Topic: BPH

Surgical BPH: 2024 Updates and Where Are We Going

by Nicole L. Miller, MD, FACS | Jan 2025

Nicole L. Miller, MD, FACS, delivers an incisive update on the surgical management of benign prostatic hyperplasia (BPH). In this 11-minute presentation, Dr. Miller outlines the current AUA guidelines, highlighting a broad spectrum of treatments tailored to prostate size. Trends in national data reveal that transurethral resection of the prostate (TURP) remains the dominant procedure, while minimally invasive options like UroLift have gained substantial traction.

Dr. Miller discusses emerging technologies, including the OptilumeⓇ BPH System. She also reviews promising data on MRI-guided transurethral ultrasound ablation (TULSA). Advanced laser techniques, particularly holmium pulse modulation, and thulium fiber laser, are explored for their efficacy in enucleation procedures, showing advantages in operative time, hemostasis, and same-day discharge rates. Miller highlights evolving techniques like en bloc enucleation with early apical release. A brief discussion on robotic-assisted simple prostatectomy includes recent shifts toward single-port approaches.

Dr. Miller stresses the importance of aligning treatment with patient preferences and quality-of-life goals, emphasizing shared decision-making as central to optimizing outcomes in this rapidly advancing field.

BPH Morcellation

by Amy Krambeck, MD | Nov 2024

Amy E. Kramback, MD, presents a detailed overview of morcellation and its potential complications, particularly in Holmium Laser Enucleation of the Prostate (HoLEP). In this 14-minute presentation, she explains the technical requirements for performing morcellation.

Dr. Rebeck narrates a video of the procedure’s steps. She highlights how challenging nodules can sometimes require additional laser grooves to enable effective morcellation.

Complications during morcellation are also reviewed. Intraoperative issues include capsular perforations and bladder injuries. Injury to the ureteral orifices, while rare, can occur during morcellation. Dr. Krambeck also discusses postoperative complications and their management, including bleeding, clot retention, and infections such as UTIs or epididymitis. Incontinence, mainly urge incontinence, is another common postoperative issue. However, with proper technique, HoLEP and morcellation present low complication rates and excellent patient outcomes.

Posterior Stenosis – Post-Radiation or Anti-BPH Procedures

by Dmitriy Nikolavsky, MD | Sep 2024

Dmitriy Nikolavsky, MD, discusses urethral stricture and stenosis management following radiation and anti-BPH procedures, highlighting surgical challenges, outcomes, and the evolution of treatment strategies.

In this 11-minute presentation, Nikolavsky explores the differences in stricture occurrence across treatment types. Surgical approaches are tailored based on oncologic status, patient preference, and local tissue health. Buccal mucosal grafts for dorsal urethroplasty are highlighted as a promising technique. Notably, dorsal-only urethroplasty has demonstrated comparable success to EPA with a lower incidence of postoperative incontinence.

Dr. Nikolavsky emphasizes the difficulties of traditional excision procedures in radiated fields, proposing dorsal-only urethroplasty as a better alternative due to its minimal disruption of adjacent structures. He shares evidence from multi-institutional studies that support its efficacy.

With a call to challenge established dogmas, Nikolavsky underscores the need to refine guidelines and expand the use of innovative approaches like dorsal urethroplasty to improve patient outcomes.

TURP in 2024

by Granville L. Lloyd, MD | Sep 2024

Granville L. Lloyd, MD, provides a comprehensive overview of therapies for benign prostatic hyperplasia (BPH), focusing on the evolution from medical to procedural interventions. In this 9-minute presentation, he highlights the ongoing development and competition among various technologies, emphasizing procedural therapy over medical management in terms of sexual outcomes. Dr. Lloyd’s presentation describes the wide array of procedural options, including TURP, Rezūm, UroLift, and newer approaches like Optilume.

The economic and clinical burden of BPH is underscored. Dr. Lloyd advocates for a personalized approach to selecting the appropriate therapy, utilizing the best tool available for each patient while acknowledging the evolving role of newer technologies.

HoLEP

by Lori B. Lerner, MD | Sep 2024

Lori B. Lerner, MD, delves into the complexities of enucleation techniques for treating benign prostatic hyperplasia (BPH), emphasizing the importance of understanding prostate anatomy. In this 11-minute presentation, she highlights how individual anatomical variations influence surgical decisions and outcomes, particularly in laser enucleation.

Dr. Lerner outlines different approaches to enucleation, involving strategic incisions to address each patient’s specific anatomy. She discusses complex cases, such as patients with a significant portion of their prostate extending into the bladder, nodular prostates, or elevated bladder necks, which necessitate tailored approaches.

Dr. Lerner’s presentation underscores the necessity of careful preoperative imaging, using tools like MRI or CAT scans, to map the prostate’s structure and guide the surgical approach. She advocates against routine excessive testing, emphasizing responsible and targeted use of diagnostic tools to inform clinical decisions without unnecessary expenditure. Lerner also addresses potential complications such as postoperative stress urinary incontinence.

