Rezum Post-Procedure: Symptoms, Recovery, & Medications

[Dr. Silva]
What do you tell the patient preoperatively what to expect after the Rezum?

[Dr. Bechis]
This is where I think I've evolved a little bit in my practice. I think like any procedure, patients go on the internet and they read Dr. Google, and so they often come in with expectations or ideas that may not quite be accurate. I usually counsel them.

First and foremost, they do get a catheter. For my practice, I typically leave it in three days. I used to do two days. I probably can go back to that someday, but I just found at two days, every once in a while, I would get someone who went back into retention. I moved to three days and I haven't really had any trouble with failing void trials.

If the prostate is larger like over 70 grams and certainly over 80 grams, then I typically will leave it in five to seven days. I explain to them, "The reason for this is just physics. You have a larger volume of tissue, we blast it with steam, the entire area gets swollen and you're not able to urinate. It takes time for all that swelling and tissue changes to start to occur."

That's, I think, the big one. A lot of men are like, "Oh, it's a minimally invasive procedure, but wait, I need a catheter?" I'm like, "Yes. It's worth it. If you can put up with the catheter for three days, seven days, and get through it to preserve ejaculation and have a pretty minimal recovery is great.”

Then I usually tell them, "You're not going to see a change right away. You might see it as early as three weeks. You might start to see improvement in your symptoms but it may take up to three months. Certainly, by three to six months is when the studies would show that that's when you see your maximum improvement. Even if you're not feeling there's a difference at three weeks, be patient, it's going to take time."

Then I also tell them, "There's a chance in my practice. It's probably about one in four men may have a worsening of irritative symptoms." For, me actually, the symptom that people pick up if they're going to get something is urethral pain. It's pain at the tip of the penis. I find it's right at the end of voiding, sort of a terminal voiding pain. If you ask them where it is, they always point to the tip of the penis. I think it's related to prostate inflammation because of the nerves for the prostate and the penal urethra are similar. I think it's just inflammation in that area.

[Dr. Silva]
Seth, you mentioned the patient, you see it three days after we do the voiding trial, then six weeks after. Then what? If the patient is doing good, symptoms are better, three months afterwards, or when do you see them again?

[Dr. Bechis]
They'll have a nurse visit at three days to take out the catheter, and then I'll usually see them around six weeks. Partly research-driven, we'll typically do a PVR and a uroflow partly for academic kind of collecting our data on it. Then if they're doing well, I'll usually see them back at three months, and then we'll definitely do an IPSS and a uroflow and a PVR and compare it to the pre-op.

I think some early data we're finding is maybe the IPSS score early on is an indicator of whether they're going to have some irritative symptoms during the Rezum recovery. I think at that six-week mark, usually, if they had some short-term irritative symptoms, they would be gone by then.

I usually joke to the patient before surgery. I say, "I'm going to wait till six weeks to see you because then you'll be really on the road to improvement." If they are having trouble at six weeks, if I haven't considered Celebrex for example, I'll try that, or rarely would I add a beta3 agonist. Although it's pretty unusual, to be honest. Usually, at six weeks they're doing really well.

Then I'll do a three-month follow-up and then usually after that, I joke. We had a MA who would make a certificate of graduation and so we would give it to them at the three-month visit or even the six-month and then send them on their way.

[Dr. Silva]
That's an excuse to just get one patient out of the office and try to get new patients in.

[Dr. Bechis]
Giving them a certificate is great because otherwise they always want to keep coming back every three to six months. They're so used to that from having medicines titrated and you're like, “You don't need that anymore. Once a year or just see your PCP and give me a call.” I would say obviously following their PSA annually, even after this procedure, but I usually defer that to the primary care if possible just to free up space to see new patients.

[Dr. Silva]
In terms of PSA, I have seen patients that the PSA after Rezum procedure goes up. I had a patient, I saw him last week, and I did a Rezum two or three month ago. The PSA was high, baseline it was very low. I told him, "Hey, don't worry. Let's just wait a couple of months." Sometimes it takes a while for that PSA to go down.

[Dr. Bechis]
I usually try to avoid it for six months just because I've run into that. You get a super anxious patient who for whatever reason is able to check his PSA every three to six months because he is just nervous. Then someone writes him an order and he checks it after the Rezum, and then it leads you down a rabbit hole just following them until they come down again.

