This update from urologist Justin Ahn, MD, covers evaluation essentials for patients with signs of BPH; what to know about various medical therapies, including side effects; and the bounty of today’s surgical options. Learn the pros and cons of advanced, less invasive techniques, including UroLift (“the Stapler”), Rez
m (removing excess tissue with steam) and Aquablation, as well as the advantages of HoLEP (holmium laser enucleation of the prostate) over the standard method of transurethral resection. so everyone thank you for joining today. And um I gave this talk to the pen south group already. Um But I wanted to try to pick a topic that was relevant and you know something that you'd see you know pretty frequently commonly. So I think this hits pretty hard at home. And so the point of this talk was really to review um what's going on in Bph management and so hopefully this will provide some updates and also just review things if it's been a while since you've had a chance to see the material. Um So I am a new assistant professor here at UCSF. And my clinic is primarily based at Redwoods in san mateo Redwood city area. Um So with that let's get started. Um Let's see here. Um So um initial evaluation for a you a god for Bph lower urinary tract symptoms. Um These are are the core basics that we get in all our patients. Uh And you should be thinking about when you see them in your office. Um The eu a guidelines specify that any patient who comes in with BPH or lower tract symptoms should get a digital rectal exam. Um your analysis and then as well as um a prostate symptoms score. So the I. P. S. S. Assessment is what all urologists use. It's sort of the base it's the baseline scoring that we used to compare severity of lower tract symptoms and I find it can be helpful because it basically hits all the main points of what you should be asking about. Lower your nutrients symptoms. So incomplete. Emptying frequency, intermittent see urgency, weak stream straining sleeping bacteria. Uh And then finally the most one of the most important question I think can be understated is what's the impact on quality of life for your symptoms. I see patients who have really horrible really high scores here but they're not that bothered by it. And then the same thing. I see patients sometimes who have very minimal bothers symptoms here but then are you know they have made a mild bacteria or mild urgency frequency but it's really bothers into their lives. So their quality of life scores up here. So I think it's really always important to ascertain how much they're bothered by their symptoms because it does guide management not infrequently. Um prostate exam. You know we're getting more with ps PSa screening has always been a controversial topic but um we're doing more prostate MRI's now um I still say that you know as part of your annual checkup or wellness check I think everyone should still get a digital rectal examination, your analysis. Um The what we're trying to do is really rule out cancer infection and um those are probably the two best screening tools that you can use. We have had some cases of there are some rare types of prostate cancer that don't raise your P. S. A. Level. So we will find these patients who have examples called small cell carcinoma of the prostate where patients have normal P. S. A. Levels but they have still have but they have a fairly aggressive process form of prostate cancer. That is not picked up with the essay but would be you know with a digital rectal exam or with other symptoms urinary tract symptoms. Um And then so optional tests also you know that are not required but optional and suggested um Separate from the way guidelines will be P. S. A. Tests like I mentioned checking a post void residual if you have a bladder scanner. You know how well other patients actually emptying their bladder. Oftentimes patients who have urgency or sensation of incomplete emptying are actually emptying their bladder. Well they just don't feel like it. Uh And saying you know if the flip side goes as well. I sometimes see patients who I feel like yeah there doc I empty my bladder fine and then they have a post void residual like of over 500 CCs. And I'm like wow what's going on? Um The nice thing about the renal bladder ultrasounds nowadays you know because of covid and trying to minimize office visits is that we can really get a lot of information now now out of getting renal bladder ultrasound and our patients and I have personally moved towards doing that. Um But the thing you just have to make sure to specify in there is requesting that the ultra sonography for check a post void residual. So that usually the patient has to come with a semi with a full bladder ready to urinate. Um And that will also allow them a better window to assess prostate size to. Um So instead of a trans rectal ultrasound or coming into the clinic to get their prostate size. Um The gallbladder ultrasound is a nice screening tool for that. And also just to assess the upper urinary tracts as well for any hydra necrosis obstruction. Um The um it's important to distinguish obstructive