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Rezum Treatment: Procedure Complications & Recovery

Author Quynh-Chi Dang covers Rezum Treatment: Procedure Complications & Recovery on BackTable Urology

Quynh-Chi Dang • Oct 26, 2021 • 867 hits

Rezum Water Vapor Therapy is a surgical BPH treatment that uses water vapor to ablate excess prostate tissue, which is naturally resorbed by the body. For small prostates close to 80 grams and little median lobe protuberance, Rezum therapy is an effective surgical option. Urologists should avoid over-aggressive ablation, as it can cause Rezum procedure complications such as bleeding and permanent lower urinary tract irritative symptoms. For Rezum recovery, patients will need post-operative anti-inflammatories, stool softeners, and a post-operative catheter.

Urologist Dr. Francisco Gelpi discusses when he uses Rezum and explains his technique on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Urology Brief

• While performing a cystoscopy during the initial BPH patient evaluation, prostate size, protuberant median lobes, and bilobar obstruction can guide decisions between surgical choices.

• When deciding between Rezum vs. UroLift therapy, the presence of a median lobe should be noted. Rezum therapy is ideal for 80-90 gram prostates with minor median lobes.

• Post-operative lower urinary tract irritation is a common Rezum side effect. These irritative symptoms usually wane once Rezum recovery and prostate tissue remodeling is complete.

• Patients should be prescribed anti-inflammatories (meloxicam), stool softeners (colace), and analgesics (pyridium) after surgery.

A backtable set up for Rezum Water Vapor Therapy

Table of Contents

(1) Rezum vs. UroLift for Smaller Prostates

(2) Surgical Tips for Minimizing Rezum Procedure Complications

(3) Post-Operative Medication Regimen for Rezum Recovery

Rezum vs. UroLift for Smaller Prostates

Dr. Francisco Gelpi emphasizes the importance of prostate anatomy when deciding on a BPH surgical intervention. While performing a cystoscopy during the initial BPH patient evaluation, he looks for specific anatomical features, such as prostate size, protuberant median lobes, and bilobar obstruction.

If the prostate is under 80 grams and only a bilobar obstruction is present, he prefers the UroLift because it provides instant patient relief and does not require a post-operative catheter. If the prostate is smaller or close to 80 grams and a median lobe is present, he evaluates its protuberance. For prostates with little protuberance, he prefers Rezum therapy. For Rezum recovery, patients will need post-operative anti-inflammatories, stool softeners, and a post-operative catheter.

For larger prostates with a large protuberant lobe, he will choose GreenLight laser therapy.

[Dr. Jose Silva]
...So Paco, after you do the UroCuff, how do you decide whether to go with UroLift, GreenLight, or Rezum?

[Dr. Francisco Gelpi]
So again, it's a very involved conversation with the guy, right? I need to be very, very emphatic about the importance of setting expectations. So when you have these conversations, what is the priority for the patient? Is it just bladder health? Is it getting rid of the nasty side effects of the medication? Do they want to preserve their ability to ejaculate? Is it not that big of a deal for them? So there's a number of different layers to that conversation. In order to simplify it as much as possible, I ask myself during the cystoscopy: okay, does this guy have any sort of median lobe, or does he only have bilobar obstruction? Then, what is the size of this prostate?

I tackle, for instance, Rezum prostates that I know that are larger than what's supposed to be done, but I have the conversation with the patient. You explain to them that this might be pushing the envelope, but some are willing to give it a shot. Yeah, we might give it a couple more injections than we otherwise would have. But again, in order to simplify it, I normally think if it's bilobar and it's smaller than 80 grams, I typically prefer UroLift. I like the Urolift a lot because it's a very easy way of getting a patient to stop medications, leave the SC and be happy, not need a catheter, and basically start experiencing improvement of symptoms almost immediately.

