BackTable / Urology / Podcast / Transcript #6

Podcast Transcript: Contemporary Surgical Management of BPH

with Dr. Claus Roehrborn and Dr. Aditya Bagrodia

In Part II, Dr. Aditya Bagrodia talks with Dr. Claus Roehrborn of UT Southwestern Medical Center about the surgical management of benign prostatic hyperplasia (BPH). You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Minimally Invasive Treatment Options for BPH

(2) BPH Treatment Options for Elderly Patients

(3) Using Ultrasound to Estimate Prostate Size

(4) Treatment Options for Large Prostates (> 80 g)

(5) Treatment Options for Medium-Sized Prostates (30-80 g) and Substantial Median Lobes

(6) Preservation of Antegrade Ejaculation

(7) Post-Operative Medical Management of BPH

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Contemporary Surgical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia on the BackTable Urology Podcast)

Ep 6 Contemporary Surgical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia

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[Dr. Aditya Bagrodia]
Hello, everyone, and welcome back to the 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. I'm your host, Aditya Bagrodia, and today we have Dr. Claus Roehrborn, the professor and chairman of urology at UT Southwestern Medical Center. Claus is a thought leader in the management of lower urinary tract symptoms and benign prostatic hyperplasia. We're very happy to have him. Last time we focused on medical management and evaluation of lower urinary tract symptoms and today we'll try to keep our focus on surgical management. So, Claus, welcome back. How are you doing today?

[Dr. Claus Roehrborn]
Good. Doing very well.

[Dr. Aditya Bagrodia]
Fantastic. So perhaps, Claus, I'll just ask you to give a very brief recap of our last conversation and the final thoughts as we move towards exploring surgical options for patients.

[Dr. Claus Roehrborn]
We talked about the evaluation of the typical patient presenting with symptoms, the assessment with a symptom score that gives us an idea of the severity of the symptom frequency and so forth. Then we talked about how it affects the quality of life and the patient's social activities and so forth. That plays a major role in the indication for treatment. Then we talked about the optional evaluation tools such as urinary flow rate, residual urine, assessment of the prostate by DRE or by imaging, and how that would help us to gain an understanding of the patient's phenotype, if you will. We also talked about medical therapy and how it's differentiated between alpha blockers and 5ARIs, PDE5 inhibitors alone or in combination together with anticholinergics, and ended up with a fairly differentiated approach to the medical management of BPH to the point that that is effective.

But I want to begin this episode by stating that all medical management of BPH is effective in at most 70% of patients. And the very important thing to keep in mind, all the studies show that a meaningful improvement in the symptom score is only achieved in 70% of patients. We forget this often. We think, "This is it. Here's a pill. Take it, it will work." No, not. It works in 70%. There is right off the bat 30% of patients, even with the best intentions, who don't respond. And then of course there are patients who have side-effects for medication, patients who are tired of medication, patients with poor compliance, and just don't respond as well, and those patients then also need to switch over to some other therapies. I would say it's far more than 30% of patients started on medication therapy that eventually fail and need to consider other treatment alternatives.

[Dr. Aditya Bagrodia]
Yeah, that's incredibly helpful. And I think just like when we talk about prostate cancer patients and active surveillance, coming out and giving them the expectation that this isn't a one-stop shop necessarily, that some proportion will progress and require further intervention, is important. Okay, fantastic. Last time we talked about absolute indications for an outlet procedure, we talked about maximal medical management and a failure to have an acceptable quality of life, and let's just say we've made a decision that we're going to be proceeding with surgery. Even over the course of my career, there's been an absolute explosion in terms of options that are available for patients. And as we start talking about the relevant patient characteristics, symptom characteristics, and anatomical considerations, perhaps it would be useful, Claus, if you could give a comprehensive list of options that are available, as you see it.

(1) Minimally Invasive Treatment Options for BPH

[Dr. Claus Roehrborn]
Happy to do it. And in fact, that list is ever-expanding. I just came off our first virtual meeting of a new society, the Society of Benign Prostate Diseases. This was just formed last year during the COVID pandemic. We had our first virtual meeting and we discussed just about all of these treatments and had presentations on them. So those treatments nowadays are grouped into minimally invasive (done as an outpatient or an ambulatory surgery center) versus the surgeries that require full anesthesia (done in a hospital setting usually and require more or less an overnight stay). Of course this is also dependent on health systems. Everybody stays more than one night in European countries and most people can go home in the United States, et cetera. So it's driven by health systems as well.

That's just one way of grouping it. You can also group these treatments by if they remove tissue or if they do not remove tissue. I'll give you an example. A TURP classically removes tissue. It's an ablative procedure and it's invasive and it requires hospitalization at least for a day. Non-ablative would be a UroLift. You place the UroLift devices and you push the tissue to the side but no tissue is ultimately removed. So ablative versus non-ablative is another way of differentiating it.

There would be a differentiating between treatments that consist of permanent placement of items, such as a UroLift, and there's a whole slew coming down the pipe, the Zenflow device, the Butterfly device, the Medeon device, all of which are experiencing trials in the United States right now and may or may not be approved by the FDA. Versus treatments that don't use devices that are implanted permanently.