versus irritated symptoms. Um You know these can overlap but the obstruction. We think about hesitancy, straining weak stream and complete emptying and then irritated symptoms which are more frequency urgency related. And it's not too often that these symptoms overlap. Um We think that part of the reason for irritated symptoms is chronic obstruction. But we also see patients who have just irritated symptoms completely and they empty and they have no obstructive symptoms and the reason that's very important distinguishes that it does dictate management. Um Not infrequently. I have seen patients that have you know I've been told they have lower unit track symptoms. You go to see a urologist and they just get a they go and get a D. Obstructing surgery right off the bat. And the problem is they had irritated symptoms all along. They weren't obstructed. So a d obstructing procedure is not really helpful and beneficial to them and really what was needed was to address their irritated symptoms. So it's really important to distinguish those two. And like I said just asking the patient checking a post void residual see how wide the empathy with ladder. Um Those are ways that we can distinguish the two. Um um in terms of medical therapy we all know that the trace the tried and trusted Flomax. And so this is straight out of the way guidelines clinicians should offer one of the following off of blockers as a treatment for moderate to severe alerts. Um Flomax um is you know the most common one that we use. Um There's a reason we actually select for Flomax uh specifically is that it's the most selective for that alpha one. A receptor in the prostate is the right the alpha one a will relax the prosthetic smooth muscle and make the channel bigger. I always patients always ask me what is this medication doing to me? It's not it's it's not shrinking your prostate, it's just relaxing it so the channel is larger. Um Silent does is another good one. Um Also selective but I think it it tends to be more of a cost issue. Which is why Flomax tends to be the go to terrorism wasn't. And Docks Association are also great but they're not as selective but they're nice if you also have a patient you're trying to co manage with hypertension issues. Um because it will have a stronger anti hypertensive effect. Uh And those, you know has it does have to be tight traded though, um and you should avoid it in patients with congestive heart failure um Cialis. You know, we see a lot of men now for erectile dysfunction and for the lower intertek symptoms. If I find a patient in that situation, I'm gonna suggest maybe, of course doing chronic Cialis or $2 bill because it has been FDA approved for both and purposes. And so the nice thing is the man, the patient's getting not only assistance with their urinary tract symptoms Um in terms of prostate relaxation, that mess that mechanism, but also with erectile dysfunction and stronger erections. And it's nice because the Cialis lasts up to 24 hours. Um The precaution that I tell every patient that I'm starting at alpha blockers is you know, there's about 10 to 15% risk of mild side effects from the medication, the main ones being hypertension. Uh can that can lead to lightheadedness or dizziness. That's why I usually tell patients if they're having those symptoms to take it in the evening time right before they get to go to bed is that way they were going to be most prone and less likely to have like Ortho stasis symptoms, um congestion you hear about not sometimes and like I said, these are all reversible medications that quickly go away. The big one that I think doesn't get talked about as much as retrograde ejaculation. So the idea that because their bladder neck is now open when they when they have that when they have an orgasm, the ejaculate is going to go into the bladder and not out the the urethra. So they have dry torment. They may have, we're gonna have dry orgasms as a side effect of these medications and it can freak them out if they're not expecting it. So I always try to mention that if I'm starting on any alpha blocker medications, uh and like I said before, these are all this, this is also reversible. So it's not a lifelong effect, It's just temporary with the medication. Um So let's talk about, we talk about how we relax the prostate medical therapy. Now, we can talk about how do we reduce the size of the prostate? And so um that's where the five alpha reductase inhibitor medications come in. Um so out of straight out of the guidelines for the purpose of symptom improvement, you can consider five alpha reductase inhibitor main medications. We usually prescribed finasteride and asteroid as treatment for patients with prostate enlargement. Um as judged to be greater than 30 CCs or on a digital rectal exam or a p. S. A greater than 1.5. So basically if they have, you know, a larger than normal prostate or if you have to have a prostate volume. Like I said with with an ultrasound or or a ps above 1.5, they are potential candidates for um finasteride therapy as well as Flomax and I'll get into that in the next slide of combination therapy. Um