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BackTable / Urology / Article
Rezum Treatment for BPH: Who Is The Ideal Patient?
Zachary Schmitz • Aug 21, 2023 • 297 hits
Rezum is one of many minimally invasive procedures that is used to treat benign prostatic hyperplasia (BPH) symptoms. When is Rezum treatment appropriate, where does it sit within the BPH treatment algorithm, and who is the ideal candidate? To answer these questions, Urologist Dr. Seth Bechis describes his approach to Rezum workup, including his process of initial treatment for BPH, and identifying ideal Rezum patients.
This article features transcripts for the BackTable Urology Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Urology Brief
• Initial workup of the BPH patient generally involves patient history and physical examination, determining a baseline IPSS score, and conducting urinalysis and PVR tests. Common symptoms of BPH include urinary frequency, urgency, and a slow stream.
• Initial treatment for BPH often involves a trial of medical therapy, typically with an alpha blocker like tamsulosin. The patient's response to medication can inform future treatment decisions, including the consideration of surgical interventions. Patient preference plays a critical role in decision-making about medical versus surgical management.
• Dr. Bechis suggests that for patients failing initial treatment, alternative pharmacological options or surgical interventions may be considered. To obtain a comprehensive understanding of the patient's anatomy, imaging techniques such as cystoscopy and transrectal ultrasound are used pre-procedure.
• Rezum is suitable for a wide range of patients, including elderly patients, those with poor heart conditions, those on blood-thinning medications, and young men. Compared to other surgical procedures like TURP and GreenLight, Rezum treatment results are gradual, taking between six weeks to three months to manifest, and the recovery is less restrictive, allowing patients to engage in activities sooner.
• Rezum may be preferable for patients who prioritize the preservation of antegrade ejaculation and those with storage symptoms such as urgency and frequency, as it causes less severe change in symptoms during recovery.
Table of Contents
(1) Managing the BPH Patient: Initial Assessment & First-Line Medical Therapy
(2) When First-Line Therapy Fails: Alternative Pharmacological Options & Surgical Interventions
(3) Rezum Treatment for BPH: Who Is The Ideal Patient?
Managing the BPH Patient: Initial Assessment & First-Line Medical Therapy
Dr. Jose Silva and Dr. Bechis discuss the initial meet-up with patients presenting symptoms of benign prostatic hyperplasia (BPH). Patients typically fall into two categories: those who self-refer without prior workup, and those referred by primary care providers with some level of workup already conducted. A typical workup involves understanding the patient's history and physical examination, calculating a baseline IPSS score, and conducting urinalysis and post-void residual (PVR) tests to understand urinary health and rule out infections. Initial symptoms often include frequency, urgency, and slow stream. Initial treatment includes medical therapy to test the patient's response, with alpha blockers like tamsulosin being commonly used. The physicians emphasized that alpha blocking therapy can be experimental and does not necessarily commit the patient to long-term medication use. Initial therapy sets the stage for considering surgical interventions if necessary, though some patients might not want or tolerate medication due to side effects.
[Dr. Silva]
Now, I'm very excited to do this episode. BPH is probably one of the most common things that I do, so definitely talking about Rezum and everything that goes with it is very exciting. Seth, a patient goes to your office, initial visit, what was the first thing you do? Was it the logistics behind division? Do you have an MA doing a uroflow? How do you go whenever you have a new patient in the office?
[Dr. Bechis]
A great question. I think there's two flavors of patients with BPH that I see. One of them is the patient who has self-referred himself and with no prior workup. The other one is someone who might be referred from a primary care provider who's already been somewhere along several phases in the workup.
Generally, for someone starting from scratch, if they come in complaining of worsening lower urinary tract symptoms, obviously history and physical to figure out a baseline IPSS score and getting a sense of where they are on that pattern. If we have the resources, usually I try to get a urinalysis, and PVR first.
I find that uroflow is nice, but if we haven't had a baseline urinalysis, we usually start with that, and the post-void residual. That gives us an initial picture of how well are they emptying, rule out a urinary tract infection, and then with the IPSS getting a sense of what type of symptoms do they have. Is it more of a storage problem? Is it more of a flow, overactive bladder versus a obstructive pattern picture?
[Dr. Silva]
For some reason, I don't know, I'm seeing less of the classic obstructive symptoms, I see more frequency, urgency that those are usually more challenging between knowing if it's overactive bladder versus actually the prostate patient in the bladder, but we can talk about that in a little bit. In terms of the symptoms, the patient may have frequency, urgency, slow stream, do you offer first pill, tamsulosin, whatever, any pill, or are you doing more tests prior to doing something?