And then there's the categorization by devices that work by laser energy versus electrocautery energy versus other energies. For example the Rezum procedure uses steam, just hot water heated by radio frequency energy, and then is injected and as the steam gives off the energy it destroys the tissue. So the energy source is another question. And to add to that there is the Aquablation treatment that doesn't use any heat per se--neither electrical generated heat nor laser generated heat nor steam--but it uses basically saline at room temperature with a very intense water pick system to destroy prostate tissue.

You can already see how complex it is, how you can group these treatments by energy source, by ablative or non-ablative, by implant versus non-implant. Then comes the question: are these treatments all suitable for all sizes and shapes? But if you look through the list, minimally invasive devices currently approved and recommended in the United States would be the UroLift device, which is an implant, and the Rezum treatment, which is a steam-based heat treatment that partially ablates tissue. Then amongst the surgical treatments there would be monopolar/bipolar TURP, the PVP, the GreenLight or KTP or 532nm laser ablation of the prostate. Then there would be a host of enucleation techniques and, as you know, enucleation now can be done with the traditional way, the holmium laser enucleation which is called HoLEP, the thulium laser which is called ThuLEP, but people do it with the green-light laser as well and it's called KTP laser enucleation, or even do it with a bipolar resectoscope device and just get into the enucleation plane.

Then we have the treatments for the very large prostates that go beyond the HoLEP or ThuLEP, the robotic or open or robotic-assisted laparoscopic enucleation of the prostate as alternatives for the very large prostates. So the guidelines still recognize the old style microwave treatment, transurethral microwave therapy, TUMT, people will know it as such. But the consensus is that this is not as effective. It is very time-consuming. It takes an hour, which is quite long, and the retreatment rates are high, so I would like to not focus too much on that because I don't think that's really a mainstream treatment any longer.

And lastly we should spend a minute or two on prostatic arterial embolization. This is something we don't do as urologists but it is done. It is done by interventional radiologists. We all need to be knowledgeable on what it does and what it can and cannot do. And the AUA position currently is to say that it should require further evaluation before it would be recommended as a treatment. That's a rundown of both the groupings and the treatments that exist themselves.

(2) BPH Treatment Options for Elderly Patients

[Dr. Aditya Bagrodia]
Yeah. I think it's safe to say that the options are plentiful and ever-expanding. Simplistically, I think of these also as transurethral options versus either transperitoneal, such as a robotic simple prostatectomy, or retropubic options, such as open simple prostatectomy, which I think is an operation that's becoming less and less common here. Fantastic. Thanks for running through those. Again, I think categorizing these as traditional surgeries versus transurethral options is something to consider. Now we'll try to actually jump into patient characteristics, prostate anatomy characteristics, that help guide a decision. Maybe we start out with comorbidities, elderly patients, and thoughts on patients that are on blood thinners. Does that immediately start impacting your decision tree here?

[Dr. Claus Roehrborn]
The age of the patient per se, the chronological age, actually the least I would say. You are an oncology surgeon, you know you operate on elderly folks, you operate on octogenarians if they have cancer. So we have to take a step back or we have to say, "This is a benign disease. It's a quality of life disease. We cannot afford an anesthetic event here." So clearly we are going to dial it down a little bit. If the patient is elderly and is frail, frailty plays a big role in the BPH population, then we'll take it down a notch and we offer treatments that are less invasive and we try to just offer those treatments which we consider minimally invasive, the Rezum treatment or the UroLift treatment if the size of the prostate allows it.

Clearly, if the prostate is too large or if there is a substantial intravesical lobe, if we choose an endoscopic operation, I would choose the KTP laser. Why? Because there is clearly less bleeding and the chances, even small, for a return to the emergency room with clot retention is higher with the TURP compared to a KTP. That's just a fact. Even if it's only 2% or 3% versus .5%, it's a difference for a person in his 80s. If it has to be a TURP then I would say of course a bipolar TURP because the use of saline reduces the risk of hyponatremia, TURP syndrome and all of this will benefit our elderly patient population.

The use of blood thinners is complicated because it's not only antiplatelet agents, which are easier to manage and easier to treat patients under. But the true anticoagulation, which used to be all patients on Coumadin and now it's basically on modern anticoagulation, be it Plavix or be it Eliquis, it's a far more complex issue. I used to say that a patient on Coumadin, we'll take him to the OR and do a green-light laser ablation up to an INR of 1.5, but there are almost no patients on Coumadin any longer. They are on Eliquis and they are on Plavix and other such drugs and you don't have graduation anymore. So those patients are difficult to treat.

Some of the treatments can be done. Sometimes a person who publishes a series of patients on Eliquis treated with even a HoLEP but that's rare. I would say if the patient can't come off the blood thinners, the true anticoagulation, I would say the KTP laser is probably as far as I would take it. In the range of ablative treatments, I would certainly do a UroLift placement on a patient on anticoagulation and have done so, on any kind of anticoagulation because the application of that lift device two or four or six times doesn't cause a great risk of bleeding.

[Dr. Aditya Bagrodia]
What about adding on 5-alpha-reductase inhibitors prior to BPH surgery? Do you have any opinions on that to mitigate bleeding risk?

[Dr. Claus Roehrborn]
Sure. These are not necessarily tied to each other. When patients are on anticoagulation, true anticoagulation, it's a different question if they're on platelet aggregation inhibitors. Many treatments can be done under aspirin, certainly if it's 81 mg. You now ask a different question. You ask a question, what if I have an elderly patient and I don't want to have a major blood loss and I want to avoid getting into a venous sinus and bleeding and so forth and so on. What is the role of 5ARIs? Well, as you know, they were developed to treat BPH and lower the PSA and shrink the prostate by 25% which they do. But there is an incredible side effect to it that people didn't realize, and it was shown by Dr. Fowler in the United Kingdom many decades ago, they actually suppress the expression of vascular endothelial growth factor in the subepithelial tissue of the prostate, and by doing that, fairly quickly reduce the prostate related bleeding.