the important things to mention about this medication is that it does take as opposed to Flomax which acts within days to weeks or within days. Really the finasteride is not going to make a difference until they've been on the medications for at least six months. So this is really a chronic you know yearly years long medication that you really have to see the full benefit and how it was tested. The reason is that you're cutting off the fuel supply of the prostate. So it takes right it's inhibiting the conversion of testosterone to di hydro testosterone. So what ends up so you're cutting off the fuel supply to the prostate and over time that results in atrophy of the prostate. But that takes time. Um The other important thing to remember is that patients on finasteride or any five alpha reductase inhibitor, you have to adjust their pro their P. S. A. Level basically it artificially will um half their their their P. S. A. Level. So if a patient has a PSR of six and then goes on finasteride their PSA will actually will come back if you were to check it will come back closer to three. But their adjusted PSA level which should be what you're taking into account with PS PSA screening would be six. So if I see a patient comes in with a PSR of two. but they're on finasteride or due to asteroid. I actually think I actually look at them from a P. S. A. Screen standpoint as a P. S. A closer to four. And so that could have implications. Right. If someone comes with a PSR of five And they're on finasteride, they're actually closer to 10 because of that compact adjustment. Um So it's really important to note when you're looking at elevated TSH whether they're on five alpha reductase inhibitor or not. Side effects with this medication are relatively low. Um There are some minority of men that can have low libido erectile dysfunction, lower Jacqueline volume and even more rare is kind of canasta or tender nipples which like I said, I rarely see. Um And also like I said, these effects are reversible with stopping the medication if they have um So let's get an accommodation therapy. So let's take the alpha blocker, right? And the final product is inhibitor to back different mechanisms of action. It's really the only way guidelines specify the same indications for five alpha reductase inhibitor therapy. So if you have prostate size over 30 CCs PSh over 1.5 or just palpable, subjective enlargement on a digital rectal exam. They are good candidates. Um The I think the big implications are deciding whether you want to put Medicaid patients on, you know, dual medications or not. You know, I know there's concerns about poly pharmacy um And then the guidelines also specify you can, if they have a mixed symptoms, obstructive and irritated symptoms. You can't consider putting someone on both an alpha blocker and an anti Colin ergic or beta three agonist anti colonics we think about would be told charity in Metro Solid Medicine, basic care. Um and then beta three agonists would be uh the main one is right now as mere background were also known as Miss Patrick, which has less of the anti Colin allergic side effects. Those medications we use primarily for urgency related symptoms. What's not recommended is putting a patient on alpha blocker therapy. So, Flomax and a PDE five inhibitor, select Cialis or Viagra as there has not been shown to be benefit to taking both for prostate symptoms. Just one or the other. Yeah. Um so let's talk about so say you have a patient who has obstructive symptoms retention. So I want to segue into that uh management options. Uh and so self catheterization, you know, the patient, the classic is that the patient will end up in retention at some point or gets and it has to get a catheter originally put in the emergency room and now the patients really worried about being catheter dependent. Um it's self catheterization I think is underutilized for a lot of patients. It's a nice alternative to surgery for urinary attention. It allows patients to maintain sexual function because they don't have to have a catheter and a bag sticking out of their penis all the time. They don't have to come in for capital exchanges every couple of weeks. Um Comes in various forms disposables that are one time use. And also reusable where patients can just watch the same catheter and reuse it. It's not meant to be a sterile cath. I mean it's just making sure they wash their hands before hand and it's meant to be a you know clean contaminated self catheterization. Um And uh basically the the good candidates for this or the patient has to be reliable to do it themselves. They have to have dexterity. So like an M. S. Or bad Parkinson's patient probably wouldn't be the best person if they don't have the dexterity. And it has to be the patient themselves. We we don't trust, we cannot depend on a full on a caregiver to reliably characterize the patients all the time. So we try to avoid uh instances where you know say a caregiver or family member wants to capitalize the patient as an as an alternative. We try to avoid that. Um So going into indications for surgery um these are the top