If there is a median lobe, then it all depends on how protuberant that is. I've started doing some of these UroLifts with the median lobe, but my preferred option for the younger guy with a prostate smaller than 80 gram prostate is probably going to be Rezum. Now Rezum is interesting because I think it's a great tool, but you have to be very careful how you sell that procedure to the patient. You have to be clear about explaining that things are going to get worse before they get better. It’s likely that they will be uncomfortable for a number of weeks. The way I handle that is to let everyone go on anti-inflammatories, stool softeners, and keep a catheter for about a week.

That was one of my mistakes at the beginning. I probably left it for a little shorter than I should have. So but once you start re-visiting and refining those things, you can explain to them and they're fine. And then anything larger than that, in particular, if there's a large protuberant median lobe, it's likely going to be a GreenLight, unless it's someone that is open to the option of robotic simple prostatectomy. I normally reserve for robotic prostatectomies for prostates with very, very large intravesical median lobes. You can just get the procedure done so much quicker than being there for a while with the GreenLight. So that's it in a nutshell, how I kind of think and navigate these things.

Listen to the Full Podcast

Patient Selection for GreenLight & Other BPH Treatments with Dr. Francisco Gelpi and Dr. Jose Silva on the BackTable Urology Podcast)
Ep 14 Patient Selection for GreenLight & Other BPH Treatments with Dr. Francisco Gelpi and Dr. Jose Silva
00:00 / 01:04

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Surgical Tips for Minimizing Rezum Procedure Complications

Dr. Gelpi usually performs Rezum therapy on 80-90 gram prostates that cannot be alleviated by the UroLift procedure. Wiith Rezum, it is common for patients to experience post-operative irritative symptoms during Rezum recovery due to the process of prostate tissue resorption. Dr. Gelpi also advises against over-treating the prostate with Rezum, as an aggressive approach can cause Rezum procedure complications, such as bleeding and permanent irritative symptoms. Instead, he focuses on widening the urethra enough to establish regular urine flow and stops surgical intervention shortly thereafter.

[Dr. Jose Silva]
So Paco, for Rezum, you mentioned the intravesical component of that median lobe. Is there a threshold of how big you're going to tackle that median lobe? Is it a matter of size? Do you evaluate that during the cystoscopy?

[Dr. Francisco Gelpi]
So I call Rezum the “leap of faith procedure”, because you do the case and you think, “Holy moly, please work, please work,” because you really don't see anything major that tells you that it’s going to work.

[Dr. Jose Silva]
No, it actually looks worse.

[Dr. Francisco Gelpi]
Yeah, if anything. Again, that's why I've sort of utilized that 80 gram threshold. I think the largest I treated was 130 grams, and the guy's doing perfectly fine. However, normally in order for me to find a happy medium, I ask myself, “Where do you have enough tissue?”

I don't want to overdo it and get overconfident, but it's between 80 and 90 grams. When I do the cystoscopy, obviously I'm looking for how much of that component to that central or median lobe is present. And then I kind of start planning, okay, is this going to be just one needle stick in the central gland? Am I going to do two, one on each side? The way that I sell this procedure to guys, I tell them, “Hey, we are trying to deflate your prostate.”

And I kind of look at it that way. Have you ever had to scope any of these guys?

[Dr. Jose Silva]
I haven't. I haven't. I started recently. So they're doing very well, but I haven't had to scope them again for now.

[Dr. Francisco Gelpi]
Oh no, it's impressive. I had a guy in particular who kept having irritated symptoms, so we did the UroFlow. We then did a UroCuff, no signs of obstruction--but he continued insisting that he was obstructed. And when I put the scope in, the thing was completely deflated. So yeah, that's why I'm saying, it's a leap of faith case. Again, you have to set up expectations very clearly from the get-go. I normally joke with them about that. I tell them, “Hey, you're going to love me, then you're going to hate me, and then you're going to love me again.” So there's a component of handholding and giving them peace of mind, but it works. In the right guy, I think it's a great, great tool.

[Dr. Jose Silva]
And that patient is still complaining of irritation or he's doing good?

