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
So hi, everyone. Uh, thank you for joining me today. And um, um, I gave this talk to the PennSouth Group already. Um, but I, 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, and 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, um, since you've had a chance to see the material. Um, so I am, uh, a new, uh, assistant professor here at UCSF and my clinic is primarily based at Redwoods in, uh, San Mateo, Redwood City area. Um, so with that, let's get started. Um, Let's see here. So, um, Initial evaluation for AUA uh for BPH lower urinary tract symptoms. Um, these are, our, 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 AUA guidelines specify that any patient who comes in with BPH or lower urinary tract symptoms should get, uh, a digital rectal exam, um, urinalysis, uh, and then as well as, um, a prostate symptom score. So the IPSS assessment is what all urologists use. Uh, it's, it's sort of the base, it's the baseline scoring that we use to compare severity of lower urinary tract symptoms. And I find it can be helpful because uh it basically hits all the main points of what you should be asking about lower urinary tract symptoms. So incomplete emptying, frequency, intermittency, urgency, weak stream, straining, sleeping, nocturia. 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 uh for your symptoms? Um, 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 bother symptoms here, but then, or, you know, they have may have mild nocturia or mild urgency frequency, but it's really bothersome to their life. 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 cause it does guide management, uh, not, not infrequently. Um, prostate exam, you know, we're getting more, uh, with PSA screening it's 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 exam and a urinalysis. Um, the, what we're trying to do is really rule out cancer or infection, uh, and, um, those are probably our two best screening tools that you can use. Uh, we have had some cases of, uh, there are some rare types of prostate cancer that don't raise your PSA level. Uh, so we, we find these patients who have, uh, uh, examples called small cell carcinoma, uh, of the prostate where patients have normal PSA levels, uh, but they have still have, but they have a fairly aggressive form of prostate cancer that has not picked up with PSA 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 EUA guidelines would be PSA tests like I, I mentioned, uh, checking a post-void residual if you have a bladder scanner, you know, how well are the 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 same, you know, the flip side goes as well. I sometimes see patients who Feel like, yeah, doc, I empty my bladder fine and then they have a post-void residual like of over 500 cc's. I'm like, wow, what's going on? Um, the nice thing about the renal bladder ultrasounds nowadays, you know, because of COVID and, uh, trying to minimize office visits is that we can really get a lot of information now, now out of getting renal bladder ultrasounds on our patients and I have personally moved towards doing that. Um, then, the, the thing you just have to make sure to specify in there. I, uh, requesting that the ultrasonographer 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 too. Um, so instead of a transrectal ultrasound or coming into the clinic to get their prostate size, uh, the renal bladder ultrasound is a nice screening tool for that. Uh, and then also just to assess the upper urinary tracts, um, as well for any hydronephrosis, uh, obstruction. Um, The, um, it's important to distinguish obstructive versus irritative symptoms. Um, you know, these can overlap but the obstruction we think about, um, hesitancy, straining, weak stream, incomplete emptying, and then irritative 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 irritative symptoms is chronic obstruction, but we also see patients who have just irritative symptoms completely and they empty and they'd have no obstructive symptoms. And the reason that's very important to distinguish is that, uh, it does dictate management. Um, not infrequently. I've seen patients that have You know, been told they have lower urinary tract symptoms. You go to see a urologist and uh, they just get a, they go and get a de-obstructing surgery right off the bat. And the problem is, is they had irritated symptoms all along. They weren't obstructed, so a de-obstructing procedure is not really helpful or beneficial to them. And really what was needed was to address their irritative symptoms. Um, So it's really important to distinguish those two and like I said, just asking the patient, checking a post-word residual, see how widely empty the bladder. Um, those are ways that we can distinguish the two. Um, in terms of medical therapy, we all know the trace, the, the tried and trusted Flomax and so this is straight out of the AUA guidelines. Clinicians