Professional education
PURE Urology - En bloc HoLEP session
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
An en-bloc HoLEP session for PURE Urology, following an invitation from Dr Chandra in Hyderabad, India. The description states that the session discussed practical tips for the en-bloc approach. It gives the context of the teaching session without a case-specific clinical summary.
I was invited by Dr Chandra from Hyderabad, India, to participate in one of the broadcasts of PURE Urology; you can find this group on Facebook at https://www.facebook.com/groups/462153345218825. We discussed the tips for En Bloc HoLEP. A nice session!
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- En bloc
PURE Urology - En bloc HoLEP session
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.
- uh dear facebook pure urology viewers urologists uh good evening one and all from india and good morning from the other side as you all know we are discussing surgical technique based videos on alternate day by pioneers experienced surgeons today we are discussing about the prostate and nucleation as you all know the benign prostatic hyperplasia is one of the commonest disease that urologists come across anywhere in the world because it's a physiological change which produces symptom to the patients and over a period of time in last two decades alpha blockers and the 5 alpha reductase inhibitors have come a big way
- that reduced but what is happening is patient is using five to six years and ten years and during that time certain certain sector of patients will develop large gland and they will not be responsive and they will present with obstructive wiring symptoms and retention which will become ultimately the indication for surgery and surgery the gold standard was monopolar to urp in front of our eyes significant change even though statistics and papers may not support because of the large number of series on monopolar trp there it is impossible to go par with it but bipolar europe has almost replaced common private practice for the prostate gland in bph but now last 10 years we are seeing even though the nucleation of the prostate is
- there for more than 20 years uh initially to be honest today our speaker professor dr fernando gomes sancha is actually one of the pioneers who has used green laser very much enthusiastically in the beginning and developed the technique of the nucleation in the world in the world i must say after that he realized that the technology is changing accordingly sir has mood and his papers and his interest has moved to the homium laser so with this what is happening is irrespective of the laser technology there is a technique also which we say that the man behind the technique is very important taking his vast experience into consideration we are privileged and very happy that dr fernando gomez sanchez accepted uh for
- this talk today and when i have gone through the literature is really into this subject and has made a lot of contribution not only this lot of videos to teach the youngsters because we all felt when we finished 10 years back our mch urology that a nucleation is not at all a surgery which is easy a nucleation causes incontinence in nucleation is a time taking a nucleation is a costly procedure a nucleation is only for large glands and not at all for medium glands these type of bias will be there slowly we also thought after seeing the conferences that a nucleation is a surgery which is changing the the trend of management of the prostate with this i will briefly ask the carrier of fernando sir good evening sir welcome to the pure
- urology talk group uh thank you for giving the opportunity good evening good evening to everybody thank you very much for the invitation sir i uh after seeing your ceo you are from spain you are you're born brought up from us in the country spain yes yes i was born in madrid madrid uh your medical schooling uh who is your mentors or in your medical schooling how you became a surgeon can you briefly tell yes well i i i liked urology in medical school and i went to uh public hospital to do my residency and then i spent uh one year with tony mundy in the in the uk trying to become a reconstructive surgeon but then i spoke to roger kirby who said ah there's not so much reconstructive surgery to do
- the prostate is is where neurologists uh you know the bread and butter of biologists but i thought about it and i started using green light and then i i devoted myself to laser prostatectomy sir i i heard that green light you have used first time what is the scientific research at that time which was involved along with you who who was the helpful to you in this production of the green light the mechanics of the green light how could you understand in the initial period well i was not involved in the development of green light this was a development where the mayo clinic was very involved okay um and uh so which year exactly it is used sir first if you remember which year it was very i started using it in 2003
- 2003 okay that time homie was there very much active also yes yes but i i shared the same the same considerations as you at that time we thought holmium education was impossible to learn very difficult only for very highly specialized centers so it didn't look as a good strategy to start for a young urologist right after his residency you know yeah yeah yeah i chose greenlight to start with okay so when the green light what made you to go a little away from the green light exactly after 2003 how many years you felt that it is very good and then what made it that it is not good no it was it was excellent in terms of hemostasis uh we developed this anatomic vaporization technique where we were we would uh
- localize the plane of dissection to to be able to vaporize the tissue down to that plane and we were quite happy but of course it was not possible to to to do it in patients with larger glands that's why we developed the nucleation they unblock a nucleation for for green light and i loved it i loved it i but i found that uh i wouldn't be a complete uh laser surgeon until i learned hollop so i started doing hollop as well and i initially i was doing the three lop technique but i tried to adapt the unblock technique that i did with green light uh to hollop and and you know the the turning point was the moment when i had to operate my elder brother you know i had to
- operate him he had a nearly 100 gram prostate and and i asked myself which tool do you prefer and i thought let's do it with homium and then of course i couldn't be insincere with anybody else you know yeah i really i really think that with green light with green light uh you have to do a mechanical dissection and sometimes the plane for mechanical dissection is not very good and um in those cases you suffer you struggle a little bit more whereas with hormone it's uh usually a very nice and very relaxed operation and it is dissecting the plane for you it's giving you very good hemostasis so i i felt you know it was time to to to move on so when did you routinely started doing with homium 2007 something 2010 i think
