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Newer Surgical Modalities for BPH

Oct 14 | 1:30 PM

Benign prostatic hyperplasia (BPH) is a common geriatric ailment in India, with a 93% incidence rate that rises with age. Physicians have a wide range of surgical procedures available to them. Lets take a look at some of the most regularly used surgical procedures, as well as some of the more recent surgical techniques.

[Music] a very good evening to everyone who's watching um my name is doctor devanshi madhya and i'm a clinical ops intern with netflix and i would like you all i would like to welcome you all to today's session on newer surgical modalities for bph and for this session we have with us dr rishikeshwar a consultant urologist and andrologist and assistant professor for urology at gsmc and km hospital in mumbai he has more than six years of experience in the field of urology and has successfully operated on more than 3000 cases along with that sir has also presented and published in many national and international conferences and research journals uh so we welcome you sir so we can start now sir thank you so much and uh good evening to all and all my metrics team and thank you for giving me opportunity to talk on this platform which is a very good initiative for resident learning and today's topic is newer modalities of surgical management in dph so shortly in about next 40-50 minutes i will throw some light on newer modalities of surgical management in bph so bph as it says is benign prosthetic hyperplasia now in the field of urology prostate is considered to be bread and better of urologist and prostate is the organ which is going extensive research and there are n number of drugs and number of therapies and number of surgical modalities coming every month every year what we used to do 20 30 years back open prosthetic was used to be the option for every bph patient but now as as advances as our technology is advancing newer modalities are coming which are minimally invasive with lesser morbidity and we are shifting toward less mini less invasive to no invasive treatment at all so in today's topic i won't be talking in the details about prostate bph or what are the regular therapies or what are regular qrps i will be throwing some light on newer modalities of surgical management in bph other than 2r2 which are currently in use or in research research phase so as you know just short about the anatomy of prostate which are clinically implicable uh factors which are related to qrp and our endoscopic surgery so as you know bph bph is benign prosthetic hyperplasia it is most commonly scarred after age of 50 years and at the age of 50 years incidence is around 10 to 20 percent but after the age of seventy years almost seventy percent men developed benign prosthetic hypertrophy and related lower neural track symptoms so it is a very common symptoms in geriatric population and previously 20 30 years back there was no drugs available only treatment used to be open restrictable so irrespective of the size of the prostate open prosthetic was the surgery which patient used to undergo but now there are wide number of drugs available such as alpha blocker file for reductase inhibitor even pdefined inhibitor so because of this previously almost 50 to 70 percent patients used to undergo open prosthetic 20 30 years back now in last two or three decades that modality changes from open prostrate to be endoscopic surgery that is too early so now suppose only 20 to 30 percent of patients require surgery because of availability of advanced strength such as time solutions in alphazosine deuterosteroid so these drugs has significantly reduced the number of operations required so now say only 10 to 20 patients of total bph spectrum require any form of surgery so now few anatomical considerations to be taken uh regarding the surgeries in regarding the anatomy as you know prostate is the gland walnut shapes approximate size of 10 to 15 cc situated at the base of the bladder and what you can see now in the left hand side image this is the coronal section of the prostate you see a very mundane and openings of urethral uh prosthetic ducts in the weather the tissue lateral to it is called as paracolor tissue so that issue is very much important in preserving ejaculation because internal spin the main male population has two sphincters one is internal sphincter and one extra splinter what you can see at the base at the particle part of the at the lower part of the prostate is external sphincter that is the voluntary splinter and what is the the sphincter circular sphincter at the junction of bloater and prostate is internal strength so that is a smooth muscle sprinter so during the surgery in any surgery trp we resect prostate from internal sprinter to the value antenna so we damage the internal sprinkler so total continent depends upon the extent sprinter only so if external splinter get damaged in such as large glands then patients become incontinent second perspective is ejaculation because loss of adrenal splinter the patient develops retrograde ejaculations so to preserve retrograde differentiation important issues is the tissue lateral to the value band and that is called as parallel tissue and the length of intra prosthetic urethral length so they say if inter-prosthetic urethral length is more than one point five centimeter and you if you preserve parachute tissue then it will preserve your ejaculatory functions because most disturbing factor after prosthetic surgery long-term complications is ejaculatory dysfunction that is unejaculation or retrograde ejaculation and second is incontinence so these two are the main complications which patient is bothered about so we will be throwing some light regarding these uh two complications in all modalities we are going to see now in the second image what you see is the zonal anatomy of prostate so you can see the prostate is mainly divided into anterior fiber vascular stoma posterior zone transitions on transition zone surround which is the importance of benign prosthetic hyperplasia because it's around the tissue and the growth of the transitional zones which causes the obstructive symptoms in bph so transition zone is very much important from pph but for prosthetic calcinoma peripheral zone is most important and what we call the central zone central there is a part in between ejaculate reduction and transitional zone so in bph transitional zone is what is more important because the sphincter receptors in the transition source these are alpha receptors which we target in the medicines these are the most important for having improving your urine flow so now choice of procedures for surgical now i am not going to talk about medical management today because medical management of prostate its complication is a separate topic to talk on so today i