The first observation was related to patients who have prostate bleeding. They have hematuria, intermittent growth, no clots, plus or minus clots. You can't find a reason for it. You look in, you see these large vessels over the surface of the prostate and those patients are considered to have BPH-related bleeding. Well, the observation was that 5ARIs work very well. The recurrence rate of bleeding from the prostate in these patients goes down from 30 to 60% to 10, 20% at the most, so it's a very effective treatment. Then people said, "Well, if that's the case, why don't we give it prior to surgery?"

And that was sort of the limit of it because here we're talking about large vessels that bleed, venous sinuses during the TURP, and the efficacy of 5ARIs to reduce bleeding intra-op is not significant either statistically or clinically. Why would I say that? I say that because the largest meta-analyses done in this field show that, by estimation of the surgeon, there is a reduction in blood loss but there is not a reduction in transfusion risk and there is not even a reduction in the patients who come down to a hematocrit or hemoglobin that is precariously close to requiring a transfusion. So if you look at it from a tangible benefit point of view, you want to avoid transfusion or having a patient so low that he is weakened and in his recovery somehow impaired. And that is not affected by the use of 5ARIs. There're about five or six randomized placebo-controlled trials that show that. I personally don't do it. It also delays the surgery by three to six months, depending on how long you do the treatment, and the benefit is minimal.

(3) Using Ultrasound to Estimate Prostate Size

[Dr. Aditya Bagrodia]
Okay. Okay. Well, that's valuable insight. As we start talking about the various components that play into the decision making tree here, my sense is that the prostate size is going to be the first major fork in the road, if you will. So perhaps we just have you start out talking about what your preferred imaging modality would be, even maybe also when you consider cystoscopy prior to BPH management in a garden variety patient.

[Dr. Claus Roehrborn]
By way of declaring my COI here, I'm not a big cystoscope doctor. I think patients are scared of the cystoscopy in the office and I think for BPH more often than not it is not really needed. You can get to a good diagnosis and indication without the cystoscopy in most cases. Secondly, the fork in the road, that Yogi Berra would say, "If you get to the fork you take it"? That's not so simple because a fork actually consists of up to three or four or five bifurcations. So it's more complex. We should remember and take a look back at 1990s. 1994, the first guidelines. And the first guidelines was a statement made to say that prostate imaging is neither recommended nor optional. It's basically thought to be superfluous. Why? Because in the 1990s we had alpha blockers and 5ARIs and we had TURP. That was it. And everybody thought it didn't make any difference whether you give an alpha blocker or 5ARI and if it didn't work you did a TURP. It didn't matter what the prostate size was.

My god, 25 years later. We learned that you shouldn't give a 5ARI for a small prostate and you shouldn't give an alpha blocker for a 100g prostate or for a prostate with an intravesical lobe. And as far as surgery goes, we learned that there is a big difference in sizes. So way forward to the modern guidelines. Both the AUA and the EAU now recommend prostate imaging. By far the most recommended approach would be an ultrasound. It's least expensive and it gives us all the answers in terms of size and if you do a good sagittal imaging you get an idea as to the intravesical lobe.

When I teach it, when I talk about it I say, "Okay. Couple of requirements." You have the bladder partially full. You need to have the fluid tissue interface otherwise you can't see the prostate either transabdominally or transrectally, so it's very important to have some urine in the bladder. So don't do it after the flow rate, do it before the flow rate so you have a full bladder. You can do it transabdominally or transrectally. Secondly, always document the widest dimension on the cross-sectional AP orientation. Measure the height and the width and then do a sagittal imaging and measure the length. And then determine the rise of the intravesical lobe from the bladder base to the tip of that intravesical lobe, which is usually posteriorly, and record it in millimeters. So you can come out with four measurements. You can say, "This prostate is 44x47x59mm and at a 7mm IVP or intravesical protrusion," or you simply say, "This is a 59 g prostate with a 5.7mm intravesical protrusion." That's all the information you need.

Now, there are many ultrasound devices that can be adapted to that. In most practices, doctors will schedule this in the ultrasound suite. I have gotten away from it. In our practice we have a mobile ultrasound with a transrectal probe that is on a rolling stand. And it can be rolled into the room and I'll just do it as if I do a DRE. I don't even schedule it. I say, "Okay, I'll do it." I'll do the ultrasound. It takes me two, three minutes. Patient gets dressed. And in that meantime the pictures are uploaded into Epic and I have them ready to discuss with the patient.

Today in our Society of BPH meeting, we had a presentation on POCUS. I don't know if you know what POCUS is, but POCUS is point-of-care ultrasound. There are five or six companies that make these devices. There's a device called Butterfly, one is called Clarius, there's another one made by GE. And these devices are handheld, less than a pound in weight, and they're directly linked to an iPhone or an Android. And from the iPhone and Android, most of them upload the images to Epic. So you can carry this in your lab coat on rounds or in your clinic, and you whip out the transducer and do a transabdominal ultrasound and get your result. That's incredible. And I want to incorporate that in my practice as well. There is even one called Clarius that has an attachment for a transrectal ultrasound. So that's the ultrasound part.

