Surgeon: Dr. Zeph Okeke, M.D.
Zeph Okeke, MD serves as co-director of the Smith Institute for Urology Endourology and Laparoscopy Fellowship training programs. He is known for developing and being the principal investigator of the novel S.T.O.N.E. classification system for kidney stones. His expertise is in using minimally invasive techniques for the management of complex kidney and ureteral stone disease, and urothelial cancers (transitional cell carcinoma) of the kidney and ureter. He also has special interest and expertise in Holmium and Thulium laser enucleation (HOLEP and ThuLEP) for enlarged prostates (BPH).

Moderator: Prof. Andreas Gross, M.D.
Prof. Andreas Gross is a Chief Physician of the Urology Department in Barmbek Asklepios Hospital. He is a TOP German urologist specialized in treatment of prostate cancer, bladder cancer, renal cancer, testicular cancer, benign enlargement of the prostate, urinary calculi, etc. The Doctor was recognized as one of the leading specialists of Germany in the field of urology and nephrology by authoritative medical site leadingmedicineguide.

 

Webinar Transcript

Jared Winoker:

I'm Jared Winoker from Johns Hopkins and behind the scenes with me today also we're joined by Dr. Tim Large from Indiana University. Who's also going to be helping us answer some of your questions as they pop up throughout today's webinar. For reference, this is an overview of our CME program for today's webinar. And for today's webinar, we're going to be hearing about Thulium Laser in the treatment of BPH. And we're privileged to have two of the foremost experts in the field who actually share a wonderful collaborative and educational history together. Our surgeon is Dr. Zeph Okeke from Northwell Health in New York. And moderating his prerecorded semi-live surgery, we're joined by Dr. Andreas Gross from Asklepois Hospital Barmbeck in Hamburg, Germany. Before we get started, I'd like to just go ahead and remind everyone of our upcoming webinar which will be taking place at the same time next week in which we'll be hearing from Dr. Manoj Monga and Brian Matlaga about PCNL Tips & Tricks.

Jared Winoker:

And you can register for this session and other upcoming sessions, as well as view any of our previously recorded webinars all by visiting the endourology.org website simply click on the education tab and then masterclass in endourology. With regards to continuing medical education for today's webinar as well as our other webinars, you're going to go ahead and receive a survey from Michele Paoli by the end of each month, all you need to do is go ahead and indicate which seminars you've attended during that month and then you'll be sent your CME certificate to the email with which you've registered for our webinars. Importantly, please do fill out the evaluation questionnaires that you'll receive at the end of the seminar today, as those are important for securing your CME credits. And finally, we also want to encourage you to use the Q&A function to ask questions today and also participate in our poll questions as they pop up.

Jared Winoker:

I'm sure doctors Gross and Okeke will do their best to answer all of your questions in the allotted time. But please be sure to check back at our masterclass website later to find our experts responses to any of your unanswered questions, as well as both a transcription and a recording of today's webinar. And so with that Dr. Gross, I will turn it over to you.

Dr. Andreas Gross:

Thank you very much, indeed. And hello from Hamburg, Germany. It's six o'clock PM here and can you see me? Can you listen to me?

Dr. Zeph Okeke:

Yes. We can see you.

Dr. Andreas Gross:

Okay, perfect. So again, it's 6:00 PM in Hamburg, Germany, seven o'clock in Israel, 9.30PM in India. So it's still time to go out for dinner after the meeting. And it's nine o'clock in the morning in the West coast. We thought this is a good time for all of you to participate at this meeting. And only for those of you in far East Asia, it's a bit awkward time. But as just mentioned before, you can look at those seminars just as well at the homepage of the Endourological Society. It gives me great pleasure to introduce Zeph Okeke this afternoon. We have a long-term friendship by now and if I would introduce him in a longer extent, I would have to use most of the time of our seminar. He is a very well acknowledged and awarded person in New York City. Let me just say one word, he is a real gentleman. And this is very hard to find in urology and I'm very happy to work with you Zeph for many years. When we met Zeph, you were a holmium guy. So what happened?

Dr. Zeph Okeke:

So thanks for that fine introduction. I started actually doing robotic enucleation after my fellowship training and I found it rather cumbersome. So I switched to the holmium laser enucleation with, I watched some videos, I watched some live surgeries and I think it was very, very difficult to really... Once I got lost it was difficult for me to find my way back. And that's when I met you and you told me about thulium laser. And as you remember, you spent two days here at our institution and as a visiting professor that was a very educational time. And I think you opened my eyes to the advantages of the holmium laser I'm sorry, of the thulium laser over the holmium later. And we'll touch on that during the talk as well and show a little demonstration. And then after that I put some more cases under my belt. I spent about five days at your institution almost a week. Again, bettering my skills at holmium, sorry thulium enucleation.

Dr. Zeph Okeke:

And honestly, I don't see myself going back to the holmium laser as a standard and for the very reasons that we'll touch on during the lecture today. I do use it from time to time when the thulium laser is not available. But otherwise, I'm a thulium guy through and through.

Dr. Andreas Gross:

Okay. So when we started working together, it's a step by step thing and I think it is very educational for our audience. If you want to learn something new, you know the standard saying every beginning is easy, you just have to want to do it. And so what is the step by step procedure? Teach us a bit.

