Optimizing BPH care: Experts discuss HoLEP, MISTs, and shared decision-making

The treatment landscape for benign prostatic hyperplasia (BPH) has significantly evolved over the past decade, driven in part by the rise in newer minimally invasive surgical therapies (MISTs). With this growing armamentarium of options comes the opportunity to tailor treatments to each patient, taking into account each patient’s goals of treatment and concerns surrounding quality of life.

However, although newer approaches are particularly beneficial for patients with small- to mid-sized prostates, treatment options remain limited for those with larger prostates, according to Kanika Searvance, MD, and Yasin Bhanji, MD, of Georgia Urology.

In a recent interview with Urology Times®, Searvance and Bhanji discussed the key role for holmium laser enucleation of the prostate (HoLEP) in the BPH landscape given its effectiveness in larger prostates. They specifically outlined the advantages of HoLEP compared with other options, emphasizing its size-independence, low retreatment rate, and quick recovery. For these reasons and despite the learning curve, Searvance and Bhanji noted the growing popularity and future prominence of HoLEP in the current BPH treatment landscape.

Urology Times: Over the past decade, how have we seen the treatment landscape for BPH evolve, particularly with the introduction of some of these newer MIST options?

Searvance: There has been a lot of change in the past decade in terms of BPH management. There's been a big shift toward minimally invasive surgery like UroLift and Aquablation. Especially for smaller to mid-sized prostates, there are lots of options. For bigger prostates, the field is still limited, which is somewhat challenging. The options traditionally have been either a simple prostatectomy or a HoLEP. So, for smaller prostates, there is a wide variety of options to treat whatever the patient's primary concerns are, but with big prostates, those are challenging for every urologist.

Bhanji: To add to that, the advantage with all these new therapies is that we can tailor the procedure to each patient. Every patient's anatomy is different, and every patient's goals of surgery are different, so having all these different minimally invasive options allows us to tailor the procedure to the patient's [needs]. That said, for a urologist, the challenge is making sure we are guiding the patient down the right path to make sure that they make a choice that's going to get them the right outcome. When there are so many different procedures available, the challenge is making sure we understand the patient's goals and what the expected outcomes are going to be with each different procedure.

Urology Times: In your practice, what factors drive your decision-making between medical therapy, MISTs, or more definitive surgical procedures?

Bhanji: It's a combination of things. When it comes to deciding how to manage the symptoms of BPH, it's a process of shared decision-making. The patient tells us what their goals are, and we help them get to those goals. Some patients are averse to surgery, and we try and manage them with a number of different types of medications we have available to us. Some patients desire to preserve sexual function, and there are certain procedures that allow us to do just that. For patients who are highly symptomatic and who have already tried medical therapy, that's a clear indication that they may benefit from surgical intervention. So really, it's the patient and their symptoms and quality of life that are driving our decision-making.

Searvance: BPH is so multifactorial. For me, the 2 big things that I'm always trying to weigh are the patient's goals and what is best for them long-term. A lot of people minimize BPH symptoms. There are a lot of data showing that a lot of patients with BPH suffer quietly because they don't feel like they have options, or they say, "This happens to everybody." They think it is age related and very common. I don't think that there is enough understanding, just in general, about the long-term effects of BPH—the hydronephrosis, the renal failure, the bladder failure. Those are the worst outcomes, and they're not talked about as much. Of course, you don't want to scare the patient when you're making decisions, but I do talk to them a little bit about part of my job being prevention. Some people want a minimally invasive procedure, but if their bladder function is already compromised, then you have to appropriately guide them toward what's going to preserve their bladder function long-term. Nobody wants to have the patient end up with a catheter, but I do counsel my patients about that being a possibility, even though it's uncommon. We do everything we can. I also counsel patients that even after surgery, you still should be monitored, and oftentimes doing 1 technique does not limit you from other techniques or mean that you will not need another procedure in the future.

Urology Times: Which patients are the ideal candidates for a procedure like HoLEP?

Bhanji: One of the unique features of HoLEP is that it's size independent, so HoLEP can really be performed for a patient with any size prostate gland. That allows us to be able to offer this procedure to a large number of people. There are also few contraindications to HoLEP. Certainly, we'd have to take into account individual patient factors—like what type of prior surgery they've had, a history of any prostate cancer or radiation, urethral stricture disease, and their anticoagulation status—but no prostate is too small or too big for HoLEP.

Searvance: HoLEP has some distinct advantages over other surgeries. I do think that historically, HoLEP has been thought of as a surgery for big prostates or for people who are on anticoagulation, but HoLEP truly could be for just about any patient. There are very few contraindications to HoLEP, unlike a lot of our other BPH options.

Urology Times: Building on that, what would you consider key advantages of HoLEP compared to other approaches?

Searvance: One of the biggest advantages to HoLEP is the very low retreatment rate. For many people, it's a one-and-done surgery. It is minimally invasive. People have a very quick recovery, and for many patients, they will not need another BPH surgery again in their lifetime. For some of our minimally invasive surgeries, there's thought to be maybe a 5-year duration or a 10-year duration; everything's graded against the classic TURP [transurethral resection of the prostate], which is somewhere around 10 to 15 years. I think that is the biggest advantage to HoLEP is that the results are very durable.

