Dr. Amy E. Krambeck
Dr. Amy E. Krambeck began her career in 2009 as a Professor of Urology at the Mayo Clinic. In 2017, she joined the Indiana University School of Medicine staff as the Michael O. Koch Professor of Urology and IU Health as a practicing urologist. She is passionate about providing the highest quality of care with kindness and compassion.

Dr. Thomas RW Herrmann
Thomas RW Herrmann is chairman of the new overarching Department of Urology of the Spital Thurgau AG STGAG Kantonspital Frauenfeld and Kantonspital Münsterlingen, Thurgau, Switzerland / Swiss, He is professor of Urology at Clinic for Urology, Hannover Medical School (MHH), Germany. Thomas does research in Urology. His current project is 'En Bloc Resection of Urothelial Cancer (EBRUC) Consortium.', 'En Bloc Resection of bladder of non muscle invasive bladder Cancer (NMIBC, ERBT)', 'Anatomical Enucleation of the Prostatae (AEEP / EEP).

 

Webinar Transcript

Xu:

Xu from the Endourological Society. Welcome to the webinar and thank you for joining. With me sort of just in the background producing here is Dr. Jared Winoker. He is the current fellow at Johns Hopkins University and will actually be joining on faculty there. We would like to thank our sponsor Lumenis, for sponsoring this webinar. And today we have a great treat for you in terms of looking at BPA treatment using laser. Today we have Dr. Amy Krambeck from Indiana University and moderating her pre-recorded semi live surgery will be Dr. Thomas Herrmann, from Switzerland. So Dr. Herrmann, I'll hand it over to you. Thank you.

Dr. Thomas Herrmann:

Sorry, I just haven't tuned tone on. Yeah, thank you very much for the invitation and for the privilege to moderate this session together with Amy Krambeck. I had the privilege to see this video up front so to organize a [inaudible 00:01:16]. I think that a game changer. HoLEP has been a real game changers introduction. And yeah, I see [inaudible 00:01:25] in the world's most probably people's. So I basically think we should start straight with the video and with the presentation of the [inaudible 00:01:40]. What do you think?

Dr. Amy Krambeck:

I agree. Let's do this. I feel so privileged to be here today and to present my video on Holmium laser enucleation of the prostate. So this is a 92 year old gentleman who's had multiple visits to the emergency room for gross hematuria. Not in urinary retention. His prostate measures approximately 255 grams and he's otherwise quite healthy. So he agreed to go forward with Holmium laser enucleation of the prostate. The procedure starts with dilation of the urethra and I have placed a 28 trench laser scope into the bladder. As you can see, the vast majority of his prostate is an extremely large medium lobe and you cannot identify the ureter or the [inaudible 00:02:35].

Dr. Amy Krambeck:

The procedure starts... I do it two cut technique. I do a three lobe enucleation especially for the large prostates. And I will make an incision from the bladder neck to the veru all the way down to the capsule. Now, this is an extremely vascular prostate but we're not having a lot of bleeding in this case mainly because laser I'm using. I'm using 120 watt Moses laser that's been optimized for BPH. So it's an upgrade to the standard Moses technology. And what does that mean? You have better energy delivery that is absorbed by the tissue and you have more hemostasis as you're actively cutting. So with this laser, I'm just making multiple cuts down the same seven o'clock incision from the bladder neck down to the Veru all the way to the level of the capsule.

Dr. Amy Krambeck:

You can see that there's quite a bit of BPH here and I will just progressively make that cut deeper and deeper also releasing the urothelial attachments at the bladder neck. And as I'm cutting you can see is actually handling those large bleeding vessels at the same time. So there's very little time spent going back and forth to coagulation. And you can see right here the blood and fibers are starting to come in. We can see that the adenoma is extending under the trigon a little bit. And that's fine, you can just follow that down to the capsule doesn't hurt anything. And again, there's some very large bleeding vessels here. On this here I'm using the CO ag button. So with my laser, I have two foot pedals. I have the left foot pedal that is on cut, which is usually two joules and 40 hertz on the Moses setting.

Dr. Amy Krambeck:

And then the right foot pedal is on one Joule and 20 hertz on the Moses setting. And by decreasing that energy, I can actually get the fiber closer to the tissue to allow for coagulation of these extremely large vessels. And I like to get the bleeding vessels as I go. I think that improves visualization, especially in these extremely large prostates where you run the risk of some significant fluid absorption if you don't control bleeding as you go. So I made that cut. It's a nice long cut and now I'm going to do the exact same thing on the other side. I like to start at seven and then move to three, but some people want to start at three and move to seven. It doesn't matter which side you start on. Just so that your cuts are equal in depth and distance from the bladder neck to the veru. But I think right here where I take down the urothelial attachments is important to do at the time of the cut, because those attachments can be difficult to release later.

