Dr. Amy Krambeck:

The objective is to identify specific examples of new technology in their critical steps and identify specific examples of different technologies, and like I said before, this is CME accredited. Today is going to be an excellent presentation, one that I'm personally looking forward to and it's entitled Enucleation is Enucleation is Enucleation. Our faculty is Dr. Marcelino Rivera. He is assistant professor of urology at Indiana University.

Dr. Amy Krambeck:

He completed his residency at Mayo Clinic and fellowship at Indiana University with me, and then he went back to Mayo Clinic and then joined IU on staff. His clinical and research interests focus on the medical and surgical management of BPH and stone disease, and he's a member of the Collaboration for Research in Endourology or the CoRE group. He has some excellent footage today in techniques that I'm looking forward to seeing. Our moderator is Joel funk.

Dr. Amy Krambeck:

He's an associate professor of urology at the University of Arizona and chief of surgical services and director of urology at Banner University Medical Center. He specializes in laser prostatectomy as well as female urology, a very unique skill set. He was actually the first person to perform a HoLEP in Southern Arizona. He completed his meds school at Northwestern and his residency at the University of Arizona, and then did specialized training in Cambridge to learn the HoLEP technique.

Dr. Amy Krambeck:

Welcome both of you, and it's so great to have you here. I just want to reiterate that this is CME accredited. You will receive a survey from Michele Paoli, which indicates which seminars you attended. You will get a CME certificate and please fill out the evaluation questionnaire at the end of each seminar. Please use the question and answer function to ask questions today. This is your chance to interact with the experts and get any question that you may have answered.

Dr. Amy Krambeck:

All upcoming webinars and registration are listed on the Endourology Society website at www.endourology.org. Without further ado, I'm going to turn the platform over to Dr. Marcelino Rivera.

Dr. Marcelino Rivera:

It's really an honor to be able to present today with one of my very favorite mentors as one of the moderators for today and Dr. Joel Funk as well. I want to just thank everyone and the Endourological Society for the opportunity to present an area that I'm very passionate about, about enucleation. As Dr. Amy Krambeck said, I'm an assistant professor at Indiana University. We're going to be looking at the evolution of the popularity in enucleation.

Dr. Marcelino Rivera:

I'll talk briefly about the improvement in laser technology and patient outcomes. I'll dive into some of the aspects of technique that I think are sometimes difficult for people initially starting out on enucleation. Then I'll talk about future directions with enucleation and what we can do for our patients. I think what you can see in this slide is the really increased in popularity in HoLEP articles. But if you were to look at enucleation to a pub med search, you would see the exact same thing.

Dr. Marcelino Rivera:

Really an increase over the last decade in popularity, in publications in enucleation. That's because I think of the AUA guidelines coming out recommending both HoLEP and ThuLEP as surgical therapies that are size independent. That increased in popularity not only in the United States, but also abroad, really is demonstrative of the efficacy of this procedure. I think the reason why we see this popularity is really because, unlike some other, maybe newer technologies, HoLEP has been very, very data-driven in terms of success and efficacy.

Dr. Marcelino Rivera:

I think a lot of us know the literature quite well, but Peter Gilling was really the first one to do HoLEP in the world, and at seven years, follow-up we still see really long stable efficacy in terms of success rates and in randomized control trials, one of the few areas where we can do that in BPH surgery. You can see that you have this durability even at seven years and really a wonderful article just published last year in the Journal of Urology.

Dr. Marcelino Rivera:

We see that even at 18 years follow-up, you have this really stable lower nadir PSA, excellent IP assess score durability, and what we see here is essentially at nine plus years, 1% retreatment rate. You are hard pressed to find a better procedure; I should say than HoLEP for our patients with BPH. I really want to dive into really enucleation in general and that endoscopic enucleation is really energy independent.

Dr. Marcelino Rivera:

What you can see here are a couple of different video spliced together from Videourology really utilizing different endoscopic techniques. Here we have a Thulium YAG Laser being utilized for a ThuLEP. Then in a minute here, we'll see the use of green lamp as another way to enucleate right here. Really, it's really not the kind of energy that you're using, it's really the technique of getting your BPH tissue, getting along that capsule and really enucleating that tissue.

Dr. Marcelino Rivera:

What we see here is the end result, which you could see with really any kind of energy. What we have here on the right side of the slide is the durability data looking at randomized trials, looking at both bipolar enucleation, holmium laser enucleation and endoscopic enucleation when compared to the previous score standard for large prostates open simple prostatectomy. What we see here is essentially in all facets.

Dr. Marcelino Rivera:

We see that enucleation not just HoLEP or bipolar or endoscopic, but enucleation is the real winner here. In terms of safety data, hemoglobin decrease, catheterization days, hospital stay, what we really see is the durability and the success of enucleation. Again, a systematic review of bipolar enucleation versus bipolar transurethral enucleation.

Dr. Marcelino Rivera:

This particular study looked at 14 studies, and what they essentially found was that bipolar endoscopic enucleation demonstrated better amounts of resected tissue, reduced overall complications, reduced transfusion rate, catheter dwell time and overall length of stay. Again, I know I'm sounding like a broken record, but I think that's the real positive thing about the different kinds of enucleation technique, you can utilize them and you know that your outcome is going to be very, very good.

