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BackTable / Urology / Podcast / Transcript #205
Podcast Transcript: Optimizing Bladder Health in BPH Treatment Strategies
with Dr. Shawn West
While benign prostatic hyperplasia (BPH) care has historically focused on immediate symptom management, often by way of long-term polypharmacy, leading urologists are now considering long-term bladder health when determining the most appropriate BPH treatment. In this episode of the BackTable Urology Podcast, Dr. Shawn West, a urologist practicing at McIver Clinic in Florida, discusses the contemporary management of BPH with host Dr. Jose Silva, emphasizing the newly appreciated role of first-line interventional therapy. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
Shifting Perspectives on BPH Management
Uncovering Silent Symptoms in BPH Patients
When Medications Fall Short in BPH Management
Comparing UroLift, GreenLight, & Aquablation for BPH
Who Benefits Most from UroLift?
Setting Post-Op Expectations: Managing Symptoms & Recovery
Educating the Next Generation of UroLift Providers
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[Dr. Jose Silva]:
Now, back to the show. This is Jose Silva as your host this week. We have our guest today, Dr. Shawn West. Dr. West attended Medical School at the University of Florida College of Medicine. He continues training at the University of Florida College of Medicine when he completed Residency. Following his urological training, Dr. West joined McIver Clinic in 2008. He is Center of Excellence for both UroLift and GreenLight. Dr. Shawn West, welcome to the BackTable.
[Dr. Shawn West]:
Hey. Glad to be here. I appreciate the invite. Looking forward to this conversation.
Shifting Perspectives on BPH Management
[Dr. Jose Silva]:
Awesome. Awesome. Today we'll be talking about body dysfunction, BPH, and essentially talk about how you go through 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.
Uncovering Silent Symptoms in BPH Patients
[Dr. Jose Silva]:
Shawn, walk us through that initial visit, that patient that comes with BPH, URI symptoms. What do you do on that initial visit? Has it changed? You mentioned being more proactive.
[Dr. Shawn West]:
Absolutely.
[Dr. Jose Silva]:
What have you done different to change that?
[Dr. Shawn West]:
The thing that NeoTract and UroLift did that I think a lot of the other types of interventions have followed suit is they really hammered IPSS, or the Symptom Score Index. They felt like that was important to really search for the patients. I think that was manifested in my practice too. I was not consistent with IPSS. I was not consistent with really asking the patients about their avoiding dysfunction. This made this very efficient.
The fact that when you walk into the room and you have this IPSS Symptom Score, you know what's going on, because there is a phenomenon of not wanting to disappoint the physician. You go to the doctor, you've had BPH, and, "Okay. Mr. Smith, how are you doing?" "Oh, I'm doing fine, doctor." Come to find out, you've had him on Flomax for 10 years, and he's up four times a night, and he's bathroom hunting everywhere he's outside, and he's not happy.
He's not comfortable telling you in every situation that, "Hey, this is failing for me." "What is failing? Is this okay? Is this just me getting old? Am I expected? Everyone says when you get old, this happens. I guess this is just part of aging, so I'll just live with it." I think that IPSS Score was somewhat liberating for patients to write down what they're really dealing with. Whether they felt like that was good or bad was not really the point.
The point is you know that that's bad. You know as a provider that you have-- They've been on Tamsulosin from their primary care doctor, they come to your office and they have an IPSS symptom score of 24, they're up three times a night, that's their bladder crying for help. One of the most important things that NeoTract and Teleflex brought into the arena was asking your patients to be honest with you about their symptoms.
I saw that in my own practice. When I really adopted that, I was amazed and embarrassed that the number of patients that I had had on medical management, "Okay. Everything looks good. Your PSA is 2.1. I'll refill your Flomax. We'll see you next year," they weren't doing well." I think the first several months of really adopting that, it was eye-opening. It really was. That's a long-winded way of saying any male patient that comes to my office-- I'm in a large urology group, we've got I think about 18, 17, or 18 partners, fortunately we've adopted that across the board.