Dr. Zeph Okeke:

So yes. And again, we'll delve into this during the talk itself. Really at the very beginning, I started with the vaporization. So vaporizing the tissue until I was comfortable with really the performance characteristics of the different lasers. And this is where the thulium laser is a tremendous advantage. The vaporization is much, much faster, much smoother and cleaner than with the holmium or even the GreenLight that which I had used previously. And then from there, I progressed to resecting a little bit of tissue and then a little more tissue and sort of as my comfort level increased, then I went to what we term vapor resection. So combining vaporization as well as sorry, vapor enucleation. Combining vaporization with enucleation. And then now I do a full on [inaudible 00:06:25] enucleation using the laser energy as needed at that particular point which again we'll point out during the video today. So I think-

Dr. Andreas Gross:

[crosstalk 00:06:34] I have prepared a videos clips to just show us the huge steps you've just explained. Shall we go into your video?

Dr. Zeph Okeke:

Yes. If we can launch the video, that would be great. Okay. All right. Okay. So a very good stop, just a little background. And before I delve into the talk we're going to, we touched briefly on my journey. We touched at the beginning of the talk on the differences between, the holmium laser and thulium laser. Just show, we'll show a short clip and I just illustrate the different in the patient of what the tissue look like after being cut with the holmium laser versus a thulium laser. And you'll see that the difference is quite apparent and very easy, night and day difference. We'll talk about instrumentation and delve into the progression of your skill set, and we'll talk about how to handle the sphincter as well as the bladder and certain anatomic considerations to keep in mind. And then we'll talk about morcellation, which is often ignored but is just as critical as the enucleation step itself.

Dr. Zeph Okeke:

So if I could give a little background, this enucleation procedure was initially described by Peter Gilling in 1996. And this was the closest anatomic equivalent, endoscopic equivalent to the open enucleation. There are many indications for it we're not going to delve into that in this talk today, but the tremendous advantage of this approach is there's certain things that we had to deal with hospitalization pain and [inaudible 00:08:26] syndrome that are a thing of past today. And now moving forward, the biggest criticism of any endoscopic enucleation procedure has always been the learning curve and how difficult this is to learn. And I hope the talk today will shed some light on how to really shorten that learning curve and reduce the, and really set you up for success. For now, in terms of the learning curve, mentoring is critical which I had in my situation. And do as many cases as you can, and always critique yourself, review your video, look at your results constantly and think of ways to improve, think of things to improve. Now-

Dr. Andreas Gross:

So may I interfere here?

Dr. Zeph Okeke:

Yeah.

Dr. Andreas Gross:

During this learning curve, I really encourage people if you are trapped somewhere in this prosthetic cavity and you don't find your way, get the instrument out you have used for many years because the patient is not your guinea pig. He has to go home and he must be happy. So maybe in the first 20 cases, I have to get my old TRE, TURP loop out in 18 cases. In the next 20, it was maybe in five cases. And until today, [inaudible 00:09:43] a few thousand of those cases. Once in a while, I just have to get my loop out, to get this clear. Don't do any experiments on the back of your patients.

Dr. Zeph Okeke:

Yes, absolutely. That's an important, critical point here. And this is part of the slide here, it talks about the ideal kits to start with 60 to 80 grams. If you schedule a patient for a TURP, this is how I started. I got the laser, the thulium laser so in this case. Vaporize one side see how it performs and try resecting and then try enucleating and see how that goes. And as Dr. Gross just mentioned, you can always resect the patients with the loop and you lose nothing and the patient still has a good result at the end of the day. And they're very, they go home happy with the results that you had promised them at the beginning. So we'll skip through some of these slides a little bit and let's kind of touch on instrumentation. So the lasers I've tried different brands. I've tried the holmium laser, thulium laser. I do prefer the thulium laser.

Dr. Zeph Okeke:

There are different manufacturers really the choice is up to you, try them all. It's free to try, they're happy to let you try their instrumentation on the promise that you might purchase it. So that's something to keep in mind, just try it all until you [inaudible 00:11:04].

Dr. Andreas Gross:

Also important is if you buy an instrument, it is not, a good endourologists can buy and work with an instrument. What you need is good service. And if you have good service from one company in New York, and this company is lousy in Hamburg, you better go for the one which is good at your place.

Dr. Zeph Okeke:

Yeah, absolutely. Very, very critical point. So in terms of your laser settings, it varies depending on your skill set and how really, how comfortable you are. The higher the Wattage with the thulium laser, the better and the faster your vaporization is. I tend to reduce my energy level to about 35 Watts, sorry my power to 35 Watts when I'm working near the sphincter and I try to stay away from the sphincter as much as possible. So again, that's something that we'll touch on during the talk itself. Now, if we could open up the other talk, I just wanted to compare incision using a holmium laser versus a thulium laser in the same patient.

Dr. Andreas Gross:

Well, that's the slide number four.

Dr. Zeph Okeke:

Okay. All right.

Dr. Andreas Gross:

Number four please.

Dr. Zeph Okeke:

Okay, good. Okay. All right. So we'll skip ahead.

Dr. Andreas Gross:

We'll skip this one.

Dr. Zeph Okeke:

We'll skip that slide. All right. So this is what the holmium incision looks like, and this is I keep in mind, this is the same patient. So on the right side we'll make an incision, on the right side with the holmium laser. And you can see the tissue is really, there's a lot of [inaudible 00:12:37] that happens over a wide field of [inaudible 00:12:42]. And we've already made an incision right at the margin in front of the [inaudible 00:12:47]. So you can see this tissue has a very fluffy appearance. Now compare that to holmium laser in the same patient. Now this is on the opposite side, and you can see the-

Dr. Andreas Gross:

That the [inaudible 00:12:58].

