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BackTable / Urology / Podcast / Transcript #14
Podcast Transcript: Patient Selection for GreenLight & Other BPH Treatments
with Dr. Francisco Gelpi and Dr. Jose Silva
Urologist Dr. Francisco Gelpi discusses surgical treatments for BPH with a special focus on the minimally-invasive GreenLight Laser prostatectomy. Listen to hear more about Dr. Gelpi’s transition from an oncology-focused practice to a BPH-focused practice, initial BPH patient workup , using prostate anatomy to choose a BPH surgical treatment, GreenLight Laser postoperative care, and the importance of BPH patient involvement and expectations. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Transitioning from a Urologic Oncologist to a GreenLight/BPH Specialist
(2) Initial Workup for Voiding Issues
(3) Deciding on a BPH Surgical Intervention
(4) Post-Operative Medication Regimen for BPH Surgeries
(5) Tips for Rezum Procedure
(6) Tips for GreenLight Prostatectomy
(7) Tips for Simple Prostatectomies
(8) Strategies for Post-Operative Ejaculation Preservation
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[Dr. Jose Silva]
Hello everyone, and welcome back to BackTable urology podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Jose Silva, your host this week. I am happy to introduce our guest Dr. Francisco Gelpi, better known as Paco. Paco and I went way back--we both went to the same high school. I actually graduated two years before him. He also spent a year in college in Boston and he went back to Puerto Rico. He did med school in Puerto Rico at the same time that I did and then residency. So it's a funny story, actually Paco got accepted to urology residency in Puerto Rico. And I was in general surgery. So when Paco got transferred to Thomas Jefferson, basically. Paco can you chip in on this and give your version of the story?
[Dr. Francisco Gelpi]
You forgot two things before that. First of all, you forgot that I used to play tennis with your twin sisters.
[Dr. Jose Silva]
True, true. I remember.
[Dr. Francisco Gelpi]
And this one you probably never knew, but I was actually a patient of your mom’s. So yeah, the funny story is that when I was a resident back in Puerto Rico, I had been looking for the potential to transfer to a different place and have something a bit of a different experience. And the opportunity came along in Philadelphia at Jefferson. When that happened, my position was actually then given to Oche. It actually ended up working perfectly. But the backstory is that you had suggested looking at Jefferson, and I called him after a night that I was on call and the lady that responded and told me that they happened to have an opening that came available yesterday.
And I told her that you had mentioned about it and whatnot. So I go through the process, get there, and then I go to you and I tell you, “Hey, dude, I got transferred to Jefferson. And you're like, yeah, that's good. But I thought it was Penn State that I had told you about.” So by total accident, I ended up calling a different program in Pennsylvania and happened to transfer there and that's where I did my residency.
[Dr. Jose Silva]
Exactly. So you spent five years or six years there?
[Dr. Francisco Gelpi]
So in total it was a six year program, just like the one that we had in Puerto Rico, but I transferred as a PGY 3.
[Dr. Jose Silva]
Okay. So then afterwards you did your oncology fellowship over at the Mass General Hospital at Harvard?
[Dr. Francisco Gelpi]
Yes. So I did a uro-oncology fellowship. It is a combined program with Mass General and Brigham and Women’s. It's affiliated with Dana Farber for two years of cancer research. I also happened to get a master's in public health from Harvard as well.
[Dr. Jose Silva]
That was actually your first couple of months when you just started doing that, right?
[Dr. Francisco Gelpi]
Yeah. So when you go there, the first summer is supposed to be this program in clinical effectiveness and it accounted for about a third of the masters of public health. So I just figured if I'm here and I can get this done, why not go for the whole thing? So I negotiated with my mentors that if I could turn every class into a publication, which I ended up doing, then they would give me permission to sit for the MPH. And it was crazy, but I got it done in a year.
[Dr. Jose Silva]
And what are you doing with your MPH now? Same as mine?
[Dr. Francisco Gelpi]
Absolutely nothing.
[Dr. Jose Silva]
I did mine prior to going to med school, but yeah.
[Dr. Francisco Gelpi]
No, but remember, at that time I was gung ho about staying in academics. I want to be part of the next generation of teachers and mentors. And then during that time, my daughter, who's 11 now, she was diagnosed with epilepsy when I was just starting my fellowship. So that was sort of the Eureka moment for me, where I said, “As much as I love this, I can not dedicate my life to my job, which was the case at that point.” And I just decided--okay, family first. And I just figured that, and I mean, no disrespect to the people that are in academics. I'm not by any means saying that they cannot do both. It's just that at that time, I needed to be available 24/7 for my family, should something happen.