here are really your sort of more hard indications and these are more relative indications down here. So renal insufficiency if they have sort of obstructive neuropathy that's coming renal damage. So those patients we think about are the ones that come in with really bad bilateral hydrogen fibrosis because they're, so their urine, their bladders. So backed up refractory urinary retention. So they're just catheter dependent um recurrent urinary tract infections, bladder stones uh and then uh crematoria secondary to prostate bleeding. So those are our hard in fact harder indications for surgery. But a lot of patients get end up getting surgery for other reasons too. And so this gets into the relevant vacations. How bothered are they? Symptomatic symptomatically. So remember that first slide we talked about the I. P. S. I. P. S. S. Score right? If they're on the quality of life score there like in the miserable range these are patients that are probably gonna benefit more from going straight to surgery or especially if they're refractory to medications or there. And then finally the other point is are they not interested in medications? We see a lot of patients who you know are in their late forties or fifties and they have you know, a good 20 to 30 years left of living and to commit them to, you know, lifelong daily medications, whether it's Flomax or an asteroid, you know, is a is a pretty significant impact on quality life as well. And also just also with costs to for paying for medications that long. Um So I have some patients who will skip will offer and skip medications and go straight to surgery sometimes and they are and it's a more upfront risk but for a longer term reward and having to avoid you know months or years of having to try medications before surgical option. Um Prostate anatomy just to give you just a review here. Very simple is I think the point is the size and shape of a prostate is variable and they don't come on 11 common size or shape. Um I also tell a patient size doesn't always correlate with symptoms. I sometimes see patients with huge prostates who don't have any urinary symptoms. I sometimes see patients with tiny prostates who have horrible obstructive symptoms. Um I granted the larger prostates tend to be more suggestive of obstruction. Um But the other reason I wanted to bring this up was that um the the transition zone we see here is sort of the middle of the prostate plan and that is what tends to be the most common cause of obstruction. And this is what we focus on when we do d obstructing procedures. Um The peripheral zone which is on the back side of the prostate is the most common place that you'll find prostate cancer, which is why we still, as urologists still encourage digital rectal exams because nine, you know, if someone has a prostate, a palpable prostate cancer, you will, there is a majority that there is a most likely chance that you will find it. You will palpate it on that posterior side, right along that anterior rectal wall. So this I think just highlights the importance of the rectal exam. Still, despite the advancing technologies we have. Um And then here you can see the prostate. This is a these are systolic api shots of prostates. Look this is the the black is the system scope coming into the bladder from the bladder outlet. And we're kind of retro flex the camera to look back on the prostate. And you can see here the prostates come in all sorts of shapes and sizes. We can even see here. Um This these are these are very prominent medium lobes. So there's we think of the prostate having two lateral lobes and one medium Loeb and they can be disproportionately large. Sometimes patients have this really large median lobe that acts like a ball valve and their lateral lobes aren't that big. So we Tyler each treatment to the to their anatomy and that's why systolic api is a common part of our evaluation for Bph. Oh so this is not and to be a memorized the entire slide but just to kind of overview of there are many different options for surgical therapy for prostate Bph. Um I'm gonna focus, I'm gonna kind of comment on most of them here but as you'll see there are some of them that are dependent on size and some of them are prophesized independent. Um So just to get to kind of go back in history for a little bit. Um This is how we used to do a prostatectomy is back in the day. It was a decision about this big in the below the belly button. Um And we would open up the bladder and stick your finger in there and basically just kind of core out the prostate. Like it's an orange from the capsule or the appeal of the of the prostate. Um patients would spend 1-2 days in the hospital, probably 2-3 weeks recovering from and uh there was some leading risk involved. Transfusion risk was not unheard of. Um And this is how we used to do it had great long term outcome results but there was a lot of morbidity around the time of surgery just because of the nature of having a large open incision in your in your lower activity. Um So that has for that we have moved away. Um They're still they're all just still do this procedure