should offer one of the following alpha-blockers as a treatment for, uh, moderate to severe LUTS. Um, Flomax, um, is, you know, the most common one that we use. Um, there's a, the reason we actually select for Flomax, uh, specifically is that it's the most selective for that alpha-1A receptor in the prostate. It's the, right, the alpha-1A will relax the prostatic 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, uh, shrinking your prostate. It's just relaxing it so the channel's larger. Um, silodosin is another good one. also selective, but, um, I think it, it tends to be more of a cost issue, which is why Flomax tends to be the, the go to. Teazosin and doxazosin 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, uh, antihypertensive effect, uh, and those, you know, and it has, does have to be titrated 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 urinary tract symptoms. If I find a patient in that situation, I'm gonna suggest maybe a course, uh, doing a chronic Cialis or tadalafil, um, because it has been FDA approved for both purposes. So the nice thing is the man, the, the the patient is getting not only assistance with their urinary tract symptoms. Um, in terms of prostate relaxation, that, that mechanism, but also with their erectile dysfunction and stronger erections. Uh, and it's nice cause the Cialis lasts, you know, up to 24 hours. Um, the precaution that I tell every patient that I'm starting on alpha-blockers is, you know, there's about 10 to 15% risk of mild side effects from the medication. The main ones being hypotension, uh, and that can lead to lightheadedness or dizziness. That's why I usually tell patients if they're having those symptoms to take it uh in the evening time, uh, right before they get, go to bed cause that way they're gonna, they're gonna be most prone and less likely to have like orthostasis symptoms. Um, congestion, uh, you hear about, uh, sometimes, uh, and like I said, these are all reversible medications that quickly go away. Um, the big one that I think doesn't get talked about as much is retrograde ejaculation. Um, so the idea that because their bladder neck is now open when they, when they have that, when they have an orgasm, the ejaculate's gonna go into their bladder and not out the, uh, the urethra. So they have dry, I tell men, they may, they may have, we're gonna have dry orgasms, uh, 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 medication. Uh, and like I said before, these are all, this, this is also reversible. So it's not a lifelong effect. It's just, uh, temporary with the medication. Um, so let's talk about, so we talked 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 5 alpha reductase inhibitor medications come in. Um, so out of straight out of the guidelines, um, for the purpose of symptom improvement, you can consider 5 alpha reductase inhibitor. Main medications we usually prescribe are finasteride and dutasteride, uh, as treatment for patients with prostate enlargement. Uh, as judged to be greater than 30 cc's or on a digital rectal exam or a PSA, uh, greater than 1.5. So basically, if they have, you know, a larger than normal prostate or, uh, if you have, do have a prostate volume, like I said with, with an ultrasound or, uh, or a PSA 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, uh, it does take, as opposed to Flomax, which acts within days to weeks or within days really, uh, the, the finasteride is not going to make a difference until they've been on the medication for at least 6 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 to the prostate. So it takes, uh, right, it's inhibiting. The conversion of testosterone to dihydrotestosterone. 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, uh, but that takes time. Um, the other important thing to remember is that patients on finasteride or any 5 alpha reductase inhibitor, you have to adjust their pro their PSA level. Uh, basically, it artificially will, um, half their, their, their PSA level. So if a patient has a PSA of 6 and then goes on finasteride, their PSA will actually, will come back, if you were to check it, will come back closer to 3. But their adjusted PSA level, which should be what you're taking into account with PSA screening, would be 6. So if I see a patient who comes in with a PSA of 2, but they're on finasteride or dutasteride, I actually think, I actually look at them from a PSA screening standpoint as a PSA closer to 4. And so that could have implications, right, if someone comes in with a PSA of 5 and they're on finasteride, they're actually closer to 10 because of that compact uh adjustment. Um, so it's really important to note, uh, when you're looking at elevated PSA whether they're on a 5 alpha reductase inhibitor or not. Side effects with this medication are relatively low. Um, there are some, about a minority of men that can have low libido, erectile dysfunction, uh, low ejaculate volume, and even