Peer Perspectives

Well, I think there are a number of very important tools in sort of a current workup pathway involving BPH. And in many of these cases, these are not tools that I used to use in sort of my more routine BPH pathway prior to this generation of kind of minimally invasive therapy as an option. And so, as sort of an interesting side note to this story, I worked recently with my urology practice on helping to develop our BPH pathway for our practice as a whole. And there were some interesting experiences in that, in that my practice has designated experts in a number of different BPH procedures. And so, while we were looking at these different doctors who have individual expertise in UroLift or in Rezum or GreenLight, one of the things we began to notice is that there were very significant commonalities among these different doctors and the way they treated BPH and the tools that they kind of brought to bear for those patients that help move them kind of through a BPH pathway. And so, you know, in working on producing this sort of more structural pathway for our practice as a whole, I realized that there were three common steps that existed for really all of these doctors. And those were essentially the IPSS, and I'm gonna speak more about that in a moment, a different or sort of more evolved version of a medication conversation, and then taking those patients from those two points on to cystoscopy. And every doctor has sort of individual elements, individual styles within that structure. And I think that's a good, a very positive thing in that it allows us to educate our patients without sort of constraining an individual doctor's way of speaking to patients. To be a little more detailed on these things and to jump into each of those elements, I think had been weak for a long time in terms of incorporating IPSS into my practice. It was something that I used maybe on new patients, I tried for a while to train my office staff in order to use it on all of my patients that carry a BPH diagnosis. And that was both under utilizing it and was proving logistically challenging. And so the ultimate goal, the ultimate point I made it to was that I give an IPSS to every man at every visit. And the value of that is honestly deep and was underappreciated by me in the past. And what you can get out of consistently using IPSS is not only quantifying BPH when patients come to you for the first time, but it allows you to track their BPH as you take care of them kind of longitudinally over time. It allows you to look at the things that you've potentially done for these patients. If you put them on an alpha blocker, if you do any kind of procedure, you can gain real data on those patients about how much improvement they get. And it allows you to look at BPH in such a more valuable and complex way. It allows you to sort out and again quantify some differences between storage and voiding symptoms. You know, it may trigger me to say you have very significant underlying bladder pathology in addition to your bladder outlet problem. And so we may take patients down different routes and certainly counsel them a little bit differently for those things. So, there is really, really powerful value to using IPSS. And that's one of the things that we found was a change that happened consistently among all the doctors in our practice that ended up doing a lot of various BPH procedures. Again, that was independent of whatever procedure it is that this individual doctor liked to do. The second really common element that we found in all of this in terms of looking at our practice was conversations related to BPH medications. This is, again, speaking only for myself, something that has really evolved for me and that I think I was not as good at in the past. And to be honest, I think being not that good at it in the past was forgivable because there was a time point in BPH where we essentially said to our patients, Look, your options are simply live with your BPH symptoms, or we can put you on medications without having a host of side effects, or we can do procedures which have a whole host of side effects. And consequently, we were not that good about talking about any of these side effects because we didn't have an option for our patients that did not lead to all of those side effects. I've now become very detail oriented in my conversations with patients when I start them or when I continue them on medications. I mean, being that most of my patients come to me on alpha blockers already. We have a very careful conversation about orthostatic related problems. I take a careful history in terms of falls. We have a very careful history in terms of the sexual impact that comes from these medications. We talk not just about retrograde ejaculation specifically, but whether there's any change in of orgasm sensation for these patients. The different classes of medications obviously have their own individual side effects. And so if instead we're talking about five ARIs, we're focused maybe a little more in that case on libido problems and fatigue and those that are related to inhibition of DHT. But ultimately this conversation I think is very important. And I think another tremendously important element of this is to talk to patients about the fact that if they start on these medications and they end up successful for them, they essentially have to take them for the rest of their lives. I think that's a deeply under counseled point to our patients when we start them on these, in that patients think that this is just gonna be simply a trial. I had a patient tell me this specifically, to be honest, which is, Doctor, we don't know the difference between Flomax and an antibiotic, and so I had no way of knowing whether you were putting me on this for two weeks to fix my problem or the rest of my life. So, ever since my own patient, quite frankly, chided me upon that, I've never made the mistake again, and that I tell every patient now when we start them on these, this may or may not be a trial, but if this is effective for you, you know, it's important to understand you're taking this for the rest of your life. And then the third element I alluded to is the cystoscopy, and I use those first two pieces of information or conversation or counseling to provide context for moving on with cystoscopy. And so I use the IPSS to say, Look, we have compelling data here that you haven't responded, or that your symptoms have worsened, or even if you responded, there's a lot of room for further improvement. We use the medication conversation to say, There are alternatives to this as an option, and we'd like to explore them. And in both those cases, what the goal eventually is, is to get those patients to cystoscopy so that I can evaluate their anatomy and I can have a conversation with them about alternatives. And like I said, this is not a dogmatic pathway in terms of timing. Patients don't all need that cystoscopy two weeks later. Sometimes that cystoscopy occurs a year later once patients decide they're ready. But it is those data points that we accumulated prior that we use to talk about moving on with cystoscopy so that we can explore the other alternatives. And the cystoscopy was that third point that I mentioned that was in common for all of our physicians. And so, everyone that is moving patients along a BPH pathway, as opposed to believing that you simply should just be renewing medications long term, uses a similar technique, and that we talk to patients about the value of cystoscopy. If you have video cystoscopy equipment, showing them their own obstruction is tremendously powerful in terms of these conversations. And so patients will look in, I will point out their trabeculations, I'll point out their lateral lobe obstruction. From a physician's perspective, I'm evaluating the amount of intravesical extension, I'm