Optilume

by Garrett D. Pohlman, MD | Sep 2024

Garrett D. Pohlman, MD, discusses the Optilume BPH procedure, a novel treatment for benign prostatic hyperplasia (BPH). In this 11-minute talk, Pullman gives step-by-step instructions for the Optilume placement procedure, emphasizing how the treatment can be tailored to individual patients based on prostate size, anatomy, and personal preferences.

Pullman discusses the safety and efficacy of Optilume, as well as data from studies like Pinnacle and Everest. He also shares that the placement procedure can be performed in various settings, including outpatient surgery centers and offices. He asserts that Optilume BPH is a promising, durable, and patient-friendly option for treating BPH.

Should MIST be First Line Treatment for BPH?

by Seth K. Bechis, MD | Sep 2024

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 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.

The Prostatic Urethral Lift (Urolift): Back to Basics

by Matthew C. Ercolani, MD, FACS | Sep 2024

Matthew C. Ercolani, MD, FACS, provides an overview of UroLift, a minimally invasive procedure for benign prostatic hyperplasia (BPH). In this 11-minute presentation, Ercolani explains his reasoning for performing the UroLift procedure and its benefits compared to other options.

Dr. Ercolani reviews the optimal patient profile, best placement locations, and areas to avoid when performing the implant procedure. He then shares a video of implantation, illustrating how to customize Urolift placement and providing a “before and after” comparison.

Rezum, Stents

by Kevin C. Zorn, MD, FRCSC, FACS | Sep 2024

Kevin C. Zorn, MD, FACS, FRCSC, addresses the challenges and advancements in managing benign prostatic hyperplasia (BPH), focusing on minimally invasive surgical techniques. In this 17-minute presentation, he highlights the limitations of traditional treatments, such as transurethral resection of the prostate (TURP), and a growing demand for effective and less invasive alternative options.

Dr. Zorn explores the evolution of BPH treatments, discussing the importance of finding office-based, quick, and cost-effective solutions. He describes various less invasive technologies, including UroLift, Rezūm, and novel stent devices like iTind and Optilume.

Zorn underscores the variability in patient outcomes based on prostate anatomy and tissue composition, noting the importance of personalized treatment approaches. Moving towards a more tailored approach, similar to the precision seen in prostate cancer management, considers prostate size and tissue composition.

Laser Selection for HoLEP

by Pierluigi Bove, MD | Sep 2024

Pierluigi Bove, MD, discusses the selection of lasers for Holmium laser enucleation of the prostate (HoLEP), focusing on the evolution and advancements in laser technology since 1995. In this 9-minute presentation, Bove emphasizes that the choice of laser depends on personal preference and experience, technical features, and economic considerations. Dr. Bove considers the Holmium laser the gold standard for BPH surgery due to its versatility in treating various prostate sizes and conditions such as stones.

The discussion then shifts to a comparison between the traditional Holmium laser and newer technologies like the Thulium laser with pulse modulation. Bove presents evidence suggesting that the MOSES effect, available with Holmium lasers, can improve intraoperative hemostasis, shorten operative time, and enhance outcomes.

Ultimately, the selection of the appropriate laser for prostate enucleation depends on various factors, including the surgeon’s familiarity with the technology, the type of procedure, and resource availability.

Greenlight PVP

by Gregg R. Eure, MD, FACS | Aug 2024

Gregg R. Eure, MD, FACS, outlines the use of GreenLight laser therapy in urology, focusing on its advantages and technique. In this 8-minute presentation, he shares that this laser therapy is efficient, with treatments often lasting under an hour and offering quicker recovery compared to transurethral resection of the prostate (TURP).

Dr. Eure shares that the GreenLight laser is ideal for underwater procedures, comparing it to different laser types, such as thulium and holmium lasers, which are primarily used for stone treatment. He concludes the presentation with practical tips, including managing anticoagulated patients, avoiding use in radiated tissue, and suggestions for patient counseling regarding postoperative expectations.

Optimizing BPH Clinical Pathway: Navigating the Next 20 Years

by Ilya Sobol, MD | Aug 2024

Ilya Sobol, MD provides a forward-looking analysis on optimizing the clinical pathway for benign prostatic hyperplasia (BPH) over the next 20 years. He emphasizes the integration of emerging technologies, personalized medicine, and patient-centered care to enhance treatment outcomes and patient satisfaction.

Dr. Sobol discusses the evolving landscape of BPH management, highlighting advances in diagnostic tools, such as improved imaging techniques and biomarker identification, and minimally invasive therapies, such as transurethral water jet ablation and laser enucleation, should be incorporated into standard practice.

Telemedicine and digital health technologies are highlighted as key components of the future clinical pathway. Dr. Sobol envisions the integration of telehealth services for routine follow-ups and monitoring. He also advocates for comprehensive patient education programs that empower individuals to make informed decisions about their care.