About this video

Surgery

En bloc HoLEP in a 250 cc prostate with occult bladder stone and need to split at the end

Dr. Fernando Gómez Sancha · ICUA

Published on YouTube: 2026-01-25 · Duration: 1:50:40

Dr. Fernando Gómez Sancha · YouTube

Language: English. YouTube audio metadata.

Surgical content for professionals. Contains footage of an operation.

En bloc HoLEP in a 250 cc prostate with occult bladder stone and need to split at the end

Playback connects to YouTube. Your search query is not sent to the player.

Watch video on YouTube

About this video

An en-bloc HoLEP in a 250 cc prostate with a bladder stone that was not visible at the start. At the end of the enucleation, difficulty moving the adenoma into the bladder led the surgeon to divide it in half. The description therefore distinguishes an initially en-bloc dissection from the division needed to complete this particular case.

This is another interesting case, of a patient with a very large gland and a stone in the bladder that I could not see at the beginning. At the end it was difficult to flip the adenoma into the bladder and I decided to split it in half.

Documented details and sources

Only details explicitly stated in the sources. Missing information does not mean it did not occur.

En bloc: En bloc HoLEP in a 250 cc prostate with occult bladder stone and need to split at the end
Bladder / diverticular stones: En bloc HoLEP in a 250 cc prostate with occult bladder stone and need to split at the end
250 cc: En bloc HoLEP in a 250 cc prostate with occult bladder stone and need to split at the end
Splitting the adenoma: I decided to split it in half.

Real life HoLEP Cases

Original title and description on YouTube

Source checked: 2026-10-06.

Available transcript · English

Automatic YouTube captions, not clinically reviewed. Names, technical terms and numbers may contain errors.

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.