and in the right hands. You know I think there's something to be said about what surgery is done in the right hands of the right surgeon. Um But a lot of because of the robotic movements, a lot of patients or a lot of providers that do robotic prostatectomy also offer for cancer. Also offer simple prostatectomy. So you're basically recreating that same procedure where you core out the transition zone or adenoma part of the prostate and then you leave the capsule, the peripheral part behind. So this is great for large prostates. It is usually a one or two night hospitalization requires a catheter for a couple of weeks while the bladder, the prostate capsule heels, it does have excellent long term outcomes. The downside is that we're still it's still a trans abdominal surgery. It does require installation laparoscopy. So there is always concerns for risk for urinary leakage, bladder, bladder leakage, um injury to the bowel. Things like that are associated with inflating the inflating the about the abdomen. Okay. Um so let's get into the less invasive therapy. So Euro lift is relatively new treatment that's come out and I call this the stapler. It's the fancy and is the local awareness that we call it. And essentially there are these suture. These tax futures we put in about 464-6 leads into a prostate. And we're not removing any tissue. Were essentially just taking the prostate and expand. And and you can almost think like tax state pushing the prostate lobes apart separating them more to open up the prosthetic Original channel. The nice thing about this procedure is it can be done as an outpatient and we can even sometimes do it in the clinic. So it's same day home. Um It is like a permanent metal vicryl implant and it doesn't burn your bridges for needing for another prostate procedure if if this one fails. The nice thing also is it usually doesn't require a catheter afterwards because apparently, you know, pretty much when you wake up from the surgery if it's had any benefit or not. Uh And also the nice thing about these less invasive treatments is it's a lower risk of sexual dysfunction. Sexual dysfunction meaning retrograde ejaculation like we talked about before. Uh and also um erectile dysfunction. Um So the next treatment that's also kind of we fall into that less invasive treatment is called resume. And it's basically a steam vaporization treatment. So we stick this, it's all these all these procedures and insist aske optically we put this um system scope into the bladder and we basically put put this needle this hot this needle into the prostate and it injects a bunch of like really hot super hot steam that essentially coagulates the prostate tissue. And um leads to sort of this necrosis process and atrophy of the prostate tissue over several weeks. Um So the other ones so that once again this is an outpatient procedure. Usually some people will do it awake in the clinic with local. I tend to just do this as a kind of an outpatient surgery just for anesthesia and patient comfort. Um it does require a short term Catheter indwelling Catheter. So patients usually are have a catheter with for 10 to 14 days after the procedure while everything because of all the inflammation effect. Um And then you're also waiting about a couple of weeks if not one or two months to see the full effect of the procedure. It probably takes about three weeks for all the necrosis and atrophy and tissue healing to occur. So you're not really seeing the full benefit of the procedure for like a delay time after the procedure. Um Once again there's a lower risk of sexual side effects. Just because like retrograde ejaculation, erectile dysfunction. Because we're not respecting that much tissue. It's really just like um opening up the channel slightly. Um This next one has gained a lot of press because it's it's fancy it's fusion guided image. Ultrasound guided, it's called occupation. It's we call it the water jet. So instead of a hot steam treatment now these are just very high pressure water jets that are put in. This is also done system topically and you do what you do. You have a, the picture here shows the rectum with an ultrasound probe, a trans rectal ultrasound probe. And then you have the system scope here coming in. The device coming in here. And basically you on a computer, you basically map out exactly what you want to to treat the tissue where you want to treat. Uh And then you hit a go button and you just stand back and watch the machine do its job for like 5 10 minutes. Um So it sounds really great. Um And so it's you know, image guided um It's minimally invasive. The issues that they've had so far with this is that one. There's not a lot of, there's a limited amount of long term data about outcomes. Um There's also concerns about bleeding risk at the surgery. Um They figured out a great with this tool. They figured out a great way to remove the tissue. They did not figure out a way a good way to have homeostasis. So there have been issues that at least in our experience with patients having bleeding issues keeping in the hospital for several for you no more than one