[Dr. Silva]
Most of the time just the patient has the annual exam with the primary and they include just part of it, and it's high. Then the patient calls, they're concerned, “Let's wait, let's wait. You had a great one last year. Let's not jump into the conclusions.”

I was going to mention. I had a patient, I think for now hopefully it's the only Rezum fail that I had. I took the patient to the OR and when I was there, it was actually open. When I did his cystoscopy in the office, it looked closed, but in the OR it was open. I was already there. I did a laser afterwards. I showed the wife, "Hey, most likely it's not the prostate," it was a patient that continued with some frequency, urgency, uncontrolled diabetes, so probably just that.

[Dr. Bechis]
Was there a lot of tissue to laser? Did you incise the bladder neck, or what did you see? That's typically what I would do just because that's all there's left.

[Dr. Silva]
I didn't want to add any… but it was open. He was open. He was good. Usually, when I do a GreenLight, do a… so I open up the lateral lobes more, but it was nothing. He was open.

[Dr. Bechis]
I think that's probably the one area that I think in general, I know we touched on it earlier, is that the days of seeing just a purely obstructive picture seem to be less frequent. Patients have more and more of these mixed pictures. I don't know if that's just because there's more prevalence of diabetes and metabolic syndrome and obesity, or maybe people are just having more bladder changes from obstruction and they're getting this urgency-frequency stuff.

I think it's tricky. You just have to really counsel them because there are times where you do a great procedure and you feel like it's going to be perfect, and then they come out and their flow is stronger, but then they're like, "I'm still having all these other storage symptoms." I think that's the one population where sometimes it's tricky because sometimes you still need to treat the outlet just to rule that out and to say you've done it, because if you just treat the overactive symptoms, you're like, "I don't know."

[Dr. Silva]
Exactly. You do the urodynamics after and it gives you mixed results, some other activity, but there might be some outlets still. It force you to go to take the patient to the OR again.

[Dr. Bechis]
The equivocal for obstruction is the worst. It's like moderate detrusorize with low flow, equivocal for obstruction, and you're like, "Great. Now what do I do?"

[Dr. Silva]
You need to tell the patient, "We need to do it again," or do something. I take pictures and, "Hey, you look open. Let's see." I open it a little bit more, but it was open.

[Dr. Bechis]
I would say that's another point I forgot to mention earlier, when you're counseling them upfront about their options. Sometimes if a patient is, I don't know, mid 60s, sometimes they think that maintaining antegrade ejaculation is really important for now.

That's another point that I forgot to say that I'll mention, is I'll say to them, "The nice thing about this procedure, too, is let's say you get it, and let's say you're one of the unlucky 4% who needs another retreatment, in five years, maybe by then we could either do it again. By then if your priorities change and maybe preserving ejaculation is less important, you could always do a different procedure then if you need it." I think the nice thing is it gives you that flexibility. You don't really take anything off the table early on.

I used to joke with patients that I think every man when they hit 55 or 60 should just get a prophylactic Rezum, keep things open. [chuckles]

[Dr. Silva]
That's the thing. I think I see every day patients, "I have a big prostate." "Your symptom score is zero." "No, but I have a big prostate." "We don't do anything about that. We treat the symptoms, sir." At some point, I think we're going to start doing something like that because the patients want it. If eventually in a couple of years, they're going to have problems-- That's the thing, we don't know who's going to have problems or not. Maybe there's going to be data in the future that probably likely we're going to be doing Rezums.

[Dr. Bechis]
Yes, that's the holy grail. When you pull that trigger?

[Dr. Silva]
Exactly. Seth, anything else you want to add?

[Dr. Bechis]
No, I think this has been great. I think one of the exciting things in this arena that we talked about is just how prevalent BPH is. So many men have it. It's such an expensive, costly disease to the health care system. Obviously, you're balancing functional outcomes, but also quality of life and symptom score and patient satisfaction. There's so many options out there, but I think really customizing your treatment plan with the patient's goals is important.

I think that's probably partly why setting expectations upfront and talking through. I think at least the approach I take is really trying to make sure every step of the way they understand the next step and what are the outcome, because I think there's often many ways to treat the same problem, right? Having the patient buying into their treatment plan is ultimately really important.

[Dr. Silva]
Exactly. That's beautifully said. Looking forward also for the next indications of Rezum. [chuckles] I heard that they're expanding the indications for bigger process. Hopefully, they'll come out with the data soon and we can offer it to more patients.