Training session in Valencia

Today I travelled to Valencia to participate in a training session. We had a very complex patient, with a huge 130 gram prostate. These big prostates can be operated, but they require a longer operating time and patience. This operation took 3 hours and we applied 750.000 joules. The prostate had an enormous median lobe that occupied the prostatic urethra and protruded inside the bladder. We managed to vaporize it and to leave a huge prostatic cavity. It was a very interesting case, big prostates are always a challenge but this one was special for its peculiar anatomy. Some urologists think that median lobes are difficult to treat with the KTP laser, but it is rather easy to vaporize them completely, you only need to know some simple tricks.


We also realised that irrigation can be improved with a suprapubic 5 mm laparoscopy trocar. I did not carry with me the Reuter trocar I use in these difficult cases (it is getting more difficult to get it into an aeroplane - it is a sharp metallic object). So this was a good idea, nowadays all hospitals have laparoscopy trocars. This enhances irrigation, the vision gets very clear and it is very useful to operate big prostates with a very small risk and good results. The patient gets a 5 mm wound in his lower abdomen, that is not much of a problem at all. I took the plane back to Madrid, we have a Bank Holiday and tomorrow I will get a chance to rest for a while. I have to return to Valencia this thursday to participate in another rather difficult case.

Training session in Barcelona

Today I returned to Barcelona to participate in a training session on Photoselective Vaporization of the Prostate (PVP) for Benign prostatic Hyperplasia. We just did one case and it was rather quick because the prostate was small. Next Tuesday we have a bank holiday in Spain, so everybody was rushing out the big cities, Barcelona and Madrid, there was heavy rain too, so the airports were colapsed. I have waited for hours at the airport in Barcelona and I got very late to Madrid, I managed to read some papers I use to carry with me, so it was not a completely waste of time. Tomorrow we have another case in Hospital San José, where I usually work, but this time it is a bigger prostate gland, aproximately 90 grams. We took a photo and look what a beautiful shot we got.

Training Marathon in Valencia

Today I have travelled to Valencia, to participate in a surgical kind of Marathon at the General Hospital.
We have operated four patients, two before lunch and other two after lunch. Fortunately, the patient's prostates were relatively small, and this has allowed us to spend a little bit more than an hour in each case.
Three urologists have had their first experience with photoselective vaporization of the prostate, and have tried the technique under my supervision. These urologists are already experienced endoscopic surgeons, and for them the learning process consists in adapting to a new surgical tool and different physical principles and technical details, but the truth is that they are operating in a familiar environment (most experienced urologists have operated hundreds or thousands of prostates with the traditional technique, transurethral resection of the prostate - TURP). One should start operating small prostates, it is definitely the way to learn. Things are not so simple as prostatic size increases and it is not advisable to try to operate a big prostate without previous experience with small ones.
All surgeries have developed smoothly, even when patients were rather old and one of them was terribly frail. He wanted to get rid of his urinary catheter and was happy to learn that there was a safe option for him. Nobody wanted to operate him in his state with the classic technique, due to the high surgical risk.
During these training seminars, once the surgeon learning the technique has had his go, I usually take over and finish the case, to make sure the patient will do well. This is the right way to learn new surgical procedures, because the patient should not have to suffer the learning curve of the surgeon. It would be very rare to experience a serious complication with this operation in the hands of a relatively inexperienced surgeon, but maybe the result of the operation would not be as espectacular if the surgery is not performed correctly.
Photoselective vaporization of the prostate (Greenlight PVP) is such a safe operation that patients will go home tomorrow without a catheter. We all finished the day happily and we went back home after a busy day.

Training seminar in La Coruña

Today I travelled to La Coruña, in the north of Spain, to participate as a surgeon in a workshop on photoselective vaporization of the prostate (PVP). I have operated a patient with a relatively big prostate, 80-90 grams. It was a challenging case, the prostate tended to bleed just by rubbing the cystoscope against the urethral mucosa. He had been catheterised for quite a long time and this caused hyperemia and inflamation. As the irrigation power of the cystoscope I use is rather limited, a minimal amount of blood in the operative field can obscure the endoscopic vision. I decided to use a Reuter suprapubic trocar to improve drainage, and connected the two channels of the scope to the inflow of saline. This allowed me to complete the operation without much trouble. The patient will have a small 5 mm wound in the skin under his umbilicus, It did not even need stitches. I have had to return to Madrid in the latest flight as tomorrow morning I have to perform a prostate cryoablation for prostate cancer at my hospital, USP San José, in Madrid.

