New (half-)training session in Barcelona

Today I took a flight to Barcelona to participate in a training session on PVP - Photoselective vaporization of the prostate. We had programmed two patients, the first case was straightforward, the second was very complex. The second patient in the list had morbid obesity and respiratory problems, and we planned to operate him in the sitting position, to increase the chances for him to tolerate the operation. His prostate was relatively big, weighing 100 g. The first case was uneventful, the second case was cancelled because the patient did not respect the "nil per mouth" instruction and he had had breakfast consisting in coffee and cookies. The anaesthesiologist thought we could not operate him with a full stomach, so we have rescheduled him for another date and I went back to Madrid.

As this blog entry is not very exciting, I will use the oportunity to show the kind of effect PVP has on flow rates. Below I show how a flow rate measurement looks like, this test measures urinary flow (volume of urine passed in mL per unit of time in seconds) and represents it on a graph. For the patient, a flowmetry consists in passing water into a funnel connected to the registry equipment, so it is a painless test. It gives very useful information.

Here I show the preop and postop flowmetry of a patient. Initially the flow was very low and bladder emptying was incomplete. After PVP, the flow improved more than threefold. The patient was able to empty his bladder completely and very quickly after the operation.

New training session in Valencia

Today, a saturday, I took an early plane to Valencia in order to participate in a training session on KTP laser for the treatment of Benign Prostatic Hyperplasia. I operated a high risk patient with a 100 gram prostate. The operation was uneventful and I hope the patient will go home later today.

This patient had a very big median lobe, that can easily be seen in this ultrasound image. The way I treat median lobes is to reduce them uniformly until I reach the bladder neck, and then I perform an incission in the midline until I see the bladder neck fibres. Later on, the bladder neck is widened laterally. This strategy avoids damaging the ureteral orifices. It is a simple and quick way of treating the median lobe and achieving a fantastic result without risk of complications. This christmas I could not sleep one night and I started drawing these in order to explain this technique to other doctors interested in KTP laser prostate surgery (PVP- Photoselective Vaporization of the Prostate).



Interestingly, one of the surgeons attending the surgical session in theatre has asked me to fly to Valencia again in March in order to operate him, he is very bothered by his symptoms and he has decided to undergo PVP. It will be my pleasure to treat a colleague.

Laser Surgery for Urinary Stones

Today we have used for the first time our new Holmium laser, Stonelight, manufactured by Laserscope.

We invited Dr. Gaspar Ibarluzea in this ocassion as invited surgeon. He is a fantastic endourologist from Bilbao. Dr. Luis Llanes, the director of the stone unit from the Institute of Advanced Urological Surgery and I helped him to treat two patients with very complex urinary stones.

Endourology has advanced significantly with the use of Holmium laser. It fragments stones easily respecting the tissues from the urinary tract and allows us to treat urinary stones endoscopically, in a minimally invasive way. Patients recover very soon and go back to their normal life in a few hours in the simpler cases or in a few days in the more complex ones. Today, endourology is taking over extracorporal shock wave lithotripsy because is more efficacious and quicker for the patient.

We operated two patients, and we had the chance to check the efficacy of this Stonelight laser in kidney and ureteral stones. We first performed a percutaneous surgery on a very big uric acid stone that filled the whole left renal pelvis and the upper part of the kidney, and then we performed a left flexible ureteroscopy and intracorporeal holmium laser lithotripsy followed by a right percutaneous surgery in the same patient.

We also had the collaboration of several companies manufacturing surgical instruments, as Olympus, Storz and Boston Scientific, that allowed us to try the newest advances in endourology, as flexible ureteroscopes, special guides and baskests, and so on and so forth.

A fantastic day, we learned a lot. My colleague from the ICUA, Dr. Luis Llanes, has plenty of experience with these endourological techniques and from now on we will be able to offer the newest endourological treatment options with Holmium laser to our patients.

Laparoscopic Radical Prostatectomy with Dr. Gastón

This saturday we had the privilege of inviting Dr. Gastón to operate with us a patient with a localised prostate cancer. Dr. Gastón is well known for having developed the technique of laparoscopic radical prostatectomy for prostate cancer and is considered the world leader in this technique. He has operated more than 3000 patients. As an example of his immense experience, he performs two or three laparoscopic radical prostatectomies per day in his hospital in Bordeaux, France.

