Faculty: Fernando Gomez Sancha & Naeem Bhojani

Moderator: Thomas Herrmann


Fernando Gomez Sancha

Dr Sancha is the Head of the Department of Urology and Robotic Surgery at ICUA – Clinica CEMTRO in Madrid - Spain, and also works at the Hill Clinic (Sofia, Bulgaria). He a specialist in Urology and highly specialised in Holmium laser prostatectomy for the treatment of BPH (Benign Prostatic Hyperplasia). Currently, he combines clinical work with academic and teaching activities, actively lecturing and training other doctors worldwide.

Naeem Bhojani

Dr. Naeem Bhojani was born and raised in Montreal. He obtained a BSc in Microbiology and Immunology and another in Physiotherapy from McGill University in 2001 and then completed medical school and urology residency at the University of Montreal. In 2011, Dr. Bhojani spent 2 years with Dr. Lingeman at Indiana University completing his Fellowship in BPH and Stone Disease. Dr. Bhojani was recruited by the University of Montreal in 2013 to build and develop Comprehensive Kidney Stone and BPH Programs. At the University of Montreal, he has the rank of Associate Professor and clinical researcher. Dr. Bhojani has published extensively in stone disease and BPH. In 2017, Dr. Bhojani was named the AUA’s Young urologist of the year representing the NSAUA. In 2019, Dr. Bhojani was awarded the prestigious clinical research scholar award from the FRQ-S.

Webinar Transcript

Dr. Amy Krambeck:

Hello. I am Dr. Amy Krambeck, professor of urology at Northwestern University School of Medicine in Chicago, Illinois. And it is my pleasure to host the masterclass in endourology. Masterclass in endourology and robotics is hosted by the Endourological Society and the Society for Urologic Robotics Surgeons. The Endourology Society of Urologic Robotic Surgeons wishes to thank Lumenis for their grant and supported this activity today. Today's topic is, does energy source matter for enucleation? Thulium reloaded versus holmium.

Dr. Amy Krambeck:

The faculty will be Dr. Fernando Gomez Sancha, Dr. Naeem Bhojani, and our moderator is Dr. Thomas Herrmann. Dr. Herrmann is vice chairman and associate professor of the department of urology and urological oncology. He's the director of the Hannover Medical School, and he is the chief of endourology and laparoscopy at the same department. His research interests focus on laser soft tissue surgery and surgery of prostate and the bladder. So, Dr. Hermann will be our moderator, and he will introduce the other faculty.

Dr. Amy Krambeck:

I want to remind everyone that the masterclass in endourology and robotics is CME accredited. We have a target audience that is developing physicians who specialize in endourology and robotics, and all aspects of minimally invasive therapies. The objectives is, at the conclusion of this activity, the participant should be able to identify specific examples of different technologies, the critical steps in techniques and differences in applications, and it is accredited. So, for your CME accreditation, you will receive a survey from Michelle Paoli. You will indicate which seminars you attended and you will get the CME certification afterwards.

Dr. Amy Krambeck:

Please fill out the evaluation questionnaire at the end of each seminar. And please use the question and answer function to ask questions today. All upcoming webinars and registration are listed on the endo urology website at www.endourology.org. So without any further ado, I will turn the platform over to Dr. Herrmann.

Dr. Thomas Herrmann:

Thank you very much for the nice introduction. Okay. So, the question is, does energy source matter for enucleation? And we're talking about basically two energy forms today. The thulium, the novel thulium lasers, and the novel mechanics of the holmium technique, mainly Moses technology. And just let me start with a few ideas now. Okay. This is just my discloser of, and potential conflict of interest. I'm a professor of urology and have moved to Switzerland. Now, chairman here of Urology Department Switzerland. And I'm still working with Karl Stortz, and LisaLaser Research. In the research collaboration, I've invented thulium as an anatomic enucleation of the prostate, and I'm inventor of the Bipolep Probe of Karl Stortz, is my share in this enucleation business.

Dr. Thomas Herrmann:

Just some words, until 2015 we were dealing with mainly HoLEP as the energy source for doing enucleation. And mainly by the incorporation of the bipolar data from 2016 onwards from the European Guidelines of Urology, which I have the privilege to work on with. It's endoscopic enucleation of the prostate. And the reason why this is, probably because we moved from energy-based perspective to a more conceptual understanding on what we want to do with energy sources. The question is, "Is this still valid?" Because, we have some novelties, novel laser energy sources. And the question is, are they game-changers or are they improvements within their energy source?

Dr. Thomas Herrmann:

So the question is, it's a game changer, improvement, or is as I said [inaudible 00:04:26], the latest craze? Something we will love to use, but we have to define whether it's important. So you could say, we now deal with two ideal lasers. We have now thulium for soft tissues and stones, and of course we have the improved version, if you would say, from holmium reloaded also for tissue and stones improved. And these are my two peers to talk to today and to entertain you, of course, with the knowledge that we have. It's my friend, Dr. Fernando Gomez Sancha. We know each other from 10 years back. He is one of the masters of enucleation.

Dr. Thomas Herrmann:

Interestingly, we came to know when he was still doing GreenLight enucleation of the prostate anatomically, this is why we found together, and he's moved to holmium laser enucleation of the prostate. And he is worldwide. I don't have to announce him, operated everywhere, teaching everywhere, and a fabulous guy. You will come to see if you don't know him yet, which I cannot believe. On the other hand, we have also a very interesting talker today. It's Dr. Naeem Bhojani. He is from the University of Montreal. He's there as associate professor in clinical researchers running the comprehensive kidney stones and DPH program. He was at Lingeman in Indiana for two years as a fellowship for BPH in stone treatment. So he is, as the other one, a convert. So, I'm dealing with converts today, from holmium to thulium and from GreenLight to holmium.

