Video Resources

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.

The system procedure is a proven minimally invasive technology designed to treat men with an enlarged prostate caused by benign prostatic hyperplasia or BPH. It has been shown to relieve urinary symptoms and improve quality of life with minimal side effects. The system treatment is often performed in a clinic setting under local anesthesia. The is the current generation of the UroLift system. It consists of a delivery handle and individual implant cartridges containing a single implant used for each implant placement. This cartridge based system enables a streamlined procedure while also significantly reducing packaging waste. The actual UroLift implant remains unchanged to sustain proven outcomes building on years of clinical research and real world successes. The UroLift System procedure begins by inserting an implant delivery device into the urethra. An inserted cystoscope provides the physician with visibility to the anatomy. Once the tip of the delivery device is in the bladder, the needle safety is pressed to unlock the device. On reaching the area of the urethra blocked by the enlarged prostate, the obstructive tissue is moved aside. A trigger pull inserts a curved nineteen gauge nitinol needle through the prostate. A second trigger pull deploys the implant, anchoring a small nitinol tab outside of the prostate while partially retracting the needle. Attached to the nitinol tab is a length of monofilament PET suture. A third trigger pull fully retracts the needle and tensions the suture. Trigger pull number four completes the implant by placing a stainless steel urethral end piece onto the suture while also cutting the suture. Depending on the prostate size and amount of blockage, additional implants may be placed in the same way. The physician will determine the number of implants needed per each individual patient to obtain an open anterior channel. The outer capsule of the prostate is firm and provides a solid anchor. This allows the implants to lift and hold the enlarged prostate tissue out of the way so it no longer blocks the urethra. The implant size is customized to each individual patient and prostate lobe. As the suture is tensioned, it also shortens, compressing the prostate lobes to the side. This reduces pressure on the urethra and provides immediate visible results so urine can flow freely. It's a mechanical solution to a mechanical problem. The minimally invasive procedure requires no cutting, heating, or tissue removal. This procedure preserves sexual function. It typically also means minimal downtime, mild to moderate side effects, and a quick return to normal activity. The system provides a clinically proven treatment for men who suffer from an enlarged prostate that may help get men off BPH medications and may help avoid major surgery.

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.

Hi. I'm doctor James Yu, a urologist in Larkspur, California. This patient is a seventy nine year old male with a seventy cc prostate, a pre procedure IPSS of twenty three, and a quality of life score of five. During my pre procedure cystoscopic exam, I identified lateral lobe hypertrophy from bladder neck to veru. I then emptied his bladder and prepared the first UroLift two system device. With the tip of the UroLift two device in the bladder, I pressed the needle safety, unlocking the device. I then pulled the device out of the bladder until the device tip was one and a half to two centimeters distal to the bladder neck and in the anterior one third of the prostate and applied the initial angle of compression to approximately ten degrees. Then I pulled the trigger for the first time, deploying the needle. I then applied additional compression to approximately twenty degrees and pulled the trigger a second time, paying careful attention to not move the device towards or away from the bladder. Pull three retracts the needle and tensions the suture, seating the capsular tab outside of the prostate. I then slightly relax compression in advance until I see the white line appear on the suture or the opposing metal surface of the device. I then complete pull number four to seat the urethral end piece and cut the suture. I then removed the device from the sheath, exchanged for a new implant cartridge, and reentered the bladder to treat the patient's right side. The UroLift II System treatment is different from cavitating procedures. My goal here is to maintain the mucosal integrity through gentle, slow movements during the entire procedure while creating a continuous anterior channel from verru to bladder neck. As with the contralateral deployment, I use the two step compression technique followed by the white line maneuver to complete the implant deployment. Following the two proximal implant deployments, I always perform a cystoscopic assessment to plan my next deployments. In this instance, I use the optional scope seal, allowing me to leave the cystoscopic lens within the delivery handle. When used, the scope seal may leave some of this sheath beak visible. During that review, I decided to proceed with the distal implant deployments, starting with the left. Due to the anterior needle trajectory and the use of a technique called kissing the Viru, I am confident in treating apical tissue. I kiss the Viru with the tip of the device and then drop my hands to move the tip of the device into the anterior one third of the prostate and not towards the bladder. I then proceeded with the standard UroLift two deployment sequence of four individual trigger pulls using the two step compression technique during pulls one and two. Following pull number three, the suture was visible, and I completed the white line maneuver before pull number four. Here, the white is clearly visible on the metal