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BackTable / Urology / Podcast / Transcript #148
Podcast Transcript: Defending the Detrusor: A Clinician’s Perspective
with Dr. Wayne Kuang
In this episode, Dr. Wayne Kuang (MD for Men LLC in Albuquerque, NM) discusses his initiative to redefine the benign prostatic hyperplasia (BPH) care pathway for patients, doctors, and the healthcare industry. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Critical Role of Surgery in Overcoming BPH
(2) Reclaiming Bladder Health: A Roadmap for BPH Management
(3) The Five Stages of Bladder Health
(4) Tools for Patient-Centered BPH Care
(5) Algorithms for Surgical Decision-Making in BPH Treatment
(6) The Ripple Effect of Education & Advocacy
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[Dr. Jose Silva]:
Hello, everyone. 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 backtable.com. Jose Silva is your host this week, and happy to introduce our guest, Dr. Wayne Kuang. He's a practicing urologist out of Albuquerque, New Mexico. Dr. Kuang is a fellow engineer, MIT graduate. We both did biology at MIT. Then he went to med school at Stanford University.
Furthermore, urology residency at Cleveland Clinic. Then you did a fellowship of Male Fertility and Andrology also at Cleveland Clinic. He specializes in vasectomy, vas reversal, testosterone, ED, Peyronie's. Today we're going to talk about BPH. In the past couple of years, Dr. Kuang is the creator of Man Vs Prostate crusade. He's the defender of the detrusor. Today we're going to talk about more of this. Right Kuang?
[Dr. Wayne Kuang]:
Yes, right. Let's talk prostate, let's talk bladder health, talk defending the detrusor. That's what we're here about.
[Dr. Jose Silva]:
Dr. Kuang Wayne, welcome to BackTable. I'm very excited. Definitely I want to dig into what started this. How did your Men vs Prostate crusade, the Defender of the Detrusor started? Can you talk about what happened?
[Dr. Wayne Kuang]:
It takes me back a little bit, which is I started practice in 2006. I think one clear memory that I had that resonated with me that, wow, BPH is serious stuff. That is, I was fresh out of fellowship. I was hot to trot. I was robotically trained. You felt like you could do everything. Seventy-year-old guy, a cowboy off of a ranch in Southwest New Mexico near the Gila Mountains. His family had brought him in and you could tell he was one of those weathered cowboys, thick in leather pants, grizzly, man of few words, never smiled, but he was miserable. On the IPSS, his score was in the thirties, never sleeping, just absolutely miserable and having suprapubic pressure and pain, urgency, frequency, not a happy man.
He had fallen victim to the polypharmacy epidemic, multiple urologists, multiple medications, higher doses, and no one had bothered to do any form of data collection on his prostate, on his bladder health. Doing a prostate ultrasound, his prostate was actually 200 grams. No one had ever looked at that and figured out, "Hey, he's got a problem." They just kept pushing the pills on him. When faced with the choices of either at that time, 2006, an open simple prostatectomy, or living a miserable life, he chose the one preferred path that he could control. He took a gun and he shot himself and killed himself.
[Dr. Jose Silva]:
Holy shit.
[Dr. Wayne Kuang]:
That was memorable, right? For me, I was like, "Wow." You come out of fellowship and you have these rosy tinted sunglasses that you wear thinking, "Hey, we're highly trained and we're going to go conquer the world." You get out into the real world and that it's really affecting people in real ways, adversely affecting them and even ending lives. It was really enlightening for me.
[Dr. Jose Silva]:
What I see, a lot of people, just like you mentioned, they go to the PCP, the PSA is low. They say, "Hey, you're good." Do you see that patient that just because the PSA is low, they think that all the symptoms that they have is normal?
[Dr. Wayne Kuang]:
Absolutely. We, as men, especially dealing with BPH, what I've learned, and we might get into this when we deal with men's health, men's wellness, is that men, we wear this armor of masculinity. Something that I talked about last year on LinkedIn is that men suffer from I'm fine syndrome. I just had a guy today actually come in. He said, "Yes, I totally get it," because it's part of my talk track. He's like, "Yes, if you don't diagnose it, then I don't have it." He's totally right. What happens is that we need a better way, and that's how we'll talk later, the five stages of bladder health. We need a way to help pierce the armor of masculinity, have men lower their defenses and recognize that, yes, there's a problem. Then we need to come in with solutions when warranted.
[Dr. Jose Silva]:
Wayne, so your journeys in terms of BPH, Defender of Detrusor has been more than 15 years. Even though in the media, this crusade is something recent, but definitely you as a urologist, it's been a long, long time because you did a fellowship. In terms of birth, fertility, so that patient drove you more to, hey, there's a real problem in terms of BPH. We need to be more active and treat these patients.
(1) The Critical Role of Surgery in Overcoming BPH
[Dr. Wayne Kuang]:
As you know or folks may or may not know, I was on faculty part-time at the University of New Mexico doing male fertility. I had a combined position with a large urology group of practice in the community which I was with for eight years. Then about 2010, I started the Southwest Fertility Center for Men where I could really focus on male fertility, vasectomy reversals. Then in 2014, I opened up a solo practice called MD for Men. It was really an experiment or adventure into understanding how do we create a place that is the go-to place for men's wellness?