Dr. Thomas Herrmann:

So, I will say it's probably the nicest part if you change your perspective, because then probably you work from the conceptual side less than from the energy side, but that also means you have a good concept. So, I'm looking forward to your talks, starting with our fellow, Dr. Naeem Bhojani, with his talk on thulium fiber lasers and enucleation. Just before that, I just want to share with you that we have another kid on the block. It's the Revolix HTL. It's also thulium laser, but not a fiber but a YAG laser. And as you can see on the left side, it works with a rod that makes some difference to the fiber lasers.

Dr. Thomas Herrmann:

We have a frequency bandwidth from five to 300 Hertz instead of one to 2,400 Hertz from the fiber laser. We have a higher pulse peak power was 1.3 kilowatts instead of 500 kilowatts that gives something for the mechanics, I think. And we have continuous wave and quasi continuous wave, which makes something for the cutting. Energy density is the word here. It has 150 watt instead of 60 Watts, so that is the power difference. So, you lose a little bit of versatility and can offer more power. The reality is it's in the clinical research at the moment. We don't have published data yet, so we will not discuss this just for you, for the completeness on what is available. So, that would be my starting point. It's the template, not the energy. But what the energy can do, we will see now. Thank you very much. And looking forward for the first talk. Naeem.

Dr. Naeem Bhojani:

Dr. Herrmann, thank you for the introduction. Thank you to the Endourology Society for inviting me to present and be part of this webinar. It's really an honor and a privilege for me to be sharing this master class with two giants in the field of prostate enucleation. So, as mentioned, I did my fellowship with Dr. Lingeman. I've done over 1000 HoLEPs until August of last year, at which point I started doing thulium fiber laser enucleation of the prostate, and I've done 41 up until now. And I'm happy to share my experience with you today.

Dr. Naeem Bhojani:

I do have conflicts of interest, so I'm a consultant for Boston Scientific, Olympus and Procept. So, I'm going to talk quickly about the technology. So, probably one of the things that's most important, which Dr. Herrmann just mentioned, there is a significant difference. We're not talking about thulium YAG, we're talking about thulium fiber laser. A thulium YAG is used exclusively for BPH. And it's very similar to the holmium YAG laser, except it's a continuous laser versus the holmium YAG, which is a pulsed laser. So, the thulium fiber laser is a... Inside the laser box, you have a long 10 to 30 meter fiber. And at its core is dotted with thulium ions. These Thulium ions are activated by a diode laser. Once they become activated, they're then placed into a surgical fiber, and then they're used in the patient.

Dr. Naeem Bhojani:

Now, this is very different than the holmium YAG laser. The holmium YAG laser, as you all know, uses a flashlight. The flashlight will emit protons, which will activate holmium ions on a crystal, which will go through a series of mirrors and then will be used in a surgical fiber. Now, to get a high powered holmium laser, you need a number of cavities. And so, that's why the holmium YAG is actually eight times larger than the thulium fiber laser. The other big difference is in terms of the noise. So, the holmium YAG, because it uses a flashlight, it emits a lot of heat. And so, you need a cooling system. And due to this, there's a lot of noise associated with the holmium YAG laser, which you don't have with the thulium fiber laser.

Dr. Naeem Bhojani:

What about the parameters of the actual laser? So in terms of energy, they both will go to about six Joules. However, on the lower end, the thulium fiber laser can go down to 0.025 Joules compared to the holmium YAG that can only go down to 0.2 Joules. And this becomes important when we're trying to do dusting of kidney stones with high frequencies. As you all know, the holmium YAG can go up to 80 Hertz, whereas the thulium fiber laser can go up above 2000 Hertz. Also, important to recognize that the pulse width can be increased significantly more than the holmium YAG laser.

Dr. Naeem Bhojani:

Very importantly, looking at the depth of penetration. If you look at the energy transmitted to tissue from the tip of the energy fiber at zero millimeters, 100% of the holmium energy is transmitted through tissue, just like the thulium fiber laser. However, when you get to 0.3 millimeters from the tip of the laser fiber, there's still about a third of the energy from the holmium YAG laser that is transmitted to tissue, whereas with a thulium fiber laser there's no more energy transmitted to the tissue. So, the thulium fiber laser is actually shallower, or has a shallow depth of penetration than the holmium YAG laser.

Dr. Naeem Bhojani:

Finally, and very importantly, is the wavelength on the light spectrum. So, if you look at the wavelength between the two lasers, they're very similar. However, when you look at their absorption in water, there's a significant difference. The thulium fiber laser is actually at the peak of absorption in water. And what this means is that the thulium fiber laser is 4.5 times more absorbed in water than the holmium YAG laser. And this becomes important when we talk about hemostasis, which we'll do later on in the presentation.

Dr. Naeem Bhojani:

So, thulium fiber laser enucleation of the prostate. So in north America, it's Olympus machine that we have here, if you haven't seen it. So, it's quite a small machine. The laser fiber has an RAF code, so you can actually load it yourself. It has a touchscreen for your manipulation of the parameters. It's like an iPhone, basically. Very, very easy to use. You have two foot pedals, so you can use one pedal for enucleation and one pedal for hemostasis.

Dr. Naeem Bhojani:

We'll talk quickly about a couple of publications. The first one is a prospective study done by Dr. Enikeev from Russia. It's a study that compared the thulium fiber laser enucleation of the prostate to the "gold-standard" TURP. So in this study, the average gland size was 60 grams. The drop in prostate volume was 80% in the thulium fiber laser enucleation group compared to 70% in the TURP group. The surgical time was a little bit longer than the thulium fiber laser group by seven minutes. Catheterization time, hospital stay and drop in post-operative PSA all favored the thulium fiber laser enucleation group compared to the TURP group. However, when you look at clinical outcomes, so drop in IPSS and increase in Q-max at one year, the two groups were very similar.