0:01Let's see. Here we are. As always, we see this these uh areas in the urethra are quite normal. No, we see them in many many patients. So, it's not a stricture. Here we are. Far this man has a estimated prostate size of 250. Look at the look at the veru. Huh. The veru is is probably here and or or this maybe this is the veru and uh he has a very very large very large gland. So again we have this dilemma. No should we enter the bladder or should we start? But in this case the man has a big stone. So, I'm going to try to enter very gently to see if we can break the stone first if we find it.
1:04Now, for the moment, I'm not seeing a stone. Where is the stone? There's no such stone. Huh? I don't see a stone. It's empty. Here, this is a problem sometimes that the outflow is compromised by the drape. You see, I leave this here. The testicles I need to go in so much that sorry, the outflow is uh a little bit compromised.
1:39Let's see. I've emptied the bladder to see if that if there is a stone. They told us there was a stone. Probably no stone visible, huh? [snorts] Mhm. That's the UO. Not so far from the ending part of the a lot of varicose veins.
2:07There's the other UOO. It's not so easy to see. Maybe. I don't know. Well, hopefully we will see it when we get uh this is one. So, the other one should be down here somewhere. Maybe here. Look at that. Huh?
2:35Very difficult to see you all. Okay. No stone. So, lucky. I'm starting to wonder if the patient we did already was the one supposed to have a stone. Okay. So, we come down again. You see, most of the times when you go in into the bladder, there is some degree of some degree of sphincter traction or damage. You see uh we we did some some little damage here. So let's mark the the white line here. The limit the limit of the sphincter.
3:25Let me focus better. Now we can see better here. This is the sphincter edge. You see how this part of the frenolum tells you, huh? Often helps corroborate your uh let's say assessment of the position of the sphincter. No, here this is going to be the 12:00 more or less 12:00 region. This is my white line here.
4:03So, let's see if we can get up here to to to to show to connect. You see at 12:00 our white line. So, we have a reference. I think it's going to be enough as as a reference. Now, this is a little thing here. So, we're going to go down here. You see this is this is the veru.
4:34We're going to go down here to score the mucosa initially and then we will try to get under under the adenoma to find a nice dissection plane. Let's see. Yubo, I'm not very happy with the leg.
5:03Open the leg a little bit more so I can get Yeah. Yeah. Thank you. It's not so much space to enter here. Okay. So, this is the entry into the paracolicular space and the localization of the plane.
5:40There we are. So we could enter this side very well as we go further down. You see this is our white line. So here see we'll come back here to to start later on the lateral plane. Huh. So I think this is now posterior plane. That's a nodule there. See if we can just connect. Here we have our original.
6:16You see entry into the paracolicular space in this side. Good. Let's go to the other side. Now you see this is a again my white line marking here. So I'm going to come up following the the floor of the vera montanum. I'm going to score the mucosa and then come medial to lateral to enter this again this paracolicular space.
6:53Again, [clears throat] very nice detachment of the plane, very nice development. Sometimes to some degree, you know, when you're going to do a very large gland, you think it's going to be much longer than, you know, a smaller prostate because of the size. But often you find out that in a bigger prostate having a better plane uh the time is not so much more the time of nucleation because we can progress very fast because the quality of the plane is very nice.
7:38We had this feeling no when we did open prostatectomy that uh you know that the bigger planes have the bigger prostates had better planes. No. And uh here I'm cutting on top of the veru to see if we can establish the posterior line of dissection.
8:03See more or less we are in the same depth. It's a coherent depth, similar depths in both sides. So, we are in a right in a good plane. Here you can see some of the beautiful plane.
8:17You see, I was not looking for a beautiful plane. I just got in there. So when I see the beautiful plane, it it works more as a confirmation that we are in the right plane rather than you know I just go in and I look for the capsular plane that I I don't have I don't need to see the beautiful plane to know that I am in a good capsular plane.
8:43This is my idea. That's That's something. I don't know what it is yet. It could be one of the ejaculatory ducts maybe. I don't know. Let's see. Or sometimes a utricle or something. You see it's Let's go up on top of that. It could be an ejaculatory duct.
9:14Usually, we need to leave them below. So if we find one like that, we we want we want to try to stay anterior to that. Sometimes we see not one but two. There we are. Huh. I'm starting to feel that uh the adenoma is heavy on my endoscope. So it gets progressively more difficult to continue towards the bladder neck. Huh.
9:46Also the angle of the plane is is changing I think. You see that's also some entry in the seminal way. So we need to keep up. It looks like the proper plane but you see sometimes there's not so much distance no between the trajectory of the educatory duct and the ampula no of intropatic uh trajectory no and uh and a very very distended capsule no or thinned thin capsule the arenoma grows so much that the peripheral zone gets It's very very thin in this huge prostates and then maybe 1 mm below the the the let's say best possible plane you have the educatory ducts. So sometimes they fall in the battle.
10:44Okay. Now we come here towards the apex to look for the white line. Okay. So here I'm going to do this deepening incision. Otherwise we wouldn't have much access. You see? So by doing that I have much better access to the lateral plane here.
11:05So we can start doing this up and down dissection of the lateral plane. Let's see where we find it. How how how it develops. Here we are slowly starting the posterior part of the lateral plane. So here there is one thing that I want to achieve and this is to to connect the line.
11:38Yeah, the lateral line with the posterior line. Let's see. There's some yellow elements there, but it looks reasonably good. Let's say looks reasonably good. We come out now. We are going to get here and we need to continue our ascending. You see cut trying to preserve the mucosa of the sphincter that we have right below of where we are.
12:09So I don't mind doing these access incisions initially. Then we will find the the proper the proper plane. Huh. So hopefully here we will be able to progress and bring the lateral line a little bit more anteriorly here.
12:38You see doing this wide wide movements that go far, you know, we don't want to do short movements. We want to have a nice more or less consistent line of dissection that will guide us. Uh if if we go into the adenoma, we can always go back a little bit and correct.
13:01And if we see that the capsule is getting too thin, we can also correct. It's a matter of interpretation. You need to be able to read the anatomical signs that the, you know, prostate is showing you.
13:19Here it looks yellow, but down there it looks too deep maybe. So, and remember this these very large glands have very thin capsules. Huh? Sometimes uh 3 4 mill mm. So, we don't have um let's say much margin. No, if we go into the capsule very fast, we go we can uh get out of of the plane, get out of the of the capsule because it's very very thin. It's very distended by the enormous growth of of the adenoma.
13:55So here again coming down looks like a reasonable good-looking plane. You see and you see that I don't get lost with minimal details, minimal anatomical details. I'm thinking more of my lines of dissection.
14:12So, in this moment when I do these uh movements, I'm looking more outside of the screen. If you know what I mean. I'm I'm trying to you see draw this line. I remember the line shape, the line uh uh structure. And then when I go back, you see I try to stay and follow more or less the same direction.
14:37the screen information, the information on the screen, it's it's confirming, uh, it's telling me this looks good. Keep going. But I'm trying to look outside of the screen, you know, make a mental image in my mind of how this this plane is looking. This was the original posterior plane. Here we have like a little ligament as as we have described before.
15:04And here now we can connect the line. You see lateral line has to connect to posterior line. We should have a uniform line that goes around the adenoma. So let's work on that because we want to have a nice reference. We don't want to we want to advance the operation but adding order not cows. So we want order.