- 2010. after that uh predominantly your surgeries are whether it is hundred or sixty or hundred and twenty is predominantly you like ohmium laser or anything this is the last question before i hand over to manas for introduction do you think that these changes will be constantly happening in the technology that we have to look now thulium fiber laser is coming already thulium was there but not so competitive with homium because uh self-separation of the tissue because of the blast effect as you said uh do you think that some more changes may happen we don't know well we have just opened the door to pulse modulation you know they they have been able to to do two consecutive pulses with volume and that has improved very significantly the cutting and coagulation properties
- so i think this new pulse modulation idea will open the door to to optimization of the tools and i'm sure we will see more and more improvements yes sir this i hand over the program to dr manas who is very keen in learning the nucleation he he wanted to do every every prostate in our group of hospitals whichever comes he says let us do a nucleation only let us not get tempted for trp that is the enthusiasm he has its privilege that manus will introduce fernando jose uh manus uh can you please uh introduce uh professor fernando now this is the program manager to you yes sir thank you sir uh good evening uh i'd like to thank dr fernando gomes sancha for
- accepting our invitation and it's our privilege to host you today sir thank you and uh dr fernando gomez sanchez is the head of the department of urology and robotic surgery at icua madrid spain actually he is a founder of the international green light laser user group and has developed the n-block green light laser e-nucleation of the prostate technique initially he was one of the pioneers of the green light major photo selective vaporization technique then he is also a director of the robotic surgery at his institution and he initially worked with the professor er mundy in reconstructive urology and he also works at the hill hills clinic in sofia bulgaria where he performs mainly the laser prostatectomies undoubtedly dr fernando gomes sanchez sir is one of
- those surgeons who popularized n block technique there is no doubt about it and sir also has a youtube channel on his name in which the real life cases of i think nearly 29 cases he has uploaded which is when a was teaching material for all the young enucleators thank you sir thank you for your time i like now i would like to give the stage to the fernando gomez sanchez oh thank you thank you so much okay so i'll try to share my screen to start sorry the video is advanced let's start from the beginning this is my operating room yes and the patient's getting ready this is an unedited case
- and in this case i was using the pulse luminesce pulse moses system the 120 watt laser this is one of the two pulse modulation lasers we have we also use the quanta system laser and well this is a typical patient we we get weak prostate catheter and i will be narrating the video but uh i'm happy to to answer questions if if there are any for example for for patients with catheters we have a protocol that we send the catheter to to the tip of the catheter to the laboratory to make a culture probably some days before the the operation and then we give the patient antibiotics for three or four days before the antibiogram
- that is because there is always this risk of sepsis in these patients and despite it's it's not very often when you do a lot of cases of course you have to leave some of these cases and that is what we do we use the the this is the equipment i use i use a richer wolf equipment i like it because it is allows you to use the same external sheath or three instruments you can use a laser scope you can use a resectoscope and you can use the morse scope or the nephroscope that we use from oscillation and of course the the more slater the piranha system i think it's uh it's very important to have a good uh a good morsel later so often we do transactional ultrasound to evaluate
- uh the prostate this case was about 80 grams in volume he had a middle lobe going in the bladder so we can take measurements and we can see if there's any anatomical abnormality that would uh [Music] would would not be detected without the ultrasound sometimes we see a clear um bph nodules invading the the the peripheral zone we can see sometimes details also as a teaching tool it's nice but also i have to say when you start your initial learning curve i think it is quite nice to have a transrectal ultrasound in the operating room because if you have a capsular preparation for example you can evaluate very easily
- if there is extravasation and if it's safe to continue or not so there it is a very simple instrument table and uh let's hope to start the case you know this there we are getting ready
- now you have your microphone connected i think because i could use the i could i could hear the typical noise from india you know the the cars [Music] yeah yeah this is the instrument and you can see that uh i like this instrument because it has a very nice uh tip that is quite blunt so if you need to do a little bit of mechanical movements with the scope it will respect the capsule it would not puncture the capsule and here this is how we connect the camera we get just getting ready we do a white balance and of course i always have an otis instrument i don't know if you use it in india but i i think uh when you have a little bit tight uh miatas for example
- yeah i prefer to do a 12 o'clock cut in the in the urethra with the ortiz urethratone than dilating uh concentrically because uh if if you have to dilate uh you might damage the urethra circumferentially and here you can see how the ortiz is a nice thing because it makes a 12 o'clock cut which is enough for the endoscope to go in and this longitudinal incision will might scar you know might form a scar but it's hardly going to structure the miata so we don't see metal strictures really huh that's the sternal sphincter you can see some changes after catheterization and this was the the prostate to trilobar prostate a very standard case not not a huge gland but uh
- well what we usually what we usually get and i guess in india uh you get uh similar cases of the fiber of course doing these smaller cases are good for for teaching no and they're nice videos as you do bigger and bigger glance sometimes the videos are not so beautiful but i think it's it's nice to to understand how the procedure is performed i usually take off the the guiding light you know some these lasers come with a light and that's the apical region and you know one of the drawbacks of of um polyp as you mentioned before was that
- there was a significant rate of post-operative stress incontinence so my area of interest let's say has been how to how to prevent that and i always thought that when you saw the classic technique the trelop technique surgeons would go and dissect the lateral lobe very very happily and when you look back the only thing left in the sphincter was the 12 o'clock mucosal strip which means that the lateral aspect of the urethra is probably de-epithelialized so [Music] here as you will see with this apical white line demarcation here what i'm doing is can you pause i wanted to ask a question here if you don't mind
- okay go ahead uh you have given incision from 12 o'clock to six o'clock on one side after that you have directly gone to the developing the plane you have not used any mechanical force here many of people just make a little dip with the beak and then they perforate the capsule is it necessary if you have a laser like 120 watts or do you think that this mechanical force to break the capsule is necessary when you are using lesser like 60 watts laser homium homium or you never recommend it well you know that they say that the surgeons must have and i will i will go back a little and play it again and uh they said that they said go back a