If you're a male and you're over the age of 40, whether you're here to talk to me about a vasectomy, or you've got a kidney stone, or ED, or whatever your problem is, we're going to get an IPSS symptom score, because that lets us know where you are. In our community, a lot of the primary care doctors initiate treatment with medications, and so you'll see a wide range of guys who are either on Tamsulosin or their primary doctor starts them on Tadalafil, we have some that put them on combination therapy.
Oftentimes the patient that comes to my office is someone who has already been on medications, who has already found that this was not helping them, and so they come to my doorstep, I do the IPSS symptom score, I also like to do a post-void residual. When I walk into the room and I know that patient's already been on medications and their IPSS Score is bothersome or their quality of life is not satisfied, then that's an easy conversation for me to take that time with them and not talk about asking them 10 questions about their symptoms, but taking that time and talking to them about what are some of the other options.
More importantly, what are the options in diagnostics? What are you a candidate for? We can do better than we are right now. That's the initial step is the IPSS, a post-void residual, obviously reviewing the meds and having the conversation about where they are and what it means. That gets back to the, you and I talked about bladder health. Urinary symptoms are bladder-related, whether they're a result of prostate enlargement, or whether they are bladder-initiated, or a combination of both. That's our job to really unearth that, and it's definitely the bladder waving the white flag.
I use this analogy on occasion to some patients, especially some of my younger patients. If you went to a cardiologist, and he said, "Hey, listen, you've got some blockage on your coronary. You're doing okay now, but we'll just hold tight until you have a myocardial infarction, and then we'll talk about dealing with the blockage. I think cardiac muscle, bladder muscle, similar in certain senses that they can't be rehabilitated. Throwing that analogy out there that, "You don't need to do this for another 20, 30 years of your life, let's deal with this obstruction and save the bladder."
When Medications Fall Short in BPH Management
[Dr. Jose Silva]:
Exactly. I think that analogy of the heart is very on point. I talked to Wayne Kwan, he has the man versus prostate propaganda, bladder health, protecting the detrusor. Definitely that analogy of the heart I think is something easy that all the patients can understand, "Hey, your bladder is very important. There's nothing else afterwards. If you damage it, that's it. It's a permanent catheter." It's very important to talk to them. Shawn, let me ask you this, there's always a guy, a patient that thinks that you're going to offer the magical pill that the primary didn't know about, but you do. What do you tell that guy?
[Dr. Shawn West]:
I've had patients that, they've been on Flomax and they say, "Well, I did some research. What about adding Avodart or Finasteride?" I say, "Okay. Well, that's fine. Let's see what some of the literature shows." I said, "Here's where you are symptom-wise. Your IPSS symptom score is a 22. If I put you on Finasteride or Avodart, let's say that drops you down to an 18 or 17," which is what the ENTOPS data showed, "that you're going to get about another three-point improvement from that medication."
Yet there is now a black box warning on Finasteride, the post-Finasteride syndrome, where you can have permanent suppression of your testosterone, decreased libido, some of those things. I said, "Maybe adding another pill is not worth the risk, especially since we may only improve these symptoms." I'll show them their score. I'll show them those numbers and what the scale means. "Does adding another medication get you, do you think that's going to get you to a point where you really are confident that you're happy from a urinary standpoint?"
That's the conversation I had. Listen, I'm not anti-medication at all. I don't want to come across like everybody gets surgery with me. A patient who's medication-naive, who their symptom score is not miserable, I think it's clearly reasonable to offer that first line as an option. That's what the AUA Guidelines suggest. Now, I obviously bring those patients back in a few weeks just to see how they're doing. Are they having side effects? How do they feel with the medications?
I'm not anti-medication, but I also think that there are some risks with medications. I think those conversations, we talk about the risk of surgery, but we're a little hesitant sometimes to talk about the risk of polypharmacy and adding another medication. We talked about the post-Finasteride syndrome. There is some data, I don't know how strong it is, but there clearly is data that talk about long-term Tamsulosin with dementia. I think we need to have those conversations.