Round Table - International Congress

Today we celebrated the round table on new surgical treatment options for benign prostatic hyperplasia (BPH). The moderator was Dr. Vicente and other participants were Marceliano García, Prof. Marberger (Viena, Austria) and Valdivia Uría.

I had five minutes to present the data published up to now on Photoselective Vaporisation of the prostate for BPH and I have included three photographs that have impacted the audience. One photograph depicting the patient I operated yesterday, smiling (I have erased his face to protect his identity), catheter free, ambulant, as if he wasn't operated at all.

I visited him the morning after surgery, and performed a control ultrasound of his prostate and a flow rate measurement. The flow was not very impressive, as not all patients manage to have a very big flow the first day. He had to carry a urinary catheter for months, and in less than 24 hours he got rid of it. The flow will improve day by day. I also took a photograph of the colour of his urine, that I collected in a glass recipient. I had to take these photos with my mobile phone, and then I transferred them to my laptop using the infrared link. So I was able to integrate them into my presentation.

The public in the room was very suprised to see this quick result. The panelists commented how impresive was the ultrasound image showing a complete removal of hyperplasic tissue. They were also impressed by the smiling patient and the clear urine.

In the photo below I am with Prof. Marberger and Dr. Valdivia, during the discussion we had after my presentation. Prof. Marberger and I met at the national congress of the Taiwanese Urological Society, celebrated in August 2004, where I presented my experience with the initial 40 patients of my series.
Tomorrow, two doctors from the Institute of Advanced Urological Surgery of Madrid will present their work. Dr. Castillón, director of the laparoscopy unit, as well as Dr. Moncada, director of the Andrology unit, so I will have to wake up early to watch their presentations.

Live surgery - International congress

Today was the first day of the International Congress on Advances in Urological Surgery and Pharmacology celebrated in Madrid, Hosted by Prof. Vela Navarrete at the Fundación Jiménez Díaz in Madrid. This is one of the biggest National Health System Hospitals in Madrid. This international congress is celebrated yearly in different venues throughout the country.

My role in this congress was to perform a live surgery. I have operated a patient with Benign Prostatic Hyperplasia (BPH) and a relatively large prostate (80 gram). The surgery was transmitted to the "Aula Magna" at the Hospital, where there were 250 urologists from Spain and many other countries.

Dr. Vela and I had a conversation during the operation that the participants could listen to. We spoke about the advantages of this new high power 80 Watt KTP laser in the treatment of BPH. Dr. Vela mentioned he had had previous experiences with a Neodimium-YAG laser, but the results of this VLAP treatment (Visual Laser Ablation of the Prostate) were not good. He also had experience with a Holmium laser, but he said the procedure of enucleation was too difficult to perform and they abandoned it. The participants were able to see how this new KTP laser achieves the same endoscopic results as the classic TURP (transurethral resection of the prostate), but without the bleeding and the risk of absorption of irrigants nor hiponatremia.

The operation was smooth and easy and the patient was sent to his room directly, tonight they will pull out the catheter I placed in the operating theatre and I am sure he will be discharged tomorrow.

Tomorrow I will participate in a round table in the afternoon where the different surgical techniques, classic and new, for the treatment of BPH will be discussed. I will present the data from the latest studies carried out in the USA and Europe, and I will also comment our experience during the last 30 months and more than 300 patients.



In this photograph, I am with Dr. Ignacio Castillón, director of the laparoscopy unit at the ICUA, that is also invited to this congress as a professor in Urological Laparoscopy, he was so nice to come to theatre to give me some support just before the transmission of the surgery began.
This congress was very well organised and all the medical and nursing personel really spent all their best to make this congress a successful one.