more rare is gynecomastia or tender nipples, um, 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 into combination therapy. So let's take the alpha-blocker, right, and the 5 alpha reductase inhibitor, two different mechanisms of action. It's really the AUA guidelines specify the same uh indications for uh 5 alpha reductase inhibitor therapy. So if you have prostate size over 30 ccs, PSA 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 medica patients on, you know, uh, dual medications or not. You know, I know there's concerns about polypharmacy. Um, and then the guidelines also specify you can, if they have a mixed symptoms, obstructive and irritated symptoms, you can consider putting someone on both. An alpha-blocker and an anticholinergic or beta-3 agonist. Anticholinergics we think about would be tolteridine, Detrol, solifenesin, VESIcare, um, and then beta-3 agonists, uh, would be, uh, the main one is right now is Mir-Bron or also known as Myrbetriq, which uh has less of the anticholinergic side effects. Those medications we use primarily for urgency-related symptoms. Uh, what's not recommended is putting a patient on alpha-blocker therapies, so Flomax and a PDE5 inhibitor, so like Cialis or Viagra, uh, as there has not been shown to be benefit to taking both for prostate symptoms, just one or the other, so. Um, so now 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, uh, will end up in retention at some point or gets and has to get a catheter urgently put in the emergency room and now the patient's really worried about being catheterdependent. Um, it's self-catheterization, I think, is underutilized, uh, for a lot of patients. Uh, it's a nice alternative to surgery for urinary retention. Uh, it allows patients to maintain sexual function because they don't have to have a catheter in a bag sticking out of their penis all the time. And they don't have to come in for catheter exchanges every couple of weeks. Um, comes in various forms, disposables that are one-time use and also reusables where patients could just wash the same catheter and reuse it. Uh, it's not meant to be a sterile cath. I mean, it's just making sure they wash their hands beforehand and it's meant to be a, you know, clean contaminated self-catheterization, um. And, uh, basically the, the good candidates for this are the patient has to be reliable uh to do it themselves. They have to have dexterity, so like an MS or a bad Parkinson's patient probably wouldn't be the best person if they don't have the dexterity, uh, and it has to be the patient themselves. We, we We don't trust, we cannot depend on a full, on a caregiver to reliably catheterize the patients all the time. So we try to avoid, uh, instances where, you know, say a, a caregiver or a family member wants to catheterize 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 causing renal damage. So those patients we think about are the ones that come in with really bad bilateral hydronephrosis because they're so, their urine, their bladder is so backed up. Uh, refractory urinary retention, so they're just catheter dependent, um, recurrent urinary tract infections, uh, bladder stones, uh, and then, uh, hematuria secondary to prostate bleeding. So those are our hard in fact, our 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 indications. How bothered are they symptom symptomatically? So remember that first slide we talked about the I IPSS score, right? If they're, if on that quality of life score they're 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 they're. And then finally, the other point is, are they not interested in medications? Uh, we see a lot of patients who, you know, are in their late 40s or 50s and they have, you know, a good 20 to 30 years left, uh, of living and to commit them to, you know, lifelong daily medications, whether it's uh uh Flomax or, um, finasteride, you know, is a, is a pretty significant impact on quality of life as well and also just, also with cost too for paying for medications that long. Um, so I have some patients who will skip, who will offer and skip medications and go straight to surgery sometimes, and they are, um, 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 a surgical option. Um, prostate anatomy, just to give you, just to review here, um, very simple is, uh, I think the point is the size and shape of a prostate is variable and they don't come all in 11 common size or shape. Um, I also tell patients 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, 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 gland and that is what tends to be the most common cause of obstruction and this is what we focus on when we do deobstructing procedures. Um, the peripheral zone, which is on the backside 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 9, you know, if someone has a prostate, a palpable prostate cancer, you will, there is a majority, there is a majo uh most likely chance that