[Dr. Bechis]
Usually, if they're brand new and we've gotten some baseline that sounds like they have some component of obstruction like a weak stream, or straining to empty, or a sense of incomplete emptying, usually, we'll talk about a medical therapy first and a trial. I usually frame it in the context of this doesn't necessarily have to be a long-term medication, it's just an experiment to see if it works.
I think some patients come in very open to medications. Others come in because they really don't want a medication. I think that's important as we'll come to, because when you think about the surgical management algorithm, I think historically, the pathway was to try medicine first, and if you fail medicine, then think about surgical options.
I think nowadays, it's a little bit more of a blended picture. Some patients may not want to take a medication or may not tolerate it due to side effects. I always frame it as let's consider an alpha blocker such as tamsulosin, and see how you respond to it. If you respond really well, and you have a significant improvement in your symptoms, then you may find that you're happy and your symptoms are better, and that's all you need.
If it doesn't work for you, or even if you decide you don't want to be on it, that's okay, but at least let's try it and see. I found some patients actually have much a greater benefit on it than they thought they would, and then they become more open to that idea versus going on to surgery.
[Dr. Silva]
Exactly. I think also some patients, they might be a little apprehensive to go to urology thinking that you're going to go to surgery immediately, so definitely offering that pill or trial period. Also, I think it gives you information and also gives the information to the patient, hey, we tried it, and it didn't work, so it can go both ways. In terms of cystoscopy, ultrasound of the prostate, when will you offer the patient that?
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When First-Line Therapy Fails: Alternative Pharmacological Options & Surgical Interventions
Dr. Bechis emphasizes the importance of a urologist's role in treating benign prostatic hyperplasia (BPH), particularly those referred by primary care providers. Dr. Bechis suggests that for patients failing initial treatment, alternative pharmacological options or surgical interventions may be considered. To identify the most suitable course of action, a detailed evaluation of the patient's anatomy through imaging procedures such as cystoscopy and transrectal ultrasound is recommended. These evaluations provide insights into the patient's condition and form the basis for a discussion with the patient about potential treatment options. Furthermore, collaboration with primary care physicians can help educate patients about newer minimally invasive procedures, facilitating earlier referrals and reducing patient anxiety. Patient counseling is an essential aspect of treatment, especially in managing expectations regarding the effects of treatment on symptoms such as nocturia.
[Dr. Bechis]
I get a lot of patients referred in from primary care. In that context, often, they may have been tried on an alpha blocker already, and then either their symptoms are worsening, or progressing where they don't want to be on it. In that sense, usually, if they're failing medication, then I'll either talk about a different medication so now that we have tadalafil as an option. Sometimes that's something men are interested, especially if they have concomitant erectile dysfunction, it can be a nice way to alleviate both.
Sometimes people, if they're gung ho on medicine, will talk about finasteride if their prostate is over 30 or 40 grams.
I think usually if they come to me, and they've been on medication, and they're still needing to see a urologist, we're usually thinking about some kind of surgical or procedural approach.
I usually tell them the next step is would be to do in my practice, the cystoscopy plus a transrectal ultrasound so that we can get the full picture of the anatomy, we can look at the prostate, we can look for is there bilobar versus trilobar hypertrophy? Do you have a median lobe? What's the distance from the verumontanum to the bladder neck? How much does the median lobe extend into the bladder? Then also, is there trabeculation and evidence of bladder strain?
Then I use the transrectal ultrasound to get a good volume assessment. I usually frame it for the patients as this, lets me give you the best picture that we can talk through all the options. I've found, especially in my clinic, where it can be very busy and time is short, and sometimes our resources are stretched.
Usually in the first visit, if I get a post-void residual in the urinalysis, I'll actually send them home with an information packet that talks about all the different procedures ranging from minimally invasive to maximally invasive. I say, "Go home and just read this three-page brochure so that you know what all the different things are. Then when you come in, and we do your cystoscopy and your TRUS, and then we'll do a uroflow after that. We can talk through which procedures fit based on what we found."
I streamline and into one appointment that way, and I do get a uroflow at that point, too, after the cystoscopy, because you've filled them up, so it makes it easy to just do it then.
[Dr. Silva]
You mentioned the primary physician. Do you guys have a great relationship with them, and they already send you the patient talking about some procedures, and the patient is already more comfortable, or they just said to you, "You deal with that"? I'm just curious.