Dr. Zeph Okeke:

Nice and clean, clean cut. And the destruction field is much smaller. And the importance of this, if I, I don't want to overemphasize. We can go back to the other talk. The importance of this is if you go too deep into the capsule, it's much easier to correct with the thulium laser than it is to correct with the holmium laser. That's what I find in my experiences. So now yeah. So this is [inaudible 00:13:29] as you go in important to assess your landmarks, this is a video of a patient who was previously resected, had regrowth of tissue. So one side we enucleated, the other side we vaporized. And this is, the point of this here fast forward a little bit, it was just really to show you the performance characteristics with vaporization. So here's the thulium laser vaporizing very fast and very clean [inaudible 00:13:54] with the vaporization. So this is that patient's right side, we vaporized the entire right side regrowth with the thulium laser. There was not much tissue there's the nucleus. So that was a perfect size for enucleation. And here's another, see if I can skip forward a little bit here.

Dr. Andreas Gross:

If you wait, may just stop a bit at the vaporization thing. This is actually what you do with the GreenLight laser as well. You just vaporize. But in opposite to the GreenLight laser, this vaporization with a thulium laser does not respect any color change. It goes on and on. So it does not get worse during the procedure, but it is extremely boring. Because you do, if you're a good one, you do half a gram per minute. And this takes the juice out of here if you have a large prostate, that's why we stopped that. Do you agree?

Dr. Zeph Okeke:

No, I agree. So and the important thing to keep in mind is the char that you see on the surface is very, it's a very, very thin layer. So 24 hours later, if you come in and look at the same patient all of that char is already washed off and you see a nice clean tissue plane. So now this is as you progress in your skill set and this is what I did, I was brave enough to start cutting off chunks of tissue. And as you can see in this video. I cut off a little piece here and I can cut off a bigger piece and this progresses and this allows you to again have good results. And this is actually a lot faster than doing a [inaudible 00:15:25] for a very large prostate. So and as you get more comfortable with something like this, so I'll just kind of let this part play to just kind of show how easy it is to cut very smooth cut, very clean, and always come back and check the sphincter, make sure you're still respecting all the boundaries that you're supposed to respect.

Dr. Zeph Okeke:

So there's an incision right at the apical margin that I'm choosing, and the performance characteristics of the thulium laser is really superior and it allows you to make a clean cut. You can see your margins, you can see your planes very well and it's not absolutely critical on the first resection to really get down to the capsule. You can always come back and correct. I think that's important to get that in mind. Dr. Gross. I don't know if you would agree with that?

Dr. Andreas Gross:

Very much so. You have an idea of the Wattage you've been using in this case?

Dr. Zeph Okeke:

Yeah. [inaudible 00:16:27] So for here, for this part here, I usually go with about 90, 80 to 90 Watts for-

Dr. Andreas Gross:

Actually this is what I'm doing as well. I put my foot on the pedal at 90 Watts and I don't change, and I have not changed for the past five years.

Dr. Zeph Okeke:

So now this video here, again shows more of the same. So we're not going to belabor the point here. But as you progress you can pick more tissue, until you get to the point where you're now comfortable enough to start the enucleation process. And the step before that is the vapor enucleation. So again, you can try to get into the capsule on the first try with your incision. And if you don't, then again, you can come back and either vaporize the residual tissue or you can come back enucleate further as you see fit. So once you're very comfortable, say here we're doing a combination of both a push and also resection. So blunt enucleation and then a resection. Now you can see here I went a little bit too deep there and I recognize it. And you can-

Dr. Andreas Gross:

And that's a very good point. That's a very good point you've just been showing. Maybe you can show it again, because once in a while you go a little bit too deep.

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

And it's a great-

Dr. Zeph Okeke:

So here I am.

Dr. Andreas Gross:

Yeah. And the great advantage of this thulium laser is you just go this two millimeters higher, and with a clear cut you are back where you are. Whereas with the bubbles of holmium laser at the end of your fiber, you would be digging a hole and this would become worse and worse.

Dr. Zeph Okeke:

Yes. A absolutely. So this is a very important point. And this is one of the points we wanted to make with this particular clip is, when you make this perforation you can recognize it. And it's very easy to correct with a thulium laser. And I'll let the video play just to show how we did this.

Dr. Andreas Gross:

[inaudible 00:18:16].

Dr. Zeph Okeke:

And this is seeing it and going just above it. And cleaning up that plane and respecting the boundary. And sometimes you might find that if you continue blunt enucleation or with the holmium laser, you end up actually making this perforation worse. So one may need to vaporize just underneath and get into the right plane. And this is one, really the selling point for me with the thulium laser is that I can easily correct my mistakes before it's too late. [inaudible 00:18:44].

Dr. Andreas Gross:

May I add one little comment on those?

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

If you're having a hole like this, you might have irrigation fluid into the retroperitoneum. And when this happened first time to me I didn't watch the abdomen of the patient, and I don't know how many liters went into the retroperitoneum. So if you have a hole, once in a while you're just push below the belly to see if this is still soft. And if you are afraid that you have some influx, we've just asked the [inaudible 00:19:17] to give some furosemide 40 milligrams so the patient is washing it out by himself. This we are working with saline, so nothing is happening.

