Surgeon: Steven Kaplan

Moderators: Alexey Martov


Steven A. Kaplan, M.D., FACS

Dr. Steven Kaplan graduated from Mount Sinai School of Medicine in 1982 and was elected to the AOA Honor Society. Dr. Kaplan’s postgraduate training included an internship and residency in the Department of Surgery at Mount Sinai Hospital as well as a residency in Urology at the Squier Urologic Clinic, Columbia University. He was an American Urologic Association Scholar between 1988 – 1990 that focused on identifying molecular markers and urodynamic parameters that herald bladder and prostate dysfunction.

Dr. Kaplan was the Given Foundation Professor of Urology and Administrator, as well as Vice Chairman of the Department of Urology at Columbia University from 1998 – 2005. And then, the E Darracott Vaughan Jr. Professor of Urology and Chief, Institute for Bladder and Prostate Health at Weill Cornell Medical College and Director, Iris Cantor Men’s Health Center at New York Presbyterian Hospital.

Currently, he is Professor of Urology at the Icahn School of Medicine at Mount Sinai and Director of Benign Urologic Diseases and The Men’s Health Program of the Mount Sinai Health System. He is a serial entrepreneur and a founder of Medidata Solutions Inc., a publicly held corporation and one of the premier electronic data capture companies in the world; Medivizor, Inc., a medical informatics enterprise; Eco – Fusion, a novel health care interface platform and InspiReN, a digital interface analyzing and enhancing the patient experience with health care professionals.

Dr. Kaplan is a Diplomat of the American Board of Urology and a Fellow of the American College of Surgeons. He is a recognized authority on the study of benign diseases of the prostate, the association of metabolic factors and voiding dysfunction and female urology. He has published more than 1200 articles, 170 abstracts, and has made over 340 presentations in more than 35 countries. He is the co - author of five books and is on the Editorial Board of Urology, Journal of Urology, and Urology Times.

Dr. Kaplan has been a member of more than 30 professional organizations, been awarded 5 NIH grants and has received over 13 million dollars in research funding. He was awarded the John K. Lattimer Award for Lifetime Achievement in Urology by the National Kidney Foundation. Most recently, he serves on the AUA BPH Guidelines Committee and is the Chair – Elect of AUA Research.

Martov Alexey G., MD, PhD

Martov Alexey G., MD, PhD, Honored Doctor of Russia Professor and Chairman, Department of Urology, Federal Medical-Biological Agency Professor of Urology, Lomonosov Moscow State University Medical Centre Head of Urology Department, D.D. Pletnev Moscow City Hospital

Educational background:
1978-1982. First Moscow Medical Institute, Moscow
1982-1988. Residency, Institute of Urology, Moscow
1988. Doctorate Thesis «Percutaneous Treatment of Kidney Stones
1988-2006. Institute of Urology, from Head of Endourology Department to Vice-President
1993. PhD degree, «Endourological Treatment of Upper Urinary Tract Diseases
2006 – p. t. Head of Urology Department, D.D. Pletnev Moscow City Hospital, Professor of Urology, Russian Medical Academy of Postgraduate Education
2012 – p.t. Professor and Chairman Department of Urology, Federal Medical-Biological Agency, Russia
2018 – Professor and Leading researcher, Lomonosov Moscow State University Medical Centre

Activities:
  • Founding Member and President of the Russian Endourology and New Urotechnology Society
  • Vice-president of the Russian Urology Association
  • Co-Editor of Russian Journal “Urology”
  • Member of EAU, SIU, AUA, Endourological Society
  • CROES, ESUT activity
  • Director of Training Center for Endourology, Moscow, Russia
  • Honorary member of Russian, Georgian and Azerbaijan Urology Association
Specializations / Interests
  • Endourology
  • BPH
  • Stone desease
  • Urooncology
Additional information
  • Over 400 scientific publications (PubMed-cited Journals), 15 books, 35 books chapters
  • 3 educational CD for Urologists (Endourology, BPH, Prostate cancer)
  • Numerous international invitations for live surgery meetings/presentations/workshops/congresses and teaching events in Russia and countries of former Soviet Union, Germany, France, Austria, Switzerland, Turkey, Sweden etc.

 

Webinar Transcript

Dr. Amy Krambeck:

Hello, I am Dr. Amy Krambeck and welcome to our masters class in endourology. This is the Endourology Society and Society for Urologic Robotic Surgeons master's class in endourology and robotics webinar series. The Endourology Society wishes to thank Olympus Corporation for their grant in support of this educational activity. This presentation today is one I've been looking forward to for quite some time, this is Modern Treatments with Classic Devices. Our faculty is Dr. Steven Kaplan, and the moderator is Dr. Alexey Martov. I feel that neither one of these need a formal introduction, because they are both such well known surgeons, but I will try to make a formal introduction.

Dr. Amy Krambeck:

Dr. Steven Kaplan is Professor of Urology at the Icahn School of Medicine at Mount Sinai, he's Director of the Benign Urologic Diseases in the Men's Health Program there as well. I think Dr. Kaplan is well known as an entrepreneur. And he's the Founder of the Medidata Solutions Incorporation, Eco Fusion, Medivizor, and Inspiren. He's also received five NIH grant awards, resulting in several million dollars of funding. He's the recipient of the John K. Lattimer Award from the National Kidney Institution. He was the chair of the AUA BPH guidelines, and he's Chair-elect of the AUA Research Committee.

Dr. Amy Krambeck:

Dr. Alexey Martov is Professor, Chair of the Department of Urology at the Federal Medical-Biology Agency. He's Professor of Urology at Lomonosov Moscow State University and Medical Center, and he's the Head of the Department of Urology at D.D. Pletnev Moscow City Hospital. He is the Founding Member and President of the Russian Endourology and New Urotechnology Society, and he's Vice President of the Russian Urology Association. He's the Co-Editor of the Russian Journal of Urology.