Bhanji: I'd agree with Dr. Searvance. The durability of the procedure is unmatched. Another good option for large prostates is a robotic simple prostatectomy, which is still commonly performed, but the advantage with HoLEP is that you avoid any sort of abdominal surgery or abdominal incisions. Also, post-operatively, patients require a Foley catheter for a much shorter duration of time compared with a robotic procedure. Oftentimes, we'll see a much better rate of hemostasis, so a lower transfusion rate, less risk of bleeding post-operatively, and less time on continuous bladder irrigation. In many patients, they can go home the same day without their catheter, depending on the patient and their unique circumstances. In addition to the durability of the procedure, it's really the ease of recovery that really, I think, benefits the patients and our practice.

Searvance: If we think about other procedures like TURP, patients spend 1 night in the hospital on CBI [continuous bladder irrigation]. With Aquablation, patients also typically spend 1 night in the hospital on CBI. GreenLight also uses a laser, very hemostatic, but it is not able to remove quite as much tissue as a HoLEP. For many HoLEP patients, they either go home without a catheter or they go home with a catheter, but they oftentimes do not need to be hospitalized overnight.

I see a lot of patients interested in procedures like Aquablation, UroLift, or Rezūm. Those are all great procedures; they work really well for certain patients. Like we talked about earlier, there's a shared decision-making approach, especially with smaller prostates. HoLEP has been very well understood in large prostates, but I think people now question whether HoLEP is beneficial for smaller prostates in a minimally invasive world. Why would I do a HoLEP when I can do a UroLift? Why would I do a HoLEP when I can do a Rezūm? My response to that oftentimes is because you will still get highly effective results with minimal complication rates. Rezūm is great, but I think we've all seen the irritation from Rezūm. Patients are very symptomatic in the first week. They are very uncomfortable the first couple of days after that procedure. People tend to have less of those [adverse] effects with HoLEP. With Rezūm, the catheter is usually left in for a week. So, even for a minimally invasive procedure like that, you're still having a catheter in longer than you would if you had a HoLEP for the same size prostate. UroLift is also very nice because it's very minimally invasive; patients do tend to have a very quick recovery from it. The results are not as durable. One thing that I often tell patients with smaller prostates is a HoLEP is still a very effective procedure for you, even with small prostate. It is still minimally invasive. It, in some ways, is superior, and I think that it's something that should be considered in small prostates just as much as it is touted for larger prostates.

Urology Times: As you know, training and adoption remains some of the key challenges with HoLEP. How have you navigated the learning curve? What advice would you give to urologists who are considering incorporating this approach?

Bhanji: It's well-known that the learning curve for HoLEP is steep, and the surgical technique is complex. There's no doubt about it. I was fortunate enough to learn HoLEP during additional fellowship training at UCLA. For me, that was helpful to get comfortable with different types of prostate anatomies and sizes and managing variations in the technique. There are many urologists who are able to pick this skill up in their practice. With the help of colleagues and partners, this is certainly a technique that can be adopted by urologists in academic settings and in community settings, especially when they have partners like we do here at Georgia Urology, where we can work together to tackle any size prostate.

Searvance: I was fortunate enough to learn in residency training how to do HoLEP. For people who don't have the ability to learn in residency or in fellowship, there are lots of other ways to learn HoLEP. They do have training sessions. There are some urologists who will welcome people and teach them the technique, the set-up, the workings of how to do the procedure, and will mentor them. There are also some urologists who will come to you in your hospital and will help guide you in more advanced techniques. There are doctors who do learn HoLEP on their own, but it is challenging. One of the things that we've all been told is if you really want to do the procedure, you have to commit to it. So, for a period of time, that would be your primary BPH technique, because the estimates say it takes somewhere around 50 cases to become fully comfortable doing the surgery. Like anything else, the more frequently you're performing the procedure, the easier it becomes.

Urology Times: Looking ahead, how do you see the role of HoLEP evolving in the next 5 to 10 years?

Bhanji: Many people may not realize, but the original technique for HoLEP was described over 20 years ago by Dr [Peter] Gilling in Australia. I think it has been highlighted more recently for the very reasons that Dr Searvance and I talked about today, which is the truly minimally invasive nature of HoLEP, how many different patients or candidates there are for HoLEP, and the durability of the procedure. When we think about the procedure from a patient perspective and from a health systems perspective, it's cost-effective, it lasts a long time, and it minimizes the strain on the health care system. For those reasons, many urologists have referred to HoLEP as the platinum standard for BPH therapy. Keeping that in mind, HoLEP is here to stay.

Searvance: HoLEP is durable. That durability is being highlighted, and it's very exciting to see patients learning more about the procedure. With newer technology, there's always a little bit of a learning curve. As some of our newer techniques come out, people try them, and then it's widely open, and then it narrows to a certain population or a certain BPH subset. HoLEP doesn't really have that. It's been very exciting to see more people be interested in learning how to do the procedure and learning more with the technology. There are lots of strong data on it, and that comforts patients. It's tried and true, and it's effective. We see great results from our patients. I think over the next 5 to 10 years, HoLEP is going to continue to grow. I think more urologists are going to learn how to do the procedure, and I think that it will continue to have a very prominent role in BPH treatment.