[Dr. Jose Silva]
And that's what threw you to a more private practice setting. You're now in Houston as a private urology group there.
(1) Transitioning from a Urologic Oncologist to a GreenLight/BPH Specialist
[Dr. Francisco Gelpi]
So I'm in Houston with a private practice group here, we're the largest private practice group in the city. And it was basically that ability to have full liberty as far as how I could use my time. There were no restrictions--it's an eat where you kill model. So it was all entirely on me, and I didn't have to satisfy any requirements. And that's why I gravitated to that. I mean is it the perfect job? It's not. I don't think there's a perfect job out there, but we're happy enough here. We've grown very fond of the city and yeah, we're here for the long haul.
[Dr. Jose Silva]
Good. So yeah, I mean, we talk often and you definitely tell me your experience as a private urologist. I'm in private, but employed. And it has different perks. I have good things, bad things, but like you mentioned, there's no perfect job. You make the most out of it, I guess. So Paco, when you joined the group, were you going to be the oncology guy? That was the idea? How was the process?
[Dr. Francisco Gelpi]
So it was pretty cool in the sense that there was no pressure to do so. I am in the west part of town. We basically have nine offices spread throughout the city. I am not in the med center. I specifically wanted to avoid the med center and the pod that I joined was pretty chill letting me do whatever I wanted and supporting me. And I guess at the beginning, my idea was to try and absorb as much of those oncology cases that no one else wanted to do or things that were a little more complex and challenging. So I kind of was offering to my partners to give those cases a crack. \
I've tried to keep my oncology percentage of the practice at about 30% or so. I do robotic cases every week. I just did a partial today. I have to lined up for next week. So it's not like it's the only thing I do, but I still do a fair number of it. And just two weeks ago I was doing an IVC thrombectomy, a RPLND surgery, and then I do cystectomies with my partner. But at the same time, it's been a process of learning that as much as I love it, the reality is it's not the most cost-effective part of urology. And hence, I decided to supplement it with doing other things that I am very fond of, and that I sort of develop a very deep interest for.
[Dr. Jose Silva]
And now you are a center of excellence for Boston Scientific in the BPH department, right?
[Dr. Francisco Gelpi]
Yeah. So that was a very interesting trajectory because when I got here, I had never done a single GreenLight before, and I happened to train in a place where we did a ridiculous amount of HoLEPs, holmium laser enucleation of the prostate. And what I ended up doing was adapting the techniques that I learned from something that’s not really available right now--because there's been so many issues with utilizing a morcellator. I ended up almost creating a new way of doing GreenLights, and that took off and drove the interest of the reps. And then from that, we jumped to Rezum and then UroLift, and now I do a good number of these cases.
We became a combined center of excellence for Rezum and GreenLight. And I just became a proctor for both procedures as well.
[Dr. Jose Silva]
So Paco, so in terms of the GreenLight, are you the only one within the group that was doing it? No one in the group was doing it?
[Dr. Francisco Gelpi]
So I was fortunate that when I joined the group, there was one of those great minds in the BPH world--his name is Dr. Ricardo Gonzalez. He used to be my partner, and I actually learned quite a bit from him while he was here. I do have a number of other partners that do them, but they don't feel as comfortable in tackling bigger glands. And I just did a 170 gram gland today and I did another one yesterday that was about 50 grams. So I guess at some point, we'll discuss my algorithm, but it's sort of become my go-to, my tweeze knife, sort of procedure for BPH.
(2) Initial Workup for Voiding Issues
[Dr. Jose Silva]
No, I didn't know you were with Dr. Gonzalez. Yeah. I definitely have seen his videos and those glands. So I am going to try to emulate that same technique. So Paco, so when a patient with voiding issues goes to your office, how do you evaluate that patient? Do you do an AUA symptom score? What's your process when a patient walks into your office?
[Dr. Francisco Gelpi]
So that's something that's changed drastically in the last two years. And let me elaborate on that. So prior to that two-year mark, I guess I was doing what I think most of us did: you come in, you get AUA, you probably get a PVR, a flow, you get the symptom score. And then you'd have a conversation with the guy and get them on medication and say, “Hey, I'll see you in a couple of weeks, a couple of months, and then we'll go from there.” About two years ago, I met a practitioner from the Northeast who basically said, “Hey, when a patient comes to see you, you need to offer something different than the primary care physician. And hence, you are the protector of the bladder and your focus should be changing the nature of that conversation into how to protect the lower urinary tracts as much as possible.” That really resonated with me. And I tried to copy his way of doing things.