Dr. Naeem Bhojani:

Second publication I want to share with you is... This is the wrong presentation. We're just gonna move through this one. This is just looking at open simple prostatectomy. So, the second publication is the learning curve. So, here Dr. Enikeev compared the learning curve of HoLEP, to thulium fiber laser enucleation of the prostate to monopolar enucleation of the prostate. So, this was basically three surgeons who had performed at least 60 TUPs, but had never performed an enucleation procedure. They were randomized to learn one of the three procedures, either thulium fiber laser enucleation of the prostate or HoLEP or monopolar enucleation of the prostate. It was a mentor-based learning, so they firstly watched videos. Each surgeon then watched their mentor perform five cases, then each mentee performed 10 cases with a mentor present in the OR. Thereafter, the mentor was no longer present, but was available if necessary.

Dr. Naeem Bhojani:

These are the three groups. There were 30 patients in each group. Average gland size was between 50 and 60 grams. Pre-operative parameters were very similar between the three groups. Here you can see the new patient efficiency. So, enucleation efficiency is the grams of tissue removed per minute. And as you can see, after about 15 cases there's an increase in the efficiency in the thulium fiber laser enucleation group, and this was actually statistically significantly different. Catheterization time, hospital stay, hemoglobin drop and sodium decrease all favored the HoLEP and thulium fiber laser enucleation group compared to the monopolar enucleation group.

Dr. Naeem Bhojani:

So, now we're going to talk about fiber size and settings. So, I used the same fiber size that I use for HoLEP, so a 550 micron laser fiber. In terms of setting, I've tried many different settings. These are the settings I use now, which I think are best. So, I use one Joule and 60 Hertz with the short pulse for enucleation, and one Joule and 30 Hertz with the long pulse for hemostasis. The reason I don't use long pulse for enucleation is that, as you'll see in a video I'll show you, the long pulse makes bubbles at the tip of the laser fiber, and this can be distracting when you do enucleation.

Dr. Naeem Bhojani:

So, what do you need to be able to do a thulium fiber laser enucleation of the prostate? You obviously need a video tower and a camera. You need a thulium fiber laser. You need a 550 micron laser fiber. You need a 26 French continuous flow resectoscope sheath with modified inner sheath, which is the same that I used for my HoLEPs, a 30 degree cystoscopic lens, a laser fiber stabilizing catheter, which again is the same that I used for HoLEP, a long nephroscope for morcellation, a morcellator, and then a fully catheter to end the procedure.

Dr. Naeem Bhojani:

I'm not going to go through the steps of enucleation, but probably one of the steps that's the most important, in my opinion, is finding the plane of enucleation and doing the apical dissection. So, the first video show you is finding the plane. So, this is 110 gram prostate. There's the verumontanum, here's the sphincter. I like to start my enucleation about one centimeter proximal to the verumontanum. The reason I do that is I find it's one of the easiest places to be able to find the plane of enucleation. So, a couple of things to notice here, first is I'm using a no-touch technique. So, about two or three millimeters away from the tissue. I do this to avoid carbonization, and I do this because it helps, in my opinion, to separate the tissue or the prostate from the capsule.

Dr. Naeem Bhojani:

The second thing to notice is there's very little bleeding. That's probably one of the main advantages of this laser, is that it's very good for hemostasis. Every once in a while, there'll be a small bleeder that you can easily coagulate with the hemostatic parameters. You can already see the enucleation plane showing itself. The other place you can find the enucleation plane is where the lateral lobe hits the floor of the prostate, as you see here. So, this I will do as well. I always cut the mucosa before pushing on the prostate, as you see, to be able to find the capsule.

Dr. Naeem Bhojani:

Now, the nice thing with this laser is once you found the capsule, if you can stay on that line of enucleation, you will see that the tissue will separate out very nicely like we get with the holmium YAG laser. So, all you have to do is follow that plane and the enucleation will be relatively easy. And as you can see, hemostasis is actually quite good. So, once you found the plane of enucleation, the next step which is another critical step, is doing the apical dissection. So, again, you'll see every once in a while I'll do a little bit of hemostasis, but for the most part, hemostasis takes care of itself. I pushed slightly on the prostate and then I cut the attachments of the prostate from the plane or from the capsule.

Dr. Naeem Bhojani:

The goal here is to get to 12 o'clock. I've already separated the sphincter from the adenoma, as I feel that it does help with early incontinence, but it's something we can discuss I'm sure. So, again, just a little bit of hemostasis, but the goal here is to get up to 12 o'clock. I find that if you're able to do these two steps, finding the plane of enucleation and doing apical dissection, you can do an enucleation. Those are the two most critical steps in the procedure, in my opinion, as the sphincter is not far away. So, it's also the slowest steps, in my opinion. I always take my time for these two steps before getting into the easier steps of finishing off the enucleation.

Dr. Naeem Bhojani:

So, just in the interest of time, we'll move on to the next video. So, now I've gotten up above. I'm at 12 o'clock, and I'm now heading towards the bladder and I'd like to enter into the bladder. I'm going to show you two videos. The first video is earlier on in my learning curve, and the second video is later on in my learning curve with the thulium fiber laser. And you'll see with this first video that I'm touching the tissue, and there's significantly more carbonization. So, if you notice, I'm touching the tissue. And you can see there's a lot more carbonization. It's not as clean as my other videos. Now, I'm going to show you a video later on in my learning curve, where I use the no-touch technique. So, you can see a significant difference from the last video. You can see I'm not touching the tissue. The tissue is still separating very well from the capsule, and there's very little carbonization. I like this much better. It's just a cleaner surgery, especially when you're early on in your learning curve.