Dr. Amy Krambeck:

So, I anticipate great talks by both of them today. The purpose of the master's class in endourology is to provide an activity for the attendees as an online program dedicated to surgical techniques in endourology and robotics. The target audience is really physicians or urologists that specialize in endourology and robotics. And the objective is to identify specific examples of new technology with the critical steps, and identify specific examples of different technologies as well as the critical steps and differences.

Dr. Amy Krambeck:

This is accredited by the ACCME. To obtain your CME credit, you will receive a survey from Michele Paoli. You will indicate which seminar you attended, and you will get the CME certification. Please fill our the evaluation questionnaire at the end of each seminar, and please use the question and answer function to ask questions today. These are imperative, this is your chance to interact with world experts and get your questions answered.

Dr. Amy Krambeck:

So with that, we're going to launch some polls just to get us started. And the first poll is here, what surgical procedure do you perform the majority of the time for symptomatic BPH outside of MIST therapies? But it looks about 67% of the attendees have answered and bipolar TURP followed by monopolar TURP, and ablation and enucleation seem to be the clear winners here. Now moving onto the next question, do you believe TURP either monopolar or bipolar can be successfully performed in prostates greater than 80 grams? And I think a lot of people feel comfortable with larger prostates, performing resection. It has quite a bit of, quite a bit to do with how you were trained and the speed of resection. So, it'll be interesting to see what our participants think.

Dr. Amy Krambeck:

And it looks like the vast majority of people do feel comfortable doing a resective procedure for prostates larger than 80 grams, about 70% felt comfortable with that. All right. And our third and final question before I hand this platform over to Dr. Kaplan, do you perform TURP as an outpatient day case? Meaning, do you send patients home the same day after your TURP or do you like to keep them in the hospital overnight? And it looks like a small minority of people are doing them as day cases, but still several, 89% want to keep patients in overnight at least to get some irrigation. All right. Well, that was a good introduction to what we're doing today. So we'll go ahead and turn the platform over to Dr. Kaplan and see his presentation, thank you.

Dr. Steven Kaplan:

Thank you, Amy. I appreciate the introduction, it's a pleasure to be part of this group and hopefully participants will enjoy this. So, this will be a presentation on multiple ways of drug a bipolar TURP. Some of it will be my own pictures or video. I also want to think Ken Kernen and Nick Warner for their contributions as well, and we'll look at various parameters and approaches to do that. And this is an evolving field and I was very curious about the poll results, because this is a interesting evolution and with new technologies. And certainly, Amy, you've done terrific work with holmium laser nucleation and for huge prostates. So, we'll see how this evolves as well.

Dr. Steven Kaplan:

So when we go in, we go in with a 30-degree lens and get sort of an idea. And I've cystoscoped patients always previous to the procedure, at another sitting. And this is a typical patient with significant urinating symptoms, you can see his bladder's very trabeculated and we do inspection. At a teaching hospital, I usually have the residents do this. With the middle lobe, they do have to kind of change the angle. This is the thinner loop that we use for most resections. You'll see a little bit later, a thicker or a band loop as the case may be. So, this is just a typical inspection we do.

Dr. Steven Kaplan:

This is a patient with a relatively smaller prostate. And this was done, I think this was actually pre-UroLift and pre-REZUM. Because this is a patient who typically we probably would have done a UroLift on or a REZUM. And it's interesting also, as when I came to Mount Sinai, I was trained at Columbia when I do a TUR is to start from the top and move my way down. Just because of I'm mostly right-handed in doing this, although left-handed with other surgical approaches, so I will start usually on the patient's left. We'll resect usually at the one o'clock position and let the lobe drop down. What's curious is that it's kind of apparently a unique technique. At Mount Sinai, most people were trained to do it from bottom up. They go from the six o'clock position upwards, and I always found it to be easier to go down.

Dr. Steven Kaplan:

And again, this is a relatively small prostate. The key thing, and certainly in smaller prostates, is just to go slow. You really want to make broad contact. I think that's one of the mistakes people do with a bipolar loop is they tend to go too quickly, and you really don't get the good surface contact, Which is the advantage of the bipolar, because it has a greater cutting ability. But you really have to go a little bit slower, and then you get the coagulation as well. We tend to finish one side, and then flip over to the other side. Again, one of the advantages of these types of techniques versus pure ablation is you're able to get good tissue.

Dr. Steven Kaplan:

And this patient has a slight middle lobe, but really nothing much. So sometimes depending on the middle lobe, I'll maybe start there as I'll show you in some of the later videos, and then work my way upwards. So, it really depends on this typical patient. One of the things we've also evolved in, that you won't see here necessarily, is to preserve ejaculation. Which I think you can do regardless of whatever surgical technique you use, is to leave the apical tissue. Which is also kind of interesting, because at least when I trained, we were told that ejaculation is preserved by keeping the bladder neck. And what we've learned is that's actually not true. You keep the apical tissue or an ejaculatory hood, whatever you want to call that, and then you can preserve ejaculation.

Dr. Steven Kaplan:

So here, we are completing on the patient's right side, I'm going the opposite side. And again, the key thing is even here with bipolar, you don't really see much bleeding. And that has to do just because of the size of the prostate and we're doing the video, we want to make it nice, is to go a little bit slower. But certainly in larger glands, you have to kind of also deal with some bleeding issues. It's usually not going to be as clean as this. Another technique, in terms of that we teach the residents, is to take long swipes. Sometimes people take bits and pieces and they wind up in valleys, and that's how you get into trouble. So if you take kind of knowing the anatomy, you can go from bladder neck towards the veru and take these longer cuts. You tend to avoid some of the divets or the peaks and valleys which can cause bleeding as well.