PVP training seminar in Barcelona

Today I took an early flight to Barcelona to participate in a training seminar on Photoselective Vaporization of the Prostate. We have performed two live surgeries. The first patient had a relatively big prostate with 80-90 grams, with a huge median lobe. He has made me sweat, but the patient did not bleed at all and the operation was a success. The seccond patient's prostate was smaller, but he had a very big bladder diverticulum. We have incised the mouth of the diverticulum with the KTP laser, to ensure proper drainage into the bladder, it was really beautiful. Soon I will go back to the Teknon Hospital in Barcelona to operate a patient with periprostatic angiomas (this is a vascular tumor, that bleeds furiously if cut), a very complicated case that probably will only be operable with a KTP Laser with safety. Tomorrow I will participate in the International Congress on Advances in Urology that will take place at the Jimenez Díaz Foundation in Madrid, and I will operate another patient in front of 200 Spanish and 50 foreign urologists.

Invitation to operate in Saudi Arabia

I have received an invitation to travel to Saudi Arabia soon, around November or December. The plan is to train a number of urologists to perform PVP (Photoselective Vaporization of the prostate) in Riyadh. For the moment I haven't got more information, but I will update this posting with the details.

Invitation to operate in Chile

Dr. Fernando Coz (a prestigious urologist from Chile and former president of the Chilenian Urological Society) and laserscope, the manufacturer of the KTP laser we use for Photoselective Vaporization of the Prostate (PVP), have invited me to train a group of urologists on this procedure in Santiago de Chile. During my stay there, from November 28th to December 1st, 2005, they have also asked me to address the Chilenian Urological Society and present the experience at the Institute of Advanced Urological Surgery, the institution where I work, with this technique. I will update this posting when I get to Chile.

KTP laser day in Valencia

Today I woke up early to take a flight to Valencia. We started operating at the General Hospital at 9.00 am, but unfortunately someone lost the filter the video endoscopic camera needs and we postponed the start to 11.00 am. In this training session I operated two patients with relatively small prostates, so there was no problem to finish before 3.00 pm.
In the afternoon, after a quick and unappealing lunch I went to a private hospital in Valencia, where they had organised a teaching session with 15 local urologists. I explained the basics of the surgical treatment of BPH with the KTP laser and then I went to the surgical theatre,where they had prepared two patients with huge prostates (100 and 130 grams). The images and sound were transmitted to the audience. Big prostates take time to operate and it took approximately three hours to finish each case, so we finished at 12.00 pm. Fotunately, both cases did very well postoperatively. I slept in a hotel in Valencia and took an early plane to Madrid where I had to operate two aditional patients with huge prostates again, so I finished around 5 pm, and finally went home to see my family and rest. I think this is probably my record, I operated 6 patients in 30 hours.

Appointed Consultant for TEKNON in Barcelona

Today I went to Barcelona to participate in a training seminar with live PVP (Photoselective vaporization of the prostate) procedures.
TEKNON hospital is one of the most prestigious private hospitals in Barcelona. This hospital has a laser unit that serves the specialists using lasers in different areas (ENT, dermatologists, plastic surgeons, Ophtalmologists, urologists) I have been appointed consultant of their laser unit and I have been invited regularly to train doctors on the PVP procedure. I have been there eight times already, training different doctors.

One of the patients today had a big bladder stone. We fragmented it and solved the problem endoscopically. It is always wise to start with the prostate first, and once the PVP is performed, the stone can be dealt with. They have told me about four new patients to operate soon, so I will have to find a slot in my agenda, that is getting increasingly busier.

Today I travelled to Santiago de Compostela, in Galicia, the north-west part of Spain. I had time to walk around a little bit and visit the cathedral, and then I went to eat octopus (one of the wonderful tipical plates here) in one of the exquisite restaurants in the area. Santiago is definitely one of the Spanish cities worth visiting. Later on we had a training seminar on PVP, we did two live surgeries. The first case was extremely difficul and required all possible surgical tricks and strategies to be able to finish the operation successfully, so the teaching value of this session was very high. This patient had a very inflammed prostate and it bled just by introducing the telescope, I used a suprapubic trocar to enhance irrigation, to be able to see but it was still relatively difficult, in these cases the surgeon has more technical difficulty to perform the operation, but the patient is still totally safe. The second case was much easier, even being a relatively big prostate. Both patients did very well and I was told they both went home the following morning.