evaluating them for presence or absence in classification of a median lobe, I'm evaluating their prostatic urethral length as sort of a surrogate to size, I'm evaluating their ability to tolerate an in office procedure. And so, all of these I think are fairly routine elements of my BPH workup at this point, and it gives me so much valuable information as the physician. And I think it provides a tremendous amount of valuable information for patients as well. I've had many patients who have said to me, I think I'm happy on meds. Ultimately, we get them to cystoscopy, they look and they see that obstruction. And to be honest, you don't need to be a urologist to see co opting lateral lobe obstruction and know that a pill is never actually gonna make that go away. And a lot of patients at that point in time, it alters their goals about what they want for their own care in terms of the balance between medications or a procedure, and very often involving them in their own decision making, their own educational process changes what future they select for treatment of their BPH. So those I think are the three most kind of important elements of a BPH workup, I suppose, but to be honest, I don't think about those things specifically as workup towards a procedure as much as I believe those are three elements of just sort of routine BPH care at this point. It isn't only patients that come to me and say, Doc, I want surgery, that go through that. It's really everybody that I diagnose and manage for BPH, albeit at different paces. I think that as BPH has changed over the recent years, as we've introduced new sort of minimally invasive technologies, and as there's been some rethinking of sort of the normal BPH paradigm, it has pushed us to be a bit more detail oriented in our diagnostic workup of BPH patients. And so I'd like to sort of start from top to bottom and talk through, all of those elements and how I use or don't use them in all of this. I think without a doubt, the mainstay of diagnostic workup for BPH in the first part just remains our history and physical exam for patients, maybe somewhat less so physical exam. But certainly working back through understanding what their symptoms are, understanding what kind of medications they've been on, understanding whether they've had good results or side effects. I think the other elements are nothing unique, quite frankly. I do continue to get uroflows just to look and see whether patients, have evidence of, you know, evident obstruction. I do continue to get bladder scans just to make sure that they're not either in acute retention or in overflow or developing elevated PVRs, which I think is certainly a later sign of BPH progression. I don't make any urodynamic data a consistent or routine part of my BPH pathway. I think that when I get somewhat more equivocal situations, I will occasionally use EuroCuff as an option, which gives you some important urodynamic data about obstruction and pressures and flow rates that allows you to plot patients into an obstructed or unobstructed or high pressure, high flow, you know, nomogram. So I think that can be useful information, And I use that to kind of help adjudicate some difficult situations. I very rarely get formal urodynamic tests in terms of straightforward BPH, unless there's very real either diagnostic uncertainty or sort of contributing or underlying conditions. And then I think the last really important part is an ultrasound. And for me, that's always a transrectal ultrasound. And, you know, the reason that's an important part for me is that I don't do the transrectal ultrasound unless I'm moving that patient on with a BPH procedure. So that's not a routine part of my BPH care, the way in which, you know, the H and P and even the cystoscopy often are now. But if I'm gonna move on with a procedure, minimally invasive BPH procedures do push us to be a little bit more detail oriented in our anatomic workup. And so, you know, I want a very effective sizing of the prostate. I wanna understand how much intravesical extension they have. I may wanna measure median lobe tissue if that's actually there. You know, I wanna understand whether their prostate is narrow or wide. And so all of these elements, I think, are important information both to make the right procedure based decision for this patient and so when you move on with the procedure, potentially, not only to select the procedure, but so that you can do that procedure as effectively as possible to get the best outcomes for our patients. I think the patient counseling elements of taking care of a patient within sort of this BPH pathway are honestly the very same elements of diagnostic tools and educational elements for us as physicians. And so, you know, the first one I use very commonly is the IPSS. And I know I've been speaking about that, but I use that not only to, quantify for my own knowledge, but that's an important patient counseling point in showing them, look, here's your score, here how your score has changed potentially over time. And I mean, often, I think patients have a very strong desire to please us as their physicians. And so they come back to us and say, I'm doing great, or that medication helped me a lot. And I use that score sheet to say to patients, well, I appreciate that perspective, but your score is still in the severe range of this. And, you know, I think that's an important thing for them to understand in terms of kind of counseling and, expectations for themselves. So, I I rely on that very heavily in terms of how I speak to my patients. You know, I think the next element is, some conversation we've had a bit already, which is talking about the medication conversation. And all of that is meant both for me to carefully understand what the patient is experiencing in terms of success or failure from medications, and side effects or lack thereof. But it's also important in that conversation for the patient to have a clear understanding that this is not the only option for their BPH and, doing our best to make sure that they understand that they don't simply have to accept or live with whatever side effects exist. And so we have conversations about orthostatic hypotension, about impact on sexual function. While I'm both taking that history from the patient, I'm, also using that as an element to educate them that these things may have been related to the medication. And if we're starting them on a trial for the first time, they may be things that they develop. So, I I think that's really an important element of it. You know, I I to be honest, I find that if I've done these first two steps effectively, many patients are saying to me, okay, I I understand that there's a way we can do better, and I don't have a lot of counseling I have to do to go from there to cystoscopy. But sometimes patients maybe didn't, incorporate everything we talked about or maybe they didn't reflect all the things we just spoke about. And so this is where in some cases I bring in bladder health as part of the picture, which is to say, I don't ever think I'm on the wrong side of attempting to scare patients with that. But if patients are sort of showing me some recalcitrance to move forward in kind of a BPH pathway, I do sometimes, introduce the element that, look. You have obstruction. I think we both agree that that's the case. And if we leave this untouched for years or decades or unevaluated, ultimately, that can lead to some irreversible bladder damage and I I think we as a specialty have been a little bit remiss in terms of developing data that clearly answers these questions. But nonetheless, I think there's a pretty well accepted paradigm that says ultimately obstruction can lead to some irreversible bladder damage. And so I try to have these conversations with patients so that they understand the choices that they're making.

