Surgeon: Malte Rieken

Moderator: Alexis Te


Malte Rieken

Malte Rieken is associate professor of Urology at the University of Basel, Switzerland. He works at alta uro AG, Basel, Switzerland and is an affiliated doctor of the Merian Iselin Clinic, Basel, Switzerland. Malte graduated from Ludwig-Maximilians-University (LMU) Munich, Germany and did his residency at the Department of Urology, University Hospital Basel, Switzerland. In 2013, Malte was research fellow in Urologic Oncology at Weill Cornell Medical College, New York, USA. Malte completed his residency in 2014, became attending urologist in 2015 and associate professor of Urology in 2016. Subsequently, Malte was attending urologist at the Department of Urology, Medical University of Vienna, Austria. His research interest is surgical treatment of male LUTS as well as outcomes research and prediction models in uro-oncology. He is member of the EAU non-neurogenic male LUTS guidelines panel, the LUTS guidelines panel of the German Society of Urology and the EAU Section of Uro-Technology (ESUT) lower tract group. Malte is also associate editor for European Urology Focus. He authored and co- authored more than 120 articles in peer-reviewed journals and book chapters and is an active reviewer for several scientific journals. For his scientific work, Malte received several national and international awards.

Alexis E. Te, MD

Dr. Alexis E. Te is a Professor of Urology at the Weill Medical College at Cornell University and Director of the Brady Prostate Center and the Urology Program of the Iris Cantor Men’s Health Center in Department of Urology at New York Presbyterian Hospital. Dr. Te graduated from Yale University and received his medical degree from Cornell University Medical College. He completed his urology residency and fellowship in Neurourology and Urodynamics at the College of Physicians and Surgeons of Columbia University.

Dr. Te is a national and international key opinion leader on minimally invasive BPH therapies including using the 532 nm wavelength or Greenlight Laser for benign prostate surgery, and is active in numerous clinical trials for BPH therapies. Dr. Te is active lecturer and clinician, honored annually as a top clinician in Castle Connelly, Best Doctors and Superdocs. He is also active reviewer and has been on editorial board of numerous journals, and has over 300 publications. Dr. Te’s main areas of academic interest and research include Prostate Disease including BPH, chronic prostatitis and prostate cancer as well as voiding dysfunction, urodynamics, neurourology, incontinence and female urology. As an innovator in medical technology, Dr. Te has patents in medical applications.

 

Webinar Transcript

Dr. Amy Krambeck:

Hello. I am Dr. Amy Krambeck, and welcome to our masterclass in endourology. The endourology society wishes to thank Cook Medical for their grant and support of this educational activity. The masters' class in endourology and robotics is an activity that provides our attendees an online program dedicated to surgical technique in endourology and robotics. The target audience is really physicians that are interested in endourology and robotics, and it is accredited through the ACCME.

Dr. Amy Krambeck:

Today's topic is Greenlight Laser in the Treatment of BPH. The surgeon is Dr. Rieken. Dr. Rieken is an associate professor of urology in Switzerland. He graduated from the Ludwig-Maximilians University in Munich, Germany and did his residency at the department of urology in the university hospital in Basel, Switzerland. In 2013, Dr. Rieken was research fellow in urologic oncology at Cornell University in New York. His research interest is surgical treatment on male watts as well as outcomes, research and prediction models in Neuro-Oncology. He was a member of the EAU LUTS Guideline Panel in the LUTS Guideline Panel for the German Society of Urology in the EAU section of urotechnology.

Dr. Amy Krambeck:

Our moderator today is Dr. Alex Te. Dr. Te is a professor of urology at Cornell University and director of the Brady Prostate Center. Dr. Te graduated from Yale University and received his medical degree from Cornell University Medical School. His urology residency and fellowship was in Neuro-Urology and urodynamics at Columbia University. Dr. Te is a key opinion leader on minimally invasive BPH therapies, including the 532 nanometer wavelength laser also known as Greenlight laser for BPH. Dr. Te has over 300 publications, so I think we should have a great event today.

Dr. Amy Krambeck:

I want to remind everybody that our next session is July 24th, and this will be Robotic Radical Prostatectomy with Doctors Tewari, Gaston, and moderators Rocco and Ahlering. This presentation is CME accredited. You will receive a survey from Michelle Paoli. You need to indicate which seminars you attended and you will get CME certification. Please fill out the evaluation questionnaire at the end of each seminar. We will also allow question and answers today, so please use the question and answer function to ask questions today.

Dr. Amy Krambeck:

We encourage everyone who's not already a member of The Endourology Society to become a member. I also want to remind everyone of the WCE in 2021 in Hamburg, Germany. Without further ado, I will turn the platform over to Dr. Rieken.

Dr. Malte Rieken:

Okay. Hello everyone, and thank you very much for the invitation and for the opportunity to share this interesting session with you. From the concept of this seminar, I think you're very much aware that we will first have the presentation of a surgical video; and afterwards Dr. Te, who's the moderator, he will go through some slides with the background of the technique. Then we'll go directly into the question and answer because we want to make this as interactive as possible. I see Dr. Te wherever he is.

Dr. Malte Rieken:

I will start now, I think, directly with the video. I think we can start with a case and afterwards we go on with Dr. Te and his presentation. This is a video of a Greenlight laser vaporization. As most of you are aware, the technique offers versatility, so you can use it for pure vaporization like in this case. But you can also use the Greenlight laser for vapor enucleation. Dr. Te will later on show some small videos on that as well, but this is a case of a pure laser vaporization of the prostate. The case I'm showing you today, it's a 64-year-old man. He has a prostate volume of around 70 cc.

Dr. Malte Rieken:

As you can see from the IPSS and Quality Of Life Index, he's suffering from severe LUTS, which were progressive during the cause of a long ongoing Tamsulosin treatment. Finasteride or Dutasteride is not very fashionable here, so usually patients don't have that. His PSA was 8.3 prior to surgery. As you can see, the Qmax prior to surgery was deprived at 6.2. As a side note, one year prior to surgery he had a perineal fusion biopsy of the prostate because of the PI-RADS 4 lesion and a PSA elevation of 12. But this biopsy didn't show any evidence of cancer.

Dr. Malte Rieken:

The equipment and the setting, so the surgery I'm doing now, this is a Greenlight laser vaporization with the XPS laser with a maximum power output of 180 watts. This is the so called MoXy fiber which is the latest fiber design and it's liquid cooled. The resectoscope we are using is a 26 French Olympus laser resectoscope. Of course, you need a continuous flow irrigation and the fiber cooling. The laser settings I'm usually using for the Greenlight laser vaporization is 180 watts for and 35 watts for coagulation.