Dr. Amy Krambeck:

And you can see that this patient has wonderful planes. You can see the capsule nicely, you can see the bladder neck fibers and you can see that nice smooth capsule with the vessels running transversely. And that's how you know you're down to the capsule because the blood vessels start to run transversely. So I made my two cuts. There's the veru, now I'm just going to attach those two cuts by connecting them. This is more like an upside down smile. So around and you just attach the two cuts very easily and then that adenoma just rolls up. And as it rolls up the plane presents itself. So I think a median lobe enucleation is the best place to start when you're learning HoLEP. And a large medium lobe nucleation is very nice because the tissue will want to remove itself it produces the plane for you so there's not a lot of digging or suspending of the tissue and you can tore it to reveal the scope and then laser the plane that presents itself to you as it rolls out. And this again, this gentleman has beautiful planes despite the-

Dr. Thomas Herrmann:

May I?

Dr. Amy Krambeck:

Yes.

Dr. Thomas Herrmann:

Just was wondering myself, okay. In this case, of course, it's a huge median lobe and this is why I think it's great to do a median lobe enucleation. I start with three lobe enucleation as well and finally today I'm doing not just because I want to do something new but because and normally I find it more easy to start with the left lobe or you could start to the right low, possibly, but I'm starting with the left lobe. You regularly do three lobe enucleation all the time? Or do you have scenarios where there is two lobe enucleation?

Dr. Amy Krambeck:

I will do two lobe if there's not a real median lobe. I will do two lobe if I'm by myself and I'm not teaching because I feel when you're teaching fellows and residents or people who are new to HoLEP, it's hard to get this tissue counter traction with your scope when you have only one cut. When you divide the prostate into three lobes, the counter traction is very easy. You only needed to think in one direction. But when you do one cut, I think it's a little tricky and I see people perforate at the bladder neck quite often when they have difficulties putting the tissue into the bladder.

Dr. Amy Krambeck:

So the only time I really do one cut is if I'm alone or if they just lack, a median lobe. But I don't think there's anything wrong with one cut, two cut and block it's whatever you're comfortable doing. Now, right here, I've got that medium lobe suspended into the bladder and I'm cutting off the urothelial attachments. And you can see I'm pinching in from the sides. And I do that pinch in from the side. So I have not yet identified the real orifices and I don't want to laser back into the bladder until I identify those. So by cutting in medially like this, I know I'm not going to hit a ureteral orifice and I'm not going to cause damage to the bladder itself. Thomas were you asking a question? I'm sorry. I might have interrupted you.

Dr. Thomas Herrmann:

No, no. I'm just watching at the moment. I think it's very wise to take the median lobe from the site anyway, especially in rectal trigonal extensions [inaudible 00:09:14] is important. What you actually... What doesn't matter if the prostate has extension if you prepare from the side. Sometimes I feel it's very large, the rectal trigonal extension, you should rather come from the side then from below but whatever it is you should apply sometimes B to B when you take a very, not super large prostate.

Dr. Amy Krambeck:

Yeah. I agree. Okay, so in this part, I've identified the veru. And now I'm doing what I call the atypical turn. So I made a little cut in the urothelium and now I'm just twisting the scope around the apex into that plane. Just like what you would do with your finger if you were doing those Super-cuic prostatectomy. You just slide the scope around the apex and then I use the laser on one Joule and 20 hertz on my co ag setting just to release some of these attachments. And the reason I use the lower setting is I don't want to have some collateral damage if I get lost and pulled back too far.

Dr. Amy Krambeck:

I think it's extremely important when you make this turn to pull your scope back. I think the biggest rookie mistake especially in big prostates is to push the scope into much because you're afraid of injuring the sphincter. And it's almost impossible to get over the adenoma if you're doing that. So you have to remember to pull the scope back and keep lasering up to get over a big prostate like this. And I just want to point out again, how dry this is. I mean, this is an unbelievable visualization. It really has a lot to do with not peeling so much and lasering more, as well as the laser energy that's being applied. It's not just applying more energy, it's getting the energy to the tissue that's important so that it can coagulate. Now, I did a little maneuver there where I wiggled the scope back and forth and that just allows it to kind of wiggle its way into that plane.

Dr. Amy Krambeck:

So just to orient everyone the adenoma is below me and the capsule is above me. And I'm going to create this plane marching forward towards the bladder neck. The sphincter is behind me. The bladder neck is in front of me and this is really a fun part of the case. It's very safe, you can identify your planes, the counter attraction is natural because the scope is pushing this issue down and so you just have to laser in front. So this is another good area for new individuals, new to HoLEP to work on because it's a safe, easy process to do. But it helps you find your plane as you're working. There we go. So this is where we're working forward and are working towards that bladder neck again. So nothing's changed is where we just left off.