After picking him up at the airport in Madrid, Dr. Gastón, Dr. Ignacio Castillón and I went to our Hospital USP San José, where we performed the operation that was uneventful. We were deeply impressed by the perfect technique and the anatomic knowledge of Dr. Gastón, who needed two hours to complete the operation with a minimal blood loss (less than 30 cc of blood). The patient was discharged on monday morning.

Dr. Gastón mentioned that this technique allows obtaining a high quality urinary continence postoperatively and that the chances of preserving sexual function is very high, specially in younger patients.
Our institution, the Institute of Advanced Urological Surgery, has reached an agreement with Dr. Gastón to bring him over to Madrid to operate our patients so they can have access to a world leader in prostate cancer surgery without having to leave their country.

Audiovisual Course on New Technologies in Urology

Today I have received a copy of the fourth volume of the Audiovisual Course on New Technologies in Urology. A training programme sponsored by Pfizer and supported by the Spanish Urological Association. I already contributed for volume I with a video and a chapter on PVP - Photoselective Vaporization of the Prostate. In this volume IV I have published an article and a video on Cryosurgical ablation of prostate cancer. This is an interesting video, it includes images of the 4D transrectal ultrasound monitorization of the procedure, a new approach we performed at the Instituto de Cirugía Urológica Avanzada (ICUA), in Madrid.
This training course will be provided for free to all Spanish urologists. The editor is one of my colleagues at the ICUA, Dr. Ignacio Castillón. He was trained as a laparoscopist in L.A., USA. 90% of the content in this audiovisual course is related to laparoscopy.

New training session in La Coruña

This Monday, December 19th, I went to La Coruña again to participate in a Photoselective vaporization of the prostate (PVP) surgical training session. We did two operations, the morning session on a patient with a 70 gram prostate and the afternoon session on a patient with a 90 gram prostate. The day was uneventful, we had time to go a wonderful restaurant for lunch, with a view of La Coruña. Octopus is the local specialty and it is delicious. I then came back to Madrid, the following day I had to operate a friend who is a Doctor and his prostate volume was 105 cc. The operation was also uneventful and I was able to discharge him in the afternoon, after two and a half hours of PVP. The more PVPs I do, the more I like PVP, recovery is so spectacular, patients go back to their normal lifes, and results are so good!!!

New training session in Barcelona

Today I went to Barcelona, to participate in another surgical teaching session at TEKNON hospital, in Barcelona. We did two PVP cases, both prostates were relatively small, so the surgeries did not take much, and everything developed smoothly. One of the patients had been operated in the past, fifteen years ago, with a TUIP (Transurethral incision of the prostate), performed with a classic resectoscope. His prostate was highly irregular, but this did not pose any problem. We did not see a drop of blod in all day, both cases were highly satisfactory.

New training session in La Coruña

Today I took a plane to La Coruña, to participate in another teaching session. The case we operated today was relatively difficult. The prostatic size was not too big, but it was richly vascularised and had a tendency to bleed. As the instrument we introduce through the urethra for Photoselective Vaporization of the Prostate is rather thin, and the irrigation of water in-and- out the bladder it provides is rather slow, any amount of blood, no matter how small, obscures vision and makes the procedure more difficult. We had to use all the surgical tricks and strategies to be able to finish the procedure successfully. A teaching session with a high learning value. The image shows the Veru Montanum, the anatomic structure where ejaculatory ducts drain into the urethra. This is an important surgical landmark, because it tells the surgeon the exact localization of the external urinary sphincter, that must be respected. A little bit upwards, both lateral lobes can be seen in part, they obstruct urinary flow in the same way as tonsils obstruct the pharynx in children...

Meeting of Spanish Greenlight users at USP Hospital San José

This saturday we celebrated the second meeting of the Spanish users of the Greenlight Laser at thel Hospital USP San José de Madrid, the institution where I work. The meeting was kindly sponsored by Davanzia, the medical company that distributes this KTP laser and other medical products in Spain. The meeting was organized with the help of USP and the Instituto de Cirugía Urológica Avanzada. We welcomed doctors working in 20 out of the 25 (soon 30) units offering this technique throughout the country. Two live surgeries were performed, one in a 100 gram prostate, by Drs. Torrecillas, Macías and myself, to show the different strategies and techniques used. This was transmitted via a videolink to the audience. In the afternoon, I performed a PVP on a patient with a 166 gram prostate. It was interesting to share the initial experience of the groups offering this relatively new technique in the country. It allowed us to share experiences and technical aspects of great interest, specially for those groups with less experience. All presentations were of high quality and I believe all participants went back home with better knowledge on the technique and convinced about the fact that PVP will gradually substitute TURP for its high efficacy and low morbidity.