Dr. Marcelino Rivera:

It's really whatever the surgeon is most comfortable with to get the enucleation performed and their outcomes are going to be excellent. I know there's always a question about is this a durable result with things that we don't necessarily know as much about? Where we have HoLEP data nine plus years, now we have bipolar plasma enucleation data up to five years, and you can see, I'll zoom in here. You have excellent PSA nadir here is 0.6.

Dr. Marcelino Rivera:

You have great flows and IPSS scores are really, really very durable now. Now we know that really, it's the technique of enucleation that results in durable results. Now we're going to talk a little bit about the technical aspects and I perform HoLEP, so I'm going to talk about holmium laser enucleation of the prostate, but really, this can apply for any kind of technology. Whether this would be bipolar or whether this is thulium or even now the new Thulium Fiber laser, it's really energy independent.

Dr. Marcelino Rivera:

Really, we're trying to establish the appropriate depth of our cut to the level of the surgical capsule. My previous training really established the bladder neck to the veru to really find that plane and in a bilobar configuration, we would cut at a six o'clock position and I will show the trilobar now. On the trilobar configuration, we're going to be performing incisions at the five and seven o'clock position and carrying these all the way down to our surgical capsule.

Dr. Marcelino Rivera:

I think this is a great technique for trainees, and I'm very fortunate here to work with excellent residents and fellows. This is the first part of the procedure that I will try and teach them because a lot of the technique involved is going to be working from the bladder neck down to just proximal to the verumontanum and utilizing your laser scope and the laser itself, or whatever technology you have to establish that plane in between your BPH tissue and your capsule.

Dr. Marcelino Rivera:

You're essentially carrying this down until you see the tangential blood vessels within the capsule itself. What you can see here is going from the five o'clock position to the seven o'clock position. We're literally cutting down and utilizing that laser scope to then push that tissue medially once we have found that surgical capsule. It's a great view right here, just establishing that plane. This opens things up for a median lobe only technique.

Dr. Marcelino Rivera:

In certain patients, I think this is a very reasonable way to perform enucleation, and really, for people trying to learn enucleation, this is a great way to train yourself after having some time with an expert surgeon and showing you the technical aspects of it. Really, this is just utilizing now the same incision techniques as our median lobe, but only enucleating the median lobe. Now, this is really only for patients who don't have any lateral lobe hypertrophy.

Dr. Marcelino Rivera:

It's a smaller group of patients that we're going to utilize this technique on. However, I will say that when you look at this particular prostate and this patient was one who was in acute urinary retention with obstructive uropathy, and you can see here essentially, no lateral lobe hyperplasia, all just the single ball valving median lobe. We were able to enucleate this in really under 15 minutes and get this patient's catheter free the next day and completely de obstructed.

Dr. Marcelino Rivera:

I wanted to bring to light some previous literature. Now, this is in TURP literature, looking at a median lobe only technique and less focused on the ejaculatory preserving aspect of it, but really the durability here with Dr. Kaplan's group at 12 years, you can see IPSS score very low, Qmax nice and stable and a very good quality of life score. I think in certain patients, especially when we're initially learning the technique, doing a median lobe only technique can get us comfortable and have excellent outcomes that are likely very durable.

Dr. Marcelino Rivera:

But again, the important thing is when you look into that bladder, when you're looking at the verumontanum and looking up, and you don't see those lateral lobes meeting in the midline, and there's a significant intravesical protrusion, I would say greater than one centimeter or intravesical protrusion this is a great technique for patients and for teaching. What you can see here is, as we back the scope out, a totally wide open bladder neck. This patient said he hadn't voided this one in 30 years.

Dr. Marcelino Rivera:

This is the kind of technique we can do for very, very specific patients, but I think a very good option. Next, I'll talk about a little bit the en bloc technique, which is now my preferred way of doing things. I was very much inspired by some of the work by Fernando Gómez Sancha and what he's been doing with his en bloc early apical release. What I've started to do in my practice is to really look at this for really all size glands, but really beginning with smaller glands, greater than larger glands.

Dr. Marcelino Rivera:

And I think for learners once this technique is learned, going around in this circular motion actually makes it a little bit easier to find the plane, but this is energy independence. This could be done bipolar, this could be done with a thulium fiber, it really doesn't matter. These are all just variations on a technique. Looking at the different kinds of techniques, there's what I would call horseshoe technique, where you enucleate your median lobe first, and then proceed with the rest of the adenomatous tissue versus the donut technique, which is where you're going all the way around.

Dr. Marcelino Rivera:

I will say that when you're first learning this, you will notice more capsular tension when you're working on the contralateral side as you're trying to get your BPH tissue into the bladder. It's very important when you're doing this to really stay on your adenomatous tissue. Here's an example of what I would call the more of a donut technique, more of complete circumferential enucleation of the tissue. And Ito et al. has a great Journal of Endourology video technique, but also article talking about their particular en bloc technique, so I just wanted to bring that to your attention as well.

