The Evolution of BPH Surgery: From TURP to Minimally Invasive Therapies

[Dr. Jose Silva]:
Awesome. Awesome. Today we'll be talking about body dysfunction, BPH, and essentially talk about how you go about seeing the patient and getting the patient to the clinic, doing the workup, deciding what type of treatment is best fit for that patient. Before we start, let's just go back to residency. What were you doing to your piece? What was going on? What was going on at that time?

[Dr. Shawn West]:
At that point in time, and I think this was the AUA Guidelines at that point in time, and clearly the teaching-- My Residency was 2003 to 2008, it was alpha blockers, then Finasteride. The patients that we were doing surgical intervention on were patients that typically were either in retention, they were having recurrent urinary tract infections. They were having bladder stones, or just were absolutely miserable that they showed up at your doorstep.

Obviously, for better, I believe that paradigm is starting to shift. The AUA Guidelines have taken some time to follow suit with more, I think, aggressive is not the word, but more proactive intervention in bladder health and voiding dysfunction. In training, obviously we had a training at the VA, and we did a lot of TURPs at that point in time. Our VA was one of the first in the State.

You have a GreenLight laser, when that technology came out, the first generation. We started doing some GreenLight TURPs at that point in time. As far as minimally invasive, it wasn't on the map. We didn't do TUNAs or, any of the thermotherapies that were being offered at that time during Residency. To be quite frank with you, I think the medical workup for BPH wasn't anything that was really focused upon in a lot of residencies at that point in time.

These were people that just showed up in the hospital with retention, or showed up with bilateral hydronephrosis, or they showed up with a bladder stone. Part of that's just the nature of a Residency program. It is a different situation than when you get on to private practice, where a third of your patients are there for some sort of voiding dysfunction. That mindset has to change. That was the training at that point in time.

[Dr. Jose Silva]:
Yes. I had a similar experience, like you mentioned. No talk about bladder health whatsoever at that time. TURPs, open suprapubic removal of the prostate.

[Dr. Shawn West]:
Right.

[Dr. Jose Silva]:
Essentially that. A little bit of GreenLight. I got a little bit of GreenLight my senior year. Mainly it's TURP, and it was, like you mentioned, those TURPs that are big problems. Nobody in the community wants to take care of them. Just go to the ER, get a Foli, and we'll start from there.

[Dr. Shawn West]:
Absolutely.

[Dr. Jose Silva]:
Most of the patients that we saw in Residency, they already had a catheter.

[Dr. Shawn West]:
Yes. You're exactly right.

[Dr. Jose Silva]:
You started private practice. You have TURP, really not much minimally invasive techniques in that moment. You mentioned the GreenLight. I think that it was a 60 watt, the first one, and then they do 120. How do you evolve? Myself, I try to just be on top of technology and just, not just from the patient's perspective, but from my own perspective, just to be ahead of time and to not get used to everything, to the norm, like to get used to just doing TURPs every day. The challenge, I will put it that way. Challenge of new technology and just be ahead of the curve. How was it for you?

[Dr. Shawn West]:
I think you bring up a great point. When I came out, I was doing TURPs for bigger glands and then GreenLights. That was really the options that we had. I too tried to stay up with technology. In my training, I did a lot of laparoscopic surgery also, and did some robotic stuff and continue to flourish, add that to my practice. When these technologies came out, I felt like this was something just based upon some of the early data and some of the research data that these were things that we needed to be able to offer to our patients.

Interestingly, oftentimes the patients are the ones who start bringing these things up, either based upon marketing or their own research. With the internet now, this isn't a situation, 40 years ago where you go to the doctor and he tells you, "This is what you're going to do," and you don't know if that's the best option or if that's your only option. Patients, there's a, I'm sure you have it in your practice too, they come in with what they think they should have.