night. Uh And there's also just the costs associated with with treat with the obtaining the machine itself. Um The reason that in the one of the big claims to fame is that they don't have as much the sexual side effects once again. Uh But that's really like these. You'll find that the this the retrograde ejaculation is really dependent on how much tissue removed. This device only treats 160° out of the 360° of prostate. So you're you're not treating the entire you're not removing a lot of prostate gland. So that minimizes the retrograde ejaculation. Mhm. Um This procedure doesn't get a lot of press the trans urethral incision of the prostate. Also called T. U. I. P. Also known locally as we call it the channel turf for the mini turf. Uh And this is nice as a less invasive option because it has a low risk of sexual side effects for patients is not it's essentially we take this hot Kateri knife and we basically kind of make we make a trough in the prostate urethra in the prostates or not. We're not really removing tissue. Were just kind of been sizing and making a larger channel through the tissue. And this is ideal for smaller prostate glands. Those younger patients who don't want as much sexual side effects or if they have what we call high bladder next, where it's based on their anatomy. Um So if you ever see this in a note, you'll know kind of you know what, you'll know what A. D. U. I. P. Or mini turf is um transmitted through sexual, the prostate A. K. A turf. This is the gold standard that we've all known about for for years. The cold, also known as the roto rooter. It is the gold standard. It has been the gold standard up until now um This is used a model polar bipolar energies hot loop and we essentially go out and shave out prostate shavings. Um and create a larger channel Patients stay in the hospital one night sometimes and you get a catheter out usually within 24 hours. So they go home. The nice thing is they go home without a catheter and they're urinating, you know Like they are 30 years old again, you know the next next day. So the nice thing about this procedure is is the kind of immediate effects. They're not having to wait for the effects to wear in um the downside with the turf has been that because of this large amount of energy you're putting into the prostate tissue, it can lead to irritated symptoms, kind of urgency frequency that can last for months after the procedure. And because you're also not removing all the prostate tissue, there is a risk for prostate adenoma regrowth. And so we always worry about those patients who are like 5, 10 years out from a turbo and they start having obstructive symptoms. Again, it's either a stricture uh more structures usually form within the first year, but it could also be just prostate tissue regrowth. So they need a repeat evaluation, repeat systems compete with us. Um So that gets in, like I said, the problems with the turf. Um The as we talked about before, the term procedure leaves a fair amount of prostate tissue behind afterwards. We talked about the energy source prostitution behind here, we talked about the high amount of energy that's put in the area. So it caused a lot of irritated symptoms afterwards. Um That can make it can affect quality of life in the post op recovery. And then this was a study from 2015 that actually looked at kind of the whole breakdown of all the different procedures for for prostates. And you can see here that about 6% of prostate tissues were all just allocated towards redoing terp procedures because of regrowth. So, terp um you know, as great as terp is we still see a lot of patients coming back that have regrowth of tissue. They need to go in for another procedure. They thought they were done with it. So long comes um this more this more contemporary treatment that we're this is one of the latest and greatest that we do uh It's called the whole upper homing laser nucleus of the prostate. We're using once again going insist aske optically and using a laser to basically core out the prostate in its natural plane. So just like we saw, I showed you before with the open technique where we would kind of use your finger to core out the the fruit from the peel of the prostate. Um that's essentially what we're doing with this. And so because of the laser, because it's less energy uh and because the laser were able to get really good homeostasis, the patients have great long term outcomes because we're basically respecting, you know, 1980, of their prostate tissue As opposed to a terp which maybe get like 50% of prostate tissue. Um And um the other nice thing is that because of these improvements, the patients were able to do these overnight hospital stay or even sometimes our patients same day The patients have a catheter temporarily, usually get it out within 24 hours. Um so it has a lot of the benefits without a lot of the side effects or downsides of other treatments. The main concern we have is transient incontinence after the thought is that um because we've done such a good job respecting here is that patients now have to rely on their external sphincter, voluntary