Dr. Marcelino Rivera:

I'm going to dive in here to the apex for a little bit of time here. Talking about the mucosal strip versus the apical release. We'll go with the mucosal strip first. This is one of the trickier things to learn when you're first training, understanding that the anterior medial prostate is still fixed to the apex with a mucosal strip that needs to be cut prior to completing your lateral lobe enucleation. Here you can see it come into view. The one thing you may notice is how far back you have to come to actually cut the mucosal strip.

Dr. Marcelino Rivera:

We're essentially at the apex of the prostate, past the verumontanum. You do see these tatters of mucosa, which may be an explanation for why we have patients who have transient incontinence that can last for a good period of time. Also understanding that if you don't hook it just exactly right, you're going to have to go around and around in a circle to release that mucosal strip again. Here you can see now we're on the left side going ahead and releasing that mucosal strip and this motion is a little bit of a challenge to learn and understand when you're actually hooking that tissue.

Dr. Marcelino Rivera:

From there, I really began to look at, can we release the apex earlier and earlier, and in this particular video, you'll see a release of the apex right after the initial incision after we get our median lobe enucleated. Here we establish the plane immediately and find each lateral aspect here up against the capsule. Then at this point I find my verumontanum and invert my scope so that I can then score the rest of the mucosa and release the entirety of the adenoma from the apex prior to doing really any other enucleation on the lateral lobe.

Dr. Marcelino Rivera:

This is really a combination of blunt and sharp dissection, and I feel that definitely avoid some of the sheer forces near that external urinary sphincter. And as you're enucleating your lateral lobes, this is going to create a little bit less traction as you're doing that on the apex. What we're seeing now is definitely a reduction in at least anecdotally patients and their transient incontinence rates.

Dr. Marcelino Rivera:

But really, the technique here is really finding the plane and finding it at the anterior aspect of the prostate, and then heading circumferentially around to get all of that tissue off of the apex first. Here, you can see a really nice plane between the adenomatous tissue and our capsule, and then just going around in a circle and completing your enucleation. From that technique, I was then inspired to go with essentially an entirely early apical release technique without minimizing sheer force on the rhabdosphincter.

Dr. Marcelino Rivera:

You can see here, going to the verumontanum and pulling back and finding where our external sphincter and our prostatic urethra are connected. Then here, what we're doing essentially is going around in a circle and committing circumferentially to that plane. To start the incision, it's just a uniform incision all the way around the mucosa, and we're finding our plane once we get through that in the lateral sulcus of your prostate, and you're going to carry that all the way around in a circle until you have released your entire apex.

Dr. Marcelino Rivera:

What you can see here is now I'm essentially getting my laser and my laser scope into the incision and deepening it all the way around in a circle, and really committing to that same plane all the way around. And here you can see this our lateral posterior aspect of the patient's left side here, and you can see the plane start to establish itself, which is a nice area to find the plane in.

Dr. Marcelino Rivera:

If you're ever having a hard time finding the plane, I'd recommend finding the sulcus in the posterior lateral aspect of the adenoma, and you can almost always find the plane there. This is a great place for learners when you're trying to find your plane, if you're having a hard time establishing it, going here and finding it. Once the apex is completely released, and you'll see here in a minute, I'll be checking my apex to make sure that all sides are released from it. You can proceed with enucleating the tissue in a two lobe or three lobe or en bloc technique.

Dr. Marcelino Rivera:

It really doesn't matter. The main thing here is that everything has been released and you're free to proceed with whatever technique you are most comfortable with. Previous literature, and what I'm experiencing now in my practice is that early continence rates are quite impressive, and patients are very, very happy after this procedure, even those with chronic catheters, which I think is one of those areas where we talk about patients having longer incontinence because of that tension on the sphincter.

Dr. Marcelino Rivera:

Another area I want to talk about that it can sometimes be a little bit difficult is the anterior dissection, and when we come across and having difficulty finding the bladder neck. Here's an area where we've already gone around the lateral aspect, and now we're trying to encounter our bladder neck. Some of the important tenets here are working from a 10:00 to two o'clock position.

Dr. Marcelino Rivera:

If you are at all confused about where the bladder next is going to be by marching forward, and really hugging that plane between the adenomatous tissue and your capsule, you'll be able to eventually see the change of your fibers to a vertical orientation. These baleen fibers, very classic bladder neck fibers here and marching through those at the 12:00 o'clock position to ensure that you're going to enter your bladder in the correct plane. Now you have enucleated your tissue and just a brief discussion about morcellation.

Dr. Marcelino Rivera:

We use the Wolf Piranha Morcellator and what we have found is that at higher revolutions per minute, on two Hertz, we're able to morcellate tissue at about 12 grams per minute versus traditionally working at 1500 Hertz. That was actually clinically significant in a brief review of our last year of HoLEP patients. The main thing is you really want to have a very hemostatic fossa, that's going to really help you to be efficient when it comes to morcellation.

Dr. Marcelino Rivera:

Here's our end result, a very wide open fossa and a very happy patient with obviously a super [inaudible 00:22:19] uro flow. Lastly, I want to talk briefly about future directions of enucleation and really what we're doing here at Indiana looking at our same day discharge experience. One of our big champions Dr. Amy Krambeck, while she was here and really pushing the envelope in terms of patients, in terms of getting them out same day.