- little please very nice they must have the the heart of a lion you know the sight of the hawk and the hands of a lady of course so if you do a little bit mechanically nucleation you have to be extremely gentle so it's not pushing to see what happens it's more like dissecting so you put the endoscope and i think in this video you will see that i do a little bit of that as well of course sometimes you enter with energy if you have doubts you can explore uh a little bit with your tip uh but of course it is a dissection maneuver which is very very careful actually what you do is you try to contact the capsule with your instrument and then slide it very gently okay so
- yeah be careful always no we we have to be we we have to use the hands as if we were ladies uh for some lady urologists who are watching us probably you don't need to do anything because you're already a lady so um there you go so uh here again i am of course the the objective of this technique is to protect the sphincter's mukosa because if you think about it most studies on holleb who had big numbers 30 25 40 even of initial incontinence but temporary uh of course you wonder how is it that the patient is incontinent for some time and then it gets better what mechanisms cause this incontinence and then of course you can
- you can think about for example stretching the sphincter if you stretch the sphincter maybe there is some uh incompetence for some time no just like if a football player or cricket player you know gets injured he has a functional impairment of his muscle for some time this could be one of the things of course incontinence can happen because the patient has bladder hyperactivity and sometimes stress can induce uninhibited bladder contractions and and the patient can leak and maybe that is a mechanism all right if you remember i have a question sir possibly don't mind because this is a surgery if can you pass sir yes this is a surgery for the audience if you go little away then they won't come back that's why i'm interrupting if you
- don't mind see now you have done a mucosal incision from the top to bottom and after that you are focusing on the floor only yes that's right you have gone you have gone nearly half centimeter to one centimeter on the floor between three to nine o'clock position yes and i cut well what i do initially the first step of the operation is to mark the white line the white line i i i call it like that because the laser produces a widening of the tissue all right this line is going to be the reference of the sphincter for the rest of the procedure then of course i connect the planes in both sides by cutting the frenerloom of the very montanum and then i will concentrate to develop the posterior plane all right yeah
- see here you are not at all going anteriorly at all at this time no uh because uh of course we want to approach the anterior aspect very very carefully okay from below uh in one side on the other side we will meet at 12 o'clock uh this moment when we can liberate the apex completely this is what i call the early apical liberation you can preserve the sphincter the sphincter is totally preserved the mucosa is totally preserved also i have to say before when i did the tree love technique i was very stressed throughout the procedure because uh you know the sphincter was always left for the end whereas here once you liberate the apex in the first first five minutes ten minutes then you're relaxed you know the patient's going to
- be perfectly continent okay okay as i said also as i was trying to explain the mechanism for for mucosal mechanism that probably explains why patients are incontinent for some time is that the mucosa of the sphincter is taken away from it you know the sphincter stripped from mucosa with the classic technique whereas if you do a very careful approach to the sphincter preserving the mucosa then the ceiling the ceiling effect of the mucosa when when the sphincter closes will remain and the patient will have immediate continence all right so that's the posterior plane development that's a sphincter edge and here of course the difficult aspect was how do i because with the green light laser you know being a side firing fiber you could do this incision very nicely you would point it towards
- the side and then you would deepen this incision very nicely so with the straight firing fiber it's a little bit more difficult and i realized that you have to cut a little bit it looks as if we are cutting on the adenoma but you have to cut a little bit the the attachments of the sphincter with the apex all right so you deepen a little bit the white line against the adnoma all right maybe for three four five millimeters and then you gain a lot of access you get a lot of access because there are some fibers that are joining the apex to the sphincter initially i try to dissect the lower aspect of of the apex you see here for example it would look as if i'm taking the wrong plane because
- you see i'm cutting on the adenoma that's very confusing for people huh and they okay you're going to leave tissue behind no no look at this we are doing this to detach the sphincter from the apex and then we will go and we will look for the good plane all right so that's the that's the thing also it is quite difficult to understand this in by watching one case yeah so that's i have uploaded many many cases online without editing trying to explain mechanism when i get victories to bulgaria you know to these sessions we get people visiting they watch uh 30 procedures in four days or something like that so uh the first day they're a little bit confused they don't understand what i'm doing second day they start you know they have
- their aha moments when they start understanding all right here we are nearing 12 o'clock and i'm very very carefully progressing from below towards the anterior part you know very carefully and trying to stay always always proximal to the white line that we marked at the beginning okay that is paramount so you don't and here we're going to find the 12 o'clock fibers you see the 12 o'clock part where we did our initial mark and initially also you have to cut a little bit into the adnoma because what you want is to detach the sphincter from the apex and then you will see that progressively the the laser is going to point more upwards because of course the anoma is going in the in the anterior part a little bit
- further up than the than the sphincter and also you have to uh sneak your way in that plane you know carefully and progressively always cutting the most distal attachments first and here we are starting to liberate the apical anterior uh part of the right side of the patient you see this pulse modulation it's uh it's quite nice this is a white line again on this side these are the 12 o'clock fibers on this side yeah i don't mind as if if i'm cutting in the process it looks as if i'm cutting in the prostate but you will see that at the end we haven't left any tissue there and i will uh show you to you with the ultrasound you will see that it's a clean dissection but of course if we take the