Dr. Zeph Okeke:

Yes. So that's an important point. I always have my other hand on top of the patient's abdomen and palpating at all times to make sure that the bladder is not number one too full, and I need to empty them. Especially if I hear the whistles and bells and the alarm from the anesthesiologist, I usually respond and check the patient's abdomen. So now here's the other lobe of this patient. So we're controlling the vessels as we're enucleating. So this is mostly blunt enucleation on this side, combined with some resection. So again, this is as you, hopefully I'm illustrating the skill progression. So we start from the simple vaporization then resecting the little trunks of tissue. And now we're actively trying to get into the right plane to the capsular plane and then enucleating bluntly. And then combining that with vaporizing as we need to, or using active energy through the concision for any [inaudible 00:20:21] that are attached.

Dr. Zeph Okeke:

And the nice thing about the, I find the hemostatic properties of the holmium blade, oh sorry the thulium laser to be rather superior to the holmium laser. The defocusing I find this so much easier with the thulium laser. And you just need to step back a little bit and you can get pretty close to the vessel because your plasma bubble that you generate with the thulium laser is much smaller than that of the holmium laser. And this is what gives you the precision that you need to directly control that vessel. And we'll see some of that later on in the later videos exactly how we [inaudible 00:20:58] every little blood vessel before it becomes a problem for us. So here, this is that same patient we're continuing the enucleation of the right lateral lobe. Now as we progress, you can see the tissue is not quite as precise. And this is illustrating the growth of my expertise and experience in doing the surgery. Some parts of the enucleation nice and smooth, others are not so smooth. And this is okay. The patient will still get a very good result, and this is really of no consequence.

Dr. Zeph Okeke:

But as we all strive in the Endourology Society to improve ourselves, you want to make this as nice and neat as possible. So we'll let this place to the end. It's almost over. And now when we get to the bladder neck, it's important to recognize that you have a rich supply of blood vessels, but from the [inaudible 00:21:50] muscle and from the mucosa of the bladder itself. And it's important to use the laser energy to not only make an incision, but to control any bleeding that you'll encounter in this part. That becomes-

Dr. Andreas Gross:

And we have those two pitfalls of bleeders in large vessels, which you know from the open procedure where you did the suture. And then these layers of the bladder, the bladder neck, if you rupture at the bladder neck and the mucosa is going into the bladder. and then the bleeders are bleeding into the bladder. And since the laser is going straight, you do not get those bleeders. But at the bladder neck, you really have to seal the mucosa off. Otherwise you're in trouble.

Dr. Zeph Okeke:

Absolutely. And this becomes critical when you start to morcellate. Because those vessels, they'll go into spasm and everything will look clear and the minute you start morcellating, then you get a lot of bleeding very quickly and you lose your vision. So as you can see here on the right side, I was pretty close to the ureteral orifice. But again, that was of no consequence. And that was not an infrequent occurrence for me.

Dr. Andreas Gross:

But frankly speaking, after I've done so many cases I've touched the orifice quite often.

Dr. Zeph Okeke:

Yeah.

Dr. Andreas Gross:

But since the penetration depths of this laser is so shallow, it doesn't do anything to the orifice.

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

Maybe an inflammatory drug for two days so the swelling is getting off. And so we didn't have ever any serious problems with that.

Dr. Zeph Okeke:

Yeah. Absolutely right. So now in planning the enucleation, I started with the three-lobe techniques. So I would enucleate the median lobe first, and then the lateral lobes. And as I got more comfortable, I've progressed to a two-lobe technique which allows me to take either one lateral lobe with a median lobe or in the patient with just a bilobar hypertrophy I would do two-lobe technique in those patients. Now as I got more comfortable, I wanted to get faster then the next most logical step is an unblocking nucleation. So if I could skip forward to that video, me see. This is sort of more of the same. So let's kind of skip forward to an enucleation video.

Dr. Andreas Gross:

Video number 12.

Dr. Zeph Okeke:

Yeah. So I just will get there very shortly. Let's see, yeah. So if you could just load up the PowerPoint once again and play that video.

Dr. Andreas Gross:

Mike, number 12 please. Thank you. Was that, would you like to comment on that? Yeah.

Dr. Zeph Okeke:

So this is let's see. Okay, so there we go. Good. Thank you very much. Okay. So here we go. All right. So now that is basically showing you the hand movement of the surgeon, as well as what you see in endoscopy on the left of your screen. So this is a pure enucleation technique, right? So we go with the scope and you assess the anatomy, know where your sphincter is, get a sense of where the ureteral orifices are relative to the bladder neck. And the incision usually is first struck on the left side and right in the crease between the veru and the canum. And so right there in the crease between the-

Dr. Andreas Gross:

Can we stop here for a second?

Dr. Zeph Okeke:

Yes. Yeah.

Dr. Andreas Gross:

Because I would like to give credit to this anatomical structure to Thomas Herman from Switzerland, he introduced me to these little vessels here. They go, like little arcs aside the veru. And this is exactly where you go and maybe we're coming back to that in a minute.

Dr. Zeph Okeke:

Yeah. This should come up in a minute.

Dr. Andreas Gross:

So now we're coming back to the veru. And you see those little arcs. They are going up here. Yeah. Right. This is exactly where you go in. Sometimes you'll see little dimples or little holes at this place. And there you may just break in, you don't need to activate your lasers. If you do such a case tomorrow, watch those little arcs. You see. One, two, three in this case.