Dr. Naeem Bhojani:

So, the goal here is to get into the bladder. We're moving approximately. So, getting into the bladder. We're just looking for this perpendicular fibers, which you see here, which are the final attachments of the prostate to the bladder neck. Once you cut in here, you'll be into the bladder. Now, for anybody who's done BPH surgery, you know that the bladder neck is the place that likes to bleed the most. So, I use the hemostatic parameters here with the thulium fiber laser. And as you can see, once again, very little bleeding. I'm someone who really likes to maintain the bladder neck. And so, we can talk about this later on, but as soon as the prostate gets above 80 grams, I don't do en bloc procedure. I do a [two lobe 00:19:43] procedure, because I find when the prostate is bigger, I have difficulties pushing it into the bladder when I want to maintain that bladder neck.

Dr. Naeem Bhojani:

So, there's two ways to do an enucleation with thulium fiber laser. You can either do manual traction, or you can use laser energy to cut the prostate off of the capsule. So, early on in my learning curve, I did a lot more manual traction. But as I've gone along, I use a lot more energy, laser energy. The reason I do that is I'm faster. So, when you do manual traction, as you'll see in a minute, oftentimes you have to go back to stop the bleeders. Whereas, if you use laser energy upfront, then you cut and do hemostasis at the same time. So here, you'll see I'll do a bit of manual traction, and then I'll have to go back and stop the little leaders. So, I find that later on in my learning curve and more and more, I'm using more laser energy.

Dr. Naeem Bhojani:

So, we're going to move on. So, this is just finding... Sorry. This is just finding the groove. This is anterior commissure, and I'll just end off with a last video about finishing off the enucleation. So, once you've basically done your apical dissection, you've entered into the bladder, now it's the fun part where I like to let my residents have their fun basically, finishing off the enucleation. You can either use a no-touch technique or you can cut into the tissue now that you know where the planes are and you've identify the enucleation plane. Again, you can see very good hemostasis.

Dr. Naeem Bhojani:

And the other thing I'd like to mention when I used to do HOLEP, I used to use a reusable fiber and I used to strip it about one to two inches. And the reason for that was that there was a lot of burn back. And by the end of the procedure, I was usually up to the blue cladding of the laser fiber. With a thulium fiber laser, it is not reusable and it comes from the factory with one to 1.5 centimeters stripped. And after 41 cases, I've never had to strip the fiber more. I've never had to use more than one fiber. So, there's a lot less burn back with the thulium fiber laser, in my opinion, and from my experience.

Dr. Naeem Bhojani:

Okay, so moving on to advantages. So, what are the advantages, in my opinion, for the thulium fiber laser for enucleation of the prostate? The first thing of course, as I've mentioned, is hemostasis. The question is why is hemostasis so good? A few reasons. First of all, we know that the absorption in water is significantly high. The second is that there's a low peak power. As well, there's longer pulse width and a shallow depth of penetration. So, basically you have lower peak power spread over a larger amount of tissue and a higher absorption in water. And it's our belief that this is the reason why the hemostasis is so good for this laser. Here's just a video I had mentioned that if you use the long pulse, you get these bubbles at the tip of the laser fiber. And I didn't like that for enucleation, but I actually like them for... I actually like those bubbles for hemostasis. I feel like it might be better for hemostasis. So, you can see the bubbles at the tip here.

Dr. Naeem Bhojani:

Another benefit of the thulium fiber laser is its versatility. It's an excellent laser, as you see, to separate tissue, separate the prostate from the capsule. But also, if you have those smaller glands, sometimes it can be very sticky. It can stick to the capsule. And so, this laser is excellent for cutting soft tissue, and so that's not an issue with this laser. And then finally, very importantly, this is a laser that is very efficient for bladder stones. Previously, when I would do a HoLEP, if I had a very large prostate gland and if I had greater than two or three centimeters of stone in the bladder, I usually did it in two procedures. I would do the bladder stones and then I would do the enucleation, but now I do both of them at the same time.

Dr. Naeem Bhojani:

So, just this week on Monday, I did a 200 gram prostate with a four centimeter stone in the bladder. And I can tell you, the stones in the bladder took me 12 minutes. So, this laser is very, very efficient for bladder stones, as it is for kidney stones. A quick word on carbonization. This has often been reported as a drawback of thulium fiber laser. First of all, there's no clinical impact of carbonization. However, it can distract you from finding... What's that?

Dr. Thomas Herrmann:

Thank you for mentioning.

Dr. Naeem Bhojani:

Yeah, no problem. So, the problem is it can distract you from the planes of enucleation, especially when you're earlier on in your learning curve. And so, that's why I always advocate for the no-touch technique, especially when you're early on in your learning curve, you will avoid this carbonization and you'll still get that nice separation of prostate from capsule. So, in conclusion in this topic of enucleation of the prostate, there's increasing literature, there's increasing interest from the urology community for this technique. In my opinion, enucleation of the prostate is the gold-standard for the treatment, surgical management of BPH. The question is, does energy source matter?

Dr. Naeem Bhojani:

What I think is important is that we understand, you need to understand the advantages and the disadvantages of every energy source, whether it's holmium with Moses, thuLium fiber laser. GreenLight, bi-polar, thulium YAG. And once you understand the advantages and disadvantages, then you can make the best decision for you and for your patients. What I can tell you from my experience is that the thulium fiber laser allows for excellent hemostasis. A very versatile laser and it's excellent and very efficient for bladder stones.

Dr. Naeem Bhojani:

Finally, learning curve. The learning curve is anywhere between 20 and 40 cases. I showed you one publication that may be thulium fiber laser enucleation of the prostate is a little bit faster to learn, but probably very similar to all enucleation procedures. I'll leave you with one last slide. About 10 enucleations ago, I did a 72-year-old gentlemen, 130 grand prostate, using the thulium fiber laser. Enucleation time was 42 minutes, morcellation time was 12 minutes, patient left same day of surgery and his catheter was removed the next day, and he's doing great. Since then, eight of my last 10 cases have been same day. So, the next step is to, hopefully, remove the catheter the same day of surgery. Thank you.