[Dr. Bechis]
It's a great question. I'd say it's a mixture of both. There are some primary care physicians and partners we have who I've met with and educated them a little bit about different procedures. Then there's others who are not very open-ended. I think, especially the minimally invasive surgical therapies like Rezum are very attractive now, especially to younger patients and other things in primary care is very excited about that as an option.
I think historically, everybody knows about the TURP, and even the GreenLight and robotic, and I think the minimally invasive are growing in their appeal. I think primary cares are interested in that. Having education with them a little bit about how it works can be helpful in terms of a sooner referral to a urologist.
[Dr. Silva]
In our practice, we're trying to establish that relation with at least the primary physicians that send more so that they know what we can offer minimally stuff so that the patient is not scared. Sometimes for some patients that might not be great candidates for surgery, they think there's going to be a long surgery, definitely, is good to let them know, hey, there's minimal invasive quick stuff, that minimal sedation or minimal anesthesia, that they're going to do fine.
[Dr. Bechis]
Yes. I think it's great. One thing I've been doing sooner in the workup too, is I tend to go straight towards the cystoscopy and the TRUS earlier in the relationship because I tell the patients, this isn't a commitment to get surgery or to get a procedure, but at least it gives us information about what are we up against.
I think in the old days, you might languish on a medication or for two, three years. In fact, maybe we know that the sooner you do a procedure in people who have severe symptoms, the better they'll be long-term.
I think one of the holy grails in BPH that we don't know yet is when is the ideal time to pull the trigger and say this is the time for you to do a procedure or else maybe your bladder will start getting worse and may lose function ultimately. I think looking inside, if you see things like trabeculations or severe median lobe, I actually try to involve the patients.
I've found that probably two-thirds of them are actually interested in seeing the results. We will watch on the screen together and I can show them and say, "Hey, look at all those trabeculations. That's a sign that your bladder has been working harder all these years. Maybe instead of waiting another five years, maybe doing it sooner might make sense for you."
I've found that involving the patient in the cystoscopy is very effective for counseling on next steps, but also it helps them tolerate the cystoscopy better. I use a single-use scope with a monitor that has video on it so I can actually record the video. If they don't want to watch, usually once it's done, they're very happy to watch the replay on it. I find that that's a really nice tool.
[Dr. Silva]
Is that the Ambu?
[Dr. Bechis]
Yes, I use the Ambu.
[Dr. Silva]
We have it as backup in our office. We use the, I think it's called the Laborie now. Well, now it's Laborie, but it was Cogentix that has sheath that you toss out.
We have that as our main instrument, but then we have the Ambu as backup because sometimes those sheaths are in back order, and, well, the Ambu has great visualization and very mobile, the monitor. Definitely that part is good. I have no complaints.
[Dr. Bechis]
How do you like the Cogentix? Do you have a good workflow for it out of curiosity?
[Dr. Silva]
Yes, I think the image of the Ambu is a little bit better. I think our monitor has been there for four years. We'll be using it for four or five years. I don't know if they have a new version now, but yes, that's the only thing but everything else looks good.
[Dr. Bechis]
Yes, I would say we looked at both of those and at least in one of my satellite practices where we just have very limited staff. I have one LVN working with me and one MA, we find that for us the Ambu is great because literally, every 15 minutes I can do a procedure.
[Dr. Silva]
It is faster. Definitely.
[Dr. Bechis]
For us, that worked out but they're both great options.
[Dr. Silva]
The other one, yes, the MA has to go and prepare the sheath, make sure that it's not leaking, make sure that it's in place, but it is a great product also. Seth, in terms of that patient that you do the cystoscopy, you do the TRUS, you decide, hey, this is the moment. Well, I'm going to take a pause.
You mentioned the bladder part, when it is going to be a good time to put the trigger, and unfortunately, now we know more about the bladder and how important bladder health is. Rather than just talking about the prostate obstruction, we know the side effects. A lot of patients that they go to the primary and they do the PSA, everything is good. They think that by just being the PSA is good, that means that the prostate is normal or that going into the bathroom is normal with age. That's not true.
Definitely, in terms of bladder health, how do you counsel the patient? Do you mention the bladder health part prior to doing anything?
[Dr. Bechis]
Yes, I think it's a really important point, and I've actually found now in my practice, I tend to do an aggressive amount of counseling upfront before any procedure. I usually tell the patient, especially for example a cystoscopy, sometimes patients come in and they say, "Oh I've had one done by another urologist six months ago. Do I really need another one?" I'd explain to them.