surface and just beginning to show on the suture. With the UroLift two system, a single delivery handle may be used for a single patient for up to eight implants. Each implant is housed in individual implant cartridges. Following each deployment, the spent implant cartridge is exchanged for a new one outside of the patient. During this exchange, the cystoscopic lens may remain within the delivery handle, reducing the likelihood of lens damage. Though I use cystoscopy and transrectal ultrasound for pre procedural planning, I also use cystoscopy throughout each procedure to not only understand the visual impact each implant has made, but to also plan for subsequent deployments as needed. Like here, I realized that I needed to place an additional stacked implant mid gland on this patient's right side. Though posterior to the previous implant, I angled the device to ensure the needle trajectory remained between nine and ten o'clock with the final planned placement in the anterior one third of the gland. Independent of planned implant location, the deployment sequence remains the same. After deployment, I return to midline and advance back into the bladder. Every trigger pull should be full, allowing movement inward and upward. The trigger should be released between steps, allowing it to pop out to the next position. A final visual assessment is an important part of the treatment. I can understand the impact of each implant and confirm if a treatment is complete. Because I took my time and planned each deliberate movement, any bleeding or mucosal disruption was minimal. This patient did very well following this treatment with the UroLift two system. He did not leave with a catheter. He is now off of BPH medications, and his post procedure IPSS dropped seventeen points to a score of six within a few weeks of the procedure. These results are quite typical for my patients, and I'm glad I was able to share it with you.

Hi everyone. I'm Doctor. David Wilkinson here in Naples, Florida. This is Janelle Buntz, physician assistant, and we're here to help you bring the UroLift System into your office. Okay, so let's talk about the workup for a UroLift procedure for BPH. First and foremost, every man who comes into our office who's forty five or older is gonna receive an IPSS score. This allows us to identify people that we need to speak to about the procedure, and it also helps us to determine the severity of their symptoms. My personal, feeling about this is men who have an IPSS score of eight or higher or a quality of life score of two or more are the people that we need to focus on presenting this procedure to. In addition to the IPSS being important to identify candidates, it's also vital in allowing us to gauge the success of the procedure and the patient's improvement after the UroLift procedure has been performed. We also do in office cystoscopies, flexible, to provide vital information about the structural component of the prostate, to help us plan for the procedure, approximately how many implants we would use, and to gauge the patient's tolerance of an in office procedure. In addition to that, we're going to do some form of volume study of the prostate: A transrectal ultrasound, a transabdominal ultrasound, or a, MRI that had been done for other reasons are all good ways to get an approximate volume of the prostate. So after we've completed our initial evaluation for UroLift including a cystoscopy and a volume measurement of the prostate, We have the patient back to the office. Once the patient has agreed to proceed with UroLift, have a very specific way in which things are arranged, to schedule a procedure day. First and foremost, we're going to go through a consent form with the patient, the risks, benefits, alternatives to the procedure. We're going to make sure that we have proper clearance to hold anticoagulation, prior to the procedure in an appropriate manner from the physician who writes that medication. We're going to make sure that we have sent in an oral antibiotic for our patient that they're going to take for three days, one an hour prior to the procedure, and then every twelve hours thereafter to completion of those doses. We're going to schedule a two week post procedure office visit to make sure that they come back and they're evaluated and we check their urine, we make sure that they're emptying and we repeat their IPSS score or their urinary symptom score. The day of the procedure there are several important things that are going to occur and I'm going to ask Janelle to talk more about those things now. Thank you. The day of arrival there are very specific things that we want to make sure occur. First and foremost we do want to make sure that they've held any anticoagulants that have been requested. We're also going to confirm that they've taken their pre procedure antibiotic. The next step will be to bring them into the office and obtain a set of vitals. This will be the first set of vitals but not the last set that they have done that day. They'll next empty their bladder before we start the procedure and a pre anesthesia assessment will take place. Then from there they'll move into the procedure room where the medical assistants and the staff will start preparing them for the procedure. So let's talk a little bit more about the equipment that's needed. First is an exam table. You can use any in office exam table that a patient can get on and off of. This happens to be one that's adjustable with height. We don't have adjustable stirrups. We use adaptable stirrups and as you can see they can adapt to the footholds that are already here. These keep the patient secure and they also ensure their positioning during the procedure. The under butt drape provides for a drainage system. Other equipment you'll need to do the UroLift procedure in your office would