- line of dissection a little bit more inside a little bit further away from the sphincter then we protect the sphincter much better all right uh the nice thing about this technique also is that if you think about it when you do the three lop technique you are uh connecting with the bladder so the the field that you are irrigating connects with the bladder here we are irrigating a very small field at the beginning and uh maybe that there is some water going in the bladder but if there is a bleeder inside this space we're going to be able to coagulate it very nicely the blood would be will be extracted and washed very easily so the visibility is excellent throughout the procedure and of course if you understand
- the the sphincter anatomy here you can see this thing you see how the apex is going further up than the sphincter and we have to sneak out our presence there slowly when we try to put the scope on top of the apical part of of the of the apex what happens is that these fibers at 12 o'clock with will verticalize a little bit and then and then of course you can only get there you have to be patient and you have to be very calm you know in a meditative attitude not anxiety you know because this is a very technical operation and if you follow the right rules and if you do what you have to do everything is going to be okay all right so here again i'm trying to cut the fibers
- at 12 o'clock of course we don't want to leave epical tissue uh at 12 o'clock because we didn't follow the right plane no so it takes a little bit of work you know at the beginning but as i said once you liberate the apex then if you understand the anatomy of an orange you can do this operation it's very very simple because you you're going to go around the adenoma with your laser typically you have to position your your endoscope to see the line of dissection or the line of attack as a as i like to call it so you see that in every moment in the operation we are seeing this line of dissection and we see in one side the adenoma and in the other side the capsule all right
- so this is how you have to position yourself you want to do the line of dissection you want to see capsule and you want to see abnormal then of course another very important aspect is where are you aiming with your laser see at the beginning we are aiming towards the center of the line there are three theoretical places where you could aim you could aim right at the line of dissection you could aim towards the capsule which would be wrong of course you don't want to cut the capsule or you could aim a little bit inside in the in the in the side of the abnorma if you if you know what i mean so initially in the operation until you reach the equator of of the dissection you have to
- to fire following the line of dissection because this is going to open uh the plane very nicely and you can see how the movement is dynamic you're not uh doing a very static operation that's the sphincter that's the mucosa on the sphincter so we respected the white line and this this patient is going to be perfectly continent all right so here of course if you see a bleeder you have to take it maybe sometimes if you leave a little bit of anterior tissue you can then go back and take it out all right so it's not the end of the world to me the end of the world is an incontinent patient but the rest is something you can perfectly well it's not the end of the world because these patients when they have
- incontinence they tend to recover over time but some some patients can be a little bit incontinent for six months or one year so that's what that's what we want to avoid they call you every day you know asking what's going to happen with my continence you know and you try to reassure them and it's quite tough but yeah we don't have anymore we don't see that anymore we don't see patients uh with with incontinence it's extremely rare we don't do physical exercises we don't recommend exercises they are fine from from day day one all right so as i said this is the orange we are peeling the orange and as the angles are going to change you know we are dissecting a sphere so you know the as we get uh
- as we approach the bladder neck if we are anterior we have to tilt a little bit out of the section downwards because we have to follow the curve of the adenoma if we are below we will have to point upwards you see so after this moment in the operation the targeting of the laser has to be more inside the line of dissection you know you don't fire against line of dissection you fire very very close to the abnormal because if you are pulling the anoma up sometimes the capsule is going to tent a little bit you know it's going to be pulled upwards so if you fire against the capsule you will open a a little hole so you have to keep the fiber very very close to the
- abnorma and if you go to one side like that like this and then go to the other side you have to bring it up a little bit more so every excursion you make with your fiber when you change direction you go a little bit further up to keep really close to the anomaly another important aspect is that you have to use your energy so it blows very very very very gently over the tissue you know this effect this coagulating effect and this dissection effect you have to find what is the lacing distance that works best for the settings you are using and what you have to try to achieve is a very soft effect that dissects that coagulates but doesn't penetrate too far this way if you go in the capsule you're going to be
- you know a little bit into the capsule but not all the way you know what i mean so if you are careful with your uh handling of the scope and the movements of of dissection you're going to be able to uh judge this is your job when you're doing the dissection after the release of the apex your job is to be judging constantly the information that your eyes are receiving from the from the screen you know you want to see what's happening you want to judge the depth of the dissection because the capsule doesn't always look the same you know sometimes we see a beautiful plane sometimes we see an inflammatory plane sometimes it looks you know it's never the same so you have to judge if you are uh leaving adenoma behind
- in that case you have to open your dissection so you can take the adenoma out or if you're going too deep in the capsule like for example in this area you see that it looks a little bit flimsy then you have to correct you have to change continue firing close to the abnormal and this way you can complete the enucleation with minimal risk of perforation and minimal risk of trouble here we are in the posterior aspect entering i think the middle lobe pockets down there you your laser know is at 12 o'clock even at the floor uh just because you wanted to be close to the prostate gland yes you see some surgeons who do call it are changing the camera or moving the fiber they tell you for example
- if you are firing at six o'clock the fiber should be at six o'clock yes 12 o'clock the fiber should be at 12 o'clock and to me one of my obsessions has been to simplify the procedure you know when you want to teach someone that he has the pedal the difficult anatomy uh he has to rotate that the camera everybody gets lost whereas if you keep the camera true okay what you see it's what you would see if you were standing there you know it doesn't rotate because if you have your your fiber let's say at three o'clock and you rotate the camera it could look as if it is at 12 o'clock no so you keep the camera as uh straight and you keep the fiber straight and and i i saw that