Dr. Marcelino Rivera:

Obviously now during our COVID pandemic, the importance of making sure that the patients who need to be in the hospital are absolutely in the hospital and pushing that forward. Getting patients out same day has really increased in our practice, and now all of our patients default to same day discharge. What we see here is that patients who discharge same day, if you can see here in the lower left-hand corner, their passage rate was much higher than those that we admitted postoperatively and we think that that is due to patients walking around and being more active postoperatively.

Dr. Marcelino Rivera:

I think one of the big differences here is our utilization of, we have Moses technology, 120 Watt laser here and able to really create a hemostatic fossa and really reduce the amount of time that patients require continuous bladder irrigation, to the point where patients are sometimes not even placed on continuous bladder irrigation, because we have such excellent hemostasis throughout the procedure. What you can see here is the difference between our Moses 2.0 BPH laser technology and traditional Slimline 550 Fiber.

Dr. Marcelino Rivera:

Now we've moved on from same day dismissal to now we're talking about same day catheter removal. This was mostly due to the observation of how clear the urine is postoperatively and the ability to really ensure hemostasis at the end of the procedure with our Moses laser. We were able to publish this just this past year with our first 30 patients, to the point where now all of our patients are defaulting to same day catheter removal, and our success rates continue to be right around 90%.

Dr. Marcelino Rivera:

These patients are extremely happy to have their catheter out within a matter of hours of the procedure, and I think it's a great selling point and really due to the excellent hemostasis after the procedure. To conclude, what we see here is the increasing popularity of enucleation really due to the results of the procedure, the durability of the procedure and the safety of the procedure. I can't reiterate that enough. It is extremely durable and safe procedure, and patients do extremely well.

Dr. Marcelino Rivera:

I would say that again, to reiterate enucleation is an energy independent surgery. It's really the, how comfortable we are with the technology that we're using as surgeons, that is the most important and getting really between that BPH adenomatous tissue and into that capsular plane. I think the early apical release, it's already been shown that we'll have better short-term urinary control from our patients and obviously utilizing better laser technology will improve our hemostasis long-term and allow for us to have continued same day catheter removals.

Dr. Marcelino Rivera:

I think the future is really bright for the people who are big believers in enucleation, and I'm just really excited to see all of the new technology and really see the new publications that are coming out almost daily on enucleation. With that, I thank everyone and thank the Endourological Society and Dr. Amy Krambeck and Dr. Joel Funk for giving me the floor here to talk about enucleation. Thank you.

Dr. Amy Krambeck:

That was a great presentation. A couple of questions came through. I wanted to ask you before we switch to Dr. Joel Funk, is there any size limitation to the early apical release technique or is it more difficult for larger sized prostates or is it very similar?

Dr. Marcelino Rivera:

I would say that it's very similar. The main thing that I see is that with the larger prostates, it may be a little bit easier to establish the posterior lateral plane when you're releasing the apex. I think when you have a good bilobar, a lateral hyperplasia, you can really see where you need to go for that apical release, but I don't think there's any size limitation for that.

Dr. Amy Krambeck:

Okay. Then, this is probably for both Dr. Joel Funk and you, what are your settings for cutting and coagulation? Start with you, Dr. Marcelino Rivera.

Dr. Marcelino Rivera:

I've gone all over the place in terms of cutting. I've gone to two and 60. I've gone down to two and 30 sometimes, but now I'm at two and 40, that's for cutting and for coagulation one and 20 is what I currently use.

Dr. Amy Krambeck:

What about you, Dr. Joel Funk?

Dr. Joel Funk:

I bounced around a little bit too but I've pretty much settled on two and 50 for my cutting settings, and I use a 1.5 and 30 typically for coagulation and I do utilize Moses settings for both of those, if I'm using one of the lasers that has that.

Dr. Amy Krambeck:

Wonderful. Well, we'll get back to more questions after Dr. Joel Funk's presentation, but we'll turn it over to him now.

Dr. Joel Funk:

As Dr. Amy Krambeck, thank you for the nice introduction. They can't seem to get rid of me here at the University of Arizona. I have completed my training here and have stuck around and currently run our enucleation program, and I am an associate professor here. I want to thank Dr. Marcelino Rivera for really doing the heavy lifting today in regards to the literature review. I'm going to focus a little bit more today on pitfalls.

Dr. Joel Funk:

These are my disclosures. I do serve as a consultant for both Lumenis and Boston Scientific. I'm a big Niehls Bohr fan, and I think that this is very true of most of us who have practiced and enucleation regardless of energy modality for an extended period of time. It is sometimes trial by fire to get through difficult situations and challenges that we may face inter-operatively or postoperatively, and that's really what I'm going to focus on today.

Dr. Joel Funk:

We're going to look at some challenging scenarios including the massive prostate. Cases where patients have had prior treatment as Dr. Marcelino Rivera reviewed. There is a large percentage of patients who have undergone prior TURP or other ablative laser techniques that you will see as you become an enucleation specialist. We'll talk about some troubleshooting and improvisation that I've had to learn over the years in the operating room involving both the laser as well as the morcellation system.

