Jan Chaseley

Good evening, everybody. Welcome to this webinar tonight on treatment for an enlarged prostate. My name is Jan. I'm the Clinical Nurse Specialist here at Benenden Hospital, and Mr Steve Garnett, Consultant Urologist, is our expert presenter for tonight. This presentation will be followed by a question-and-answer session, and if you'd like to ask a question during or after the presentation, you can do so by using the question and answer icon, which you'll find at the bottom of your screen. This can be done with or without leaving your name, and please note that this session is being recorded if you do provide your name.

If you would like to book your consultation, we'll provide details for that at the end of the session, and I'll now hand you over to Mr Garnett. You'll hear from me again shortly.

Mr Steve Garnett

Great. Thank you, Jan. Let's just get this going. Okay so what we're going to talk about in this session about prostate enlargement is what causes it what symptoms people get what we do to diagnose it and what treatment options there are particularly focusing on the new robotic treatment that we've recently introduced here at Bon Hospital which is called Aquablation® but also touching on some of the other treatments we do including TURP and [Music] Urolift® so I'm a Urology Consultant I've been working at Belnenden for 15 years or so now and I've been doing prostate work for a long time obviously and I started introduce some of the new technology into this region as it became available and including robotic surgery and I do both prostate cancer and benign prostate work in my NHS and private practice so what are we talking about with prostate enlargement What we're really referring to is what's technically called benign prostate hyperplasia, or BPH. We now use the term BPE, benign prostate enlargement. This is a bit more understandable, but it's benign, which means non-cancer enlargement of the prostate, and it's extremely common. It affects about half of men from the age of 50 onwards, and as we get older, it affects more and more of us, so by the age of 80, nearly 90% of men will be affected by this.

So about three million men in the UK do have urinary symptoms associated with benign prostate enlargement I think this is a useful picture because it shows you know very graphic what we're talking about so on the left of the picture we've got what a normal prostate looks like so this the prostate is a small normally about a walnut sized gland which sits underneath the bladder and obviously the bladder holds the urine and then when you pass urine it comes out through the urethra which runs through the centre of the prostate when the prostate gets enlarged it doesn't just grow outwards it grows inwards and so it sticks or blocks the urethra and by doing that it causes the bladder to have to squeeze harder and work harder to try and get the urine out and you end up with a reduced flow because of this blockage and because you may struggle to empty your bladder very well you can often leave urine behind and that in turn means you have to go to the toilet more frequently and because the bladder is the muscle here and the bladder becomes enlarged and thickened and when that happens the muscle can become what we call overactive or start squeezing when you don't want it to so often people also get problems with feeling like they need to rush to the toilet and that's what we call urgency we don't exactly know why people get benign prostate enlargement we know that it's linked to male hormone testosterone and people only get enlargement of the prostate if they have the male hormone testosterone obviously most men do so but exactly why or how that affects the prostate cells to make them enlarged and why prostate enlarges more in some people than others we don't really understand but it is a as I said a very common thing as we get older so we talked a little bit about this already but as the prostate enlarges and blocks the urethra the symptoms typically are difficulty getting started to have a pee going more often reduced flow having to get up more at night feeling you haven't emptied your bladder and that can lead on to more severe symptoms like problems with urine infections if you're not emptying your bladder and as I mentioned also this feeling of urgency of having to rush to the toilet, and in more severe cases or situations, if you're really not emptying your bladder very well, you can get problems with stones forming in the bladder, which again can lead to urine infections. So what's the sort of diagnostic pathway that happens? well usually most people will try and see their GP I know it's not always easy but see your see a doctor first and there'll be some basic tests done in the G GP practice and you may be started on treatment by the GP and that may be all you need but if you end up being referred on by your doctor to a urology department like here at Benenden Hospital then you would come up and we would want to test your urinary flow rate which is something we do by getting you to pee into a machine essentially that measures how well you're passing water and that gives us a good idea of the degree of blockage from the prostate so we do that we check to see if there's any blood or infection in the urine we want to check your prostate size and you may well need to have a camera examination of the prostate and bladder although not everyone needs that and that's an endoscopic examination which is called a cystoscopy If your symptoms are not bad or if they're quite mild, you may not need any specific treatment. You may be able to manage them a bit by adjusting what you drink, when, and that type of thing.