sphincter for continents. So we tell patients it's more of a transient stress incontinence for the usually for the first couple of weeks, rarely extending more than a couple of months where the men are going to have to use pads. We always joke with patients that they'll be able to uh they'll be there, their wives will be able to to relate with them because of, you know, stress and cons they have after childbirth that the men can finally experience the same experience. Um But like I said, this is more transient and we usually recommend um kegel exercises or pelvic floor exercises and they're dry after sometime within that time frame. Um So just to give you sort of a picture of what this looks like, you can imagine that Terp was essentially us going in and kind of taking these individual shavings little by little to get the prostitute you out. The holdup is really following those natural planes like I said of the prostate to really get a complete resection of the prostate tissue. And so because of this, the the re intervention rates, the risk of prostate regrowth is you know, essentially minimal. And if you want to I tell any patient if they want the one and done procedure, never going to need a prostate procedure ever again in their life. This is the procedure to do. Um So just to kind of go over some steps, this is we start with uh taking out the median lobe and like I said, there are three lobes of the prostate. And sometimes we can actually get away with doing a partial hold up. So well actually for men who want to maybe left less risk of incontinence or less risk of um sexual retrograde ejaculation, side effects. We can do just one or one out of three loaves at a time. Sometimes if they just have one big medium level, just treat the median lobe actually and leave the latter lobes behind. Um And they can still get a really good outcome. Um And then like I said, the if after the median lobe, we then take out the two lateral lobes on each side. Um Like I said, basically used all through a laser instead of this kind of shaving into uh shaving into the bloody prostate tissue. Um So if we do our job really well. Uh This is the outcome. So you can see here, this is a picture of a Sista Skopje. Uh This is the prostate foster right here and then you can see the bladder in the background. This is the once again the system scope coming in, looking back on the bladder outlet, and you can see this nice wide open channel that is never going to cause obstruction again for this patient. Um, so, and interestingly, even patients who have, has been shown to even be benefits to work for patients who have a contract, I'll bladders. So even patients who come in with, you know, neurasthenic bladders, not your spinal cord patients, but patients who have uh we don't have any more bladder squeezing capability because of bladder pathology can still get benefit because we, because we have reduced that resistance so much from the prostate. So, um this is what I think relevant, just things to think about that you may hear and if you see these patients after they've had their surgeries, retrograde ejaculation, like we talked about which is temporary with alpha blocker medications. It is more permanent with these medications and it is proportional to the amount of prostate tissue that we've removed. So, um like I said, I tell patients that if I've done a good reception or a good hole up for a good term procedure, you will have um retrograde ejaculation. That is a sign of how much tissue we've removed. Transient stress and contents we talked about that. Um usually as transient responds more stress related. So coughing sneezing, not like a Floridian contents and usually responds to kegels or public kegels or public floor exercises. Um hey materia usually resolves within the 10 to 14 days. It's not uncommon. That will see patients they have crematoria, it gets better in the first 4 to 5 days for the material goes away and then about 10 days after the surgery, the patient calls us again and talks about how they're having him a tree again most of the time. What's happening is that the scab that is formed the kind of the healing scab is formed over there. Your europe helium is Uh finally slumped or fell off. And so what we're seeing is that residual just sloughing off of the scab tissue. It usually doesn't result in significant material that requires any intervention. But it's something that I always counsel patients about. Um not that I really have to allow the full at least 14 days if you're not on blood thinners. Um for the full result to wait for your material, fully resolved um irritated symptoms. So you're those, we talked about it more common with high energy procedures. So Terp resume the steam treatment or even the Euro lifts. Because these are all these are either you're putting a foreign body there, you're putting a bunch of energy into the prostate tissue and waiting for it to atrophy. These are all um sources for irritated symptoms that will eventually go away. Can be managed with anti Colin. Ergic or irritated medications like I said maybe gran or oxy oxy button and