Dr. Zeph Okeke:

So and it as Dr. Gross has mentioned, it's very easy to get into the right plane. Right here, you just have to pick your spot correctly. Sometimes you do see these divots, they look almost like what you see in here with my arrow. Go in through that plane and the adenoma lifts off. And it allows us to get into the plane between the posterior plane and the lateral plane. And we sweep laterally on the left side all the way circumferentially. And if you look at the, if I can pause the screen, the hand motions of the surgeon I have to really almost run a circle with your fingertips. If you imagine the open surgery, the open enucleation where we put our finger in and it's a wide arc that you paint with your finger. Same motion with this scope here. That you're going all the way, and as we do which is common practice for us. This allows you to identify the sphincter and release the sphincter as early as possible.

Dr. Zeph Okeke:

So here we are, we're in the anterior plane, that's the lateral portion of it. You can see the sphincter here and the sphincter bends. And now we're getting ready to incise the sphincter. The point that I want to make as far as the sphincter is concerned, if you want to avoid or minimize incontinence, release the sphincter early, stay away from the sphincter. The anterior attachment of the sphincter is much more proximal than the posterior attachment. So you almost have to follow a slanted line from the anterior portion down to the posterior portion of the sphincter compartment. So the earlier-

Dr. Andreas Gross:

Let me, I'll just give a comment on the incontinence at this stage.

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

Since we are emptying the prosthetic cavity so completely, many of our patients, I would say 25% of our patients do have some stress incontinence during the first six weeks or so. Because there's simply no tissue left. And their sphincter has not been doing any work for the past 25 or 30 years. So I tell all my patients be prepared that you have some stress incontinence for some weeks. And then they can handle it much easier as they go home. And after one week they release a few drops and then they think I have destroyed their sphincter. We did a follow up on our patient on more than 2,000 patients after one year, we had a de novo incontinence of 1%.

Dr. Zeph Okeke:

Absolutely. That's an important point to make. It is temporary when it does happen, but it can be very distressing to the patient and therefore, to the surgeon. So now after we incise the sphincter entirely, important to cut as close to your adenoma most possible. So really stay away from the sphincter. So here we're carrying the incision to the other side and all the way back anteriorly. And again, once we identify the sphincter which you'll see in a moment we again, inside the sphincter. So you coming up here you can see the sphincter, sphincter and its attachment. And we're going to cut as close to the adenoma as possible really following that line and respecting the sphincter as much as we can. So we get very very close to the adenoma. It's okay to leave some [inaudible 00:30:21] adenoma's tissue on the sphincter than to actually damage the sphincter itself. And as I said, you can always come back with the thulium laser. You can come back and correct your mistake very easily. But be careful at first.

Dr. Zeph Okeke:

So now what you really have to think is whether you can really increase your speed, and you can still be more aggressive and try to be faster in enucleating everything until you get to the bladder neck. So I'll let this play through. So you can really appreciate how delicate this is and you notice we slow down tremendously to really release the sphincter and make sure we know what we're doing. And we can see everything clearly. Hemostasis is important as you encounter the vessels, cauterize them before they start to bleed. So you'll notice every now and then it looks like we're being distracted by the bleeding, but actually we're proactively looking for the vessels like there, cauterizing the vessels as we go along. All right. So we carry on the enucleation and here we're being a little more aggressive again because we've released the sphincter and this is all purely just prosthetic attachments which on perforating vessels had numerous attachments to the capsule with some perforating vessels. And we're trying to control the vessels as we go along. So the enucleation carries on just with the blunt tip of the resectoscope. And again-

Dr. Andreas Gross:

If you look at the upper right picture at this stage, you see we hold the instrument upside down actually. It is easier to do it this way. I always try to have a 90 degree angle to the surface of the prosthetic cavity.

Dr. Zeph Okeke:

Yes. And it's important also to remember the outline of the prostate, the borders of the prostate, it's not a straight line. So keep that in mind, stay, pull your camera back a little bit so that you have a global view of the edges and the control of the prostate, so that you follow it instead of making an incision that then gets you either too short or too far in. And then you're into the capsule. So as the enucleation carries forward, we'll let this play a little bit and I'll speed it up very shortly as soon as I can. Okay. So now once we carry this enucleation to the bladder neck, then we can slowly start to... So here we have a middle window and we're, we can see a better crossing because of the bladder neck, and we've made a window into the bladder and we can see. So now this is another, you can say level of comfort once we're here, then you just need to follow the contour of the prostate as it attaches to the bladder neck and carry that incision circumferentially.

Dr. Zeph Okeke:

And again, slowing down as we mentioned earlier during the talk, there are a lot of vessels and it's very, very rich vasculature here. Some of that can be stubborn to control. So take your laser energy, and this is where basically the blunt enucleation ends, and you need to [inaudible 00:33:25] with laser all the way circumferentially around to control the bleeding. And it's much easier to separate the vessel. So here's another vessel. And as I said, the precision of the thulium laser is such that you can just pinpoint control of that vessel with very little effort. And the irrigation is great. You have a very nice, clear view. If your field of view gets too bloody, do not be afraid to deploy your resectoscope and take that loop and control your bleeding. You're doing yourself and the patient a lot of favors by doing that. You lose nothing. It doesn't make you a worse surgeon. It just makes you a much more careful and conscientious surgeon and a doctor for your patient. So here-

Dr. Andreas Gross:

Just say a word about the bladder. You try to keep it full empty, or what is your approach?