Often, people can just be reassured to know there isn't anything more worrying going on, but if you've got more severe symptoms, you may need to think about starting medications and the different types of medications. two broad groups medications is to shrink the prostate down in size and medication to open up the prostate and allow you to pee with a slightly better flow if the if the medication's not suitable for you or if it's not working well enough or if you get side effects from the medication which a lot of men do then you may need to consider intervention or procedures on the prostate and three main ones certainly that we offer here at Benenden Hospital would be Aquablation®  TURP and the Urolift® there are other procedures such as laser procedures but they're actually fairly similar I would say to the TURP so let's talk a little bit about Aquablation® which as I said before is a fairly new treatment certainly not very widely available in the UK at this time it has been widely adopted in in the United States but it's quite new here it's approved by nice and recognized as a valuable and good treatment for prostate enlargement and it's the only treatment that's what we call a robotic procedure so this involves setting up the equipment and mapping and scanning your prostate and then deciding exactly what we want the ablation limits to be and then we actually get a robot to do the ablation with the surgeon standing there with me standing there this uses high velocity or high pressure water jets so there's no cutting and no heat involved and because of this there's fewer side effects and the high press water ablates or destroys the prostate according to the limits that we've mapped out by doing this it relieves the pressure on the urethra and allows you to pee with a better flow we do this under general anaesthesia because it's really important that we don't have any movement once we've started the procedure but as I say there's no cutting and no heating involved this is just a quick shot of some of the equipment and it's is quite sort of involves a lot of computerized technology to map your prostate so it does involve using an ultrasound probe to scan your prostate and then accurately measure the limits of how much prostate we want to ablate which does make it extremely accurate real time procedure which allows us to be a bit more precise than some of the other treatments so as I say we're accurately targeting what we want to remove in terms of prostate tissue it's a combination of a robotic machine that holds the Aquablation®  arm and real time live ultrasound scanning that gives us a very detailed view of the whole prostate rather than just the inside and it's an integrated system set up so that the ultrasound and the Aquablation®  robotic probe talk to each other with a with a interface and a computer generated program it takes about an hour to two and usually it's a one night stay in hospital you would need a Cath in for that one night it says spinal or general but we would usually do that under a general anaesthetic this just has a little video to show you in a bit more detail exactly what's going on so what you can see before I start the video here is this is the robotically controlled Aquablation® arm or treatment and right at the end here this is the water jet that that is fired out under high pressure and this is the prostate tissue that we want to ablate or remove so it's been mapped out these green dots are the mapping that we've done to describe how much prostate we want to remove and you can see the very outer bit of the prostate is Left Behind and this area here which is where the ejaculatory ducts come out into the prostate is preserved in this little tile here What you can see is the ultrasound image that we use to generate this map and decide how much we want to remove from the ultrasound.

