Surgery
Surgery presented at UROVIVO 2021 Congress: En bloc enucleation of the prostate
Dr. Fernando Gómez Sancha · ICUA
Dr. Fernando Gómez Sancha · YouTube
Language: English. YouTube audio metadata.
Surgical content for professionals. Contains footage of an operation.
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About this video
An en-bloc prostate enucleation recorded for the virtual UROVIVO 2021 congress. The published description identifies a Lumenis 120 W laser with MOSES 2.0. It does not provide case-specific measurements or postoperative outcomes.
This video shows the operation we recorded for the UROVIVO congress that this year took place virtually. It shows an En bloc enucleation of the prostate using the Lumenis 120 Watt laser, with MOSES 2.0.
Documented details and sources
Only details explicitly stated in the sources. Missing information does not mean it did not occur.
- En bloc
Surgery presented at UROVIVO 2021 Congress: En bloc enucleation of the prostate
- MOSES / MoLEP
It shows an En bloc enucleation of the prostate using the Lumenis 120 Watt laser, with MOSES 2.0.
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 rome sancha and this is the video i presented at the euro vivo congress of this year which was celebrated online due to the endemic and they asked me to produce a video trying to show the outside view as well as the endoscopic view of an and block a nucleation using the luminous 120 watt laser with the pulse modulation setting moses 2.0 so we i was asked to select a patient with about 80 grams prostate and so we did this was a man who had to
- wear a catheter because he couldn't void and this is a view of the operating table we have the mosses fiber and we have the richer wolf endoscopic equipment and we like to do these transrectal ultrasounds especially when you have visitors to show them the anatomy of the prostate uh through trans-rectal ultrasound before the procedure and then we will look at how good our job was at the end when we are still finishing the operation we can do an intraoperative transrectal ultrasound to
- check the quality of the job so this was a prostate which was not so large uh but had a relatively large middle lobe intravenous cycle middle lobe and of course the man needed treatment because he had a refractory urinary retention and in order to get him rid of the catheter we had to perform surgery so everything was ready to start and this is the operating room at the icua clinica centro in madrid where we usually work and we usually schedule uh four or five enucleation cases when we have a surgical session and we can do this either in the morning
- or in the afternoon typically these operations take less than one hour and uh in this case i think we we will complete the operation in half an hour so i haven't changed the speed of the video or anything just [Music] wanting to show the the real life case and there we are that's a scope from richard wolf the special blunt tip uh that is uh useful for mechanical dissection when it is needed and also very careful uh i mean very very good instrument as it has excellent irrigation it's a 26 wrench standard endoscope the same
- external sheath is going to allow us to use the laser cystoscope our receptor scope if we if we wish which is sometimes useful to do additional hemostasis at the end or to remove fragments that are not easy to mercilate and a nifroscope or a morseoscope that will allow us to use the morcellation device you can see there's some the cupidus in the urethra this patient but it was a little bit hard to enter so i decided to do an otis urethrotomy of the navicular urethra so this is the otis instrument and i did a small cut at 12 o'clock which is uh giving the urethra much bigger caliber it's much easier to enter i know i think it is a very careful
- way of increasing the size of the urethra that will not result in metal structures i think it's better than dilatation and that's why we use it and just a mild [Music] cut at 12 o'clock opens the caliber a lot and so that's what we use so this is the moses fiber being connected to the laser console and we are ready to start you can see the endoscopic view the bladder is a little bit traviculated there is a middle lobe as we had seen in the previous ultrasound that is the moses fiber and we are just adjusting the settings i'm going to use two joules 50 hertz
- for nucleation and 140 for coagulation and i like to take out the aiming beam i don't really need it that's the initiation of the white line i like to mark the white line initially this is the 12 o'clock limit between the sphincter and the apex of the adenoma so this line is going to go around and try to separate the sphincter from the apex of the adenoma and the objective of this is to protect the sphincter's mucosa you know by cutting where we want we allow sorry we avoid the mucosa breaking where it wants
- during the dissection we know that classic techniques for hollop used to to carry the risk of early stress incontinence which was most of the times temporary but still the patients were unhappy with having to wear pads and leak urine for some time after the operation so that is because the original techniques didn't pay too much attention to the protection of the sphincter i think in my in my opinion so that's why i mark this lower limit of the operation it serves as a reference for the rest of the procedure and [Music] i like to cut a little bit this
- apical lower posterior fibers before i try to localize the plane this is the frenulum of the very montanum so you cut over the very montanum you will be able to connect both lines both planes here you see that's a little bit of mechanical push very careful trying to find out where is the the proper plane and in this case for some reason didn't detach very easily so instead of forcing i continued with the dissection uh using the moses holmium energy see that there is some bleeding at the beginning of the procedure and that's because there are many congestive mucosal vessels