you'll find it. You'll, you'll 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, uh, despite the advancing technologies we have. Um, and then here you can see the prostate. This is, uh, these are cystoscopy shots of prostates. Look, this is the cyst, the black is the cystoscope coming into the bladder from the bladder outlet. We're kind of retroflex 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 median lobes. So there's, you think of the prostate having two lateral lobes and one median lobe, and they can be disproportionately enlarged. Sometimes patients have this really large median lobe that acts like a ball valve and their lateral lobes aren't that big. So we tailor each treatment, uh, to the, uh, to their anatomy and that's why cystoscopy is a common part of our evaluation for BPH, um. So this is not meant to be a memorize the entire slide but just to kind of an overview of there are many different options for surgical therapy uh for uh prostate BPH. Um, I'm gonna focus, I'm gonna kind of comment on, uh, most of them here. um, but as you'll see there are some of them are dependent on size and some of them are pro size independent. Um, so just to get, to kind of go back in history for a little bit, um, this is, uh, how we used to do, uh, prostatectomies back in the day. It was an incision about this big, uh, in the, uh, below the belly button. Um, and we would open up the bladder and stick our finger in there and basically just kind of core out the prostate like it's an orange, uh, from the capsule or the peel of the, uh, of the prostate. Um, patients would spend 1 to 2 days in the hospital, probably 2 to 3 weeks recovering from, and, uh, there was some bleeding risk involved. Uh, transfusion risk was not unheard of. Um, and this is how we used to do it. 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 abdomen. Um, so that has, for that, we have moved away. Um, there's still, neurologists still do this procedure in, 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, um, movements, a lot of patients or a lot of providers that do robotic prostatectomy also offer, uh, 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, um, the peripheral part behind. So this is great for large prostates. Uh, it is usually a one or two-night hospitalization. Requires a catheter for a couple of weeks while the bladder, the prostate capsule heals. It does have excellent long-term outcomes. The downside is that we're still, it's still a transabdominal surgery. It does require insufflation, and a laparoscopy. Um, so there is always concerns for risk for urinary leakage, bladder, bladder leakage, um, injury to the bowel, uh, things like that are associated with, um, insufflating the, inflating the, the abdomen. Um, so now let's get into the less invasive therapy. So UroLift is a relatively newer treatment that's come out and I call this the stapler. Uh, it's the fancy and it's the colloquial way that we, we call it. And essentially there are these suture, these tack sutures. We put in about 4 or 64 to 6 of these into a prostate and we're not removing any tissue. We're essentially just taking the prostate and expand and, and you can almost think like tack sta or uh pushing the prostate lobes uh apart, uh, separating them more to open up the prostatic urethral 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. Uh, so it's same-day home. Um, it is, uh, like a permanent metalvicral implant, uh, and it doesn't burn your bridges for needing, uh, for another prostate procedure if, if this one is, fails. The nice thing also is it usually doesn't require a catheter afterwards, but you 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, uh, erectile dysfunction. Um, so, The next treatment, uh, that's also kind of we fall into that less invasive, uh, treatment is called Rezoom, uh, and it's basically a steam vaporization treatment. So we stick this, so all these, all these procedures are done cystoscopically. We put this, um, cystoscope into the bladder and we basically put, pump, put this needle, this hot, this needle into the prostate and it injects a bunch of like really hot, super, uh, 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 night, so that once again this is an outpatient procedure. Uh, usually some people will do it uh, awake in the clinic with local. I tend to just do this as a kind of an outpatient surgery, uh, just for anesthesia and patient comfort. Um, it does require a short-term catheter, indwelling catheter, so patients usually 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 1 or 2 months, uh, to see the full effect of the, of the procedure. It probably takes about 3 weeks for all the necrosis and atrophy and tissue healing to occur. So you're not really seeing the full benefit of the, uh, procedure for like a delayed time after the procedure. Um, once again, there's a lower risk of sexual side effects just because, uh, like retrograde ejaculation, erectile