Dr. Joel Funk:

Then just briefly some postoperative challenges and tips. Dr. Marcelino Rivera's described that, and one of the questions is about the size independent nature of anatomic enucleation of the prostate. That's been a question this morning, but is it really? What I wanted to do is just give a case presentation here of a 73-year-old guy. I got a phone call late, I think it was a Tuesday afternoon from a fellow urologist in Montana, wanting to emergently transfer a patient for BPH which is obviously an unusual consult.

Dr. Joel Funk:

It was a patient who is in retention but really did not have a significant medical or surgical history other than a couple of prostate biopsies. He'd been managed long-term on Flomax and some medications for his hypertension with a BMI of 42. The patient's MRI was relatively impressive in regards to his prostate volume of about 440 cubic sonometers. This really was my initial thought, was this something that I really wanted to undertake?

Dr. Joel Funk:

But we did work to get the patient down here and did really have a successful outcome for him. I think that one of the key things to remember when facing these really massive prostates is that we really have options. The surgical duration, the surgical access and inter-operative management. One of the lessons that I stress with both our residents here as trainees and when I assist with other attendings at other institutions who are trying to adopt an enucleation technique is, it doesn't all have to be done in one sitting.

Dr. Joel Funk:

A large prostate like this certainly can be staged. Frankly, early in my learning experience when I faced a large prostate and would decide to do a median lobe and a lateral lobe, and then discontinue the surgery, I have yet to have one of those patients allow me to go back and treat the remaining lobe. They do exceedingly well and certainly that's anecdotal, but over 11 years, I can't think of a single patient for whatever reason that we have not completed an entire enucleation that we've actually taken back to remove the remaining tissue.

Dr. Joel Funk:

Particular to this patient, because of his BMI, the access was relatively difficult. When we went to scope the patient, our resectoscope basically was hubbed with a view of the bladder, but we were still in the prostatic fossa. I do think that thought process of if the prostatic urethra length is bordering on that nine to 10 centimeter length or even longer, and the patient is obese. I think that that's a good situation to have this discussion of a temporary perineal urethrostomy.

Dr. Joel Funk:

I typically do them myself. I know others partner with their reconstructive colleagues to openness. It does allow for easy access. It does allow for better manipulation of your scope during the procedure and realistically, the patients tend to do very well. We will close over a catheter. We do do a RUG 10 days postoperatively and remove the catheter at that time and essentially treat them like a bulbar Urethroplasty patient.

Dr. Joel Funk:

Intra-operative management, especially on these large prostates, one thing that I would really stress is hemostasis as you go. The challenge of trying to move efficiently during one of these cases can be significant because everybody goes into this case thinking it's going to be a long one. My message is, we need to be meticulous about hemostasis as we enucleate as opposed to continuing to open up a larger and larger vascular bed that then can make it quite difficult to get that level of hemostasis that we need to safely morcellate.

Dr. Joel Funk:

I do think that it's important to spend time as you progress with our meticulous hemostasis as opposed to trying to play catch up at the end. I do think that that tends to be much more efficient. My approach typically is that if we're doing a single incision or bi lobe technique after we remove the first lobe, we spend our time then really getting hemostasis on that surgical capsule on that side prior to proceeding to the other side. I don't cut there.

Dr. Joel Funk:

Then, once we've completed the enucleation, I do significantly focus on really getting that good hemostasis. One of my mentors during residency always said, if it's bleeding and you can't see it's anterior and it's distal, and I think that that has held true in my practice. The bladder neck and the anterior distal area of the prostate are the areas where I really focus on making sure that we do not have large venous bleeders that make our visualization compromised during enucleation.

Dr. Joel Funk:

Because that's really critical to efficient enucleation, but also to avoid any misadventures with the morcellator. Then one option that that we've utilized in those difficult cases where a patient may have bleeding despite an effort at good hemostasis is actually to bring in the trans abdominal ultrasound and morcellate under ultrasound guidance. This was a technique that Tom G. and David Xu from UCSF described and presented, and they published on this subsequently.

Dr. Joel Funk:

And I do think that it can be reassuring, especially for those marginal visualization cases to place the abdominal ultrasound on the patient and you can actually visualize your scope and morcellator and the adenoma and make sure that you're staying centered in the bladder. Then ultimately, there’s the, and this is for my experience learned through morcellator malfunctions, for lack of a better term is delayed morcellation.

Dr. Joel Funk:

I think that with ultrasound guidance, this, we do quite rarely, but if you have a mechanical failure with your morcellator. Last year we had a case where we use the Wolf system and the pump that establishes our vacuum failed inter-operatively and we don't have a second system to borrow from. Some of these decisions get made out of necessity, but in reality, whether it be for bleeding or mechanical malfunction of your system, delayed morcellation, always keep that in your back pocket.

Dr. Joel Funk:

My approach typically is to morcellate as soon as we have that technical aspect corrected, or if we are delaying due to bleeding 24 hours later. The tissue will become quite soft, morcellation is very quick, and I do not replace a catheter at the end of morcellation. I send them to the recovery room, make sure they can urinate, and oftentimes we will discharge them directly from the PACU if we've had to do delayed morcellation.

