🚨 AEEP DILEMMA! 🚨 👉 285-g prostate with a 90° bladder neck angle 😳 👇 scope can’t pass beyond the distal 1/3 of the prostate. What would you choose? 🤔👇 1️⃣ Perineal urethrotomy 2️⃣ Enucleation till mid prostate 👉 open transvesical to retrieve

I start en bloc at apex (no need to enter the bladder first) and then the bladder neck is easily reachable… 100% success rate, no need for open or perineal urethrotomy…

That’s what I said to the patient but I still didn’t reach even apex couldn’t reach high in the sky 😂

You reach the apex perfectly in the video... should be able to complete en bloc. I have not done a perineal urethrotomy in more than 10.000 enucleations with some pretty big prostates...

Once you start releasing the apex, the endoscope on top of the adenoma allows you to capitalise on the mobility of the prostate inside the pelvis, and you can reach the anterior part of the bladder neck as well

A pity to open the patient abdominally or perineally when it is perfectly doable without incisions... I would leave that option for cases where the endoscopic approach shows impossibility to progress (which I have never found myself yet).

Yes it unfortunately the only way to proceed going above 12 o’clock apex was impossible would post it later so what’s your choice for such scenario 😎

Mobilising enough posteriorly and laterally allows the adenoma to descend and usually gives you access to 12 o'clock. The alternative is to cut through BPH tissue at the apex anteriorly until the anterior plane of both sides can be connected... then review at the end with a resectoscope to see if that tissue becomes amenable to resection

Exactly this movement was impossible by any mean , extra long sphincter ring and acute bublbomembranous angle ✌️

Open tranvesical simple prostatectomy

A superb reply here 👇explain every thing

I feel you already you selected No 2

Just do en bloc Holep and you will be able to fully enucleate

Supravesical endoscopic prostatectomy

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Open adenomectomy.

Yo hice meato perineal y otroa opción fué enucleacion en bloque hasta el tercio medio, morcelación parcial y finalmente pude acceder hasta el final. Saludos

Nice

Not unusual with big glands. I start a 6 o’clock groove to create working space. Advance the scope gradually in that groove till the bladder. Avoids forcing the angle. Protects sphincter, minimizes mucosal trauma of Externalsphincter. Nevertheless Both options should be on the list