I chose it specifically not the number one place, but the go-to place, a place where men will tell another man, "Hey, that's the place you need to go to." We're building community. With that, it was the mission that how do we empower men with the guest experience to evolve fearlessly into the best versions of themselves? Part of that, so vasectomies, testosterone, Peyronie's, erectile dysfunction, BPH. They're all really part of men answering a simple thing, which is, what am I scared of? We have to help men face, embrace, and move through their fear so that they can become the best version 2.0, the best fathers, the best sons, the best colleagues, the best bosses.
That was how we started out. I wanted every pathway within the practice to be simple, safe, effective, efficient, and personalized. When I came to BPH Care Pathway, I, over the first 10 years, there was a cognitive dissonance. There was something that wasn't quite right. Jose, you and I trained for years to be solution-finding surgeons. Yet I found myself being a pill-pushing physician. Instead of helping men be the best version of themselves in the operating room for BPH, I was mostly taking care of them in the office. I'm guilty of doing the prescriptions and the refills.
Where else was I taking care of them? In the emergency room. When they came in with stage four, late-stage BPH retention, coaching for other physicians and other groups, the number one thing when I asked is, "Hey, when was the last time you were called from the emergency room for a guy in retention?" For you, Jose, what's the largest volume you've been called about?
[Dr. Jose Silva]:
5,000.
[Dr. Wayne Kuang]:
Exactly. Three, four, five leaders. Then if I asked a secondary question, what percent of those guys are on BPH medication?
[Dr. Jose Silva]:
Probably all of the.
[Dr. Wayne Kuang]:
80%? 90%?
[Dr. Jose Silva]:
At least on Flomax, yes.
[Dr. Wayne Kuang]:
Exactly. Treats as cognitive dissonance. What am I doing wrong? Here we have all these guys showing up, and I am following the guidelines. There's a disconnect. There's a cognitive dissonance. There's something wrong with the system. I was part of that problem. I recognized that I was just trying to be a great urologist. How was I doing? I was towing the party line. I was following the AUA guidelines. It was not happening. The healing and the curing wasn't happening in the operating room. Like I said, it was in the office with prescriptions and in the emergency room with Foley catheters with guys with late-stage BPH.
I had become something that I wasn't comfortable with, which was a pill-pushing physician instead of a solution-finding surgeon. What I realized is that, and this is over a whole decade, is I was straying too far from our Hippocratic Oath. I think I became so fearful that I was going to harm someone by doing something that I should not have done, like a surgery prematurely, potentially, that I forgot that you can equally harm someone by not doing something that you should have done, like intervening soon enough within the window of curability to save a bladder, to prevent that late-stage BPH.
Really understanding that and recognizing that, in my world, if I wanted to create a pathway that's simple, safe, personalized, effective, and efficient-- effective, right? It's doing the right thing. I recognize that just managing symptoms with the AUA guidelines, we could elevate that. We could do better. For us, it was prioritizing the preservation of bladder health. That is a higher calling that we all can share and believe in. Then to be efficient, I needed to recognize that it's not just in the treatment and the post-treatment phase of the care pathway, but actually in the pre-treatment phase, what are we doing before we treat to optimize how we make that decision with our patients about the right timing to intervene for a mechanical problem that deserves a mechanical solution.
(2) Reclaiming Bladder Health: A Roadmap for BPH Management
[Dr. Jose Silva]:
Wayne, in terms of the workup of the patient, prior and after you're switching your mindset in terms of how you're going to approach or tackle this problem, do you make any changes or what goes through when a patient comes to the office for urinary symptoms? What do you do? What is the talk? Just walk us through with that patient.
[Dr. Wayne Kuang]:
When we talk about the care pathway, it's going to be individualized, to your practice, your staffing, your operational systems, the hospital you work out, the healthcare system you work within. In effect, for myself right now, I have a two visit pathway, and I think it really starts with using the IPSS for what I feel it truly should be. Right now, I feel like it's terribly mislabeled. It's called the International Prostate Symptom Score. It really should be International Prostate and Bladder Symptom Score, but obviously, that would be too much of a mouthful. Actually, I've playfully been advocating we should change it to the International Peeing Symptom Score.
At least we can keep the IPSS part, because playfully in many ways, at least in my opinion, and now with a recent journal article came out this year the Canadian Urology, in some ways, I don't think it accurately predicts the degree of BPO or benign prosthetic obstruction or how severe their situation is. Playfully, it could be considered the imaginative prostate subjectivity score. We all have had guys where you're like, "Is that really your IPSS now that I've seen your prostate and your bladder condition or the speculations? How can your IPSS only be a seven?"