Dr. Malte Rieken:

Back in the old days, we were once told that you have to start with a lower power output, even with this 180 watt laser, to activate the fiber and then later on switch it to a higher power output. But I stopped doing that, and a lot of other people I know who were doing laser vaporization also start right away with 180 watts, usually. We are starting with the cystoscopy of this case. And so this works, hopefully. Yeah, here we go. Brilliant. Of course, we are checking the sphincter function. Now we don't see a lot, but then we have housing the sphincter. This is the area of the veru, and now we are already in the bladder.

Dr. Malte Rieken:

And of course, like always, you check the bladder first and you want to make sure the location of your urethral orifices so that you are aware of these and, of course, you're not injuring them during the surgery. You can see they are relatively far away from the bladder neck, so we are not having any conflict with the urethral orifices. We can see them over there and that's all fine, so we are safe to go. The next step, of course, it's the start of the vaporization. Usually, from the technique I'm applying this also depends a little bit on the prostate size and on the shape of the prostate.

Dr. Malte Rieken:

In this man, we don't have a very large median lobe. What I'm usually doing is I really start incising laterally. I'm getting relatively close to the tissue, as you will see in a second. This sometimes may lead to a blockage of the fiber. But usually, I'm doing this to get to the bladder neck relatively fast and also get to the fibers of the capsule to really expose the tissue. Because from my impression, if you really start not incising but just vaporizing along, then you're losing time. Also, you are often not too close to the tissue, and then your situation is not very efficient.

Dr. Malte Rieken:

I'm starting here ,and as you can see, I'm really getting very, very close to the tissue. This is something maybe the manufacturer doesn't really like and you can see also the fiber switch is off in this event, and later on you will see that it automatically stopped because I got to close once again. But what I'm usually doing is, and you can see, I'm really incising there because I want to expose the fibers. I want to get down to the tissue so that I can really work along. Of course, in the beginning specifically, I make sure that the urethral orifices is far away, that we are not having any issues there.

Dr. Malte Rieken:

But in this case, the urethral orifice is far away. Also, once you really start incising the tissue, then you also will acknowledge that, usually, you are increasing also the distance and you're not having any issues with the urethral orifice. As you can see, so I'm starting really incising there and I'm moving the fiber along, and sweeping sideways. I'm really close to the tissue so that I can really expose the tissue there. You can see sometimes there are some tissue bulging up from anteriorly and then we are just vaporizing this away to create a kind of channel and some deep incisions on the side.

Dr. Malte Rieken:

This is the start of the process and as we are going along, of course, you want to see bubbles. That's very, very important because this technique is a laser vaporization and you have to have an appropriate distance. If you are too far away from the tissue, then you always have the problem that you are not vaporizing in an efficient way, so you stay close to the tissue. Like usually two to three millimeters, that's the maximum, so that you're having a really efficient way of surgery there.

Dr. Malte Rieken:

Then we are moving on after the start, so we are getting to the next step. I'm doing here because I was starting on the left side. I'm now vaporizing the tissue on the left lobe and also some interior tissue. Of course, this video has been cut so you will see that we made some progress in between. As you can see, you can already see it down there that we made on the left side already some nice incisions while the tissue on the right side hasn't been treated yet. I'm doing also this in that prostate to have a nice flow of irrigation so that I can expose the tissue appropriately.

Dr. Malte Rieken:

Also, I don't want to lose myself somewhere because if you start left and right, and then you go along, and of course also with the Greenlight laser, it can bleed sometimes. Then you may get lost specifically if you're dealing with a larger prostate. You can also see that usually there isn't a lot of bleeding with this technique as long as we are not having a very vascular prostate. Here you can see that this tissue here anteriorly. You can also treat it nicely and you just treat it wherever it falls in your way, as we already created a very nice faucet where we started with the vaporization.

Dr. Amy Krambeck:

Dr. Rieken, can I ask a question?

Dr. Malte Rieken:

Of course, sure.

Dr. Amy Krambeck:

You said that you used a 26 French scope. Is there any time that you would use a smaller scope, like a 24 or a 22? Or is 26 the standard for you?

Dr. Malte Rieken:

Usually, in our center, it's the standard. Also the center where I trained it's the standard because if you… The scope we are using, it just has this kind of size. If you go to 24, then you don't have an appropriate irrigation technique with this kind of scope. I'm very much aware that often now there's a trend to having smaller scopes, and maybe Dr. Te is also using a smaller scope in his center, but usually, we also don't have a lot of issues with the urethral strictures, so this works very well for us on the long-term perspective.

Dr. Malte Rieken:

But I'm aware that, of course, you can also handle a different way if you have a scope where you have still an adequate irrigation. I think that's very, very important so that you're not losing vision.

Dr. Alexis Te:

Yeah. You can go ahead with the video, but my perspective on the scopes is that different brand scopes have different flow characteristics, depending on where the inflow and outflows are, and the holes in the side. I still use a 21 French Circon ACMI Continuous Flow Cystoscope which is made by Olympus, still. It actually has the best flow characteristic because the flow goes over to fiber and returns at the tip. Obviously you have resectoscopes sheets. They're also continuous flow without that extruding tip.

Dr. Alexis Te:

That extruding tip is actually useful because it allows you to move the tissue around like you do when you enucleate tissue. You can push it around and actually push the tissue away from your fiber so you get a little distance so it's not collapsing on your fiber.

Dr. Amy Krambeck:

Okay. Thank you.

Dr. Malte Rieken:

Okay. As you can see, so now I'm starting with the right lobe and it's the same thing I did with the left lobe. Of course, I'm checking the location of the urethral orifices and then I'm also making some deep incisions here to really expose the tissue in between. Because in that way, also, you later on can vaporize it very efficiently, which is left in the middle and then you can work as fast as possible. Of course, I mean, there are different techniques. Dr. Te will also show you, but this is the way which usually works very well.

Dr. Malte Rieken:

Of course, if you have some tissue which is blocking your vision, you can just vaporize it and then you can continue in the location of the bladder neck and just make some deep vaporizations and incisions here to have a nicely exposed tissue and to have an appropriate faucet later on. And so we are starting with the right lobe and we're just going along, and you can see that the effect of vaporization in this case is also very nicely. Here, I'm just checking once again the urethral orifice to be sure we are far away and we still have a lot of tissue where we can work along as this guy doesn't really have a true median lobe but he has a lot of tissue bulging in there from the middle.

Dr. Malte Rieken:

Okay. We'll go along and this is just vaporization. We stay close to the tissue like always so that you see a nice bubble formation. I think that's always your quality controls so that you're treating the tissue. Because once you don't see a lot of bubbles, then, you know that you're not working in an effective way. Then you're also having a lot more coagulation effect which reduces your effectiveness of vaporization and also may lead to more irritative symptoms. This is the first part. We are moving on because we have two slide presentations of the same case.

Dr. Amy Krambeck:

As you move forward, Dr. Rieken, there's two questions.

Dr. Malte Rieken:

Of course.

Dr. Amy Krambeck:

Do you use normal saline irrigant fluid?