Now, if you are lucky, the patient had a high PSA and already had an MRI of the prostate. Then you're golden because then you have the size and the shape precisely. You see the urethra, you know the course the urethra takes, you know what the anatomy is like and what you can and can't do. And sometimes you're lucky that the patient has a high quality CT scan with and without contrast for evaluation of hematuria or for a prior stone disease or for a tumor disease or for some kind of follow-up. So then you use that cross-sectional imaging. But the AUA guideline clearly says don't order an MRI just to get the prostate size. It'd be a little wasteful for money.

(4) Treatment Options for Large Prostates (> 80 g)

[Dr. Aditya Bagrodia]
All right. Fantastic. I must say that I've used the rolling ultrasound in our clinic and it's pretty user-friendly. You can get the information that you need at the point of care, which is clearly nice. Okay, great. Understood that the size isn't the only fork in the road but perhaps it gives us a reasonable place to start. And maybe the smallest sliver of the pie is going to be large prostates. So let's start out with large prostates. A, how do you define that?

[Dr. Claus Roehrborn]
That was a heavy debate amongst the BPH guideline committee members: what is large? And some people, even the peer reviewers of the guidelines said, "Give us guidance. Give us numbers." And we refuse. Because some people can resect a 60 g prostate, some can resect an 80 g prostate, some can resect 100g prostate and we don't restrict that. So what is large is a little bit in the eye of the beholder. We suggest that large for most doctors starts at 8 0g. Because I really doubt that many of our current trainees can resect 40 or 50 g of tissue safely. Why would I say 40, 50? Because that's the transition zone tissue you want to resect if you're faced with an 80 or 90 g prostate. That's how much you want to resect. And most of them can't. So to me, large starts at 80. Anything above 80, either I want to sit there for 4 hours and do a KTP laser, which is still incomplete, or I do a bipolar TURP and I'll do it all myself with no trainee involved to do it quickly, or I just go to the category large prostates, which starts at 80 and goes to the 100 g or 200 g and 300 g.

And in that category, the best choices right now are no longer the open prostatectomy either retropubic, the old Millin approach, or suprapubic, but the best choices are either a robotic assisted laparoscopic enucleation, which 90% is done transvesical. Only 10% is done retropubically, opening the capsule. It's just the robot is not really well suited to do it, and you'd have to release the bladder, like for a radical prostatectomy, so there's a lot of reasons not to do it. It's a transvesical robotic assisted laparoscopic, which works extremely well. Sizes 80 to infinity. Now, there are 20, 30, 40, 50 places in the United States where there are real experts who can do holmium enucleation or a thulium enucleation, and this is the same thing. The sky is the limit. They enucleate prostates from 80 to 150, 200, 300 g.

What happens, though, is after a robotic enucleation you put the prostate in the bag and you take the bag out and if the prostate is 100 g or 200 g takes the same time. The morcellation, as you know, takes longer. So you enucleate transurethrally 250 g or so, the morcellation time takes longer. So maybe this is a detriment for HoLEP in 200 g, 300 g and the benefit of the robotic assisted enucleation. But then again, there are patients who had prior surgery or have reasons not to do a laparoscopic surgery for whom only the transurethral approach is applicable.

We have found in our training program and others have found that if you have a busy training program and the residents do a lot of robotic radical prostatectomy, the learning curve for a simple prostatectomy is fast, efficient, and they learn to do it safely. I love, love the idea that our residents leave here and if they are seeing a 200 g prostate, they know what to do and they have a tool to apply to that patient. So that's the story on the very large prostates. 80 g and above for me, and for others maybe 100 or even 120, but for me it starts at 80.

[Dr. Aditya Bagrodia]
Yeah, I think that's really helpful to help start the discussion. I'll ask you to comment on two things as it pertains to bipolar TURP. Why exactly is there a size cutoff if you're not going to be contending with the same fluid disturbances, post-TUR syndrome, when it comes to a bipolar TURP?

[Dr. Claus Roehrborn]
I suppose, theoretically, there is none. Now, that depends a little bit on how your setup is. In the 1980s studies were done on body temperature changes with irrigation. If you commit yourself to use body temperature saline irrigation for a bipolar TURP, I suppose you can keep on going. If you don't do that, then eventually the core temperature decreases, the longer you resect with room temperature normal saline, and eventually this becomes an issue. The patient becomes hypothermic and, as you know, coagulation parameters change and the patient doesn't do as well. But if you go with the warming, I presume you can keep going.

An argument against that is as follows: If you follow basic geometry and you calculate the inside surface area of a bowl or of a ball, the prostate ultimately becomes like a bowl, right? The opening is towards the bladder neck and the rest of it is this bowl-shaped configured prostatic capsule. The more you resect the larger the surface of that bowl gets. It's just the inside surface of what a ball would be on the outside. And it becomes harder and harder to stay oriented and to be good about your hemostasis. Particularly for trainees. They pretty soon get lost if the prostate is 60, 80, 90, 100 g in size and it's just harder and harder to execute this fully.

Secondly, if you have a very large prostate and you resect that, you have to do a lot of coagulation at the end. And you do all this coagulation and the patients oftentimes, 10 days, 14 days later, they shed this surface scab tissue and they start coming to the emergency room with fresh bleeding. So I must say that there are practical reasons, teaching reasons, training reasons, and also health reasons that I wouldn't do it. If I can do a robotic assisted enucleation in 90 minutes time, then I don't want to be there for three hours of general anesthesia time and approximate that effect with a bipolar TURP.