Dr. Thomas Herrmann:

Thank you very much for these excellent early impression with this new fantastic tool that we've been hearing now since the last three years on various meetings. I've been brought up with the old thulium YAG continuous wave. And I'm very happy that you mentioned the carbonization stuff, because that was one of the line of defense that we fought at these days, 2007 onwards, with the holmium community. I think what we reached today is the same boiling purposes like the holmium laser provides with cooking the irrigation fluids to coagulate. I think that is one of the things just to comment for that. And you are in Montreal, so you are now around the corner of a giant, Mostafa Elhilali, maybe one of the best teachers for HoLEP. There were a lot of good ones. And he, as you said, was a mechanic, because he pushed a lot until the end. You wouldn't say he did a bad job.

Dr. Thomas Herrmann:

Just one brief comment to that, I think it's always a combination between... It's sometimes it's more visible and not at least I always say it's like the two hands in open surgery over the roadblock, the progress. You hold it away with the sheath and you cut with the other side. I think that's not problematic. And just one thing, we will continue this later, the interesting thing is that the physical properties of that lasers don't change, because of the higher reabsorption or absorption in water. And the funny thing is, that we can now do no-touch. Isn't it funny? Because, it will be absorbed in water as well.

Dr. Thomas Herrmann:

So, there must be something and we can discover it, because we will see some more pulse modulation talks and insights of Fernando. And if you like, we can discuss everything in a whole, because you rose up a lot of things technically and concept-wise that we can discuss with Fernando later on. Is that fine? Super. Now we will see Fernando. Thank you for this nice talk.

Dr. Naeem Bhojani:

My pleasure.

Dr. Fernando Gomez Sancha:

Excellent presentation, Naeem. I am very honored to be here today with all of you. And I'm going to discuss the evolution of holmium, which is a pulse modulation. And I would like to go back to the past to put things in perspective. And I think it's always interesting... Well, these are my disclosures. And if we go back to the past, the first anatomical description of the prostate was in 1538, and poor patients would have to rely on catheterization until the end of the 19th century. It was Ambroise Pare who devised the first blind operation in the prostate in 1564. And McGill performed the first open prostatectomy in 1888. So, if you still do open prostatectomy, you're doing a very old operation.

Dr. Fernando Gomez Sancha:

There were some developments in technology. Edison described the incandescent lamp and Hertz studied high-frequency current, which was paramount for the development of endoscopic surgery. Later on, Freyer described his transvesical approach to prostatectomy, and that was the table they used at that time. Hugh Hampton Young in 1909 described the punch prostatectomy, a blind procedure to take out carnosities of the prostate. McCarthy in 1932 came up with the first modern one-way resectoscope and the [Bobby 00:29:54]. Mill described the retropubic approach for open prostatectomy. And then, of course it was the continuous flow resectoscope from Iglesias, which popularized the endoscopic approach of TURP, which has been considered the gold-standard for a lot of time. I don't like this term at all. I think it discourages improvement. People get fixated with this idea of the gold-standard, but we have been challenging the old operations to make them better. And this is why we are all here today.

Dr. Fernando Gomez Sancha:

You know Hiraoka, well, maybe you don't know, because it... This man described the first endoscopic enucleation of the prostate and en bloc approach. It was interestingly, an early up calibration technique. And I hear that he operated thousands of patients in Japan with very good results, but he never published his experience, which made him go largely unnoticed until Gilling started using a holmium laser to describe the HoLEP procedure, the three-lobe lab procedure. And this was of course revolutionary, but it was technically difficult and there were a lot of impediments to do this operation. Morcellation was less developed. And it was a problem to adopt this technique. And I have to say that Thomas wrote this wonderful patient where he inspired himself in this phrase, "A rose is a rose is a rose" to say that things are what they are, and an enucleation is an enucleation and it's going to have good outcomes irrespective of the source of energy used. And it's an interesting idea.

Dr. Fernando Gomez Sancha:

Holmium works a little bit different than thulium. Typically, there is going to be a deposition of energy into the water. A lot of energy that is going to heat the water to a temperature that is not compatible with being water. This is super-hot water. It's water that shouldn't be water. So, the transition to vapor happens in a way that generates this plasma bubble, which is not the same as the bubbles that Naeem was describing before. I think when he uses these settings that produce bubbles in the tip of the fiber, what you're seeing are vapor bubbles. But this is a plasma bubble, and this generates a shockwave. It is a pressure wave that can sometimes reach 100 bar. So, it's like a little explosion in the tip of the fiber that is going to provide the holmium with this special characteristics.

Dr. Fernando Gomez Sancha:

Typically, with the normal holmium, we had four different situations. If you fire the fiber too far from the tissue, there will be no effect, because the water would absorb the energy. The commutation bubble would produce a shockwave, but the shockwave doesn't even reach the tissue. If you get closer to the tissue, you can see the mechanical effect. And we have all experienced with holmium how the plane sometimes open, and there is no visible thermal effect on the tissue. And that's because you are at a distance that produces separation of the plane following the path of least resistance, developing the anatomical plane that we were used to develop with the finger. And of course if you get closer, then this heat can also coagulate the tissue, and then you have a combination of mechanical effect plus coagulation. And this is the desirable effect, because it opens the plane and at the same time provides coagulation. And then, if you get closer, this explosive effect would have a cutting effect on the tissue.

Dr. Fernando Gomez Sancha:

But, we have seen that there is a sophistication in the pulse modulation that Lumenis has brought into the market with these two consecutive pulses. The first pulse is going to produce an initial bubble, and the second pulse is going to travel... Let's play it again. Play it again. See, this is the regular pulse up there. And if you look at the lower image, there are going to be two consecutive pulses. So, the first pulse is going to produce a smaller bubble, but then the second pulse is going to travel through the bubble. So, the energy will reach much further away from the tip of the fiber.

