In this interview, Steven Kaplan, MD, from the Men's Wellness Program at the Icahn School of Medicine at Mount Sinai in New York discusses treatment goals, shared decision-making, and long-term implications of currently available therapies for patients with benign prostatic hyperplasia.
Urology Times®: How have treatment goals for benign prostatic hypertrophy (BPH) changed in recent years, particularly with the growing number of available and minimally invasive surgical therapies (MISTs)?
Kaplan: People are looking for a more sustainable improvement, perhaps [one that doesn’t involve taking] a pill every day. In the past, there were fewer options, and people are looking at things like [having] sustainable success, being able to have reasonable improvement in quality of life, and not [having] potential [adverse] effects of some of a medication.
We have recognized that while medications remain the number 1 treatment that urologists and probably most health care [providers] advocate for, [many people] may not want long-term use of a medication, [particularly considering] long-term [adverse] effects. With the ability to do procedures in the office and improvements in surgery, there may be a swing in what patients would like to do, advocate to do, or tolerate.
Urology Times®: What is the role of shared decision-making in the treatment of patients with BPH?
Kaplan: Patients are becoming more versed—given the internet, marketing, advertising—but it doesn’t mean they understand it well, unfortunately. Sometimes, we spend a good portion of our interaction with patients dissuading them or disabusing them of some of the notions that they may have. That being said, in general, the consumer, or the patient, is becoming a little bit more aware and a bit savvier about what’s out there. There’s a visceral appeal to be able to have procedures that may be relatively easy to do, to not [have] to take a therapy every day, and to not [have] sexual function affected.
Patients will come in, and, based on an evaluation, I try to have a conversation with them about why certain things may work and certain things may not work. They may come in [wanting a certain procedure], but we have to go through the process of explaining why that may not be best for them. In my experience, most patients come to me for my advice, and they will accept it. That doesn’t mean they’re going to do the procedure or therapy right away, but at least they’ll understand.
Urology Times®: What are the long-term implications of medical therapy for the treatment of BPH?
Kaplan: Data [have] emerged about long-term use of medications, in particular long-term use of certain classes of agents, such as 5-alpha-reductase inhibitors (5ARIs) and antimuscarinics, [which] have been associated with cognitive changes, dementia, and depression. While we know this more definitively with a medication such as oxybutynin, the jury is still out on 5ARIs. In addition, conflicting reports about the long-term use of alpha blockers and in particular tamsulosin and depression / dementia remain.
Most BPH medications, probably more than half of BPH medications, are prescribed by [doctors other than] urologists. Those physicians don’t have access [to surgical treatment] and don’t do minimally invasive procedures. So if you go to your primary care physician and say, “I get up at night with the need to urinate,” or, “I want to run to the bathroom,” they’re not going to offer a procedure, because they don’t have access. They’re going to give medications. So that’s a whole group of patients who we don’t even see unless they fail therapy and/or they have [adverse] effects of therapy, and then they’re referred to a urologist. So, that’s 1 group, and, frankly, that’s probably the majority of patients.
Then you have the group treated by urologists. There’s a balance, because some urologists don’t do procedures and/or [they] believe that medication should be the first at-bat. Could those algorithms change? Sure, but at least the traditional teaching has been, let’s try some medications and see how you do. I like to try medication first just to see the patient’s response. If I see a patient respond to a medication, and then, for whatever reason, he doesn’t want to take it long term, I can have another conversation to say, “Hey, at least I know that you’re probably somebody who will get better with a minimally invasive therapy, because I see how you did with medications.”
Urology Times®: What is the role of transurethral resection of the prostate (TURP) in the evolving treatment spectrum for BPH?
Kaplan: One of my colleagues, [Kellogg Parsons, MD, MHS, FACS], says it best [when he comments], “I don’t think the TURP is the gold standard. I think TURP is a historical standard.” That’s a better way of looking at it, and I think it’s a good term. I now do Aquablation; we’re doing among the most [of that treatment] in the country right now, and that’s a surgical procedure. It’s not a TURP, per se; it’s a water TURP. For me, the GreenLight Laser Therapy, holmium laser, electrosurgical TURP, [and] Aquablation are surgical technologies. Some patients with large prostates who are in retention [are] going to have one of those procedures.
