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Kevin Zorn the following educational video will highlight stepwise techniques to ensure minimization of bleeding easy Foley catheter placement and optimal patient outcome ultimately there are four aspects one being hemostasis controlling a bleeding number 2 removal of any residual tissue in the bladder an easy catheter placement that has a traumatic and finally light compression of the prostatic fossa to minimize capillary and venule bleeding to summarize when the surgeon has completed vaporization the first step is to turn off outflow and inflow into the bladder this allows a distended bladder to compress any significant venule bleeding and the first step is to look for any arterial bleed the surgeon should address those immediately then to open the outflow to allow a slow release of bladder hydrostatic pretension to look for any significant capillary or venule bleeding once addressed the bladder will be emptied approximately 50% of its fluid to reassess for any other significant bleeding and to confirm a defect within the prostate that there should be no slumping of the anterior tissue which would suggest residual tissue finally remove any tissue from the bladder through either water flow use of grasper or a basket subsequently the Foley catheter placement this should be done with a completely full bladder an insertion of a 20 French 2-way catheter over a stylet to prevent any irritation of the prostatic fossa and to quickly fill the balloon with 30 milliliters of saline the Foley should then be retracted so that the balloon sits against the prosthetic fossa at the bladder neck and a trick that I have learned is to use a 4x8 moist dressing to make a single knot around the catheter and slide up to compress the product fossa the bladder should then be rinsed two to three times prior to connecting to the bag to ensure that there is no other significant bleed we now see the completion of vaporization of the anterior apical tissue we see a view from the very Montana of an open prosthetic fossa with small debris the marked micro particulate that is emitted from the laser vaporization tissue has been completely removed down to the capsule circumferentially the prostate was measured at 58 grams in this patient here we can see there is a lack of flow and finally a back drawing of flow which is the valves that have been closed using the tension in the bladder to help eliminate some of that fluid the bladder should be then emptied about 50% and quickly reevaluate it to see any significant bleed so we've already checked for arterial bleed by stopping the flow we've looked now for venous bleeding and any small particular material should be removed we're coming in a third time here to address some small bleeding you can see from the left side of the screen the patient's right prostatic lobe and so the fiber is brought back and using a combination of either vaporization or the coagulation mode to achieve hemostasis there will always be some small little capillary using particularly near the end of the case which I tend not to address these will simply be tomp and added by the catheter and surgeons should be reassured not to spend significant more time and delivering more energy to the capsule here we can see we've exchanged out the laser fiber for a grasper this is the same grasper used during our ureter osku P and used to bring out any pieces of tissue that may have been chiseled off near the bladder neck particularly patients with median lobes these are brought out completely with the scope we can see here being brought a traumatically out and brought to the back table for assessment these will be sent off for pathology confirm benign tissue the small laser 23 French scope is then reinserted a traumatically through the urethra here we can see the sphincter the very montana back into the prostatic fossa there is a slight light pink material but still transparent again addressing any remaining tissue here another small piece is seen and that is to be removed some of these the patient may easily be able to void but simply for pathological evaluation and thoroughness of technique and quite easy to do that is the purpose of our grasper removal one last inspection again to ensure no remaining tissue or injury to the bladder and this will lead to the case completion at this point the outflow valve is closed we are simply filling up the bladder and you'll see a black screen we're simply disconnecting the camera and handing to my assistant to show you an unedited timeline of the procedure here we can see the scope still into the penis filling up the bladder with the outflow we're simply removing the light turning off the light source not to injure or burn the patient and I'm waiting for that bladder to be full and this will allow for again a distension the prostatic fossa and a much more easier insertion of the Foley catheter prior to beginning the procedure I have the Foley catheter which has been mounted with the stylet well lubricated so I'm going to wait and simply to look for a small dripping around the cystoscope and a feel the patient's abdomen to make sure there is a nice full bladder stop the inflow gently and slowly take out the cystoscope you can see a gush this is a good sign of a complete tissue removal the Foley catheter is then placed a traumatically in the right direction the stylet allows us to make that change toward the sphincter the direction and not to get stuck at the bladder neck and potentially stare out bleeding so here you go you can see the scope is in the style that comes out there's an icy flecks of clear fluid and before everything gets that decompressed I want to fill up that bladder balloon with 30 milliliters of saline push this in quickly and what I want to do then is bring the Foley catheter out and to deliver a little compression so this is a trick I've learned through a colleague in Korea simply taking a wet four by eight tying a single knot you can see I'm going to give it a good squeeze just to make sure that it really sits tight against the Sai lastic catheter cut the edges off the intention not to injure the catheter and simply then to glide takes a little bit of practice and slide it up just to allow for some puckering at the glans penis and this isn't going to again going to allow for some compression from the balloon at the bladder neck prevent any significant bleed simple premise of caveman therapy which is simple delivery of pressure to any site that is bleeding and this is something that I found for next two-three hours during which the spinal anesthesia wears off allows for a much smoother post-op hemostasis and clear urine so again we've completed the case I'm going to fill the bladder a few more times just to make sure that any small material is removed and have a nice clean Eve luxe prior to going to the recovery room all in all this is about s 5 to 10 minute landing sort of the same premise of landing a plane to slow down do the same systematic steps just to ensure patients have reproducible outcomes I hope you find this educational video helpful to you and your practice and your understanding as a patient if this may be the situation for undergoing the surgery thank you for your attention write for me capstone project samples for money City College, Harlem.