Urethral surgery masterclass

Today I operated two patients at the University Hospital de La Princesa as invited professor. Both patients carried relatively complex urethral strictures. This problem is relatively unfrequent and it is difficult for a single urologist to acumulate experience enough to be able to operate these patients with confidence and good results. The surgeon must know many different reconstructive techniques and often the decision about the surgical procedure to perform is taken intraoperatively. I was lucky enough to learn with Prof. A. R. Mundy at the Institute of Urology in London. He operated from 4 - 11 cases per week. I worked for him for a full year.

Both strictures today were reconstructed using a buccal mucosa graft. The mucosa, or the inner lining of the cheek is an ideal substitute for reconstructing the urethra, because it is designed for a humid environment (inside the mouth). This Hospital invites me periodically as they want to learn these techniques. This is the fifth surgical session we have celebrated.

Appointed faculty member of the ESU

Today I received an invitation to join the faculty of the European School of Urology. This institution is intimately linked to the European Association of Urology, and the European Board of Urology and its mission is to elevate the quality of urology teaching around Europe, participating in congresses and courses throughout Europe each year. Being a faculty member carries the responsability of being available for these congresses and to be able to deliver unbiased scientific lectures at an international level. Each faculty member specialises in certain areas. I will lecture on minimally invasive surgery for Benign Prostatic Hyperplasia and Prostate cancer, and also on urethral reconstructive surgery.

PVP session in Valencia

This morning we have operated two patients at the General Hospital in Valencia, in a training seminar on PVP (Photoselective Vaporization of the Prostate) laser prostatectomy. Both surgeries were uneventful, as usual. Patients will be able to return to normal life in two or three days. We had a technical problem, as the laser system was just installed, the light went off twice during the first operation, so we had to wait for some minutes before continuing. Luckily, this operation does not cause bleeding, so this small problem did not have any negative consequence for the patient. We used the time to discuss some technical aspects of the operation with those attending the seminar. Then I came back to Madrid to see my patients. This week is being a little bit hectic.

Live surgery - Meeting of the Vasc Urological Society

The Vasc Urological Society invited me to participate in the 10th live surgery meeting of this society. There I operated a patient with Benign Prostatic Hyperplasia with a High Power (80 Watt) KTP laser. The meeting had two theatres prepared for live surgery. I was operating and Dr. Richard Gaston, maybe one of the best urological laparoscopists in the world, performed a radical cystectomy for bladder cancersimultaneously in the contiguous theatre.

This is a view of the theatre where I performed the operation. The cameraman filmed the outside view, and another camera filmed the endoscopic view, both were transmitted to the congress room.

I had a microphone so I cound talk with the moderator of the live surgical session, Dr. Valdivia.

During the operation we had a conversation on the advantages of PVP (Photoselective vaporization of the prostate) in comparison with traditional TURP (transurethral resection of the prostate) and open surgery.

From time to time the conection was sent to Prof. Gaston's theatre, altough the attending urologists were able to see the endoscopic image in a small frame in the screen.

I was lucky, because the patient had a 50 gram prostate, so I managed to complete the operation in about 70 minutes. I tend to be as agressive as I can in removing hyperplastic tissue, because I believe this will provide the longest lasting possible result to my patients.

The patient did not bleed at all during the procedure. Right after I finished, another surgeon was in charge of performing a TURP with a plasmakinetic energy generator, a sophistication of traditional TURP. It did not change my mind, KTP laser prostatectomy is much safer and allows a quicker recovery of the patient. If you look at the image, the left irrigation bags (with clear irrigaiton fluid inside) were used during the KTP laser prostatectomy, the right ones were used to irrigate the plasmakinetic TURP. I think this photograph is self-explanatory.


This is the urine bag of the patient after the operation. I left a bladder catheter for 5-6 hours after the operation, because it was performed under spinal anaesthetic, and this can paralize the bladder temporarily. After that short period of time it can be removed and if the patient voids normally, he can go home. As there is virtually no blood loss during the operation, there is no postoperative anaemia, and patients feel great. They can go back to normal life and even to work in two or three days.

Vitoria is a beautiful city, with a very surprising old part of the city. I was able to visit the cathedral that is being refurbished, but it is not closed, because they want to show tourists the discoveries they did when they started excavating. In the entrance there is a sign that reads "open due to refurbishing", very interesting.

Vasc urologists are very good, and also very nice and friendly. I will also take with me the good memories of the vasc cuisine.