tight even after the dation but I could eventually go through it and do the procedure and it was an uneventful procedure no bleeding perfect fosa H the second problem is that we have have this elevated steps in the outer sheet between theator in the inner sheet and the inner sheet in the outer sheet this step creates a lot of trauma in the meatus and in the membros rra and
- the last problem is the greater effect we have this concept that the holes in the AO sheet can create friction like a vegetable grater and sometimes at the end of your procedure you have a very damaged urra and sphincter and then after two or three months you have the perfect FAA but you have a strictor and this is extremely frustrating for the patient and also for the doctor he came for a minimally invasive endoscopic proceder and this patient had to do an open uroplasty to fix the strictor and this is very frustrating H the incidence is not so high but every case like this probably can be prevented if we change our mindset and if we check in the literature we can see that the strictor rate is not so low this recent paper
- from two centers in the US and Egypt with 100 patients in each group of Toran holip using 26 French sheath they reported almost 8% strict rates in ethopia arm and almost 5% in the whole group so this is is not low in my perspective so the second option is to adjust the instrument to the retra with holip we have a very small fiber is 550 Micron and we don't need to use the 26 French sheet to do the nucleation we have the 24 French sheath available from Richard wolf and now we have a 22 French and 18.5 French sheath and this is the idea you have a 22 fren reector scope that is 22 Continuous Flow and rotatable so you can reduce the trauma by the rotational movements and it needs a special 2.9 mm scope originally this
- was an EOS scope for oscopy by the gynecologist they reduces the size but you can treat any size of prostate with this instrument a few days ago I treated my larger prostate so far 400 G in the MRI it was 332 but the specimen weight calculating the the more sated weight reduction and the periphera Zone it was estimated in 400 G and with perfect vision another modification is that I needed to reduce the steps so I propose a new obturator it's a blunt and bigger so you have only one step between the operator and the the outer sheet and I asked them to create very small holes more holes but smaller holes to reduce the friction with the greater effect and the gynecologist also had the 18.5 French ultraslim rectoscope then I
- tried and it works too so in smaller glands below 80 gam I use the 18 French Rec scope in all my cases this is more than 50% of my cases and bigger than 80 g I use the 22 French sheath so this is the comparison it's too big 26 too big maybe not for all urras if a patient has a catheter for many weeks the urra is dilated 26 probably it's okay but in 30% of the cases 26 is too large 22 is a is a great combination of excellent irrigation perfect vision and you can treat any size of gland but in my practice this is too large in some cases and now we have the 18.5 frame sheet that allow you to do the nucleation of uh any gland too but the visual is not so perfect the irrigation is not so perfect like the 22 so I I
- decided to use only for smaller glands so we published this this paper and Video in neurology video Journal describing this new concept of minimally invasive laser nucleation of the prostate with this Li holip 22 French and the ultra Li holip 18.5 French so I want to share another live case from last year March 24 it was a large gland 130 gram in a 67 year old mail and when I was introducing the 22 French sheet the bber ritra was really is small and this patient came from another state from s Paulo his Ries came together and I said okay this is a large gland the ideal endoscope would be 22 but I think it's too long to be working with high friction and I didn't want to dilate so what I did was to downsize the
- reector scope for the 18 French Shah to perform the nucleation and then after changing you can see that the 185 French could pass through the narrow part of the Boomer rra without trauma this for me is was a GameChanger now we have options not all patients fit the large instruments and you can adjust your instrument to the rra of the patient maybe not for all patients like I do but probably you see in your practice as small uras like this but how can we morate so the standard uh morcellation H proposed by Peter Gilly was to have an adapter a bridge that could fit the long nephroscope from pcnl in the outer sheath of the 26 French rectoscope but then we proposed as L moros scope I said okay we need to
- downsize the optical system to be able to fit a 5mm working channel that could fit all morcellator blades and to have a good irrigation and this is was the project I'm very thankful and grateful for for RZ for believing in this concept and in this idea and this is the moros scope so it's not so new since 2021 so I'm using for four years it you don't need any adapter it was not for pcnl you can just remove the inner sheet and introduce it in the same outer sheet of the 22 French system and they even put a logo with my name in it so the moros scope the idea is to have a very small Optical system it's fiber optic so we compromise the quality of the vision is like an oscope and but it has good uh Vision