dysfunction because we're not resecting 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 of, it's, it's fancy. It's fusion guided, it's image ultrasound-guided. It's called oculablation. It's, we call it the water jet. So instead of a hot steam treatment, now these are just very high-pressure water jets, uh, that are in, uh, put in. This is also done. Cystoscopically and you do it, you, you have a, the picture here shows the rectum with an ultrasound probe, a transrectal ultrasound probe. And then you have the cystoscope 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 area 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, uh, 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 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 hemostasis. So there have been Issues at, at least in our experience with patients having kind of bleeding issues, keeping them in the hospital for several, for, you know, more than 11 night. Uh, and there's also just the cost associated with, um, With treat with the uh obtaining the machine itself. Um, the reason that in the, the, one of their big claims to fame is that they don't have as much the sexual side effects once again. Uh, but that's really like it's you'll find the, the, the, the retrograde ejaculation is really dependent on how much tissue removed. This device only treats 160 degrees out of the 360 degrees of prostate. So you're really, you're not treating the entire, you're not removing a lot of prostate glands so that minimizes the retrograde ejaculation. Um, this procedure doesn't get a lot of press. The transurethral incision of the prostate, also called TUIP, also look locally as we call it the channel turp or the mini turp. Uh, and this is nice as a less invasive option because it has a lower risk of sexual side effects for patients. It is not, it's a it's essentially we take this hot cautery knife and we basically kind of make you, we make a trough uh in the prostate, urethra, in the prostate. So we're not, we're not really removing tissue, we're just kind of incising 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 necks where it's, it's based on their anatomy. Um. So if you ever see this in a note, you'll know kind of, you know, you'll know what a TUIP or mini turf is. Um, transurethral resection of the prostate, AKA TRP. This is the gold standard that we've all known about for, for years. They're called also known as the roto router. It is the gold standard. Uh, it has been the gold standard up until now. Um, this is used to monopolar, bipolar energy hot loop. And we essentially go out and shave out prostate shavings, um, and create a larger channel. Uh, patients stay in the hospital one night, uh, sometimes, and they 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're 30 years old again, you know, the next, next day. So the nice thing about this procedure is, is the kind of immediate effects. You're not having to wait for the effects to, to wear in. Um, the, um, downside with the TURP has been that because of this large amount of energy you're putting into the prostate tissue, it can lead to, uh, irritative symptoms, kind of urgency, frequency that can last for months, uh, after the procedure. And because you're also not removing all the prostate tissue, there is a risk for pro. Prostate adenoma regrowth. And so we always worry about those patients who are like 5, 10 years out from a TURP and they start having obstructive symptoms again. It's either a stricture, uh, more rare strictures usually form within the first year, but it could also be just prostate tissue regrowth, so they need a repeat evaluation, repeat cystoscopy with us. Um, so that gets in, like I said, the problems with the turf. Um, the, as we talked about before, the, the TURP procedure leaves a fair amount of prostate tissue behind afterwards. We talked about the energy source, uh, prostate tissue behind here. We talked about the high amount of Energy that's put on the area so it caused a lot of irritative symptoms afterwards, um, that can make, that can affect quality of life in the post-op recovery. Uh, and then this was a study from 2015 that actually looked at kind of the whole breakdown of all the different procedures for, uh, for prostates. And you can see here that about 6% of prostate tissues were just allocated towards, uh, redoing T TURP procedures because of regrowth. So TURP. Um, you know, as great as TURP is, we still see, right, 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 along comes, um, this, the more, this more contemporary treatment that we're, is, is one of the latest and greatest that we do. Uh, it's called a HOLEP or homing laser nucleation of the prostate. We're using, once again it's going in cystoscopically and using a laser to basically core out the prostate in its natural plane. So just like we saw I showed you before, uh, with the open technique where we would kind of use our finger to core out the, the, the