- for the beginning for the posterior dissection this is the entry into the bladder here yes we find this vertical fibers of of the bladder neck and we know that this is a pathognomonic uh sign that we can enter the bladder interiorly now of course this uh wonderful uh irrigation of a small space changes a little bit if there is bleeding you know you want there will be blood going in the bladder of course and then it will be more difficult to have a nice view to my advice is if before you enter the bladder complete your hemostasis because that way when you open up uh you will have good visibility that's checking for the uo you see this is a live this is a real-life case you can see that
- oh how long it took but 20 25 minutes something like that so you don't need of course i have known thousands of cases but but i have to tell you it's very frustrating that after so many many years working and hard you know and trying to understand anatomy and everything when i teach someone uh to do this procedure and i watch them doing it after some time i think wow it was not so difficult for them you know so that's a pleasure this this is this is uh something you can learn and this is something you can do and very proficiently and i have to tell you i know that in india you have an enormous surgical volume and you are a truly surgeons you know in some
- hospitals in in in our part of the world people would go to the operating room once a week or something like that whereas you're every day i think working working operating doing what a urologist does no but i tell you this is a very enjoyable operation this is a very enjoyable operation you you become a fan of it you love it and the feedback from the patients is so amazing they're so happy and really when i when i go for dinner after work you know i can drink wine because i know nobody's going to call me in the middle of the night you know what i mean it's a very nice it's a very nice uh operation and it really changes uh everything one important looks like you are not at all
- using your thumb into the into the mechanism of front and back you are using see you are using just like uh one piece you are not at all using your uh front and back mechanism no uh some you know it's very common when when when we invented the radio the tv you know yeah that was the radio so the first time they did tv they thought uh let's film someone with a piece of paper and a big microphone and let's broadcast this on tv you know okay you have the imagination to realize that they could do you know the big brother uh on tv you know what i mean it's it took many many years to develop this this understanding and the same happened when holmium started someone had the
- idea kuns i think the german professor had the idea to develop a trigger like a trp device but i think this is a wrong idea i i prefer to hold the fiber with my fingers you can see it in there because that gives you the sensitivity to uh become closer uh or or push the fiber inside when it's needed you see so it's a very dynamic manipulation of the fiber and you adapt to the tissue and it makes your uh operation much more precise so that's why what i recommend in that case uh am just imagining can you use a 18 french nephroscope in your hands which is smaller if the urethra is small and then do the same job if it is 20 degrees angulated yeah i mean
- telescope well i don't know if the nephroscope allows for continuous flow yeah you might need to put a suprapubic or something to to to allow for some outflow but you are not using the uh you are not using the you are using left hand only to hold the instrument that's all yeah yeah the left hand drives the instrument on the right hand of course the two hands are working together but you can see that i use my fingertips you see i don't yes a big pressure and i don't do hard movements this is now the final hemostasis yeah you see it's a very fast procedure and uh i have to mention something it's very important and people underestimate this this is a teamwork you know because you have to change instruments
- sometimes we have to use a sector scope look at the sphincter yeah yeah yeah preserved so now we are preparing to change from oscillation and here's where the team helps you you know you cannot uh invent oh this is the ultrasound here you can see oh it's rectal ultrasound the quality of the uh resection there was a little bit of tissue at 12 o'clock here you see because the altitude never never lies to you yeah or but if we look at the if we look at the side view all right you can see it's a very nice very nice fossa sphincter preservation was very good so we were we're quite happy huh they as i said teamwork is is paramount because if there's any more selection
- problem you can see that uh that uh you cannot you cannot operate the most later are scrubbed you are by the patient so you need your people your nurses to to do it all right so this instrument changed for example no now we change from the laser system to see how my nurse is helping me take it out i go in so we don't decompress the bladder too much and we can move on very fast now i'm feeling the bladder while the nurse is giving me the musculature with the blade and if you have a nicely trained team then you will minimize uh the problems all right now the bladder is full more slater is going in and i'm getting ready for for more selection so teamwork is the key word i
- remember uh circulating nurse i told her keep the blood the bags full keep the water running especially during marcellation but she was new and she didn't know that she had to puncture the bags all the way so the tip of the tubing you know didn't go into the back so i when i looked i the bags were full but there was no water going in you know so the thing is even the circulating nurse can have an impact in the result of the operation of course everybody was frightened about more selection but i have to say if you do good hemostasis if you are careful and this is the standard positioning you can see the the tissue is at uh above okay at 12 o'clock hello clock you see the the blade but
- the blade is not too close to the lens many people are afraid to push the blade inside because they think that increases the chances of catching the bladder but you see there are two black triangles around around the blade on the lower part of the screen there are two black triangles if these triangles are black it means that the bladder wall is far away all right so you need to push the the tip of the moss later at least to see these triangles if they become pinky then you know you're getting close to the bladder and then of course you have to change your position you have to feel the bladder better yeah so that black is nothing but a distance away from the wall so that you don't see anything it's a dark room
- it's a dark yarn it's it's protective okay so it tells you that you're not close to the bladder wall yes the irrigation has to go in and then of course you have to be very careful because you see now the musculation is efficient we are seeing that the musculature is covered with tissue which means that uh there is little water coming out there is water coming out but not too much if you have inefficient morcellation you will see the mouth opened so if you keep sucking sucking sucking the bladder is going to to be emptied very fast so you know if there is an unefficient marcellation be very careful and stop for a moment don't keep the pedal on when you can see the inside when you can see the mouth the jaws