medications like that. Less common risks or U. T. I. S. So you know, always good to check in your analysis with culture this using these response temperature antibiotics usually occur within the first week after the interventions. Um Urethral strictures are always something. We are rare. Probably want a couple of percent or less but we always want to keep an eye out. So the classic is that about a couple of weeks or a couple of months after the procedure. The patient notes that their symptoms are starting to, they're obstructive symptoms are trying to come back. Which usually shouldn't happen with a good reception or d. Obstruction procedure. The effects should last. You know at least company knows happy year. If not longer correct. All these functions very rare is usually more associated with the high energy procedures like the terp But even so like like I said the risk with them are pretty low like in the far less than 5% range. Um interestingly we find about when we do these procedures. About one in 10 men will will find incidental prostate cancer. So I always counsel these patients that even with their prior P. ECE screenings and everything like that there is always this there is this small possibility. We may find prostate cancer at the time. The majority of the time. Uh It is low grade and it can just be observed. Um having having any sort of the obstruction procedure does not eliminate there um opportunity to have radiation treatment or have surgery down the road for cancer removal. Um So um it's usually a non event and something we just keep it out for on the biopsy when we when we extract the tissue from the specimens. Um So this summarizes all the treatments I've talked about. I've highlighted the ones in green that we offer here at UCSF. Um I personally do all these procedures including the whole procedure. I am a strong believer in it as you can tell. Um But I think for the reasons that I mentioned but I as because we want to offer all the treatments we try to be um offer, they all have their pros and cons and I offer every one of them to our patients here. Um The last one I didn't really talk about so much is prostate artery embolization. Um This is essentially interventional radiology guided and they go in with catheters and balloons through grind puncture. They have to calculate the prostatic artery which is tiny and then put some coils or some something to um basically cause ischemia to the prostate gland. Um It's very operated dependent. I've seen mixed results with it. Patients ask about it. Um It takes weeks to months for improvement once again because you're just cutting off the blood supply. So you're waiting for the prostate tissue to die off. Um It has been we right now reserve it for patients who are not good surgical candidates or they're having really bad bleeding. Um Those are really who it's reserved for. Um And also I know that certain insurance carriers won't cover it for just straightforward Bph. But we do refer to Ir if the patients ask. Um So to summarize there's way too many ways to treat in a large prostate. Um But I hope at least this helps summarize in frames what we can offer patients. Uh And how you can help and also help you to counsel them if they're asking. Um evaluation is important to rule out obstruct to confirm obstruction, not irritated symptoms and to rule out infection and malignancy. So infection by checking your analysis malignancy with your analysis in a plus or minus P. S. A. Or a digital rectal exam. Um The choice is really dependent as you can see on the patient's risk tolerance for side effects and also based on the urologist skill sets. Um So with that um that's all I have to talk about Bph. I just wanted to put in a shameless plug for our new clinic here on Redwood City that we just opened last month. This is where I am based full time. Um Access wise. It's great. We actually have a lot of patients that come down from the bay area because they don't want to deal with driving in the city or paying $30 for parking. So we're located right here in the strip mall. Free parking, there's a bunch of other commercial grocery store, coffee shop banking, get all your stuff done Just off the 101 freeway in San Mateo by San Carlos Airport. Um I have availability same week and probably conceived people within 48 hours. And um we're doing a lot of video, video visits so especially for the patients up in the North Bay to save on the drive, we can do a lot of that. And I also am here to serve as sort of a way to get patients in the door quicker to eventually see our UCSF urology specialists if they need it. But otherwise I'll be specializing in kind of general male and female urology here. Um So this is just not an exhaustive list of kind of all the conditions were treating but we will have a significant procedure capability at our clinic, Sista Skopje vasectomies um transmitted ultrasound um uh and um fully catheterizations, things like that. Um And so with that there's my info and uh and for any referrals, here's the information. Um So I thank you for everyone for taking the time to listen and attend tonight. Mm hmm.