Dr. Zeph Okeke:

Yeah. So the bladder has to be distended to a certain extent, not overfilled. Again, you palpate the patient's abdomen to make sure that the bladder is not being overfilled. But having the bladder distended really gives you some back pressure on the venous bleeders. And again, it helps in terms of hemostasis. So that's how I usually like them almost completely full but I have very good outflow with suction that allows me to regulate the amount of outflow that I have depending on where I am and what I'm doing and what the circumstances of the patient are. But ultimately, as I mentioned earlier, if I need to, I will take my loop and cauterize any vessels that I cannot control with the laser and-

Dr. Andreas Gross:

We always try to keep the pressure in the bladder, just slightly above the diastolic pressure. So you don't have any venous bleeders you only see the arterial bleeders. And then the arterial bleeders are the only ones that matter. At least at this stage of the procedure. Later on of course, you take care of all of them. But during the enucleation, I just want to see the arterial bleeders.

Dr. Zeph Okeke:

So now here we're on the patient's right side again, carrying that same bladder neck incision circumferentially. Working on the right side here and then the very last part will be done posteriorly, and releasing the posterior plane and its attachments to a bladder neck. Again, this is where you need to slow down. It's very, very easy to undermine the bladder neck if you're not careful. And stay in the plane. Stay basically, if you go too high up, you will be cutting into the adenoma and you won't to have a clean resection plane. If you go too low, you'll undermine and go under the bladder neck. Very easy to do. So again, important to keep a clear view with hemostasis, as you can see, we take our time during this enucleation really controlling all the vessels that could become problematic. So now we're in the posterior plane and we're carrying the incision all the way around. And this carried forward will release the prostate adenoma into the bladder.

Dr. Zeph Okeke:

Okay. So now at this stage, this is when I tell my team to start preparing the morcellator. And it's important to start testing the morcellator, making sure that it works. And if you can afford it, if your center can afford it, have a backup morcellator. Sometimes these things can be problematic and you may not have the time and the luxury to troubleshoot during the surgery itself especially when you're pressed for time. So it's better to have the backup morcellator ready in case you need it. And this way if there's an issue with the first one, it's a quick swap to the backup morcellator and you carry on with your case. And then afterwards you can troubleshoot and figure out what happened to it and why it was not working properly. So now this is [inaudible 00:37:27].

Dr. Andreas Gross:

Just say a word about the carbonization please.

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

That was an issue when we started and we were still competing with hanging people, this fight is over. I see a great advantage of the carbonization. Can you bring up my points for that? I think carbonization makes the tissue yellow or brownish. And if you then bluntly break the prostate, the correct layer appears white. And then you know exactly where you are, whereas in a holmium procedure, everything is white. And once you get lost, you are lost. And so I found carbonization very helpful.

Dr. Zeph Okeke:

Yeah. So as I mentioned, the as more to the point that the char looks like a lot of tissues being vaporized right there on the surface. But all of that, you look in 24 hours later, it's completely gone and everything is nice and clear. But to your point, it is very helpful to have this here as a layer and as a guide to tell you exactly where you need to be. So again, it has its tremendous advantage which the holmium laser also right here, the tissue is fluffy and it's hard to get lost, especially if you greased the capsule. And it's just much harder to find exactly where the right plane is. And of course, with experience, you can find your way back. But it's so much easier and I think I find it time-saving to be able to do this with the thulium laser. So here, we're at the very last end very last bit of the enucleation step. And if we can start preparing to load the other video just to make some points about the morcellation next.

Dr. Andreas Gross:

Before we go there, one of our listeners is asking, how do you prevent the break of the laser fiber?

Dr. Zeph Okeke:

Yeah. Oh, the-

Dr. Andreas Gross:

I wouldn't have an answer, can you give it.

Dr. Zeph Okeke:

Okay. Yeah. So the important thing is number one the laser fiber itself, we use a 500, 600 micron fiber and very easy to break if you put it on too much, if you bend it too much. So it's an important thing if you have a laser guide that protects the laser fiber itself, if you don't have a laser guide, a 6.5 range open-ended ureteral [inaudible 00:40:05] makes an excellent guide and can really help to protect the laser fiber itself.

Dr. Andreas Gross:

Could you comment on temperature or height of your irrigation fluids? You have any SOPs for that?

Dr. Zeph Okeke:

Yeah. So, I tend to use warm irrigation. The temperatures really don't get that high in my experience with the thulium laser in there. So and you're constantly irrigating, so that there's a constant exchange. So there's no significant increase in the water temperature that is appreciable or dangerous in terms of the patient.

Dr. Andreas Gross:

Would you use their body temperature?

Dr. Zeph Okeke:

Yeah. So I use a warmer, which for us they tend to keep the operating rooms a little bit cool. So I think it's probably an advantage for us to have the irrigation warm. Now, as far as the height of the irrigation, I tend to elevate the height. We use three [inaudible 00:41:09] bags and I elevate it as, to a comfortable enough height that I have good flow and I don't have to use any kind of pressure irrigators or anything of that sort. And again, I'm regulating the outflow with suction. Active suction. So very often the intravesical pressures that we're introducing with the irrigation is really not that much. And I hope that answers the question. All right. So are you [inaudible 00:41:38]

Dr. Andreas Gross:

The capsule penetration during the procedure, there was a very nice and awarded talk during one of the latest AUAs. If you perforate the capsule, it doesn't do anything to the patient except you might have some influx. And you watch this influx, as we said earlier, during the session. Do you agree, or you think capsular preparation is something?

