A panel of experts discusses the evolution of BPH treatment, as well as how their practices have been affected by COVID-19.
The management of benign prostatic hyperplasia has undergone a sea change, with several new minimally invasive treatments profoundly affecting the treatment paradigm. In a recent webinar sponsored by Teleflex, a panel of experts discussed the evolution of BPH treatment, as well as how their practices have been affected by the coronavirus disease 2019 (COVID-19) pandemic. What follows is an edited portion of their conversation. (For the full webinar, go to https://bit.ly/2PvQCV6)
The panelists were moderator Gregg Eure, MD, Urology of Virginia, Virginia Beach; Steven Gange, MD, Summit Urology Group, Salt Lake City, Utah; John Kaspar, MD, Associated Urologists of North Carolina, Raleigh; and Brian Mazzarella, MD, Urology Austin, Austin, Texas.
Eure: How would you say your practice has changed in the past few years, especially with the emergence of minimally invasive treatments?
Kaspar: It has changed dramatically. When I first started in urology in the 1990s, there was transurethral resection of the prostate (TURP). As we progressed through the 1990s, several medications emerged, including doxazosin (Cardura), terazosin (Hytrin), finasteride
(Proscar), and tamsulosin (Flomax). The number of TURPs declined and medical therapy became the standard of care.
Then as things shifted in the 2000s, we went into different types of procedures. There was transurethral needle ablation (TUNA), transurethral microwave therapy, and laser procedures. We tried to find something less invasive than TURP. In 2013, the prostatic urethral lift (UroLift) was approved. That has become a mainstay of my practice.
Gange: During my training, BPH was treated with TURP. That’s all we had. I did several hundred in my residency, and then continued them after residency. Then drugs came along, and as John mentioned, became the standard of care. These drugs did give some sense of satisfaction, improved urinary symptoms, and improved quality of life. It wasn’t really until later that we realized we were essentially putting in a “placeholder” without any potential for cure, without any potential even to intercept the inevitable progression of detrusor failure. In the 2000s, we tried other procedures. In the end, all those procedures, even including TURP, had an excessive degree of morbidity. Sometimes, there’s bleeding; sometimes there’s a need to stay in the hospital. These procedures are associated with bladder neck contractures, urethral strictures, and sexual dysfunction, especially ejaculatory dysfunction.
As men become more savvy, they don’t want to experience those adverse effects if avoidable.
In 2011, I was an investigator in the LIFT trial and I did the first UroLift procedure in North America. I have found it to meet the needs of these patients in terms of getting them off of medications and avoiding the morbidity of more invasive procedures. It has been the mainstay of my BPH management.
Eure: What has been your experience with treating larger prostates with UroLift?
Gange: The FDA recently granted an expanded indication for UroLift to treat prostates between 80 cc and 100 cc. Some of us have treated prostates beyond the 100-cc level. I’ve treated a patient with a 135-cc prostate. It’s also good to know that there is no lower limit in size, and we’ve treated some really small prostates successfully.
Mazzarella: When discussing any of these minimally invasive procedures, in my own practice, as you get into more complex anatomy—things like larger prostates, elevated bladder necks, median lobes—there are 2 questions. One is, can you get an acceptable surgical outcome? The second is, have you talked to your patient and made sure you’re picking the right option for them? When I use UroLift, which I do very frequently, as I get into these upper ranges, I absolutely think I can get a good surgical outcome for that patient. I’m
also very careful to talk to that patient and explain to them, “Your anatomy is a little bit more advanced, a little bit more complicated. You are probably at higher risk than [a man with] a 40-gram prostate of this not being as successful as you want and maybe needing something else done.”
As we treat these more challenging cases with a less aggressive approach, we just want to be sure our patients understand the choice that we’re recommending.
Kaspar: I agree with Brian. Expectations are really important, whether you’re operating on a small prostate or large prostate.
Eure: I’ve been doing UroLift a little over 5 years now, and it’s very nice to have that as an option for the patient with a 20-gram prostate. I do a lot of GreenLight laser procedures, but that is challenging for those smaller glands, whereas there is no lower limit with UroLift.
Mazzarella: Another point I’d like to make is that a smaller prostate makes me suspicious as to whether I’m treating true BPH or whether I’m dealing with an elevated bladder neck. That concern does potentially inform the approach I’m going to take.
Those patients are still candidates for UroLift and do well. But they are also candidates for TURP or transurethraI incision of the prostate. You want to make sure that you are picking the right approach that solves the problem the patient has. In that smaller range, I’m a little bit more diligent about considering that.
Eure: Please discuss your experience treating middle lobes with UroLift.
Gange: Gregg, I was inspired by the MedLift study you conducted. I was very skeptical, until I saw the data and talked to some of the investigators. I wasn’t going to do middle lobes with UroLift. However, having started that process a year and a half ago and done about 60, I think it’s a remarkable opportunity to deploy this device. I tend to do them in the OR, however, because of the risk of bleeding.
As we know from the MedLift trial, and I’ve seen this in my practice, these are our happiest patients. These patients get a 13.5-14 point improvement relative to the L.I.F.T. study with the bilobed prostate. It’s been a great addition to my practice.
Kaspar: I agree. These are men who fail medical therapy right away. When you hear a patient say that Flomax doesn’t work, either he has a real small prostate and a bladder neck problem, or he’s got a middle lobe. The cystoscopy becomes very important. When you go into the OR and displace that middle lobe, the outcomes are tremendous.
Mazzarella: One of the vexing elements of talking about and treating middle lobes is that we have no standard definition of what constitutes a middle lobe in our specialty. Some urologists will say 3% to 5% of their BPH patients have middle lobes. Another urologist will tell you that 50% of their patients have middle lobes.