Dr. Malte Rieken:

Yeah. This is saline irrigation. This is normal saline irrigation.

Dr. Amy Krambeck:

Okay. Do have a time limit on how long you will vaporize?

Dr. Malte Rieken:

No. No time limit. As it was saline, I mean, we also treat very large prostates from time to time when the situation is necessary, and usually, there's no real time limit. I really can't remember cases where we have a lot of fluid retention or something like this as long as you don't open any major weakness complexes, usually not having any risks. I think that's also, with the aspect of safety, an advantage.

Dr. Alexis Te:

That's a good point, Dr. Krambeck, because earlier in the Greenlight experience, some people were saying you get better visualization with water. But actually if you read the earlier literature, there were significant complications from water like you have with the early TUR syndrome. Because you still can get re-absorption of water and end up with myoglobin anemia and renal failure. That's been documented in the literature, so you always have to use saline. If you get a saline infusion, it's not as bad, and you can go for a pretty long time. You don't have those issues of what we would call dilutional hyponatremia or TUR syndromes with normal saline irrigation.

Dr. Malte Rieken:

Absolutely. And so now we are moving on to the next step, so this is the vaporization of apical tissue. You can see there's the veru and we have the tissue which is bulging here from the side. I was just sparing it in this case to leave it to the next step so that we also have a very nice flow of irrigation already. The rest of the prostate has already been opened and now we are treating both apical areas next to the Veru to make sure that this is also appropriately opened. I think there now is a situation where I was too close to the tissue and the fiber stopped... Maybe this will be coming in a while.

Dr. Malte Rieken:

But you can see I'm getting relatively close to the tissue, and usually I'm not having a lot of issues with that. I think that's also an advantage specifically if you're close to the Veru and if you're in this area so that you can also work very precisely. I think that's also one of the advantages of this specific fiber type compared to the predecessors, which means that the tip of the fiber is liquid cooled. Then that way, usually you don't have a lot of issues of carbonization of the tip even if you get closer to the tissue to handle prostates when it's necessary to get closer there.

Dr. Malte Rieken:

You can see so now we are opening up the area close to the Veru and we are vaporizing this apical tissue to have a nicely opened faucet. We have already this. Of course, you can also do some coagulations in case there are some bleeders. Usually you have some at the bladder neck. There's also this coagulation mode when you have the blinking of the fiber, and that's one option how you can coagulate bleeders. The other option is that you either put really the tip on the fiber and heat it up. That's one option.

Dr. Malte Rieken:

Or the other option as well is that you just get away from the tissue and so you have more distance between the bleeder and the tissue, and then you vaporize as well. In that way, as you increase the distance you will also cause more coagulation. There are different things of managing it. Now we are moving on to the final steps. You can see we have some tissue which is coming anteriorly, and I'm just vaporizing this away as well. Then we can also check once again whether there are any bleeders and whether the faucet is nicely opened. In this case, you can see that on the side we still have some tissue, so I'm vaporizing this as well.

Dr. Malte Rieken:

But as you can see down there, we have the Veru and this is already our faucet which is well opened. Here, we still have some tissue which is bulging in, so I'm vaporizing this as well. Then I think we are about to finish this procedure by opening it appropriately and without any issues regarding bleeders or something like that. Okay, let's see. I'm vaporizing the tissue up here.

Dr. Amy Krambeck:

Dr. Rieken, there's a question that came in.

Dr. Malte Rieken:

Yeah. Absolutely.

Dr. Amy Krambeck:

Due to charring, it's difficult to see the capsule fibers at times, so they don't know if they've reached the capsule if there's charred tissue. They feel like the charred tissue can cause some irritative symptoms. Do you have any comments on this?

Dr. Malte Rieken:

That's true and I think that's one of the important steps, and it's also one of the challenges with these techniques. Because, I mean, back in the old days we were always told it's very easy to see where the capsule are, but as you can see as well, it's not that easy. Usually, what we do is by really incising it starting from the bladder neck, this is the way how I expose the fibers there, and so how I can identify them better. That's for sure. Also, with the charred tissue which is floating around there and like at WCE a couple of years ago, Dr. Gillings said he doesn't like vaporization because it looks like his dog's breakfast, what's left in the prostate faucet.

Dr. Malte Rieken:

I mean, it's true. If you are looking for aesthetics, there may be some other issues. But usually this charred tissue from my point, from my impression, and also from my experience, as long as you stay relatively close to the tissue and as long as you don't have a lot of coagulation you are causing, you're not having this strong degree of irritative symptoms. Also, from the randomized studies which have been conducted in comparison to TURP, at least if you trust the data which has been published there, the rate of dysuria or however you want to call it, seems to be comparable.

Dr. Malte Rieken:

While, of course, there's also different evidence which shows like if you just look at cohort studies, the rate of dysuria seems to be higher. But generally speaking, I think the key really is that you stay close to the tissue, that you really try to avoid having a lot of coagulated tissue. I think that's, from my point of view, the most important aspect. I think that's also the difficulty of this technique because you really need some experience and not getting tired during the procedure so that you automatically have more distance and cause more coagulation.

Dr. Alexis Te:

I think that's pretty key. When people actually see charring, it means that their technique needs to be refined. Charring shouldn't occur. If it is there, that means you have deep layers of coagulation necrosis and a higher rate of dysuria. For example, I don't think prostates who had radiation therapy would be an appropriate therapy because they would get a lot more charring because those are pretty much a vascular fibers prostates.

Dr. Malte Rieken:

Okay. By wrapping up this case, I just want to let you know about the postoperative course. The duration of surgery was 70 minutes, I applied 500 kilojoule of energy. The catheter was removed the second postoperative day. This is usually our routine here in Europe due to various reasons. At six months' follow-up his IPSS decreased to 4, Quality of Life 1. PSA decreased from 8.3 to 2.8. The estimated prostate volume vitreous, although of course there's always some variation, that is around 25 cc. But I think looking at the PSA drop you can appreciate that an adequate amount of tissue seems to have been removed in this case.

Dr. Amy Krambeck:

I'd say it was a beautiful surgery. Absolutely wonderful. I just have one more question before we move forward.

Dr. Malte Rieken:

Of course.

Dr. Amy Krambeck:

It's do you leave the catheter in longer if a patient is anti-coagulated?

Dr. Malte Rieken:

Usually not, honestly. Even if they are under coagulation, our routine is second postoperative day. Of course, this has also some [inaudible 00:23:12] reasons. But generally speaking, usually even those who are under anti-coagulation, we don't leave it longer in there. No, usually it's not necessary.

Dr. Amy Krambeck:

Wonderful. Perfect.

Dr. Malte Rieken:

Thank you.