15:30We want to move on. We want to progress but in an orderly way. There we are. Coming up. So that's looking very good. This is the posterior lateral line. Let's see what's bleeding. There's probably something. So let's see if we can spend a little bit of time doing hemostasis. You know, in this very large glance, I think it pays off to be careful and thorough with with the hemoasis. You don't want to build up uh many many vessels bleeding at the same time. Huh? You want to get a good heistasis before you progress. Take your time because sometimes spending, you know, 1 minute and a half here or 2 minutes doing some hemoasis might save you then more minutes later. Uh so here it's looking good. Huh.
16:28But we want to make sure that there's no active active bleeding. This plane was getting deeper. I think as here it looks a little bit deep. So maybe you see we corrected. So we want to solidify the heistasis before we continue. No.
16:57Okay, good. Sometimes the bleeding comes from the arenoma and that's not such a worry unless it doesn't allow us to continue know with with the operation. Okay, so let's go down. We want to do the let's say early aical release. So here when we come anteriorly we have to find this this spot. You see this is where we marked the the limit.
17:23So, we want to reach here more or less at 12:00. Huh? And that's like the anterior plane. We want to go all the way up if we can and remove all the uh the nomatus tissue from the apex.
17:41As I said, I don't believe that leaving tissue there is necessary. Some people do it because they feel that they get less close to the sphincter. But in my experience, uh patients are quite happy with their continents even when we remove all that. And I have seen a couple of cases of patients with residual obstruction because there was some residual tissue hanging from the from the sphincter area, hanging from the apex. So it behaved like a an obstructive uh piece of tissue. No. So here here what I want to achieve when I'm going anterior like that is I want to achieve some mobility of the apex so that the apex can come down. Uh so the apical bit of of the adinoma can descend. you know I really uh detach it from the
18:37ceiling so that then we can get much much better access towards uh 12:00 region. So this is now anterior line. Let's see how the anterior line connects to the >> what's the problem?
19:00Okay. We saw some vessel here. So this this is quite quite nice. Nice plane. H nice plane even you know for a very large cl. Now when we come down here you see we have very good access there. Okay. So now we go to the other side. Here's the limit that we marked.
19:23Hopefully I can show it to you. This is the Swintes Mucosa. And here I'm going to come and follow the the white line up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up up towards this uh let's say 12:00 uh region here.
19:46And let's see, we already entered a little bit of the lateral plane before. You see this is where we entered before. I still have trouble with the leg. But let's see here. See, I have some conflicts of space to to reach this this plane. It looks like some DPH tissue here. So I want to go around the VPH to to seek the most capsular possible plane. No, sorry to I like to keep the fiber at 12, but in this case I have no not very good access because of the leg position and we already forced the leg quite a bit. So I want to remove this this little bit.
20:44There we are. Sorry. So, let's see if I can now start to concentrate on keeping up and eccentric enough in order to come and connect to the posterior line that we had. Huh, this looks like a good plane. You can see the BPH elements are going to the left. You see? And I'm staying close to the to close to the capsule here.
21:22Coming up and down and connect I want to connect to the posterior line. So we have a nice reference a uniform uniform reference. So initially when you are learning maybe the speed goes even you know slowier uh you go a little bit like that you see and uh you try to understand and then when you get a little bit more experience you start enjoying this lines long lines you know you you you can follow them very well and uh when I'm teaching people I ask them you know on my way up.
22:09On my way up, this line is going to go to the left or the right, you know, and everybody knows the answer because we are dissecting a pseudo spheric structure, you know. So, logically this line, this slightly curved line is going to go to the left. So, they already have some, you know, prediction capabilities. Of course, the more prostate you operate, the more you do, the more confident you are. But it's pretty simple, you know, and that's how you know we can speed up a little bit the procedure. Not running. I don't want to be out of control, you know. I want to have control of what I do. But you find the speed that gives you, you know, the maximum possible efficiency for the case. I'm seeing that the plane doesn't bleed too
23:01much. So that you know encourages me to continue let's say working at this pace you know if I found that whenever I pass there is more and more bleeding then maybe I would slow down huh okay so here we are here we are hopefully we can stop this bleeder here and we want to come further up but we have a lot of uh let's say tissue up here. You see we have to release the attachment sopically first before we can continue with our dissection. Remember to remain eccentric.
23:48Remain eccentric. Remain attached or close to the capsular line here and try not to cut through the adinomatus tissue. Try to stay out. You see, I don't push too much upwards. When I when I notice here some resistance, you know, I don't go up further up because I know that I can put a lot of traction on the sphincter and I don't want to do that.
24:11Okay. So, here this is where I reach comfortably and then I come out out again. This is a stubborn uh vessel. Let's see if we can finally control it. And then coming out, you see you come to the upper so to the aical limit you see here apical limit and try to continue the liberation of the attachments at the aex trying to get to the most capsular possible plane here you saw that we took a little bit a route down there but now we found this better plane so we are going to take that and I'm going to connect the new line that I've done with the previous line so that we can continue. You see, we can continue this this route. Uh we we have taken a better plane here.
25:11And now let's continue before I go to 12. You see, I try to dissect more because the more I dissect, the more it moves and the better the axis. So you see it's very strategic. And maybe if you want to get to 12 and you have a lot of trouble, what you have to do is try to dissect a little bit deeper around the the preparing for that, you know, before trying to reach the the 12:00 tissue. So here as we come out, still some vessels here. It's a big vein.
25:50See if we can dry it up. Sometimes we find this uh plexus areas where there are many vessels and wherever you fire you find some some bleeding that's not bleeding. Okay. So we come out again. You see here we have attachments here that we want to cut with the laser and not not with the shaft of the endoscope coming up. Everything is white so we know that we are in a safe place.
26:25So here we can come down again and connect again. You see here that was a prop proper good plane and now I think we are going to cut the 12:00 tissue here. Huh? This is one side. Now we are connecting here.
26:49We are connecting here. And we can go from side to side drawing this long line that I can imagine initially and then I can make happen. You know, I can achieve to, you know, draw the line that I imagined first.
27:12Here this is the other side. This is anterior tissue. So now we are drawing the anterior line. And you see coming all the way up remaining eccentric. This is capsular capsular plane I think.
27:27So now we are joining antiorly. Okay. So even in a very very large gland like this we can try to maintain the order and the you know the strategy coming around when we have little discrepancies in the plane we have to choose where to go.
27:52Huh? You see that sometimes we could be dissecting a plane that is 1 mm deeper or more superficial. That's why some people think or say that the prostate is not like an orange. It's more like an onion because you could find, you know, several planes of dissection maybe close to each other, you know. So you need to there's not always just one plane. There could be more than one uh layer of tissue that you could start to to dissect and and follow and it would still be a good let's say capsular plane. Let's see if we can dry this up because it's it looks very frightening there. This man has a lot of varicose veins in the prostate and the bladder neck and everything. Let's see how it behaves. But now you see here
28:57when I come up like this, it's because I I I remember more or less how the line was working, how the line was. Here we [clears throat] are coming now around. You see this continuous work? The fact that I'm dissecting when I move to the right, dissecting when I move to the left, even when the effect is smooth and careful, you know, it allows us to progress relatively fast in the operation. Here, as always, I want to remove the lateral attachments before we try to go to the bladder neck because again, if there are attachments up here laterally, I call this the hammock attachments.