That can be good or bad. Essentially, you have to be able to have conversations about things that are cutting edge, things that are minimally invasive. That's a buzzword, whether you're talking about surgery, whether you're talking about minimally invasive subspecialties, as far as ENT, and orthopedics, and cardiology, everything's shifting that way. Coming out of practice, you're trying to keep yourself sharp in some of those early things. UroLift, it was around, I think, 2016 or '17, where that really started to manifest itself as one of the minimally invasive options that was on the market.

[Dr. Jose Silva]:
Yes. NeoTract, now Teleflex, they definitely did a great job in advertising and getting those patients in the office asking, "Hey, I want that. I want that."

[Dr. Shawn West]:
That's exactly right. I had several patients ask me about it before I even really took it seriously as far as taking the next steps of becoming comfortable with that technology. They did a good job of not only marketing that to physicians, but also to patients, they said, "Hey, we have this litany of research that shows we can do this maybe a little better than the other options that you have." Maybe you don't need the sledgehammer right off the bat just because of the side effect profile and potential complication risk of the TURPS. They hit it from both sides, and I think they were very successful in that.

[Dr. Jose Silva]:
Shawn, so let's go specifically into UroLift or minimally invasive techniques. Other than size, what else you see? Let's say, you do a cystoscopy in the office, what will tell you, "Hey, you might not be a candidate for UroLift?

[Dr. Shawn West]:
Yes, I tell you, one of the things is, you talked about median lobes as far as what does that look like? Is that patient a patient that you take off the table? That's where ultrasound comes into advantage for me because I've had a lot of success with treating median lobes with UroLift. Those are the guys that you de-obstruct so quickly that on their post-op visit, they're bringing you bottles of alcohol and wine, [chuckles] and things like that.

I do not shy away from a median lobe, as long as it's not a pedunculated, ball-valving, large gland. The one that I always look at that I say, "This isn't going to work," is the one that looks like the entire floor of the prostate is raised. If I can get to the bladder neck and I can see a sulcus on either side of the prostate, I have a pretty good chance of pinning that tissue up and out of the way.

Now, oftentimes a median lobe will auto select these patients out from UroLift. I do preceptor ships and everybody wants to see a median lobe, "Well, let's see a median lobe." Oftentimes if you have a large median lobe or a median lobe, the other lobes of your prostate are large too. Sometimes that kicks them out of that a hundred milliliter range. I think if someone does not have a sulcus, that they have a fixed floor of the prostate, that's one that's not going to do well with a UroLift.

The most challenging ones in my opinion are the patient who has a raised bladder neck. They have interior tissue and oftentimes they'll have a short prosthetic urethra. Those can be very challenging. Fortunately, some of the technique has evolved to where we're obviously moving more interior with those initial bladder neck implants. That's raising the roof, so to speak, of the prosthetic urethra. Those are ones that I'm always looking at what degree of angle they have. Am I going to be able to negotiate this? Those are the big ones. I do not exclude someone who's had radiation. I think that's still a very viable option for UroLift.

You and I know, at least I know early in my training, the patient had radiation or had seeds, but they have adenoma around the prosthetic urethra. They're miserable and doing a TURP or any intervention on them is very, very challenging just from their prosthetic, the lack of vascularity, and how that tissue doesn't heal. I think UroLift in that cohort of patients is a great option to try to deal with some of the obstruction without worrying about prosthetic calcification, bladder neck contracture, urethral stricture, bulbar stricture, all of those things that, we associate with doing any type of ablative intervention for someone who's had radiation to their prostate.

[Dr. Jose Silva]:
You mentioned the medial lobe. For me, also this happened, when I started doing UroLift, I did a lot of GreenLight at that time. I did a cystoscopy in the office, but then when I went to the OR, the medial lobe didn't seem that big. Then, "Well, this could have been a candidate for UroLift."

[Dr. Shawn West]:
Right.

[Dr. Jose Silva]:
Also knowing that discrepancy and knowing that it maybe it's not as big as it seems, that's where the ultrasound plays a role.