Dr. Fernando Gomez Sancha:

So, basically what you see when you're operating is that you have double effect. One is the opening of the plane due to this explosive effect. And the other effect is the coagulation of the tissue. And that I think it's possibly unique to HoLEP. And we can discuss also after that, and I will show some reason for this. I'm sorry, the quality of the video maybe was not so good. There is also other forms of pulse modulations, and this is a Quanta System laser that has different ways of modulating the poles to obtain different effects. Most of these were developed thinking of stone treatment and improving stone breakage, but we are seeing that the virtual basket is, which is similar. As you can see, it's two consecutive pulses, are very useful as well for enucleation. This is the virtual basket and you can see a similar profile. There's this initial pulse and it's followed by a second pulse. And this was designed to reduce retropulsion with stones, but it's also very interesting for BPH.

Dr. Fernando Gomez Sancha:

And this is another case, this time with the virtual basket system. We had a stone in the bladder, and it's also very fast to break these stones. This system has 150 Watts and a lot of possibilities to modulate the effect. So, we are seeing similar cases, as you described Naeem, on patients with stones and BPH. It's very nice to be able to use a single tool to do it all. And also when you look at the properties, when you want to dissect the plane, you get very nice tissue separation, and as well very nice first pass hemostasis, which is to me the game-changing feature of this new pulse modulation. Not only it keeps opening the plane as holmium did, but it provides very good hemostasis, especially when you're dissecting. So, you can focus on dissecting the plane and not to keep the hemostats. You don't have to stop to coagulate and things like that.

Dr. Fernando Gomez Sancha:

So, basically what I think is happening it's that the first bubble is going to open the plane exactly as it did before, but then the further reach of the energy is going to provide a coagulation effect on the tissues. It's really a big difference. And you notice it very, very soon when you start using these lasers. And also, there's a better cutting property to it. So, when you have to cut fibers, you have to cut tissue, it's a little bit better than classical holmium. And I have to say coming from GreenLight and having operated with thulium and thulium fiber laser as well, and we can discuss my experience later, my feeling was that every time I used GreenLight or I used holmium or I used thulium, I was appreciating the good properties of each of these energy sources. Greenlight was very good with coagulation. Thulium was very good with cutting, for example. Holmium would open the plane in a way that neither of the previous lasers would do.

Dr. Fernando Gomez Sancha:

And now with post-modulation, with these systems, my feeling is that I have a holmium laser that has a property similar to GreenLight in the sense that the hemostatic is very good. And also similar to thulium in the sense that the cutting has improved. And this is for me the main reason why you might say that you can the plane with the thulium fiber laser, but I think... Of course, we can all enucleate. "We can enucleate with a spoon," I like to say that. Once you are an expert, you can use any tool to do enucleation, but there's a big difference between holmium pulses. Holmium pulses have a very high peak power. When you use two Joules, you can reach this maximum peak power of 10 kilowatts. And when you use lower energies, it goes a little bit lower.

Dr. Fernando Gomez Sancha:

But when you look at thulium pulses, you see the peak power is usually very, very, very small. And this peak power is going to be responsible for this cavitation bubble effect. So, I think that there are two different leagues. Holmium can produce cavitation bubbles and can provide a proper opening of the plane, whereas thulium and thulium fiber lasers possibly are less efficient in that respect. So, I think this is a very important concept to keep in mind. And this is why when we perform holmium enucleation, we can peel the plane very nicely. Whereas, with thulium we have a tendency to cut. I mean, we can be anatomical, of course. Even in your videos, Naeem, I could see that you tend to push sometimes to check that you are in the right plane. And this is fair enough, but there is a difference. And it's important to outline that difference.

Dr. Fernando Gomez Sancha:

There's some papers, Dr. Amy Krambeck has been very, very active publishing on this new pulse modulation lasers. These papers showed that the operating room time was decreased. If you think about it, if you have a laser that coagulates, at the same time that dissects, then you save time. You don't have to spend time doing hemostasis at the end or during the procedure. Also, same day catheter removal, or same day operations are a very big tendency now with enucleation, which seems incredible really. When you think about the history of urology, where we come from, operating a patient with a prostate bigger than 100 grams and sending him home the same day, and sometimes even without a catheter, it's a really, really big, big change. A game changer, I would say.

Dr. Fernando Gomez Sancha:

And then, there's this paper comparing Moses 2.0. This was a further sophistication of the pulse modulation with Moses to make it even better. And also there was the reference that possibly having this kind of tool makes learning the procedure easier in the sense that, if you can have a tool that dissects the plane following the right plane and that coagulate at the same time, it might make this operation much easier to learn. And I think this is really another game changer, because we know how enucleation has been difficult to adopt for many surgeons in the past.

Dr. Fernando Gomez Sancha:

Also, there is this recent prospective double blind randomized control trial comparing MOSES with HoLEP. And it was shorter operations and comparable, of course, functional outcomes and complications compared to traditional HoLEPs. So, we're starting to see papers coming out. I use an en bloc technique for prostates of any size. I found out that if you rotate the head, normally if you push one lobe first and then you rotate following the same rotational movement with the prostate, you can tilt any prostate irrespective of the size into the bladder. This is probably true for almost every case. And I haven't prepared videos here. I have a lot of videos in YouTube. If you look for my name, you will find that I have real-time cases. I have like 28, I think, cases where you can see the operation from beginning to end with all the comments about the technique, et cetera.

Dr. Fernando Gomez Sancha:

But, we had our own experience comparing MoLEP, which would be the left column, with HoLEP in our center. And you can see how we have gained probably 15 minutes in our operating time. You see this was a specimen weight of 56, which is almost 60. It was probably around 75, 80 gram prostates. We took 32 minutes of surgical time, 22 minutes of enucleation time and very faster morcellation as well. This is another aspect that has improved in the previous years. And, of course, we had excellent tolerability, very little complications. So, it was very good. And you can see here, the surgical time was reduced. The enucleation time was reduced. We had a very wonderful ablation rate of four grams per minute. And we also shortened the time we devoted to hemostasis at the end of the procedure with similar... I mean, these are boring. You can see these results on, on flow rates, prostate volume, PSA reduction, et cetera with any form of enucleation.