And now anyone that comes in with symptoms basically gets a symptom score and a conversation, but most of them end up getting some sort of lower urinary tract imaging. I typically do pelvic ultrasounds because most of my patients are Hispanic, so I’ve transferred to ultrasound. I have it set up in a way that we own an ASC, and when they get the cystoscopy done, they immediately move to our imaging center where they get the pelvic ultrasound. Now we have incorporated UroCuff, which I'm not saying that everyone needs to get a UroCuff, but it's also one of those things that we can throw in and evaluate if their urinary tracts are at risk of compromising their upper tracts.
Next, it’s do you want to consider their medications, or do you want to consider an intervention? That's kind of how the conversation goes. But it's more than anything again, focusing on bladder health and bladder function preservation.
[Dr. Jose Silva]
So are you doing your cystoscopies in the OR or the office?
[Dr. Francisco Gelpi]
So that's a very touchy subject with my practice right now because we had the ability to do them in the office. I am hopeful that we can go back to that, but in a way to try and incentivize people from using our surgery center. All of that equipment was moved away from the offices and hence you kind of have to centralize everything. So I had to kind of get creative about how to make as much as I could in the same patient's visit so that they would not get a little frustrated. Again, it's a very hot topic right now with my practice. I am trying to recover a couple of those things being done in the office. I just purchased the Pro-Nox machine with the intention of bringing my UroLifts and Rezums to the office. So yeah, chances are by the time this thing airs, it might be a different story, but right now I'm still doing them at that facility.
[Dr. Francisco Gelpi]
So Pro-Nox is again at the suggestion of another friend from another practice is basically a patient administered nitrous oxide device. The beauty of it is that it's a 50/50 mixture between oxygen and nitrous oxide. You basically don't require any licenses, certifications, nothing. It's all the responsibility of the patient. Obviously there is some monitoring involved, but the reality is it's a very simple way of having a patient very comfortable at the time of doing any of these office-based procedures--vasectomies, UroLifts, trusses, prostate biopsies--any of these things are perfect for this mode of anesthesia. And yeah, and we've been running with it for the last couple of weeks and so far, I absolutely love it.
[Dr. Jose Silva]
I found myself having more issues. I do cystoscopies in the office, but every time I get more pushback from the patients. Even though I use the UroJet and numbing agents, there are people trying to push back. So hopefully we can get Pro-Nox in the office. And that way, maybe I can do more cystoscopies instead of just like you mentioned doing the Flomax and coming back in four weeks to see how they’re doing.
[Dr. Francisco Gelpi]
But I will tell you that the eureka moment for me was just having the audacity to change a little of the way that the conversation takes place. I have a lot of pictures in my office. I show them what a normal bladder looks like. This is what a very compensated bladder looks like. You don't want to be there. So you kind of get patients engaged. So as far as the Pro-Nox for the cystoscopies, I'm not saying it's an absolute must, but yeah, every now and then you're going to have that guy who wants to be comfortable. I actually encouraged patients to be awake because I want to show them what their anatomy looks like.
But it's all a matter of the conversation. And just to give you numbers, all across the board in my practice, the BPH patient that walks in turned into a procedure in probably about 5% of cases in the past. And that's been looked at. I've managed to get that now closer to 50% and it keeps going up.
[Dr. Jose Silva]
50?
[Dr. Francisco Gelpi]
50. So it's just a matter of having the conversation. I never ever push them into getting a surgery. I don't want to have them leave the office thinking, “I absolutely need to get something done”. Again, it's a very interesting conversation that I've learned how to have now, and it's completely different to the one that I used to have when I finished training.
(3) Deciding on a BPH Surgical Intervention
[Dr. Jose Silva]
So Paco, definitely that's very important. The bladder health, we never talk about that. And for me, when I started doing UroLift, I think that's what they started pushing. The patient needs to be aware of that bladder health because it can continue to worsen. So Paco, after you do the UroCuff, how do you decide whether to go with UroLift, GreenLight, or Rezum?