Dr. Alexis Te:

That was a great video. You really touched upon a lot of the important points. Just to emphasize what we were just talking about, anti-coagulation, it's the Greenlight laser technology, or 532 nanometer, or KTP as all these acronyms were in the past, is actually already 20 years old. I first did this 19 years ago, so it's really evolved. What I'd like to do is just summarize some of the things that Dr. Rieken has done in a slide show that I have put together just so that we can also see the different techniques and the important points of doing Greenlight.

Dr. Alexis Te:

The first thing we need to realize is that the Greenlight has a specific wavelength. It's actually the 532 wavelength primary chromophore is oxy-hemoglobin, but it's actually transmitted very clearly through water. It doesn't absorb in water at all, so that's one big advantage because in an area irrigation of water you can actually have all the power go right into the tissue; whereas opposed to ND:YAG or the Diode, it's an equal absorption. Then with the Thulium, the primary chromophore is water, so that's why you get a nice explosive event as you go along. That's a pretty important point.

Dr. Alexis Te:

The next part about the Greenlight laser that we know about is that it's high powered, transmitted through water with no energy absorption in the irrigant, and you get a very thin layer of coagulation if you do this correctly and sweep very quickly. It's a side-fire and the end points really a TUR-like cavity. Now, the thing about the Greenlight is that it's actually gone through an evolution over the years and now we have basically a cap that covers the part of the tip of the fiber because the mirror, if it's very hot, will melt and then you don't get the deflection.

Dr. Alexis Te:

It's important to get that 70-degree deflection by preserving that Sapphire mirror at the end, and so we have a saline that pulls over and cools off the tip. What's interesting about the Greenlight also is that it has a feedback mechanism using infrared to measure the heat at the end of the tip. If you notice in the very beginning when Dr. Rieken was a little too close to the tissue, it blinked. That blinking tells you that you're getting too close and you're getting too hot, so you move away so you don't damage the tip which is heat sensitive.

Dr. Alexis Te:

One of the important factors, I think, when we're talking about coagulation necrosis, is that while the optical penetration depth of the Greenlight is very shallow, if you spend too much time on it, you will have thermal penetration there. Because it's more like it's basically heating and you're getting your heating by conduction through that tissue. And so that's what you don't want to do. If you spend too much time there, the heat will go deeper and deeper, and deeper through just being next to it. That's why it's sweep speed. How long you spend that time is all a learning process in order to learn how to do this.

Dr. Alexis Te:

The optimal working distance is really 0.5 to 3.0 millimeter. You will estimate that. The other thing that you should realize is that the spot size, as you get farther, gets bigger and bigger. If the spot size gets bigger, you have less power density. It's good to be at a certain distance where you're using as much power as you can. The good part about the 180 is that you have a variation of using power when you don't want that much power. Proper sweep speed is really to keep an efficient vaporization by evidence of the bubbles. The bubbles are really your feedback mechanism to knowing that you're reaching 100 degrees Celsius to vaporize the tissue away.

Dr. Alexis Te:

If you go too fast or too slow, it can either be not heating it up enough and can result in excessive coagulation. You just need to determine the proper speed by power, distance, and tissue composition. It's a learning curve but once you get to it, the big thing is the feedback, it's the bubbles. Just remember when you don't heat high enough and it's under a 100 degrees, there are no bubbles, you get coagulation but deeper levels of coagulation necrosis. If you're vaporizing very efficiently, it's because you're 100 degrees and you're boiling the tissue away.

Dr. Alexis Te:

Recommended use for fiber. The fiber is very sensitive, so you want fewer interruptions so that you could save time. You want to get better consistency and better patient outcomes. The recommended condition, keep the cap clean, no tissue contact, good cooling flow, maintain the motion to keep the fiber clean. If you do that, then you won't get premature degradation. The things that you want to avoid, tissue adhering at the beam exit, embedded tip into the tissue, fiber's in contact with the tissue, no cooling flow. You want air bubble to stick on the cap and also firing the beam inside the sheath or calculi and brachytherapy seeds.

Dr. Alexis Te:

If you hit a stone or a brachytherapy seeds, it'll reflect back and potentially damage the crystal. [inaudible 00:28:20]. Tips in general, we want the common pitfalls to avoid. If you do a preoperative ultrasound cystoscopy, you'll know your complex anatomy. I think that's pretty important to know. The other thing is you respect the anti-coagulated patients, although we have very good data that showed up. I've been doing this for over 10 to 15 years and I realized because it's main chromophore is oxy-hemoglobin, anti-coagulated patients or what I would call coagulable patients who were a challenge, were really things that changed it for Greenlight.

Dr. Alexis Te:

In fact, the AUA Guidelines say that you can do this in anti-coagulated patients. I usually don't hesitate to operate on patients on Coumadin now with this particular laser, and I keep the INR in the low twos. But it gives you a lot more flexibility with the anti-coagulated patient, but you just have to respect that. If you are just starting in general, make sure that it's chronically you want to avoid patients who have indwelling catheter in your initial experience. But you certainly can do that once you get more experience. Then practice systematic approach when you do this.

Dr. Alexis Te:

Now, what's interesting about the original Greenlight AUR, most of the safety data has been attained. That same power density for the safety that is equal to the MOXY 120 which is the XPS laser at 120. You could do most of your lasering at 120 and then get up to 180 depending on how many bubbles you've got, and then follow the BPH guidelines. Now, today we saw the pure vaporization side to side. I'm going to show you vapor enucleation. Although I must say Dr. Krambeck and Dr. Gillian always have developed the enucleation procedures, so in a lot of ways they were the leaders in enucleating prostate and getting good results.

Dr. Alexis Te:

We basically, as we're using Greenlight, has taken a variation of that and called it vapor enucleation. Here is an example of it using the XPS laser. Here's the standard way of doing this with circular motion. But one thing, I've been doing Vapor enucleation for the last, I would say, 15 years now but this shows it with the HPS laser fiber which is a much older laser fiber. But basically you saw the same way. You want to make those incisions all the way down to the crossing fibers that you can actually see. I usually like to go at six o'clock, take it down to the level of the trigone or the bladder neck, and then match it up to where I could see the veru.

Dr. Alexis Te:

And then at that point, you just carve it away and then vaporize away the tissue. The nice part about doing these types of vapor enucleation procedure, you could see that most of my lasering is done sideways instead of directly into the patient, thereby minimizing the amount of deep laser coagulation because you're directing the heat into the tissue that's being removed. That's a nice way to do this. It's a sideway vaporizing trimming, and so that's how you do this. Now, as an example, this is the new modern laser. With the 180, it allows you to really vaporize tissue much faster with a lot more.

Dr. Alexis Te:

This is a 10x view sped up so that we just save some time to view this, but basically the same six o'clock incision, 50% of your tissues. Actually, you vaporize as you make this incision and you can see that middle lobe that's intravesical, it's just going away and splitting it right down to the level of the veru. You can see that down there as you can see from the veru all the way into the trigone from that point of view. Then I just make it bigger and bigger, and bigger, and bigger. Then as we get to the point where we got a nice little channel that's nice in the middle, then you go up to the top at about seven o'clock to do one side of the lobe.