- of of the blades you know what i mean because then you will empty the bladder of course you can palpate the bladder if you want uh throughout the procedure to to check that it's full uh one of my colleagues when he started doing holy he would have the nurse with an ultrasound probe checking that bladder was full i don't think that's necessary but uh well you have to be conscious as as you know this is an operation with where the surgeon has to be present you cannot be thinking about your holidays or especially this part yes you cannot be thinking on other stuff you you cannot be thinking on your daily problems you have to be present in the operation when you're doing the whole new phase the nucleation phase you have to be
- analyzing the information the direction of the fibers of the capsule you know the depth of the dissection am i leaving tissue behind so what is the distance that i'm using from the fiber to the tissue to get the effect is the effect good or can i make it better by more difficult modifying the the distance or the speed of my movement now you have to be actively actively thinking and observing and learning you know because this is what makes you a good surgeon and what will help you and the same with with more selection you cannot just look uh [Music] to another way yeah you have to be very very very very present and very careful and look at the details and you have to be thinking how
- much water is coming in how much water is coming out for example i don't use a second inflow you can see i have only one inflow and typically in many many people use two inflows and that is because i have this balance in mind all right also the wall system has a better balance than in between the water that enters and the water that the most later sucks than other systems you you will have to you would have to see what happens with your system but if you do the test you feel the bladder you put the morse later blade in the in the bladder neck area and you start sucking without sucking tissue you will observe how fast the bladder collapses all right when the bladder wall is uh totally distended it's very difficult
- that the suction device will suck the mucosa into the mouth of course you see that i'm always looking up with my instrument i never rotate it to one side or the other because that increases the chances of catching the the bladder look how safe it i'm sitting on the bladder neck almost almost in contact with the bladder neck and there is no catching the bladder at all you see so but if you leave the bladder to to collapse then the the the suction can take the mucosa and then you will have an accident yeah also one thing i want to say and it's very important especially for people who are starting you know if you get to a point where visibility is not good you know if you think about it when you distend the
- bladder in assistoscopy it starts bleeding all right so if you keep the battery standard for a long time uh it's going to bleed and maybe it's difficult to get good visibility so that's why i think it's good to have a good morcellator because then you can morsel it and go but if you find in any holy procedure a moment where you're out of your league you're out of your depth you know you cannot handle what's going on the best thing to do is to put a catheter tell the patient it was not safe to continue all right the patient will tell you thank you very much doctor that you didn't take unnecessary risks with me you know and then two or three days later you go back you finish your work if there was
- bleeding the bleeding stopped if there was any problem you know but have it i have had to do that a couple of times in my life but i would do it again you know if i find a case where there is a problem that i cannot assure that it's going to be safe to continue then put a catheter in and go and then you will you will avoid any any accident which which should never happen so this is it this is the this is the case uh the patient was sent to the room with a light irrigation the nurses in the rooms tried to stop the irrigation if it's possible and then the next morning we have a protocol to remove the catheter we tell the nurses to wash the bladder
- we tell the nurses to to deflate the balloon pull the catheter out four centimeters so the tip of the catheter is going to be in the fossa and typically there are clots there so they can wash the they can wash the clots and when the urine comes out clear without clots they fill the bladder before they remove the catheter so the first void is going to be immediate all right so they put 250 300 and the patient voids immediately and then they uh give the patient 20 milligrams of furosemide and then of course after two or three hours they can go home all right so this is it uh this is the video and um fantastic and the type thing is uh unedited video this is an unedited video you see it was four minutes
- uh total time a little bit less than that i think we are going to wait the the specimen so you can see but you can see that the water coming out is quite clear there is no drama the patient is happy the nurses in the rooms are so happy the the anesthetist is reading the newspaper you know he doesn't even need to be there because he knows the patient's absolutely safe you know what i mean yeah yeah it's a great operation we don't have stress we are calling for the next patient you know and uh this is the this is the tissue uh basket and uh we're going to try to wait it to show you how much tissue we were able to remove so it's no longer an operation of three
- hours duration you know it's it's no longer a dramatic operation it's usually relaxed we do five five cases in one morning session or one afternoon session uh so for example we start operating at three pm and by eight or nine o'clock usually we can do one hour per case because we change the patient in 20 minutes and operations take an average of 35 40 minutes so of course if we do a very large gland it will take longer so now she's waiting she's trying to wait the empty the empty thing to subtract it from the total weight so this was not a very large gland but
- we we have done uh 200 grams of tissue in under one hour of surgery you know this is when everything works out really well but it's incredible these patients go home the next morning so it was 61 grams very tissue probably the prostate was 80 grams or 85 grams in volume i guess some of the tissue is vaporized some of the tissue is crushed with more solution but well it's a nice it's a nice nice operation it's a nice cavitation of the prostate and well i think everybody should really invest some time and efforts to try to do this you can do it with a bipolar system you can do it with a laser i work in bulgaria with a low power
- laser at 36 watts if there are stones we break the stones if and then we do the prostate if there is a concubine and bladder tumor we would do the enucleation first and then we would resect the tumor we have done uh urethroscopies as well so i'm going to stop the sharing of my screen and we will take some questions based on the audience questions you you have done little exaggerated lithotomy do you want to comment on the position or it doesn't make any much difference no i i use a social lithotomy social domain it's uh right angles right angles following right angles on the so i don't i don't think forcing the the lithogram is necessary yeah