[Dr. Francisco Gelpi]
So again, it's a very involved conversation with the guy, right? I need to be very, very emphatic about the importance of setting expectations. So when you have these conversations, what is the priority for the patient? Is it just bladder health? Is it getting rid of the nasty side effects of the medication? Do they want to preserve their ability to ejaculate? Is it not that big of a deal for them? So there's a number of different layers to that conversation. In order to simplify it as much as possible, I ask myself during the cystoscopy: okay, does this guy have any sort of median lobe, or does he only have bilobar obstruction? Then, what is the size of this prostate?
I tackle, for instance, Rezum prostates that I know that are larger than what's supposed to be done, but I have the conversation with the patient. You explain to them that this might be pushing the envelope, but some are willing to give it a shot. Yeah, we might give it a couple more injections than we otherwise would have. But again, in order to simplify it, I normally think if it's bilobar and it's smaller than 80 grams, I typically prefer UroLift. I like the Urolift a lot because it's a very easy way of getting a patient to stop medications, leave the SC and be happy, not need a catheter, and basically start experiencing improvement of symptoms almost immediately.
If there is a median lobe, then it all depends on how protuberant that is. I've started doing some of these UroLifts with the median lobe, but my preferred option for the younger guy with a prostate smaller than 80 gram prostate is probably going to be Rezum. Now Rezum is interesting because I think it's a great tool, but you have to be very careful how you sell that procedure to the patient. You have to be clear about explaining that things are going to get worse before they get better. It’s likely that they will be uncomfortable for a number of weeks. The way I handle that is to let everyone go on anti-inflammatories, stool softeners, and keep a catheter for about a week.
That was one of my mistakes at the beginning. I probably left it for a little shorter than I should have. So but once you start re-visiting and refining those things, you can explain to them and they're fine. And then anything larger than that, in particular, if there's a large protuberant median lobe, it's likely going to be a GreenLight, unless it's someone that is open to the option of robotic simple prostatectomy. I normally reserve for robotic prostatectomies for prostates with very, very large intravesical median lobes. You can just get the procedure done so much quicker than being there for a while with the GreenLight. So that's it in a nutshell, how I kind of think and navigate these things.
(4) Post-Operative Medication Regimen for BPH Surgeries
[Dr. Jose Silva]
So you mentioned the medications you give the patients. Do you usually give the same medications for Rezum, UroLift and GreenLight patients?
[Dr. Francisco Gelpi]
Yeah, I had to simplify it for my scheduler because she used to mess things up big time. So any procedure that I do for the prostate in that regard, it's always the three, it's Pyridium, Colace and Meloxicam.
[Dr. Jose Silva]
From Dr. Gonzalez, that's what he recommends and that's what I use.
[Dr. Francisco Gelpi]
I think it makes a huge difference, particularly the anti-inflammatory part of it. So I've been doing it now for a while. Why Meloxicam and not others? I mean, it's just because it's the one that people typically like here at Houston.
[Dr. Jose Silva]
Are you doing the 50 milligrams once daily or 7.5 milligrams twice daily?
[Dr. Francisco Gelpi]
It depends on the age, but normally the 7.5 milligrams daily if they are older and I'm a little concerned about their renal function. If they're younger then I give them the full 15 milligrams and they do perfectly fine.
[Dr. Jose Silva]
So I started doing this back in Puerto Rico. I started doing 7.5 milligrams twice daily for no specific reason. I mean, it's just the same thing.
[Dr. Francisco Gelpi]
Yeah. It's just to help them with that inflammatory phase that everyone's going to go through.
Dr. Jose Silva:
So when you're doing a UroLift, you usually place two or four clips for implants. If one is misplaced and it goes into the bladder neck, what do you do? Are you using a grasper?
[Dr. Francisco Gelpi]
Yeah, normally a grasper.
[Dr. Jose Silva]
And you try to twist it first to see if you can reposition it?
[Dr. Francisco Gelpi]
Yeah. But I mean, and I think this is probably the number one mistake that we all make when we are learning how to do UroLift, right? We're used to seeing that very wide bladder neck that you normally get with say a TURP or a GreenLight, right? And this thing is not designed to mimic that--it's designed basically to protect the bladder neck. So at the beginning, I was firing them maybe a little too close to the bladder neck. So every now and then I had to go back in and remove then put a new one. I guess I’ve finally figured it out that I need to go a little farther than whatever my mind tells me, but it's okay. And by doing that, I’m kind of protecting myself from myself. And yeah, when I first started doing UroLifts, I was only utilizing them for influence, because that was more cost-effective than the ASC.