It does have a lot of value. When those guys come in, number one is I have them fill it out by hand. I want their memory of what it's been like to live with their symptoms right in front of them. Then they sign their name. They're accountable for it. They can look at it and go, "Wow, that's me." Then I take it and I say, "Wow, that's you. Mr. Smith, I just want you to know, I'm so glad you came in today because this is a problem. We worry about you guys when that score is eight and above. Not just about the prostate, as it says right here, but actually a little known secret, Mr. Smith, is that it's really about your bladder health. That's why we have to talk today because--"
That's when I segued to the next point, which is critical. We have to provide a sense of urgency and gravity to the situation. I let them know, "Hey, there's only two main organs that you can't transplant. Your brain and your bladder. Your bladder is that amazingly complex that you cannot transplant that. We need to take care of it. It is that precious. That's why, Mr. Smith, we've got to figure out what's going on here."
With that IPSS, what I do is I roll right into the five stages of the bladder health. If you want it, we can go into that now, talk about the five stages of bladder health. What that really does is that-- When I've done a lot of coaching for other physicians, other groups, the number one question I get is, "Hey, doc, how do I get men to do those procedures? How do I get them to choose a MIST or an IST or a MOST or a LIST? The number one thing is we are not here to get them to do anything. We're here to guide them. We need to be their Gandalf to their Frodo. We need to be their Obi-Wan Kenobi or Yoda to their Luke.
How do we do that? Like in every great story, we provide a map, and we provide advice along the way. That map, that virtual map is the five stages of bladder health. We're trying to highlight what is at stake, which is bladder health, if the choice is made not to take definitive action about your prostate care to preserve your bladder function. That's what the five stages of bladder health, I roll into that. It's critical. We talk about the five stages of bladder health. Because then we end with like, "Okay, what do we need to do?" Because together, we don't want you to be a victim of late stage BPH. We need data. What does that data look like?
As you may or may not have seen my talk about how we might want to think about remodeling or reengineering the guidelines, is that when we get to that point, there's three main pieces of data that we need. Prostate size, prostate shape, but most importantly, detrusor function. We're big advocates. All Defenders of the Detrusor are big advocates that all patients should get good bladder health counseling, talking about what's at risk, which is bladder health, that we want to prevent late stage BPH.
Then get a good bladder health baseline, assessing detrusor function so we can risk stratify what bladders are at risk. At that point, I'm hoping that with the guidance, the guardrails, the safeguards from the academic thought leaders, that they can say, "Hey, so once we have risk stratified based on detrusor function, how do we now select the best deobstructing technology based on prostate size and prostate shape?"
[Dr. Jose Silva]:
In terms of bladder health or the detrusor function, what are you doing? You work off your dynamics. How are you evaluating for that?
[Dr. Wayne Kuang]:
Once we've gone through the talk track on that very first visit, I'm getting prostate size with a transrectal ultrasound on that very first visit, because already I have a good sense of where they're going, a sense of intravesical prostatic protrusion, size, and I'm already beginning to shape some form of path that I can guide them down. Then they come back for a second visit, and obviously, assuming UA is normal, PVR is acceptable as well as the PSA. Then on the second visit, I'm doing a cystoscopy. I'm filling them up at the same time and then doing a UroCuff.
That's what works for me in my office. I think globally, I think we need to get back to the fact that the cystoscope is the sword of the Defenders of the Detrusor, because we can find that globally, and we need to get back to trusting the truth of trabeculations. We've forgotten it. It's right there in front of us when the bladders are struggling, but we've really lost our sight a little bit. I think that now with the Man Vs Prostate crusade, we're just reorienting, redirecting the ship, and I think that's exciting. Yes, on the second visit, I'll do cystoscopy, fill them up, do a UroCuff. With two visits, I now have all the data that I can then present to them and we do that through the Man Vs Prostate Report Card. That really just helps guide them and they understand already that our shared goal is to avoid them getting to stage three, four, and five.
(3) The Five Stages of Bladder Health
[Dr. Jose Silva]:
I'm sure you see those patients that, "Hey, I'll be fine." Then you go in and the detrusor, they have severe trabeculations. Even though the PBR is low, but still, you have a big prostate, 60, 80 grams, kissing lobes, but they say, "I'll be fine. Why am I going to do a surgery?" Then that UroCuff will give you the information or the transition to, "Hey, we need to do something before that bladder goes to stage five." Wayne, can you go over the five stages of their function or bladder damage, sorry?
[Dr. Wayne Kuang]:
The five stages of bladder health, that's really fun. For folks who want to learn more, feel free to go to manvsprostate.com, it's a free download, as well as the Italian Brigade of Defenders of the Detrusor led by Defender Luca Cindolo. He really picked up on this and really has put his academic wisdom on the five stages of bladder health and you can get that in the journal of Nature of Prostate Cancer and Prostatic Diseases and that's with that–
Go to www.manvsprostate.com. Really insightful comments from him from a very nicely academic perspective. The five stages of bladder health, amazingly, has really taken off, at least on LinkedIn to the point it's been inspirational for urologists around the world. There's Defender Sonny Schlein of Schlein Catheters and Prostalone. He actually did a painting. If you get a chance to see it, it's amazing. I couldn't believe it.
