Dear All,

After reading this post and I think I can help explain what happened.

We use very fine instruments to perform PVP, tipically a 21-23 French
cistoscope. Irrigation is very precarious when compared to a
resectoscope (which is usually 24-28F). This means that a tiny bleeder
that would not obscure visibility with a resectoscope can obscure the
view with a cystoscope, because the flow of saline is not fast enough
to remove the blood in the surgical field.

Some prostates bleed by friction with the cystoscope, the same way your
nose would bleed if you introduce a metallic instrument and move it in
an out (ouch!!). Sometimes, maybe one in twenty prostates, you find
this kind of bleeding that obscures vision. It is not a bleeding that
would cause a significant loss of blood (I have checked haematocrit and
hemoglobin postop in patients that bled during surgery and there was no
significant change). So, visually, the cystoscope overestimates
bleeding, just because blood tends to remain there, and is not flushed
out properly by the irrigation flow.

The problem the surgeon faces in this situation is that vision is not
good, and thus it is not possible to fire the laser continuously (it
would be mad to fire it withouth knowing where you are aiming), there
are a lot of pauses and the procedure gets lengthier and lengthier.
Also, this wavelenght is absorbed by hemoglobin, so the laser energy is
partially absorbed before touching the tissue, this means that the
tissue does not reach the temperature necessary for vaporization, and
heat is dispersed inside the prostatic tissue, causing excessive
coagulation. This in turn causes edema, and postoperative inflammation.

The look of the prostatic fossa was irregular because the vision was
not good and did not allow for the creation of regular surfaces in the
prostate. Also, excessive coaugulation and inflammation causes
inflammatory cysts and these bleed easily on contact.

This is a problem many surgeons face with difficult prostates. My
preferred way out of this problem is to place a suprapubic trocar
(tube), this is easily done with a full bladder, through a small 5 mm
puncture in the skin under ultrasound control. Then I use double
irrigation through the scope (I connect another irrigation system to
the outflow channel), and drain the saline throught the suprapubic
tube. This means that a nice flow of water comes out the tip of the
scope, and this flow pushes the blood away from the telescope, so
vision is perfect. This allows completing the procedure without any
problem. The laser beam travels through crystal clear saline and
vaporization efficiency is maximal.

When the procedure is finished, I remove the trocar and place a sticker
on the 5 mm wound. I take the catheter out six hours after the
operation and patients are sent home after voiding. The sticker is
removed 7 days later.

Very few surgeons know this trick despite presenting it in meetings and
talks. Some surgeons opt for using a resectoscope to perform
haemostasis benefiting from a better irrigation, and then continue with
the cystoscope performing PVP.

I guess this was a suboptimal result. Enough to improve symptoms with
minimal risk, but with insufficient removal of tissue. We know from
TURP that when insufficient tissue is removed, patients have more risk
to need aditional procedures with time... but who knows, he might do
very well for life.

The Greenlight laser allows to perform a safe operation and hemostatic
properties of this laser are unparallelled. Sometimes it is tricky to
control a single bleeder, because a bleeder is a column of hemoglobin.
This laser has affinity for hemoglobin. This means if you fire on the
bleeder, it will cause vaporization and lots of bubbles inside the
bleeder, and this explains why bleeders open up when you fire on them.
The way round this is to fire around the bleeder, this causes tissue
heating and retraction and stops the bleeder. Another problem with
current cystoscopes is that if an artery bleeds, you have 15 seconds to
control it before vision is spoiled by blood. With experience, one
learns to avoid these problems and to control them safely.

Remember, having a greenlight laser is like having a surgical knife. It
does not mean that you know how to use it.

A PVP can be a disaster in the hands of an unexperienced doctor. And it
can be an unbelievably good operation in the hands of experienced ones.
As any instrumental technique, it is the hand of the surgeon which
determines the good or bad outcome of an operation.

I do not personally know Dr. Lin, but I have only had good references
from him. And I can tell you, prostates pose very difficult situations
to surgeons sometimes, I have seen a world class surgeon transfuse 24
units of blood in a difficult TURP...

I keep on thinking that PVP offers the best balance between safety and
efficacy in BPH surgery.

Big glands must be tackled by VERY experienced surgeons.

All the best,

Fernando Gómez Sancha
http://drgomezsancha2.blogspot.com