- but as soon as we open up this posterior space and get the procedure going the bleeding is minimized so that's now the establishment of the initial line of dissection or line of attack as i like to call it posteriorly you see now we have connected the same plane posteriorly so we can go from side to side with the fiber at six o'clock but as soon as a small space has been created i'd like to position the fiber at twelve o'clock and i keep it static there i don't like to rotate the fiber or rotate the camera so the camera is always telling me the truth of what we are seeing you know if you rotate the camera what is at six o'clock would look as if it is three o'clock
- you know so that's why i like to keep a steady camera and i like to keep the fiber also in the same position i think the 12 o'clock position is optimal for this procedure see that i'm following this line of attack line of dissection and i find this extremely useful because you see you just have to position your scope in a way that the line of dissection is in the middle of the image you could see both capsule and adenoma at both sides of the line and your only judgment during the dissection of these planes is where are you going to aim the laser and at what distance of of the tissue you're going to aim you know this uh effect this moses effect as you can see
- provides excellent dissection of the plane you know the pulses have a very high peak power that produce uh you know an a shock wave it's like an explosion in the tip of the fiber that produces a shock wave and then this shockwave is going to allow you to dissect the plane the the second pulse you know because moses is uh setting a pulse modulation which emits two consecutive pulses instead of that pulses like that it does you see and when when you have this second pulse second pulse will travel through the bubble generated by the first pulse and it will provide it i mean the laser with a much better hemostasis you know at a
- bigger distance from the tissue so we can see that we have two combined effects one is the opening of the plane so these explosions this shock waves are going to open the plane following the path of least resistance and second effect is going to be the coagulation of of the tissues so it's going to provide us with excellent hemostasis excellent first pass hemistasis which means that when you do your dissection the the simultaneously to to to dissecting you know the hemostasis is going to take place so you don't have to worry too much about maintaining a good hemostasis of course we're going to see some vessels but uh the the amount of work and the
- amount of attention you need to pay to keeping a good hemostasis is much less than what we used to see with the with the regular holmium laser that didn't have a pulse modulation so you see when i start ascending laterally towards 12 o'clock in one side initially i do the lower dissection and then i can start coming further up here see in the apex i don't mind cutting on the prostate a little bit at the beginning because that will separate the sphincter from the apex of the of the anoma also anteriorly this is very similar to what we did at the beginning of the procedure but then of course once you have separated the sphincter from the apex you have to look for the good plane so
- typically these incisions will stay in the apex and uh we will go eccentric or external to that so we can take the whole adenoma out we don't want to leave a big bulk of tissue anteriorly because we are cutting through the anomal so once you have already separated the normal from the sphincter it's very important to look at the direction of the fibers that are pointing upwards in both sides to make sure that you reach we reach the uppermost plane and we don't leave apical tissue behind okay so that's uh that's 12 o'clock fibers you see here i'm cutting some of the 12 o'clock fibers
- exactly where the line of attack was sorry the white line was marked you can see that's the sphincter on the right side here i'm going to cut again on the prostate i don't mind now about the plane what i'm trying to do is just to cut the fibers that unite the the apex to the sphincter and then we're going to bring this incision a little bit upwards trying to make sure that we remove optical optical tissues and then noma here it's important to to connect the the lines it's important to connect the lines you see try to to work you see laterally but connecting to the previously developed line so this is going to facilitate the procedure greatly
- later on and of course by separating the lower part of the of the adenoma what we are achieving is some better mobility of the apical part uh so when we are coming towards the 12 o'clock area we will find that we can see a little bit better we can displace the anomaly a little bit better than if it was completely stuck there you see we did incisions but then of course we need to go and look for the good plane because we want to remove all the adenoma and here you can see that i'm coming towards 12 o'clock it's important to cut horizontally there and it's important also to look at the direction of the plane and try to follow