[Dr. Jose Silva]:
I saw your post of the catheter, but no, I haven't seen the painting.
[Dr. Wayne Kuang]:
I'll have to put that back out again, but it's got the saintly bladder being attacked by these five demons representing the five stages of bladder health. We have to recognize the bladder is being victimized by the villainous prostate as that prostate is getting bigger and growing tighter. The five stages of bladder health, as I said, is really the talk track that allows us to guide patients to make the best decision as well as to pierce the armor of masculinity that allows them to lower their defenses and to reach for something greater for themselves, which is a life well-lived, catheter-free and chemical-free. It's a verbal map like we talked about.
The reason why, if we're going to talk about, take for example, cancer, we talk about late stage prostate cancer, nobody wants that. Same thing with BPH. We talk about prostate cancer affecting one in eight men. We should be at least as concerned about BPH, which is affecting eight to nine of ten men and preventing late stage BPH. To say that, we need to have the stages. The five stages are predicated on the fact that it has to have relatable terms. We're talking about the prostate is the size of a golf ball and the shape of a mini donut. We express a sense of gravity that, yes, the bladder is only one of two organs that cannot be transplanted, the brain and the bladder.
We've reinforced that, "Hey, Mr. Smith, this is a problem when the IPSS score is eight and above. Then we need to make an analogy where people can relate to, as you and I know, really the perfect [unintelligible 00:20:00] for the heart is valvular heart disease or aortic stenosis. If we got into valvular heart disease with our patients, we'd never get out of that room. Luckily, we have ischemic heart disease, and people can understand that. As a result, I created the five stages of bladder health. As that prostate is getting bigger, the donut hole is getting tighter. Mr. Smith, we talked about the heart is a muscle that pumps blood, the bladder is a muscle that pumps urine through that prostate. As that donut hole gets tighter, stage one, things are going to slow down.
Then stage two, if we don't take care of that problem, the bladder now over 5 years, 10 years, 15, 20 years, is going to be overworking, struggling, quivering, becoming overactive, causing those symptoms, Mr. Smith, of urgency, frequency, getting up in the middle of the night. Then stage three, I think is one of the most important. "Mr. Smith, if you don't take care of this, your bladder will start to act out like a rebellious child, and it'll squeeze without your permission, cause you to leak down your leg." Why is that important? Because it's not even covered. Urge urinary incontinence is not covered in the IPSS.
I will say, at least from my experience, and Jose, you may or may not feel the same, but that's the most embarrassing and shameful. I've had guys who stopped leaving the house because they were leaking down and smelling funny and embarrassed to be in the shopping mall. Then stage four, Mr. Smith, just like the heart can have a heart attack, the bladder can all of a sudden stop working, you choke in the emergency room, needing a catheter. Then stage five, just like your heart can go into heart failure, your bladder can go into bladder failure and you may need a catheter for the rest of your life.
The one difference is, Mr. Smith, is if your heart went into heart failure, you can still get a heart transplant. With the bladder, that's it, game over. You're living with that situation and that's not okay. That story, that verbal roadmap that we're guiding them down, activates them to make the best decisions for themselves. I'm not telling them what to do, but they're self-activating to take action about their situation because they don't want to be that guy that gets a late stage BPH.
They don't want to be that guy that was warned about it and chose to do nothing and then ended up with a dead bladder. It's the fear of catheters, the fear of emergency room visits, retention, leaking on themselves, and that vision, that dream for themselves to live their best lives, the best version of themselves, chemical-free and catheter-free, that is going to have them want you to get the data to find out what's going on.
[Dr. Jose Silva]:
Exactly. You mentioned the fear, but also, unfortunately, some patients think that it's normal part of aging, that it's just, "Hey, I'm getting old, it's normal." Maybe their parents had it. The father had it, so they're used to it. No, there's treatment. There's treatment. Like you mentioned, there's things that we can do so that you have a better life. You mentioned earlier during the segment, education. Do you go and talk to PCPs about this and start talking more about bladder health instead of just the prostate?
[Dr. Wayne Kuang]:
Absolutely. For us, the vision for Man Vs. Prostate, it's a garage-grown, grassroots crusade for us to redefine the BPH care pathway. It's going to take all of us. It's going to take a village. I will tell you, at least here in the Americas, primary care docs are overwhelmed. I just worked with a primary care doc on Saturday, and he's like, "I don't have time. I need help. I've got 15 other problems I got to take care of in 15 minutes. How am I going to really dive into that?" That's why it's going to take a collaborative effort on all of our parts. Primary care physicians, specialists, mid-levels, urologists, industry, academics. We're going to all have to work together.
Yes, the primary care docs need to be enlightened. We need to help them, I think, with mobile apps or online education, having a campaign that goes a national shout out to Defender Austin Slaves, who did some research and reached out to our company. It's going to cost us about $247,000 to try and launch a national campaign. Obviously, grassroots, we're not there yet, but how do we get the message out directly to the patients so the patients are coming in pre-educated for the primary care doc, pre-educated about the issues, the late stage BPH, when they meet with the urologist.