Dr. Amy Krambeck:

Sorry about... I don't quite know what happened but the screens got shared differently. As we work forward here, you can see that it's changing. The fibers are going up and down and I call this the bailing of the prostate. So it looks like the bailing the whale. And you know, you're in the perfect spot. These are your bladder neck fibers. So you have done a great job developing your plane when you see that. And now we just released this bladder neck fibers and march into the bladder. Now, sometimes this couldn't be a little stressful if you're first starting out because you're going into a dark space but really, if you see those up and down fibers you know you're in the right place. And right now, I try to get the bleeding bladder neck vessels while they're in front of me because they can be very difficult to get to after you release the prostate.

Dr. Amy Krambeck:

So I've gone into the bladder, that was the other lobe of the prostate fibers. And I like to make more of a straight cut on these bladder neck fibers that makes the bladder neck larger and it makes it a lot easier to advance the prostate into the bladder by widening out the bladder neck. Thomas, do you widen out the bladder neck as well?

Dr. Thomas Herrmann:

No, actually, I don't. I try to preserve the better neck as it is. The circular fibers because I am a little bit afraid of though I hardly seen it. I try to preserve the better neck as it is. I own small incisions in the end if I see a [inaudible 00:14:13] that use scarring like in all to me the anastomotic leakages. So [inaudible 00:14:35] I rather do two lobe or three lobe because I want to have these push the lobes.

Dr. Amy Krambeck:

Okay. So now we've gone back. I've entered the bladder. In my case I took down the bladder neck. Now, I'm dividing this lobe into two pieces. Again because this is such a large prostate for me I would spend a lot of time trying to deposit this into the bladder. So I am just dividing the left half into the right half. I call it the dividing the anterior Kama shirt. So now I've created a right lobe and the left lobe, and I divide that urothelial strip that was there. I'll move the scope back and forth to make sure all the tissue attached. And now we have a nice divided left and right lobe. There was some urothelium that bunched up at the beginning and I'm just going to stop this and move back real quick to show you but I cut that right back here.

Dr. Amy Krambeck:

This is what we call a urothelial strip. Is this little piece of tissue right up here. Some people will do it in circle. Some people will do an atypical early release where they laser that piece of urothelium at the very beginning. I like to do it once everything else is released and it's just dangling there. But at some point some way no matter how you do it, you have to get rid of that attachment at the sphincter. And so now I'm just showing again how I'm dividing the lobe in half. Thomas, do you do an early apical release? Or do you release the urothelium at the sphincter later?

Dr. Thomas Herrmann:

I must say that is one of the most convincing measures that I use so far to prevent early stress urinary incontinence. I think first, and if go from this group and say, "I'm doing it since I read it." And I think that the whole discussion on prevention incontinence is a little bit of a virtual debate. If you have a mature setting. I think Hemendra Shah, he made a nice publication that years ago and he said that the learning curve itself and the manipulation around the centric region by the [inaudible 00:17:16] more proper piece of procedure that [inaudible 00:17:23] that I think and preserve during the muco... I call it mucosal pack or muco-band preservation.

Dr. Thomas Herrmann:

To keep the mucosal completely intact that is covering the centric region is the key to early continence and if you reject that, and it has to regrow in you will have one, two, three months stress urinary incontinence because not only the thickness of the mucosa is not there, but the sensor is also not there. So keep the sensor and the mucosa and then you will have no stress urinary incontinence. [inaudible 00:18:13] that is my thought on that.

Dr. Amy Krambeck:

Right. That's a good point. I'm really... That's interesting. So on the video, we've released the entire right lobe. And now just going to address the left lobe here. So once you've released that urothelium attachment to the sphincter and really getting rid of the rest of the lobe is very easy. You just follow the plane, deposit it into the bladder, then you have to start on the other side. Now like Thomas, he likes to start in the patient's left I like to start on the patient's right. It all just depends on how you like to make your turn and how you like to work. So what this patient has left is this left side. You can see this enormous blood vessel here that I'm just trying to gently control with the laser so that it does not cause issues later.

Dr. Amy Krambeck:

And now again, I just put my scope in and I'm twisting around very easy this prostate. Even though it's big, it has beautiful planes. So it's extremely easy to know where to go. Now I know that when I did that anterior plane, I got all the way over to two or three o'clock. So I know when I should be running into that open plane again and you can see it that I will laser into an open space, which means I'm in the perfect plane as I make that turn around. And just attaching the plane to the old plane to get this lobe out. And the second load goes so much faster than the first because you've done most of the heavy lifting already. And I'm just coming up around the top of the prostate at the apex joining the old plane that I previously created.

Dr. Amy Krambeck:

And this is again, just a very large prostate so it takes a long time to get up over that apex and join the old plane. Now some people do top down approach. I think top down is great for small prostates. I think for large prostates, it can be very difficult to find this plane anteriorly because you're trying to cut through this large amount of tissue. But really, I think enucleations are phenomenal procedures and if you find a technique that works for you, that's what's important. Something that you're comfortable with and that it's safe for the patient and is efficient. That's the most important thing. So I come up over the top there. You can see it. Go ahead.