- uh the the size of the nephroscope the the working element and the outer inner sheath is 24 by 26. uh we have two systems we have a 26 and we have a 24. yeah so we can use uh when the urethra is a little bit smaller we use the 24. there is a brazilian urologist who is using even 18 french or 20 french instruments for a nucleation and if you think about it with these new pulse modulation lasers which give you excellent hemostasis we will see a tendency to reduce the the size of the scopes uh moses effect do you feel it is obvious because there is a 100 watts laser there is 120 watts laser from luminous
- the luminous claims moses effect is the speciality of the laser but the majority of the pointers in laser says that there is no effect like that it is only the pulse width which has come into the picture if you make short or long pulse width the same effect can be reached with 100 watts also a comment on that yeah i have heard that people who use long pulse width get a very nice hemostatic effect but well you know i think pulse modulation carries a big advantage in terms of cutting better and coagulating better but as i said in in bulgaria we use the standard holmium 36 watts and we do huge glands 300 300 grams we did last
- week what are your laser settings in home for with 60 watts laser that is 35 what's effective yes he we use i think two joules the same it's about 18 18 hertz only impact yeah the space i mean you can you can do higher settings but these lasers tend to heat up and stop because you are lazing continuously you know most of the operation you are dissecting the plane there's no stopping time when you pass the laser fiber in a neutral position it comes at it comes at six o'clock if i am not wrong yes you are doing 90 of the procedure with laser fiber at the 12 o'clock position
- yes and you are using in the opposite direction to do it entire sweeping especially on the top side of the prosthetic you are using the laser fiber at the 12 o'clock and then going with the gland yes yes of course uh as i said the the the idea is that you want to simplify the procedure yeah so some in some moments maybe if you had the fiber at nine o'clock or a little bit to the side maybe it would be a little bit more comfortable or or easier but that would be at the cost of having to move your hands and to you know what i mean making the procedure more difficult so i chose the 12 o'clock position and i keep it there because it simplifies uh very much the procedure and when people
- are learning it also they also are happy to know that what they see in the screen is what it's happening in science okay do you have difference between i am asking an important question because i do also a nucleation with thulium fiber laser apical release early versus mucosa complete release early is mucosa incision necessary all around or you can do half of the gland then develop the groove and then cut little mucosa and develop the groove then cut little mucosa and then in the last part you go proximally so that you leave the plenty of mucosa i mean to say initially only your inside is the mucosa some say that go deep or one centimeter mucosa some say that
- there is no need just cut at the on either side of the veru and then slowly cut the mucosa i think the the relevant aspect is that if at the end of the procedure the mucosa is lining the sphincter okay i think the patient will be okay how you manage that probably it's not so important uh i have done tree lobe technique but marking the 12 o'clock uh white line around the the apex at the beginning and uh by doing that i get the same results in terms of continents the apical release i think contributes to stretch the sphincter a little bit less because if you think about it once the sphincter is released when the sphincter is if this is the sphincter yeah as the sphincter is totally released when you
- move the scope up and down the sphincter is going to go with the scope whereas if you are working in one lobe and the center is still attaching the other side maybe you're forcing a little bit of distension of the sphincter so i don't know but i think if you if you preserve the mucosa no matter how you do that but of course if you do it at the beginning then you have a very nice landmark because when you start operating there's some bleeding the visibility is not so good and then if you want to go and know exactly where the landmark was and you want to mark it then it's going to be more difficult thing of the procedure is very tight yeah but as we start moving around it
- relaxes you know and then maybe they're not so clear if the anterior lobe is not very thick it is separated just by the lateral lobes when you are planning n block sometimes you will break the mucosa in the center and you will find again going back to the retropubic region easily if it is thickness some thickness is there you can like you have shown parallelly you have gone and just blew dome and then you entered in the center part in the of later on you came but sometimes if you miss that you will convert it into biloba ah well of course if you if you have that then you have done a 12 o'clock incision or you can complete it and then you will you will do the incision and then you can still
- do and block but uh instead of having a total complete donut you will have a horse shoe harshal type of uh yeah deal i think the most valuable aspect of this and block approach i think is the protection of continents the rest is a matter of uh personal personal taste you know whatever you believe in whatever you you want if too much large lobes with a median lobe is there even after experiences surgeon is planning for n block when one lobe is pushed other loop gives resistance instead if the at least the median lobe has gone into the bladder then some amount of the space will be there for you to act what is your comment on more than 150 grams with a median lobe
- well you know when i see a very big middle globe in the bladder i'm very happy because it increases the volume of a norma significantly but it doesn't increase surgical difficulty if you think about it on the interact with the middle lobe at all you know we are just dissecting the amount of tissue that is in contact with the with the surgical capsule right so inside the bladder it really doesn't matter it doesn't change uh what you do so for instance if i have a big big gland with a big big middle lobe yeah and i push down my scope too too much to enter the bladder you know yes i don't have a bladder i don't i avoid doing that because many times when you do that you split the sphincter at
- 12 o'clock you know what i mean yeah you might incontinence because of that so what i do is i start then blocking nucleation and uh even in prostates where there is no reach into the bladder because of the length of the prostate you always can reach the bladder neck from below you know what i mean so the bladder the middle lobe is not a problem and what i have done in the very very large glands when it's difficult to push the adenoma in the bladder is you can very fast split it in two you know you do a six o'clock incision in the arnold you get inside the the proper prosthetic urethra yeah you cut this is already a vascular tissue and then it's it gains mobility and you can push it in the bladder