include whatever form of anesthesia you're going to use. In our case, we use a nitrous system with the system that we have. It's patient administered, meaning that the patient is gonna hold the device themselves. When they breathe in, get nitrous and we have them breathe in and out through the circuit. But I'm gonna share a few tips with you to make sure that your patient has the best experience if you choose this system. Number one, if they're using the mouthpiece, they need to use the nose plugs. If they don't use the nose plugs and they're exhaling through their nose, they'll be sharing the fun of the nitrous with you during the procedure. Number two, it's very important to have extra tanks of oxygen and nitrogen available in case those run out during the procedure. Number three, one of my MAs or nurses is at the head of the bed and for me they manage my fluids during the procedure and they monitor the patient. They're also a verbal coach to the patient to make sure that they're breathing in slowly through the circuit and out through the circuit to ensure the best, comfort during the procedure. You're also going to need a video monitor. You're going to need, a light source, and you're going need fluids. In our case, our video monitor and our light source are combined in one, but whatever you have in the office already is typically going to be more than enough to get the job done. We've adapted and added three liter bags, so that we have more fluid available during the procedure. We have a Mayo stand set up, at the surgeon's side, and that's gonna hold our UroLift cystoscope and another Mayo stand that's set up behind for the MA or the nurse to hand the implants from. Standard things, gauze, lubricant. Down by my foot, I have a large sharps container, but you just need some type of container for your biohazard or your medical waste. So your urology consultant will be vital in coming into your office, helping you assess the space you have and making sure you have the proper equipment. They'll also help you do a walkthrough of the UroLift procedure with your staff prior to actually doing this in your office. But this is simple to adapt to your office and to offer this great procedure to your patients. So let's talk more about fluid management. It's important to utilize a three liter fluid bag. Sterile water is preferred for better visualization. We also use large tubing with a spike and a Luer lock adapter. This is going to allow to adjust for the fluid and the rate of flow during the procedure. An additional thing that can be useful is how we manage this fluid bag. We've got the adjustable IV pole that can be raised to increase the flow, or a trick that we've learned that has been useful is to twist the bag and create better flow by squeezing it. And we have found that this is useful during the procedure. Two more important points to make about fluid management during the actual procedure. Number one, I try to run my fluid slower than I would if a patient was asleep in the OR for patient comfort so I don't over distend their bladder. Number two, at the end of the procedure, I attempt to leave their patient's bladder as full as possible so that they're able to void and we're able to check a post void residual before they go home. So let's talk about fluid collection during the UroLift procedure. There are multiple ways to accomplish this, and that can be as simple as a large rectangular basin at the foot of the bed, a kick bucket. In our case, we like to use this under butt drape that has a funnel attached to it. We've modified this by cutting the tubing and letting it drain via gravity into our collection container. You'll also notice under the collection container there are trucks pads on the floor. This helps keep the floor dry and avoid large amounts of fluid on the floor. In addition to these, there have been other solutions created via suction and, other containment systems that your urology consultant would be able to help you with at the time you plan to set this up in the office. Let's talk disposal. The used UroLift implant devices are disposed of as medical waste. The fluid is disposed of just like an in office flexible cystoscopy. So right now we're going to talk about positioning. This is really important when preparing a patient for an in office urolift. We use adaptable stirrups in the office. These are really different than the adjustable stirrups on an OR table. So positioning, especially keeping the patient's bottom really low on the table, opens up their hips so that the surgeon avoids a bone strike. So once your patient is positioned, we use a standard lithotomy drape. It does get modified so that the fluids that are draining at the time of the procedure can funnel into the under buttock drainage system. And this is what it looks like after the drape has been modified and the patient is ready. So now we have the patient ready for the procedure. I'm going to review, where our team members stand and how I prefer to do the procedure. I have two team members with me, one at the head of the bed to manage the nitrous and the fluids. Used to have three. One person did the fluids, one person did the nitrous and coaching the patient, but we figured out what could be more efficient and just use one nurse or MA in that position. My second nurse or MA is going stand at the foot of the bed with me. They're going to open the implants for me. I'm going to take the implants sterile, use them. When I'm done with the implant, I'm going to put it in the sharps container that I keep by my feet, and then the next implant is going to be open for me to grab and use again as the procedure continues. You can use as many team members as you choose. We choose to use two because it helps us to be efficient and to work in smaller spaces. So now that the procedure has