Dr. Thomas Herrmann:

I think the charm of top down is that you cut away from the surgical capsule. I think this is if you have already exposed the ventral capsule and you cut down you can first of all, preserve this mucosal flap very nicely and you can cut away surgically so that perforate fully. But as you said, if you have a huge and gross and part of the prostate from the right [inaudible 00:21:26] zone, but I always try to do it pair of central pattern as I call because that really lets you cut from where you have already exposed to the mid lap. This is again as you said, you have to find a version with the safe and produces a good early results and therefore everybody has his own technique which is good, because this tells that you achieve good results with it.

Dr. Amy Krambeck:

Yeah, I agree. Okay. Here is the urothelium that urothelial attachment now and it's nicely on stretch. So I can just cut this safely away from the sphincter, because that lobe is almost completely released. And there's just a few more attachments left. I like to come back to the corner of the lower plane in the lateral plane and work that forward. And that's just an efficiency tip. So by working in the corner plane, I keep the lateral and the inferior plane all moving forward together. Sometimes when people learn, they want to work the bottom, then they want to work the side and then they have to keep those planes trying to marry them up. But if you can actually work the corner forward, you'll work both planes forward at the same time it will make you much faster.

Dr. Amy Krambeck:

So I try to... Usually when I'm teaching fellows, I teach them to work the bottom and the sides and then once they get that down, then we start working the corner. I think it's a little more difficult on your counter attraction. You're bouncing the tissue a little differently, but once you can get that it's far more efficient. And this lobe is coming out very nicely as well. Thomas, do you think that in every prostate there's an area that's kind of sticky and the plane is not well defined?

Dr. Thomas Herrmann:

I think in smaller prostates where the two lateral lobe, yeah. I think Amy where they are not nearing very well you have into position of the anterior part and I think you have sticky part and then vessels go to the pro overlay pedicles, the sticky part.

Dr. Amy Krambeck:

Yeah, I agree. Okay. So just now I'm trying to get that last move into the bladder here which should be happening very quickly. It's kind of hard sometimes to get the lobes to deposit but I do prefer morcellating inside the bladder. I think it's safer. I know some people will morcellate in a fossa and I think that works if you have really good hemostasis. So the bladders now full of prostate tissue, complete enucleation has been done. I will spend several minutes drying up because I want to see when I'm morcellating, I feel like safe morcellation can be done if you dry up the fossa. Now this fossa is about as big as some people's bladder it's really large. But it's actually relatively dry.

Dr. Amy Krambeck:

I believe at this point I've turned my flow inflow and outflow off to look for any obvious bleeders. Now I'm moving to morcellation. I will put two inflows on for morcellation and move my main wide line to the outflow and then I'll put a secondary line on the nephroscope. So I've left [crosstalk 00:25:19] and I've put them in the nephroscope. Oh, yes, go ahead.

Dr. Thomas Herrmann:

I just wanted to ask because there was also some questions with regard to gravity irrigation, and what gravity... What [inaudible 00:25:41]?

Dr. Amy Krambeck:

So you're cutting out a little bit but I think you asked what gravity irrigation I use. I use them and a normal sailing four liter bags. And I'm going to back that up just because it's hard to... Hold on one second. I use normal sailing four liter bags to morcellate. I have two inflow tubings. One is up to a Y of two bags, and the other one is up to a single bag and that's more of the safety net. I have only inflow, the outflow is the morcellator. There is no other outflow other than the morcellator. That's a mistake I hear people make a lot when they're learning, they put another outflow out and then they get a bladder injury. But then I just keep the tissue in the middle and morcellate. This was about a 10 minute morcellation for this case and that is now done.

Dr. Amy Krambeck:

I switch over back to the laser scope down just to control any residual bleeding and dry this up. And really, this guy has very little bleeding. This is just wonderful. I always check the back wall of the bladder to make sure there's not an inadvertent injury. I checked for residual tissue in there and put the foley in over a mandarin. And this is what this gentleman look like. This gentleman went home that same day. He did not spend the night, 92 years old, he did not get a blood transfusion and he had his catheter removed the next day. So he had a very good outcome. He had 233 grams enucleated for this case. So Thomas, I'm going to stop sharing. I'll let you take over the screen.

Dr. Thomas Herrmann:

So I brought up some slides because we have been discussing and it answers to a lot of questions that have been raised. In the meantime, I try to [inaudible 00:27:49] and I don't know. I'll have to put that over otherwise you don't [inaudible 00:27:55]. So as you know, we have been the discussing several issues during the talk and I just put up here this slide of the ins and outs and [inaudible 00:28:34]. What [inaudible 00:28:37] of very small say [inaudible 00:28:54] scaring around state the recent issue. If you I have MLL, what do you...