Dr. Alexis Te:

Also basically, go down lateral to the urethral orifices so that you can enucleate that part of it or VapoEnucleate that part of it all the way down. You just basically wall up at it, just the same way with that other video that I showed you. But you could see I'm not that close to the tissue. This is a 180 laser, the spot size is a little larger. You can vaporize a lot more tissue very quickly if it's very vascular, and you can see it move away. Now you see the bleeder there? The same technique. Right over there, low power coagulation. Just be persistent and it'll be coagulated. You see no bubbles there. That's being coagulated and you remove that tissue. Same thing over there. For the sake of time, I'm going to go forward now.

Dr. Amy Krambeck:

Dr. Te, does the 180 laser fiber have a time limit on it like the 120?

Dr. Alexis Te:

One of the interesting things that I would tell you is that the 180 laser fiber is not a perfect fiber. I think that it needs a little bit more modification. I wouldn't say time limit, but the time that I find the laser fiber starts to degrade is around 300,000 to 400,000 joules. What you notice about the tip of the laser fiber is that instead of going at 70 degrees, it's pointing straight in. It does pop out around 500,000 to 600,000, although I have taken it to 700,000 without any degradation, but it takes a lot of skill and care not to heat up that fiber too much.

Dr. Alexis Te:

It's not the perfect fiber. The glue at the cap sometimes comes off. If you look at the mod database, the number one reason for having a problem with the fiber is the fiber tip just doesn't last, or falls off, or breaks. It needs to be perfected a little bit. And so those are one of the challenges that I think with that fiber. But up to 200,000 to 500,000 joules is more than enough joules to take care of a prostate. If you're doing this Vapor enucleation on a 72 gram prostate, I use properly half the amount of joules. Instead of 500,000 I average around 250,000 for that one. You use less power by Vapor enucleation because you're removing tissue and then taking it out.

Dr. Amy Krambeck:

Okay. Thank you.

Dr. Alexis Te:

With this experience, I have been able to do very large glands in general, and so it's pretty clear that you can do this. Although, I would say that with large glands, experience is the key. Tips to handle bleeders, we talked about lower the power, lower the power in the generator, put the foley. One of the things I also do is I leave the foley in for 15 minutes, pull out the foley and I use the clot as a coagulant to seal off the bleeders. The other thing that you should watch out when you're looking for bleeders is to watch the blood pressure, because if the blood pressure is very high, sometimes you get a lot of backflow or Venus backflow.

Dr. Alexis Te:

If the blood pressure is around 110 or 120, it's a good pressure to have when you're actually having an irrigant. The concept is sort of laparoscopic insufflation to control bleeding. It's never as bad as it looks, but it's important to look at the bladder neck for important bleeders. Anyway, as everything else, we're all surgeons working with a long stick and operating at the end of that little stick, so it requires a little bit of skill and experience no matter how you do this. And so that's basically the challenges of all these procedures until we get to a robotic procedure that's like Lasix. Any questions?

Dr. Amy Krambeck:

Dr. Te, do use a morcellator when you do Vapor enucleation?

Dr. Alexis Te:

No, because what I actually do I call it the laser morcellation. If you saw the tissue over there, I leave it on a stock. At the very end, I leave the tissue on a stock and I go 180, and I just basically vaporize the remaining of the little pieces that I can remove easily through a resectoscope sheet. At the end of my procedure, I might switch from a 21 French Laser Cystoscope. I'll switch to a 26 French or 28 French resectoscope sheet to remove the pieces with a rigid grasper. It's very quick to do that rather than using an Ellik evacuator.

Dr. Amy Krambeck:

Well, that was a wonderful presentation. Both Dr. Rieken and Dr. Te had excellent points. There are several questions in the inbox here, so I'm just going to pose them to both of you. Doctors Te and Rieken, how would you manage a large median lobe over 100 grams? It's a very large median lobe. What would be your approach?

Dr. Alexis Te:

I've been doing this for over 10 years and what I usually do is exactly the way the video was. I start at the six o'clock position and laser my way down with broad swath, and then as I go along to the edge, I carefully cut at six o'clock. The most important part about a median lobe that rises intravesically is that if you go over to edge of that intravesical lobe, it's easy to shoot it into the bladder and get a perforation, or you might accidentally get the urethral orifices. I like to go at six o'clock until I could see the trigone. Then once I see the trigone, then I know I'm in a safe zone. I could see inside the bladder laterally, I see where the urethral orifices are.

Dr. Alexis Te:

Then the next part is I go at seven o'clock or five o'clock, which is basically aiming lateral to the urethral orifices, again, taking that incision all the way down to the level of where I see the bladder neck. You're sort of looking over the hill and then coming back and shortly cutting it behind the hill until you get to the level of the trigone. Then once you get to the level of the trigone, or at least level to the bladder neck, you've got an easy straight path that you can just get the pizza pie cut. Then you can take that lobe and vapor enucleate it and vapor morcellate it too.

Dr. Amy Krambeck:

How about you Dr. Rieken, any…

Dr. Malte Rieken:

I actually do it similar to what was Dr. Te saying. If I have a large median lobe, I try to really isolate it. I want to make sure that we don't injure the urethral orifices, so I also cut on the side of the median lobe, so I try to isolate it. Then once you really know where the margin is and once you see the bladder neck and your landmarks like the urethral orifices, then you can easily vaporize it away just from the side under controls.

Dr. Malte Rieken:

I think it's very, very important to really isolate the median lobe to know where your landmark structures are and not, as Dr. Te also said, just get over it and just laser somewhere. Because then you may have bleeding, you lose yourself in the bleeding, you may injure the bladder. I think it's very, very important to have a clear vision all the time and to be safe.

Dr. Alexis Te:

The other part about a median lobe about bleeding is that if you cut at six and you cut at seven, and you vaporize sideways, you'll actually see a lot of the blood supply going to that medium lobe. I like to do this six o'clock, seven o'clock, and then a retrograde cut underneath that lobe. As you do that, the lobe gets more and more avascular then it becomes very easy to laser that thing away without any bleeding.

Dr. Amy Krambeck:

Another question that came in here is what is your preferred anesthetic? Do you ever do this under like a pudendal block or a spinal? I guess the specific question is have you done this under a pudendal block?

Dr. Alexis Te:

I actually have. I've done this under a local in the office but it depends on how big the gland is. If it's a small gland, you could probably do this under a prostate block under local in the office. But I wouldn't suggest this. It's just very challenging with patients like that. My preference actually with very, very large glands is I actually do what I would call a periprosthetic block. I wouldn't call it a pudendal block. It's really a periprosthetic block, the same block that you use for a prostate block for prostate biopsies. We do a very good periprosthetic block and I like to do them under general anesthesia just because I can control their breathing as well as their blood pressure very well.

