South Africa Roadshow - Cape Town

We took a morning flight to Cape Town. The most turistic city of South Africa. One could say Cape Town is like Marbella in Spain. The Weather was splendid, but we did not have much time to visit the city. Just after arriving to Cape Town, we went to the University Hospital, where the urology staff attended my lecture, that was followed by an animated discussion. It seems that public hospitals will take some time before adopting this technique, mainly because of lack of funds to invest in new technologies. One of the questions asked by these urologists was that with PVP there is no tissue that can be sent to the pathologist for histological analysis. I explained that if a tumor is suspected, then biopsies are indicated prior to PVP. Also I told them that when we decide to treat a patient with drugs, there is no tissue for histology...
Then we rushed out of there because at 6.30 pm we had another lecture where all urologists in private practice in the city were invited.Again I observed the same effect in the urologists attending this lecture, they were fascinated by PVP. When we were finishing the lecture we started hearing explosions outside, and when we went out to find out, a fantastic fireworks show had started. A good end for this lecture.... Tomorrow we will travel to Durban, to participate in the last lecture scheduled in this hectic roadshow.

South Africa Roadshow - Johannesburg

After the first lecture in Pretoria, we travelled by car to Johannesburg, where we had to meet a very prestigious urologist interested in this technique and later on that evening we had a new lecture scheduled where all the urologists from Johannesburg were invited.
The lecture was a success, when urologists used to do TURP (transurethral resection of the prostate) see the data, the results and the videos of PVP, they realise how superior PVP is. Seeing that one can get the same endoscopic result without the risk of bleeding, impotence and incontinence, they are convinced that this is the way to go. We had a lively discussion, and after this intense meeting, it looks like several hospitals in Johannesburg will be offering this technique to their patients very soon.

South Africa Roadshow - Pretoria

After the meeting in London, my wife and I travelled to South Africa invited by TecMed, the new distributor of the Greenlight laser in this country. My task is to lecture in Pretoria, Johanesburg, Cape Town and Durban, during the launch of Greenlight PVP in this country.
Just after landing, a driver picked us up and took us to the Welgevonden game park, a private park where we would be welcomed. The idea was to participate in a game drive prior to the roadshow and the tough task of lecturing everyday in a different city. We would sleep in the park before leaving for Pretoria.
I was so lucky to see a group of lions (a wonderful male lion and three female lions) an elephant, rhinos and other animals during the daytime. But the most amazing experience took place during the night. We took the car, and used very potent torches to localize the animals at great distance. The light is reflected by the animals' retinas and shines allowing us to locate them. We witnessed three female lions chasing a zebra in front of our car. Luckily, the cebra escaped, and the three female lions and the male later came about and roared loudly just by our car. These cars are not closed, and I swear it was impressive to have those big lions roaring just a couple of meters away from us. An experience I will never forget.
TecMed CEO, Mike Milford, drove the car. He is in love with Africa, its nature and its animals, and his enthusiasm is contagious. An african saying "if you drink from the Zambeze river, you will always thirst his water and this thirst will never be quenched" will surely prove to be true with me. I am sure I will do my best to come back to this wonderful country.
We spent the night in wonderful bungalows with a wonderful view. There is a small lake in front of them and many animals came to drink water. I woke up at 5 am and sat in the terrace to enjoy the sunrise, with the lions roaring in the distance. Maybe this time they managed to kill their pray.
Then we travelled to Pretoria where the first lecture should take place.

We had approximately 30 people. South Africa only has 200 urologists, which seems a low number in comparison whit the 2000 urologists we have in Spain. The technique was very well received among the urologists present in the room, and some of them expressed their interest in adopting PVP as their preferred treatment of BPH.