[Dr. Jose Silva]:
Exactly. Like you mentioned, either the IPSS or the AUSS, essentially that patient, if you don't do that, you do a pill, they're going to feel a little bit better. Like you mentioned, most of the time they think that it's a normal aging process. You're improving what they think is normal for them, so you're making them a little bit better. There's other ways that they can be actually better without taking pharma pills or anything like that. Usually my practice, what I do, if they're naive or they've been Flomax, I try Tadalafil for a month, but I'll bring them back to do a cystoscopy, do the ultrasound of the prostate.
[Dr. Shawn West]:
Sure.
[Dr. Jose Silva]:
Then, in that time, see how they do it and continue to talk about something else. Shawn, go through what type of work you do with those patients?
[Dr. Shawn West]:
Yes, absolutely. I have the conversation with the patient and I can tell you the last time that I've had someone that I said, "Hey, I think this is important. I don't like your symptoms. I think this is important." That's part of what, getting off track just a bit, but I think as urologists, we need to come in that room with some conviction about what we're seeing on the IPSS Score and what we know ultimately lies for them in the future. A lot of these guys think it's age-related. We talked about that. I think it's important because if your physician feels that it's important for you, then you're going to do it. You're going to say, "Yes, well, this must be important. We need to take a look at this." Sometimes it's, "Well, we can do this if you want to," or, "We can try this if you want to." They're there for you to give them some guidance.
I think when we get to that point that we feel like we need to talk about some diagnostics, we need to have a little bit of conviction about it. I think that's real important. Patient comes in and we agree that the next step is a further diagnostic discussion. I talked to them about what the diagnostics entail. This is a quick office-based procedure where we're just taking a look inside the bladder, allows me to see your prostate anatomy, and it makes you feel like you really need to urinate for about 10 or 15 seconds. That's how I'll describe the cystoscopy.
You hear it in our office, we will then roll them over on their side right after the cystoscopy, and we'll do a transrectal ultrasound. That gives me a good size measurement. I like the transrectal ultrasound. Obviously, it's a little more invasive, but I also think that it is a little more accurate. I think it does a great job of outlining the median lobe, and it's just how large is the median lobe, and does this thing have any intravascular protrusion? I like doing the transrectal ultrasound, and again, describing that as just a quick prostate exam with an ultrasound probe instead of my finger. That's the next step is those diagnostics.
Now, I will add that if I've got a patient who has predominant overactive bladder symptoms, and maybe doesn't complain as much about the obstructive symptoms, I'll go ahead and do a UroCuff on those patients. I don't UroCuff all of mine, but I will do a UroCuff in those patients. If that shows high bladder pressures, then I feel more confident that this clearly is a prostate-related etiology, or at worst, this is mixed.
This is obstruction and OAB. If the UroCuff does not show any degree of obstruction, I'll still consider an anatomic workup, or maybe instead of the anatomic workup, maybe I consider an anticholinergic, or maybe we talk about one of the beta-3 agonists, as a trial, before we go through the diagnostic part. That's my workup for those patients. Before they leave my office, so we have the conversation, I'll say, that we need to do the diagnostics, I will go ahead and give them some paperwork on several modalities.
I'm very clear with them that, "This isn't a choose the one that's got the glossiest picture," but I tell them, "I want you to educate yourself on these options. The diagnostic test will tell us what's going to be the best for you, what you're the best candidate for, and what your success will be long-term with these options." These are more educational tools, so that when they come back and you do the diagnostic testing, you can then have a conversation that, "Hey. Here's what I'm seeing. I think these two are your best options," or, "Hey, based upon your anatomy, I feel strongly that this is your best option moving forward."
As you're well aware, size, their anatomy is going to select out some of this. Some of this, "Which one do you choose, which one do you--?" Their workup is going to tell the story, so to speak. When you talk about customizing a treatment for a patient, as a consumer, that sounds appeasing, that this person is really trying to customize this for me based upon my anatomy, based upon my prostate size, and what's going to give me the best chance of success.
Comparing UroLift, GreenLight, & Aquablation for BPH
[Dr. Jose Silva]:
Very good. Shawn, so what do you offer to patients? What do you have under your repertoire?