[Dr. Aditya Bagrodia]
Yeah, I wholeheartedly agree. Certainly in the bladder cancer world, I would say that a properly done transurethral resection of a bladder tumor is a case that requires a technical skill set and all TURBTs are not the same and similarly all TURPs are not the same and I appreciate you highlighting that. Last comment before we shift on from the large prostate world is you mentioned a four hour KTP. I think this is something that's an easy trap to fall into when it comes to doing KTP prostatectomy: you ablate for some amount of time, regardless of prostate size, you take a look from the veru into the bladder and say, "Yes, nice, good looking channel. Let's call it a day." And clearly you're going to be making a return trip here. Can you talk a little bit about what your number that you have in your head in terms of energy per gram so that when you look over at your KTP machine, you've got so many watts or joules or kilowatts--I can't even remember the unit anymore--and you say, "Yeah, I think I've done a good job."

[Dr. Claus Roehrborn]
The problem is that many surgeons who use KTP, they don't know the size of the prostate, so they are going in sort of blinded and then they start vaporizing and then they are saying, "Okay, now I'm done." And when you look back then with an imaging study, cross-sectional imaging, you realize that was just a very surface layer and he didn't really get to the bulk of the prostate. We see this all the time. Unfortunately, the kilojoules, that's what the unit is that we measure--kilojoule energy that is applied-- is not recorded by the device. The company, Boston Scientific, doesn't really know how many kilojoules each doctor applies for each treatment. I keep it fairly religiously and if I go in for, let's say, a 50 or 40g prostate, I want to end up with 200 kJ. And I would say that 200 kJ should ablate approximately 20g of tissue. I can do that, if I stay on the laser and I use about an energy of 150W or 160W, I can do that in approximately 20 minutes.

So these are my yardsticks. The time that the laser is on, and not that I'm looking around or the trainee's looking around, but the time the laser is on, the energy that I use, which ranges from 80 to 180, so I shoot for 160 as my top power setting, and then the total energy would be 10 kJ equating about a gram of tissue. That also happens to be a gram of tissue ablated by that laser per minute if you are efficient and if you know how to do it. If you are only in there and you turn the laser on and you are too far away, you don't create bubbles, you don't ablate the tissue, then all bets are off. I don't know how much tissue is ablated, maybe very little. So a well-trained, well-experienced KTP laser resectionist can do a gram a minute, and a 40 g prostate 200 kJ would be appropriate. I would probably do 300 kJ for a 60 g prostate.

[Dr. Aditya Bagrodia]
Okay, fantastic. I'll just try to briefly summarize. Large prostates, we're looking at bipolar TURP, can be technically challenging, comes with fluid and temperature changes, potential bleeding risks that are considerations. KTP prostatectomy, I think you need to be committed for the long haul to really get a good job and serve the patient well. Then you've got the simple prostatectomy, probably most frequently done via a minimally invasive approach with the benefit of avoiding an enucleation step, and of course conversely it is a transabdominal surgery. And then lastly HoLEP, minimally invasive option, technically challenging, limited to certain areas of expertise, and then the morcellation step. So that's really helpful I think, just to unpackage how to think about those. Maybe before we jump into more average size prostates and symptom, patient preference, anatomical considerations, I would ask you suprapubic tube at the time of surgery in patients with retention, is that something you do pretty reflexively? If you could just offer a thought on that.

[Dr. Claus Roehrborn]
Yeah, that's an unresolved issue in research in LUTS and BPH, and just as there is no answer for the detrusor hypocontractility, there are really unclear indications for it. I use a suprapubic tube in patients where I suspect that there will be a problem post-op with the resumption of normal urination and a voiding efficiency of greater than 50%. How do I do that? Well, I get my idea, my gestalt, from the phenotype. Is the patient young? Is the patient old? If he is already fairly old, does he have a high retention volume, is the voiding efficiency only 20, 30%, what does the bladder look like on ultrasound or on the MRI? Is it already heavily trabeculated? Does he have diverticular is there evidence for long standing obstruction? All of this would lead me to say, "Well, I put an SP tube in as a bladder retraining tool and let the patient come to a point where maybe his voiding efficiency improves to 70 or 80% and then take the tube out."

Every single factor changes it a little bit. For a patient has a lower retention volume and is younger, I would be less prone to do it. If I look inside and the bladder wall looks good and there is not too much in the way of trabeculation, I would be less inclined to do it. If I look in during the surgery and I realize the prostate really is visually obstructing and the lateral lobes are really compressing the urethra, oddly enough, I would be less likely to put an SP tube in because I'm thinking, "Well, this patient I can convert from a high retention volume to a low retention volume just by unobstructing him." The biggest risk is clearly an octogenarian with a high retention volume and a modest sized prostate and when you look in you see this heavy trabeculation with these fibrous strands run through like sails and diverticular everywhere and you realize the prostate isn't even that big. Then you know you are in trouble, and that patient gets an SP tube. Because to convert that patient to a normal urination would be very difficult.

(5) Treatment Options for Medium-Sized Prostates (30-80 g) and Substantial Median Lobes

[Dr. Aditya Bagrodia]
Okay, fantastic. Now we're moving away from the large prostates--the Texas-size prostates--more to average and smaller prostates and perhaps just to give the next layer of options some categorization and phylogeny.