Day Case Prostatectomy Workshop at King's College Hospital, London

Yesterday I went to the Day Surgery Unit at King's College Hospital in London, to participate in a Workshop on Day Case Prostatectomy using Greenlight PV.
Mr Gordon Muir (the smiling doctor with a yellow shirt) was the organiser of this meeting and he performed two live surgeries. Both interventions were transmited through a state of the art surgical video system. The Day Case Unit at King's is really outstanding. The goal of these units is to reduce hospital stays to a minimum, so patients are operated in the morning and sent home the same day, before 8 p.m..
The multidisciplinary approach, with specialised anaesthetists, motivated surgical and ward nurses and perfectly coordinated personnel allow to perform surgeries in the morning and sending the patient home later on the same day. It is a concept that is being pushed forward, as it reduces healthcare costs.
In the case of Benign Prostatic Hiperplasia (BPH), the advent of the KTP laser has allowed this operation to be performed in the morning and patients to go home before 8 p.m. All patients are operated under general anaesthesia, and that allows a faster recovery. We in Madrid favour spinal anaesthesia, that requires six hours of recovery, so although most of our patients go home at 9-10 pm, some of them feel they want to stay overnight and are discharged the next morning.
My contribution was to present two lectures on surgical alternatives to the treatment of BPH and it's comparison with Greenlight laser photoselective vaporization of the prostate.

So it was a very interesting session where I could appreciate how this operation is being performed in London, and the great enthusiasm among local urologists. The faculty of this meeting was impressive, with the assistance of Neil Barber and Killian Walsh, also pioneers in this technique. Killian is also an old friend. Gordon, Killian and I worked together at the European Society of Residents in Urology when we were specialising in Urology, many years ago.

Tonight I will travel from London to South Africa, where we will spend a week visiting different hospitals in Johanesburg, Cape Town, Durban and Pretoria.

PVP Workshop in Mumbai, India (2)

I am on my way to Madrid from Mumbai, and I take the opportunity to write this while I wait at Heathrow airport in London. Yesterday we operated four patients, and I assisted the urologists from Hospital Aly Khan in Mumbai,
Dr. Deepak Batura, Dr. Ashiq A. Raval y Dr. Percy Jal Chibber, while they performed a case. I then was asked to operate a very high risk patient. All surgeries were uneventful and satisfactory. We then went to visit the patients in the ward and spoke to the family members, who were very impressed to see how well the patients tolerated surgery and how clear the urine was...
Happy and tired, after finishing at 5 p.m., I enjoyed Dr. Ashiq A. Raval's Hospitality, he took me for a quick shopping sesion and he invited me to visit his family and for dinner. After enjoying his immense hospitality and his wonderful family's company, (and the very exotic flavours of the uncountable plates he laid on the table) I was taken to Mumbai's Airport. While I was waiting to embark, I met Lorna Kelly, a wonderful american woman who told me about her friendship and experiences with Mother Teresa, from Calcutta. It helped time pass quickly, as I was embarking at 02.40 a.m. I will get to Madrid at 10.30 a.m. and I hope to be able to reach home and sleep.... tomorrow I have surgeries scheduled in Madrid. This trip to Mumbai has been short but intense, and I wish I could return to India soon, and also bring my wife along with me. India is an amazing place.

PVP Workshop in Mumbai, India

Today I have participated in a workshop on Greenlight PVP (Photoselective Vaporization of the Prostate) for benign prostatic hyperplasia in Mumbai, India. I was invited by the prestigious Hospital Aly Khan, the hospital has purchased a KTP Greenlight Laser to be able to offer this technique to their patients. Mi role was to present the technique to a numerous group of local urologists and to contribute to the training of the urologists at this hospital.

The workshop commenced with a presentation on the technique in front of 70 attendees, followed by a vivid discussion with the audience and with the participation of various very prestigious Indian urologists.

In India there are approximately 1200 urologists, that cover a population of 1000.000.000 people. In Spain there are 2000 urologists to cover 46.000.000. One of the urologists who I will train tomorrow told me he had done over 15.000 TURPs (transurethral resection of the prostate (!!!!).

Mumbai is well known within India for its rapid adoption of new technologies, but this time Delhi pioneered in the adoption of this technique.

After the end of the session, I was given a commemorative gift. Then we went to the Surgical theatre and I have performed two PVPs with a live link to the meeting room, and the audience did not stop asking questions during both operations. The first patient had a 50 gram prostate, the second one had a bigger one, approximately 80-90 g. Both operations were uneventful. I am sure tomorrow both patients will be happy, without a catheter.

All the attendees agreed that the technique is a leap forward in BPH surgery, there was no blood loss at all during surgery and the endoscopic result was very convincing. The main problem for the generalised adoption of this technique in India is that the cost of a TURP for the patient is roughly 800 USD. The cost of one laser fibre is higher than that, so it is a relatively more expensive technique. All these patients could not afford the operation and have been operated free of any cost.