Invitation to operate in Chile 4

Today we returned to the theatres of the Military Hospital in Santiago de Chile to carry out the last surgical training session. It has been a privilege to get to know this urology department where all urologists are great specialists and also fantastic human beings. We have again operated three patients and I will return to spain with the nice feeling that the urologists of this department have taken advantage of the training and are now able to carry out a PVP (Photoselective Vaporization of the Prostate) correctly and in a safe and efficacious way. Two o fthe patients we operated yesterday voided without problems, the last one had some difficulty and we decided to keep a small urinary catheter for a couple of days. The surgical result was very good, so he will do well for sure. All patients had clear urine and felt very well.

Coming to Chile has been a very enriching experience and it has been a privilege to be able to share some time with the urologists from the Military Hospital. The head of the department of urology, Dr. Fernando Coz is a fantastic urologist and a wonderful person. This morning he was able to operate one of the patients with technical perfection. After the satisfaction of having contributed to this department and their future patients, I will take some time to rest visiting the south of Chile with my wife.

Invitation to operate in Chile 3

Today we performed three new cases of PVP (Photoselective vaporization of the prostate) at the Military Hospital at Santiago de Chile. We did two simple cases with prostatic weights of 40 and 50 grams and a more difficult one, with 79 grams, that was very successful and I was able to complete it in one hour and fifteen minutes. We visited the patients operted the previous morning, and were catheter-free and voided wonderfully, their flow rate was 12, 14 and 18 mL/s, and it will improve further day by day. The personnel working at the military hospital was very surprised to witness the results of this technique.

The Military Hospital in Santiago is very nice and it looks as a wonderful hospital, but they are building a new one and they will move there next year. The theatre's personell is really nice and efficient. The urologists working here have enjoyed this experience because they thought this technique was something different. They thought PVP was a slow and less spectacular than it really is. I have taught them all the tricks I know to perform it safely and efficaciously.

During the afternoon, I dictated the conference "PVP (Photoselective vaporization of the prostate, a new horizon in the treatment of BPH" in the auditorium at the Military Hospital. After my presentation we had a discussion that was very fruitful, with very good questions from the floor related to the technique.

Invitation to operate in Chile 2

Today we had the fist surgical session, with Dr. Fernando Coz, head of the department of Urology of the Military Hospital in Santiago de Chile. We have operated three patients with relatively small prostates (40-55 grams), so the session was uneventful. It was a very fruitful session, all the attendants learned the physical bases of laser-tissue interaction and we have reviewed all the tips and tricks that make PVP (Photoselective Vaporization of the prostate) a safe and efficient operation. Tomorrow we will perform three more surgeries and then I will dictate the conference I announced in the previous post of this blog.

Training and conference in Chile

Today I travel to Santiago de Chile. I have been invited to train the urologists of the Military Hospital of Santiago de Chile on PVP (Photoselective Vaporization of the Prostate). We will operate three patients per day during three days, November 29th and 30th and December 1st. The 30th I will also dictate a conference at the Military Hospital, organised by the Chilenian Urology Society.

Training Marathon in Bilbao

I spent the whole day in Bilbao training a group of urologists on PVP (Photoselective Vaporization of the Prostate). We operated four patients, the first one had a 120 gram prostate and the rest had prostates weighting 40, 60 and 70 grams. We stopped for lunch and I had the chance to enjoy again the vasc cuisine, always a wonderful experience. These surgical sessions are quite intensive but the learning value is very high. The bad part of it is taking the return flight, it is always late, and when it arrives to Madrid they take it to the parking lot which is usually very far away from the terminal..... I arrived at home at 12.00 pm and fell into bed. Tomorrow I have to operate in Madrid and I will travel to Chile this sunday.

New surgical Session in Valencia

After operating a urethral stricture in the Hospital de La Princesa in Madrid, I took a plane to Valencia, where we conducted a training session on PVP (Photoselective Vaporization of the prostate) for Benign Prostatic Hyperplasia. I trained four local urologists. We performed two interventions, a 40 gram prostate and an 80 gram prostate, that progressed smoothly. I then came back to Madrid by plane, tomorrow I have to operate more cases of PVP at my hospital, Hospital USP San José, in Madrid.