will be more focusing on other surgical therapies so which are the factors which just considers that which patient should undergo which surgery so it mainly depends on what is the size of prostate it roughly it is divided prostate less than 30 gram 30 to 50 gram 5200 gram and more than 100 grams then patients bleeding grease because prostate is a highly vascular organ and it receives blood supply from internal artery infrared recycle artery and then these arteries develop get divided into two branch arteries of flocks and burden hop so arteries of clocks are at one o'clock and eleven o'clock arteries of bedok at five o'clock and seven o'clock these are the artists which are very much important during the qrp because these sites one o'clock eleven o'clock five o'clock and seven o'clock which we need to take care of during this section because the leading risk is highest at this point and if we control these leaders earlier then there will be less bleeding during the process so patients bleeding grease like some patients with a high volume gland more than 50 cc hundreds of these glands are very much vascular these are high risk of developing bleeding intraoperatively and post operatively and some prosthetic buildings are very indolent and we have to stop the surgery because of prosthetic ultra building sometimes so incidence of prosthetic artery prosthetic bleeding during the turp is like point five to one percent but it can be deadliest it can lead to a loss of life third factor is age so depending upon age like i said early age like patient is 15 60 they are more worried of their sexual function so we have to offer them modality which will preserve their sexual function that is uh decrease erectile dysfunction or decrease retrograde ejaculation or unejaculation then co-morbidity lies these patients are usually more than 60 or 70 years almost half of them have diabetic hypertensive had underwent any interventions like coronary angioplasty bypass grafting many patients are on dual anti-platelets which are more risk for bleeding so we have to consider these comorbidities then surgeon's experience and preference so now during the urology training trp is the basic which is considered as basic that every pasta technology should know how what you are what is meant by trp and he should at least do 10 qrp as per curriculum so that he should be well versed with the urp techniques and the complication arousing from it other surgeries for prostate like laser trp other minimally invasive rv these come as an advanced therapies so we do not expect that mch pastor technology should know this but we at least minimally expect that whoever is passed out msh or dmv already should know at least how to manage qrp or how to do trp this is the basic so surgeon's experience because laser surgeries it requires high skills and there is a lot of learning in such patient such cases so surgeon's experience is very much important factor in choosing the surgery and availability now again availability of instruments because trp instruments there are wide plethora of instruments required endoscopic instruments required laser required so depending upon availability you are set up because if you are operating in remote setup you may not get bipolar trp you will always get monopolies rp so depending upon your setup and availability of your instrument you you are supposed to choose your modality of therapy and you are offered this so this is like a shared decision with your patient and you you have to offer these these are the options for you these are your concern and you can with your patient proper counselling you can select and this will be best for you so now basic is qrp uh added this slide because qrp is considered as the gold standard for any prostate surgery and any data of any newer modality is always compared with qrp monopolar diverp because it is considered the gold standard so as you can see in turp using the endoscope and receptor scope we resect all the glands and we remove the chips so in first left hand side you can see all the bph adenoma second picture in middle picture you can see a recycle scope being used for to remove that adenoma piece by piece using either monopolar cautery or bipolar cautery and third picture it shows a completion complete surgery so you can see bladder neck is wired internal sprinter is totally gone entire adenoma is gone only prosthetic capsule is remembered or a venomous antenna and you must be knowing that the level of resection is we have to always should be proximal to variable antenna so as to preserve your external spindle so what are your minimally invasive techniques so minimally invasive techniques is a techniques which we use through natural orifice like natural verifies europe all the prosthetic surgeries endoscopic surgeries are carried out to transcendentally so these are called as transurethral surgeries and open surgeries which are millions prostatectomy young's prostatectomy this used to be open surgery and these require abdominal incisions so in minimally invasive surgeries it is again divided into two surgeries mainly resection techniques and ablation technique so what is the difference between them so in the resection technique we just cut the tissue like we cut the butter it's like we separating the butter from entire it's the so it is like removing it chip by chip we are not ablating the tissue while in ablative techniques we are destroying the tissue so we are using higher energy vaporization technique laser technique so that tissue gets vaporized so tissue gets destroyed we don't get tissue as such after these techniques but after resection techniques we get tissue to send for histopathology so this is the major difference between the resection techniques and ablative application techniques so the example of resection techniques is what we which we talked with prp either monopod or bipolar a second is laser inhibition that is holy tulip or uh thule vapor resection and in ablative techniques what we will be seeing in further uh further slides is water vapor energy ablation echo obligation microwave thermotherapy and other techniques minimally invasive are prosthetic urethral lift transverethral implantable netanyahu device that is ti nd prosthetic ultra embolization and inter prosthetic injection so we will see about this in forthcoming slides so now first is what is prosthetic urethral lift so prosthetic urethra lift it is also called a zero lift it is a trans prosthetic implant introduced in the urethra and used to compress the prosthetic tissue thereby increasing the urethral lumen and reducing obstruction to the mental urethral patency so as you see in these two pictures upper picture is the prosthetic adenoma so you can see because of increasing the transitional zone or increasing the density of transitional urethra is getting compressed so what