[Dr. Francisco Gelpi]
No, he's doing fine. I mean, again, this is a very complex conversation. I get it. It's a very abstract thing for patients to understand. Right. You're basically telling them, hey, you've been an athlete for all your life. And all of a sudden you're going to sit that guy, and he wants to get out there. That's what happens to your bladder. Your bladder kind of gets a little unstable, and you just need to allow for the remodeling phase to take place. And the symptoms stopped, but it took a while for him to finally get it.

[Dr. Jose Silva]
Exactly. And then yeah, some patients do develop that overactivity, even with GreenLight, with the symptoms but like you mentioned. It's just that part of the bladder, and we are adjusting to the openness they're going to have now. So Paco, in terms of treatments, I know the reps always emphasize not over-treating the prostate. The data also suggests that more is not better.

[Dr. Francisco Gelpi]
Yeah, so I will tell you one thing that I learned from UroLift . What I'm going to explain in a second is a little abstract. So bear with me, but the whole premise of UroLift is creating that into your channel, right? So going back to our training, where the main idea is: hey, I have to do that TURP that will resect every last bit of tissue so that it's as open and wide as possible, right? But the reality is you don't need to do that. The diameter of the urethra basically will dictate the flow. So why do we need to make this very large posterior fossa and get it all well resected, if it's going to funnel into whatever the diameter of the urethra is? So I've sort of incorporated some of those ideas into the way that I do my GreenLights, into the way that I do my Rezums. So yes, when I do a GreenLight, do I want it to be complete wide open? Of course, but I really concentrate and focus on making an interior channel that kind of mimics what UroLift would have done.

And going back to your point by being a little bit more selective and specific in that regard, the amount of irritated symptoms that I've seen in the last year or two have plummeted. And just because you want to do good enough that you get them to pee, that they're comfortable, they have a good flow, and you don't want to overdo it. And now you have to deal with that nasty bleeding that could happen or that burning or stinging that they sometimes complain about when you're a little too aggressive. So yeah, the little things that you kind of start changing matter as far as technique. And it's basically helped me drastically.

Post-Operative Medication Regimen for Rezum Recovery

Dr. Gelpi prescribes 3 post-operative medications: pyridium, colace, and meloxicam for Rezum recovery. Dr. Gelpi notes that meloxicam is an effective anti-inflammatory drug and prescribes 15 mg a day to his young patients and 7.5 mg to his older patients.

[Dr. Jose Silva]
So you mentioned the medications you give the patients. Do you usually give the same medications for Rezum, UroLift and GreenLight patients?

[Dr. Francisco Gelpi]
Yeah, I had to simplify it for my scheduler because she used to mess things up big time. So any procedure that I do for the prostate in that regard, it's always the three, it's Pyridium, Colace and Meloxicam.

[Dr. Jose Silva]
From Dr. Gonzalez, that's what he recommends and that's what I use.

[Dr. Francisco Gelpi]
I think it makes a huge difference, particularly the anti-inflammatory part of it. So I've been doing it now for a while. Why Meloxicam and not others? I mean, it's just because it's the one that people typically like here at Houston.

[Dr. Jose Silva]
Are you doing the 50 milligrams once daily or 7.5 milligrams twice daily?

[Dr. Francisco Gelpi]
It depends on the age, but normally the 7.5 milligrams daily if they are older and I'm a little concerned about their renal function. If they're younger then I give them the full 15 milligrams and they do perfectly fine.

[Dr. Jose Silva]
So I started doing this back in Puerto Rico. I started doing 7.5 milligrams twice daily for no specific reason. I mean, it's just the same thing.

[Dr. Francisco Gelpi]
Yeah. It's just to help them with that inflammatory phase that everyone's going to go through.

Podcast Contributors

Dr. Francisco Gelpi discusses Patient Selection for GreenLight & Other BPH Treatments on the BackTable 14 Podcast

Dr. Francisco Gelpi

Dr. Francisco Gelpi is a private practice Urologist in Houston, Texas.

Dr. Jose Silva discusses Patient Selection for GreenLight & Other BPH Treatments on the BackTable 14 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2021, August 25). Ep. 14 – Patient Selection for GreenLight & Other BPH Treatments [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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