Dr. Steven Kaplan:

So, it requires a little bit of patience. And here is actually, we're going a little bit slower than we normally do. But again, you can help with preserving bleeding. We've evolved actually over time to really concentrate also on the apical tissue and leaving it here. We've learned a lot, and we can discuss a little bit later in terms of what we've learned from some of the other techniques and technologies such as laser and aquablation, about how we can modify even the electrical resection here.

Dr. Amy Krambeck:

Can I ask a question?

Dr. Steven Kaplan:

Sure, please.

Dr. Amy Krambeck:

So, these are beautiful swipes that you're taking. And when I've watched other people do TURPs, sometimes they will leave the tissue stuck to the capsule. There are these hanging tags. How are you doing that, are you keeping your foot down on the pedal the entire swipe all the way through?

Dr. Steven Kaplan:

Right. And also ... that's a great question. So what the key thing is keeping your foot on the pedal and then at the end, swipe up a little bit. Because if you do that, then it kind of clips the bottom of it. So you sort of lift your hand up slightly, and then you're able to disconnect the tissue from the prostate itself. It's a little bit of an upward ... at the end of the swipe, you kind of lift up a little bit on the loop and that really helps a lot. So here is, sometimes we will ... most of the time with smaller prostates I'll just use the loop. But with larger prostates, we tend to do a sandwich technique. And we'll show that to you in a couple of minutes.

Dr. Steven Kaplan:

So, one of the things I find kind of interesting also is the way people use the button. And they want to use, they tend to run the coag. So, people have to understand the mechanics of this. If you aren't cutting, you have to stay in one spot. Excuse me, if you're on coag setting, you have to stay on one spot for it to work. You can't continue the motion and coag, it doesn't ... that's not the mechanics of the loop. Here we're actually vaporizing in the cutting setting, but the coag should be a spot.

Dr. Steven Kaplan:

Here's a patient, so this is another patient with more of a middle lobe. And we've actually published our results with doing a middle lobe only TUR. And I think what we've learned also is it's probably less successful in patients with 120, 140-gram prostates. But certainly patients with I would say, 40 to maybe 60-gram prostates and they have just this big middle lobe sitting in the way, you can do just as middle lobe only. Now this is ... and we evolved in this technique as well. So it used to be we would just resect the middle lobe, but what we've learned actually is we go with the five and six o'clock position. So, this is a patient actually we're doing a trilobar resection. But I think what we've learned is for a middle lobe only TUR you swipe down at five and seven from bladder neck to veru, and then it just sits up like a big lollipop almost. Then you can resect and vaporize.

Dr. Steven Kaplan:

So this is using a faster technique, and you can see this is where you want to sort of make time up. And then you can basically use this sandwich technique, this is in larger prostates. And again I go, tend to be a little bit slower. This is a video for one of my colleagues. You can use both the combination of the loop as well as the button for vaporization. This is in a cutting setting, not in the coag setting. Should also be remembered that one of the things, that certainly as we teach the residents, sometimes they ... you have to torque the loop towards the tissue. That's a common mistake people make, which is why they lose vision. Because if you just leave it in the middle and think you're going to just cut away, it's not going to work. You don't really take advantage of the continuous flow that way.

Dr. Steven Kaplan:

So here's someone who doesn't mind ... we'll cut and not coag. I tend to do things a little bit differently. I tend to ... I'm very neat, so I like my desk clean at the end of the day. So the same here, I will go after bleeders and just keep it clean. Because eventually, you're going to have to get them anyway. I like to get them particularly if they're beginning to obscure my vision. This is more of a quicker technique using both the loop as well as the button for vaporization. And we've adapted frankly as well in terms of what are thresholds for TUR. It was interesting to see that most of the people on the poll are comfortable with doing over 80. And I used to do 120, 130-gram prostates. But I must say that I probably didn't do as good a job in retrospect as we would have liked, simply because they're big. I think we're also evolving in terms of our algorithm, and we talk about that a little bit later.

Dr. Steven Kaplan:

So again going back to the button, just very important to get good contact. And the way you know you get that is you get those bubbles. And you've seen from here that when you make good surface contact, you're able to really vaporize the tissue. So here's a bleeder, and you don't run back and forth on it. You just really sit and coagulate that. That's very, very important just in terms of technique. Here again, if you run it on the cutting setting, it will coag as well. You can see that white blanching of the tissue, which means you're making good contact, and the bubbles. Here I would say it's probably a little bit more superficial, and we'll show you a little bit later that it needs to be a little bit deeper.

Dr. Steven Kaplan:

So here's Jonathan Warner, and he's done some really interesting work. And I've not done this technique. So, this is an enucleation. And he uses a thick loop, you see that's a thicker loop. This is how he creates ... it's kind of similar to what I guess, Amy, you do when you do the holmium in terms of creating the planes for enucleation. Again, full disclosure, I've not done this technique. Full credit to Jonathan for providing that, and I appreciate that. He kind of maps out both proximally and distally. Then you can see, look how much he uses the loop and the tip of the resectoscope as his finger almost as a guide for doing this. It's a really cool technique, and you can see how he's manipulating the scope. Usually using that and the loop as kind of his finger guides. He tries to get out towards capsule. If it bleeds in the way, obviously he's going to take care of that.

Dr. Steven Kaplan:

And I think just watching this is kind of very, very interesting. And you really need to know your anatomy and feel comfortable in terms of what the capsule is. For those who enucleate, whether it's using here a bipolar technique or holmium like you do, it really means just a confidence and understanding of the anatomy. Where you actually develop those planes, so you can create this really good balance in terms of where you resect. Most of it is actually, it almost looks manual in terms of just creating these planes. You can see, or look how far he's torqueing. It's just a fascinating way of doing that, and then can resect out as it sits there. He kind of, if you will, devolumes the prostate after it's sort of sticking up for him. He can just go to town on some of this and this is a very, very large prostate. He can resect some of this once it's just sitting right in his face, as he's doing here.