I think personally I'm a little greedy. In the past I think I've been more tolerant of outside cystoscopies, especially earlier in time. Now I tend to tell the patient, "I'd rather do my own and go over it with you because I can really counsel you on exactly how your recovery will go based on things that we might see." I think patients really appreciate that.
I think preparing them for all the potential side effects after a procedure, if they're over-prepared, I feel like they tend to do much better and they end up actually not having as many severe symptoms probably because they're prepared for it. I find showing them the bladder and saying, "Hey look, your bladder's really trabeculated", or another one is if they comment that they have storage symptoms.
I get a lot of people, especially people in their 70s who come with severe nocturia and I tell them to be fully transparent. If you have four times a night that you're waking up, this procedure's probably not going to get you down to zero. I usually quote them half.
I say, "We'll usually get it down by half. If you're waking up four times, we'll probably get you down to waking up two times at night, or if you have really bad urgency and overactive bladder symptoms, the hope is by opening your obstruction this will cause your bladder to relax and retrain and recalibrate, and hopefully, those urgency symptoms will get better. We now know probably one in three or one in four men will continue to have those kind of symptoms even if we treat the obstruction. We may have to put you on a different medicine like a beta-3 agonist later."
I've found that if I warn them upfront, because a lot of them come in expecting this procedure will take them off of meds and it'll cure everything and it'll cure nocturia. The reality is it may make it better, but it may not get it to zero or they may continue to have storage symptoms. I think tuning their expectations is really important and helps for the success of the procedure.
[Dr. Silva]
I don't know how you feel about this, but in terms of, you mentioned nocturia, I tell the patient, I think the propaganda that was created on nocturia, I think most of the time it's not BPH or anything related, because I do the AUA symptom score, and the patient, "Well, that's at night. During the day I'm…
You're not having a problem of the process of the bladder, it's something else. You're either snoring or sleep apnea, something else, diabetes, something else. I don't know, but what are your feelings about that?
[Dr. Bechis]
That's a great point because I would say probably, every clinic I get a couple patients who come in with isolated nocturia, they're in their 70s, they're really tired because they're getting up so often at night and they come to me, they're exhausted. Then you ask them, well, how many times are you getting up during the day? They're like, "Oh I don't go to the bathroom during the day. I pee every five hours. It's just at night."
I always say that's a red flag because if your prostate is causing obstruction, it should be causing obstruction all the time. It's really hard because sometimes you end up treating them with a procedure, but I think you just have to be really honest with them up front to say, listen, this doesn't quite fit the paradigm. I use the clogged toilet analogy a lot. I'm like, "If your toilet is clogged at nighttime, it shouldn't unclog during the day. It's going to be clogged all the time and we're trying to fix that."
I do a lot of pulmonology referrals for sleep studies. I've been very impressed with how often either a CPAP mask or giving someone a CPAP mask, they may have one and they never use it, and that can be helpful. The other thing also is sometimes I'll do a trial of a beta-3 agonist alone because that has been approved for nocturia. I've been impressed with sometimes that'll treat the nighttime symptoms. I'll just have them take it at bedtime.
Rezum Treatment for BPH: Who Is The Ideal Patient?
The choice between different treatments for benign prostatic hyperplasia (BPH) is influenced by numerous factors such as the patient's overall health, size of the prostate, and personal preferences for outcomes. The conversation between Dr. Silva and Dr. Bechis highlights the efficacy of Rezum, a minimally invasive surgical therapy, as a versatile option for BPH, especially for patients with prostates ranging from 30 to 80 grams. While the results aren't immediate - it might take up to three months for symptoms to improve - the recovery process tends to be gentler with fewer restrictions on patient activity. Importantly, Rezum might be a preferred choice for patients prioritizing the preservation of antegrade ejaculation and those who have storage symptoms such as urgency and frequency, due to its less disruptive impact on recovery.
[Dr. Silva]
Seth, you do the cystoscopy, you do the ultrasound, the patient has a 40, 50 gram prostate and you guys decide, "Hey, we're going to do the Rezum." I don't want to go into Rezum versus GreenLight or something like that, but let's say you decide let's do the Rezum. Who's a candidate for Rezum? Who's not a candidate for Rezum?
[Dr. Bechis]
I think, yes, especially with the era of the MIST therapies, the minimally invasive surgical therapies, it's really changed the landscape a little bit. The nice thing about Rezum is pretty much everybody is a candidate if they meet the size criteria. Rezum, the original studies were all done for prostates around 30 grams up to 80 grams.