Hello, I'm Doctor. Philip Butler, a practicing urologist in San Diego, California. I've been practicing urology for over thirty years now and as you know we've been trained to treat BPH with a variety of techniques initially with open prostatectomy and TURP and then noticing that our patients wanted more therapies that were less invasive we switched to treating with medications and with non surgical options such as balloons, lasers, heat treatments, and a lot of different things that have come and gone. Stents, you know all of this, but it's been fun to be studying these things, but we know that they didn't always work. So where did that come when I became a middle aged man? Well I started having some symptoms. Those symptoms were bothersome to me. Most notably urgency to urinate. I found that when I was in surgery sometimes I was starting to have some urgency and that distracted me and obviously it's difficult to scrub out of surgery so sometimes I felt pretty uncomfortable. Didn't want that and when I traveled, you know forget the window seat anymore, I was sitting in the aisle seat and I knew where the bathrooms were. And at nighttime I was getting up three times a night. By the afternoons of a hard day, early evenings, I was kind of fatigued. So I thought, these are symptoms that I don't really want to live with, my quality of life being impaired. Now, amongst all those other surgical options we've been providing, about twenty fourteen I became aware of the UroLift system of the prostatic implants. I started providing that pretty rapidly in the office to my patients. Great results and I said, you know what, I'm going look into this for me. So after the usual work up, finding out I was a good candidate, I decided I'm going to have a UroLift and I'm going see if it can take care of my symptoms. So, I had it done, a few days of discomfort, I got back to work in three days. It didn't stop me from doing that, it didn't stop me from going back in the gym right away, so I was happy about that. No need for catheterization, done under local anesthesia so I was happy about that. Result wise it took about three weeks, the urgency started to improve and now I'm one year from that UroLift. No nocturia, I don't get up at nighttime anymore, I don't have to worry about the length of the surgeries I'm doing anymore. That's a big relief. Traveling, I guess I've gotten used to the aisle seat now, but I can sit in the window if I want to. So I've been quite pleased with the results.

I've begun my UroLift experience back in March of twenty eleven as part of the LIFT protocol. So LIFT was designed as an in office local anesthetic protocol. We were given some leeway, but essentially patients were given ten milligrams of Valium orally. They were given intravesical lidocaine and intra urethral lidocaine. Since lift and through additional experience, I stopped using the intra vesicle lidocaine. I felt like the catheter that was placed in order to deliver it was uncomfortable and I never really saw value to that intra vesicle lidocaine. So I've continued to use the intra urethral lidocaine, twenty cc's of chilled lidocaine jelly placed for twenty minutes with a penile clamp. The benzodiazepine, I've seen some safety concerns in some elderly folks. I have essentially backed away from it and use it now selectively in patients who exhibit anxiety or some sort of difficulty with the screening procedures, the cystoscopy and truss. I no longer use Valium, I think it lasts a little too long, comes on a little slowly. I tend to use alprazolam or Xanax, a milligram or two milligrams depending on the patient. Since LIFT, I've treated well over five hundred patients and the vast majority of those have been in office local anesthesia patients. In the entire seven year experience, I've had to abort three procedures and in each of the three, I am very confident what I was backing away from was anxiety and not pain. I think that with the local anesthesia that we provide, the procedure is very tolerable. We use slow deliberate movements. We have a blinding screen. We have a verbal anesthetist at the top of the table. I think pain isn't the issue. I think urgency can be an issue, so the filling of the bladder too quickly or periodically through the procedure, that tends to be the complaint of our folks. But I do think it's my responsibility to gauge who's able to do this without some anxiolytic medication. The determination of a patient who's too anxious for strict local anesthesia is made at the time of cystoscopy and or transrectal ultrasound. I think it's somewhat subjective. I feel like I'm good at it, but three times in my career I've been not good at it.