Invitation to the National Congress in Portugal

Today I received an invitation to participate in a session on minimally invasive surgery during the National Urology Congress in Portugal. This will be my first task as a member of the faculty of the European School of Urology. My lecture will be on "Minimally invasive treatment of BPH".

Meeting at King's College Hospital: final programme

Today I received the final programme of the meeting on Greenlight PV laser prostatectomy for the treatment of Benign Prostatic Enlargement that will take place at King's College Hospital in London in March 24th. Mr. Gordon Muir organises this meeting, he is a well known european expert in PVP. I have prepared two presentations. The Urology department at King's has been a pioneer in the adoption of this technique in Europe.

New urethral surgery training session

This wednesday I was invited to operate a patient with a complex urethral stricture to the Hospital Universitario de La Princesa, in Madrid.

He had a long urethral stenosis involving bulbar and penile urethra, and when we explored it surgically it affected all the length of the urethra. The operation was uneventful and we needed 4 hours to reconstruct it with a combination of free grafts taken from the inner side of the cheek (Barbagli's operation) and a long cutaneous flap from the penis (Orandi's operation). I was told that all the patients we have operated up to now are doing well. I am happy for them.



This week has been rather hectic. That same day we had to operate a patient with a kidney cancer and we performed a laparoscopic nephroureterectomy, and I havehad to operate 10 PVPs (Photoselective Vaporization of the Prostate) this week, and some of the patients had very big prostates. So I am kind of tired.

Although I still have much work to do on the presentations I will carry out in my forthcoming visits to India, London, South Africa and Paris, I am looking forward to them, so I can take a break. My wife will come along with me to London and South Africa, so we will also have a chance to enjoy some time together.

Advanced Renal Laparoscopy Course

I have spent last Friday and saturday participating at the first course on Advanced Renal laparoscopy organised by the Escuela Europea de Laparoscopia Urológica (EELU) in collaboration with the Instituto de Cirugía Urológica Avanzada (ICUA). Dr. Ignacio Castillón, director of the EELU and director of the Laparoscopy Unit at the ICUA, organised the course. In this ocassion, we had 16 students who had the opportunity of attending comprehensive conferences on renal laparoscopy, sessions of full time surgical videos analysis and to experimental surgical theatres. There were six invited professors including me and we had the privilege of having Dr. Hervé Baumert with us. He is currently working in Paris and Cambridge and is considered one of the top laparoscopic urologists in the world. We were amazed by his impressive collection of surgical videos.

The course was supported by Olympus, who brought some laparoscopy towers and by Ethicon Endosurgery, that provided us with a full range of laparoscopic instruments. This way, students had access to theoretical knowledge on advanced renal laparoscopy, and also to the experimental surgical theatre, where they could train on the different surgical operations performed on kidney and ureter (radical nephrectomy, partial nephrectomy, and so on and so forth), while they were able to experience the newest surgical instruments and devices, as the new Harmonic dissection device from Ethicon, and other useful devices in renal surgery, as the LapraTy, Hemolock, etc..

Thanks to the support of the Hospital Clínico Veterinario of Madrid, the spotless coordination of Ana María Muñoz, the nursing efforts carried out by Vanessa Cuadros and the almost supernatural coordination and planification abilities of Dr. Castillón, the course has been a success.

New plans for future courses: To include training in renal cryosurgery, to offer simultaneous training to nurses (to allow the surgeon to bring over nursing personnel to the course). The European School of Laparoscopic Urology is consolidating as one of the best training centers in Europe.

Da Vinci video (in Spanish)

This video shows how the Da Vinci Robot works much better than the photos I published below. It contains surgical images, showing how the anastomosis (or suture) of the bladder and urethra is performed during a robotic radical prostatectomy for prostate cancer. I has been prepared by Dr. Ignacio Castillón, the director of the Laparoscopic department at the ICUA (Instituto de Cirugía Urológica Avanzada).

Surgical images can be unpleasant for some people, so do not access this video if you do not have a strong stomach..

Those who dare to watch it will be amazed and will foresee how will surgery look like in the future.

