Seth K. Bechis, MD

Seth K. Bechis, MD

University of California, San Diego

La Jolla, California

Seth K. Bechis, MD is a board-certified urologist specializing in diseases of the urinary tract, including kidney stones, benign prostatic hyperplasia (BPH) or enlarged prostate, and men's health issues. Dr. Bechis completed fellowship training in laparoscopy/robotics and endourology at the University of California (UC), San Diego School of Medicine, and residency training at Harvard Medical School, Massachusetts General Hospital in Boston. He earned his medical degree from UC San Francisco School of Medicine and holds additional Master of Science training in biomedical research, also from UC San Francisco, focusing on ways to prevent and treat diseases. As a member of the Comprehensive Kidney Stone Center at UC San Diego Health, Dr. Bechis has a special interest in advanced surgical treatment, medical prevention, and research on kidney stone disease. He has surgical expertise in percutaneous nephrolithotomy (PCNL) for complex stones, ureteroscopy, and shockwave lithotripsy. Dr. Bechis specializes in all procedures of the prostate including minimally invasive procedures such as Rezum water vapor therapy and UroLift, as well as robotic surgery and GreenLight™ Laser photoselective vaporization of the prostate (PVP). Dr. Bechis serves as the associate program director for the UC San Diego - Kaiser Laparoscopy/Endourology Fellowship in the Department of Urology at UC San Diego School of Medicine. His current research includes improving surgical techniques and clinical outcomes in stone disease, as well as tools for stone diagnosis and opiate-sparing pathways for managing pain. His research has been featured in peer-reviewed medical journals and he has authored chapters for university handbooks. Prior to joining UC San Diego Health, Dr. Bechis worked at Massachusetts General Hospital and Harvard Medical School, where he taught residents and medical students in the operating room and clinic.


Talks by Seth K. Bechis, MD

Should MIST be First Line Treatment for BPH?

Seth K. Bechis, MD, explores the question of whether or not minimally invasive surgical therapies (MIST) should be first line treatment for BPH. He begins by highlighting the prevalence of BPH in men over 60. He acknowledges that combination therapy is extremely effective in combating BPH in the short-term, but it has several long-term risks which impact patient QoL.

Dr. Bechis highlights the negative side-effects of the 5-ARIs, alpha blockers, and surgery post-medication-failure. Side-effects included increased risk of cardiac failure, dementia, depression, and sexual dysfunction.

Dr. Bechis then examines current MIST procedures for BPH treatment, including prostatic urethral lifts, water vapor thermal therapy, temporarily implanted nitinol devices, and balloons. He examines the durability, effectiveness, and side-effects for each procedure, and compares them to patients on medication

Dr. Bechis concludes by comparing the cost-effectiveness of MIST procedures to the cost of medication, taking into account IPSS improvement and Quality-Adjusted Life Years over time. Overall, he suggests that MIST procedures should be explored as a first-line treatment for BPH.

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Making Sense of BPH: Which Treatment for Which Patient – Review of Guidelines for BPH

Seth K. Bechis, MD, reviews the 2023 American Urological Association (AUA) guidelines for benign prostatic hyperplasia (BPH) treatment. Dr. Bechis begins by enumerating the currently available procedures for BPH treatment, with less invasive approaches favoring ease of use, minimal morbidity, and minimal ejaculatory problems versus the more invasive approaches favoring definitive efficacy and durability of results.

Dr. Bechis shares the 2023 AUA guidelines on surgical management of BPH and explains considerations for treatment choice include prostate size, presence of a median lobe, and preferences regarding sexual function. He covers guidelines for:

Prostatic Urethral Lifts
Water Vapor Thermal Therapy
Temporarily Implanted Prostatic Devices
Greenlight Photoselective Vaporization of the Prostate (PVP)
Drug-Eluting Catheters
Holmium Laser Enucleation of the Prostate (HoLEP)
Robotic Waterjet Treatment (Aquablation)

Dr. Bechis concludes by explaining how he counsels patients by reviewing the data together and involving them in shared decision-making. He stresses the importance of anticipating recovery pathways and post-op hurdles for each treatment.

