BackTable / Urology / Podcast / Episode #6
Contemporary Surgical Management of BPH
with Dr. Claus Roehrborn and Dr. Aditya Bagrodia
In Part II, Dr. Aditya Bagrodia talks with Dr. Claus Roehrborn of UT Southwestern Medical Center about the surgical management of benign prostatic hyperplasia (BPH).
BackTable, LLC (Producer). (2021, April 23). Ep. 6 – Contemporary Surgical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Claus Roehrborn
Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
In this episode of BackTable Urology, Dr. Claus Roehrborn, chairman and professor of UT Southwestern Urology department, joins our host Dr. Aditya Bagrodia to discuss surgical and post-operative management of benign prostate hyperplasia (BPH).
First, Dr. Roehrborn summarizes the different BPH surgical options based on invasiveness, use of ablation, implantation, energy source, and anatomical approaches. UroLift and the Rezum procedures are the most common minimally invasive options, while the monopolar/bipolar TURP, prostatectomies, the Greenlight (KTP) laser, and different enucleation techniques are the most common surgical options.
Next, Dr. Roehrborn discusses how patient characteristics and prostate size can help guide surgical options. He cites frailty and old age as push factors for minimally invasive techniques and greenlight lasers. To study prostate size, he recommends the point-of-care ultrasound (POCUS) because it is inexpensive and gives all the needed measurements before surgery. For large prostates (over 80 g), he proposes enucleation, simple prostatectomy, and minimally invasive treatments. For small or average-sized prostates (30-80 g), he considers all surgical options to be viable, but favors TURP or enucleation if the median lobe is substantially enlarged. He also assesses the risk of anejaculation for each approach: Urolift has no risk, Rezum and aquablation have minimal risks, other techniques depend on individual skill of the surgeon.
Dr. Roehrborn suggests a follow up visit at 1 month to evaluate urination and to stop all medication. However, he notes that some patients resume anticholinergics or beta-3-adrenergics because their storage symptoms persist. He also notes that 5-alpha-reductase inhibitors prevent prostate re-growth in genetically predisposed patients. In general, he encourages urologists to have a specific plan of action for every post-operative drug they prescribe to patients.
Society of Benign Prostate Diseases:
AUA Benign Surgical Hyperplasia Guidelines:
AUA MRI Prostate imaging Guidelines:
EAU Lower Urinary Tract Sympton Guidelines:
POCUS Butterfly Device:
POCUS Clarius Device:
[Dr. Claus Roehrborn]
That was a heavy debate amongst the BPH guideline committee members: what is large? And some people, even the peer reviewers of the guidelines said, "Give us guidance. Give us numbers." And we refuse. Because some people can resect a 60 g prostate, some can resect an 80 g prostate, some can resect 100g prostate and we don't restrict that. So what is large is a little bit in the eye of the beholder. We suggest that large for most doctors starts at 8 0g. Because I really doubt that many of our current trainees can resect 40 or 50 g of tissue safely. Why would I say 40, 50? Because that's the transition zone tissue you want to resect if you're faced with an 80 or 90 g prostate. That's how much you want to resect. And most of them can't. So to me, large starts at 80. Anything above 80, either I want to sit there for 4 hours and do a KTP laser, which is still incomplete, or I do a bipolar TURP and I'll do it all myself with no trainee involved to do it quickly, or I just go to the category large prostates, which starts at 80 and goes to the 100 g or 200 g and 300 g.
And in that category, the best choices right now are no longer the open prostatectomy either retropubic, the old Millin approach, or suprapubic, but the best choices are either a robotic assisted laparoscopic enucleation, which 90% is done transvesical. Only 10% is done retropubically, opening the capsule. It's just the robot is not really well suited to do it, and you'd have to release the bladder, like for a radical prostatectomy, so there's a lot of reasons not to do it. It's a transvesical robotic assisted laparoscopic, which works extremely well. Sizes 80 to infinity. Now, there are 20, 30, 40, 50 places in the United States where there are real experts who can do holmium enucleation or a thulium enucleation, and this is the same thing. The sky is the limit. They enucleate prostates from 80 to 150, 200, 300 g.
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