New training session in Valencia

Last friday I travelled to Valencia to participate in a training session that would entail operating four patients. On friday I performed a Greenlight PV procedure on a patient with a 90 g prostate. Then I was taken for dinner to a very nice vasc restaurant. After a short sleep (we had dinner at 11.00 pm) we started early on Saturday morning and I operated three more patients with a 60 g prostate, then a 90 g prostate and then the last patient's prostate weighed 130 g. We finished at 5.00 pm and then I returned to Madrid, totally exhausted after a very intense week.

Training Session in Robotic Surgery

Today I took a plane with my colleague, Dr. Castillón to participate in a training session on Robotic Radical Prostatectomy with the Da Vinci system. This system allows the surgeon to operate from a surgical station, as in the photograph, and provides 3D visualization of the operative field inside the abdomen. This is the state of the art treatment for localised prostate cancer and it allows to obtain spectacular oncological results, as well as high rates of urinary continence and sexual potency preservation after this operation, that are not obtainable with open surgery.

We are trying to achieve to adopt this technology at the Instituto de Cirugía Urológica Avanzada, in collaboration with Hospital USP San José from Madrid. The problem is the high cost of this equipment, so if there is any benefactor reading this and wanting to help us, we will be happy to hear from him. We want to be able to offer this treatment for prostate cancer patients in Madrid. We are starting our training in order to be able to operate our patients soon.
This robot is intuitive and allows the surgeon to conduct surgical operations with safety and precision from the very beginning.

This is the robot and the four arms, it will be position by the patient and the robot will manipulate the surgical instruments. It is a slave robot, it obeys the movements of the surgeon hands, that holds two very sophisticated Joysticks with his hands. The robot even corrects tremor of the surgeon's hands. 3D vision inside the abdomen helps visualizing tissues with unseen quality of image and enhancement.


The surgeon is relaxed, sitting in the surgical console, and an assistant changes the instruments of the robot when the surgeon requests it. It is no doubt the way surgery will follow in the future.

It is a fact, medicine is becoming more and more technologic, and technology is expensive. The best doctors in the future will not necessarily be those who study more, or those with more natural ability and dexterity for surgery, but those who have access to the latest technology, that will be very costly, but that will offer unparalelled results in the treatment of urologic diseases.

New training session in La Coruña

Once again I flew to La Coruña to participate in a training session. In this ocassion we had a difficult case, a patient with a 135 gram prostate. After spending the afternoon there, I took the plane back to Madrid. This is a busy week, this Thursday I will do an early morning PVP and then I will take the plane to Bilbao, in the north of Spain. I am going to witness a case of radical
prostatectomy for prostate cancer with the "Da Vinci" surgical robot. Then I will travel to Valencia Friday and Saturday, where I will conduct a training session where we will operate four patients. In order to make this posting more interesting, I will explain what kind of instruments we use for Greenlight PVP.
This is a photograph of the cystoscope we use for PVP, it is thinner than the classic resectoscope used in TURP (Transurethral resection of the prostate). The laser fiber is introduced throuhg the cystoscope's working channel, and is provided with a plastic knob that allows to rotate it, introduce it or withdraw it easily to ensure prostate vaporization. The black piece is the telescope's visor, traditionally one would look through it with the naked eye, but when working with lasers eye protection is a must, that is why we connect this visor to a surgical endoscopic video camera, but in order to protect the camera from the intensity of the greenlight laser (the reflection of the laser light could break the camera), we use a filter between the visor and the camera. This explains why in the photographs of the technique I publish here, the laser fibre appears green, but in the endoscopic videos the laser light looks like orange. This filter blocks the specific wavelenght of the greenlight laser (532 nm).

Invitation to South Africa.

Yesterday I received confirmation of an invitation to travel to South Africa to participate in lectures in different cities on Greenlight PVP (Photoselective Vaporization of the Prostate).

I was told that there are still no Greenlight units installed in South Africa, but there is a great interest in the technique.

After the workshop at King's Hospital in London I will depart to South Africa to participate in lectures in different cities in South Africa. I will return the 1st of April to Madrid.

I will update this entry as soon as I receive additional information.