So then I had to kind of get a little creative about that. We have a facility that basically runs as an ASC, but it's not a formal surgery center. So then we can bail as if we were in the office. And then that allows me to use more implants and enhance the cost effectiveness of the procedures. So now I feel that I get better results because I don’t have to decide whether to put 4 or six clips in. Money is not that big of a deal, and I just wanted the guy to pee right. And that took me a while to kind of figure out a master. But yeah, I'd say the sweet spot is usually going to be somewhere between four and six--very seldomly would I put in more than six. I feel that, if I had to do that, then I selected the wrong procedure.
[Dr. Jose Silva]
And you're doing a Foley on specific cases with bleeding or something?
[Dr. Francisco Gelpi]
At the beginning, maybe we had a little more of that bleeding. What I typically see is only 1 in 10 guys, if anything, are going to go home with a catheter. But for the most part, they all go home with Foley.
[Dr. Jose Silva]
Good. Yeah, me too. So I started with Foley and then I changed it because I haven't had any retention afterwards. That first night is horrible for the patients, but then afterwards they do a lot better.
[Dr. Francisco Gelpi]
But again, you set up the expectations.
[Dr. Jose Silva]
Exactly.
(5) Tips for Rezum Procedure
[Dr. Jose Silva]
So Paco, for Rezum, you mentioned the intravesical component of that median lobe. Is there a threshold of how big you're going to tackle that median lobe? Is it a matter of size? Do you evaluate that during the cystoscopy?
[Dr. Francisco Gelpi]
So I call Rezum the “leap of faith procedure”, because you do the case and you think, “Holy moly, please work, please work,” because you really don't see anything major that tells you that it’s going to work.
[Dr. Jose Silva]
No, it actually looks worse.
[Dr. Francisco Gelpi]
Yeah, if anything. Again, that's why I've sort of utilized that 80 gram threshold. I think the largest I treated was 130 grams, and the guy's doing perfectly fine. However, normally in order for me to find a happy medium, I ask myself, “Where do you have enough tissue?”
I don't want to overdo it and get overconfident, but it's between 80 and 90 grams. When I do the cystoscopy, obviously I'm looking for how much of that component to that central or median lobe is present. And then I kind of start planning, okay, is this going to be just one needle stick in the central gland? Am I going to do two, one on each side? The way that I sell this procedure to guys, I tell them, “Hey, we are trying to deflate your prostate.”
And I kind of look at it that way. Have you ever had to scope any of these guys?
[Dr. Jose Silva]
I haven't. I haven't. I started recently. So they're doing very well, but I haven't had to scope them again for now.
[Dr. Francisco Gelpi]
Oh no, it's impressive. I had a guy in particular who kept having irritated symptoms, so we did the UroFlow. We then did a UroCuff, no signs of obstruction--but he continued insisting that he was obstructed. And when I put the scope in, the thing was completely deflated. So yeah, that's why I'm saying, it's a leap of faith case. Again, you have to set up expectations very clearly from the get-go. I normally joke with them about that. I tell them, “Hey, you're going to love me, then you're going to hate me, and then you're going to love me again.” So there's a component of handholding and giving them peace of mind, but it works. In the right guy, I think it's a great, great tool.
[Dr. Jose Silva]
And that patient is still complaining of irritation or he's doing good?
[Dr. Francisco Gelpi]
No, he's doing fine. I mean, again, this is a very complex conversation. I get it. It's a very abstract thing for patients to understand. Right. You're basically telling them, hey, you've been an athlete for all your life. And all of a sudden you're going to sit that guy, and he wants to get out there. That's what happens to your bladder. Your bladder kind of gets a little unstable, and you just need to allow for the remodeling phase to take place. And the symptoms stopped, but it took a while for him to finally get it.
[Dr. Jose Silva]
Exactly. And then yeah, some patients do develop that overactivity, even with GreenLight, with the symptoms but like you mentioned. It's just that part of the bladder, and we are adjusting to the openness they're going to have now. So Paco, in terms of treatments, I know the reps always emphasize not over-treating the prostate. The data also suggests that more is not better.
