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ΣΥΝΈΝΤΈΥΞΗ
T.S.: During the original description of the ECIRS procedure, you used the GMSV position. What are the benefits of this position? During conventional PCNL procedures which position do you mostly use? Are you a fan of prone or supine PCNL?
C.M.S.: We are only using a supine-modified position since 2003, with occasional minor modifications in very particular patients. In particular, the Galdakao Modified Supine Valdivia (GMSV) position is our position for the combined approach, and for standard PCNL too. In our daily practice, we always start introducing the flexible ureteroscope instead of the ureteric catheter, with a 2-2.5 Fr difference in diameter. Usually, the retrograde endoscopic access is possible in about 90% of our procedures, giving us the possibility to fully support all the following steps; in the remaining 10%, also the application of a ureteric catheter as a second choice becomes a combined endoscopic approach. In my opinion the GMSV position makes this retrograde approach easier, although feasible also in prone position. There are many different positions, also on the flank, but the GMSV position is the easiest one, also for the anesthesiological assistance (with immediate access to the tube and optimal control in case of any kind of cardiovascular or respiratory complication).
F.N.: You are one of the experts of endoscopic enucleation of the prostate. According to your experience, do patients who undergo EEP benefit from best intraoperative and postoperative outcomes when compared with patients undergoing conventional TURP?
C.M.S.: Enucleation is for sure an important evolution of the endoscopic technique. What is the concept of the enucleation? The endoscopic enucleation is a challenge, because we replicate endoscopically what we used to do in open surgery with our finger, with huge advantages. First of all, bleeding is very well managed because enucleation starts from the capsular plane, therefore you are coagulating every artery at the origin, not ten times during your resection, every time you encounter an arterial branch. Additionally, you can radically remove all the tissue of the adenoma, thus in the end, the results in terms of outcomes and recurrence are for sure better after EEP. In the end, if we consider also the learning curve, I think that endoscopic enucleation may have an advantage too. We have a long learning curve
in endoscopic enucleation, this is undoubtedly true. The bias of considering the learning curve of TURP shorter is that normally in TURP the surgeon does not remove all the tissue. If you are making a channel, stopping every time for coagulation and leaving 80% of the adenoma, for sure the procedure will be easier, but I think that we also have to be serious in the evaluation of this concept. If we consider the long-term results, then things change. If you operate a 100 grams prostate with EEP or TURP, I think you can immediately understand that EEP might be easier than TURP for this case.
F.N.: Could you share with us the story behind the development and evolution of the en-bloc no-touch HoLEP technique?
C.M.S.: This is a very good story, because in my life I performed a lot of open, laparoscopic and endoscopic surgeries, but at the beginning EEP was really hard and painful for me. My scrub nurses didn't want to scrub in with me anymore, because of the long time - three to four hours - for a single EEP. I started with the three-lobe technique, which was published by Peter Gilling in the Nineties, but I found it really challenging. My solution was to switch to a one-lobe technique, doing only one incision instead of the three traditional ones, and to change the place where I performed the initial incision to find the capsular plane. In the traditional technique, the starting point was the bladder neck; in my modification I used to start around the verumontanum, where you don't have a lot of adenoma tissue and you can find the plane very easily in every kind of prostate, reaching the bladder neck afterwards. After doing this, we follow the plane rotating around the adenoma on both sides. At the end, we have this horseshoe-like piece of prostate which is en-bloc, but also with one incision.
Simultaneously, we started to work on the other concepts. The first one was the “no-touch” technique (using the vapor bubble developed by a pulsed laser in a non-contact way, to separate the adenoma without burning the tissue anyhow).
The second important concept was the “low-power” approach. We decreased the energy used during the enucleation by 70%. We are now using for both Holmium:YAG and TFL 30 Watts, instead of 100-120 Watts, as many colleagues are doing. Especially in the learning curve, it is better to have a sort of power limit, because when you are very skilled, you can do any
Tεύχος 33 | Iανουάριος - Φεβρουάριος 2025
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