1. GREENLIGHT LASER PROSTATECTOMY PROCEDURAL TECHNIQUE Dr Charles Chabert

2. GLP Technique Basic principles Modular approach (IGLU) 2 Charles Chabert

3. Key Points Being familiar with fibre landmarks Working distance Rotation speed Vaporisation & Coagulation Charles Chabert

4. Learning GreenLight Proficiency with the basic procedure is typically achieved in approximately 10 cases After the first 10 cases you can expect to Reduce OR and laser time Progress to larger glands Treat patients who may be on anticoagulants Treat patients with additional co-morbidities 4 Charles Chabert

5. Identify Fiber Markings 5 The triangle on the cap is 180degrees from where the laser beam fires The red stop sign is aligned with the aiming beam of the fiber Charles Chabert

6. Fibre Landmarks Charles Chabert

7. Aiming Beam Before firing the laser, the laser aiming beam and fiber cap must be clearly visible through the cystoscope The red aiming beam indicates the location of where the laser energy will be directed. Caution: Do not fire the laser unless you can see the red aiming beam on the targeted tissue 7 Tissue Charles Chabert

8. Laser Deflection Angle Be aware that the laser exits at a 70° forward deflection angle to the fiber axis Note: Use caution when treating tissue at the bladder neck to avoid damage to ureteral orifices or trigone / bladder 8 8 Charles Chabert

9. Fiber Handling The Blue Triangle must be visible under cystoscopic view or inner sheath damage may result. 9 Don’t pull backWrong directionCorrect direction Charles Chabert

10. Laser Tissue Interaction Depends on the following parameters: Tissue composition Laser wavelength Power / energy settings Mode of laser operation Vaporization vs Coagulation Fiber handling technique 10 Charles Chabert

11. Distance to Tissue 11 1.8 mm ≤ 3.0 mm Visual Clue: work 1 fiber cap width from tissue Optimal working distance to tissue is 0.5 to 3.0 mm Charles Chabert

12. Results/Benefits: Collimated beam makes tissue removal rate is insensitive to fiber-to-tissue spacing over the 1 – 3 mm operating range Faster procedures without requiring unrealistic control of fiber position Less chance of unintentional coagulation Larger fiber to tissue distance leads to cleaner fibers and longer fiber life. Why Does A Collimated Beam Matter? Charles Chabert

13. Speed of Tissue Vaporization Bubbles indicate vaporization efficiency To increase vaporization: Slow sweep speed Check distance from tissue (near contact) Increase power To slow down vaporization Increase sweep speed Decrease power 13 Charles Chabert

14. Proper Sweeping Speed 14 Correct = Vaporization Incorrect (too fast) = Coagulation Charles Chabert

15. MODULAR TECHNIQUE: INTERNATIONAL GREENLIGHT LASER USERS (IGLU) 15 Charles Chabert

16. Key Steps 1. Insertion of cystoscope 2. Creation of working channel 3. Vaporisation of lateral lobes 4. Median lobe & bladder neck 5. Completion & IDC insertion Charles Chabert

17. Introduction of Cystoscope Charles Chabert

18. CREATION OF A WORKING CHANNEL Charles Chabert

19. Modular Approach Charles Chabert

20. Median Lobe Charles Chabert

21. Bladder Neck Charles Chabert

22. Completion of procedure Assess Haemostasis Insert IDC Flush out bladder debris Timing of TOV Charles Chabert

23. Acknowledgements International GreenLight Users group Charles Chabert