fruit from the peel of the, of the, of the, uh, prostate, um. That's what essentially what we're doing with this and so because of the laser, because it's less energy, uh, and because of the laser we're able to get really good hemostasis. Uh, the patients have great long-term outcomes because we're basically resecting, you know, the 9080, 90% of their prostate tissue as opposed to a TURP which maybe get like 50% of prostate tissue. Um, and, um, the other nice thing is that because of these, uh, improvements, uh, the patients, we were able to do these, uh, overnight hospital stay or even sometimes outpatient same day. Uh, 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. Um, the main concern we have is, uh, transient incontinence after, um, the thought is that Um, because we've done such a good job resecting here is that patients now have to rely on their external sphincter, uh, voluntary sphincter for continence. So we tell patients it's more of a transient stress incontinence for the, usually for the first couple of weeks. Rarely is it's extending more. More than a couple of months, uh, where the men are gonna have to use pads. We, we always joke with patients that they'll be able to, uh, they'll be, their, their wives will be able to, to, uh, relate with them because of, uh, you know, stress incontinence 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, uh, recommend, um, Kegel exercises or pelvic floor exercises and they're dry after some, um, within that time frame. Um, so just to give you sort of a picture of what this looks like, you can imagine that TURP was essentially us going in and kind of taking these individual shavings little by little to get the prostate tissue out. The whole up is really following those natural planes, like I said, of the prostate and to really get a, a complete resection. Of the prostate tissue. And so because of this, the, uh, the re-intervention rates, the risk of prostate regrowth is, you know, essentially minimal. And if you want, we, I tell any patient if they want the one and done procedure, never gonna 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 3 lobes to the prostate and sometimes we can actually get away with doing a partial hold-up. So we'll actually, for men who want to maybe less risk of incontinence or less risk of um sexual retrograde ejaculation side effects, uh, we can do just 1 or 1 out of 3 lobes at a time. Sometimes if they just have one big median lobe, we'll just treat the median lobe actually and leave the lateral 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 use all through a laser instead of this kind of shaving into, uh, tissue 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 cystoscopy. Uh, this is the prostate fossa right here and then you can see the bladder in the background. Uh, this is the, once again, the cystoscope coming in looking back on the bladder outlet and you can see this nice wide-open channel, uh, that is never gonna cause obstruction again for this patient. Um, so, and, uh, interestingly, even, uh, patients who have, uh, has been shown to even be benefit, uh, to work for patients who have acontractile bladder. So even patients who come in with, um, you know, uh, neurogenic bladders, not your spinal cord patients, but, uh, patients who have, uh, who don't have any more bladder squeezing capability because of bladder pathology can still get benefit because we've, because we've reduced that resistance so much from the prostate, um. So, um, this is what I think relevant just things to think about that you may hear, uh, and you, if you see these patients after they've had their surgeries. Retrograde ejaculation like we talked about which is temporary with uh 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 resection or a good whole-up or a good TURP procedure, you will have, um, retrograde ejaculation. Uh, that is a sign of how much tissue we've removed. Uh, transient stress incontinence, we talked about that. Um, usually is transient responds more stress-related, so coughing, sneezing, not like a florid incontinence and usually responds to Kegels or pelvic uh Kegels or pelvic floor exercises. Um, hematuria usually resolves within the 10 to 14 days. It's not uncommon that we'll see patients they have hematuria, it gets better in the 1st 4 to 5 days or hematuria goes away. And then about 10 days after the surgery, the patient calls us again and talks about how they're having hematuria again. Most of the time what's happening is that the scab that is formed, the kind of the healing scab that's formed over their urothelium is uh finally sloughed 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 hematuria that requires any intervention, but it's something that I always tell some patients about. Um, not that, you really have to allow the full at least 14 days if you're not on blood thinners, um, for the full result for, to wait for your hematuria to fully resolve. Um, irritative