Dr. Amy Krambeck:

That is a fantastic technique. One of the participants asked, what would make you choose between a button and a loop?

Dr. Steven Kaplan:

So, I almost always use a loop. And if it's really big and there's bleeding, I'll add on the button. There are times when just ironically if you, if I've had a very large intravesical lobe that's really protruding back ... and it reminds me of a couple of patients like this. There is where it's hard to get the loop in and know your anatomy. With the button, you can debulk and get it down to a point where you're seeing your anatomy a little bit better. And I think that helps a lot. But I would say the vast majority of time now, I'm using the loop. I have ADD, I can't, it's hard for me to just whittle it down with a button. I like these newer buttons as well, but the loop helps me just go a little bit faster. So, that's why I usually will do a loop.

Dr. Steven Kaplan:

And sometimes I'll do a sandwich technique. If I feel there's a lot of bleeding or more bleeding than I would like or it's a big fossa and some capsule, then I will use the button to kind of finish it up in terms of coaging. And the vision seems to be better when you put the button in. So, it's actually Jonathan Warner. I wrote Nick, so my apologies. But they provided a lot of these techniques. I think the thing is you just got to be where you're comfortable. I think we're all evolving, frankly even I have. I have ... now shifting my algorithm from where in larger prostates and going more towards aquablation for those, because I just found that to be a very good technique. Obviously holmium is a terrific technique as well and nucleation, I mean those are all great for bigger prostates. I think the place where this may really impact more than any place else is how many simple prostatectomies we wind up doing. Because I think our patients would rather have a transurethral technique that can be done, or a spinal for example, than an abdominal approach.

Dr. Amy Krambeck:

Those were fantastic videos, and just a nice array of techniques there. I have one more question before we switch to Dr. Martov. You talked about leaving apical tissue, and have you noticed that when you leave the apical tissue that you have any improvements in early continence?

Dr. Steven Kaplan:

Well, I've not had the continence issue frankly. That's not been at least our experience with doing a bipolar or even monopolar TURP. The reason we focused on that was really because of ejaculation. So in the population that I take care of, a large portion of them for religious reasons, antegrade ejaculation is no big deal. So we've evolved, and I've been very ... I've learned a little bit over the years in terms of how to preserve that. And I've just found that leaving the apical tissue is all you need to do. It's interesting to see, and we had a seminal publication a couple of years ago. But other people have described ejaculatory hoods, leaving apical tissue, et cetera, et cetera.

Dr. Steven Kaplan:

And that's another advantage of doing things transurethrally. Because if you're going to do a simple prostatectomy, whether robotic or open, you're going to get retrograde ejaculation. I mean it's just going to happen, because you can't with your fingers or with instruments preserve that. So, that's another advantage of transurethral approaches. Which is why I like ... again, while I don't do the holmium enucleation. It's a beautiful technique for larger prostates, and I think aquablation as well. And we've done them in 200 and 250-gram prostates now, aquablation. So for me, that's becoming more of my go-to for larger ones. Where the breakoff point is, I think we're all going to learn and the answer's I don't know. Will I start doing them over 80, even though I'm comfortable with TURPs over 80? I don't know yet. I think that's something we're all learning, it's going to be fun.

Dr. Amy Krambeck:

Well, it's great. And I said that was the last question, but people keep asking about this apical tissue. So, let's just answer it. How much do you leave, and then does it affect their Q max or have you noticed any decrease in their voiding?

Dr. Steven Kaplan:

Right. So no really change in voiding, because I think the money is proximal. I've always felt that way. It's usually the bladder neck tissue, and it's more of that proximal tissue. If you can imagine, essentially you leave the end, maybe 5% to 10% of each of the lateral lobes behind. And for those of you who've done aquablation, it's called a butterfly cut.

Dr. Amy Krambeck:

Yeah.

Dr. Steven Kaplan:

So if you can imagine just leaving a very thin butterfly with the vera up like this and the tissue like that, that's it. You don't have to leave that much tissue. It's more leaving kind of this flap on both sides, and that's really ... it kind of works. It's hard for me to explain it verbally, I'm thinking of it just visually in terms of a butterfly. It's not much tissue, and it has not that effect. But once you kind of protect the veru and the ejaculatory ducts, you can see them and you haven't resected any of there, that's all you need to do. It's actually a very good technique, and it makes me think that you can do surgical approaches and still preserve ejaculation.

Dr. Amy Krambeck:

That's fantastic. Well, thank you, Dr. Kaplan. Wonderful presentation. They'll keep giving questions while Dr. Martov talks, and at the end we'll answer more questions.

Dr. Steven Kaplan:

Mm-hmm (affirmative), thank you.

Dr. Amy Krambeck:

Dr. Martov, you are up to bat.

Dr. Alexey Martov:

Okay. Dear colleagues and friends, this a great pleasure for me to participate in this event. We have seen the nice presentation by Dr. Kaplan. And now I'm going to present current status of TURP and discuss with you, do we still need it? There are well known absolute and relative indications, but most frequent reason for BPH-related surgery are LUTS reluctant to medicines. And this slides illustrates how urologists perform TURP three or four decades ago. It was not only uncomfortable, but also there were risks of infection complications.