[Dr. Francisco Gelpi]
Yeah, so I will tell you one thing that I learned from UroLift . What I'm going to explain in a second is a little abstract. So bear with me, but the whole premise of UroLift is creating that into your channel, right? So going back to our training, where the main idea is: hey, I have to do that TURP that will resect every last bit of tissue so that it's as open and wide as possible, right? But the reality is you don't need to do that. The diameter of the urethra basically will dictate the flow. So why do we need to make this very large posterior fossa and get it all well resected, if it's going to funnel into whatever the diameter of the urethra is? So I've sort of incorporated some of those ideas into the way that I do my GreenLights, into the way that I do my Rezums. So yes, when I do a GreenLight, do I want it to be complete wide open? Of course, but I really concentrate and focus on making an interior channel that kind of mimics what UroLift would have done.
And going back to your point by being a little bit more selective and specific in that regard, the amount of irritated symptoms that I've seen in the last year or two have plummeted. And just because you want to do good enough that you get them to pee, that they're comfortable, they have a good flow, and you don't want to overdo it. And now you have to deal with that nasty bleeding that could happen or that burning or stinging that they sometimes complain about when you're a little too aggressive. So yeah, the little things that you kind of start changing matter as far as technique. And it's basically helped me drastically.
(6) Tips for GreenLight Prostatectomy
[Dr. Jose Silva]
And when you do the GreenLight, are you doing the channels at five and seven, and then going down to the verumontanum and then resecting the median lobe and then lateral lobes?
[Dr. Francisco Gelpi]
So I do something that you probably haven't seen. It's kind of like using the HoLEP technique where you would create these channels at five and seven. And then I connect those and I enucleate that middle portion with the beak of the scope. And then after I leave that tissue hanging, I blast it with 180 and I mean, again, prostate from today, perfect example. 170 grams, most of it was a median lobe, and the procedure took me 15, 16 minutes because most of what I do is concentrate on that median lobe, enucleate using the scope as if it was my finger. And then by the time you're done there's stuff on the sides, yes, you shave it off, but you don't have to be overly aggressive. Once you've done that, those incisions which mimic the transurethral incisions of the prostate. And then when you take that valve like mechanism of the median lobe, I mean, those guys are going to pee like a champ.
[Dr. Jose Silva]
And you go down to the channels in 150 and then 180 to the middle?
[Dr. Francisco Gelpi]
Actually, no. I do my channels with 80 because I am very, very cognizant of the irritated symptoms they can get when you mess up the bladder neck and anything in the vicinity of the trigone. I would make the channels with 80. I connect them with 80--and that's the part probably that's the hardest to explain in something like this which is not visual. But once you are able to disarticulate that piece of tissue--I mean, this thing, if you're in the right place and the right layer, this thing just peels off, just like when you're doing an open simple prostatectomy, right?
And then I just allow that tissue to sit there and I aim away from the floor of the prostate so that I'm not causing any of that burning, and that tissue in the middle just disappears. It's pretty cool.
[Dr. Jose Silva]
Wow, well, that's very impressive. 15 to 16 minutes for 170 grams.
[Dr. Francisco Gelpi]
I pick the guy up because I know that most of it is a median lobe and that's what I'm going to have to work on hard, right. So if you have a guy that's 170 g and it's all lateral lobes, you're going to be there until tomorrow.
[Dr. Jose Silva]
And yeah, you mentioned for the Rezum that you leave the catheter for a week, but for GreenLight, it’s just overnight?
[Dr. Francisco Gelpi]
Yeah. I think what happened was it had to do with the way that my clinic was set up. So all of my partners typically do it for one day. I'm kind of OCD, so I keep it for two. Do I have any data for that? Not really. It's just the way that it worked for me. Same as most of these guys, I don't know in your office, but I probably see 60% of my patients are Hispanic and they don't like the idea of removing the Foley at home so they come to the office. And I think what happened was that I normally do these cases on Mondays and Wednesdays, and there was an opening for my MA to kind of handle those and that's the way it worked out. But yeah, and to kind of go back and just give you an idea of how long I keep Foleys and so forth--UroLift normally nothing, Rezum, when I started, it was three to five days, and now it’s at least one week.
And then GreenLight is usually two days. If I do a robotic simple prostatectomy, I typically keep it in for about a week. I normally don't do any cystograms because I've never had any leaks. There was a guy that was miserable with it. I did this cystogram at three days and the bladder was perfectly fine, so we pulled it out. However, I feel that a week is more than enough for, not only the bladder to heal, but also for those bleeders at the prostate fossa to kind of expand and not cause any issues moving forward.
[Dr. Jose Silva]
And in terms of the GreenLight, you mentioned the lateral lobes. So how far up do you go? Sometimes I run into trouble when I start going towards the lateral lobe, but if there are very tall lateral lobes, you go in the middle and then the top part falls like a roof or a ceiling.