29:55If I if I don't cut these attachments, then displacing the adoma downwards is difficult. And sometimes we need to go quite down here in order to reach the the bladder neck. I think in this case it's not so difficult. But I wanted to show you that you need to go in both sides. Here is the bladder neck already.
30:16Uh but you need to clear this lateral attachments in order to get proper mobility of the adenoma so it can come down. And when it comes down it will allow us to to um access the bladder neck. Sometimes the bladder neck is very low. No. So you have to go over the adinoma and then downwards towards the bladder neck and the only way to reach there is by releasing all these lateral attachments that are holding the adoma in place. You know they're it's hanging from here. So when you bring them down like this when you cut them we gain a lot of mobility and then the the bladder neck is easier to expose and approach. Here we are.
31:06In any case, this is something we're going to need to do at some stage. So, it's about uh choosing the right strategy, the one that gives you access to the places you want to access without having to force the scope, without having to struggle too much. No, here we already saw that we were reaching the the bladder neck fibers here. I think I'm going up to Yeah, here. Huh? So, you see here's the bladder neck now.
31:43So, I'm going to go quite at the edge of the bladder neck here to see if we can open a wide opening. So, I'm trying to imagine the shape of the orange, you know. I'm trying to imagine how the bladder neck looks like in order to open it up.
32:10Remember, this man had a very, very funny looking uos. We'll have to be vigilant when we get there. Okay, here we are. This is the lateral line. Now it's a little bit more flat. You see, because we progressed a lot anteriorly and not so much here.
32:39Lateral line. Lateral line. We'll see how it connects with the posterior later. You see, when when you want to keep control of what you do, huh? Don't let Don't let the as I said I'm sliding the endoscope over the arenoma. So that is moving me around the arenoma and it's helping me uh let's say point towards the line of dissection towards the yeah the line of dissection.
33:14And um but sometimes there's going to be little jumps. No, we're going to jump a little. So be careful with these jumps. So try to get control of your scope as soon as you can because you want to be under control. Huh. Here. Let's see if we can come up here.
33:32This is the bladder neck opening in this side. So I'm trying to imagine how how it goes. You see, I can see some of these fibers coming down. They tell me more or less where the where the bladder neck wants to go. Let's see here. I don't mind contacting the tissue because actually what I want to do is to perforate because I know that on the other side we have the bladder. So it's safe to perforate here. That's why I touch the tissue you know that enhances the cutting properties. Although also we have to remember that this disruptive cutting will not will not give us very good hemostasis. So we we have to go through you know again over this region to find some bleeders because they will be and sometimes the bleeders are around
34:25the corner so you don't see them from the inside. You have to go a little bit around the the bladder neck to to see them. Okay. So now the bladder neck is free here. All the anterior all the anterior uh fossa is uh looking good.
34:41Let's check some hemostasis. We don't see a lot of blood, but maybe if we control some little bleeders, we don't have to control them later. Huh. So, here we have something. As I said, in the bigger prostates, it's worth keeping running a good good heostasis.
35:09Here you can see that I'm using the same setting I used to dissect for coagulation. I just increase the distance, defocus the beam a little bit, the focus, the incidence of the energy on the tissue so that I can uh qualate.
35:26You can see there's a little bit loss of focus because we are normally focusing very close because we are dissecting the plane. Here there's some clot also. So you can fire against the clot because this laser, you know, breaks stones. So it breaks the clot too. And this will help us also um check the hemoasis. Do some additional hemoasis because the clot formed because there's something bleeding. No.
35:56So let's spend a little bit of time trying to get good heistas. We've been here before. or I think but there must be some little little vessel that is accumulating some blood around here.
36:24Here again I'm using the same setting. The same setting I use for a nucleation to deposit some soft heat soft energy coagulative energy on on the on the prostate. No here also we start to see better. So you know when when you find that's another you know uh ejaculatory duct I think from the other side maybe. So let's now come to the line of dissection. See if we can connect continue the connection on the dissection. You see this is posterior line here. This is trying to connect to the lateral line.
37:10So I'm getting some of the posterior dissection. Now remember when you are posterior you need to get your targeting right. You need to target towards the edge of the arenoma. Let's see if we could focus slightly better.
37:32Let's see if we can develop because sometimes you try to go deeper in one region and you don't realize that there's attachments on the other side that are limiting the mobility of the adenoma. So you don't have much access.
37:46So if you start to feel that it's difficult to access a place just go around you know dissect more mobilize more and then when you go back to the place where the access was difficult you you see that it has been facilitated by further mobilization no of the of the adenoma. So we have of course sometimes we have a clear idea of what we want to release in order to achieve a specific access to specific place. But sometimes when we cannot access a place and we don't know really why working on gaining general mobility of the adoma will will help you. Huh. So I don't know if I make myself understood. But here we are coming trying to connect posterior with anterior.
38:53You see trying to release and you can understand that now when I push the anoma up it will go further up than before because it was firmly firmly attached down here. So, if I want to go to the posterior, you see, I need to release this lateral attachments. Otherwise, there's no way.
39:13No, it's like trying to uh get get your hand into a, you know, I know a case or something without opening the the locks, you know. So, we had to unlock the mobility The more we liberate laterally, the more access we will have also posteriorly.
39:43Huh. So, let's come up here. We we should be able to come almost uh close to the to the to the bladder neck. Let's see because it's better of course if we can see the bladder neck up here.
40:00See that's blatter neck region. Now we are getting very very close but I have to say it's it's very far. It's almost uh difficult to reach with the scope because there's a long distance between the meatus of the penis and the bladder neck here.
40:22I haven't seen that I cannot reach the bladder. So let's say sometimes I find some difficulty reaching this uh these places. Sometimes I find difficulty but normally I have been able to work my wayh you know that uh some surgeons are very happy to do uh perinal access for the endoscope.
40:48You know when they cannot reach the bladder they open up a perennial throtomy to introduce the scope below the testicles and then have more reach and be able to do the very large glands. But in my experience I didn't need to do I I never I never had to do one. I think the probably the case where you might need to do it is the the man with a penile rigid penal prostesis semi- rigid because in this cases the there's a there's an absolute limitation to how far you can reach the yo was here under the vessel here so we are quite safe now here in the bladne neck you see so I'm trying to gets closer and closer to the midline because if I want to elevate the adenoma and push it inside the bladder, I'm going to need to Ah!
41:46Ah, look at the stone. [ __ ] That's a problem. That's a problem. Okay. I don't know if it I should break it now. Now that we are here, let's use the magneetto. Let's use the magneetto see if I can pulverize it >> rather than producing a lot of fragments. Let's see.
42:12The kamak appeared. It's very hard. Huh. Let's see with virtual basket. No, it's very hard. It's a hard stone. It's incredible. We couldn't see it before, huh? I don't want too many fragments, but let's see what we can do. No, there's always what you want to do, what you intend to do, and then there's always what you end up doing. Not necessarily the same.
43:14So, you can just try, you know. Of course, now for the moment we have very good heistasis in the capsule in the fossa. So maybe the only problem might be in general I like to do the stones first because when the when the mucosa of the bladder and the prostate is is still intact all these fragments can be washed out very effectively. You know it's a hollow hollow stone. You see it's very very incredible.
44:03But if you have a let's say if you do the enucleation first and then you do the stone then many fragments are going to fall in the fossa and then the fossa has some little clotting little clots and it becomes more difficult to wash these fragments out. No, but let's see. We can do what we can do.