Dr. Amy Krambeck:

I think Thomas asked me a question. That audio is kind of going in and out. From Levy asked if what is the size limit for HoLEP and for me I truly believe if you have a prostate that's 50 grams or less you could probably treat it any way you would like and get a reasonable result and the patient will void well. But for larger prostates, I think that you do significantly better with HoLEP.

Dr. Amy Krambeck:

In my program, I only offer HoLEP. So I'll do HoLEPs for small prostates. I would say for a beginner, I would shy away from small prostates. I know it's counterintuitive you think, "Oh, small prostate should be easier than a large." But you lack the tissue planes, you lack the room to work and it can increase your risk of perforation and injury. So smaller prostate should really be one of the last things you try to do when you're learning HoLEP. Are you back Thomas?

Dr. Thomas Herrmann:

Exactly. [inaudible 00:30:21] that you presented. I think it's equally complicated. The question was rather believe that all prostate and larger as bladder and then strictures then to your pee, small.

Dr. Amy Krambeck:

So and again, I didn't quite hear the question but I believe the smaller prostates are at high risk for bladder neck contracture. I don't think it's any higher than TURP. And there's several meta analyses that indicate that it might even be lower most likely because we're not using monopolar. If you're using bipolar, I think it makes no difference. But with mono polar, you can get energy bleeding down the scope and give a stricture of bladder neck contracture. With HoLEP or any other type of procedure where you're removing tissue, or smaller prostates, you run the risk of a bladder neck contracture, which I'll quote my patients around two to three percent will get a bladder neck contracture. So that's the big concern with the smaller prostates. But I think that's a concern. Yeah, yeah.

Dr. Thomas Herrmann:

Exactly. That is exactly what I brought with this slide that smaller pipe gets the higher the risk. If you don't do an added procedure like enucleation we have a higher chance of damaging the surrounding tissue. Yeah. And how soon do you do for oral anticoagulants. What is... On that?

Dr. Amy Krambeck:

So with oral anticoagulants, I try to stop them if possible. So if the patient does not have a contraindication for stopping their anticoagulation, then I will stop it for the procedure and then restart it once the catheter is out. Even a week if they have no issues with stopping it that long. But if they have to take the medication, and they can't stop it safely, then I will do the procedure on anticoagulation. I think with the newer laser technology, we have better hemostasis and so the big concerns about significant bleeding is not as great anymore. We are able to control these bigger vessels and you got to stay in the right plane. Your slide here shows if you get too deep you can get into these big peripheral vessels. These venous sinuses are very difficult to handle even with a good laser.

Dr. Thomas Herrmann:

So, what... The new Holmium technologies offer as an extra to what we have had before. So the question was, what does Moses technology offer more than the conditional Holmium laser with a Moses effect?

Dr. Amy Krambeck:

A very good question. And I have to tell you that I was definitely not... At the beginning I was not even interested in trying a different laser. I had done over 1000 HoLEPs with a standard 100 watt and thought there was absolutely no way to improve upon it. And then I tried using the Moses laser and it's definitely a different surgery. You don't spend nearly as much time controlling bleeding and the bleeding that you are controlling is a discrete blood vessel that you can see.

Dr. Amy Krambeck:

It's better energy delivery, the bubble collapses away from the laser tip. So the energy is expanding outwards so you get this... Not to sound corny, but you get to Moses effect you get the fluid is starting to part and it will also dissect the tissue for you so you don't actually touch the tissue. And then you get less break back onto the laser fibers. So you rarely are adjusting your laser fiber for break back. You don't have to strip it you can just put the laser fiber in and then use it

Dr. Thomas Herrmann:

So there have been some publication in the last year on block... I think we've already discussed an [inaudible 00:35:36] we have penetrate. So would that the advantage of most technology is an effect I know that you are handling the energy better [inaudible 00:36:09]. And-

Dr. Amy Krambeck:

Ben can you-

Dr. Thomas Herrmann:

The question is, is it... Sorry, is it... I just want to come back. Is it HoLEP? Or is it Moses HoLEP or is it a very, very experienced surgeon who can benefit from this technology?

Dr. Amy Krambeck:

Yeah. So I think this technology benefits everyone. So I have two partners one that's two years out of training and the other one that's just less than a year out of training and they're doing HoLEP and sending their patients home the same day. And we're taking their catheters out the same day now. And I think part of it is technique clearly lasering more, appealing less, finding the right plane. But the other part is the laser. I think the laser is far more hemostatic. And I think it benefits the early learner because they're not spending a lot of time trying to control bleeding, they feel more relaxed, they can take their time and learn how to do it without this big bleeding concern and they can see what they're doing. And then the more experienced surgeon, I feel like it can change your practice. You can send the patients home, you can take their catheters out the same day and you can do it safely without complications. So I think it's a benefit to everyone.