One of our playful hashtags that we really want to get out to patients is hashtag, hey, what about my bladder? We want them pushing the dialogue, and we can do that through collaboration to build communities, whether it's within industry, within online amongst patients, whether it's within academics, with the AUA, the EAU, and the NICE, building communities, consistently sharing that message.
For example, healthcare industry representatives, there's a Defender Trey Dorman from NeoTract asked, "Hey, what do we do?" A very simple thing is start collaborating with other industry companies within diagnostics, and work with devices to share this message. Also in our marketing, we need to be very consistent in showing the bladder being beat up with trabeculations. A great one is when OptiLume came out on the front cover of Journal of Urology. I was like, "Yes." If you look at the picture, the bladder has trabeculations. On the academic side, AUA, EAU, NICE, you need to put good pictures of normal bladders versus trabeculated bladders that all urologists can download and put on the websites.
Every time a patient comes to a website from a urology practice, they're seeing a beat up bladder, we're consistently sending the same message that, "Hey, bladder health is what is really a priority, the preservation of bladder health." Then the second thing is internally and externally, we need to challenge the orthodoxy. Medications, and this is a very important point. Folks ask me, "Hey, are you anti-medications?" No, we're pro-data and we're pro-education. Part of that education is medications, yes, have their role, but not as therapeutic measures. They need to be relegated and reassigned to a category of temporizing measures, similar to a Foley catheter.
Guy comes in with stage four retention. In the emergency, we temporize the situation with a Foley catheter. A man comes in with symptoms, stage two or stage three, overactive bladder, [unintelligible 00:26:34]. We temporize the situation with medications, "Hey, but Mr. Smith, there's a bigger problem going on here." We need data to figure out what needs to happen.
That's a really important challenge to the orthodoxy, that medications are not a therapeutic measure, but a temporizing measure. Another one is just the use of language. We talk about benign prostatic hyperplasia in our guidelines, but that's a histology. We need to really get back. Words matter. If we use the word obstruction, that word affect our thought, affects our actions and affects our habits, because obstruction means there must be a solution that means de-obstruction, and chemicals don't de-obstruct.
[Dr. Jose Silva]:
I remember in residency, there were only four real indications for treatment. It was urine retention, persistent hematuria, I think renal failure, and I don't remember if it was recurrent UTIs or bladder stones. By that time, you're already probably stage four, stage five, and that's when you do a treatment and you're not going to get him back to a baseline. You're going to try to alleviate some of the symptoms, but really, maybe you're not going to do nothing outrageous in terms of quality of life.
[Dr. Wayne Kuang]:
That's a challenge right there. That's perfect. Challenging the orthodoxy, what's an indication? Then just redefining, like, "Hey, how do we find the right patient with the right prostate to intervene at the right time within the window of curability?" Some folks have said, "Hey, Wayne, are you an advocate for just early surgery for every guy?" No, we're an advocate for finding the right time in that shared decision-making process that fits both the surgeon and the patient when warranted. I think that's really important, is that the right timing.
[Dr. Jose Silva]:
Wayne, why do you think we don't talk more or when we did residency, and I don't know if currently there's talk about detrusor, but why we don't talk about detrusor enough? It's like after residency now that you have the Defender of the Detrusor. You're doing the LinkedIn, all the agenda. Why do you think we don't talk about this more?
[Dr. Wayne Kuang]:
It's a fantastic question. The conversation about earlier intervention within the window of curability to preserve bladder health has been around for 20 years. Defender Andrea Tubero from Italy published a great paper in 2001 talking, early intervention is needed to protect the bladder. It's been around for 20 years, but that was a different time. We did not have many tools on our tool belts. We had monopolar TURP, and we had open simple prostatectomy with incredible morbidity and mortality. As a result, medications came along with a perceived more favorable benefit to risk profile.
Then we had industry dollars pushing pharmaceuticals. Think of all Flomax, all Hytrin, Cardura, et cetera, et cetera, 5-alpha reductase inhibitors, OAB medications, and the device industry and pharmaceutical industry really started putting a lot of money into that. I think it just distracted us a little bit, also because we didn't have many good other options. At that time as well, we weren't feeling the full impact of late stage BPH. We are now feeling the full extent of men living longer with all these problems.
Because of that, I think that was a big part of it, and then on top of that operationally, it's just not that easy to get guys to do a cysto or to do pressure flow studies. It takes work, but things are changing. We live in this golden age of BPH. Where pressure flow studies, whether it's Urocuff or [unintelligible 00:30:25], things are getting easier with AI and so forth, with the operational efficiency of cystoscopy. Now there's disposable cystoscopes. You don't have to worry about trying to get that prepped and ready and worry about sterilization. I think we're starting to break the habit. In the past it was just too easy to prescribe and refill.