Dr. Alexis Te:

It's almost like an intubated sedation, so it's a lot safer especially with very complicated cardiovascular patients. The most important thing that makes this procedure easy is that you really have a very hemodynamically stable procedure. You don't get a lot of bleeding, you don't get a lot of infusion, so it's very easy. And so long as you have a very good anesthesiologist, they use very minimal general anesthesia with a periprosthetic block and you can go on for hours. They wake up very, very well like this.

Dr. Amy Krambeck:

[inaudible 00:41:04].

Dr. Alexis Te:

My only issue with regionals is that the blood pressure can really vary depending on how awake they are, how nervous the patient is, so it's not as perfect as people would think it is.

Dr. Amy Krambeck:

I would say we had that issue with enucleation. Dr. Rieken, at your institution do you do anything different?

Dr. Malte Rieken:

No, we also do the same thing. Usually most of the patients are under general anesthesia and some of them are under spinal anesthesia. Depending on the situation, some prefer to be awake; some even prefer to look and to join the procedure by looking at the procedure and they want me to explain what I'm doing. But generally they prefer to either sleep or they're under spinal and get some sedation. But you have some guys who really want to talk to you and, yeah, participate actively.

Dr. Alexis Te:

Yeah. But I think that it's true. Even with enucleation, with the homeo, I think you would find it a lot easier if you do a periprosthetic block and general with a very light general.

Dr. Amy Krambeck:

That's an excellent point. I've not done a periprosthetic block, and that's something to try.

Dr. Alexis Te:

What I like about the periprosthetic block is the post-op. In the post-op, when they're lying around the catheter to irrigation, or if they need it or even with things that are like a regular TURP, the periprosthetic block I use marking and lasts for three or four hours. Even with my prostate biopsies, you do your biopsies in the office, patients are happy for four hours after your biopsy, and by that time their pain is very minimal.

Dr. Amy Krambeck:

A great, great tip. Now both of you had previously touched on anti-coagulation, that you'll do the procedures on Coumadin. Will you do it on all anti-coagulants or anti-platelet medications like the novel newer generation anti-coagulants or Plavix? Is there any limit for either one of you?

Dr. Alexis Te:

Well, in our institution, aspirin is not an issue. Baby aspirin, people are doing no matter what. Maybe aspirin doesn't count anymore as an anti-coagulation at our institution. The challenge is when you're doing it with Plavix, Eliquis or any of those things, then usually the number one reason is because of atrial fibrillation. The way I approach it is I will have a discussion with the cardiologist or internist and determine the risk of them being off of it. Obviously, if they bleed more, the risk is a transfusion. Is the transfusion more a risk or not for that patient? Do you want them to have it or not? I like to get them off, but I restart them right away.

Dr. Alexis Te:

But if I operate on them regularly on it, and because it's the risk of them having a problem and it's very minimal, the patients that I think that are most challenging are not the patients who are getting anti-coagulation medications. It's the patients who are hematologically challenged. Those factors that require transfusions are basically hematologic compromise post-op and they need transfusions afterwards. Those patients are the toughest ones. There is only one anti-coagulant. That's not my favorite, it's Lovenox, because they tend to be very unpredictable.

Dr. Amy Krambeck:

What about you, Dr. Rieken?

Dr. Malte Rieken:

We are also operating under anti-coagulation. Of course, I mean, aspirin is not an issue at all and also things like Plavix work well. But what we see, and I think we even published this together with Dr. Te, is if you really have some patients who get two or three drugs, then also the risk of delayed hemorrhage, not during the procedure immediately afterwards but like after three or four weeks, you may experience that they tend to have more bleedings. I think that's an issue. Of course, that's the reason why you always should talk to the cardiologist. Sometimes you just have this patients where it's necessary to continue or who are already in retention, then you don't have a lot of alternatives.

Dr. Malte Rieken:

But, of course, these are patients who are also at higher risk of having some issues after surgery. I think that's very important to balance. But generally speaking, it's not an issue. During surgery usually it's never an issue, but afterwards sometimes you have some drugs which may cause some trouble.

Dr. Alexis Te:

I've operated on patients where [inaudible 00:45:21] in the fours on Coumadin emergently and my problem wasn't during the procedure. It was always afterwards. I think that was risk affluence, are not any different with any technology, whether it's holmium, TURP, bipolar, whatever you want to do. I think those risks post-op are similar across the board.

Dr. Amy Krambeck:

I would agree 100%. There's a great question that actually came in for Dr. Rieken during his talk, and asked if you ever demarcate your distal margin of the prostate before you start lasering since sometimes the anatomy will change as you're working and the shape of the prostate changes. Do you ever do some intermittent lasering at the apex so that you know what you're [inaudible 00:46:12]?

Dr. Malte Rieken:

No. Usually I'm not doing this, honestly. I mean, it's like always, so there are some surgeons who prefer to do this, who tried and who are marking the area around the apex, but I'm honestly usually never doing it. Personally, I always had the impression that I feel rather comfortable. But of course, you always should respect the veru to be sure of what's going on. I think that's important because if you just go along… And, for example, that's also one of the reasons why like in the video where I showed you I'm really opening up the proximate part first before I go to the area of the veru just to be sure that this is preserved until I'm safe and I can work along there.

Dr. Malte Rieken:

I think that's, from my point of view, the key. But, of course, that's always up to the discretion of the surgeon and whether you feel comfortable. I think there's never one truth, but you always should be comfortable and safe with the technology and the technique you're using.

Dr. Amy Krambeck:

Mm-hmm (affirmative). [crosstalk 00:47:12]. Oh, go ahead, Dr. Te.

Dr. Alexis Te:

About demarking the things, occasionally I do demarcate because one of the things that we've been doing lately is ejaculatory hood sparing. I just like to know where I am in order to preserve the ejaculatory hood as much as possible for those guys who are concerned about retrograde ejaculation. Not so much, it's just nice to know where you are at times. The other part about knowing where you are instead of marking it is I like to keep my scope in one position, right over the veru, and then extend my fiber in and out.

Dr. Alexis Te:

I don't like to move the whole scope back and forth because it's easy to lose your position. The concept is really to try to do a cone, so you're opening it up like a cone like this. If you stay at one point, it goes like this so that you know where you are all times. You're right over the veru and you're not going to pass the veru, and it's a straight scope. Those are tips that if you were losing your position over a super large gland. Just go back to the veru 0.1 and you know where you are, and then you can work your way back from there.

Dr. Amy Krambeck:

Do either of you ever use the Greenlight to treat urethral strictures?

Dr. Alexis Te:

Not a good one to do.

Dr. Malte Rieken:

Never.

Dr. Amy Krambeck:

Okay. Okay.

Dr. Alexis Te:

I think that the perfect technology for that is a homeo.