we do in prosthetic electrical lift we place implant at the two position at a two o'clock and four o'clock uh sorry two o'clock and at a ten o'clock and which helps in retracting those lobes laterally so we increase the patency of the urethra so in lower picture you can see these two black lines which are holding the urethra apart so it is like pulling the urethra apart from midline so it increases the your diameter of prosthetic urethra and it decreases your lower track symptoms so it is ideal in patients which are having less than 80 gram of prostate with nobilian look because it is only used for to retract lateral lobes so if a patient is having median though then this therapy will not work and this is minimally invasive short endoscopic surgery procedure lasts only about 5-10 minutes and can be done under local anesthesia and this is a very good alternative to patients which are highly comorbid patient there are patients which are not fit for any anesthesia but patients which are having significant lowering attract symptoms and which are not controlled on medical therapies so transactionally you can see at a two o'clock and at ten o'clock these are two pins white color pins which are retracting the lateral lobe and it is compressing the lateral lobe towards the capsule and so as to maintaining the patency and the advantage of this is low rates of local symptoms along with minimization of impact on sexual function so these patients usually do not develop erectile dysfunction because after the resection of prostatic tissue there is high chances of developing erectile different dysfunction or decrease in the quality of erection because of the common blood supply arising to the penis and prostrate and there is ejaculated problems which i discussed that retrograde ejaculation or an ejaculation so these sexual function is preserved in these patients so this can be ideal for young patients but which are not fit for you or patients who does not want to compromise their sexual functions for some reason which are like early 50s or 60s patients so there are some studies which are which are comparing this euro lift with conventional trp so also improvement in ipss ips is the international prosthetic symptoms code so there is a score which contains seventh factor and eight factor is quality of life in uh index it is a modification of au score which contains which is uh the short form it's called as fun p score it is a 35 point score each point has each component has a five points and uh it is uh graded as mild moderate severe mold is zero to seven moderate is eight to nineteen and twenty to twenty five severe so improvement is ips score is seven to eight points so after trp they say improvement is almost 10 to 15 points but in eurolift it is up to seven to eight points and quality of life index it is increa uh change in quality of life index there is two to three points and section main quality of life indexes improvement is preservation of sexual function so it is not as comparable to eorp but as sexual functions are preserved so many patients perceive it as improvement in quality of life index so it is an option for men who are poor candidate for more invasive procedure and those who refuse to accept the risk of prp but find medical treatment ineffective or unacceptable so these are again few papers which are few significant papers which are comparison euro lift with uh other modalities of treatment so again there is significant improvement in a us core that is symptom scores and q max also increases by three to four points and which is sustained in one year or three years but after the debt of three years or five years there is higher chances of retreatment because this surgery fails after three to five years because there is again in growth of lateral lobes and this procedure again require skills and learning learning curve is there and if this uh this euro level get migrated then it's very difficult to remove so this should be done by very skilled surgeons so this is the eu european association of urology uh last year's guidelines so they they have included eurolift in their guidelines now that is the procedure eurolift improves ips's qmax and quality of life index and it has given grade 1 a evidence so this is considered 1a is supposed to be highest level of evaluation so they have now incorporated prosthetic eurolift in their guidelines and their recommendation is offer prosthetic urethra lift to men with lower urinary tract symptoms interested in preserving ejaculatory function with prostate less than 70 ml and no middle though so this has to be offered to a man who is keen on preserving his sexual function but a man in 1780s which has a high ips symptom score and which he has higher obstructive symptoms then 2rp is much better than eurolift in such fashion now second is water vapor energy application so what is water vapor energy operation it is called as a wave therapy and that system is called as resume system it is a convective water vapor thermal energy to update the prosthetic tissue so now we are discussing acro ablation further so difference between the water vapor energy application and hyper ablation is in water vapor energy ablation we are using water vapor that is a heated water but in activation water is at normal temperature and we are using a water force that is a pressure of the water jet as a source of resection and but in water vapor energy application we are using its heat therapy it causes coagulated necrosis and it decrease in tissue so this is the main difference between water vapor energy ablation and acquiration so water vapor injected transversely in the transitional zone at 103 degree celsius for a nine second at pressure slightly above the interstitial pressure so what is normal our normal interstitial tissue pressure so just above that we inject water vapor at 103 degree celsius for nine seconds at various levels so it starts from just one centimeter below platter neck you can see this device so it has an endoscope and it is a retractable needle which is inserted into prostate so it is inserted in a transitional zone so it is a depth of penetration is uh 9 to 10 mm so at a various level starting from one centimeter below knee bladder neck we inject it seriously and we causes coagulated necrosis of transitional zone bilaterally so over a period of time this coagulated necrosis it causes death of the the ischemia of direction and so the transitional zone size decreases and urethral lumens pidens so it is done at three o'clock and nine o'clock bilaterally at one one meter distance one one centimeter distance so this is how the system looks it is a computerized procedure it is composed of a generator with handheld delivery device that includes a transverethral reject systroscope and a 18 gauss retractable needle which we see in the which we have seen in