That was compounded by the fact that men had the armor of masculinity and I'm fine syndrome. It's just easier to refill it because they said they're fine. What we need to get back to, once again, we are not anti-medications. We're pro-data. Put the cards on the table. We have never had a better time to get data to put in front of men and say, "Hey, this is who you are. This is your bladder function. This is your prostate situation. These are your options." Now we have just a plethora of surgical de-obstructing technologies in all the surgical categories of least invasive surgical therapies, minimally invasive, invasive, and most invasive. This is a great time for us to really tackle this problem and stem the tide because there's a tsunami coming of late stage BPH.
[Dr. Jose Silva]:
At the level of the AUA, even in the guidelines, they revise it all the time, but really they don't talk about detrusor. It's very vague in terms of the options, but they do mention a lot of the pills. How can we change that language in terms of the AUA guidelines or the AUA being a force to help bring that information to the patients and all urologists about, we need to change the paradigm and focus on the detrusor.
[Dr. Wayne Kuang]:
Once again, it's going to take a village. It's going to take healthcare industry reps. We need you to be evangelists. I need you going out there and challenging doctors, challenging practices. Ask them that question, "Hey, what happened in the emergency room when that guy came in four [unintelligible 00:32:16]? Why did that happen?" Then obviously, you can introduce what your technology does to help facilitate that BPH care pathway to prevent late stage BPH because that's a shared common goal. Man Vs Prostate is really working at the grassroots level trying to direct a patient.
We're going to try and launch BPH 360 in the spring equinox to really directly get the good information to understand that there's three things that we talk about. The three Ps, prioritizing the preservation of bladder health, putting an end to the polypharmacy epidemic, and preventing late stage BPH. Then on top of that, we're coming out, the EAU incontinence commission just put out a manifesto that they submitted and they had key opinion readers sign it. We're doing the same thing, just saying, hey, this is what we think we get and I get it too. Please understand. I recognize who I am and who I am not. I am just a small community doc in the desert.
[Dr. Jose Silva]:
You're more than that, man.
[Dr. Wayne Kuang]:
That's the truth. I do not have the academic experience and expertise of all the literature. We need everybody to chip in, but also really focusing on the patients. I do believe that, hashtag, hey, what about my bladder? If patients are pounding, "Hey, what about my bladder?" I know you're talking about my prostate, but what about my bladder? It's going to drive that change on multiple levels.
At least that's how we're hoping to get there. The Man Vs Prostate manifesto, direct to patient education. Really having us talk about, just like here today on your podcast and other podcasts, how do we get there? Also, the publication that came out in the Journal of Nature, Prostate Cancer and Prostatic Diseases, that was huge, really, to just give it a little bit of meat and authority that, hey, there's something here that we need to talk about.
That's what we're hoping, just changing the conversation, challenging the orthodoxy and being willing to have that conversation. Oh, the other thing is I want to bring up burnout and moral injury within urology. It's because we got away from being who we are. We're solution-finding surgeons. BPH is 30% of most practices' workload, but only 6% of their revenue. It's also not fulfilling. We're not fixing problems. We need to get back to what brings us joy as surgeons. I think all those things, we start thinking about it, talking about that, feeling it, and listening to what I would call cognitive dissonance and resonance, what feels right, and letting that be our guide.
(4) Tools for Patient-Centered BPH Care
[Dr. Jose Silva]:
Exactly. You mentioned resources and getting help from the industry. In my office, in every room, I have the diagram from UroLift about the different stages of bladder health, or at least the picture, which I showed the patient, "Hey, this is what we're trying to prevent. Once it's at the end, that's it." Most patients, "But I was never told this. I was told the PCP says that everything was fine." That's why I asked you at the beginning of this, because sometimes the PSA is one of this. They think that everything is normal. They're talking about prostate cancer-wise. Definitely BPH or [unintelligible 00:35:25] is something different. It shouldn't be normal with your age.
[Dr. Wayne Kuang]:
The resources are critical. The number one resource is our minds. We have to come in to recognizing this is a mechanical problem, that this is a mechanical solution. Medications are part of the equation, but they are temporizing measures, and that we are going to be their guide, and we're going to get them the data. Number two, very simple, our eyeballs and our hands. When you look your patient in the eye, you hold up their IPSS with their handwritten IPSS score and their signature in the bottom, and you say, "Hey, Mr. Smith, this is a problem." That is a huge resource. That is a huge igniter.
When they hear it from someone they trust, "Oh my gosh, that's a problem?" "That's not fine, Mr. Smith." Right there. That takes care of that whole problem you talked about. Then our hands. I use a lot of gesticulation showing the prostate as a mini donut getting tighter, the bladder squeezing like an octopus. The reason why I bring it up is we have it all right here. Yes, those resources like the pictures of trabeculations help, but you don't have to always rely on those. If you guys do have that trabeculation photographs showing the progression from a normal bladder to a severely trabeculated bladder with cellulose, that is fantastic.