Dr. Joel Funk:

It certainly can be a disappointment to have to face that, but it's always, in critical distress that safe morcellation, and it's not the end of the world if your morcellator breaks on you during a case. The prior treatment to the patient also is another thing to look at that this is a common thing we're going to see. I see it quite frequently for patients who've had UroLift. This patient had undergone it a couple years ago and had been returned to both a 5α-Reductase inhibitor and an alpha blocker, and was on a direct oral anticoagulant.

Dr. Joel Funk:

His TRUS volume with me was 116 milliliters, so I think it's quite obvious as to why the UroLift was unsuccessful for him. This is a video that Dr. Humphreys at Mayo Scottsdale has shared and one of his fellows put together a couple of years ago. We actually published on this, looking at treatment after a UroLift and really if we're using a laser energy source, it really is quite straightforward.

Dr. Joel Funk:

The tissue planes are very well-preserved even with prior TURP or with UroLift to allow you to proceed and ablate those suture lines, and then the nitinol tabs that sometimes you will encounter, especially in that borderline large prostate, where the outer tabs may not have been inserted all the way out to the surgical capsule as is demonstrated in the video.

Dr. Joel Funk:

Really, the challenge with these tabs though is, is during morcellation, because regardless of whether you're using a store's DrillCut or a Lumenis Morcellator or even the Richard Wolf system they do tend to jam the morcellator blade, and that can be challenging. I think it's always a good idea to have a spare blade available in the room if you are doing a post UroLift specifically enucleation. Then the other area where I think that troubleshooting and learning from mistakes or challenges is around the laser and I categorize these as laser hiccups.

Dr. Joel Funk:

Fiber burn back is sometimes an issue especially with reusable fibers, and then the other category is really power issues. We do use single use fibers with the Moses system that we have. Prior to that I would use reusable fibers quite frequently to keep costs down, and in fact, I'd use the reusable fibers until they were too short to reach from the laser generator to the scope. But those do tend to get a little bit brittle with time, so just if you're reusing fibers expect more burn back.

Dr. Joel Funk:

Management of cladding I think is really a personal thing I tend to not want to spend the time stripping that back, but I do think it's a good idea that if it bothers you to strip back a good five to seven centimeters of fiber before you even start, because you know you're going to have some burn back. Then instrumentation really is in regards to the decision to use a fixed laser bridge or to use a Kuhn's working laser element. I've transitioned to the working element.

Dr. Joel Funk:

I do think that that provides for less burn back, but again, that is just my anecdotal experience. The other area really is around these power issues where we may see that you may have a brick failure inter-operatively and function at reduced power. Certainly, the literatures plead with descriptions of series utilizing low power sources, so if we have to run at 60 Watts or even 40 Watts, it is perfectly reasonable to continue with your case and finish your enucleation. Then finally troubleshooting as the morcellator.

Dr. Joel Funk:

I think the decision of which morcellator is somewhat personal. I do think though that there is data to support the reciprocating as opposed to... Excuse me. The oscillating as opposed to the reciprocating blade in regards to enucleation efficiency. Regardless of whether it's reciprocating or oscillating, there's really not much of a learning curve to utilizing it, but the efficiency of the oscillating blade is significantly better, both in the literature and in my experience.

Dr. Joel Funk:

The other kind of morcellator issues are that inability to engage tissue around this topic and then the beachballs and then also team efficiency. The handpiece is always make sure that your tubing is open. Sometimes the hand piece will be occluded with a very gristle or tough piece of prostate tissue, and that can be either in the tubing or in the block clamp system, or even your tissue trap. Particularly to the Wolf system, those tissue traps do tend to be occluded over time.

Dr. Joel Funk:

Typically, around a hundred grams is where I feel like it starts to lose efficiency because the suction and vacuum transmitted to the handpiece is decreased because of that occlusion. Switching out those tissue traps can be very helpful, especially on larger prostates. Then blade speed. Dr. Marcelino Rivera touched on this. I do think that for those large pieces, especially when we're initially morcellating, utilizing a higher blade RPM is helpful.

Dr. Joel Funk:

The small pieces, when you get down to those little pea sized or a garbanzo bean sized pieces, I actually reduce the speed of my blade and I'll even go down to 800 RPMs, just to try to keep from flicking those pieces off as the blade reciprocates back and forth. I think beach balls with the newer system from Wolf, my personal opinion is that I don't experience these as much, but I do think that it's something to be aware of with the VersaCut more so.

Dr. Joel Funk:

I used that for about six years before switching and these very tough gristly balls of prostatic tissue or adenoma can really be a challenge to morcellate. I think your options there really are to try to pull those pieces back into the prostatic fossa, where they have less ability to get away from you, or if you've spent a significant amount of time on one of these pieces and it just does not seem to be coming, you can look to delaying that if you give it a day or two, those pieces definitely will soften up.

Dr. Joel Funk:

That doesn't necessarily require a stay in the hospital. We've done this safely discharging the patient with a catheter in place and having them come back two or three days later. Again, those pieces are very easily treated at that time, and then no catheter once you complete that morcellation. This last topic of team efficiency, I think it's critical that you really have a well-trained team to, especially with the Piranha system, which is a closed system that requires the canisters to be exchanged on larger prostates.