[Dr. Shawn West]:
I don't do mini TURPs. Right now, UroLift, GreenLight, and I do some aquablations. Personally, I think aquablations are better in a larger gland situation as opposed to a smaller gland patient, although they obviously advocate for any glands. The reason I say that is that's a bigger procedure. There is obviously more bleeding. There is a postoperative catheter for a longer period of time. Those patients are admitted. There is a documented higher complication rate with that procedure. I use aquablation in patients who have glands that are not candidates for a minimally invasive option, but are adamant about maintaining ejaculatory function.
[Dr. Jose Silva]:
What will be your cutoff? What will you get? 80 grams? We're talking 100, 120?
[Dr. Shawn West]:
Typically, I would say the majority of my UroLifts are, I always say, well, you can do it up to 100 grams, and I have. I clearly have gone up to that 90 gram range. For some reason and maybe this is just anecdotal, I feel like prostates, they hop from 80 to over 100. I don't see a lot of 91 milliliter glands, or 98 milliliter glands, or 88 milliliter glands. Again, that may just be anecdotal, but I feel like anything under 80 milliliters, unless there is some type of anatomic, something that would preclude that, I'll clearly offer that to a patient.
With the understanding that UroLift is safe, we don't burn any bridges, there's no complications. Do you have a patient who's done a UroLift that has a bladder neck contracture, or a fossa navicularis stricture, or a bulbar stricture? No, but I've got plenty of guys that I've done TURPs on that have had that. I'm thinking that ballpark for UroLift. Either their median lobe's too large or their gland's too large, I'll typically aim for GreenLight.
Over 120 to 150, that's where I'm talking about an aquablation. Really, I almost look at an aquablation as something that prevents a patient from needing a whole lap or a simple prostatectomy. I've done a few glands, up to 200 milliliters, and they've done very well, some of them in retention, and they've done very well with the aquablation. It allows me a tool to tackle those bigger glands without them needing a much more invasive procedure.
[Dr. Jose Silva]:
I'm doing a lot of aquablations. I talk to the patient in terms of, "Do you want something that's invasive?" UroLift is really the only thing that you can offer that has zero side effects into a sexual side effects. Zero signs of retrograde ejaculation. I think it has to be a perfect gland. If there's a medium lobe, then you start talking about the combination therapy or weight about, we're going to do this first, see how much time it lasts. It has to be a conversation with the patient regarding what they want to do. You want to try something less invasive first, and then go from there?
[Dr. Shawn West]:
I think you bring up a great point. I think that that's one of the things that I try to do is, "What's important for this patient?" I'm very upfront with patients about, "This is what the retreatment percentages are. This is what the data shows. This is what we have from a data standpoint as far as retreatment, as far as needing something else done. We also know that we don't have the ejaculatory issues, we don't have any of the other complications.
Some patients are okay with the fact that there is a higher chance of needing a retreatment with a minimally invasive, in my hands, a UroLift, than if they had a GreenLight from a 10-year standpoint. They understand that, but they're also willing to, because of the side effect profile and what's important to them, they're okay with that. I'm very upfront with all of my patients and so the patients that I have that don't get the response from a UroLift or fail a little sooner than they wanted to.
I've not had a patient that's upset or angry or you said that this was-- That's not happened. I think setting those guardrails there and setting those expectations right off the bat regarding minimally invasive procedures is important to do. It keeps you out of frustrated patient down the road. I've done over 500 UroLifts. Like I said, I'm sure clearly every one of those hasn't been perfect, but I truly don't remember a patient that we've had to do something else on that's been frustrated or felt like, "I had no idea this was going to happen. Why didn't you tell me that at three years there was a chance that I may need something else done?"
I'm upfront with them right off the bat. That takes that off the table and patients are okay with that. You and I were talking about other subspecialties and cardiologists. We'll think about from an orthopedist. Maybe he thinks eventually you'll need a knee replacement. Maybe you don't need it right now. I would try to squeeze as much life out of my normal knee as I could. If he says, "Hey, we can do some arthroscopic surgery and there's an 85% chance that at five years, seven years, you're not going to need a knee replacement," I'd sign up for that. I think that's all the specialty, sub-specialties are that way. I think we have to have that conversation with the patient too. We don't have to completely de-obstruct them the most aggressive approach right off the bat, unless we think clinically that that's what they need.