Quick tip, get two of them, one in the patient consultation room, get another one, put it on a foam board, attach it to the wall right next to the cysto, or hanging off the side of your cysto monitor so you can show exactly what their bladder looks like versus the one that you already taught them about in the pre-cysto counseling. The other resources out there, for example, Man Vs Prostate, we're trying to create flow charts, report cards, list of surgical categories, decision making aids for patients that should be coming out this spring, as well as flow charts for each types of practices depending on what you have, whether you have Cystotrust Uroflow, Cystotrust Urodynamics, Cystotrust Urocuff.
There's not one way to skim the cat. As long as you're presenting all the data about detrusor function, prostate size, prostate shape, and talking about the five stages of bladder health in however you want to do it, that could be very helpful. Then there are more formal avenues for resources. One that just came out is called bphtool.com. Based on a lot of data, especially the COMBAT trial, it lets you look at if you put someone in medications, Tamsulosin, Dutasteride, combination therapy, what can you expect their IPSS score to improve by, as well as what is the potential risk for acute urinary retention episode over the next four years?
Wow, now we have a tool. For medical legal, they say it's not a clinical tool, but take it for what it is. Now you have something to say, "Hey, look, Mr. Smith, that's your risk. We don't want that risk. Our goal is to keep you out of stage three, four, and five. This is something we need to think about." Other resources out there, just a big shout out to the Canadians. They have the decision-making tool for choosing types of surgeries, de-obstructing technologies that might best fit a certain patient for his prostate. That's also another great tool and resource.
[Dr. Wayne Kuang]:
How do they come up with that, choosing which technique is better? It's just based on the size of the prostate, based on the length. What are they using to–
[Dr. Jose Silva]:
Predominantly size, but it's something definitely to check out and see if you can incorporate it. I don't think it has all of the technologies, because as you and I both know, the technology are changing very rapidly. Man Vs Prostate is really working now to look at, how do we now personalize the therapy? What do by that? If we look at UroLift, it really is focusing on the roof and laterally. Many people have had issues as I coached folks up on the floor, that high bladder neck, moderate bladder neck. The way we solve that with UroLift, so you braise the roof, create an anterior box.
Then REZUM is a little bit different. It's working more laterally, not so much anteriorly, and it's a little bit on the floor. Then now we have iTind, for example, in the category of list, which is bringing in a combination of the roof at a twelve o'clock time, five and seven o'clocks, creating a relaxing incisions like a twip, allowing the lateral walls to relax away to the sides and dropping the bladder neck. Now, can we define that further, choosing surgical technologies based on the specific anatomy? I think we're going to get there. Then you have invasive surgical therapies in the category of IST and MOST, which is really a circumferential therapy. Looking at the surgical categories way past just size as a criteria, but really looking at shape and then [unintelligible 00:40:20] function.
(5) Algorithms for Surgical Decision-Making in BPH Treatment
[Dr. Jose Silva]:
Can you go in and tell us more or less your algorithm in terms of deciding more or less what was the best procedure for each patient?
[Dr. Wayne Kuang]:
In Man Vs Prostate, do what you do well and do a lot of it, saving as many bladders of the now and of the future. What I tell people, we're all different. If we were all the same, we'd just all do the same fellowship, right? There are folks who are ablative, extirpative. There's people who are reconstructive, and different technologies will appeal to different urologists. That's why we came up with those four categories, least invasive surgical therapy, minimally invasive surgical therapy, invasive surgical therapy, and most invasive surgical therapy. Have an action plan or an offering for each of those categories so you can meet the men where they are. Once again, we're just guiding them. I hope that helps. Obviously, do what you do well because there's so many good options.
[Dr. Jose Silva]:
I just started doing the Aquablation and I really enjoy it. I started doing it like three months ago and I'll probably stick to it. I was doing a lot of Greenlight before that. Now I'm doing more Aquablation. I think based on the ultrasound guide, I see the big hole there.
[Dr. Wayne Kuang]:
Some of those images are really impressive. That's a very interesting topic, which is when we talk about technologies, and you may have or may not have seen that I created the four elements of efficiency for the BPO care pathway. One is treatment durability, a man's vitality that we need to honor and respect and optimize and preserve. We're trying to de-obstruct for the right prostate, the right patient within the window of curability. That's number three. The last is economic sustainability. I don't know with the data out there, but when we look at great technologies like Aquablation, does that mean replace the technology in every hospital? Is that sustainable economically? I don't know.
I do know we have a severe backlog throughout the world. In Sweden, they've had a huge rise in retention, stage four. UK as well. We're about to be hit by that here. We're already being hit by that. If we talk to urologists around the country, everyone's hearing about guys going in retention. Catheter rates for self-catheter going up. When we look at all these technologies, how do we find that right blend of economic sustainability, treatment durability, man's vitality and the window of curability? That's going to be an interesting part for Aquablation specifically as we move forward.
[Dr. Jose Silva]:
Are you doing any office-based procedures with BPH right now?