[Dr. Claus Roehrborn]
Clearly for the average size prostate there are a plethora of things that can be done. Both the Rezum and the UroLift are recommended by the AUA guidelines between 30 and 80 g. This was done during the studies. This was the size range that was tested. The Teleflex or NeoTract company has also done a study in patients up to 100 g and the FDA approved UroLift but I personally don't like to use it above 80g. I think I stick with 30 to 80 g. In that same category is also HoLEP and ThuLEP. In the same category is the KTP laser. In the same category is the transurethral resection or even transurethral vaporization with electrocautery.

[Dr. Aditya Bagrodia]
Maybe I'll interrupt you for just a moment, Claus, and ask you, among all of these options, of which pretty much everything is available, how does the median lobe presence or absence affect your decision?

[Dr. Claus Roehrborn]
I think this is, fortunately, an insight that has made, finally, it's way into the guidelines, both the EAU and to some degree the AUA guidelines, the recognition that the intravesical lobe plays a major role. Starting with the least invasive. The Rezum treatment has clearly shown that if you put the needle in the median lobe, if it's present, you get a better improvement than if there's a median lobe and you don't put the needle in. So putting the needle in, injecting the steam, ablating that median lobe gets you a better improvement than if you leave it alone. So the Rezum works out okay for the median lobe. You'll likely have a longer catheterization time, but it in the end works out.

The UroLift is approved because there is a study that was done, called the MedLift study, where they took a UroLift device and sort of stapled that median lobe to the side. There's a risk in exposing that wire. There's a risk in maybe having material exposed to the urine and forming stones, and there's a risk it doesn't work if you don't do it a lot. So, I don't like to do it because I think there are other treatments available for it, but it is technically approved for it.

The KTP or GreenLight laser is a bit odd because it shoots down in a 70 degree forward motion, so if you vaporize over the median lobe, eventually you get through it and then you hit the trigone. And that's just something I don't like to do or teach the residents because when you hit the trigone you can easily hit the ureteral orifice and then you coagulate it and it's a question of do you put a stent up and how long and what are you going to do about it. So substantial median lobe, I don't like the KTP all that much, I have to admit. For substantial intravesical lobe I like preferentially to do a TURP because I can very elegantly lob that median lobe off without jeopardizing the trigone, the UOs, taking it flush off the bladder neck and I think that's the most elegant way of going about it.

If people want to stay minimally invasive they can do the Rezum, and if people have access to it they can use the Aquablation. But the Aquablation has its own limitations. In many cases after one passage of the water pressure, water pick ablation, the lowermost component of that intravesical lobe, which basically protrudes into the bladder like a tongue, still is there. It's not completely gone and you have to go in afterwards and take a loop and resect it--at least that last bit of it because the Aquablation often doesn't completely eliminate it. That has to do with the fact that the water pressure makes it bounce a little bit and as it bounces, it doesn't get ablated--it just evades the pressure. That's the best way of putting it.

So big decision point, the intravesical lobe. No medical therapy. Please don't give medical therapy for substantial intravesical lobe ever. Doesn't work and it's just a waste of time and money. Choose your weapon carefully. If you have access to not much then use your TURP loop. It's the best tool yet. If you have it and you're really good at it you can use the GreenLight laser. You certainly can use the HoLEP. The Aquablation, but caveat, you may have to resect tissue at the end of that Aquablation. And if you have the Rezum you can do it and stick the needle in. And use the UroLift only if you're really, really good at that because it's a technically difficult move to make.

[Dr. Aditya Bagrodia]
Okay. In summary, there isn't any contraindication to any of the technologies that are available, is that fair? Technically speaking.

[Dr. Claus Roehrborn]
Well, the FDA has approved the UroLift for a median lobe based on data the company submitted. The AUA guidelines do not recommend it. So you can take your cue from that. The MedLift study was not a sham control trial, a small cohort of patients, and done by a few expert surgeons, so that's the reason for that. I just think that if a practicing urologist sees that sort of thing, he should go with what works the best. And at the first go round. And to me it seems like if you have that ablating it with the loop is nearly ideal because you can put the loop under it, you can lift it up, you can then resect it, and it's done safely, just like you would a bladder tumor that looks like one of those trees that grows into the bladder where you go with the loop under and hook it, and you know you got to go down to the stem. The same here. You have to go down to the bladder neck where the median lobe originates from.

[Dr. Aditya Bagrodia]
Okay. Fantastic, fantastic. Median lobe, I think you've given us some guidance that TURP still carries the day as the gold standard in this clinical scenario. One momentary comment on is there even a role for monopolar TURP if you have both options available?

[Dr. Claus Roehrborn]
I am probably both old and old school. I actually like to do monopolar TURPs and I post my TURPs very specifically and in a differentiated manner for monopolar and bipolar. If I know the prostate size, if it's 40 g or 50 g or less I post it as a monopolar. There's several reasons for it. First of all, some of our trainees don't go into a hospital where the bipolar is immediately available. It's not available everywhere. Secondly, the bipolar resectoscope loop is $500, the monopolar is $150, so it's a big price difference. Thirdly, and Olympus and Storz will hate me for saying it, the monopolar loop, when you look at it, is much thinner. It's just like a really thin wire and the anatomical excavation of the prostate cavity can be done more elegantly and more precisely than with the bipolar loop. There's no question in my mind, but that might also be because I trained for decades on the monopolar.