Dr. Alexey Martov:

There are several types of TURP. The first one is so-called pseudo-TURP, when the surgeon makes only the way to urine and leave the most part of the adenoma. Second kind of TURP differs from the third one, only with the amount of the resected tissue and total TURP is performed only in case of prostate carcinoma. Conventional TURP is the oldest BPH procedure, and three well known techniques were described. First one is the Barnes technique, the most traditional one. Operation begins with the median lobe resection, then followed by resection of lateral lobes until all adenomas remnants will be removed. Second operation type is Nesbit technique. It allows to provide early coagulation of main arterial vessels which supply lateral lobes. Alcock-Flocks TURP was developed to maintain orientation during the removal of large glands, using lateral grooves. Such tunnels improved irrigation and provided better visualization.

Dr. Alexey Martov:

Subjective and objective results of surgery still equal through the years. TURP remains so effective as it was three or four decades ago. The operational is with rapid relief of the symptoms and to improve the urinary stream. The major risks of monopolar BPH surgery are so-called water intoxication syndrome, bleeding, and electric burns. Here are the data from the large burn study which enrolls more than 10,000 patients. As you can see, complication rate increase proportionally to the prostate size. When the resected volume was more than 60 cc, TURP was a rather dangerous procedure with transfusion rate 9.5%. TUR syndrome about 3%, and surgical revision about 10%.

Dr. Alexey Martov:

Anyway, the technical developments allow to introduce into the clinical practice bipolar and laser techniques which are currently comparable with TURP. We have widened our TUR techniques. And nowadays, there are four validated monopolar and bipolar techniques for BPH electrosurgery. Incision is used when the prostate volume is small without median lobe and intravesical protrusion. Vaporization has an advantages when the bleeding is likely. Is bloodless and easy, good option for small and medium bleeds and ideal for one day surgery, but with increased reoperation rate. Enucleation is the recent technique which employ the same principle as simple prostatectomy. But time consuming procedure with a regularly long learning curve, but with excellent long-term durability and short hospital stay.

Dr. Alexey Martov:

Let me return to the TURP status, we are continue to improve. We have seen the surgeon in a very uncomfortable position, and now we can sit quite well and see the detailed digital picture. HD-endoscopy let us not only protect our risk, but we could estimate the prostate and other important [inaudible 00:27:16] better. It's also easier to teach TURP, because the doctors could see little operations and then see full-lengths operational video. Instrument innovations for TURP include digital camera and motoroptic for better visualization. Last versions of bipolar and monopolar generators which are safer and have friendly interface continues flow irrigation, rotating sheath in many, many, many others. The bipolar technology, where the current runs only on instruments, is the most important innovation. It diminish so-called TUR syndrome, and one of the most terrible and fatal hazards of monopolar TURP.

Dr. Alexey Martov:

All above mentioned allows to remove huge amount of tissue is TURP now, just discussed about it. There are a lot of randomized clinical trials comparing mono and bipolar TURP. Now, it's clear that the efficacy is equal and the safety of bipolar surgery is better. And as for bipolar surgery as for resection, it's absolutely equal. But as for coagulation I'm ... not agree, because the coagulation for monopolar TURP is better I think.

Dr. Alexey Martov:

And now I would like to highlight some tips, tricks and potential difficulties of the procedure and how to manage them. If the introduction of the sheath in the meatus or urethra is difficult, it's a value to lubricate and then perform Otis urethrotomy instead try to force the instrument. Here's a small video about Otis urethrotomy. In case of large penis or gland, it's also possible to use extra-long resectoscope. The length is six centimeter longer than conventional one. The sudden erection could complicate TURP, local cold anesthetic at the base of the penis or adrenaline intracavernously are required. For TURP in general, and especially for the middle lobe resection, the systematic approach is essential. It's better to do parallel cuts from the intravesical top of the lobe towards the veru. The urogenital orifices and veru must be checked. And you can see short cuts and prolonged cuts in this video.

Dr. Amy Krambeck:

Dr. Martov, what sized French of a scope do you use, what is the size of the scope?

Dr. Alexey Martov:

Usually 26 continuous flow.

Dr. Amy Krambeck:

When you ... do you ever use 28?

Dr. Alexey Martov:

Yes. In very large glands I saw, I use 28 of course, yeah. And I use Otis urethrotomy before.

Dr. Amy Krambeck:

Okay. And I use the same for mine as well.

Dr. Alexey Martov:

Yeah. There is a possibility to damage the orifices, especially if there are close to the middle lobe. Please note that the distance to the orifices could be more if the blood is full. And another hazard is too aggressive resection at six o'clock position, it may lead to the perforation. If the lateral lobe is large, it is a value to make so-called orientational channel. It make the irrigation better and the resection easier. After the removal of the lateral lobe, the wound area should be smooth. So prolonged cruciate cuts are advisable in such situation. And as for apical remnants in order to avoid the urodynamical narrowing at the level of apical tissues it is important to evaluate the sphincter zone and detect the tissue remnants in, at this position.

Dr. Alexey Martov:

Bleeding management, the arterial bleeding deteriorates the endoscopic view and must be stopped once occurs. It's necessary to avoid false coagulation, the latter happens if the sheath presses on the tissue and the bleeding stops. Once the instrument moves, the bleeding continues. In such case, the resection of the residual tissue is advisable. The venous bleeding is normally it couldn't be observed during the resection. The partial close of the inflow could detect it. And if yes, coagulation, diuretics and the tension position of the catheter are necessary.

Dr. Alexey Martov:

Typically there are two ballon position after TURP. The placement balloon in the fossa is justified in case of large gland. In this picture, you can see. If the fossa is small, the balloon is inflated in the bladder and keep in the tension position at the bladder neck. You can see it in this video. And tension.

Dr. Amy Krambeck:

And you will place that in the fossa to control bleeding?