[Dr. Wayne Kuang]:
I do iTind. For me, that's been a great option. For my situation, which may not be for others, I think once again, just have as many tools in your tool belt in each of those surgical categories. Like I talked about before, I like how it's actually treating all four areas, interiorly, the roof, the floor, that bladder neck, bringing that down and allowing the lateral walls to relax to the side. Every surgeon, every practice is different. Make sure you have something for LIST, MIST, IST, and MOST.
[Dr. Jose Silva]:
Yes, good to know. Last week, we just got approved to start doing the iTind. I'm going to add that to [unintelligible 00:43:34].
[Dr. Wayne Kuang]:
Because every guy's different. There are guys-- When we talk about LIST as a category that's non-permanent technologies done in the office with minimal risk, MIST is going to be permanent technologies done in the office with low risk. The invasive surgical therapies or IST is going to be permanent technologies done in the hospital with medium risk. Then you have MOST, which is going to be permanent technologies done in the hospital with high risk. That's at least how I use it as a patient education tool. Obviously, there are unique variants from each surgeon that can minimize risk in each of those categories, but it just is a general guideline.
(6) The Ripple Effect of Education & Advocacy
[Dr. Jose Silva]:
Wayne, so you mentioned the resources on Man Vs Prostate. Any of us can go there, even can we direct patients there to the website?
[Dr. Wayne Kuang]:
Absolutely. They can go to the website, and they can log in. When you register, they'll get sent the five stages of bladder health, which is really plain spoken. I try to find that space in between too academic and too plain spoken. Then right now, we're coming out-- Last year we produced about 30 educational videos for patients that we're going to try now put out in the spring for patients to be educated about just a different approach or a different perspective for the BPH, BPO care pathway where we are prioritizing the preservation of bladder health. We are trying to put an end to the polypharmacy epidemic, and we are trying to prevent late stage BPH. That should be coming out. Then also we have an educational series for physicians as well and urologists. That'll be fun.
[Dr. Jose Silva]:
Oh, great. Wayne, anything else you want to add? I think we covered everything that you're doing. Definitely it's been years in the process, and I think it's great you're putting the word out, trying to, for us as physicians or urologists, change the way we talk to patients, change the way we approach this disease. I think it's incredible what you're doing. I think everybody should start thinking about bladder health instead of just the prostate.
[Dr. Wayne Kuang]:
Absolutely. I think if we do that-- I'll end with this. The world is dark right now. There are so many shadows now. It is rare that we as a tribe of Defenders of the Detrusor could use our cystoscopic swords and our pressure flow shields to fight for something that is so true. It is the light, a little bit of light, but it's so rare nowadays. It's for us to find something where everyone wins, patient, doc, the practice, the healthcare industry, healthcare systems. It can be a win for all. I think it's a real-- It's an experiment. As you know-- you may or not. During the pandemic, I wanted to learn how to face my own fear with playing music, so I started playing on the streets.
What it is really an adventure in sharing, giving, and receiving energy. Every time I get surprised by the Man Vs Prostate, is as we put out this energy, we receive it. It will disperse in a positive ripple effect that can affect positive change with our personal, professional, community, and global relationships. I ask everyone, I was just recently in Buenos Aires at Malba, the fine art museum there. They had an exhibit on habiting and transforming. To inhabit is such a word that we don't use that much. How do we inhabit our spaces? Really feel it, sit in it, breathe in it, touch it, smell it, and then transform it in a positive way and watch that positive ripple effect.
I think we can do that. I think it's a great social experiment. What can happen globally? How did the Italian Brigade start? How did the Scandinavian Brigade start? The Colombian Brigade now. Nephrologists there and general surgeons are catching on. They're not even urologists. That's fun. We need something like that. A little bit of light that we can hold in our hands and then share with others. Just a small thought, how do we inhabit and transform our space in a positive way?
[Dr. Jose Silva]:
I'm glad you're doing it. Every time I go to LinkedIn, I see your messages. They're definitely very motivating. I like being part of this movement that you have created. Like you mentioned, it's great expressing the change to the patient. That knowledge, having the patients change their mind. It's not about the prostate only, it's just preserving bladder health.
[Dr. Wayne Kuang]:
More so, it's about just guiding them and being their partner on their journey. Our goal is to let them be the hero in their own story, their own adventure, where they saved their own bladder from the villainous prostate. We're just there to be their guide.
[Dr. Jose Silva]:
Awesome, Wayne. I'm really glad you came to the show. We'll keep in touch, definitely. Thank you for being here. We'll continue supporting your course and try to just promote the message the Defender of the Detrusor. It's just great what you have created.
[Dr. Wayne Kuang]:
Thank you and for your support. You've done a great job of spreading the news with BackTable Urology, really educating and getting that message out globally. I can only imagine your numbers, your click-throughs, and the touching of lives all across the world. Thank you.
Podcast Contributors
Dr. Wayne Kuang
Dr. Wayne Kuang is a men's health urologist in Albuquerque, New Mexico, CEO of MD for Men, and the founder of the ManVsProstate Crusade.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2024, January 23). Ep. 148 – Defending the Detrusor: A Clinician’s Perspective [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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