- that direction you see so we don't leave too much tissue uh attached to the external sphincter during the operation you see sometimes you have to insist it's important to to bring the scope out a little bit to check what we're seeing to check on the sphincter as many times as necessary and to to to make sure that we are in the right plane and that we are protecting the sphincter you see once we come to this point where the sphincter is totally released from the apical adenoma we i mean you experience as a surgeon a great relief in the sense that you know from this moment on the sphincter is totally safe so you can just concentrate on
- following and dissecting the line of dissection around the adnoma we have a circumferential line of dissection or line of attack and if you position your scope as i mentioned before you see having this line of dissection in the middle you can see a little bit of capsule and a little bit of adenoma your only concern now it's going to be to touch the adnoma from the capsule circumferentially and if you understand the mechanism of an orange you know you understand this it's very easy it's very easy now you have to of course try to be very very careful and look at the details that the capsule is showing you know the anatomy is
- showing us because it's important to of course the line will orient us of of the direction of the dissection but sometimes we can find nodules sometimes we can find small indentations in the capsule so maybe you you went a little bit deeper than than you wanted you can see the sphincter is perfectly preserved mucosa is lining the sphincter perfectly but now we can go all around the apex you see to develop this this plane here anteriorly i thought maybe there is a little bit of a noticed issue so let's revisit this area come up a little bit and try to detach this little uh amount of tissue there i think it's many times inevitable to
- leave a small amount of tissue close to the sphincter i i know that some techniques people recommend to to cut a little bit further inside from the sphincter anteriorly so sometimes it happens and it seems to have no importance in terms of a good result of course we have to leave as minimum tissue there as possible and here you can see how the circumferential plane is followed we are enjoying a very very good irrigation you see the little space that we are irrigating [Music] and the power of the irrigation of this scope make it possible to tackle you see bleeders and
- the blood is going to be washed out very efficiently i think much better than when you do a three lobe or an incision technique because if there is blood it's going to go in the bladder here none of this fluid is entering the bladder and uh we're just irrigating this small space another advantage that we discussed at the meeting was the the advantage of being able to work almost continuously see as the plane is circumferential you don't need to go in to orientate yourself you don't need to go out you don't need to wait so the actual pausing time you know the time where you are just watching and not doing anything useful is very little that's why these procedures are so fast so here you see i'm changing my strategy
- and instead of of firing against the line of dissection i'm firing a little bit more inside a little bit more against the adnomatous edge of the line and that is because the the direction of the planes uh are changing and now as we are following a relatively uh spheric pseudospheric strict structure initially the the dissection angles were opening towards anterior towards lateral towards posterior and now the ankles seem to be closing towards the center of of of the bladder neck you know so if you would fire against the line of attack maybe it would be inevitable to enter the capsule
- of the prostate but if you're careful and you and you put your fiber a little bit closer towards the enoma you're going to see that the energy you are firing will cut the the links between the anoma and the capsule will cut the fibrous links there and we'll give you some soft easy i don't know how to say it subtle coagulation effect on the capsule but we're not cutting into the capsule or perforating in the capsule so that's the way i see this procedure optical liberation first once you have the apical liberation you have to go around the adenoma but as you get closer to the bladder neck the fiber has to start pointing
- inwards pointing towards the adenoma rather than towards the capsule because we want to be able to detach the abnorma but without perforating energy hitting the the tissue here going around around around keeping the fiber very very close to the to the tissue will allow us to do this dissection without perforating you can see that only coagulation reaches the capsule while we're dissecting this plane also we discussed at the meeting that it's interesting when you have to do this posterior plane close to the bladder neck sometimes it's very useful to come from medial to lateral so from the middle sorry from the from the lateral i said from medial to lateral no from lateral
- to medial you see if you open up the bladder neck like i'm doing now you see getting closer and closer to the bladder neck until we can enter the the bladder and and then cut the the bladder neck uh it's then better knowledge of the anatomy we know better this is the entry into the bladder you see that below the circle of fibers we find vertical fibers this is the inequivocal sign that we are entering the bladder here that's mucosa of the bladder and now i'm going to cut the bladder next circumferentially following the direction of the fibers of of the bladder neck on both sides and then we will leave the
- posterior dissection for the very end it's important to know that holmium has this explosive effect that sometimes rips a little bit the mucosa of the bladder neck so we might have bleeders in the bladder neck we will have to check before going uh into more solution it's interesting to have a look at the uos also because we might damage the eos although damaging euros with hormium seems to have little consequence in the sense that the depth penetration of the coagulation is very limited so the tendency of the retro orifice to stricture is probably very very small so in case there is some lesion of the ureteral orifice