[Dr. Jose Silva]:
No. I'm going to steal that analogy. I love it. There are patients that they want to have the aggressive, but most people don't. They do want to go slowly and try to keep a small portion or to do less damage to the prostate as possible.
[Dr. Shawn West]:
Sure.
Who Benefits Most from UroLift?
[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 ones that I always look at that I say, "This isn't going to work," is the one that it 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 oftentimes 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 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 do a fair amount of 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 of 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 a 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, they 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 talking 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 passing 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.
Setting Post-Op Expectations: Managing Symptoms & Recovery
[Dr. Jose Silva]:
Shawn, you mentioned the catheter. Who do you leave a catheter, who you don't?
[Dr. Shawn West]:
Anyone that I do any median lobe work or if they have a really high bladder neck, because oftentimes when you deal with a high bladder neck, you're going to get a fair amount of edema because you're likely going to because some tear of the commissure. You're going to get the commissurotomy, so to speak. Those patients do have a little more edema and swelling. If anyone's on aspirin, I'll leave a catheter overnight, and then just the gestalt.
The guy that you put an implant in, maybe you hit a prostatic varices, you're sticking a needle in there and every now and then you'll notice some bleeding. If I don't feel really comfortable with that-- I've never cauterized the prostate after I put a UroLift in there or placed an implant. I would not advise doing that. I'll put in a catheter, put on a little bit of traction, and those guys do just fine. Those are the three absolute indications in my mind. If it's a younger patient, I put four implants, they don't have a large gland, absolutely, we'll let them, void in the recovery. If they can't, then they leave a catheter in for about 12 to 18 hours at the most.
[Dr. Jose Silva]:
Yes. Like you mentioned, for implants, I usually don't do any catheter or anything. I think that's part of the selling point. It's the only procedure that I offer that they don't have a catheter.
[Dr. Shawn West]:
Right.
[Dr. Jose Silva]:
I tell them, "Hey, if there's bleeding or something like that, then you might have a catheter, but that usually doesn't happen."
[Dr. Shawn West]:
Yes, absolutely.
[Dr. Jose Silva]:
Shawn, so let's talk about post-op. What do you tell the patient what to expect?
[Dr. Shawn West]:
Sure.
[Dr. Jose Silva]:
What medications do you give and what to expect?
[Dr. Shawn West]:
Obviously we check their urine in the office and we make sure there's not an infection. I give them preoperative IV antibiotics before the procedure, SKIP protocol type stuff. I'll send them home on tramadol. I typically don't send patients home on antibiotics. There's not any literature that supports that. I know in some of these chats about UroLift, they talk about, "Well, I send them home with three days of Levaquin. I want to prevent an infection."
There's no data that supports putting patients on antibiotics after a UroLift. I do send them home with some tramadol. I have the discussion about just like any procedure, and I do this right before they go back. Remember, any surgery, you are going to have some irritation. No one has had any surgery where they feel better immediately afterwards. That first week, some frequency, urgency, you're going to see blood in the urine. You're going to have some irritation when you urinate, but that will get better typically within the first week. Again, reiterating those expectations. The other thing that does is that minimizes the calls. That minimizes the calls to the on-call doctor, to the nurse that you're having to return because people think something's wrong because you've discussed with them a minimally invasive option that's going to help your symptoms. If you don't spend a little bit of time to tell them that first week may not be great, then they're going to think something's wrong, right?
They're going to think that you did something wrong, that I shouldn't be feeling like this. Having those discussions, right before we put them to sleep with the family there, that, "Hey, this is what to expect, and this is normal." Give them the tramadol, and I try to avoid narcotics because, obviously we don't want to do anything that's going to quiet the bladder too much. That's what I do from a postoperative standpoint.