Dr. Amy Krambeck:

Okay. Another great question that came in is some of these surgeries can last two, two and a half hours longer. Is there any tips or tricks that you have to escape neck and shoulder pain from the surgeon? I'm listening intently. How do we do this?

Dr. Alexis Te:

That's a good question. As urologist, I think we all suffer that cervical stenosis issue that we're all afraid of. I guess lots of massages and get a resident to help you.

Dr. Amy Krambeck:

Anything from your end, Dr. Rieken, on that?

Dr. Malte Rieken:

I think you really have to find a position which is… I mean, you should optimize. Of course, there's the setting right from the start. I mean, that's for sure. You should be sure that like the foot pedal is not too far away, that the screen you're looking at… I mean, of course, this always depends on infrastructure at the place you're working, that the screen you are having it's really not too high so that you are not having the issue of looking upwards all the time. I think that's very, very important. Of course, if you have some residents who can help you in between it's nice. But if you have to go along all the time…

Dr. Malte Rieken:

I mean, there are some guys who are using some chairs with armrest or something. I usually never use this. But I think it's very, very important to a layout right from the start of the surgery where you feel comfortable, specifically as it's for sure if the prostate is big and if you're vaporizing due to any reason, then it may take some time, then of course it can get stressful.

Dr. Alexis Te:

Yeah. I think that's true. The screen, the position of the screen is so important. It's easy for the screen to be high up and then you're looking like this all the time and by the end of that case your neck is straining. It's good to have it in front like the way you look at a computer screen and get yourself to a comfortable position. Probably we're all waiting for the day when we can just wear our Google glasses or Apple glasses and do our resection that way.

Dr. Amy Krambeck:

That would be wonderful. Yes. But I call it building your nest. You have to build the nest before you start working.

Dr. Malte Rieken:

Absolutely.

Dr. Amy Krambeck:

Make sure you're comfortable. Yeah.

Dr. Alexis Te:

Unfortunately in this world other people are building our nests.

Dr. Amy Krambeck:

Yes, there is limitation. There's a combination of two questions. Do you have any tips for those that have to use a 120 watt laser instead of a 180? Then another question says, do you think that an 80 watt is too low of energy for this procedure now? That's kind of an 80.

Dr. Alexis Te:

If they're using an 80 watt laser I would say you probably should throw it out the window, because that technology is pretty old. I bet you that a lot of those lasers, the alignment is probably a little off and you'll have a higher rate of complication. The 120 laser I think is still being supported, but I'd be pretty concerned about the internal alignment of that laser. I would say that HPS laser is over 10 years old now, and so I don't know if that's appropriate to keep using in this day and age. The XPS laser is the one that's still being manufactured and supported. And so I would be careful with the older lasers.

Dr. Amy Krambeck:

What about you, Dr. Rieken?

Dr. Malte Rieken:

I fully agree. I personally also don't have any experience with the 80 watt lasers anyway, and with the 120 watt as well. I mean, if you have it and if it's still supported, you can use it. But generally speaking, I think it's really the issue. If you have it, like with the 120 watt, and you want to make a more efficient surgery, then you really should try to go into the direction of Vapor enucleation rather than full vaporization; because this may even take more time because the efficiency of the 120 watt is still much lower than of the 180 watt. I think that's one of the tips.

Dr. Malte Rieken:

Also, from the experience we had at our center, we saw that somehow the hemostasis with the 120 watt lasers was not as good as with the 80 watt laser, so that's another issue where you have to be a bit aware of that. But, of course, if your institution only has the 120 watt model and you want to operate on the patients then rather try to move into the direction of Vapor enucleation to make it more efficient.

Dr. Alexis Te:

I mean, I've been involved with this laser technology from the GL 80 watt quasicontinuous and helped them with the development of the 120 to the XPS, so I'm pretty familiar with all of that. I would say that the old fibers that went with the HPS 120 does break down pretty easily, that mirror especially on contact. Once you get to the MoXy 180 watt XPS laser, it's very hard to go back to that old technology. I do know that some people do enucleation like the way you do, Dr. Krambeck, and then use a morcellator.

Dr. Alexis Te:

They tend to use that really as an enucleation procedure to make initial incisions and then really enucleate with the tip of the scope in the classic holmium way and then morcellate. I've seen people do that with the bare fiber or with the HPS tip, so that's just something that you could think about.

Dr. Amy Krambeck:

Okay. Well, we have a few questions that are unanswered yet, which we can answer on the transcript that'll be available later, but I'm going to turn it back to Dr. Te if you have any closing remarks or take home points that you would like to point out from this presentation.

Dr. Alexis Te:

I think that lasers are here to stay for a long time. It's just that, like anything else, technology needs to be refined and advanced. I think all of us know what they are. The future is that it's here to stay and we still have different surgeons with different tools. What I always tell everybody, as surgeons know your technology, know its limitation, know the mechanism of actions and you'll get a better result every single time. I think Dr. Rieken has done a great job and Dr. Krambeck with your homeo and it's been awesome. I think all of us know that we can accomplish a good enucleation or good resection.

Dr. Alexis Te:

The challenges of any BPH patient is understanding BPH voiding dysfunction and trying to get to the goal of having a patient void better with less symptoms. That's a little bit outside of just a pure surgical therapy.

Dr. Amy Krambeck:

Okay. Well, I think both Dr. Te as the moderator and Dr. Rieken as a surgeon, you guys did a phenomenal job. I thought it was a great discussion, great techniques, and tips, and tricks. They are going to give me the slides back so that I can remind everyone about the upcoming conference. The World Conference of Endourology will be in 2021 in Hamburg, Germany. Then next week we will have another one of these webinars that will be focused on radical prostatectomy with Dr. Tewari and several other surgeons. I think that everyone should try and tune in for that.

Dr. Amy Krambeck:

Also, I want to remind everyone that you will get CME credit and that there's a process for that, and that will become available. We do actually have about two minutes left, so I'm going to ask you one more question. Dr. Te said that he does the perirectal block. Dr. Rieken, is there anything that you do for dysuria or burning that occurs afterwards?

Dr. Malte Rieken:

We usually don't do any periprosthetic block, although it sounds very appealing. Generally speaking, like from the initial postoperative phase, the patients have some dysuria. Of course you can give some [inaudible 00:56:33] or something, but of course, this needs some time to work. I think the management in the recovery room with energetics there helps. But, of course, the block is definitely something to try out.

Dr. Amy Krambeck:

Okay. Then we still have two minutes.

Dr. Malte Rieken:

Wow. Fantastic.

Dr. Amy Krambeck:

What do you quote as the incontinence rate for this surgery, short and long term?

Dr. Alexis Te:

If you divide it to stress incontinence versus urge incontinence, I can predict people who will have urge incontinence issues. You manage those with Myrbetriq or whatever AOB medication. Stress incontinence is extremely rare. I almost never see it just because we're never really near the sphincter. I know that classically with enucleation, with holmium, you really are pretty aggressive at the apex. We clearly leave tissue behind there.