- i mean there's several things you can do one would be to place a double j stand for some days but it is possibly not necessary i think it's important to advise the patient and then follow him up into by kidney ultrasound to see that there's no dilation of the kidney and if there isn't then i think you you shouldn't worry too much about it see this is what i was meaning to do before to cut the bladder neck come downwards see trying to limit the amount of noma that is still connected to the peripheral zone now this is this is where the vessels are in the prostate typically bladder neck and
- here this is the cut of the ladder neck the localization of the erytal orifice which is a little bit close and then from the side it is safer i would say or easier to progress towards six o'clock below the adenoma so that uh see only a small pedicle is fixing the anoma to the to the latter neck area so that is the cavity and if you if you look at the time of the video we're going to complete the is enucleations in possibly 20 minutes you can see that this this operation in blocker nucleation has become
- really really fast using this pulse modulation moses and it to me it offers several advantages over a regular holmium one is better coagulation and better cutting as we already mentioned but i think the most relevant aspect of moses i think is that it makes the procedure easier to learn see the fact that you can carry a good hemostasis throughout the procedure makes it easier for beginners to to learn to perform hollow but i think that's very good news because some surgeons have been always reluctant to to learn hollap thinking it's a very difficult to learn technique
- but i have to say it is not so difficult you just have to learn your landmarks you have to see a number of procedures so you can understand what capsule look is normal you know how the look of the capsule changes from patient to patient and how to recognize you know the landmarks the sphincter etc and then actually carrying out the operation is not not difficult so i would encourage all of you who want to move forward from turp to consider learning a nucleation i think nucleation is a natural evolution of torp trp was the endoscopic
- means to remove the anomalous tissue but after many many years i think the iglesias receptoscope came in 1975 or something like that where it popularized the urp i think well you you have to see a nucleation as a evolution of drp it's an endoscopic approach with modern instruments that uh allow you to to remove the whole anoma and to do a proper uh debulking of of of the fossa that is the transrectal ultrasound after the operation you can see how there's an amazingly big fossa that is quite anatomical and you'll see the lateral view now you see
- that's the fossa that's the scope i keep a full bladder to perform this transrectal intraoperative ultrasound and uh well i think it's quite satisfactory so uh after checking this we're going to move on to performing the marcellation and this is the second phase of the procedure if you look at the watch it's only 20 minutes have gone by and we're going to start with a more solution so we have to change instruments and i will take the morse scope or the nephroscope and i will help ask my nurse for for help to take the scope out and change very fast so we don't decompress the bladder sometimes there's some minor veins that do not bleed because there's some
- pressure in the bladder so if you release this pressure maybe you have bleeding and worse visibility that's a little bit of focus and that's the morcellation blade going in you see all this time i left the irrigation inflow open and the outflow closed because we want to keep a full bladder and the only outflow is going to happen through the mouth of the morse later blade that's why it sucks the tissue towards the the jaws of the of the most later blade and this is the piranha musculature from richard wolf and it really has changed our lives in the sense that it allows us to take out a lot of tissue per minute we our average is 11 grams
- per minute but we have measured sometimes up to 18 or 20 grams per minute of course mercelation is limited when the contact of the tissue with the most later is not good and in some occasions when the prostate is very fibrous it might be a little bit difficult to morsel it but in general it's a very fast procedure and you know that you have a window of opportunity of about 20 minutes when you keep the fosa even when you have done a good hemostasis beforehand and you keep the force distended and the bladder distended for more than 20 minutes you you start seeing that uh the quality of the vision is not so good there's some um some difficulty
- in in seeing properly and this is paramount for musculation because you want to make a safe safe more solution [Music] so you can see it's progressing really well that's the water coming out through the most later and the tissue canister where the tissue is hold that allows you to send it for histological analysis later on more selection continues you can see that i like to keep the fiber the the blade a little bit separated from the tip of the scope because if you keep it very close there might be interference between the tissue that you want to take out on the tip of the scope and also because as you can see half of the screen anteriorly sorry uh granularly or