So I still use it and I still see there's a role in it. I teach the residents: if you do a monopolar I don't care if it's 10 minutes or an hour, every time you get a BMP at the end, check your sodium, because if you do it you know it and if you don't do it you never know what happens. Fortunately, in smaller glands the sodium changes are very minimal and it's pretty safe.

(6) Preservation of Antegrade Ejaculation

[Dr. Aditya Bagrodia]
Okay, fantastic. If I may, for smaller glands of course there's going to be some considerations and perhaps I would ask for you to speak a little bit about transurethral incision of the prostate and even a little bit more broadly on options that are going to be prioritized when preservation of antegrade ejaculation is a priority.

[Dr. Claus Roehrborn]
It used to be said that ejaculation has to do a lot with the bladder neck and every time you mess with the bladder neck you get anejaculation or retrograde ejaculation. And then there is a school of thought that says the antegrade ejaculation hinges on the apical tissue that is right in front of the verumontanum. Currently, most people think that it's just the apical tissue that preserves the ejaculation. Now, just in our meeting this morning I raised this question because it is known that the incision of the bladder neck actually causes 30 to 50% retrograde ejaculation even if you don't come close to the verumontanum. So I'm old school there. I think the bladder neck must play a role in it, perhaps not the only role.

When patients come and they are really, really interested in ejaculation function, fortunately we have excellent studies that use the MSHQ ejaculation questionnaire and they with absolute 100% certainty guide you. The UroLift treatment has no impairment of ejaculation. Period--in no patient that is reported. The Rezum treatment has maybe in 5% maybe in a little bit more but not more than 10% of patients ejaculation impairment. For the incision of the bladder neck either at the six o'clock or four and eight o'clock, up to 30 or 50% of patients have retrograde ejaculation. The Aquablation, due to the fact that the water jet is stopped just shy of the apical tissue, has an ejaculation preservation that is surprisingly high, 95%. So the vast majority of Aquablation treatments enjoy normal ejaculation if you turn this device on so that, with the so-called butterfly cut, this hood of tissue in front of the verumontanum is preserved.

If a man comes in and says ejaculation trumps, then I'll look at him and say, "Okay, let me check your prostate size." If the prostate size is 30, 40, 50g I say, "Let's try a UroLift." If it's a really small prostate I say, "You can try a UroLift. We can also try an incision and I'm not carrying it all the way to the veru. We can see how that works." If it's a larger prostate I say, "Well, let's do the Aquablation treatment because that will give you the best chances of preserving antegrade ejaculation."

Now, full stop. There's a lot of surgeons who claim they can preserve ejaculation to 70, 80, 90% even doing a TURP, doing a GreenLight laser, doing a HoLEP, as long as they preserve this hood of tissue in front of the verumontanum. Well, the problem is that that doesn't seem to be easy to duplicate by others, A. B, the very principle of the HoLEP operation is to make an incision in the mucosa at the apical tissue, so that tissue by definition has to go as part of the package. So I'm really unclear on that. And most of these studies are single center, single investigator. So I'm less enthusiastic about this idea of leaving a little tissue behind close to the verumontanum and I secondarily don't believe you achieve the same efficacy necessarily. So, ejaculation preservation. UroLift tops. Rezum second for the smaller glands. Aquablation for the larger glands. And then comes all this artistry and the individual people who can do it, presumably, with good success, even when they do a standard TURP.

(7) Post-Operative Medical Management of BPH

[Dr. Aditya Bagrodia]
That's really nice, I think, practical, implementable information, Claus. Thank you for that. We're approaching an hour and there's so much that we could unpack, technical details and so forth. I wanted to get your thoughts and suggestions on what to do with medical management of BPH meds, finasteride, Flomax, and so forth, after you've done your outlet procedure. How do you typically manage that?

[Dr. Claus Roehrborn]
I follow up with my patients usually at one month, or shy of one month. I have everybody come in. I want to make sure the urine is clear, that they're urinating okay, that there's no issue, that they don't suddenly have urethral stricture or meatal stenosis or some other concerns and issues. And at that visit I make sure they stop any and all medication and I turn them off in Epic, which is very important because that way I can track whether they're off or not. I really think a surgery should obviate the need for any medical treatment. Period. Full stop.

Now, having said that, there are lots and lots of patients who take medications either throughout their postoperative period or they resume it afterwards again. And the number one medication following surgery are anticholinergics and beta-3 adrenergics because we don't always eliminate with the surgery the storage symptoms. The storage symptoms persist, and the patient goes back on anticholinergics. Is that our mistake, is that our problem? Maybe. Maybe it means we came too late. Maybe we came at a point when the bladder already is so irritable that these storage symptoms dominate and that the patient doesn't make a full recovery in respect to the storage symptoms. So I do that too. I have to because patients come in and say, "Doc, it's all great. The flow is great. Everything is wonderful. I still have this urgency. I still get up at night, and is there anything I can do?" And I say, "Okay, time limit. We'll take it for three months. I'll see you back in three months and we'll see how you do." Anticholinergics or beta-3 adrenergics.