Dr. Zeph Okeke:

Oh, yeah. So it depends on the degree of the capsule perforation. So for a major capsular perforation, which I had in my very early experience, I panicked and opened the patient and the patient is still very happy urinating well and [inaudible 00:42:21] for a very long time. But as with time, I found that really minor capsule perforations that we have all the time during enucleations and also with TURPS very commonly, they really have no consequence. You don't have to necessarily leave the catheter any longer if you are concerned. No one will fault you for leaving the catheter a couple of days longer. At the end of the day, you're looking for a good result for your patient. So makes-

Dr. Andreas Gross:

This here was a-

Dr. Zeph Okeke:

Yes.

Dr. Andreas Gross:

I'm sorry. This here was an 80 gram prostate. You agree, that's a good size to start with or?

Dr. Zeph Okeke:

Absolutely. Yeah. And I think-

Dr. Andreas Gross:

How did you start?

Dr. Zeph Okeke:

Yeah. So 80 gram prostate is a very, it's a nice ideal to start with. You can enucleate very well with that. It's not too big. And if you need to, you can convert to a trans-urethral resection for a prostate that size very easily. So that's good, happy prostate to start with. Smaller one tend to be a lot more difficult than very large ones. And I will make a couple of points in terms of very large prostates. I've done a few patients who are 400, 500 grams with really bad comorbidities. And those patients I've had to stage their surgeries. I tend to do a three-lobe technique in those patients. So I would enucleate one lobe, morcellate, enucleate and morcellate and then two days later, come back. I keep them in the hospital.

Dr. Zeph Okeke:

I come back two days later and finish up the job there. And so far that's paid off for me very well, just staging it that way instead of rushing and opening the patient and prolonging their recovery. And I have to say the patients are really, really appreciative that they don't have any pain post-operatively to deal with. That's one major advantage of these enucleation procedures that we do.

Dr. Andreas Gross:

Perfect. And this is the video. And now you can show the morcellation stuff.

Dr. Zeph Okeke:

Yeah. So if you can load the other video and we'll talk about the morcellation. So while the video is loading, the important thing with the morcellation as I said, if you can have, great. So if you can have a backup morcellator, have one, make sure you have a nephroscope. I use a second inflow and I turn off the suction and the only outflow is through the morcellator itself. And as need be I may empty the patient's bladder. And I'm constantly palpating the patient's bladder to make sure it's not fully overly distended. Keep your eye on the morcellator blade at all times. It's very easy for that thing to chew through the bladder mucosa very easily, and you will end up with a big mess. So as you're morcellating make sure you keep your eyes on the screen. If the view gets to bloody take a resectoscope or even your laser and come back and cauterize anything that's bleeding. You really need as clear of a vision as possible to morcellate safely.

Dr. Zeph Okeke:

As exciting as enucleation is and as tedious as the morcellation is, the morcellator is really where you need to really, really give it all of your attention. For not and frequently little pieces will migrate into the prosthetic fossa, that you can handle with the grasper through your nephroscope. It removes that very easily. For the much more tedious and really firm and dense nodules, laser vaporization is an easy way to deal with that. And just vaporize it down to a small enough size or even resect it down to smaller pieces that you can then reengage a morcellator to get rid of those pieces. So and this is where it's very easy to make a mistake. So I would caution you to really pay as much attention to the morcellation itself as you do to the enucleation. The enucleation [inaudible 00:46:15].

Dr. Andreas Gross:

There is nothing in medicine, that you cannot do it in a different way. I've been in Singapore at a meeting and there was a professor from China, and he said, "You always have to have the hole of the opening of your morcellator later at six o'clock." And we all, we do it at 12 o'clock. And I tell everybody, try to keep the opening at 12 o'clock. You agree for 12 or Six?

Dr. Zeph Okeke:

Yeah. I tend to keep it at 12 o'clock. It's easier for me to really keep an eye on what is going on. And I just find it much more-

Dr. Andreas Gross:

You have more space [crosstalk 00:46:56].

Dr. Zeph Okeke:

Yes. I have more space.

Dr. Andreas Gross:

You are not going down.

Dr. Zeph Okeke:

Precisely. And I'm always worried about once the bladder is fully distended, I think I have as I said, much more space anteriorly than I do posteriorly. And I think I just have a much better vision. I can [inaudible 00:47:10] because it is collapsing towards me on the left and the right of my field of vision. So much easier than if I was turning it upside down.

Dr. Andreas Gross:

So one of our viewers is asking about rectal injury. I'm happy to say that I've never had one. Did you have one, frankly?

Dr. Zeph Okeke:

No. I'm happy to report I've never had one. And again, it's all about just being meticulous. And again, if you have to leave some tissue behind and then vaporize the remaining tissue, do that easily. Especially at the beginning of your experience, you don't want a catastrophe that you cannot handle very easily. So now I tend to give Lasix, intraoperatively and postoperatively. That's just my practice. Not many surgeons do that. A standard for me is a 22 French Foley catheter continuous bladder irrigation. I keep them overnight and take out the Foley catheter the next morning. And most of the patients report and go home without a catheter.

Dr. Andreas Gross:

Where do you locate the Foley catheter? Into the prosthetic cavity or at the bladder neck?