- the upper part of the image is all occupied by the adenoma the lower part is occupied by the blade but at the side of the blade there's two black triangles that show you that you are not near the bladder wall you know if you start seeing two pink triangles then you're very close to the bladder neck also you have to take into account that the bladder neck is now white in color so if you start seeing white maybe you're very close to the bladder neck one thing that i cannot stress enough is that a nucleation is a teamwork it's very important to have a team that can really help you if there is some difficulty with more solution
- you know who can pinpoint understand localize diagnosed diagnose the the problem and then solve it so to allow for for continuing more solution i think this is slowly coming to an end see the tissue is coming out very fast and as i said it can be submitted to histological analysis there on the lower part you can see how slowly i'm withdrawing the scope to enter the prostatic fossa bringing the tissue with me sometimes when the prostate has been when the abnormal has been reduced in size you can go back inside the fossa and finish the modulation of the last
- part of the anoma this has some advantages like you know the adenoma if it disengages from the tip of the morse later will not go anywhere it will remain nearby and then the suction of the morse later will lure it again against the jaws of of these blades of course your sight has to be in the screen so you cannot even check how much water you have left that again is uh stressing the fact that all the team needs to know what to do you know there are accidents or there could be accidents when someone who is perceived as not having an important role in the operation uh makes a mistake you know the
- circulating nurse who is in charge with keeping the water flowing in must understand the importance of that job you know so it's a team effort and when the team is properly trained everything flows very fast and the nucleation becomes a very simple operation you know we do these five cases in one day the next day the catheter is going to be taken out in the morning we have already publications showing that this operation with moses 2.0 can be performed in an ambulatory setting and i agree that this is a very big advantage in some hospitals in some healthcare systems and
- this is coming to an end now as you can see tissue finally has been morcellated this is the nearing the end these are the beach balls that we can see at the end typically more fibrous tissue that is more difficult to more slate so you have to be very careful sometimes if there are too many or more isolation is already starting to fail because the bucket is nearly full you could consider entering with a receptoscope just leaving the external sheath in the urethra and using the loop to extract some of these fragments so here you can see when the scope is removed the flow of urine is very nice there is a good transmission of the
- pressure applied suprapubically to the flow and of course we need a catheter for some hours this catheter will be taken out the next morning initially we wash the bladder we take down the balloon we wash the fossa we feel the bladder with 200 meals or or so and then we ask the patient to void right away right after the catheter has been removed this way they they get confident that they can pass water and then we give them 20 milligrams of lassix to make sure that in two or three hours they pee two or three times and then they can go home so there you are half an hour for the procedure let's see now how much tissue we took out so you can get an idea and this was half an hour
- for a nucleation followed by marcellation and this is the end of the procedure this is moises rodriguez another urologist working in my department he's a great guy he knows a lot about stones and lasers and he's a fierce publisher he likes to write papers and very happy with him in our department and he helped in this occasion to record the video footage from the outside camera there you see there's an irrigation going in and coming out almost like water so this is quite normal nowadays with this uh pulse modulation and uh well i hope
- uh this uh illustrates how good uh endoscopic inhibition of the prostate with hormium laser is how big advantage this pulse modulation like moses technology has become and i think it's going to facilitate the transition to hollap or two an atomic endoscopic nucleation of the prostate for many urologists who still do trp trp might be the most frequently performed operation in the world but it's certainly not the best patients after hollip feel better void better they bleed less they have to stay in the hospital less they have to keep the catheter less and
- they have a more durable result so there's no no reason to believe today that eorp is better than this on the contrary i think it's some desirable option for the majority of surgeons and if you learned how to do a trp perfectly available sorry capable of performing this is the weighting of the canister so we can subtract it from the total weight of our specimen and there you see that we removed about 60 grams of tissue so quite a normal prostate in our hands this is the standard case we do every day and
- this is what i was asked to show at the congress so uh i hope you enjoyed the video and i hope you enjoy this opportunity to watch many many operations in thanks to youtube and i hope if you're doing a hollop it will help you and if you're not doing it it will motivate you to try to learn if you commit to learn you will learn you will be very happy and your patience uh even more so thank you very much for your attention i hope you enjoyed the video and if you need anything from us you know where we are all the best