Then comes another group of patients, not in my practice I hope, but there's another group of patients where they say, "Yeah, it's not so great. The flow is still kind of weak." Well, that's probably the bladder muscle and the patient didn't have invasive urodynamics, so you don't know how good the bladder muscle is. So what do doctors do? They give an alpha blocker. Now, that's the limit for me. If I trim out the prostate and the bladder neck, why should I think that alpha-adrenergic receptor blockade of the smooth muscle at the bladder neck plays any role? I don't. And since we know the alpha blocker treatment doesn't affect the detrusor muscle, and we have essentially no treatment that affects the detrusor muscle, I draw the line. I tell the patient, "Look, it's just a waste of money. And time. And effort. And it's just make-believe. An alpha blocker can't have a meaningful role after a well-executed TURP or KTP or HoLEP or Aquablation. So there's no such thing.

Next, 5ARIs. Yeah, there are some patients whose genes make their prostate grow back. I can't understand it. But you measure your baseline PSA after a TURP or an Aquablation or a RASP and it's low and then it goes back up and you say, "What is going on?" And if it's not cancer it's BPH tissue. So I have patients that are put on a 5ARI and okay, full disclosure, I put them on dutasteride a week. Every Sunday after church, I say. Why? Because I know that that prevents the regrowth. And it's cheap, it induces less side effects, and the patient feels he takes an active part in the regimen. So I have a lot of patients who take a single dutasteride every Sunday morning because I don't want their prostate to grow back and I've seen they can do it. Either genetically predisposed or by some other mechanism. So, as you can see, for every drug that can be given before or after surgery, I have a specific plan of action, if you will.

[Dr. Aditya Bagrodia]
Yeah, that's really nice. And you touched upon this, and I think this would be generally considered standard practice if you've allowed significant time after the outlet procedure and have persistent refractory symptoms, it's probably a good idea to get invasive urodynamics plus or minus cystoscopy to evaluate for bladder neck contracture or other anatomic issues and problems and then of course the function of the bladder and character of the outlet as well. Is that fair?

[Dr. Claus Roehrborn]
I cannot overemphasize that. I'm not a person that sends every patient to urodynamics but if you failed to improve the flow rate and the patient still has a crummy flow rate, the first question is not necessarily will an alpha blocker help? The first question should probably be, provided you did the surgery well, does this mean this patient's bladder is just done for? Does it generate any pressure? And at that moment you can assess that with a urodynamic study.

[Dr. Aditya Bagrodia]
Again, there's so many things that we could talk about. One clinical scenario that I think we encounter not infrequently that's of particular interest to me as an oncologist, are patients with fairly significant lower urinary tract symptoms requiring or requesting an outlet procedure who are ultimately going to receive radiation for prostate cancer. Any specific considerations in that type of patient?

[Dr. Claus Roehrborn]
If that's the case and if that's the clinical scenario, I would say that in that patient I would do not a KTP laser, I would do the cleanest TURP or a HoLEP because what I want to achieve is a clean surface that heals and epithelializes well and creates a symmetrical, nice, biconcave cavity so that the radiation physicist can do a proper planning and that the radiation is less likely to induce damage. If you give the radiation in a poorly healing field of necrotic, partially coagulated tissue, you probably induce a lot more symptoms than otherwise. So my number one goal is to go with the treatment that I know I can create a nice, symmetrical cavity. B, I leave behind the best chance for an epithelialization healing in the shortest period of time. And I guess another consideration is I wouldn't use Aquablation or KTP because I honestly feel like, since the patient has cancer, it gives an opportunity to analyze the tissue.

[Dr. Aditya Bagrodia]
All right, Claus. Well, I really thank you again for your insightful comments on surgical management of BPH. If I may take a stab at putting some words in your mouth, for a large prostate, enucleation such as HoLEP or simple prostatectomy, preferably minimally invasive, would be the preferred options. Average-sized prostates, lots to consider. All options are technically available, but it would seem if you have a median lobe that you would perhaps favor TURP or enucleation procedures, though the others may be appropriate perhaps in slightly more infirm patients or patients that have more of a frailty index or are on blood thinners. And then in this group as well as the small group prostates, when you're factoring in the prioritization of antegrade ejaculation preservation, there are some considerations where the UroLift procedure would be a good option, Rezum and Aquablation would be good options, incision of the prostate slash bladder neck would be a good option. Is that a fair practical take-home summary?

[Dr. Claus Roehrborn]
Yeah, I think that is a fair practical take-home summary. I also am in good standing with the AUA guidelines that come out at the AUA in Las Vegas this year. They are fully updated for both surgical and medical and they have an algorithm that encompasses both and what you just paraphrased is pretty much the tenor of the guidelines. The guidelines differ a little bit from the FDA. People are always worried why is the FDA saying this and why is the AUA saying that? You have to always remember the AUA guidelines make recommendations for the general practitioner in the best interest of their patient. The FDA takes into consideration just basically the study material submitted by a company. So there's often a little bit of a discrepancy there and I don't mind that at all. I think that's our professional prerogative to make differentiated judgements on these treatments. And what you just said is sort of my belief system.

[Dr. Aditya Bagrodia]
All right, Claus. Well, thank you again for your time and my wheels are already spinning about perhaps a surgical tips and tricks lecture series to have excellent outcomes, get patients safely through the whole experience. So I thank you. And thank you for listenership for tuning in.

[Dr. Claus Roehrborn]
Well, thank you very much for having me on the show.

Podcast Contributors

Dr. Claus Roehrborn

Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 23). Ep. 6 – Contemporary Surgical Management of BPH [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.