been completed let's talk about what happens after the urolift for the patient. The first thing that they're going to do is go empty their bladder. We want to make sure that they urinate completely before they leave the office so we'll check a post void residual. If they're unable to void then a Foley catheter may be placed. They'll also get the last and final set of vitals and the post anesthesia examination is completed we also will give them a card for their wallet and go over the expectations of what they can expect following the procedure and Doctor. Wilkinson will go over that some more. Thank you Janelle. We're very specific in what we review with our patients. We have written information that we give that's provided by Teleflex and we go over that verbally as well. So the things that we tell our patients to expect are possible burning with urination or dysuria, hematuria, blood in the urine for two to three days after the procedure, passing of clots intermittently, frequency of urination, urgency of urination, and perineal pressure. And when I say perineal pressure, I'm very specific about that. I don't describe it as perineal pain. The way I liken it to a man is to say if you were sitting on a bike seat or riding a horse the pressure you would feel on the perineum is not unusual after this procedure. Our personal preference or my personal preference with this procedure is to use Tylenol for the first forty eight hours. Once the hematuria has discontinued, I tell patients it's okay to take non steroidal anti inflammatories. In my experience, I haven't written narcotics for this procedure, but that's completely up to your discretion and your patients. Thank you for watching. We hope that you found this video educational. If you have any further questions or want more information, please reach out to your local urology consultant.

I have been doing UroLift for a little over three years or so now. I've done about two fifty cases, the significant majority of them in the office setting, although my initial first set of UroLift was all done under general anesthesia in the operating room. So, I did about my first eighty five cases under general and then roughly my next one hundred and fifty or so under local in the office. So, speaking about the anesthesia protocol that I specifically use, as I said, we do our UroLifts in the office, and so we use a local protocol with a prostate block. And so, what that looks like in our setting in my office, we have two different procedure rooms we use to accomplish a UroLift. One is an ultrasound room, the other one is a cystoscopy room. So we do the prostate block in the ultrasound room. The block is basically, for the most part, a lot like a normal prostate block that most urologists would use for a prostate biopsy. And so, that's basically five cc's of injection into each neurovascular bundle on the left and the right. The injection we use, is zero point seven five percent Marcaine and it actually has a little bit of gentamicin mixed directly into each syringe of the injection. There's two things that I do differently when I'm doing a block prior to a UroLift. One is that when I'm numbing the neurovascular bundles, I would hope to get some anesthesia to the bladder neck as well, and so I try and get a little bit of that local to track kind of in the direction of the bladder neck. I did that injection in a transverse plane on ultrasound, and so when I'm looking at it, I'm looking to, kind of infiltrate some of that local between the seminal vesicle and the base of the bladder and base of the prostate. Then the other difference that I do when I'm doing a block for UroLift is I place an extra five cc's on both the left and the right side, the lateral aspects of the prostate down in the direction of the apex, just in the hopes that that helps again with some of the patient comfort with actually placing the UroLift devices. So that kind of covered the way I do the prostate block. And then, as I said, we use two different procedure rooms in our office, and so our patient is then in the cystoscopy portion of the procedure. And this part is generally pretty straightforward. We place some viscous lidocaine in the urethra, mostly as a both a numbing agent and a lubricating agent. We place a red rubber catheter and drain the bladder. We have an installation of a combination of chilled Marcaine and chilled lidocaine, total of sixty cc's in combination of those two. Then the red rubber catheter comes out. And, I think one of the significant benefits to doing the block in advance is that you'll hear a lot of people who do just intravesical or intraurethral, then give the patient time to soak to let that medicine take effect. And I skipped that step entirely. Because of the block, I think that the patients are actually, basically numb. And so once I've completed the urethral and intravesical installation, I begin the procedure, immediately at that point. There certainly are some points to take into consideration when you're deciding, whether an individual patient is the right patient for local or whether this is the right protocol for your office. One of those is you want to make some assessment of whether that patient is going to tolerate an in office procedure at all and can get some pretty good assessment of that during the workup phase of deciding on UroLift. And so I think in all cases, will have done a flexible cystoscopy and you can evaluate that. I do a truss sizing for the vast majority of patients. And I actually really like the symmetry that comes with doing both of those in the workup because then once I've finished the truss sizing and the patient and I have made a final decision for UroLift, I can explain that there's gonna be a two step process on the day of the procedure. One is the truss block and they've already undergone