next picture with 12 vapor emitting holes located at the tip of that delivery device so this whole system is called as a resume and now outcomes so outcomes after this procedure there is 12 reduction in ips score at 2 weeks and there is increased 50 reduction at 3 months so because it only forms coagulated zone of necrosis which further over the period of time it causes dislodgement from original tissue so initially there is no increase in symptoms uh improvement in symptoms but as of uh duration progresses after one month and three months patients start improving uh flow and there is no significant change in erectile dysfunction the retreatment rate has four to four four point five percent for trp retreatment retreatment rate are supposed to be five to fifteen percent over a period of ten years so now here surgical retreatment rate that is four point four percent at three years which is very high as compared to conventional trp so again this therapy does not remove entire adenoma it only removes transitional zone so this is again only can be done in our clients up to 50 say 50 to 70 mm 50 70 cc of gland not more than more glands which are having more volume more than 100 cc or which are having median though and this uh therapy has to be done under localization or usually generalized finalization because we are using water vapor some patient may experience discomfort so because we are causing destruction of tissue psa level initially increase which normalize after one month or one week or one month and only adverse effect of this year because we are causing coagulated necrosis we are not removing any tissue during the procedure it causes edema in the transitional source which lets you transient during the retention so this patient may require catheterization for five to seven days post surgery this patient uh experienced dysuria significantly because we are upleading the mucosa and keeping it over there so the storage symptoms worsens after this procedure for first few days and some patient developed frequency urgency urge leak urinary tract infection hematuria and poor strain now this is the vibration so you can see this is the robotic arm this is the robot guided system so whatever we can on left hand side you can see the system uh which is containing card and it's sonography transfer rectal ultrasound it is done under the guidance of trans rectal ultrasound on the right hand side you can see the this device which contains cystoscope balloon which is inflated in the bladder and you can see thin stream of jet which is coming at a six o'clock so this is the pressure what we see in the cutting instruments in cutting industry they use a high level of water pressure to cut the glass or cut the diamonds or even to cut the pattern the same principle is used in this aqua ablation so we are using the very thin stream of water jet at a high pressure which causes ablation of prosthetic tissue so what was his outcome so again outcomes are these are very good as compared to other modalities so over a period of time over a period of three months quality of life improves pvr decreases flow rate improves and ips score decreases so patient initially patient do not may not enjoy improvement in ipss or quality of life but over a period of time over three weeks all the symptoms improves and the change in ips score is more pronoun with acquire ablation or 50 20 gram again this this procedure used for 50 to 80 gram postage size operative time were similar between uh trp there was studies comparing accomplishments with the conventional drp so operative time was found to be similar with qrp and with much lower resection time for acquiration as this is a robot guided citizen so the precision is more so we predefined with trust guided ultrasound we predefined our marks up to what level the restriction is to be done and then accordingly act vibration is carried out can you play the video of application so this is the system vibration they are putting translator ultrasound and this is the scope transurethrally you can see the prostate and bladder transverethrally now with ultrasound garden they are marking their territory of resection so whatever you can see is that a prostate so point of resection are decided in both transverse as well as survival section so the resection in this acquiration is very controlled robotic guided and as you can see the water jet is used to upgrade the prostate gland so this causes entire distraction and the water along with particles of prostate drain is removed so in time say 30 to 40 minute entire procedure is carried out for 50 cc of gland you can resume the presentation so what is the benefit of this vibration as in aqua oblation resection is controlled robotic guided so there is precise points the chances of incontinence is very low and precision is very much better but the one point which is uh debated till now because this is a removing entire prostate without uh vision vega urologist doesn't have any control so if there are bleeders if they are bleeding point that cannot be controlled very effectively by robot so there are concern that some patient might develop uncontrolled building after the acquiration so still trials are going on whether to how to control the bleeding or whether the outcome the outcome of bleeding control into european acquisition is comparable or not and ejaculation is preserved in again this because we can preserve the parachute tissue and the three section is very much in control so ejaculation is preserved in few patients and again ea eu guideline european association of urologic guideline we have given level of evidence 1b act via ablation appears to be an effective as qrp both subjectively and objectively however there are still some concerns about the best methods of achieving post treatment hemostasis so whatever i said in the trp under vision we can achieve hemostasis after that excession but in acquiration we don't have any access for hemostasis after acquirations so this is the one concern and their companies addressing into that and so recommendation they have written that inform patients about the risk of bleeding and the lack of long-term follow-up data now next modality of treatment is ti nd that is temporally implantable neutron devices now this is a very short procedure it can be done under local anesthesia so this is the procedure is done in patients who are not uh able to undergo any procedure which are high risk for any anesthesia so in this uh procedure you can see the upper left image this tinnitus device which gets inflated after putting in the prosthetic urethra and it causes radial compression on the prosthetic tissue so this is how you introduce it with the introducer in the prosthetic editor you inflate the device so it readily expand the prosthetic tissue it is a pre-loaded and dedicated delivery system deployed in the