"My conclusion is to do what you know best, learn a new technology from an expert, and consider participating in a clinical trial,” writes Gopal H. Badlani, MD.
Dr. Badlani, a Urology Times Editorial Consultant, is professor of urology, Wake Forest Baptist Medical Center, Winston-Salem, NC.
The new AUA guidelines on surgical management of BPH reflect changes primarily in new minimally invasive approaches to the management of the enlarged prostate. In considering what is new, one should think about indications for a given procedure, the individual patient’s goals, surgeon’s bias and learning curve, availability, and affordability of the technology.
Patient bother with male lower urinary tract symptoms such as slow flow, hesitancy, and sense of incomplete emptying and retention are most common. However, men with overactive bladder, nocturia, post-void dribble, and “older male with prostate” as indications are less responsive to surgical therapy.
Patient factors such as medical risk for anesthesia, use of antiplatelets/anticoagulants, gland size, and gland anatomy play a role in selecting the type of procedure, as do patient expectations, such as desire to maintain antegrade ejaculation at the expense of long-term success, catheter duration, and time from treatment to improvement (transient dysuria/frequency/incontinence/recurrent retention).
Surgeon variables are training and familiarity with a technique, number of patients treated in a month to enhance the learning curve, and desire to be on the forefront. Availability of a team to deal with transient issues post treatment and ability to manage secondary bleeding as well as re-treatment are other variables.
Availability of new technology is also dependent on clinical setting, such as a trial at a center of excellence or hospital partner/large group willing to support it. The surgeon bias is difficult to assess.
The individual technologies are discussed in the “Hands On” article in this issue (page 1), which mentions enucleation as a technique that needs to be considered when the gland is larger. It appears that many of the ablative technologies such as lasers and the bipolar device can achieve enucleation, albeit some require use of a morcellation device. Added indications for minimally invasive surgical therapies such as large glands and median lobe require an experienced practitioner.
Cost is a hidden factor in the United States and other countries where health insurance covers approved technology but is a real factor where cost is out of pocket. Hospitalization is expensive in the U.S. but a less important factor in other countries. Capital and disposable cost is a factor in low- and middle-income countries where traditional monopolar TURP still rules despite the safety of saline-based ablation devices.
After participating in a number of trials from balloon dilation to water ablation and publishing on them, my conclusion is to do what you know best, learn a new technology from an expert (preferably hands on), and consider participating in a clinical trial (based on patient volume and institutional support). Shorten your learning curve by accumulating cases and doing them in a short time, stay with technology to overcome initial hurdles, and be honest about your outcomes (not what is published in the literature by the expert).
“The expectations of life depend upon diligence; the mechanic that would perfect his work must first sharpen his tools.”-Confucius
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