Urology Times®: What factors shape your decision to recommend minimally invasive surgical therapies?
Kaplan: If patients come in with urinary retention, they can’t urinate, or they’ve failed multiple voiding trials, in general, I’ve not used minimally invasive therapies. Some data are emerging that you could use [them] in retention, but the data are really stronger for patients who come in with symptoms.
I evaluate all patients before I make a recommendation. I want to do diagnostic procedures, including cystoscopies, transrectal ultrasounds, and bladder function measurements. I’m very data driven and precision driven. At a minimum, they have to have a measurement of their prostate size and determination of their prostate configuration if they’re going to have a minimally invasive procedure. Being very data- and diagnostic-oriented, [I use that information] to decide whether I want to [use] a UroLift or Rezum [device] or an iTIND [second-generation temporary implantable nitinol device]. For me, it’s about prostate size and configuration. So if a patient has a prostate that [weighs more than] 80 g or 100 g, I tend to not do minimally invasive therapies. There’s data that they may work, but I’m not as enthusiastic about [using them on] such large prostates.
So where do I use the UroLift, and where I do Rezum? It depends [upon] whether or not they have what’s called an intravesical or middle lobe or [a] large middle lobe. If patients have what’s called bilobar hypertrophy, and their prostate [weighs] less than 80 g, even though [UroLift] is approved [for use in prostates weighing] 80 to 100 g, I’m not a big believer [of using it] in prostates [of that size]. If they have bilobar hypertrophy, I tend to favor [use of] the UroLift. But if they have a middle lobe, I tend to favor [use of] the Rezum.
With the Rezum procedure, I put a catheter in patients for 2 or 3 days; in the UroLift procedure, I only put a catheter in about 10% or 15% of patients. If I was a patient, I would rather not go home with a catheter. So if I had a prostate that [weighed] 40, 50, [or] 60 g, and I didn’t want to take medication with added [adverse] effects, I’d rather have a [procedure involving] UroLift or Rezum.
The testing really helps us nail down which is a more preferable procedure. I try to be very diagnostic-oriented—that helps me pick the right procedure. Does that mean I always get it right? No. Does that mean a patient always does well? No. But I think I increase the odds by doing the right thing for the right patient.
Urology Times®: What does the next several years look like when it comes to the treatment of BPH?
Kaplan: There are a lot of new technologies that are in clinical trials, so I expect it to be more [and] not less for a while. As the reimbursement and economic structures change, that will continue to be the trend. I don’t see them decreasing. I still see a significant increase in these for the short term, over the next 5 years.
With all of these advancements, I’d like to see better diagnostics so that we can answer the questions of why certain therapies, even TURPs, [fail in some patients]. It’s not in an insignificant [number] of patients. We just presented data at [the annual meeting of the American Urological Association] last year, where even with a TURP, the retreatment rate at 1 year was approximately 5%. Sometimes, it’s the wrong diagnosis. For example, if you have a patient who just gets up a lot of night to urinate, how much is a TURP going to help them? They have another reason why they may be having their symptoms. And they’re almost doomed to [have failure of] even medical therapy, quite frankly, if they just get up a lot at night to urinate but don’t have a lot of daytime symptoms.
I would like to see us do a better job with diagnostics, frankly. If we’re more precise with diagnostics, and we know the patient has bladder obstruction as the cause of their symptoms, they’re more likely to do better [after prostate therapy], regardless of who does it. But if you’re going to do a therapy on a prostate in a patient whose primary reason for having their problem is not their prostate, [the therapy is more likely to fail, and the problem is] more likely to recur. If I would like to see us do something better as a community, [it would be] doing a better job at more precisely diagnosing why patients have problems in urinating. That, overall, would be the best thing to help clinicians do the right procedures.
In short, better diagnostics, more precise diagnostics, [and] more precision-driven therapies will improve the field. Let’s make the precise diagnosis of why patients have their symptoms, and we’ll be more likely to use the precise therapy that will create good, more sustainable results. That’s where the field needs to go.