Dr. Alexey Martov:

Yeah. To position in the fossa, and in the bladder, okay. The floating unresected tissue are the most frequent cause of presented dysuria after operation. And in this video you can see, you see phantom lobes here. And the main causes of post-operation dysuria. So, they have to resect it of course during the operation.

Dr. Alexey Martov:

Like to conclude that TURP in 2020 is cost-effective, efficient and durable procedure, has a low complication rate and well-established retreatment rate. And no one of alternative treatment types for many, many years couldn't offer such advantages. And I don't know what the better, TURP now or enucleation. I like TURP and like enucleation too. And thank you very much for your attention.

Dr. Amy Krambeck:

That was a wonderful talk. I, we learned quite a bit. And there was several questions from the audience on your talk.

Dr. Alexey Martov:

Yeah.

Dr. Amy Krambeck:

Once of them was, do you always use the Otis urethrotome?

Dr. Alexey Martov:

No, no. No. No. I calibrate urethra in every case. But as for Otis urethrotome, only when I use big resectoscope, 28 French. Or when I see a narrow urethra or meatus.

Dr. Amy Krambeck:

Perfect. I use it too, and I don't know a lot of people that use it actually. I think it's a very helpful device. And then when you preserve that apical tissue, you showed a video with some apical tissue preserved. Are you doing it for the same reason that Dr. Kaplan does it, to help with preservation of ejaculation?

Dr. Alexey Martov:

It depends. When I speak with a patient about ejaculatory-protective TURP, I do it. I save some tissue near the veru. But in the usual way, in the usual cases, I evacuate all tissue near the veru too. So, I use a so-called sphincter test. Control sphincter, external sphincter, and evacuate all the tissue near the veru.

Dr. Amy Krambeck:

Perfect. And for both of you when you use this preservation technique, what do you tell your patient is the likelihood that they will get, they will be able to preserve their ejaculation? Is it 100% or is it 70%, or what is the likelihood that it will work?

Dr. Steven Kaplan:

[inaudible 00:37:56].

Dr. Alexey Martov:

So their preservation TURP, I think more for younger patient, if I spoke with any patient about ejaculation preservation of course. And we discuss with the patient about it. And if the patient want to have a antegrade ejaculation, I do the ejaculatory protective TURP of course, many ages.

Dr. Steven Kaplan:

Yeah, I tell patients that we can get it to 95%. And people say, "Can you guarantee?" We can't guarantee anything. But usually if you do that, I think it's a terrific possibility to maintain ejaculation. Or a middle lobe TURP only was kind of the prelude to doing that, we found almost universal preservation of ejaculation. So we've learned a lot, and I think we're evolving. And as Professor Martov says, it has to be for the right patient with the right type of discussion. But I think we can almost approach minimally invasive type of numbers with some of these techniques.

Dr. Amy Krambeck:

That's phenomenal. And I did, I personally had a question about the extra-long resectoscope. So they make that for TURP, they don't make that for enucleation procedures if you're doing holmium. Have you ever had cases where the extra-long resectoscope would not work? Like if the patient was morbidly obese with a large prostate, would you ever do a perineal urethrostomy or some other technique to do the procedure?

Dr. Alexey Martov:

As for me, I prefer a extra-long resectoscope. And if their prostate is very, it's huge. In the case of a very huge prostate, I use it, extra-long resectoscope. And it's not special instrument for a laser surgery, but it's possible to use it with optical obturator. No problem with laser, I use it.

Dr. Amy Krambeck:

Perfect. Perfect. Several questions about stricture disease, so do you notice any difference in urethral strictures when you use a bipolar versus a monopolar versus a button? Has anybody seen any differences in this?

Dr. Alexey Martov:

No. As for me, no.

Dr. Steven Kaplan:

Mm-hmm (affirmative).

Dr. Amy Krambeck:

Okay.

Dr. Steven Kaplan:

Yeah, I agree.

Dr. Alexey Martov:

No any differences.

Dr. Steven Kaplan:

I also want to get back to a question you asked, Amy, before about the Otis urethrotome.

Dr. Amy Krambeck:

Mm-hmm (affirmative).

Dr. Steven Kaplan:

And I love using that, I can't find anyone who's manufacturing it now. But we used to love that, it virtually eliminated completely the rates of meatal stenosis. So now we just dilate the 30 French, as Professor Martov was alluding to as well. But if you know how to get one and you can find one, and know who makes one, let me know. Because I love that instrument, I think it was just perfect for these things.

Dr. Alexey Martov:

I would agree with you. I agree with you.

Dr. Amy Krambeck:

Well, it sounds like we need to talk to some companies then to get that back.

Dr. Steven Kaplan:

Yeah, Lepus used to. Well, it was ACMI. And then that was, gotten under the umbrella of Olympus. But they don't seem to make it anymore. So, I think it's a great instrument.

Dr. Amy Krambeck:

Yeah. And I agree with you, I think it virtually eliminates the meatal stenosis, it's a wonderful device. There's been several questions that came in asking what your settings are for cut and coagulation, can you both comment on that? Dr. Kaplan first.

Dr. Steven Kaplan:

So in the bipolar, it comes ... it's kind of a preset. I'm trying to remember. I think it's 200 and 120, although I may be wrong, because just literally it's a preset. And I don't really adjust. Sometimes some of the rep will come in and they'll say, "Hey, try different things." And I find that you don't have to really adjust too much, very rarely. So, I'm not 100% sure. I think it's 200, 120. I would have to check on that, but there is a preset mode that goes together with their loop and electro button.

Dr. Amy Krambeck:

Okay. Dr. Martov?