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Lasers in Stone Surgery: Principles and Tips/Tricks for Lasers in URS and PCNL

Seth K. Bechis, MD, discusses applications, principles, and tips for using lasers in ureteroscopy and percutaneous nephrolithotomy. He begins by providing an overview of currently available laser technology, including short vs. long pulse and pulse modulation lasers, and their underlying mechanics.

Dr. Bechis then delves into how to match the appropriate laser with the desired treatment result based on the pros and cons of each device. Dr. Bechis provides real-world examples and use cases for laser devices, including:

Low Power Holmium Lasers
High Power Holmium Lasers
Pulse Modulation Lasers
Thulium Fiber Lasers
Thulium:YAG Lasers

Dr. Bechis concludes by summarizing laser-based approaches to stone treatment, explaining that important considerations include the desired treatment result and the laser’s pulse energy, frequency, and pulse width/modulation. He notes the importance of accounting for unique patient factors, such as anatomy and comorbidities, in addition to the technology’s capabilities when selecting laser treatment.

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Point-Counterpoint: HoLEP vs. GreenLightTM PVP – GreenLightTM PVP

Seth K. Bechis, MD, compares GreenLightTM photosensitive vaporization of the prostate (PVP) to holmium laser enucleation of the prostate (HoLEP,) illustrating how PVP can safely and effectively treat benign prostatic hyperplasia (BPH) in small and large prostates. Dr. Bechis first establishes BPH prevalence and expenses. He then cites American Urological Association (AUA) guidelines on the surgical management of BPH, noting that PVP may be used on small and average prostates.

Dr. Bechis explains that large prostates are also good candidates for PVP, and PVP can offer an advantage for patients on anticoagulation. Dr. Bechis then emphasizes that 180-watt laser use contributes to properly, safely, and durably treating BPH and creating functional outcomes after two years, regardless of prostate size. He compares data between PVP outcomes on small and large prostates, reviewing differences in operative time, lasering time, and energy per unit volume of the prostate. He evaluates the similar data found between small and large prostates treated with PVP, including hospital stay, quality of life, and International Prostate Symptom Score (IPSS).

Dr. Bechis then explores a 2017 study that found that PVP creates durable results at four years, provided that energy density remains at 3 KJ/cc or higher. Dr. Bechis also stresses that keeping the retreatment rate low for PVP depends on using the correct energy density. He continues by noting that there are fewer complications with PVP compared to HoLEP. Dr. Bechis completes his discussion by examining PVP’s relatively simpler learning curve and proficiency maintenance while also highlighting PVP as a financially sound option in BPH treatment.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: HoLEP vs. GreenLightTM PVP – HoLEP.”

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Point-Counterpoint: Holmium vs. Thulium Laser – Holmium

Seth K. Bechis, MD, discusses concerns with thulium fiber lasers (TFLs) and highlights holmium laser capabilities and their benefits. He opens by reviewing laser procedure terminology and noting the holmium laser’s increased reliability in comparison to TFL. Dr. Bechis analyzes misconceptions of TFL frequency capabilities and examines the pulse features of holmium lasers. He highlights pulse modulation in holmium lasers, a feature that allows urologists to reduce retropulsion.

He continues by examining the short and long pulse settings of holmium lasers, emphasizing that issues associated with short pulse fire, such as retropulsion and fiber degradation, can be solved with long pulse. Dr. Bechis discusses the variety offered by holmium lasers and eases concerns associated with the holmium laser’s special circuit requirements. He reviews MOSES pulsed laser modulation and similar technology.

He also explores different stone treatment methods, including fragmenting, dusting, and popcorning. Dr. Bechis stresses the significance of popcorning, noting that the holmium laser surpasses TFL in this technique and provides the retropulsion level necessary for effective fragmentation. He then reviews advantages and disadvantages of dusting, fragmenting, and popcorning, leading to a discussion on whether dusting or fragmenting is preferable in stone treatment.

After reviewing multiple studies, including a study from the EDGE Research Consortium, Dr. Bechis notes that there is no clear winner between dusting and fragmenting and pinpoints caveats to the literature on the subject. He then analyzes thermal injury concerns with TFL. Dr. Bechis concludes with a focus on the holmium laser’s ability to maximize efficient power and minimize heat, explaining TFL’s relative inefficiency and additional heat concerns.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Holmium vs. Thulium Laser–Thulium.”

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