folded configuration anchoring leaflet slider into six o'clock and position digital to bladder neck and these struts expand and exert longitudinal pressure on the prosthetic urethra bladder neck at 12 o'clock 5 o'clock and 7 o'clock and this causes a radial compression in three directions like a mercedes benz so it increases or widens the lumen this device is kept in the urethra for five days it causes ischemic necrosis of that gland and fibrosis and increase in the lumen so after five days we have to redeploy the device and remove it out so it is only kept for temperature so it is called as temporary because it is only kept for five days it causes ischemic changes fibrosis and it widens the rumen so uh these are the some few uh studies which has compared the effect efficacy of ti nd against urp and other therapies and outcomes at the one year so prosthetic strains have a limited role in the treatment of moderate to silver lodes due to lack of long-term data common side effects and high migration rate so migration this is the very much concerning complication of this device many a time this device get migrated into the bladder or distally and migrated device is very much difficult to remove so this again this therapy has to undertaken by has to be undertaken by surgeon which is very much experienced in deploying and removing these devices and till now this doesn't have any strong recommendation for uh any guidelines in any guidelines for the management of pph now these were whatever three we saw these were the minimally invasive techniques which are alternative to surgery now we what we are going to see is the laser so these lasers in urology had caused major impact in the management of stone as well as prostate so there are n number of innovations in laser in last two to three decades and which have improved the efficacy and effectiveness of all the prosthetic endorological surgeries so right from argon laser ktp laser now we are using wholum laser thulium laser and advanced thulium fiber laser so your field of photology has undergone evaluation evolution over a period of two decades and now we have increased uh control over how we fire the laser its delivery systems its power its coagulation and we can manage glands up to even 200 to 300 gram effectively using laser so now you can see the visible spectrum of our light is approximately for 400 nanometer to 750 nanometer what is beyond 750 nanometer is called as infrared spectrum what is below 400 uh spectrum is called as ultraviolet spectrum so what we use generally in urology infrared spectrum so ndr holmium mat cholimium has a wavelength of 2100 nanometer thulium has 2040 and other lasers are ktp and co2 laser it has 10 000 nanometer uh wavelength but co2 laser is used only for superficial surgeries is most commonly used for dermatological surgeries or in penile surgeries removing of any penile plaque any penile growth so usually for endoscopic surgery co2 laser is not used most commonly what we use is caterpillar that we used to use before now holmium and thulium laser have replaced almost all the lasers so this is the how laser developed in urology previously it used to be ndr laser now through the series of ktp laser ktp uh lithium borate laser that increase in the wattage you previously we used to 60 baht 150 right now we have a device is about 180 or 200 and now spectrum has entirely shifted over volume laser to enthusiam hyperlaser so what are the difference between these laser and what is its significance so as you can see these are depth of penetration so these are the top penetration in the tissue so ktp has only point eight mm penetration while holmium yacht has point four mm penetration and thulium has point to penetration co2 laser as i said is a superficializer it has a very low penetration 0.02 mm and ndia has the highest penetration that is a 10mm so what are the implications of this penetration so it it it is important for the zone of coagulation or zone of ischemic necrosis after post surgery so major uh more the depth of penetration more the zone of coagulation and lesser the level of penetration more is the precision of your surgery so the complication rate decreases so that's why holmium laser and thulium laser are preferred nowadays and also it depends upon their characteristic that at what level water level almoholmium level holmium laser and thulium laser is almost completely absorbed in the water so it is a very good candidate to use in underwater saline because it is called as a knife because it is cut precisely wherever you want there is no increased depth of penetration like in india glazer or diode laser so the depth precision of depth is not under your control but in wholemeal laser and thulium laser it is called as knife because you can exercise exactly whatever you want and it won't go beyond your penetration what is the physical property of laser which is used to treat prostate so laser property first is uh coagulation then vaporization so at a low heat low power it causes only coagulation of the tissue but at high heat and high power it causes vaporization of tissue so it is called as photothermal effect so in a photo thermal effect which what we used in the stone so it just destroyed the tissue so it causes vaporization of that tissue and the tissue is not available for retraction or retrieval so there are different kinds of laser use for different kind of setting most commonly used is ktp laser ktp laser is you uh uh used to call as a green light laser and uh which was used previously for photoselective vaporization are posted but now most commonly used is fully holmium and coolant so these are some jargons so what is the difference between vaporization resection and in nucleation so these are the some jargon that pvp whole app to lab resection for uh i will explain what is different between vaporization and the resection inhibition so these are the terms so hol means holmium tuhu means pulium green light is ktp laser pvp is again photoselective vaporization of pleasure that is used by caterpillar so this is the difference between vaporization in nucleation and resection if you can see so what is vaporization in vaporization we use laser in a contact mode so the entire tissue is destroyed so there is a vaporization of that tissue the tissue is not available for retrieval so we are causing like we are burning all the tissue of that prostate with touching the that laser fiber with the prostate so it causes vaporization so it is mostly used with sci-fi there are two types of fire fibers used in laser one is end firing and one is side firing what we use for uh stone surgery is end firing but what do we prefer for vaporization and prostate system is side firing and for e-nucleation we prefer again end firing so in vaporization in upper um above image you can see vaporization is like ablating all