Dr. Joel Funk:

And as we use dual inflow, the outflow is really through the morcellator, so we are really at the mercy of the efficiency of the team switching that out. Spending that time educating the team on that, and also on the troubleshooting issues that can occur with the morcellator, I think are extremely helpful and can reduce that anxiety during morcellation. When we look at postoperative stuff, I really divide this into bleeding pain and bladder spasms.

Dr. Joel Funk:

The hematuria, my little limerick for the residents, if it's merlot the PACU is a no-go. Really, as that prostatic fossa contracts at the end of the case, by the time the legs are down and we're moving over to the gurney, if it's not lightly tanged or clear, that in my experience is that the catheter is not in the right place. Something is abnormal, and that should trigger you to not go to the recovery room. Sometimes the balloon will slip back into the fossa.

Dr. Joel Funk:

Sometimes the irrigation is occluded. Sometimes the catheter has been misplaced in the fossa or even behind the pterygoid and I have had that experience a couple of times. It's just a question of, and a recognition that if it's not clearing significantly within enucleation, you need to investigate it before you wake the patient up. I do think that Dr. Marcelino Rivera and the team at Indiana really has asked this question of, do we even need a catheter?

Dr. Joel Funk:

Gross hematuria, it's much easier to get a clot out through the urethra than it is through the port of a three-way catheter, and I think that the data that they're presenting, I think will really change how we manage this going forward. Again, pain. Typically, if you're having pain that's requiring narcotics upon discharge, there's some other issue going on. Most of the time in my experience is related to bladder spasms.

Dr. Joel Funk:

I wouldn't typically use antispasmodics or anticholinergics routinely, but I do think for the patient who really has difficulty, who may be, has baseline severe detrusor overactivity, they can be helpful. The biggest thing is just getting that catheter out. Fluid overload and abdominal distension. Fluid overload really occurs in those prolonged cases where the surgical duration goes past two hours.

Dr. Joel Funk:

Again, if we reference back that first patient, I typically recommend that if you really feel like this is going to be a long case, put yourself on a clock as to when you want to stop. And once I hit that two-hour duration on a large prostate, that's when I start to have a discussion with anesthesia about, do we want to give a diuretic? And this is primarily to avoid those airway concerns of fluid absorption and edema. Abdominal distension. This is again, learned through mistakes.

Dr. Joel Funk:

Third space versus a real problem. What I'm referencing here is that question of, do we have a bladder injury from a morcellator and we're infusing our CVI into the peritoneal cavity? Or is this third space fluid related to a capsule perforation or a prolonged case? A couple of pictures from a case of ours from several years ago, where we can see that there's a large amount of retroperitoneal fluid and then down in front of the bladder, but this is truly an extraperitoneal process.

Dr. Joel Funk:

This doesn't require exploration. This requires fluid management and diuresis. We had a series of two cases and one of those was the look in the belly with the general surgeons, the second case we learned from that experience and said, "Wait this out and diurese the patient." He did well and went home postop day two. I do want to try to leave a few minutes for questions, but I do a couple just partying statements and it really resonates with what Dr. Marcelino Rivera said, which is, is that regardless of energy source, I think that anatomic enucleation is about a mindset.

Dr. Joel Funk:

It's a decision that this is an approach that you as the surgeon are going to utilize regardless of prostate size. This isn't a technique that I think that people successfully master only utilizing it for those prostates where an open prostatectomy or a robotic simple would be the only other option. I advise trainees, you need to walk before you can run and practicing this technique and integrating it into all prostate size is about, if nothing else, drinking the Kool-Aid that this is the right way to treat bladder outlet obstruction secondary to BPH.

Dr. Joel Funk:

Remember that complications will occur. I hope you've gotten the impression that certainly I do not have a complication for your practice and in reality, like we've all probably learned during training or at some point in our career, if we're not having complications, we probably aren't doing enough cases. And that despite this, everything is manageable. There are ways as hopefully I've demonstrated to manage these misadventures that may occur.

Dr. Joel Funk:

The challenges from an anatomic standpoint that a patient may present, or the logistic or equipment challenges that you may face inter-operatively. I think that that's important an expectation setting for patients. I do think that some of the move towards early apical release and reducing that tension on the rhabdosphincter is helpful in reducing that transient incontinence.

Dr. Joel Funk:

But the 80-year-old guy who's got detrusor overactivity and is in urinary retention with obstructive uropathy, he really needs to hear that, as Dr. Alan Wein has said in the past, sometimes you have to make people wet to make them dry, and that patient may face a transient incontinence period, but that we can get them through it. Then just in closing, I just want to recognize Mr. Tev Aho. Tev was instrumental in me learning and adopting this technique.

Dr. Joel Funk:

I really think that he's been a champion of anatomic enucleation for going on two decades and just generally an all-around good guy. This is him running in Boston pre pandemic. A final thank you to him for his mentorship, and also thank you on to the Endourologic Society, Dr. Amy Krambeck and Dr. Marcelino Rivera for asking me to participate today. Thank you.