- good lights and two large irrigation channels and we have a 5 mm working channel that work with any Morel in the market and for me the irrigation is the most important part of the moros scope and this moros scope has an excellent irrigation but is it smaller better do we have evidence that this could prove provide some benefit we have a couple papers but this is the best one from my friend Mario sofra in Tel Aviv and he compared 26 with 22 holip and the operating time was the same he had to do some metal dilation in 70% of the 26 French group but only 23% in the 22 French group group so here we see that some patients still have tiers even for the 22 the efficiency was similar so milp was 0.94 gr per minute and H 0.8 what not
- statistically significant but M MIP was slightly Superior H the hospital state was the same the complication was the same the incontinence rate in the postoper per period was very different the definition of incontinence here was any drop of urine in the underwear so it was a very strict definition in the MIP group in the first month he saw 15% and in the hoip group 40% this is high but it it has to do with definition okay and we see a 62.5% reduction in the incontinence rate with the same technique the same surgeons but only reducing the size of the scope in 3 months it was zero in the MIP group and 3% in the holip group what about stors it was not a very large group so they had only one meatal
- strictor in the 26 French group but MIP was also Superior and then we now have this new project is the high flow a nucleos scope the idea is to improve the irrigation and the visualization in the opical part of the procedure why because so this is the first purpose build in nucleus scope before that we were working with rectoscope for trp and this was designed for enucleation okay so if you remember the iges this is light from the eases concept the inflow comes through the inner part of the inner sheath and comes through the holes the small holes in the outer sheet and Between the Sheets there is a small space that the irrigation comes through the outflow stopcock so if we check the the shape of the inner sheet it is
- larger at the tip and this long ceramic tip obstruct the first four line of holes of the outflow so for TP is not a problem but for a nucleation when we are working at the Apex and doing especially doing the early Opa release at the mosa sometimes we have a very vascular mucosa you have a very poor outflow because the holes are blocked inside of the membros retra so the elaz receptos scope was not designed for nucleation especially the in Block nucleation that Fernando me and scon and many others uh use for for the technique so we post this new design it has a short metallic tip and then we have these grooves at the metallic tip that allow the outflow not only through the holes in the outer sheet but also uh
- from the front Between the Sheets so we improved the outflow in the first four line of holes and this New Concept of the grooves allow the front outflow and we did this in vitro evaluation with a pressure pump using 60 mm of mercury which is equivalent of 81 cm of water using a glow finger as as the bladder comparing 26 22 and 18 French using the ceramic tip and the new metallic tip high flow system and this is the the the lab test we use a a barista uh flow meter to check in one uh minute how much fluid would we have through the outflow and consequently through the inflow using this this concept and then we closed the holes using a tape to check how was the outflow with the ceramic tip and the
- metallic tip 2226 so when we close the holes we only have front entrance of fluid and what was the results with the 22 French high flow with all holes open compared with the 26 with the ceramic tip we had similar outflow 20 250 ml per minute and 283 mm per minute with the ceramic tip 26 so 26 is a little Superior if we have all holes H allowing the outf flow but this is not what happens in in real life because when we are working the holes are blocked in most of the part especially at the Apex so we did a comparison of this new high flow system 22 French with a 22 French ceramic tip blocking the holes and the results were surprising because the new system if we close the outflow from the holes only from the front
- entrance still allowed 145 ml per minute and only 17 mm per per minute with the ceramic tip so it we increased more than eight times the flow and then we did this comparison 22 French high flow system with this 26 French ceramic tip blocking the holes and if this is real life okay we are releasing the Apex the sphincter and even with the ceramic tip we still have less flow with the 26 French sheath than with the 22 French we have 41% more flow with this new design and I think this would be a game Cher for the in nucleators around the world currently is only available with the 22 French but we are working also for this new uh concept with the 18 French sheet and I work in Brazil in the enlarger
- prostate Institute I I'm part of the one of the center of quanta training La lab to to to to learn the holip technique in Latin America I'm one of the three centers like Fernando in Spain and I also do these trainings for RZ medicine technique these are my contacts my email my Twitter account I also have an YouTube channel but I don't upload a lot of videos like Fernando so Fernando's channel is the most uh complete source of of knowledge but it would be a pleasure to have some of you here if you want to see by yourselves this this New Concept thank you again Fernando for the opportunity and bye-bye