- also sometimes i have done intra capsular morcellation so if you have a big piece in the capsule that you cannot look state into the bladder you can morsel it inside the prosthetic fossa okay okay before completing no no at the end of course you have to complete you have to complete the the dissection but you can always in the very difficult cases you can always resort to things that you wouldn't do in the normal cases like inside the adenoma but i'd rather incise it at the end when the prostate has been mostly dissected off the capsule than to do an incision at the beginning when it's going to bleed more you if the median lobe is going intra i mean intravenous cycle median lobe what are the tips like do you distance
- the bladder to avoid the urethric injury when you reach the margin of the bladder neck to the bladder and you will follow that mucosa from one end to other like a like acoustic uh any any tips to inadvertently you will be closer to the ureter most of the times yes in the big in the big middle lobes the distance gets uh very close and you have to look at the uo to check where it is there's no there's no other way of course we enter anteriorly and then we cut the better neck yes so when a point where we think i can go in and look at the euro you have to to look at it and cut medial to it of course okay in the case that you do you owe injury
- in my experience it hardly ever produces any problem because homium has a very very shallow penetration of the energy so probably it's uh it would be much worse to do it with green light for example that penetrates much deeper but with with with hormum if you see uh that you got too close to the uo or even that you sprayed a little uh of the uo with energy most of the times i think you can leave it as it is and just monitor the kidney postoperatively and nothing will happen okay minus you want to ask any questions otherwise yes sir sir uh sorry i also used that bipolar harman look for enbloc early apocalypse inflation what is your experience about that sir i i haven't got a lot of experience with
- bipolar i have done a number of cases with the the companies that bring the instruments from easy to try and uh well it's perfectly feasible if if you want to do bipolar i think there's already data showing that it's a safe safe procedure uh i don't like the way that most people do bipolar in the sense that many people for example resect the middle of first and then they try to enucleate i would recommend you to if you're going to do bipolar to do an unblock technique as well because it's perfectly feasible and if you start resecting then the visibility is not good you know it's it's different of course if you don't have a more selector you can do bipolar nucleation you leave the you tilt the adenoma into the bladder
- but you leave it hanging from from six o'clock or connected to the six o'clock pedicle and then you can resect the anoma uh quite safely it's usually blockless but of course it's not very practical in very very large uh glands so you know when i when you're going to talk to a manager of the hospital and you are chandra you're a manager i'm also a urologist surgeons come to you saying why don't you buy this equipment or that equipment no but i think the question is not to go to the manager and say i need you to buy me a mercenary that costs uh i don't know this money i think that you have to communicate with him we could do the open prostatectomies or the trps we could do them almost ambulatory
- you know with less than 24 hours stay uh we don't need to transfuse uh patients the high-risk patients are going to do much better you know so when you make the picture how your department would look like when you have already adopted this technology and when you can do it then of course the investment looks very silly you know most later cost is not so much and also i would also ask the manager to to save a little money for training you know go to one department where they do good good hollap and learn from them you know watch how they do it this costs a little bit of money so if you're going to make an investment in a laser dramas will come to you sir for a few uh if you permit
- come and visit if you want yeah he is very fan of you anytime anytime you want yeah manas any more questions no sir thank you sir thank you thank you for watching presentation excellent presentations are you you are you involved in that and you are mentioning the time and you are so practical uh very few european surgeons have shown this life completely like this and you you are really involved in the surgery and shown the common points only thing is uh the the honestly last comment i wanted to make again being a urologist for last 15 years and being the owner of three hospitals now i know that 120 watts laser is still not very cost effective in india that is where people are looking
- your video next time whenever you go to bulgaria this 60 watts laser how you do it will the tissue get separated so well with 60 watts because you use two joules so it's the same pulse this is less repetition so it's instead of it's more like tac-tac-tac-tac but it opens the plane very nicely maybe the hemostasis is not as good uh when you have to use it and speed speed of rejection sir this 30 minutes is too much we have never had 30 minutes and nucleation even if it is 80 grams 30 minutes is too short time that saves everything money the time everything it saves but is it possible with 60 whatsoever uh we we can do very fast times as well but uh we are faster with with uh with
- moses and the the laser from quanta system as well there are two brands providing this pulse modulation now and uh we are a little bit faster but we do fast operations what i told you before about 200 grams in one hour uh was with the low power laser so you can you can perfectly do fast operations with a low power laser what we observed in tfl is like after releasing the mucosa and apex then if we use mechanical force a lot of gland gets separated and in between if you use the laser then it may be faster but i doubt how much amount of the traction we are putting even though it is released on the sphincter axis and the even the stricture as a matter of fact in your
- case hardly i have seen any forward and rotational movements i have not seen single time in your this video i hope in all the cases you are doing only just just rotation it's clearly ladies fingers it's a finger tip operation very very very gentle operational dental operation you are doing that's why you are saying incontinence is zero so uh you need a there is because if you look at the population of the 65 year old men uh incontinence it's it's already regarded not even a day we cannot convince it's very rare we don't we don't have patients who have to wear pads for months you know it's it's very unlikely that this is happening great sir we learned that that finger ladies fingers is a very important point we could observe in your
- dissection fantastic i really we have a lady urologist with us also hopefully she will she'll do a better job and thank you very much for being with us and if possible maybe a couple of months afterwards we love to see the same unedited video with 60 watts sir if you are kind enough we can do that low power low power no power and nucleation because that will be very very interesting for all of us because it's cost effective thank you very much great for your attention and