the gland or destroying all the grain using contact laser in nucleation is like a removing tangerine from its peel so as you can see in the second image using the holmium laser or thulium laser we just make a plane of resection we take a cut it is called as three lobe technique because we resect median lobe first then two lateral lobes so it is a three log techniques what we do we take a incision at five o'clock seven o'clock we first go till the base uh till the prosthetic capsule and we detach that entire adenoma from capsule like removing tangerine from its peel and then we remove all that lobes which bring that lobes in the bladder and with the use of oscillator we remove those look or some people use bipolar vaporization or other systems resection to remove that load and what is the resection the resection is same as trp so rather than using uh monopolar or bipolar current we are using holmium or thulium most commonly trillium is used for resection uh so we are just making cut in the prostate using laser so this is the basic difference between vaporization in nucleation and resection for vaporization we most commonly use uh caterpillar cooling laser and now holmium xps system that is newer advanced system with side firing probe so it is very much effective in vaporization it is a side firing proof with 180 byte or 200 watt and that can be used for vaporization of prostate in nucleation we most commonly use holmium and thulium so again the difference between holmen and thulium holmium and thulium both has same approximately same wavelength but the difference between volume and thulium is holmium is pulse mode pulse mode it it doesn't fire continuously while thulium is continuous modulator so there is coagulation is better in thulium as compared to the holmium but there is formation of scar so scar tissue is formation is there on pulliam but again as in comparison holmium and thulium outcomes are similar comparable but some people say that with whole bm uh resection time is low and with thelium your coagulation is more but again these are subjective data meta-analysis has shown the efficacy of both wholemeal and thulium is same for the short term as well as long term and again for vaporization these are the technique so why you can see the right lower image this is a contact laser side firing which we using for vaporization of prostate so you have to keep sweeping the laser while if you are when we are acting you have to keep keep sleeping the laser for 30 degree so it doesn't causes more penetration of coagulation but it's causes so uniform zonal coagulation so in upper image you can see if laser fiber is kept at zero degree the depth of penetration will be lower but for a 30 degree the depth of penetration will be smooth and it it is very much effective in vaporization of that prostate so we have to sweep the laser 30 degree in less than 1 mm so contact distance between prostate and your fiber should be less than 1 mm so laser initiation whatever i said holy holy pen to the these are two modalities of you know it is called a laser knife because of precision of techniques and adenoma is more selected adenoma is pushed into the bladder and oscillator is used so it modulator again takes 15 to 20 minutes to remove that tissue whatever we have excised and it is lesser effective when initially used for ablation cholmium and thulium are not used for object ablationism is vaporization so it is better used for e-nucleation because it saves the time and it is evolved with modification to be primarily used for innucleation and it is done with a bare fiber so it is again end fire end firing probe bare fiber means what you can see the glass tip of that fiber it is called as bear so it is a bare fiber and it is reusable so you can use same fiber for different surgeries so these are there are some studies meta-analysis which are comparing the outcomes of different laser ktp laser fully olap and various resection methods using uh tulip and holy so the catch points where holmium laser through resection and in equation had the best if you have seen maximum flow rate thulium laser through vapor resection so this is vapor resection is combination of both vaporization as well as resection so you are vaporizing the prostate as well as removing a chip so it increases it decreases your time whole mm laser through e-nucleation was best for pvr improvement so post point ratio because we are completely removing the in in any nucleation the size of the prostate removal is com supposed to be more than resection because you are entirely removing the adenoma from its capsule and the recurrence rates are also less in nucleation as compared to resection and the diode laser through vaporization was the rapid estimating post-operative in the indwelling catheter while to it was the longest so one differentiating factor amongst the all is intraoperative blood loss intraoperative time then the uh post-operative catheter time so usually for regular trp monopoly therapy we keep catheter for three to five days for laser in nucleation some people even remove catheter on the day of surgery or next day because the hemostasis is very much good epithelium and thulium and for some lasers like diode or pvp very other than coagulation ablation where bleeding is right this patient may have to keep catheter about three to four days so the whole meme and pulliam has the highest efficacy rate in terms of post-operative catheter drive so it can be even after next day you can remove the catheter in wholemeal thorium lasers so the early recovery is more common uh more favorable in home and uh in nucleation so again these are various studies which are comparing all the latest modalities so pre-operative post approached volume uh qmax and ipss were similar in between all the groups like tulip and holy also in long-term data in lasers there are only one problem is the initial incontinence after enucleation in large glands more than 100 incontinence which improves after three to six months again it depends upon your technical factors surgeons experience but long-term data as they say that trp both monopolar bipolar drp and laser after for long-term dapper data the results are comparable but the recurrence rate is lesser in uh holmium or thulium in nucleation as compared to conventional trp and coming to the complications so some complications are common to the surgery itself so what you can see early post operative complications that bleeding urinary infection uh acute urinary retention clot retention these are common to all modalities of treatment so mdp e2rp is mono productive rp which is a used uh monopolar quadrant with a glycine for bipolar views ns pvp is again green light laser pvp has because is only superficial coagulation so secondary bleeding are more and disuria is more because we are keeping uplated mucosa inside the