[Dr. Francisco Gelpi]
So that's where the HoLEP technique is very helpful for me, right? Because when we did HoLEPs, at least the way that I learned it at Jefferson, we would originally do our five and seven incisions for the median lobe. And then you would make a 1:00 and an 11:00 incision on the sides. And then when you follow that, the lateral tissue just falls or plops down. And I use that to my advantage because as I mentioned before, now I'm not super worried about having to remove all that stuff. So I want to lower it and shave it enough so that I create a good channel, but not really trying to get into that meat of the prostate at the five and seven where you know you're probably going to get into some bleeding.
I typically always leave all the tissue in the vicinity of the verumontanum for the end, and I normally lower the energy there. Again, because if you get in the right spot, I mean, it's perfect. But if you mess up some of that deeper tissue, it's going to start bleeding. And yeah, instead of just eyeballing it, just find that edge of the lobe which is usually at 1 and 11, and once you get there, it just plops down.
[Dr. Jose Silva]
Sometimes you're torquing the cystoscope a lot. You don't know how much torque you're going to put in it. You're very, very high on the prostate, an area that maybe visually you're not seeing anything--it's just water flowing. And sometimes it's really hard to say where you're at if you don't know the area. In your case, because maybe you had that exposure to the HoLEP, you know--but you never go that high when doing TURPs, for example.
[Dr. Francisco Gelpi]
Exactly. I just happened to have the benefit of learning HoLEP and figuring out how you want to disarticulate it. And the reason you do so is because it puts you in that plane that minimizes bleeding. But like anything else, there's 100 ways to skin a cat. This is what makes sense to me. I've managed to turn it into a way that I can do it with a number of these guys and feel comfortable that the guys are going to go home, and I'm minimizing risk, and so forth. And yeah, I mean, am I always kind of trying to learn and improve the technique? Absolutely. I mean, you keep learning little tricks here and there.
(7) Tips for Simple Prostatectomies
[Dr. Jose Silva]
And Paco, you mentioned the simple prostatectomy. You also mentioned big glands or big intravesical components. So for those patients, the size wouldn't matter, it is actually how the prostate looks intravesically or also big glands. For more than 200 or 250 grams will you do a simple prostatectomy?
[Dr. Francisco Gelpi]
No, I've actually done simples on guys that have smaller prostates than that. I mean, I think the smallest that I've probably taken to a simple was probably in the order of 120 or 130 grams, but it was all intravesical protrusion. So again, I sat down with a guy and I told him I can be there with this laser and take care of this, or I can do this other approach and make sure that I'm going to get it all from the inside. And it's a matter of them really deciding what resonates the most with them. But yeah, when you have those very large intravesical protrusions, man, it's awesome because you really remove a substantial amount of tissue. The other guy that I would say that makes sense is when you have--and I just had this case a couple of months ago--a guy with a history of elevated PSA and some high-grade PIN.
He was very nervous about his PSA. So I told him that we were going to not only going to address his lower urinary tract symptoms, but also handle some of that prostate tissue. And interestingly, his PSA kind of normalized for his age. And it was because of the sheer amount of tissue that we managed to remove so.
[Dr. Jose Silva]
And in that patient would you do a biopsy first?
[Dr. Francisco Gelpi]
Yeah. So he had an MRI and was referred by one of my partners after I started doing these things. That guy from today, as a matter of fact, it's a patient of one of my partners. By the time that they come and see me, they usually have an MRI, which I kind of use as a way of comparing to--okay, what do my measurements tell me? Is it compatible with what the MRI is saying? Am I seeing something that is very much protruding into the bladder? Yeah, it's one of those things that you can never go back and say, hey, there were two cases that were identical. There's always little nuances about one or the other. And again, what I like about the way that I do it right now is the fact that, yes, we're a center of excellence for Rezum and GreenLight, hopefully soon for UroLift, but I put them in a room where they see all these posters.
So I tell them, “Hey, I'm not married to any of these things. I just want to figure out which is the one that makes the most sense to you.” And when you kind of put it that way, I feel that they kind of trust you even more because I don't want to be the guy that goes to bed with Boston Scientific just because I am their proctor. And it's a pretty cool process that I'm sure you also have to go through because we are not trained to think this way when we are in residency.
[Dr. Jose Silva]
Exactly.
[Dr. Francisco Gelpi]
So yeah, it's been an interesting path.