Dr. Alexey Martov:

I use standard power for resection. As for monopolar, I use 220 where it's for resection and 80 volts for coagulation. As for a bipolar, it depends of the generator. What kind of generator do you have? But I would say that as for resection mode, it's very good and we have very good resection with bipolar and monopolar. But as for coagulation, I think a monopolar, coagulations are better. Because we haven't such kind of motors performed coagulation, some kind of and some variety of coagulation as you have in monopolar. And as for monopolar, we can use spray coagulation. And as for bipolar coagulation, we need full contact for good coagulation only.

Dr. Amy Krambeck:

Yeah. So, is that what will guide either one of you to do monopolar versus bipolar? If it's a bigger prostate with a lot more bleeding vessels, will you use monopolar as opposed to bipolar or no?

Dr. Alexey Martov:

A bigger prostate, it's better to use bipolar. Because we use saline and no dangers about TUR syndrome. As for monopolar, it's very dangerous. Because it's-

Dr. Amy Krambeck:

Is there any real role for monopolar anymore then?

Dr. Alexey Martov:

Mm?

Dr. Amy Krambeck:

Is there a role for monopolar, when will you ever choose monopolar?

Dr. Alexey Martov:

Monopolar for prostate less than 100 grams. And for bipolar, but previously I use monopolar for 200 and 300 grams. But now I have bipolar, it's better. It's less dangerous and it's more comfortable to work with bipolar, because less complication rate, less dangerous of TUR syndrome. Less hazards, so it's better.

Dr. Amy Krambeck:

Okay.

Dr. Steven Kaplan:

Mm-hmm (affirmative).

Dr. Amy Krambeck:

Dr. Kaplan, do you ever use monopolar anymore?

Dr. Steven Kaplan:

No. It's interesting. So a couple years ago, decades, we helped popularize the vaporization, transurethral vaporization technique using the new generator. What we found is, Alexey mentioned that the generator was very, very important. Because it's a resistance issue, and some of the widely used monopolar generators could not be adapted. And there were some very good adaptors, adaptions. But then we started doing the bipolar, and I haven't done a monopolar in probably 10 years. So, I don't find any particular advantage of using a monopolar. It's really a cost issue, frankly, for a lot of other places around the world. But here in the US, once they've adapted that, it hasn't really been an issue.

Dr. Amy Krambeck:

Perfect. Perfect. Another question that came in is have either of you ever used staged TURP techniques? So resect one load, bring them back a little bit later. How would you do that, and why would you do that? Dr. Kaplan?

Dr. Steven Kaplan:

So a while ago, yes. There were a couple of patients who maybe have had 150, 160-gram prostates. Didn't want to have a simple prostatectomy, were too sick and we did a staged TURP. But today frankly, I think now with newer techniques, there's really no upper limit. As I said before at least with aquablation, and I presume you will have the same experience with holmium enucleation, you can, we can do prostates 200, 250 grams. I mean, next week I'm doing four aquablations. And I think the average size, 170 grams. Which would be someone in the past I would have just referred out or have done a simple prostatectomy. But now we can do that, and I'm sure you're comfortable doing that as well with your technique. So, we don't have to do staged anymore.

Dr. Amy Krambeck:

What about you, Dr. Martov?

Dr. Alexey Martov:

I usually use staged technique, and I consider that the main principle of TURP is to provide systematic approach while the tissue is resected. And you should never resect new area until ... you don't finish the previous one. More comfortable for teaching staged technique, and you should make one cut next to another, you should recreate in staged manner. It's better. It's less dangerous, more comfortable. And it's better, I think so.

Dr. Amy Krambeck:

Wonderful. Another question for you, Dr. Martov, you talked about the phantom lobes causing dysuria or burning. How long will you wait before you suspect a fantom lobe? Because a lot of people will get burnt, burning and dysuria after any urethral procedure. So at what point do you say, "Well, this could be residual tissue and I need to do a scope and look."?

Dr. Alexey Martov:

Depends on, of patient clinic.

Dr. Amy Krambeck:

Yeah.

Dr. Alexey Martov:

If the patient after the operation, after three month have LUTS, I have to examine this patient. Maybe phantom lobes will cause LUTS, and I will operate him.

Dr. Amy Krambeck:

Okay. So it's by three months, really there shouldn't be much burning and-

Dr. Alexey Martov:

Three months, maybe a little bit later. But it depends of the patient, of his symptoms.

Dr. Amy Krambeck:

What about you, Dr. Kaplan? Is that your approach too, or?

Dr. Steven Kaplan:

With, I lost the beginning of that question? I'm sorry.

Dr. Amy Krambeck:

Oh. Persistent dysuria after the procedure, do you, when do you suspect that there's some wrong?

Dr. Steven Kaplan:

Yeah, I mean I tell patients regardless for the first month, they may get worse before better. And that's for anything, frankly. Because I'd rather them say, "No, it wasn't so bad." And I always give them the most conservative things. What would make it worth ... I've seen patients have dysuria and urgency at a month and two months, and they're fine at three and four months. It's some patients, I'm kind of leary about giving them de novo medications. Because those have side effects, and it also depends on the bladder. So for example, because I do preoperative pressure flow studies on everybody. So if somebody's got a very low bladder capacity preoperatively, I know that that patient's going to have urgency and frequency. It's going to take a while for them to adapt. It's kind of individual, I can't say that there's one metric. We try to use all the metrics together and then manage expectations.

Dr. Amy Krambeck:

Got it. Got it. Well, that probably is into a couple of other questions. And one of the questions was, what is your standard workup before proceeding to surgery? And so, you do pressure flow like urodynamic studies on all your patients.

Dr. Steven Kaplan:

Yes.

Dr. Amy Krambeck:

Do you do cystoscopy as well?