Dr. Amy Krambeck:

That was a fantastic talk, Dr. Joel Funk, and great tips, great advice on what to do in difficult situations or with complications. Thank you for that. We have quite a few good in here, so let's see if we can get as many answered as possible. Do either you Dr. Joel Funk or Dr. Marcelino Rivera, do you utilize any other energy source to gain hemostasis? Dr. Joel Funk we'll have you go first.

Dr. Joel Funk:

Yeah. Early on in my experience, I would sometimes pull out the bipolar if I had a difficult bleeder at the bladder neck. I think that with gained experience the ability to get that hemostasis does improve, but I always think that it's a good idea to have something in your back pocket, and the bipolar energy source is an easy one to use because it doesn't require a change in irrigant for the case.

Dr. Amy Krambeck:

Perfect. How about you, Dr. Marcelino Rivera?

Dr. Marcelino Rivera:

I haven't used an alternative source of energy. I think the main thing is that, as Dr. Joel Funk had said, we really are meticulous about hemostasis as we go, so it's usually not a problem getting them dried up with just the laser.

Dr. Amy Krambeck:

Perfect. Do either one of you have any experience with the Lumenis 60 Watt laser?

Dr. Joel Funk:

I don't, other than experience where we've lost a brick and it had to function at 60 Watts. I think that a 60 Watt unit is perfectly adequate to do enucleation with. It's just a recognition that it's going to be a little bit slower.

Dr. Amy Krambeck:

Okay. I've not utilized it either, but it I think it's a 30-amp unit, so you don't have to rewire your OR, which is nice, but I do think you have less energy and less hemostasis. What about 5α-Reductase inhibitors? Do you guys have any requirements on when to stop those before surgery? Any comments on that, Dr. Marcelino Rivera?

Dr. Marcelino Rivera:

No. I have a patient who stopped their 5α-Reductase inhibitors immediately after the surgery. It's really not a problem in terms of their overall outcome. They go in typically on maximum therapy and they come off and we're done, that's it. They do very well with them.

Dr. Amy Krambeck:

I think a long time ago with the Lumenis Morcellator people were trying to figure out ways to make the tissue less rubbery, so they would stop it, but I think with the newer morcellator, it's probably not as problematic. Dr. Joel Funk, have you ever utilized tranexamic acid during a case before a morcellation or afterwards to decrease bleeding?

Dr. Joel Funk:

No, I haven’t it, and I think that that's an interesting idea, but I think that my experience, especially transitioning to the Moses technology, the level of improvement in hemostasis that we get, that I think that it's really probably not something that's needed.

Dr. Amy Krambeck:

How about you, Dr. Marcelino Rivera?

Dr. Marcelino Rivera:

Interestingly enough, we used it once yesterday. I was in the operating room. We had a patient who prolonged catheter and it was just a beast of a case, very bloody, large, big pulsatile vessels. Went fine, but we were like, "Maybe we should try a little TXA." I've talked to some of my colleagues who use it every case. They use it and a gram of enucleation and then a gram of morcellation. They swear by it.

Dr. Marcelino Rivera:

This particular patient didn't have any significant risk in terms of cardiovascular history or thromboembolic events. We gave him a gram. Anecdotally, by the end of the case, we were very meticulous about hemostasis, but he was bone dry, but how much of that is TXA? How much of that is just us being meticulous? It's hard to know, but I have several colleagues who do use it.

Dr. Amy Krambeck:

Okay. Then we have one minute. Can you answer, do you think there's any preference between thulium and holmium laser energy? Dr. Marcelino Rivera. Like if you had both available to you, which one would you choose and why?

Dr. Marcelino Rivera:

I would always choose a holmium laser. It's the work horse it's going to treat your stones; it's going to treat your BPH. I'm very comfortable with it. It's a non-continuous laser, which also lends itself well to I think teaching as well. Yeah, holmium all the way.

Dr. Amy Krambeck:

Okay. What about you, Dr. Joel Funk?

Dr. Joel Funk:

I would agree. I think that thulium holds great promise for a stone disease, but after the amount of time I've put into a holmium, as I'm very comfortable with it that I would always choose that.

Dr. Amy Krambeck:

Okay. We can ask one more question. What is your incidence of retrograde ejaculation in stress urinary incontinence, Dr. Joel Funk?

Dr. Joel Funk:

My counseling and my experiences is about three quarters to four-fifths of patients will have retrograde ejaculation. Transient incontinence is probably in that 15 to 30%, depending on patient factors. Persistent or bothersome stress incontinence, we looked at this last year in our series and it's about 1.3%.

Dr. Amy Krambeck:

Well, thank you both. You guys did a great job and we'll go to our transition outsides, but it was a wonderful presentation and very informative. Thank you all. I would like to remind everyone that this, again, is CME accredited. You will be getting a survey and we encourage everyone who is not already a member to join the Endourology Society. Your membership dues provide you with many benefits, including the Journal of Endourology, Videourology and Endourology Case Reports.

Dr. Amy Krambeck:

Please go to the website and I would like to remind everyone to continue to save the date. The WCET is in 2021, September 23rd, through 25th in Hamburg, Germany. With the vaccine, I'm very hopeful that we will be able to attend in person for this meeting. Thank you all for being here today and have a wonderful holiday season.