Dr. Zeph Okeke:

So, yes. I have tried both and I find it so much easier to leave it at the bladder neck. And I overinflate their balloon. [inaudible 00:48:23] standard is 60 to 80 CCS of fluid in the balloon. Just to prevent it from falling into the prosthetic fossa. I've tried to get a prosthetic fossa but I think it's the design of the catheter itself that we have that makes it problematic. It's not long enough to stick into the bladder constantly to get us a good inflow and outflow and that's part of why I park mine in the bladder. What about you?

Dr. Andreas Gross:

Yeah. That's a good point. My standard is in the prosthetic fossa and I over inflate the balloon until it's clear. But as I said, the mucosa from the bladder neck, I cannot reach if we have a large prostate. This morning, we had a 220 gram prostate and we don't have a Foley catheter of this size. And then we overinflate the balloon and just pull it to the bladder neck and you put some traction on it. There's one question from the audience about urethral strictures. You have a comment on that?

Dr. Zeph Okeke:

Yeah. So that's an important point. Very good question. So early on in my experience, I had a lot of meatal strictures. And I found that for patients with very tight urethral meatus, I do a meatotomy at the very beginning of the surgery. And I haven't had that issue since. Now we've had approximately I'd say probably five bladder neck contractures since I've been doing this surgery. And so far we've been able to take those patients back and resect the bladder neck. The characteristics of who develops the bladder neck stricture or not I cannot predict. I've had it in very large prostates and I've had it in very small prostates. So part of these are the young patients, old patients. Again, the numbers are too small for me to really make any kind of reasonable judgment as to why it occurs.

Dr. Andreas Gross:

So, where we don't have any curves as we have in the classic TURP, this is why we have by far less strictures. And I agree, I cannot say which is the patient or who is the patient who will develop a stricture? My belly says the small prostates, they are a little bit worse than the large prostates, but there's... This is EDM level four B. Yeah, go on. Anything else for the morcellation?

Dr. Zeph Okeke:

Yeah. So the, I think those are the key points for the morcellation itself. There's different, here in the United States, we have Wolf and we have Dornier as the providers of the morcellators and I've used both. I tend to prefer the Wolf morcellator. I think it just performs much better than the Dornier equipment. So anyway, that's why I use it.

Dr. Andreas Gross:

Yeah. For those who are facing difficulties with morcellation, David Leavitt, who was a fellow at your institution Zeph, he produced award-winning video on tips and tricks in morcellation. This is a very valuable lead video because there are so many little things that may obscure. That's little pieces of the morcellate stuck into the morcellator or whatever the pressure doesn't go up and how you can handle the bleeding and so on. It's a very valuable video.

Dr. Zeph Okeke:

Yeah. So just on that topic let me just add that tiny chips, especially if you do any kind of urethral resection can tend to clog your morcellator. So that's something to keep in mind just disassemble it and flush the morcellator blades and that usually will solve that problem. And again, just make sure all your connections in terms of the precious fields are in place, so that you have a vacuum that allows you to have the continuous suctioning that you need for this. Yeah. So now, in terms of surgical outcomes excellent across the board, holmium is similar to thulium. Again, the... Just to highlight what I think is important to take away from this talk today is number one set yourself up for success. Right? So watch a few of these cases, have some mentoring all the way along and today, as Dr. Gross, you can attest to. I saw him asking questions and still get tips. You can never... You can always learn something new.

Dr. Zeph Okeke:

Someone's always doing something better in a different way that might be useful for you. So initially expect to have long operative times and just plan for it. Maybe do two cases a day. And then as you get more comfortable and much advanced in your experience and expertise, then you can add more cases. You can up to three cases and four cases just depends on what you can handle and what your available instrument can handle for you at your institution. Start with vaporization, progress to vapor resection then vapor enucleation and then full enucleation as you see fit. And all the way all the while record yourself, review your videos, compare what you're doing to what others are doing. If you have the availability of a mentor, ask questions, get input, get some more training and feedback. And those are really the important things. Have your [inaudible 00:53:50] set and ready, don't be ashamed to use it. You're not a weak person for doing that. You're doing your patient a favor, and you're certainly giving yourself a good night sleep when you do that.

Dr. Zeph Okeke:

And with the morcellator, be absolutely careful pay attention to the morcellation that is critical. That way, you can do the most beautiful enucleation if you perforate the bladder, then who cares, right? The patient is angry and upset about the perforated bladder, and you have to deal with that. So pay attention to the morcellation. It is just as important as the enucleation itself.

Dr. Andreas Gross:

Those are the best closing remarks. So I have only one word to add and saying to every one of my residents who is starting the procedure. I know you will become better than I am, but don't try to show me during the first five cases. And if they accept that, we have a good training program. I think this is it for today. Zeph, thank you so much for your time. And for all people backstage, Nickel, for your organization, Michael, for the background for the videos, Jared, for the questions. And if I forgot anyone, please excuse me. And I'm going home now for a good night drink. And Zeph you have to work a little bit more it's Friday noon probably.

Dr. Zeph Okeke:

Yes. Thank you all very much for the invitation. This is a very good series and please tune in next week for the next lecture at the same time. This has been very educational and I'm looking forward to it.

Dr. Andreas Gross:

Thank you.

Michael Evans:

Thank you everyone.

Dr. Andreas Gross:

Still 114 people in.

Adrian Joyce:

Yes. Or more.