Urethral surgery masterclass

Today I have operated a very complex case of urethral stenosis at the Hospital de la Princesa in Madrid. As I commented in this blog before, I am invited to this hospital whenever there is a urethral stenosis case. This patient had a very long bulbar urethal stenosis. We have managed to reconstruct this with a double buccal mucosa free graft in a dorsal position. In this image, we have worked in two teams. I prepared the urethra and two surgeons took the grafts from the inside aspect of the cheek. I have had to rush off to the airport, as I had to operate in Valencia the same afternoon.
The surgery today was a success.

Invitation to perform a live surgery

Today I received a letter inviting me to perform a live surgery, a PVP (Photoselective vaporization of the prostate) during the 11th International Congress that will take place in Zaragoza.

Urolap 2005

Today I will attend the International Course on Laparoscopy - Urolap 2005, organised by La Paz Hospital. It is probably one of the best courses in the world in laparoscopy, due to the quality of its organization, the quality of the live surgeries and because all the current world experts are here. I have attended as a student, I did not want to miss it. During this course I have contacted Dr. Gastón, one of the three or four best laparoscopic urologists in the world, and he has accepted to come to Madrid for a teaching session in our surgical theatre. He will operate a patient in January in collaboration with Dr. Castillón, the head of the Laparoscopy unit at the Instituto de Cirugía Urológica Avanzada.

New surgical session in La Coruña

Today I travelled to the northwest of Spain, to La Coruña, to participate in a very difficult case. A patient with a prostate larger than 150 grams. I could not see any ultrasound of the patient before surgery, but his digital rectal examination revealed the pressence of a massive prostate. Endoscopically it was also huge, and very long (7 cm). Maybe the biggest case I have done (I operated a 200 gram prostate once, but it was easier to operate).
We finally managed to complete the operation without much trouble, I think the patient will do very well. We spent more than 3 hours in theatre, it gets long and one gets tired, but the result is very satisfactory. In cases like this the usual spinal anaesthetic is not enough, so the anaesthetist must perform a combined anaesthetic spinal + epidural, that allows for new bolus of local anaesthetic to be administered if the surgery is prolongued. This way patients are confortable during the procedure.
Then I returned to Madrid, I will operate three cases in Hospital USP San José. Two of them are high risk patients, one is very bothered with his bladder and the second one has been catheterised for months, he was not considered fit enough for surgery and his doctors told him he had to live with a catheter forever. Maybe the KTP laser prostatectomy will be their only chance to recover a normal life. (update November 16th.... all three cases went fine, all patients are happy and back home already).

Basic Laparoscopy Course in Madrid

Yesterday I participated as invited teacher at the Basic Laparoscopic Urology Course organised by Dr. Ignacio Castillón (upper photo), director of the Escuela Europea de Laparoscopia Urológica (European School of Laparoscopic Urology) in collaboration with the Instituto de Cirugía Urológica Avanzada (Institute of Advanced Urological Surgery).

The objective was to initiate in laparoscopy techniques to a group of eight urologists. Nowadays laparoscopic (keyhole) surgery is taking over open surgery and has important advantages for patients. Urologists have to learn these techniques in courses like this and aquire the surgical skills before they can apply these techniques to the treatment of their patients. .
The course took place in four different surgical theatres, perfectly equipped thanks to the generosity of Olympus and other sponsoring companies that provided laparoscopy surgical instruments. This initiative would have not been possible without the collaboration of the Hospital Clínico Veterinario, an ideal place for this kind of courses. The presence of other very experienced urologists as Dr. Estébanez, laparoscopist from San Sebastián, and Dr. Páez, head of the department of urology of the NHS Hospital of Fuenlabrada in Madrid, helped to ensure that the quality of the training was superb. The participants in the course thought the course was "excellent", as it showed in the evaluation forms we provided them at the end of the course. The Escuela Europea de Laparoscopia Urológica (European School of Laparoscopic Urology) organises basic laparoscopy courses and also more specialised courses as the one in Advanced Renal Surgery that will take place in February. Urologists interested in these courses can contact the school coordinator, Ana María Muñoz, her telephone number is +34914352844.