Most of the data at least that we have for the long-term outcomes is based in that range. Usually when I quote patients the success rates, specifically 4% failure rate, surgical failure rate at five years, 1% to 2% per year, that's for prostates in that range.
The nice thing is you can do it in the office with minimal anesthesia. I usually do it in the operating room, but we use a monitored anesthesia care or less. The nice thing is there's not really a patient, there's not a contraindication. Especially people who are elderly, people who have really poor hearts, even people who are on blood thinning medications, I think this can be a pretty forgiving procedure, young men. It's nice, I think the old paradigm of, "Oh, you're too old or too sick to have a TURP." You could have one of these procedures instead.
The other point on who is a candidate, I think the main decision tree is probably in addition to using size, it's probably anatomy and then also sort of patient preference on outcomes. If we think about like comparing a MIST like Rezum to a TURP, a GreenLight, I think there's some nuances there, but the extreme examples.
Often if someone has more severe symptoms, let's say they're in retention or really have a high IPSS score, something like a surgical procedure will treat the outlet immediately. The next day or whenever you take their catheter out, if you void trial them, I tell them they'll be peeing right away. They might have some symptoms and have a period of kind of bladder retraining that they have to go through with some urge and maybe urge incontinence, but they'll have a quick resolution of their symptoms and then they have to get through a recovery.
In contrast, the Rezum treatment may take six weeks to three months to see a gradual improvement in your symptoms, but because it's gradual, you don't have an extreme recovery period per se. You can get a Rezum and you can be pretty active. You can go out and do heavy lifting and do sports sooner. There's not a lot of restrictions. You may have some irritative symptoms, but in general it's relatively minor.
I think part of that is important too, especially when you have someone with a 50 to 80 gram prostate, is what are your goals in recovery? Then also, the ejaculation question. Preservation of antegrade ejaculation, how important is that? For some men, it can be very important. I usually joke that I say, "Most men in your age group who come to me for trouble urinating aren't looking to still have kids," but that would certainly be a consideration. That's another area.
That's how I draw that broad strokes between a minimally invasive and a more involved surgery as the immediate versus the more gradual improvement.
[Dr. Silva]
You mentioned the overactivity symptoms afterwards. For this patient that have been obstructed for a long time, I think we definitely will resume. I don't see that severe because it's a gradual process versus the immediate relief of the obstruction. For some patients that I have had for two months, maybe even three months, they have been miserable just with severe overactivity. Eventually, it settles down, but I haven't seen that with Rezum, so that's definitely something. For those patients that have frequency, urgency, more relative symptoms with a big prostate, they do good.
[Dr. Bechis]
That's actually a really good point. I see the same thing and I think after you make that point, I may even lean towards that a little bit more. The patients who have a lot of storage symptoms and urgency, frequency, if all else is equal, that may push me towards the Rezum just because they don't have a severe change in their symptoms during recovery.
[Dr. Silva]
I'll give you my story. When I started doing Rezum, I started doing Rezum because patients want it. I didn't believe-- or I wouldn't say I didn't believe in the technology, but it's different than with a TURP, you see the opening, with a laser, you see the opening. With Rezum, you need just to trust on the procedure, trust on the technology. Then the mechanism hopefully will work at some point. I think my first three Rezums that I did, the patients wanted it. I did the first ones and the patient did great, and then I have been doing a lot. How was your experience?
[Dr. Bechis]
I would say it was very similar. I was very excited about it when it first came out because I think compared to other procedures, so I did UroLift and GreenLight, and TURP. For UroLift there's anatomical considerations. You have a median lobe, for example, and the nice thing here is it's a little bit more agnostic. Rezum is agnostic to anatomy. That was nice.
The first few that I did, you inject the steam. Maybe you see some blanching of the tissue, maybe you don't, but you don't see any big changes. You're thinking, "Oh, I hope this is where the magic happens." You don't really get that immediate feedback, and you're like, "Well, I hit the median lobe. I hope it goes away."
To your point, I think people do really well. I've done cystoscopy on a few of them for other reasons afterwards for a recurring stricture or some other things. I've been very impressed by the defect that's created. You can really see down to the capsule.
We joke because our fellows and people who do HoLEPs here, when they look at that they say, "Oh, man that's the capsule." They actually admit that they're impressed by what they see, which is hard for people to do HoLEPs because they're very proud of-- The HoLEP is the beautiful technique to get to the capsule.
Podcast Contributors
Dr. Seth Bechis
Dr. Seth Bechis is a practicing urologist and associate professor with UC San Diego in California.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2023, June 7). Ep. 101 – Treating BPH with Rezum [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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