a version of that. And then the second part is the cystoscopy and device placement, but they've already undergone a version of that as well. And so I think it really helps them, with understanding and comfort from what's gonna happen, on the day of the procedure. But certainly, some assessment of, how well those patients are gonna tolerate the in office portion is an important step. So I think the second major consideration to take into account is the individual patient's anatomy. And this is a part of the normal UroLift workup to understand the lateral lobes and the median lobes and the overall prostate size. But I do think you want to become diligent if you're going to look at in office procedures at trying to make some assessment of the bladder neck height because that I think is the most challenging anatomy to treat under local in the office. And so you're paying attention to how much you're deflecting with your cystoscope. You can get a little bit of assessment, at the time of the ultrasound. In the end, this is not an easy thing to make an actual quantitation about, in advance but that is one of the major considerations, I think. In spite of that consideration, I would also say that it is a very, very rare patient that you cannot technically complete UroLift in the office due to the bladder neck height. And so, looking at my own office's experience, as I said, we've had almost five hundred patients between the two of us and exactly one patient had to be aborted due to that anatomic consideration. And so that that concern, while valid as a concern, is not a limiting factor very often. One other consideration or limiting factor is the use of the Valium. And while I think for the majority of patient experiences, the anxiolytic portion of that is helpful for them in their comfort on the day of the procedure, I also don't think there's any doubt that there can be some risks and downsides. And I certainly make some assessment for my patients of whether or not they're elderly or particularly frail. And in those patients, I choose to omit the Valium completely. And also, of course, when any time you're going to be using Valium, you need to warn the patients about what that's going to mean and the fact that they certainly can't drive themselves home. And so that is something that I am very cognizant and careful of when using it, on any patient in the office.

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.

Let me just give you a brief experience of my process with UroLift. I started in about twenty fifteen. Those were my first cases. I started in the operating room where we used propofol anesthetics. However, you find the operating room very inefficient. You wind up doing a case for five or ten minutes and sitting there waiting for turnover for another forty five minutes to an hour. That's a waste of efficiency and time. So we wanted to move this to the office quickly. I spoke to some of my colleagues and learned their anesthetic protocols and then we rapidly moved it after about fifteen to twenty cases into the office type of setting. Well my practice is a large group practice. It contains fifteen urologists with six extenders. We each sort of do our own little subspecialties and my subspecialty is actually female urology and reconstruction. Let me tell you about the transition of anesthetics. We started, like I said, in the operating room with the propofol anesthetic and we quickly moved into the office type of setting. We did the local anesthetics initially with some Valium or Ativan with a narcotic like Lortab or Vicodin. Then shortly after that a black box warning came with a combination of these two drugs and you had to scratch your head, am I really going to give this to an eighty year old male who can be sedated for a while? So then it changed our protocol a little bit and we tried prostate blocks and I found a prostate block with some Valium or Ativan worked about fifty percent of the time. I used to use that also for tune up procedures and again found that same situation, fifty percent success rate. We were introduced then to nitrous oxide for other procedures in our office such as vasectomies, Botox therapies or even just simple cystos and prostate biopsies. We introduced that into the office and I decided to quickly try this with the UroLift procedure and it worked tremendously well. It's really changed the way I've done this procedure. I use the ProNox system. There are two systems out there. I particularly use the ProNox because it's an easy system. It's a fiftyfifty mix. It becomes a class one anesthetic which is very similar to just giving a Valium. No additional equipment is needed or pulse oximeters or EKG machines and no other certifications required. Another system is the nitrocele grade system. It can be titrated from thirty to seventy percent. It requires a little bit more equipment in the room, it requires a scavenger, it requires some monitoring, and it requires additional certification. From a cost standpoint they are about equal. Nitrous works very quickly and rapidly. It's actually breathed in and absorbed through the lungs, through the bloodstream, into the tissues. Within about five breaths through either a snorkel or a mask, it decreases your pain threshold, it makes you more relaxed, and it makes you really apathetic. It also works in the brain on dopamine and endorphins to really calm you down and relax the whole system. Things to watch out for while using nitrous are first off, you've got to have good patient selection. Men who are oxygen dependent or women oxygen dependent, you really want to avoid using nitrous oxide because of the combination. Guys who've had pneumothoraces or COPD or severe emphysema. People who've had bowel perforations, those are the population but hopefully we're not seeing those in our office setting.