Xu:

Amy, there's a question from the poll board here asking about the other pulse modulation technologies with some of the other lasers that are available. Is there enough data on that? Or do you think it will make a difference as well too like Moses has? Or do we just simply not know yet?

Dr. Amy Krambeck:

Yeah. That's a very good question. And I don't think we have enough data to say how that will work. I can tell you that I have used the standard holmium laser with widening the pulse width. I have used the standard holmium laser with standard Moses. And then I've used the holmium laser with Moses modified from BPH. And foreign away that Moses modified for BPH is significantly better than any of those variations. With other technologies I just don't know how that'll do, but I'm interested to find out. I think it would be a good test.

Xu:

Two other questions about beginning. Other people have a question about can a beginner start with a low power laser? What are your feelings about that?

Dr. Amy Krambeck:

Well, I think that they can. I think that there may be some frustration with that. I think that it's definitely possible that you could have some frustration because of the bleeding and how long it takes you. You're going to be slow already, and then a low power laser will make you even slower. However, there is a total complete school of thought that believes you should lower the laser settings down to a lower power when you're learning. I've never taught that way, but some people do believe that. So if all you have is a low power laser and you're dedicated to learning and you really want to do this then I think it's okay. But I don't think you'll stay with that low powered laser, I think you'll eventually increase it.

Xu:

And what do you think the learning curve is? How many cases would you need a with a tutor basically to be able to do it by yourself? You mentioned your fellows being on staff now. Obviously, they've done quite a bit with you, but what about others?

Dr. Amy Krambeck:

Now that is the million dollar question. And I think it really depends on the individual. So there are some people that take to it like a duck to water and they need 10, 15 cases and they're ready to go. But the vast majority of us aren't that way. And I think really it's around 30 to 50. And you need to be doing it regularly. You can't do it-

Dr. Thomas Herrmann:

I believe so.

Dr. Amy Krambeck:

Yeah. You can't do it once a month. You need to be doing this case once a week, at least if not more because the repetition and doing it close together is what you need to do. So the people who are successful are people who have departments or partners who are supporting them and funneling them cases. The other thing is choosing the right prostate. You don't want partners that are funneling you 250, 300 grand prostates. That is the worst, worst idea ever. You want to be in that sweet spot that 80 to 100. Those are the perfect cases to be doing HoLEP with.

Xu:

A lot of questions about morcellation which I know from my limited knowledge is one of the most dangerous parts of this operation. Do you have any tips on when you have a big adenoma that is almost hard like a beach ball and it's very difficult to engage it in the morcellator. What tips do you have for that?

Dr. Amy Krambeck:

So for that situation, if it's a lot of adenoma left, I mean, you just started morcellating and it just will not morcellate then you probably should just open like a small cystostomy, reach in, pull the tissue out and then close it back up. I've only had to do that a handful of times. Usually, you've morcellated the bulk of the tissue, and it's this 10, 15% of the tissue left that's just really, really hard. And in that case, what I've done is I put the catheter in, run irrigation overnight and then bring them back the next day and the tissue will soften with the irrigation overnight and you can morcellate and leave them without a catheter and send them home. So...

Xu:

Great. That was one of the other questions actually, do you ever do a two stage morcellation? So that would be a good opportunity to do that too.

Dr. Amy Krambeck:

Yes. And I've done that several times when there's these beach ball. And also, it's really dependent on your morcellator. Not all morcellators are created equal and some create those beach balls and some don't have a tendency to do that.

Xu:

So that's actually another question that someone had in terms of, what is the best morcellator? I don't know if there's any data out there that you're aware of, or which ones you've tried and which one you might prefer?

Dr. Amy Krambeck:

Yeah. Well, there's actually quite a few that just came on the market that I saw that I have not trialed. I've only trialed the Lumenis and the Wolf and they both have benefits and drawbacks. So the Lumenis Morcellator is never going to break ever. You're not going to have to troubleshoot it you very simple assembly, simple for the staff. You're not going to be dealing with it breaking down but it does create those beach balls. The Wolf Morcellator does not create the beach balls but gosh, it does break down a lot. There's a lot of moving parts to it and there's a lot to troubleshoot while you're using it.

Dr. Thomas Herrmann:

The problem [crosstalk 00:43:16].

Xu:

Sorry, Thomas go ahead.

Dr. Thomas Herrmann:

I think with morcellators, there are two others. There's [inaudible 00:43:23] one and the Hawk from China. And I think that all those who have rotating [inaudible 00:43:36] they depend... This is the problem with the [inaudible 00:43:54] they are [inaudible 00:43:58]. So what you're saying in this blade [inaudible 00:44:19].

Xu:

I apologize. We're having really bad connections with Dr. Herrmann's audio unfortunately. Dr. Krambeck, what about irrigation that you use during morcellation. Do you use device or gravity bags? Or what do you use for that?