Dr. Fernando Gomez Sancha:

And we also had some experience with virtual basket. And, again, we operated patients with about 80 grams of prostatic volume, and we had 40 minutes of total surgical time with a 60 gram prostates. And if you look at the stress urinary incontinence rate post-operatively, in this cohort of patients it was zero. So, I think in conclusion and before we start our debate, I think enucleation is feasible with a variety of energy sources. Different energy sources have different features. It's important, I think, that the surgeon understands the tool, because when you understand your tool, you can make the most of it. And these differences are important, but it doesn't mean that you cannot enucleate.

Dr. Fernando Gomez Sancha:

Pulse modulation enhance cutting and coagulation properties of holmium. It allows to do faster enucleation procedures. It provides a better first pass hemostasis, shorter catheterization times, ambulatory procedures. And there is this idea that we have to prove and that we have to study that probably this will open the democratic session of HoLEP, so that people who thought that would never be able to do HoLEP will find out that they can do it and it's not so difficult to learn. I think the endoscopic enucleation of the prostate is a natural evolution of TURP into something better, more complete, more anatomical, and it should be widely adopted. I think that these recent technical and surgical technique improvements make it now more attractive than ever. So, thank you very much. This was my part. And I am hoping to have a nice debate with my colleagues.

Dr. Thomas Herrmann:

Thank you very much for this nice talk. So, as I said in the beginning, we are dealing with two converts, so there must be something in these new energy sources which they use. So, my first thought in asking you would say... So, this is what I said, "We have now energy sources that are more mature, so they have overcome some of their limitations. And with these two lasers, I think they have come a lot of their shortcomings in the past. And I think the biggest shortcoming of both, and I'm speaking of thulium YAG as well, is the hemostasis in both. I think that is clinically visible. That is what we have been told in every meeting.

Dr. Thomas Herrmann:

The other thing is, what I would like to express is that holmium with the Moses technology obviously does something different, what you've just seen. So, I always say it's the energy source of COVID, so more distance. And that is something in particular which is really changing the way on how we can do the surgery. The question is besides the hemostasis, which I think is a very valuable point, if we are talking about enucleation, there were some questions of the audience. What you said, I think I would agree. It's easier to do it, but do you think that it is so good that you would say it is better to learn with that? So, my personal experience is that, when I'm teaching enucleation I start with bipolar, switch to HoLEP, because that's what everybody wants to do.

Dr. Thomas Herrmann:

And thulium was a little bit left behind since we have the new Revolix HTL. People tend to use that, because they're interested in that. So, my feeling still is that it's easier to do a pure mechanical enucleation. That's why I was talking with... And again, I quoted Elhilali, you did a great deal with gland enucleation when you were doing GreenLight, and I think those results were fantastic as well. So the question is, because we're teaching the audience at some stage here, do you really think both of you that these energy sources that you have today really make the change with regard to teaching? Coming from GreenLight, and one thing, we've heard that. And now to Naeem, starting with Naeem, do you think it's easier to learn thulium fiber laser inoculation than your 1000 HoLEPs that you have been doing? So, with regard to the learning curves, we always have to include that. It's institutional learning curve, personal learning curve. Your idea, Naeem.

Dr. Naeem Bhojani:

So, I think that's an excellent question. I think there's this one study that I showed where the learning curve might be a bit better with a thulium fiber laser. My personal opinion is it's about the same, regardless of any resource. I think if you're using the holmium, holmium Moses, bipolar, GreenLight... I find GreenLight a little bit trickier, because of the side fire and then sort of [inaudible 00:49:27]. I think you're looking at least 15 to 20 cases with a mentor. I don't, honestly, believe that one is faster than the other. And I haven't seen strong data to support one or the other, to be honest. I know people say often, "Oh yes, it's easier with this laser, or with that energy." But, I think it's about the same. If you have a good mentor and you can identify the planes, about 15 to 20 cases it's going to take.

Dr. Thomas Herrmann:

Thank you. And Fernando [inaudible 00:49:55] question-

Dr. Fernando Gomez Sancha:

One of the reasons why I switched from GreenLight to holmium was that, of course, if I found a stone in the bladder, I had to use a holmium and a GreenLight to do enucleation. A holmium to break the stone and then GreenLight to do the enucleation. And the other one is that, not every prostate has a very nice dissection plane. We see a lot of inflammatory prostates, where when you want to do a mechanical dissection, it is very difficult. And here I think is where holmium shines, because you can find your plane easier with energy than with mechanical moves. Sometimes you have to push too much that that could lead to accidents. So, my feeling, I have used thulium fiber. I worked in Bulgaria and they brought it to us. So, I did 20 cases in one session with thulium fiber laser. And initially, it was a little bit strange. And then, I managed to do it very nicely, because of these mechanical pushing. I was familiarized with mechanical enucleation, what you described Thomas as ThULEP.

Dr. Fernando Gomez Sancha:

So, the problem is when you find them a bad plane. Again, when you have a thulium laser fiber, I think you went to face the same difficulty, the plane is difficult, or you have to invent the plane. Of course, all these differences probably are not so relevant when you are an expert, because you can probably operate a line. You don't need... But, in terms of learning, I think there might be an advantage for these lasers that provide better hemostasis. I think this is quite good use.

Dr. Fernando Gomez Sancha:

And I have seen two people do their first cases with post-modulation holmium. And to be able to finish the first case, the first time they sat with me by their side, hitting them in their head, "Don't go this way. Correct your plane," and like that, but they were able to finish their procedure. So, I think there is something there. And this is my opinion. Of course, it's not an easy to learn technique. Case-selection is very important. A mentor is important. Simulators are important. You want to learn, you have to learn properly. But, probably it's going to become, I'm convinced, it's going to become more democratic than before.