[Dr. Jose Silva]
Good. And it’s definitely better for the patients. I mean, they're asking for more simple procedures, more bladder next pairing, or at least less sexual side effects. They want that. Some of them don't want to take medications. They're looking for something more permanent in that sense or just one thing and done like you mentioned. I mean, you start doing procedures in the office and I think that's the way urology is heading at least in this BPH scenario--doing more stuff in the office, more cost efficient, less co-pay for the patient as well. And yeah, I guess that's where we're heading.
(8) Strategies for Post-Operative Ejaculation Preservation
[Dr. Francisco Gelpi]
Now that you mention the whole sexual side effects, that was a big part of me getting involved in things that I had never done. Again, when you and I trained, there was no HoLEP or Rezum.
[Dr. Jose Silva]
GreenLight had just started.
[Dr. Francisco Gelpi]
It had just started but the energy was not that good. And again, I trained with literally zero GreenLights. But one thing I was going to say is that I had a very uncomfortable situation with a patient a couple years ago. This guy was young, maybe 55. He comes in with a full-blown urinary retention. So I scoped him and found a massive median lobe. I don't recall now the size of his prostate, but it was closer to 100 or 120 grams. And we talked about the options. I did a GreenLight. The guy comes back, and he's peeing like a champ. And then he comes for his post-op, I think, three months later and basically accuses me of stealing his manhood. So I sit down with him and I'm like, what are you talking about? He was like, yeah, I'm not ejaculating. And I'm like, are you not experiencing the pleasure associated with it? And he tells me that he’s not seeing the white stuff.
And I sat down with him and I told him that we had talked about it. He said I mentioned it, but he didn't know it was going to be like that. And it got heated and he almost punched me--it turned into something very aggressive, right? I had to fire the guy from the practice and whatnot, but it was sort of an experience that I had to learn from. Now when guys come in, sometimes they ask me why I’m spending so much time talking to them about these sexual side effects. And it's because it's a reality. I mean, these things can happen. And I have guys who I tell, “If ejaculation is the most important thing for you, then we're definitely not going to take the most aggressive approach.” And again, with a heavy Hispanic population, that’s definitely part of their manhood.
It sort of seems almost like something to laugh about, but it's a very important part of the way that I conduct my business. And that's how I looked into these other alternatives at the beginning.
[Dr. Jose Silva]
And that's exactly right. I had a patient in the same scenario. He had a Foley catheter, and I did a GreenLight. At that time, I wasn't doing a Rezum or a UroLift, but he's been great. But yeah, he came back because he was worried about ejaculating. I had to tell him that it wasn’t going to come back. He started crying, and I said, “Are you trying to have kids?” But yeah, we sometimes think about just the obstruction and really don't think about other effects. Now with all these new tools, ejaculation preservation is possible, and for younger patients, it's great. I mean, you don't even have to worry about that as long as they fit.
[Dr. Francisco Gelpi]
Exactly.
[Dr. Jose Silva]
Exactly, exactly. So Paco, any take home messages? Anything you want to add to this?
[Dr. Francisco Gelpi]
No, what I would say is I mean, as far as BPH goes, this is not rocket science. Again, I kind of gravitated to it because I had a particular interest in the laser technologies that were out there. And I felt that it was a way of really helping these guys. And yeah, I mean, in the span of just a couple of months, we managed to achieve a center of excellence title and proctorship. And it's a really integral part of urology. And if you can find that happy medium where you're doing something that's really helping someone and it's also a cost-effective tool, I mean, that's the best of both worlds, right? It's funny, I was talking to one of my partners. He's a little older and he's still doing GreenLights. He doesn't do anything else. And it's sometimes frustrating to tell him, “Hey, just venture and try one of these other things in someone else.”
Just don't use a cookie cutter approach because there's more than one way of skinning a cat. So the only takeaway in that regard is just to feel comfortable being "a little adventurous" about trying new techniques. They might surprise you in the way they did for me.
[Dr. Jose Silva]
True. That's exactly right. So Paco, thanks for being on BackTable Urology. Definitely the best of luck. I mean, you're doing great. You're moving forward and creating new things over there. Congratulations on the center of excellence. You mentioned that UroLift is coming. So again, congratulations, and we'll keep in touch.
Podcast Contributors
Dr. Francisco Gelpi
Dr. Francisco Gelpi is a private practice Urologist in Houston, Texas.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 25). Ep. 14 – Patient Selection for GreenLight & Other BPH Treatments [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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