44:23We can do our best. Only this is a lot of fun, huh? It's incredible. I mean, when you talk about enucleation, people, you know, have a mental picture of how how it is. I have to say we we find a lot of cases that are a lot of fun for the surgeon because you get a lot of surprises and uh you get to see funny things sometimes not so funny.
45:04What I mean is that you find a lot of interesting cases more than funny interesting cases. Here we are progressing slowly. This is the new, you know, magneetto setting. Magneetto setting is very similar to TFL. So, it allows to achieve dusting more than fragmenting. You see, and we're producing a lot of dust and small fragments as well.
45:32I'm working at 30 watts, which is okay, you know, for the bladder. I I wouldn't do I don't do stones, so my knowledge of stones is quite limited. But I hear that uh in the urtor you have to use very very low very low frequency and very low power very low energy to try to avoid heating the urtor and damaging the stricturing or so here we're producing some dust.
46:14and some little fragments. Let's see how many do we have later. See if we can evacuate them using the venturi effect before we finish the enucleation. So we're seeing extremely interesting cases huh today and yesterday very very hard.
47:00I don't have a lot of access. Let's see. We can get the horns. What is the composition of this stone? Do you know? Do you know some of you clicking? >> Say again. What? What did you say?
47:40I don't know. I don't know. I don't know. Stones. I'm an ignorant of stones. But I guess this is a typical look no of a certain composition. I don't know which composition produces this top these stones.
47:56It's hard. Spiky. I'll find out and see if I learn it because I'm lazy when it comes to stones. I don't treat these patients. I always refer them to my colleagues. We have some very good stone masters in in Madrid. We have Lianes and we have Moes Rodriguez.
48:29They are stone masters and they're very good. So I feel that I can focus on BPH rather than trying to do stones myself which would be you know I would need to start learning like a resident.
48:53When I was in London, I had an opportunity to learn stones with Hugh Whitfield and uh but I prefer to stay with Tony Mandandy to to learn some more ith reconstruction. For me, 6 months was probably not enough to so I prefer to, you know, get more knowledgeable about ithl structures and reconstruction.
49:21And uh over time I thought maybe it was not a good decision in the sense that of course now I can do urethroplastes but I never really got to learn modern stone treatment. No as a resident.
49:37In my first years we will still do open surgery for stones and uh urethroscopy was becoming popular. rigid urethroscopy. So in my hospital as a resident, I didn't get exposed to much urethroscopy and uh uh PCNL was not done.
50:02So that's why I remained an ignorant. But I do have to treat the bladder stone sometimes. And this seems to be very very hard. Huh? It's it's taking time and patience also. So you see I think the endurologist have to be patient because what we do especially I think the the stone work is a little bit boring for me. I mean breaking these stones is uh quite boring.
50:41Let's see if we can get some of this rubble out. [clears throat] Feel the bladder again. Let's focus more on the on the bladder now. So of course uh it's important to train people to be knowledgeable about everything. you know like uh residents should know about everything but then in your professional life I mean you you have to remain let's say more or less informed of what's going on in the world no in your specialty but when you focus too much in one area you lose track of the rest no I do robotics oncology so but for example in my country all this experience with expensive drugs for imunotherapy and uh you know prostate cancer drugs they are only used in the public system so when you work in the private system of course
52:01we still treat localized tumors no but even when you study because I've tried I've tried to study all these metastatic prostate cancer drugs and everything but when you don't see the patients and when you don't use the drugs you tend to forget very very easily the detail. No.
52:20And the for example so in my practice I see localized prostate cancer but not so much metastatic and as we don't use the drugs no you you don't get so knowled knowledgeable about them. No. No, but I think there's a role for super specialists.
52:53I think that uh all the things that I learned over the years are now easily shared with other people and uh it's for the benefit of the patients. So I always thought that we have urologists in the world with very different talents. No, we have very nice teachers, communicators, politicians and uh surgeons, you know, each each one plays a role, I think, which is important. Let's see. That got stuck there. That little stone still very wide. Let's see if I can make it smaller.
53:36And now hopefully it will come out. So we had to stop the enucleation to try to remove the stone. Okay, I think most of the work is done. I hope there's some crystals, some dust here.
53:58But here we are again. Let's let's get oriented again. This is the this is the UO. This is the bladder neck. Now we are inside the the fossa again. There hasn't been m much much bleeding. Now we focus again to the right distance. Let's do some hemoasis. Now that we are here, try to get the best possible visibility as we approach the bladder neck from below.
54:24Good. So now we have the other side here. It's a very very large gland. Very very big. And this is now let's see the access to the bladder neck. Here is the UO. Okay. So we need to mark a little bit better our bladder neck dissection here so that we can establish a safe reference so that we don't go anywhere near the UO.
55:00So this is the arenoma. This is the bladder neck. This is the UO. So we want to come probably here. This would be bladder neck. You see from the inside now we are connecting to that place. So that we leave a a nice reference here.
55:19So when we come from below when we lift the the prostate at the end we have a nice reference and we don't need to go back in to check where is the U because we know that it's going to be lateral to this to this point. Uh so here it is.
55:34This is a medial reference here. So this way we will protect the the UOS. Okay. Good. So now we need to go you see from 12 to 6 trying to get here below. Let's see. This see seems to be detached.
55:52Let's see what we have here. Water is good. No, it's getting obstructed. Now I can lift a little bit of the adenoma here. It feels very heavy. Feels very heavy. But you see it's almost we're very very close to the to the bladder neck. Let's see if I can lift this a little bit and hope hope to push this into the bladder. Let's see if it will go. So I do a let's say constant pressure to see if I can get more some mobility. I couldn't. Let's see if this has helped me reach places where we couldn't reach before. Here there's still some attachment of Let's see now. It's a big big big prostate. Let's see if I can bring it into the bladder. I'm pushing carefully, but it doesn't move too much. So we are
57:00a little bit stuck here. So I'm going to show you a trick. When you have a big prostate and it's very difficult to to mobilize it, you can come inside the prosthetic urethra and split the adenoma. Okay. So let's do a line that comes here. As I said, most of the times I managed to tilt the prostate into the bladder in one piece.
57:24But I think I'm going to show you this trick because even when you when you have done an in block uh operation you see it gave us very good mobility very good orientation the ability of dissect uh dissecting the sphincter releasing the apex early etc.
57:42So we have a lot of advantages of the end block approach. But when it comes to tilt the adenoma into the bladder, you can as well choose to split the adinoma in two parts. Okay? So here you see I'm cutting through the prostate. There's no bleeding at all because this is already almost completely devascularized. You see? So we have we have the adenoma here.
58:09I'm cutting through everything starting in the prostatic urethra and then coming down. You see it's a huge prostate. Now this incision will take me maybe 5 minutes. And where are we here? You see this is the this is the bladder neck.
58:36Let's see if we can cut split the adenoma in two pieces. I used to say that this is not necessary usually. But if it is, of course, you need to know how to do it and I'm not how do you say I'm less and less a fundamentalist. I think you have to be practical.
59:02And if you need to split the adnoma into pieces, then so be it. That's a piece of work, huh? Because here, yeah, we are reaching the posterior plane. This is posterior plane. You see here is the entry into the bladder. I think this is the bladder neck bladneck region.
59:53So now we gain a little bit mobility. But if we want to have the ultimate mobility, we need to go up, you see, and cut the anterior commisser as well. You see here, this is the adenoma. This is the anterior commissioner. You see? So now we cut it open.