symptoms, so those we talked about more common with high energy procedures. So TURP, uh, resume the steam treatment or even the Uolift because of these are all, these are either you're putting a foreign body there, you're, you're putting a bunch of energy into the prostate tissue and try, um, and waiting for it to atrophy. These are all, um, Sources for irritated symptoms that will eventually go away can be managed with uh anticholinergic or irritative medications or uh like I said, Myrberon or oxy oxybutynin medications like that. Uh, less common risks are UTIs. So, you know, always good to check a urinalysis with culture. This use these response to empiric antibiotics, uh, usually occur within the first week after the interventions. Um, urethral strictures are, are always something we are rare, probably 12% or less, but we always want to keep an eye out. So the, the classic is that about a couple of weeks or a couple of months after the procedure, the patient knows that their symptoms are starting to Their obstructive symptoms are starting to come back, uh, which usually shouldn't happen with a good, uh, resection or de-obstruction procedure. The, the effect should last, you know, at least, uh, couple, you know, half a year if not longer. Erectile dysfunction is very rare, is, uh, usually more associated with the high energy procedures like the TURP, but even so, like, like I said, the risks with them are pretty low, like in the less than 5% range. Um, interestingly, we find about, when we do these procedures, about 1 in 10 men will, will find incidental prostate cancer. So I always counsel these patients that even with their prior PSA screenings and everything like that, there is always this, there's this small possibility we may find prostate cancer at the time. Majority of the time, uh, uh, uh, it is low grade and it can just be observed. Um, having, having any sort of de-obstruction procedure does not eliminate their Um, opportunity to have radiation treatment or have surgery down the road for, you know, for cancer removal. Um, so, um, it's usually a non-event and something we just keep an eye out for on the biopsy when we, uh, 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, uh, do all these procedures including the whole up procedure. Uh, I, I'm a strong believer in it as you can tell, um, but I think for the reasons that I mentioned, uh, but I, as because we want to offer all the treatments, uh, we try to be, um, offered, they all have their pros and cons and I offer it 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, uh, interventional radiology guided and they go in with catheters and balloons through a groin puncture. They have to cannulate the prostatic artery which is tiny and then put some coils or some, uh, something to, um, um, basically cause ischemia to the prostate gland. Um, it's very operator-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. Um, but we do refer to IR if the patients ask. Um, so to summarize, there's way too many ways to treat an enlarged prostate, um, but I hope that this, this helps summarize and frames what we can offer patients, uh, and, um, 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 irritative symptoms, and to rule out infection and malignancy. So infection by checking urinalysis, malignancy with a urinalysis and a plus or minus PSA 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 urologists 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, uh, on Redwood City, uh, that we just opened last month. This is where I'm based full-time. Um, access-wise, it's great. We actually have a lot of patients who come down from the Bay Area because they don't want to deal with driving in the city or paying for $30 for parking. So, we're located right here in the strip mall, free parking, uh, there's a bunch of other commercial, grocery store, coffee shop, banking, get all your stuff done. Just off the 101 freeway uh in San Mateo, uh, by San Carlos Airport. Um, I have availability same week and probably can see people within 48 hours, uh, and, um, we're doing a lot of video visits, so especially for the patients up in the North Bay to save them the drive. We can do a lot of that and I also am here to serve as sort of a, a way to get patients in the door quicker to eventually see our UCSF urology specialists if they need it. Um, but otherwise I'll be specializing in kind of general male and female urology here. Um, so this is just a not, not exhaustive list of kind of all the conditions we're treating, but we will have a significant procedure capability at our clinic, uh, cystoscopy, vasectomies, um, Uh, transrectal ultrasound, um, uh, and, um, fully catheterizations, things like that. Um, and so with that, there's my info and, uh, uh, and if for any referrals, here's the information. Um, so I thank you for everyone for taking the time to listen and attend tonight.
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.