Dr. Amy Krambeck:

Yeah. That's a great question. I do not use a device. Devices have to measure pressure and then they run a pump based on the pressure and any variability in that can allow the bladder to decompress. So when you're morcellating or even lasering you don't want the bladder to decompress. So I use just gravity. Gravity is set at five feet and I use a wide tailing bag. So I have two bags connected to one two beam and therefore liter bags. So we keep both of those full during the case.

Dr. Amy Krambeck:

With more isolation, I add a third bag in a single line as a backup. It's kind of your safety belt or your helmets in case one of the other lines were to run out for some reason. But there's been questions about morcellating and I think people have a lot of concern about that. But in reality, that's the first thing I let residents do. The intern or the junior level resident gets to more sleep for me. Because if it's set up right, and you get good visualization, it really should be the easiest part of the case.

Xu:

Absolutely. Now what's the rate of stricture, typically after a HoLEP?

Dr. Amy Krambeck:

Yeah. So it's low. It's around one to two percent. And usually, you see strictures if you're spending a long time. I use a 28 French scope. If the urethra is tight at just the media so I'll use an Otis urethrotome to open up the urethra. If it's tight on the entire length, then I'll switch to 26 French scope. But the key is to keep the scope loose in the urethra. So you don't want to tight around the urethra then try and prevent stricture.

Xu:

Do you dilate the urethra routinely before doing the HoLEP?

Dr. Amy Krambeck:

I do. I do. So I'll use sequential Van Buren sounds and dilate just to the level the sphincter. There's no use trying to dilate all the way into the bladder because you'll just make the prostate bleed. Usually they're quite big prostates. So I'll dilate up to 30, 32 to French even just to make it nice and loose around the scope.

Xu:

Some people had questions about how long you would leave the catheter in for usually you said overnight.

Dr. Amy Krambeck:

Yeah. So at the end of November, we started taking the catheters out the same day. So if I have a day full of HoLEPs, the first two patients will have the procedure and then in the afternoon, they go to the clinic and get their catheter removed. We've tried to remove them in the hospital and that just doesn't work so well. Patient really needs to get up, walk around, get dressed, just kind of wake up from the anesthetic and then we take it out that afternoon. It's a to 90% success rate with that. So out of the patients, we've tried to do this with 90% of the time, they're able to void, they don't go back to the emergency room they just go home.

Xu:

One person actually asked, what if they left the catheter in for extra time between three to five days, would that make a difference?

Dr. Amy Krambeck:

I don't think it would help and I actually think it might make your stress incontinence worse. When we've had bladder injuries or issues along those lines where we've had to keep the catheter in longer, I feel like those patients leak more. But that's just anecdotal I don't have any hard data to support that. But leaving it in longer, it's not going to be a irreversible damage, it just may make that temporary leakage worse.

Xu:

So they get to trial void the next day if they fail that, what happens then and how common is that?

Dr. Amy Krambeck:

So the trial void next day failure is very low. It's less than 10%. And we will put the catheter back in and leave it in one more night if they're willing to stick around and try another day. But it's usually just one or two nights. The times that I've had prolonged issues with voiding is patients who have other issues like some mild dementia that will really make it difficult for them to void because they're not really in tune with their bladder. Used to be clot retention was a real problem, but we just don't see that anymore.

Xu:

So that actually brings me to another question is, how many times do you have to run continuous splatter irrigation or CBI? And is that very common at all?

Dr. Amy Krambeck:

It's not very common. Our discharge home is around seven percent. So seven percent of the time a patient is bleeding a little more than we thought and we have to keep them in the hospital for continuous irrigation. So it's very rare that we do that. But if you have to, it's not a fail. It's just what that patient needs.

Xu:

What size catheter do you normally leave after a HoLEP?

Dr. Amy Krambeck:

So we played around with this a little bit too. Currently I leave at 22 French Foley catheter. In the past I've left in 18 French. I think 18 French doesn't get the initial residual plot out as well. So we went back to the 22. So that's what I leave.

Xu:

And what about five ARIs, do you stop those before doing HoLEPs? Or what's your management of that?

Dr. Amy Krambeck:

So I don't. I try to stop them as soon as I possibly can, because I think there's a lot of side effects to that. But I don't it changes the surgery much. I used to believe that it made morcellation more difficult, but I'm not a... No study has supported that. I don't think it improves with bleeding. I don't think it decreases bleeding or improves hemostasis. I've just not really seen much benefit with it.

Xu:

Okay. And what about, how do you deal with stress incontinence right after the surgery?

Dr. Amy Krambeck:

That is a very common concern with HoLEP is, people worry a lot about the stress incontinence and I tell these men, "You got a really big prostate. I've got to remove a lot of tissue. You have a 30 to 40% chance that you're going to have some leakage right after surgery. So I want you to be prepared for that." All men learn how to do kegel exercises at six weeks if they're still having leakage, and usually it's a combination of stress and urge. We call it quick on the trigger. I got to go. I got to go right now and they just can't get there. So we will start Anticholinergics for a short period of time and they do pelvic floor rehab. So they do public forum exercises. And the vast majority who get the temporary incontinence, it's gone by three months. Occasionally, it takes up to six months but that's not the norm.