1:00:13So we have two pieces in the bladder, not one in the in the prostatic cavity, not one. Need to go all the way up to cut. So we split the adnoma too. Crazy know this huge prostate. Mhm.
1:00:41Let's go more antior and see what's going on here. And we can go antior over the interior commissioner too. to cut. We would see the bladder neck also there here when we reach this point.
1:01:03And now we will increase the mobility of this lobe a little bit and that will help us probably tilt it into the bladder much easier. In extreme cases I I have had to start more selecting in the fossa. you know if if you cannot possibly you know tilt uh sorry tilt yeah push push the anoma into the into the bladder then you have to start morcellating in the fossa this morcellation usually carries very good visibility it's not so fast because the prostate needs to move for morcellation for effective morcellation and this is anterior commissure Interior tissue.
1:01:51Anterior tissue. And here we are. Now I think probably we have two loes. Huh? One lobe. This is the lobe. So when I push this lobe into the bladder, probably probably it's going to respond better to my my movements. Let's see.
1:02:08Even if I want to come down here, you see, and I can lift a little bit. I can reach and see better what is you see what is remaining. You see before we didn't have access here to to detach because I think if if the adnoma is properly detached you don't need to push too hard to to bring it into the bladder usually you know so most of the times the problem is that the prostate is so big that you cannot reach down here you cannot reach down here to catch the remaining attachments below. No. So when when the tissue is still attached, it's it's difficult to to mobilize it. Let's see. Now this is uh this lobe.
1:02:52Let's see if it will go. If I push it towards the bladder, I think it's starting to move. Let's see what we have here. You see there's still I think more attachment. Here's the bladder neck.
1:03:08Probably need to detach this little attachments and let's hope to negotiate the passage. So, you have to be patient. Push carefully. Try to see if it uh you can dislodge the huge lobe and push it into the bladder gradually. Once we get one lobe in the bladder, it will be much easier to to push the other one. No, the second one.
1:03:40You can see that there is some distance now between the lobe and the capsule. So, we are managing to to get it here. Probably we didn't split it completely. Let's see. That could be another reason. I think this is not completely split.
1:04:00It looked as it as as if it was, but probably there's still some connection here. That's why it doesn't want to go. So, let's finish the split posterly. Let's see where we are here.
1:04:21So, you see, we find difficulties and we use a technical, let's say, solution for every difficulty we find. No, we try to solve the problems. Now, I wanted to show you this splitting technique. Sometimes if you spend five more minutes trying to negotiate the passage, it will go. But I think in this case, probably was a good idea to split because, you see, because I think it was quite difficult to mobilize this this beast.
1:04:56Here we are now. I think it moved better. Let's push it more. Now it's in the bladder. I think this one. Huh. Let's see. You see it's going into the bladder and it's showing us the final little attachment here.
1:05:16That's why it doesn't go completely. You see here we have bladder neck and there is some little attachment here. Here we don't worry so much about the UO because we marked very nicely the lateral. Do you understand what we're doing? We we cut the orange in two parts and now thanks to that we're getting mobility and we're getting uh the possibility of tilting the the adnoma into the bladder.
1:05:39Huh. So there we are. Now if we push it's totally mobile now in the bladder. It might still be some some little attachments to the other lobe. Huh? They were, you know, they were born together and they lived together all their life. So, it was quite difficult to separate them.
1:06:00Now, here we have a lot of space now because the fossa is half only half uh full filled by the tissue and here I think we have some residual attachments. So now when we push the arenoma hopefully it will it will also tilt into the bladder. We need to check that there's no nothing let's say keeping it attached down here.
1:06:33Sometimes the prostate is so big that it doesn't fit in the bladder. So so I don't want to move so much. I want to I know just investigate here near near the bladder neck. That's the bladder neck. And down here probably there's still some uh tissue holding holding the adenoma attached this little bit.
1:06:59Now when we push it into the bladder, it goes. So the enucleation is finished. It's been 1 hour and 6 minutes. It was of course we did the stone in the middle, but uh it was a challengeh.
1:07:15But you see if you if you lose your patience you know if you despair during the operation u of course you can stop you can put a catheter and come back another day to finish. This is something I would recommend to do you know rather than converting to open surgery or anything like that because you see when you come back after some days the visibility is very good the you don't need to to wait too many days and maybe even the day after I think if you come back you find that everything is improved you understand much better what's what's going on you know with with with the tissue and what's going on with the this is the fossa Uh let's check heostasis.
1:08:04You see if we did our homework during the operation, there shouldn't be much bleeding because we were stopping to coagulate a little bit. But of course, we need to check the heistasis and the fossa and see if there's any residual tissue that we left.
1:08:25Here we are coming out antior anterior plane. Many times when I when I had to return to for for bleeding most of the bleeders were here anterior close to the sphincter because yeah we need to check on both sides to see that there's no procedural bleeding. Hemoistasis is quite good. You see sometimes we find little vessels that are going to compromise the visibility and maybe if it is a small artery maybe we don't see it very well now but when you put a catheter and the arteries pumping you know you start seeing that the patient bleeds postoperatively you bring him back to the operating room and then you find that there was a small artery pumping that you couldn't see because you didn't have the patience to
1:09:20to check. You know sometimes even with the patient it could with the patients it could happen that also uh I think that it's my personal opinion know when when you use a energy that is so disruptive like homeium I think that sometimes the vessels are not cut and coagulated properly they're just you know severed by the action of these explosive boiling bubbles and uh Sometimes these little arteries could be experiencing a spasm. So they don't bleed so much and then after some time they start uh bleeding.
1:10:05So many things can happen. You you can only do what you I mean your best. There we go. This is all anterior. Okay. I think we have good visibility. Reasonable reasonable visibility. Here is the blad neck.
1:10:29Here is the UOO. Where is it? Here. The other one is also safe. So, let's try to morelate. Uh, Alex. Of course, these are these cases are not for beginners. uh you need to develop your skill, develop your confidence and then patiently patiently get to do bigger prostates.
1:10:58So it's not only a technical thing, it's also your attitude, you know, the the patience, the confidence, the resource resourcefulness, you know, you need to have resources like in this case, I cannot push the adrenoma in one piece into the bladder. What should I do? Well, we have a we have a solution.
1:11:23Huh? It took us 5 minutes to split the adnoma in two pieces and then we could handle this massive prostate. Um, as I said, I did a 400 g prostate once that uh flipped perfectly easily into the bladder. So, you can never tell no when when you will have difficulty or not. So I always recommend to learn about other techniques you know so that you see how other people manage you know their inucleations because you find some good ideas sometimes although as I said this is as simple as them orange you know on the skin of the orange and when you find a solution it's very simple no instead of pushing the whole anoma you you split in two then it's easier to manage both loops separately.
1:12:29Okay. Yeah. So complex cases I remember I when I was a resident I went to the operating room one of the first days and someone said hey come come and have a look the urology ologists are operating in theater too, you know. And then I went there. Oh, grab a grab a grab a you know one of these ladders to to water is good. Yeah.
1:13:14>> So I started looking over the shoulder of the urologist a senior urologist. He was doing an open open prostatctomy and he took out the adinoma and I could see the surgical field you know overflowing with with blood.
1:13:29The guy was suctioning. He got a white gloss and put it inside the prostatic fossa aspirating preparing the knots you know the the the stitches to to stitch the the bladder neck and everything. And I thought, well, what did I get myself into? You know, am I going to need to do that myself?