prostate so patient storage symptoms worsen for initial few days uh in in nucleation you are removing entire gland without any coagulation so patient doesn't usually uh develop storage symptoms after holy portfolio surgery but these patients develop transient incontinence after surgery and chances of blatant expenses are seen more common after holy pain too now most common uh most worrisome complications of monopolar tr is to syndrome that is because of use of hypertonic uh glycine and because of its effect so by using bipolar trp and laser we are mitigating that pr syndrome late complications of all the modalities of treatment as i said is ejaculation dysfunction erectile dysfunction and chances of restriction regrowth and lateral extensors so ejaculation problems retrograde ejaculation complications is most commonly seen after holy point collapse in nucleation because we are entirely removing the gland we are entirely removing the bladder bladder neck area so retrograde ejaculation is more commonly seen in whole app surgery but in qrp if you preserve urethral length if you preserve paracordicular tissue then the chances of retrograde ejaculation has decreased and bladder neck stenosis is supposed to be more common after monopolar surgery now these are various uh landmarks papers which has compared helium lasers versus qrp so according to this uh paper the come outcomes of theliam as well as uh trp are comparable but there is just change in uh there is just significant you can see the p values so just only chances of developing tur syndrome then estimated resection weight and the hospital say hospital stay and catheterization time so these are the only significant difference between the to lab surgery and even conventional rp center rest long-term complications rate long-term outcome are comparable only short-term outcomes like catheter catheter catheter free days and hospital stage bleeding these are significantly different which are which favors thulium laser over trp again in patients who are anticoagulants which are on anti-platelets we prefer these patients under uh doing them under laser surgery because it has again precision and hemostasis is very much good in uh thulium cholmium then bipolar trp and then it is least in monopoly so patients which are on anticoagulation these are always prepared to undergo laser surgeries so these are again few papers which are comparing different types of modalities uh trp versus thulium trillium versus formium so again all these meta-analysis and this is long-term outcomes are comparable only these modalities of treatment differs for short-term outcomes and these are final recommendations which are implicated in eiu so eau has incorporated all lasers uh ktp laser thulium holmium and they have strong recommendations for these laser for moderate to severe symptoms and up to gland 50 to 80. so all these vaporization resection in nucleation they say it is best for a gland up to 50 to 80 gram or less than 100 gram but people who are experienced in in india as well as outside they can do e nucleation hole and tulip even up to glands of 200 their case reports that these 200 300cc gland has been effectively exercised and nucleated using cholinium as well as thulium laser so it depends against surgeon's experience and technical skills so now uh prosthetic artery embolization so this is not an endoscopic surgery but this again come as a minimally invasive surgery so prosthetic arterial embolisation as other impulsion we selectively embolize inferior vesicle artery and in the branch of prosthetic artery so we use various uh porous materials to embolize it this is not recommended by eiuri of aua because the results are this are still not very good this is prosthetic artery embolization is ideally only reserved for to treat the prostate related hematuria this is called as indolent hematuria most of the uh patient five to seven percent patient of prostate present with hematuria so this is the last result in the process in the management protocol of prostate related hemorrhage that is prosthetic ultra immolation but because after the prostatic artery embolization when they studied this patient for long term they found to decrease in the size of the prostate so that manipulated that data just to see whether this can be used to decrease the size of prostate so there are some studies of prosthetic artery embolization purely for bph and lowering attract symptoms so this is you can see through in there cycle artery selective embolization of prosthetic artery and they use spherical particles polyvinyl alcohol particles which travels or dislocate dislodge in the distal branches of prostatic artery and cause their shrinkage and then ischemic necrosis and pilotal procedure has to be done bilateral internal cycle altery interval cycle artery and then prosthetic artery so the adverse effect again these are same as uh other embolization that is post embolized syndrome need for reoperation sometimes because of aberrant arterial supply bleeding may not stop or there might be new bleeding then in such cases male require emergent surgery imagine prostate immersion resection so always it has to be done where setup will both urologists as well as interventional radiologists are available so the outcome these are prosthetic artery embolism is always considered to be inferior in all modalities as compared to prp or any laser surgeries and it is only benefit of this is we are avoiding surgery so any patient who do not want to undergo any transparent surgery because of its associated morbidity or if patient is not fit for any anesthesia then in only those patients only we can try for steady artery embolusion still this is uh in research we do not have any long-term data so the for recommendation eiu again these are given recommendation that offer prosthetic artery embolization to man with moderate to severe luts who wish to consider minimally invasive treatment options and accept less optimal objective outcomes compared with transfer with resection of prostate so the outcome after this surgery is always gonna be inferior so there won't be any much improvement in ips's score and the last part is intra prosthetic injection again pressure various researchers have studied intra prosthetic injection which can cause coagulated necrosis of the prosthetic gland so they use uh botulinum dioxide but again they have found that the cortisone toxin is not effective then came again newer molecule molecule that is prx302 so this is the performing protein which is get activated after incoming combination with psa which increases the porosity of the cells and which causes lysis of the cells so they have studied this prx-302 which is found to be effective in reducing the prostate size so prx302 is uh injected uh transparently under ultrasound guided and atropine uh sorry botyl and toxin they