I think middle lobes can be divided into 3 categories. Category one is just a hump of tissue. It’s not obstructing, it’s not problematic. It does not in any way inform which BPH procedure I’m going to select. The second category is more broad based and has intravesical extension and a lot of times arises from the lateral lobes. It’s fairly immobile. The third category is a pedunculated type that is fairly mobile. This is entirely my own classification that I use to help make the decisions. But I think UroLift, GreenLight, and TURP can really treat almost any of these anatomies. One of the conclusions in the MedLift trial was that UroLift outcomes were independent of what size of median lobe was being dealt with.
Eure: How has the COVID-19 pandemic affected your practice?
Kaspar: Well, it’s dramatically affected practices worldwide. We all saw a decrease in elective cases over the past couple of months. We are seeing the slow return.
We have the luxury of having a big footprint in our office, but we did reduce staff, so there were only about 4 doctors and 1 PA in the office during that time. That has been increased as of late. All patients are given a questionnaire asking about things including fever symptoms, travel to high-risk areas, loss of the sense of taste or smell. They’re all getting their temperature taken. No other guests beside the patient are allowed in the office. Sometimes, we’ll allow a family member if the patient has some disabilities and would have difficulty remembering.
We are not testing any patients in the office, because it’s so difficult. In the operating room, any case on the schedule is being tested.
Mazzarella: Our protocols have been very similar to John’s as a whole. One thing I would add is being very aware of the element of patient anxiety around this. I think that addressing that comes in a number of forms. It comes in being very communicative with our patients, having them understand what the office has put in place to try and protect the patients from COVID-19. We have to make sure they know that we are keeping our patients safe from our staff and our staff safe from our patients. I think they also want reassurance that after they read these policies and then come to your office, that you are adhering to them.
We should not underestimate how concerned our patients are, and rightly so. As urologists, we generally care for an older patient population that is at very real risk if they were to contract COVID-19. And in spite of all the screening protocols that John talked about, almost every community has some examples of community spread now. We need to remain very diligent and we need to be very careful about telling our patients that we’re doing everything we can to keep them safe.
Eure: Those are good points. There have been a number of studies showing patients are afraid to come into the hospital; they’re sitting at home with illnesses, because they don’t want to go to the hospital and get COVID-19. But at least in my experience, they’re much more willing to come to your office if they see you’re taking precautions and doing the safe things, such as testing before procedures. That’s really been very helpful to get our business back on track.
Kaspar: I’d like to touch on telehealth. I think most of us instituted it almost the next day (following the shutdown). Now the question is, what are we doing as we start to resume and open our offices? How are we using telehealth [going forward]?
Eure: I still think that’s an unknown. There’s definitely a role in the future. We are probably going to have to fight for it and get our patients to fight for it. I think there’s definitely a telehealth role for some of the initial visits to explain the concept of BPH and what the options are, as well as follow-up in-between visits to reassure patients. We’re going to have to fight to keep it, because the carriers don’t want to do it.
Mazzarella: I think that provided that we are able to keep access to telehealth, it can actually offer some real opportunity in the BPH pathway. You’re right to be concerned about all of the logistical elements of that. We all need to be being a little bit more proactive about our evaluation of our BPH patients. The [International Prostate Symptom Score (IPSS)] is a major tool to use in that case.
In the past, if you were going from a paradigm of renewing Flomax for your patients and then not reevaluating them for 6 months, telehealth potentially offers you the opportunity to check in via telemedicine even to get that IPSS form out to them digitally in advance. If it works in your office with the advanced practice providers to maybe have them handle some of that conversation. It’s an opportunity to be a little more proactive about our evaluation and care of our BPH patients.
Eure: How have you changed your practice in the past few years? For my own part, I include bladder health into the patient discussion. For a lot of patients, BPH is a confusing disease. But they understand the bladder; it’s a muscle whose job is to push urine through this obstructed prostate gland. Preserving that is important. That’s really helped to enlighten patients and get them through the workup process and think about treatments.
Kaspar: One of the big things for me has been doing a cystoscopy and an ultrasound as part of the workup. Like you, Gregg, I’ve become focused on bladder health. I use my father-in-law as an example. He had a TURP 20 years ago for a 60-gram prostate. He was in retention before he started, was in retention after the TURP, and had to catheterize for 20 more years post procedure until he passed away. That’s something that sticks with you and makes you think, how many patients do we have that are in retention? We do a TURP because we think that’s the best procedure to get them out of retention, and they’re still in retention on intermittent catheterization. To me, earlier intervention is very important to preserve bladder function.
Mazzarella: My pearl is that an early cystoscopy is tremendously valuable. We live in a world where our patients expect us to inform them of all the options. If you’re not doing a cystoscopy, you are allowing a patient to choose between alpha blockers or 5-ARIs and providing them no information about what exists from a procedure-based approach.
The other point I would make is that if you have the capability either for video cysto or to capture photos, you should do so. A patient’s understanding of what’s going on with their BPH changes dramatically the moment they see their own obstruction. Very commonly, I’ll have patients who seem to want to continue on medications. I show them their lateral lobes in real time, and they know within that moment that a medication is never going to fix this problem. That dramatically changes what they choose going forward.
Gange: I have learned so much about BPH in the past decade, that I don’t do anything the same. I am much more likely to [hone in with] the IPSS document and ask further questions related to quality of life.
I’m also a lot more aware of the emerging side effects of drugs. I have a hard time saying to a patient, “This Flomax is going to fix your problem and you’re going to do just fine on it.” I don’t think I believe it anymore. Certainly, I have patients in my practice who are still taking medications for BPH, but we’ve almost always had a conversation about it to the effect that maybe this isn’t the best long-term solution.