[Dr. Jose Silva]:
Yes. I usually, for TURP in general, I do pyridium, antibiotics, just prophylaxis, the ibuprofen 800 or meloxicam, I tend to alternate, and stool softener. For UroLift, I do a little bit of combination of those and also do gabapentin for three days. That seemed to help a little bit in those initial days. I started doing BNO NMS right during the procedure because I was in the OR just to see and you tell me, the biggest complaint right there in post-op is that pressure. I wanted to see. I tried, sometimes it worked, sometimes it didn't, so I stopped doing it. It will be interesting to see if those BNO NMS really help because they tend to help with bladder spasm in general.
[Dr. Shawn West]:
It's interesting. I know this is something off the cuff, and there's no literature behind this at all because I looked it up. I've had two patients, and it's interesting, in the last two months, they had some Valium. They took a low-dose of Valium the first day or two following the surgery, and they said that it was amazing. It relaxed them, helped with any spasms and some of the irritation from urination. I haven't adopted that, I'm not sure if I want to get into that, but I've had two patients, individual of each other, that had Valium as needed, not from me, just from someone else, and said they took that, and that it made a big difference. I'm not sure if you've ever had any experience with that.
[Dr. Jose Silva]:
I use Valium only for the vasectomies, but it's not a medication that we, in Residency, use, so it's difficult for me to add new medication. Opioids-
[Dr. Shawn West]:
Sure.
[Dr. Jose Silva]:
-narcotics, things like that, the presence, so who knows? Maybe it works. The problem, I guess, if the guy's sleeping better with the Valium, then what was it? That nocturnal symptoms, it's never just the prostate, it's a combination of stuff.
[Dr. Shawn West]:
Right. Absolutely.
[Dr. Jose Silva]:
Yes, so who knows? Then they want more, so that would be my only concern.
[Dr. Shawn West]:
Right. Exactly.
[Dr. Jose Silva]:
Then you're stuck.
[Dr. Shawn West]:
Then you're stuck. That's right.
[Dr. Jose Silva]:
Shawn, I think we covered a lot of bases here today. Anything else you would like to add?
[Dr. Shawn West]:
No. I typically will see them in the office, my UroLifts or even a GreenLight, I'll see them in a month. If a patient at that two-week mark, now if they're in retention and you need to watch them a little closer to make sure they're avoiding, that's one thing, but I'll see them at one month. Typically at that point in time, I'm coaching them through. At that point in time, typically the inflammation has improved, a lot of the real bothersome symptoms have resolved.
Obviously the frequency, the urgency, some of those symptoms may persist, and coaching them that, "Hey, that can sometimes take up to three months." I know in the TURP literature, they talk about three months as the window of allowing the bladder to readjust, and talking them through that mark. Then I'll see them at three months, and I'll do an IPSS Score at that time, and that's really when I can compare, "Hey, here's where you were, and here's where you are now," and, hopefully, they have the outcome that they expected.
Educating the Next Generation of UroLift Providers
[Dr. Jose Silva]:
Excellent. Shawn, you mentioned you're a preceptor for UroLift?
[Dr. Shawn West]:
Yes, I've been doing that for a few years, and that's been a good experience. Obviously, you interact with different people who are on different levels of their learning curve, and it keeps you on your toes. You're having to make sure that you're on your game, and that you are comfortable with this technique, and so I think it's led to better patient outcomes for me. I really do.
I enjoy it. I enjoy having the conversation, because it allows me to talk about BPH in general. That's the real conversation. It's not just UroLift, but it's, "Hey, as urologists, we need to be doing the IPSS. We need to be looking for these patients. We need to be having conversations about bladder health." UroLift has been the avenue that's allowed me to have these discussions with a lot of our colleagues around the country, and I'm very blessed to have that opportunity.
[Dr. Jose Silva]:
Excellent. If somebody would like to go to Jacksonville to see you, they should talk to the UroLift rep, and go from there, right?
[Dr. Shawn West]:
Absolutely. Absolutely.
[Dr. Jose Silva]:
Dr. West, thank you for being on BackTable. Really enjoyed the podcast, and hope to see you soon.
[Dr. Shawn West]:
Thanks, man. Appreciate it.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2024, December 10). Ep. 205 – Optimizing Bladder Health in BPH Treatment Strategies [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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