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kind of surgery using also 100 Watts, because you are modulating your distance from the tissue and the speed of the movement of your instrument. When you are a beginner, you are not able to do this. If you stay for too long in one single point with this very high energy, you can cause prolonged and intense postoperative voiding symptoms to the patient.
The third and last concept is the “early detachment of the sphincteric mucosa”. In the first technique, this detachment was performed at the end of the operation, just attempting to avoid traction during enucleation. The new technique we presented in 2019 was the “totally en-bloc technique”. We didn't do any kind of incision, starting directly around the verumontanum till 12 o'clock, detaching completely the sphincteric mucosa at the beginning, in order to avoid any kind of traction on the sphincter and its subsequent incompetence after EEP. Always remember that your rigid endoscope is inside the urethra, therefore any kind of movement can stretch the sphincter laterally or towards the bladder, causing its direct damage and thus urinary incontinence for six or twelve months or even longer. I think that incontinence is the worst complication that a patient can have after BPO surgery (or after prostate tumor surgery), heavily affecting the quality of life.
T.S.: There are many energy devices for performing EEP, such as bipolar energy and different lasers. Moreover, new lasers are constantly released, such as the TFL and the pulsed thulium-YAG laser. In your opinion, which is the ideal device for performing EEP?
C.M.S.: I am a lover of pulsed lasers! I started with Holmium-YAG laser, now I also use TFL and Thulium- YAG laser. In my opinion, for doing a real enucleation, you have to use these pulsed lasers, because they are able to produce a micro-photomechanical dissection of the adenoma from the capsular plane thanks to their vapor bubbles. For sure, I prefer to perform enucleation using an energy-driven approach rather than blunt (macro-)dissection followed by laser coagulation. I have to underline that enucleation can be carried out with any kind of laser or energy (bipolar, monopolar, plasmakinetic). If you only have the bipolar resectoscope, instead of doing a TURP, you can start to do the enucleation with bipolar, with a more mechanical approach than lasers, also requiring more coagulation. In this way you can learn EEP and afterwards choose your favorite energy source, depending on your financial
possibilities and on your working environment (lasers are a bit expensive...). I think that nowadays, at least in Europe, it is not possible to do endourology without at least one laser.
T.S.: In your opinion, which is currently the “best” laser for stone disease management? What characteristics should the “perfect” laser have?
C.M.S.: You have to take a look of what you are doing during your lithotripsy. Sometimes you need fragmentation, sometimes you need dusting. I think that the best laser is the laser able to do both. In the past, we had the Holmium:YAG, which is very good for fragmentation because of its peak power up to 12,000 Watts. When TFL came into the market it started to do a very good dusting, because of its lower peak power and wider range of energy and frequency settings. TFL has more controlled energy and a more targeted, homogeneous laser beam compared to Holmium:YAG. The Thulium:YAG laser lives now a second life, because the continuous wave mode of emission works as usual on soft tissues, bit its pulsed emission makes it effective also for stone treatment. In January 2024 we tried for the first time in the world the CyberHo Magneto 150 W by Quanta System. I think that in this laser you can satisfy 95% of your endourological needs, because of the possibility to decrease the minimum peak power of the Holmium:YAG from 2000 Watts to 500 Watts, similarly to TFL, improving the stone dusting effect. In any case, nowadays there is a continuous evolution of lasers. If we have the opportunity, we have also to be present in this field, because it's very important that we give our opinion on the clinical effects of such fantastic devices.
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