1:13:54You know, put my finger there, provoke all that bleeding. And and I did a lot of open prostatctomies as a resident. Typically in my hospital, the second year resident and the third year resident would do the open prostatectomies.
1:14:10And um so we became very good at it you know but occasionally things would go south. Huh. I remember once my colleague was uh we packed the patient and we had to do cardiac resuscitation you know on top of the chest of the patient because he was it was a very heroic um time. No. And uh operation. And so when I when I heard about lasers and BPH, I I was very interested because I thought, you know, this is this is probably the only thing I regret I think is that I should have taken a plane and go to New Zealand with Peter Gilling to learn when I was younger. You know, it took me many many years to to get to learn Hollip.
1:15:08And um that's why I I when I talk to younger residents, I tell them go to to see the best surgeons in the world. Choose something modern and you know go to learn. So we still have one more case for today. But now when we do the 100 g prostate it will be will seem very simple. No everything is relative.
1:15:50It is good that you see these cases because you you realize no there is some complexity to them but behind this behind this complexity there is a simplicity and uh there is a method and if you follow the method if you follow if you know how to use the energy if you know how to dissect a plane if you know how to correct when you start deepening too much if you know the steps of the operation And then you can tackle any case with this methodology. You know, >> you do same.
1:16:38>> I do the same steps always. No. In the >> follow the steps. Same steps. >> Same steps. Trying to liberate the apex early carefully mobilizing enough so we can have a good reach there without putting too much traction on the sphincter.
1:17:00One of the main advantages of unblock and I I didn't realize it until recently when I saw you know Mario Suffer's study about the radial traction on the sphinctter is that when you do and block you can use your scope to to push the adoma a little bit and mobilize. So when when we move the adenoma, we see how it moves inside the capsule.
1:17:30But we don't realize that by putting pressure on the adenoma in one direction, for example, when I'm anterior to the adenoma and I push down carefully, not only the adenoma descends inside the capsule, but the whole prostate descends. You know what I mean?
1:17:45Because there's mobility inside the pelvis of these organs. So by doing that I'm releasing some of the pressure on the sphincter. No, some of the traction on the sphincter. And I think so you can do that within block. I think if you do three loops or two lopes, it's much more difficult to capitalize that that mobility to reduce swing traction if you know what I mean.
1:18:27So you agree with me know that you have to be patient. So finally this was the patient we I was starting to doubt if the previous patient was the last patient. You know sometimes we get confusion because the Bulgarian names for me in in cerillic >> are difficult to read.
1:19:03wood. >> So, I knew we had a 200 g and then a 250 with a 3 cm stone, but I was starting to doubt this was the the one. Okay, change lubo tough, huh? But I'll tell you, you you will enjoy it very very much. Hol is it's very very nice. You feel very well. And when you're in control, it's and then you see the patient the next day. He's walking around. He's happy. He pees.
1:19:50So you you are you feel that you you were able to to achieve something significant. Let's open the water. Let me know when it's ready. See the visibility decay. So sometimes if there is a little bit of bleeding, Schumanov, the patient is starting to tremble a little bit.
1:20:16>> Dr. Schumanov. >> Yeah. Yeah. >> Maybe >> it's cold. Maybe. >> Yeah. You use It's a little bit coldish and it's >> okay like this. You're progressing really well. >> Let's see. No, no, no. It's uh but it's going to be lengthy after all. It's 1 hour and 20 minutes now.
1:20:45>> So, it's going to be a long procedure. He's shivering a little bit. No. And sometimes it's a very skillful, you know, how do you say that? You finish a case and you think, "Wow, it's it was difficult. It was not so easy, not so by the book, you know, because they tell you you have to have perfect visibility for morulation, but not always you can get perfect visibility, you know what I mean? It's sometimes you can. So if you have the experience and the confidence and you can try to safely more select even in low visibility conditions maybe of course you do it. No if if you feel that the risk is too much then probably it's better to stop the catheter and come back another day. No.
1:22:01So here we can still see some. No we are and also I think the morulator helps a lot. If the morulator is slow and bad you will suffer tremendously. No. Whereas if the morulatorator is is fast and reliable here, you see I'm in a safe position and the tissue is coming to us.
1:22:21So the mouth is covered with tissue. I'm not sucking too much water. So when you go back, you have to try to involve your nurses, your nursing team to help you as much as uh Lubo and Alex here helped me. They you see they're both looking at the screen all the time.
1:22:47They they are in the operation. It's not enough for the nurse to be in the operating room. She has to be in the operation itself. She has to be looking. So for example when we find this difficulties in visibility sometimes when I go to coagulate again if I have to stop morcellation and go in to coagulate there's a lot of clots in the fossa we don't see very well so often I enter with a rectocope rather than the laser again you know and um so she already has it prepared because she has seen cases she knows that in these cases sometimes we need to enter also when we do such such a large glands you don't want to leave pieces of tissue inside.
1:23:32So sometimes even when it doesn't bleed and everything I enter with a rectocope to check that uh everything was finished properly. This was probably it's a bit beach ball. Huh. So it's a hard nodule probably. You see it doesn't want to be moreated. Let's go for the other big piece and then we'll check at the end.
1:23:58So having a a good team is very important because if if you as a as a surgeon, you have to control everything that goes on in the operating room. You know, you're more stressed because you have to control your work and the work of others.
1:24:16Whereas if you can trust them that they will do their work, then you can focus in your work much more confident, much more relaxed. Here we are. >> It's becoming a little bit long operation. No, 1 hour and a half. Change >> change loop or change >> bladder is well distended. Let's see.
1:24:52During the changes I stopped the inflow water. So we took out about 100 g I think already. You see the water is coming a little bit reddish. No the color in the in the container is a little bit reddish. Not so not so clear.
1:25:14But of course, the post at the wound is huge. So, it's impossible to have perfect perfect visibility sometimes. Let me know when he's ready. Alex The most blades are produced together, you know.
1:26:04So the rotation of the inner blade and the outer blade are calibrated. So you cannot mix, you know, an external blade with an internal blade from other set. You know what I mean? You have to instruct your nurses to keep them together if you're going to use them again if they are reusable.
1:26:29And uh try not to confuse because sometimes you see boxes where they have external sheets, internal sheets, the risk is that when you use two that are not produced together might there might be friction friction and with so much with so much rotation the friction might heat up the the blade you know and cause uh trouble. So sometimes during morcellation you get a little bit scared. because the for example the middle lobe mucosa no sometimes shows up and you think oh that's the bladder no so h there's sometimes uh some emotion and some confusion so but again if you stay in the in the safe spot you check that you don't suck too much water normally we can successfully be also sometimes incredibly when you do
1:27:52the morcellation the pressure in the bladder acts like heatic. It's a heostatic situation. You know the the bladder is has quite a lot of pressure inside and uh then the bleeding let's say stops and you get more and more visibility throughout the the morcellation. No, typically is the opposite. No, but sometimes we see that that we start with good visibility and it uh keeps getting better and better.
1:28:32So when we have to do massive prostates, you know, like 400 grams, 500 grams, sometimes I tell the patients, I might uh stop uh to to do a second stage the next day or the day after because if if the enucleation takes too long, you know, I did uh 500 gram and it took me two hours to enucleate, I'd rather stop, put a catheter and come back uh another day for forsulation the tissue gets very soft because it's uh it's decaying it's uh rotting inside the bladder you know it gets very soft and then the morcellation is very efficient because soft tissue goes very fast so we can I remember I morelated 470 g in for 40 minutes so was more than 100 grams per minute sorry for more than 10 grams per in it.