Dr. Amy Krambeck:

Okay. Then final question in the last 90 seconds, do you think there's going to be a next evolution in lasers, to 220 or 240 watt Greenlight? Or do you think this is the end, that 180?

Dr. Alexis Te:

I think that actually the future's hard to say. I mean the future right now, if you look out there, is really minimally invasive office procedures, and the other part is something robotic or automatic that takes our surgical skill out of the equation, which is things like Aquablation. I think that something that incorporates that laser technology into this robotic procedures probably will be the future. It's just a question of intellectual property designing that.

Dr. Amy Krambeck:

Right. Do you agree with that, Dr. Rieken?

Dr. Malte Rieken:

Yeah, I think as well we are moving more into the direction of robotic procedures as well in this area, although we definitely still have a long way to go. But, of course, we're always very excited to see what's coming up next. I think lasers definitely are a great tool for this kind of surgery and they will help in developing new technologies.

Dr. Amy Krambeck:

All right. Well, thank you both so much for a wonderful webinar. I thought it was fantastic. Even as an enucleator, I just loved watching your videos. They were wonderful, so thank you both. Again, don't forget to join us next week. Bye-bye.

Dr. Alexis Te:

Thank you Dr. Krambeck and The Endourology Society.

Dr. Malte Rieken:

Thank you. Thank you very much. Thanks a lot for the invitation. Bye-bye.

Dr. Amy Krambeck:

The question was what techniques do you have to limit bubbles that are in the field of view? Do you try Trendelenburg position? What do you do for that?

Dr. Alexis Te:

Actually it's scope-dependent. Very early on when I was working with this technology, bubbles were always a pain in the neck, and that's why I use the Circon ACMI Continuous Flow Cystoscope because it pushes the flow of the irrigant right over the fiber. Especially if you have bleeding, it pushes it away under the fiber across your field of vision away from you, and then pulls in the bubbles or the blood through the top. You're sort of going like this, around. It's like a circle, right over the fiber coming back on top because that's where the holes are.

Dr. Alexis Te:

If you look at a lot of the different scope, like for example the Olympus scope, the return or the inflow is on the side right next to the inflow, so you can get a turbulence right in front. That's one reason why. It's just picking your scope and picking up where the bubbles are coming in and out. If you have a top lip of the scope, the bubbles tend to accumulate underneath that lip. I actually like to tilt my table in reverse and not in Trendelenburg but reverse Trendelenburg with the head going up so that the bubbles float away from you into the top of the bubble.

Dr. Alexis Te:

In fact, it's routine. All my nurses know that as soon as I put my scope in, they'll tilt the table at about 30 degrees like this, like a plane, and then the bubbles always go up. Then later on, as that becomes less of an issue, I'll bring it down like this.

Dr. Amy Krambeck:

Okay. Anything different you would do, Dr. Rieken?

Dr. Malte Rieken:

As we only have this Olympus laser resectoscope, I think it's very important as well. The NT Trendelenburg positioning, I think that's one key because as Dr. Te already said, then really the bubbles are going away from your vision field, and I think it helps a lot. The other thing as well is, of course, it's how you manage the prostate generally. There are some surgeons who start, especially if it's a large prostate, they just start somewhere in the middle and vaporize. But then of course, you also have the problem that the bubbles get stuck somewhere in the faucet.

Dr. Malte Rieken:

That's the reason why I usually really try to open up the bladder neck first, especially if the prostate is larger, so that the babbles are really getting into the bladder and not get stuck somewhere in the area where you are working.

Dr. Alexis Te:

Yeah. I always move the middle lobe first. The other thing that I used to do in the very old days, like 15 years ago, was I would put in a suprapubic tube because the irrigation went in one way and came out the other way. It was great because the bleeding really was never an issue with that and the bubbles were never an issue with that. But I stopped doing that one because one time I pulled the SP tube out and the guy nearly [inaudible 01:01:52] from the SP tube.

Dr. Amy Krambeck:

Yeah, that would throw you a little bit. But I think-

Dr. Alexis Te:

Yeah, so I stopped doing that because of that.

Dr. Amy Krambeck:

They actually did that when I was a resident at Mayo when they were first starting the Greenlights. They would put those SP tubes in and it worked well. The other question was specifically for Dr. Rieken. They said, “Have you ever considered using a smaller scope and then switching to a larger scope to gain hemostasis if you needed?” Or I guess another way to ask this question would be do either of you ever switch to a resectoscope to help with hemostasis?

Dr. Malte Rieken:

From the Olympus scope we have, actually you can switch directly to the resectoscope, so you can use the same instrument. I personally use it from time to time if it's necessary. Either if you have some bleeders where you have the impression that you're not able to manage them with a fiber and then I just switch to the resectoscope. If you look at the data, you can also see that surgeons are using this. Sometimes you have situations where you have the impression that close to the apex you have some tissue that you really want to make sure that you are cutting this away, and you are a bit frightened with the laser that it's not too precise.

Dr. Malte Rieken:

Then I'm also using a resectoscope, a bipolar one, because in the end it's not about trying to really force the technology until the end of the surgery. The impression that I have to [inaudible 01:03:21] something else, and I have it available, and it's for the good of the treatment and for the good of the outcome of the surgery, then I don't have any issues in switching. Although usually also hemostasis shouldn't be an issue but sometimes you just say, “Okay, just give me the lube,” and then you handle it. But this is my pragmatic approach of handling things.

Dr. Amy Krambeck:

I like it.

Dr. Alexis Te:

My view on it is that you do what you're really good at. Some surgeons who are not comfortable with getting hemostasis with any laser of any technology will go back to what they actually know how to do. Just keep the tools of what you're comfortable with next to you. Obviously, bleeding is always less with the laser, so you want to do it as much of it as you can. But every once in a while, you get an arterial bleeder that you can't control with the laser only because you can't really… The nice part about using a bipolar mushroom is that you could put that thing right over an artery and get hemostasis because you're doing a combination of two things.

Dr. Alexis Te:

One, you're controlling the bleeding with pressure with that balloon, which you can't do with the fiber. You can do it with the tip of a scope, which I have a video for, and then you cook that vessel. The only thing that maybe twice in 20 years, 15 years I've taken a mushroom out and used, and got coagulation for a large bore vessel that I came across and couldn't control. And so that's the only time I've ever used it for.

Dr. Amy Krambeck:

I like that statement, use what you know. I think that's really important. I also like Dr. Rieken's statement of don't push the technology just because you're pushing the technology, so great answers. That was the only two we did not get to. Dr. Joyce, do you have anything else to add?

Dr. Joyce:

No. I just have to say to all of you, it was a great session and great webinar with lots of tips and tricks, which I really appreciated.