This is speeded up on the video here that I'm going to run, but basically we're using an ultrasound to map the prostate, decide how much we want to remove, and then the robotic arm controls how hard the water is, how fast the water jet comes out, and how far it goes down and across. So let's just run this, and we can see what actually happens, so the water jet will be firing side to side under robotic control so it's a bit like a windscreen wiper going across side to side and ablating or destroying the prostate and we by setting the depth the robot then and computer then decide how much power is required to achieve that depth that's just showing some water coming out of the system as we're doing the procedure and you saw a little picture there which was a view inside of the wiper going from side to side and then as we get towards the end here it slows down and there we go not a great view at this point but you can see just about see the jet going from side to side and it does one side at a time at this end bit because this is where the ejaculatory ducts and bits of stuff that allow you to ejaculate R and one of the benefits of this procedure is it has a much lower rate of affecting ejaculation so what are the benefits it doesn't usually affect sexual function which is obviously very important and a lot of in fact most prostate procedures and operations do affect ejaculation or sexual function because there's no cutting and heat people do seem to recover very quickly from it as I say it's usually one night stay in hospital in the over that and a lot of patients have been coming back and saying to me are Hess or discomfort they had which is always very nice to hear no incisions or Cuts and because it's robotic it's extremely precise and as you can see we're able to map out exactly how much we want to remove and how deep we're going to go with any medical procedure there are some risks and side effects Obviously, there's always a small risk of a urine infection with any procedure on the prostate, so you would have antibiotics at the time of the procedure.

You will see some blood in the urine of most people, and it can be a little bit difficult to start peeing immediately after the procedure. Again, that's the same with any procedure on the prostate. Incomplete bladder emptying is again an issue because some people are having this procedure done because they can't pee at all, so we can't guarantee that you'll get back to normal function straight away. Usually, these side effects are mild and settle down in a couple of weeks, so I would say it's best for men with moderate to severe urinary symptoms.

If you've got very mild symptoms, you probably don't need it, but we would need to do an assessment to determine if it's going to be the right thing for you, and there are always various options. One of the nice things about Aquablation® is that it's suitable for most people. Some of the other treatments can be limited by prostate size or shape, but Aquablation® is pretty widely suitable for most people, so let's just talk a little bit about other treatments. So what's the most commonly performed procedure for prostate enlargement that has been around for a long time? The TURP procedure, or transurethral resection of the prostate, What this involves is putting a camera instrument down the urethra into the prostate, and through that there is what's called a receptor scope, or a little electrical loop at the end, which is able to cut through the prostate using a combination of electricity and heat that allows us to take little chips away from the prostate and essentially core out the prostate from the inside. Now, it's a very well-established and good treatment, and many thousands of men have this done every year and have very good outcomes from it. It's certainly very successful at improving your urinary symptoms. It does have drawbacks in that it's very likely to affect ejaculation, and a small number of men have problems with erections afterwards. However, it is, as I say, very commonly performed and very reliable in terms of improving your urinary symptoms I just went back for a second. Yeah, so the TURP can be done under a spinal or regen anaesthetic; it's not done under a local anaesthetic. Most patients here at Benenden would have a two-night stay in hospital and have a catheter in for those two nights afterwards. You tend to have some blood in the urine, and that can go on usually for a couple of weeks, but sometimes a little bit longer, and all the bits of prostate that are removed will be sent off to be looked at under the microscope to see if there's any sign of prostate cancer. That's a routine thing, and I would say that TURP remains the most widely performed operation for prostate enlargement, certainly in the UK.

I think there are some advantages to Aquablation®, but the TURP, if you're not so concerned about sexual function, is a very good treatment, and I'm also going to talk a little bit about the Urolift®. The Urolift® is a smaller procedure. it's probably the most minimally invasive treatment that we can offer and I think rather than comparing it directly with Aquablation® or TURP it's probably best to think of it as kind of a step up from tablets or a replacement for people who find tablets causing them severe side effects or problems but it doesn't give quite as pronounced and Improvement in flow and urinary symptoms as a TURP or Aquablation® does but what it involves is putting small implants into the prostate that pull the prostate open because there's no cutting or removal of prostate tissue it's a fairly quick procedure it usually takes only about 15 minutes to do and it's usually done as a day case and most people do not need a catheter but I would say it doesn't cause as significant Improvement in urinary symptoms as the other procedures and it's like most things in life you kind of you have to weigh up the pros and the cons and if you've got quite bad symptoms you probably need a slightly bigger procedure than the Urolift®  but if your symptoms are annoying but not too severe then the Urolift® may well be a good option for you it says local anaesthetic there but we generally don't do it under a short general anaesthetic because patients do find it a bit uncomfortable under local anaesthetic we got a little video here just to show what the Urolift®  involves so this is a model of the prostate and you can see the enlarged prostate lobes on each side and what we'll do is just run this through so what we're going to see now is the view that we get so that's putting the instrument into the prostate and we fire these little implants through the prostate so we compress the prostate fire the clip through it deploys on the outside of the prostate and then it's pulled back and the prostate is tensioned in a compressed state so we usually put about four of these in depending on the size of the prostate and you can see by doing this it's pulling the lobes of the prostate open or pulling them apart to create a better Channel through which you can pass urine so this isn't suitable for very large prostates because the clips simply can't open it up enough and it's also not suitable for every shape of prostate because some men have a what we call a middle lobe of the prostate which is prostate tissue between these two lobes so prostate tissue sat right here in the middle and if you've got that then pulling the sides open clearly isn't going to isn't going to do the job. 