Dr. Naeem Bhojani:

So, I did about a dozen GreenLight enucleations. I think I was looking for a better hemostasis. And the hemostasis was better, but the side fire lasers, it makes it very difficult to enucleation. When you can't, like Fernando says, when you're trying to separate the prostate out, if you have to use the laser and it's going sideways, I thought it was not good. And that's why I liked the thulium fiber, because you have the hemostasis of the GreenLight, but you have fire laser.

Dr. Fernando Gomez Sancha:

This cross [inaudible 00:53:00] having to switch from one energy to another is very interesting. For example, in my personal experience, I came from GreenLight enucleation before I used holmium. And I realized with GreenLight that doing a three-lobe technique was not practical at all, and I decided to go en bloc. And when I started using holmium, I was already very proficient within en bloc. And that's why I could adapt very easily to en bloc or holmium. So, I think, my personal impression with thulium fiber laser... And tell me if I'm wrong. I'm going to be a little bit aggressive here. I think probably thulium laser fiber is very good for stones. It opens new possibilities, because their parameters of the laser can be tweaked much more and wider than other existing holmium lasers.

Dr. Fernando Gomez Sancha:

But, as always companies when they put a product in the market, they say, "This is very good for stones, and it's also very good for these other indications." So, they're always looking for further indications. And I think having used both lasers, if you give me one to choose, and I'm respecting that thulium laser fiber provides very good hemostasis. And I agree with that. It's very good hemostats. It does not open the plane the way holmium does. To me, this is a great advantage that thulium lasers or thulium fiber lasers cannot offer. So, that's my opinion. I think thulium laser fiber is very good for stones. You can do enucleation with it, but probably it's not the best laser for enucleation.

Dr. Thomas Herrmann:

I would add the following. It's a low power laser, it's 60 Watts. And that's what you know, if you're familiar with a vaporizing laser, you would find this a little bit disappointing is what I brought in the beginning. But, there's another one out with 150 Watts, where you have both the vaporizing and the new pulse modulation features. I think it is easier if you are an experienced holmium surgeon and if you have an institution which is run under holmium to then, because people have seen you doing it or have a lot of videos to show, that you then pick up this technique and learn holmium.

Dr. Thomas Herrmann:

I wouldn't say what you said when you gave this orange is always coming up. I think the specimen looks identical. So, if you are not experienced or not, if you train people to follow the plane, you're not losing the plane. I think this is as with holmium as not... And in addition is with holmium, you don't know whether you've lost the plane, because everything is boiled. So, this is why I'm a big fan of teaching mechanical enucleation, because then you see the completely untouched peripheral zone. And that is the only time where you really can see and survey through the whole procedure that you are on the plane. And this is why I start teaching with mechanical enucleation first and then the energy source is secondary.

Dr. Thomas Herrmann:

I believe that this energy source, Moses, is speeding up the enucleation a lot, especially because of the very weak coagulation properties. Imagine, we are talking about the least penetrating lasers. So, they had to improve hemostasis. I think this is very important, but I think apart from that, I think a lot we have to know and we all know there's a lot of bias from people that are loving their energy source. At the moment, we do not have any head-to-head. And a head-to-head would only make sense in the best practice multi-institutional comparison to really show what can go up.

Dr. Thomas Herrmann:

I think all those lasers have improved a lot. I think the TFL, what we saw has little bit little power. This is why it looks a little bit of versatility in the high power range representation here. Moses still is not very good at vaporizing. If you love that, you will miss that. But what we definitely have achieved is, we have now better tools than five years ago. And what we have been discussing a lot as well is that we have improved our concept and technology. And just one last comment from my side two-lobe and en bloc. I think three-lobe is out, because it is complicated to start with the first lobe. And two-lobe and entire lobe or en bloc starts with a lateral lobe. That is what we do with open prostatectomy and with robotics as well. So, I think we have 38 seconds left.

Dr. Naeem Bhojani:

So, one last word from me, I think what's important is, if you can, try out the different energy sources and then you'll be able to decide for yourself what you find best for you. I did many, many HoLEPs and I find thulium fiber laser is better for me, my personal opinion. But, it might not be the best for somebody else. I think it's important to try the different energies and find what's best for you.

Dr. Thomas Herrmann:

That's the last and best comment. It's, you have to find your technique and your energy source to provide best care to your patients, either in-house or ambulatory and take care. Thank you very much for your attention.

Dr. Naeem Bhojani:

Thank you.

Dr. Amy Krambeck:

So, before we pull up the last slides, I want to let Dr. Gomez say his last word really quick.

Dr. Fernando Gomez Sancha:

Yes, no, what I wanted to say is that if you don't do enucleation, you have to start. This is the most important thing. I mean, this seminars shouldn't be here to discuss among a small group of people who do HoLEP or enucleation in the world. We need to push enucleation forward. And if you want to do it, you can do it.

Dr. Amy Krambeck:

Thank you.

Dr. Naeem Bhojani:

Agreed.

Dr. Amy Krambeck:

All right. Well, it was a wonderful, wonderful discussion. And I know that the viewers love this. So, we'll take the last few slides here. So, for all of you that are with us, thank you. Next Friday, March 19th, we have the multiparametric MRI. Faculty is Dr. Turkbey, Dr.Choyke and Dr. Gupta with moderators Dr. Sanchez-Salas and Dr. Polascik

Dr. Amy Krambeck:

Next slide. We encourage everyone who is not already a member to join the Endourology Society. Your membership dues provide you with many, many membership benefits including full text online access to the Journal of Endourology, Videourology and Journal of Endourology Case Reports. So, please go to the website www.Endourology.org.

Dr. Amy Krambeck:

Next. And finally, save the date. We are planning the WCET in 2021, September 23rd through the 25th in Hamburg, Germany. It looks like it will be a go. So everyone, please put this on your calendar and plan accordingly. Thank you for joining us today.