Dr. Steven Kaplan:

Yeah. So we will do a cystoscopy, a transrectal ultrasound, and a pressure flow study. Now some of that, there's been just interesting analyses of that. So the pressure ... or the reason I do a TRUS is because looking whether I'm going to do a minimally invasive procedure a REZUM versus UroLift, middle lobe, no middle lobe, et cetera. And I want a volume. And for me, intravesical prostatic protrusion is a big metric for me in terms of predicting which procedure I'm going to do. Cystoscopy, I don't want surprises at the time of surgery. I can cystoscopy in my office, so it's kind of easy to do. Pressure flow studies, I mean I was trained that way. There are data to suggest that it may be helpful, data to suggest that it's not helpful. It's certainly not mandated be any stretch.

Dr. Steven Kaplan:

But particularly in New York, maybe our patient clientele, they come in thinking that they know more than I do. And maybe sometimes they do, I like to know what their bladder function is. And you want to know whether they're obstructed or not. It's not that I won't do a TUR in an unobstructed patient, it's just the likelihood for success may be less. I think that helps a lot. Certainly there's these classic criteria of when to do pressure flow studies. Neurogenic bladder, a younger patient, patients have previous therapy, I think we would all agree. But I've done pressure flow studies in everybody and I haven't found that to be a pushback in, from patients. They're fine with it.

Dr. Amy Krambeck:

Wonderful. Dr. Martov, what about your standard workup?

Dr. Alexey Martov:

IPSS, first one. Transrectal ultrasound, second one. Urogenetics of course, but not a pressure flow for all and no any cystoscopy before.

Dr. Amy Krambeck:

Okay.

Dr. Alexey Martov:

No. No.

Dr. Amy Krambeck:

No. Okay.

Dr. Alexey Martov:

And then it is of course ... yeah.

Dr. Amy Krambeck:

What if they have failed a prior procedure, will you do cystoscopy then? What if they have failed a prior surgery, like they've had a TURP before and they still can't urinate?

Dr. Alexey Martov:

No. No. I use so-called [inaudible 00:52:09]. So inside the operation, I decide it and I do cystoscopy. So it's, I don't need cystoscopy before.

Dr. Amy Krambeck:

Perfect. Perfect. Great. And another question that has come up several times during the talk is do you, either one of you feel that patients need to try medication first or do you feel more like you want to take them to surgery earlier than what you used to do? Do you rely on medications as heavily as we did maybe five, 10 years ago?

Dr. Alexey Martov:

Sorry.

Dr. Steven Kaplan:

No, Professor Martov, you go first.

Dr. Alexey Martov:

Or whatever, it's okay.

Dr. Amy Krambeck:

Sorry.

Dr. Alexey Martov:

It's-

Dr. Steven Kaplan:

No, you're in Moscow, you go first.

Dr. Alexey Martov:

Yeah. So medication of course, just start with medication. And when it's failed, surgery.

Dr. Amy Krambeck:

Okay. Perfect.

Dr. Steven Kaplan:

So, I've evolved. And having been involved in virtually every clinical trial for medications, it's kind of an evolution. And maybe because I've gotten older, so it's also what my tolerance is. But I'm beginning to think ... now we with long-term unintended consequences of maybe 5-ARIs and alpha blockers, cognitive issues, depression. Again, it's evolving. Why would we take, let's say a 55-year-old man and give him medications for 20 years? For me, it doesn't make sense for a quality of life disorder. You can try it for a short period of time, but why ... and again, it's mostly for symptoms. So for my perspective, that's a patient who I begin to have conversations early about a minimally invasive procedure.

Dr. Steven Kaplan:

Now if we have a huge prostate ... and for some reason, we've been seeing a large amount of men in their 50s with prostates 100, 150 grams. It's just been crazy lately. But that's a patient I would not give medications to, I mean what's ... it doesn't make sense. So I think it's evolving, and I think we have to be open to the possibilities that perhaps we should take different approaches. And again, it has to be patient-specific. When we talk about patient-oriented, patient-centered care, that means something. We can't do it, the same thing for everybody. So, it depends on which patient that we're talking about.

Dr. Amy Krambeck:

Perfect. Well, last question and then we will switch to the final slides. What factors do you use to determine when the catheter will come out? What is the deciding factors of when you will take that catheter out for the patient after a resective procedure, Dr. Kaplan?

Dr. Steven Kaplan:

So for me, often it's logistics. So in my schedule, I operate on Wednesdays. In a patient let's say who had preoperative retention ... and I do mostly outpatient, same day procedures. Most of my TURs, 90% of my TURs go home the same day. So, they'll go home with a catheter. The patient's retention, I'm not taking it out the next day. We've just found it doesn't work very well. That patient may have a catheter in for two or three days. But it's usually bleeding or preoperative retention and I'll modify accordingly, and it has a lot to do just with office scheduling and logistics than it does with anything else.

Dr. Amy Krambeck:

Perfect. Dr. Martov?

Dr. Alexey Martov:

I agree with the Dr. Kaplan, the same, depends on bleeding. And my patients have catheter not more than two days, usually one day.

Dr. Amy Krambeck:

Wonderful. Well, you both were so informative. I've learned a lot. They were wonderful presentations and I've truly enjoyed working with you both. So, thank you for your presentations and your time. For the audience, please remember that on December 11th, we have Innovative Robotic Techniques and Technologies. And we'll have surgeons Jens Rassweiler and Ahmed Ghaza. The moderators will be Duke Herrell, Evangelos Liatsikos, I can't say that every time, and Aly Abdel-Karim. I think this is going to be a great presentation.

Dr. Amy Krambeck:

And we encourage everyone who is not already a member to join the Endourology Society. Your membership dues benefit you in many ways, you get the Journal of Endourology, video urology and case reports as well as endourology case reports. So please go to www.endourology.org. And again, save the date, WCE 2021. September 21st through 25th in Hamburg, Germany. We hope to see you all there. Thank you very much and have a great day.