injected transparently so again for in eiu guidelines they have given that bottleneck toxic toxic should not be used for posted but results with prx 302 are comparable or it is beneficial in early researches and still long term data is not available so now coming to the complications this is the side sexual dysfunction which is more patient this long-term complication so as you can see sexual dysfunction that is the ejaculatory dysfunction erectile dysfunction so it is the most common after holy so laser surgery causes most more ejaculation or retrograde ejaculation and it is less common with other ablative techniques which has seen water vaporization or prosthetic lift and this is the final slide so this is the algorithmic approach for the prostate so what this is like which surgery should be used for which size of prostate so if patient is fit for surgery anesthesia always prefer uh them to undergo trp or laser surgery if patient is not fit for any anesthesia then these minimally invasive techniques these are prosthetic urethral lift and tind this can be used so depending upon the size of the prostate if prostate size is less than 50 we always usually prefer monopolar trp for size say 5280 we prefer bipolar drp laser resection vaporization in nucleation for client size more than 100 100 to 150 again laser e nucleation is better and more than size of 150 this is a rough uh grading there is no at such size wise any guidelines for what size which has to be taken so it depends on surgeon's experience but for more than 200 usually 150 to 200 uh people usually prefer open prosthetic robotic or laparoscopic prosthetics or nowadays with a skillful surgeon even the clients up to 300 cc they can have resected using holmium laser and more oscillator thank you this was the all my presentation regarding newer modalities of surgery in the management of dph that was truly an insightful session sir all right so since there are no requests i will just uh ask what i saw earlier um sami had asked why is no pain or severity felt during the early stages of bph and is there any marker to pinpoint other than psa ps usually for banana prostate hyperplasia there is no markers these psa and markers are only for screening for prosthetic cancer so as such for a bps there is no marker only we follow them clinically that is depending on patient symptoms ips score a us core and ultrasonography we measure profit size median low thickness of bladder upper track changes and post point residue and another test is zero flowmeter 15 millimeter ml per second is considered to be normal and well shift cut if anything below 15 and the loss of bell-shaped curves denotes uh there is significant obstruction and why patient earlier do not develop pain because the pathophysiology of bph is a chronic process so this develops over a period of five years 10 years this is not an acute process so patient tend to get adjusted to these symptoms and again in ipss score there are two symptoms there is storage part that is fun part frequency urgency nocturia and voiding part is poor stream intermittencies training and sense of incompetitive vibration so patients are more bothered about storage symptoms when patient develop secondary urinary tract infection secondary hematuria secondary bladder stone this patient develops storage symptoms like increased frequency nocturia then patient tend to comes to the urologist otherwise patient usually tends to uh neglect their voiding symptoms as age-related symptoms so initially there are obstructive symptoms but over the period of five to ten years because there are secondary changes in the bladder like bladder wall thickness and development of secondary neurological changes or neurological dysfunctions which causes frequency urgency nicuria nocturia repeated urinary tract symptoms which leads to the other some symptoms and which then patient present to the urologist you can play that ureter lift for uh yes so this is the urethral lift device this has a rigid endoscope and at roughly two o'clock and at ten o'clock or three o'clock or nine o'clock we fire these staple pins and which causes retraction of these transition lobes toward the peripheral lobe so this is how luminal patterns is maintained [Music] this you can see the difference pre and post surgery that was the video i guess there are some questions in the chat box has asked how to correlate cc volume of prostate with a weight in gram so cc volume of prostate is is equal to say a gram so it is a rough correlation there is no exact as such how to correlate the prosthetic size with cc and gram but roughly gram is taken as a cc and the formula of calculating ccr gram is the whatever length breadth and width we see in the procedure suppose if i had done 5 into 4 into 3 so we have to multiply all three like five into four into three and take it's a sixty percent so if it is five into four into three it comes as a sixty then sixty percent of sixty so roughly forty but that is the formula for calculate the uh volume of the prostate and most the most accurate modality to calculate the volume is that a transactive ultrasound not on the trans abdominal ultrasound and the second question is what is the aur syndrome as a side effect of prv aur is acute urinary retention so after post urb you are after removal of catheter there might be some chips which causes uh or blood clots or there is after monopoly trp there is one of coagulator necrosis after seven to 15 days these get shades of is shredded off in the urine and these might cause acute retention because it blocks the urethra so this is the aur syndrome after the this is a very insightful session and i'm sure we can have many more such sessions in the future uh thank you so much sir for your time it was glad to have you thank you all of your team thank you all of your netflix team and uh this is very insightful activity and uh very much required nowadays for president learning and i hope i was uh very clear and i uh there might be some technical words which i might have because this uh in one hour to explain all the prostate for urologist is like a very very difficult task because prostate is like a 10 hour stop for us and so if i hope uh i would be able to uh set some light through some light on it if there is something some improvement i would happy to help or i would happy to accept and improve myself in the future and i hope to see you again all guys and all the best for all of your team and keep doing it thank you

BEING ATTENDED BY

Dr. Divyansh Garg & 586 others

SPEAKERS

dr. Rishikesh Velhal

Dr. Rishikesh Velhal

Assistant Professor urology at GS Medical College & KEM Hospital, Mumbai

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dr. Rishikesh Velhal

Dr. Rishikesh Velhal

Assistant Professor urology at GS Medical Col...

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