[Dr. Shawn West]:
That's exactly right. I've had patients where I put on my HNP, slight median lobe but no intravascular protrusion. Then when you put those initial two bladder neck implants, it stretches that out and there's essentially no median lobe tissue at all. It's completely flattened out. You're exactly right. What often we think is a median lobe, that ultrasound, especially the transverse ultrasound, that'll help you out. If you don't see a large volume of tissue in that bladder space, then that oftentimes will flatten out.

The other thing with UroLift is now with that advanced tissue control device. Essentially it's almost like a tennis racket and it really allows you some control over that median lobe tissue to pin that infralaterally. That, to me, has made that technique a lot easier in managing the median lobes. You're exactly right. I think some of this is that we think's a median lobe, you get in there, you pin those lateral lobes away at the bladder neck, and a lot of that median lobe tissue flattens out real nicely.

[Dr. Jose Silva]:
Shawn, are you doing these cases in the OR, or in the office, ASC?

[Dr. Shawn West]:
Most of them I'm doing in ASC. We were doing a fair number under nitrous in the office and those actually went fairly well. I think you can tell how a patient tolerates a cystoscopy, how well they're going to do from a nitrous standpoint. Obviously sometimes an older patient is a little easier to relax than a younger patient. If I've got a guy with a high bladder neck and he's 52-years-old, I'm going to have to apply a fair amount of pressure to really open that up. He may not be the best office candidate.

From a logistical standpoint, to be honest with you, it was just carrying the device, and purchasing that amount and holding that month to month to do them in the office setting. For me, I do them in the ASC. They obviously purchased the implants. We're working on some things now to where we can get some of these back in the office. We are working towards that. I should be shifting some of that back into the office. The ones in the hospital, I'll tell you, I'll typically do the larger glands in the office. Because the coding and billing from an ASC is a little different than an inpatient, remember, we can place seven implants.

I've not done that often, but you're allowed seven implants at one setting. I clearly don't want to do that at an ambulatory surgery center. That would obviously upset them. They would lose a significant amount of money. If I've got a patient with a bigger gland or someone, I know I'm going to definitely need at least six implants on them. They've got a long prosthetic urethra or I know they have a large median lobe and we're going to need to use an extra implant on that. Sometimes I'll do those in the hospital just from a reimbursement standpoint for the surgery center.

[Dr. Jose Silva]:
Yes. I will say when I started doing the UroLift, my delivery in terms of the patient saying, "Hey--" I do them in the OR because I don't have an ASC close to where the office is. The patients got scared when you say OR. Some of them don't want to go to the OR. It's more expensive or also they think they're going to go on the general anesthesia.

[Dr. Shawn West]:
Sure.

[Dr. Jose Silva]:
I started changing the delivery. I also talked to anesthesia, "Hey, these patients that get UroLift, they're going to go on their sedation, deep sedation, and it's going to be a 5, 10 minute case."

[Dr. Shawn West]:
Right.

[Dr. Jose Silva]:
When you start having that process, definitely the patient, "Okay, that's fine. You're going to put me to sleep a little bit, but then I can go home."

[Dr. Shawn West]:
Right.

[Dr. Jose Silva]:
The patient is more willing to do that because then they will say, "Well, if you're going to take me to the OR, let's do something more aggressive. If you're already going to--"

[Dr. Shawn West]:
You bring up a great point. I think that's part of the delivery part where all of the patients that we do in the surgery center, we ask the anesthesia, "Hey, let's try to do this under Propofol." If there's an airway issue or someone that has bad OS, sleep apnea, sometimes I'll do an LMA. The majority of mine, we do them under Propofol. It's clean. They wake up, they feel, they don't feel like they've been knocked out.

Those patients also have a better chance of avoiding trial if you don't want to leave a catheter in place. If you give them general anesthetic, it just takes a little bit longer, I think for them to wake up from that. The ones that you're going to leave a catheter out, I think the Propofol is the right way to go, for sure. You're right. Hey, this is just a quick outpatient procedure. We'll put you under just almost like a colonoscopy, and those kinds of word associations evoke more of a sense of calm about what you're doing as opposed to we're doing surgery.