Invitation to King's College Hospital, London

At last we have a definitive date for the meeting at Kings College Hospital in London. March 24th. Mr Gordon Muir is organizing a fantastic workshop devoted to PVP (Photoselective Vaporization of the Prosate). Lectures, round tables and live surgeries will take place in front of Urologists, GPs, anaesthetists and other people interested in this technique. I will contribute with a couple of presentations. I guess if someone wants to attend he will have to contact Mr. Gordon Muir at King's College Hospital, London.

New trip to India

Again I have been invited to travel to India. This time I will visit Hospital Prince Ali Khan in Mumbai. The first weekend of March I will spend some time there with the urologists to contribute to their training on PVP (Photoselective Vaporization of the Prostate).

Live surgery at the International Congress in Zaragoza

Today I have participated in the Urology International Congress celebrated at the Hospital Miguel Servet, from Zaragoza, organised by profs. Rioja, Liédana y Roncales. It is a very impressive congress, the organization was superb and the scientific program very attractive. Multiple national and international experts were invited. The conference hall had three giant screens where urologists attending the congress could see three simultaneous surgical interventions and hear one of the three conversations going on between the surgeons and the moderators of each surgical session. Congratulations to the organisers!!!.

This Hospital Miguel Servet is interestingly in front of the football stadium "La Rosaleda", where the local team scored 6 goals to Real Madrid football club, who could one produce one miserable goal. I have had the strange feeling that everybody here looked suspiciously happy and their smiles were probably wider than usual. I am not exactly a football fan, but one perceives these things..... and my team is Real Madrid.

My contribution to this scientific meeting was to perform a live PVP (Photoselective Vaporization of the Prostate). The patient was relatively young, and suffered Benign Prostatic Hyperplasia, and although the prostate was small, weighing 44 g, it caused him bothersome symptoms. After visiting him in the Hospital room and chatting for some time explaining the operation and what to expect in the postoperative period, I went down to the surgical theatre. They were operating another BPH patient with a monopolar electrosurgical unit. Monopolar resection is a sophistication of the instrument used for the classic transurethral resection of the prostate (TURP) it allows better cutting and apparently a shorter catheterisation time for patients. It uses saline as irrigant, and this avoids the TURP syndrom (absoption of irrigant into the bloodstream, and dylutional hyponatremia) that can happen when a solution with glycine is used as irrigant. But coagulation is less than perfect, and the patient bleeds during surgery. When they finished, a catheter was inserted and a traction was devised to diminish postoperative blood loss, they said the catheter would stay in for a couple of days.

Then it was my turn. The PVP operation was uneventful and I was able to vaporise BPH tissue and reach the capsule of the prostate in just 45 minutes. During the operation, I had a microphone that allowed me to explain the operation and I also had an interesting conversation with the moderator, Dr. Miñana, who posed very interesting questions. I tried to summarize the advantages of this technique as well as the mechanisms of laser and tissue interactions. The audience was very impressed, specially after having seen a monopolar resection, which did not avoid bleeding.

The patient did not bleed at all, and he told me he was happy when he was being carried to the ward, as he had heard all my explanations during surgery. I asked the urologists who will do the follow up to pull his catheter out six hours after surgery and told them that he could be sent home later that day if they wanted. Each time I do this operation I get more convinced that PVP is superior to any kind of prostatic resection, be it with a bipolar or a monopolar generator.

After the succesful surgical session, I went to a local restaurant and then took the AVE (the high speed train) towards Madrid hoping to get some rest tonight.

New training session in TEKNON, Barcelona

Today I travelled to Barcelona to participate in a training session on PVP (Photoselective Vaporization of the Prostate) for BPH (Benign Prostatic Hyperplasia). We did two cases, one was a very high risk patient, who was obese, and had an aortic aneurism, dilated myocardiopathy and other serious conditions. His prostate was relatively big, with 90 grams. The operation was uneventful and today we managed to finally operate him, as this time he did not take biscuits just before scheduled surgery (some days ago we had to cancel the operation for this reason). In spite of the high surgical risk, we managed to operate him and to let him catheter-free. He had been catheterised due to an acute retention of urine and after that, he was unable to void spontaneously. Then we did an easier case, a 60 g prostate, that was also uneventful. I then took a car and drove towards Zaragoza, a three hour trip to reach this city. Tomorrow I have to participate in the International Congress performing a live PVP in front of 200 + urologists from Spain and other countries.