1:29:27Yeah. It's a big bulk. One one of the pieces was probably middle lobe and lateral lobe from one side and the other piece was lateral lobe. Now I'm sucking water. large process. >> It's a big one. You can tell not only by the, you know, >> perceived size. Yeah.
1:31:28>> Antibolic. >> Say again. >> For the larger, >> the larger antiolic sacks for the patient. >> Anti-ambolic. Um normally we don't use separine or anything in these patients because they usually they're long short surgeries.
1:31:47>> Mhm. >> So only when they have risk factors you know so we don't give them heperine or anything. Um you know only if they have history of trombosis previously or something like that.
1:32:03And um probably having the legs elevated like this, I tend to keep the leg the foot over the knee. So the foot is higher than the knee. So the the return of the blood is is easy. No. And uh there's very little.
1:32:24I haven't seen much. I think I've never saw uh deep venous trombosis after after enucleation. I've seen them after robotic prostatctomy but not after after hol. That's why I don't like very long procedures, you know. It's a 1 hour and a half, 2 hours, more than two hours. I I don't feel very comfortable. Change, Luba.
1:32:55Change. Okay. More tissue coming out and more to come. Now the first basket is nearly full. I think would be going to be 200 g plus probably because the basket holds 200 I think. [snorts] Okay.
1:33:20Let me know when it's ready. In Madrid, we have 5 liter containers. The guys from Richard Wolf doesn't don't like them so much, but they work really well with us and we we reduce the number of changes we need to do. You know, when the bucket fills, of course, if it's 5 liters, it fills faster, sorry, more slowly. No, and we don't need to do so many changes.
1:33:54It's interesting that the mosulator needs a certain atmospheric pressure to work. So we tried to use this pirania system in Colombia and it didn't work because it was very high. So the atmospheric pressure was very low and the morcellator cannot be used in these places in Cusco in Peru and all these cities that are quite high.
1:34:19It doesn't work. [ __ ] It's very big. Now we can probably bring it in the fossa. Let's see. Now we are in the fossa. It doesn't move very freely. Let's see. So, I brought it back in the bladder.
1:35:45I'm not happy with this pedal. Let's put it correctly now. Also when you learn holip I think it's important to to do cases many cases together. So don't do one case per month. If you try to learn by the time the next patient comes, you forgot everything you learned before. You know what I mean? So you need to do two or three cases, four cases per week during your learning curve. Uh so that if you can do more then if you could do let's say two cases per day then you would learn very fast.
1:36:55As I said, the best uh option I think is to initially organize a workshop with someone who is an expert. So he can show to the hospital people, to your anesthetic colleagues or nurses, the medical director, the manager of the hospital how good the treatment is. And then when you sit down to learn, everybody will understand that it takes a little while to learn, but they already have seen the the how it works. when you know how to do it. No, if you try to learn, if you do the first case in the hospital, people will be likely discouraged, you know, the anesthetist will not be happy because it takes too long and it bleeds a little bit and at the end you had to convert to TRP, you know. So, try not to learn alone. Try to learn with
1:37:43someone who can teach you. And um some people are doing uh like groups of two like you know one does one part the other one does the other part like that. I don't not sure that's helpful or not. Of course it means that in the department it's not only one guy carrying all the weight you know there's two people learning but I'd rather try to do one case complete case each. You know, the problem is that at the beginning, um, many many people are stressed with the procedure and they they get tired, they get exhausted.
1:38:20You know, you do a 2-hour dissection and then you need to morillate. So sometimes one does the enucleation and the other one does the morcellation, you know, so when he starts the morellation, he's fresh.
1:38:45We're getting to the You see the nodules? This these are the beach balls, the hard part of the of the alenoma >> again. Okay, Lo, what change? You see, we're sucking now more water and not not so much tissue.
1:39:12Relax. Relax. It's pco. We're almost done. But the water is clear. You see now it's getting clearer. So bleeding little bleeding stops. Lubo, let me know when I'm ready. You see, it's getting longer and longer.
1:39:46This is 1 hour and 40 minutes now. Ready? Also when we empty the basket we we feel that the the morcellation is better because the morcellator has two boxes. The unit has two boxes. One box controls the motor, the motor that I have in my hand, and it has a screen to to do the the settings to choose the the frequency and the speed of rotation as we saw as we discussed yesterday.
1:40:31The other box is generating vacuum. Okay, it's a vacuum generating machine. But as you can see, there is a tube coming out of this machine. This is connected to the water bucket. No.
1:40:46So the there is vacuum in the in the water uh bucket and the vacuum has to transmit through the basket. You see to reach the through the tubing to reach the point the the the mouth of the of the blade. No, you want suction on the mouth of the blade. So it has to go through that intricate uh you know let's see if we can do upside down Lou uh boton please.
1:41:20No it's not. Let's see it's not working very well. No. Okay. So what I try to say is when the basket gets full of tissue the suction doesn't the negative pressure doesn't reach the the mouth of the morcellator so blade so much. So we see that the efficiency of morcellation is lost a little bit.
1:41:48So here we are. This is the upside down morcellation. This is quite helpful when the tissue is a little bit harder. It's considered to be safe because between the bladder and the morator you have the tissue of of the proatic tissue. So and the advantage is that uh when the tissue is harder as the adenoma tends to float up you know we are waiting for it up here and it enhances the contact.
1:42:23You don't need such strong suction to to be able to morelate when you are upside down. So this is how many Asian urologists morcellate or it's it's more popular in Asia than in Europe. But I find it very useful.
1:42:41You see it's a huge gland. Huh. And this is a fast morcellator. So imagine using a slow morsel. Be crazy. There's no suction in the ball. Let's see. Looks very round. It's like a nodule.
1:43:49You see, it's hard. Probably water is coming out, but not so much tissue. Let's see. Maybe it's kissing the the tissue, but it's not so efficient. And you see how fast the water comes out. You know, the water bucket is being filled very fast because it's harder tissue.
1:44:48It's a massive prostate. Very large. I think uh will take more than 200 grams out because it's taking a long time to morillate and it looks as if the morulation efficiency is okay for most of the procedure. So this is the hardest piece for for sure.
1:45:18You always get the harder hardest tissue at the end. Nice. Come on. >> Almost. >> Almost. Yeah, there's some some little piece inside. There's another one we left before. I think might be more here inside the fossa.
1:46:00Little fragments that come Hopefully we don't leave any piece in the bladder. I think it's it's clean still here. Okay, let's change again and we finish. Let me know when we're ready.
1:47:10Now I'm in the fora picking up this little pieces. Alex, can I go in with our rectocope for a moment just to check? I don't think we I think it's I don't want to leave any fragment or So many fragments came out of the main pieces.
1:48:06That's a little stone. Yeah. Okay. Let's enter with our setocope for a moment to check that everything's okay and then we can put a catheter. Huh. Nearly finished. Tough work. Can you help me here at this?
1:48:32Thank you. Take this with you away from me. Thank you. Let's get the water on the light. Here we are. This is the bladder. You see, sometimes they could be some more fragments or something. It's a trabaculated bladder and it has some diverticulums.
1:49:11This was the UO here and the other UO here. Mhm. It doesn't seem to be hopefully this will come out at some stage. I don't know. Typically, you what you don't want is a piece of tissue inside one of these diverticulums because it's a spoiled bladder. This guy has a horrible Horrible bladder this man.
1:49:52Okay. This is a sorbital. >> Yes. >> We can if you see some vessel we can this is a monopolar rectocope that adapts to the instrument. So with the same external sheath we have uh I don't think it's bleeding too much. It's we've been able to morillate with relatively good visibility. Okay. So let's come out.
1:50:17Now and look at the sphincter. See if we can get away. You see this is the sphincter here. We managed to keep the mucosa covering the sphincter. I think he's going to be fine. Huh.

Patient guide · Back to the library