Xu:

Will you still remove the catheter on the same day and someone who was on anticoagulants?

Dr. Amy Krambeck:

We will if they're not bleeding. It really has a lot to do with the color of the urine. We just looked at our anticoagulation data now and I was always under the impression that the newer generation anticoagulants were the problem. But it's actually the patients on Coumadin. So it's after they stop their Coumadin coming in and then they restart it and then they get super therapeutic and they bleed. So maybe we need to rethink the usage of Coumadin. I thought it was safe, but I think I'm wrong.

Xu:

What do you quote your patients as the rate of either transient incontinence or permanent incontinence with this procedure?

Dr. Amy Krambeck:

So the transient I say is around 30 to 40%. Permanent is around one to two percent then we say it's permanent if it's there a year after surgery.

Xu:

Okay. And what-

Dr. Amy Krambeck:

I used to-

Xu:

Sorry, go ahead.

Dr. Amy Krambeck:

Oh, go ahead. I used to say I couldn't predict patients that would have that leakage, but now as I've done more and more, of course, anybody who's had radiation is a prime issue. I mean, if they had it before, if they had an after that radiation seeds, it's all the same. It's a real problem and I try to avoid doing HoLEP in those patients. Neurologic issues, stroke, Myasthenia Gravis is a real problem. Anything along those lines, you have to have a real conversation with the patients. Dementia, Alzheimer's, talk with the family to make sure they understand what they're getting into.

Xu:

What about percent of erectile dysfunction?

Dr. Amy Krambeck:

It should not at all affect their erections. So we do a full evaluation of their erections before surgery. So they fill out a complete questionnaire and it does not change from pre to post up. What does change is, retrograde ejaculation. So that's a real conversation that you have to have with the patients because when you see them all they want to do is urinate well, but then after the urinating well they're like, "What happened to the ejaculation? What's going on here?" So you have to truly inform them because this can be an issue for some men.

Xu:

We've got a lot of questions from people from all over the world actually asking about how do they learn this? If they didn't do it in their residency or didn't do it in a fellowship? Are there proctored programs? Are there certain courses that are hands on either in North America and in Europe? What do you have to say about that?

Dr. Amy Krambeck:

Yeah. I think this is the biggest hurdle for HoLEP adoption is, how do you learn it when you didn't learn it in fellowship or in residency? There's a few ways to go about it. There are some programs that will let you come watch surgeons and then bring the surgeon to your location to proctor you. Different companies will offer that mainly the laser companies or the device companies. So that's one way to go about it. The other way is to reach out to someone that you know is doing HoLEP. We've had people get temporary privileges for a week or two come here and learn how to do HoLEP and they leave. I know some really great surgeons. Chandler, Dora, he learned how to do HoLEP on his own. He watched videos and just started doing it. So and he's a-

Xu:

I imagine that's a very difficult thing to do.

Dr. Amy Krambeck:

I think it is, but I think a lot more people are doing it than you think. And then we're working on potentially an online training program for patients. They're just like you have an online trainer for physical fitness you can have online training HoLEP, you just have to make sure you're safe. That's the big thing.

Xu:

That's great. Well-

Dr. Thomas Herrmann:

There's-

Xu:

Thomas, how's your audio now? Maybe you can just close out our session. I think we're coming to the end of our time.

Dr. Thomas Herrmann:

I'm very sorry that it didn't work out. My audio receding was well but obviously, my input was very limited. I'm very sorry for that but I tried to answer a lot of questions in the internet. So I'm sorry-

Xu:

Thank you.

Dr. Thomas Herrmann:

But I think I'll answer some of the questions raised without talking over the phone. I'm so sorry.

Xu:

No, thank you. It's our apologies, I'm really... It's too bad we didn't get your input and everything because both of you have so much expertise and I want to thank both of you for joining us here today and Amy, sharing your thoughts and your expertise. And you too Professor Herrmann for this too. So and thank you to our sponsor Lumenis for this webinar. Please do join us next week when we are going to be talking to Khurshid Ghani and he is going to be showing us his dusting technique and our moderator will be Evangelist Lee Icicles from Greece. So thank you for that.

Xu:

And at the end of this webinar, you will be directed to a page to fill out a end of webinar questionnaire. And then at the end of this month, Michelle Pioli, because you've registered for this will send you another link to get your CME credits. So thank you again to Lumines and thank you again to attending. I'm sorry for the poor audio that we have for our bad connection but thank you again Professor Herrmann and Dr. Krambeck. Have a good day everyone.

Dr. Amy Krambeck:

Thank you for having us. Bye bye.