There so that's what the Urolift®  involves so those are the three main treatments I wanted to talk about obviously we're very excited to be doing Aquablation® treatment here which is not very widely available in the UK and I've been very pleased to see patients coming back having really good outcomes from that and very pleased with the procedure that they've had which has been nice to see so the TURP is a is a long-standing treatment and will be suitable for many patients the Aquablation® treatment is newer and has perhaps fewer side effects in particularly on sexual function and the urolith treatment itself is a smaller procedure that can be done as a day case and doesn't actually have any real sexual drawbacks but may not give as much improvement certainly doesn't give as much improvement in flow and some of your symptoms compared to the other two treatments but is a quicker procedure so I think what I'll do is I'll stop there we're open for questions and you can do you can ask a question by using the icon at the bottom of the screen so what I'll do now is just hand over to Jan to help me with the questions and if we get some questions and we'll run through those.

Jan Chaseley

Lovely, thank you. That was a really informative presentation, Mr Garnett. So yes, thank you for putting your questions in; if you have any, please add them to the question-and-answer icon. So, one question that you probably have already answered is: after the procedure, does ejaculation occur internally?

Mr Steve Garnett

So what the question is referring to is what we technically call retrograde ejaculation that means that when after some prostate procedures when you when you have sex when you ejaculate nothing comes out and the ejaculation goes backwards into the bladder it's not dangerous and men who have that after procedure still have an orgasm but nothing comes out and obviously it does feel different and you can't have children now that occurs in most men who have a TURP or a laser procedure certainly about we would say about two-thirds of men with Aquablation® it's much less common it happens in about 10% or one in 10 men that means it can happen and I certainly couldn't guarantee to you that it can't happen but clearly it's much rarer much less of a problem after Aquablation®.

Jan Chaseley

Thank you. Can an enlarged prostate return after treatment, and if so, how frequently?

Mr Steve Garnett

Yeah, so the prostate can continue to grow clearly. That depends a little bit on your age, because it tends to grow quite slowly. If we look at the rates of retreatment after TURP, about one in 10 men has needed retreatment by 10 years, and the rates with aqua ablation don't have a 10-year follow-up yet, but at five years, it seems slightly better than TURP, so there is a chance of it going back, but it is a slow process for most men, as I say, about one in 10 after 10 years.

Jan Chaseley

Thank you, and does the Urolift® have a permanent effect, and if not, do you have further treatment later on?

Mr Steve Garnett

The Urolift® I mean again, the problem with a lot of the newer treatments is that I can't give you answers to long-term sort of follow-up questions because we simply don't have that because they're new, but five years probably, the retreatment rate for Urolift® is about twice what it is for a TURP or Aquablation®, so that means yes, it's probably more likely that you would need further treatment, but you can have further treatment either a repeat Euro lift or a TURP or Aquablation®, but it doesn't prevent that simply because you've had a Urolift®.

Jan Chaseley

Thank you, and if there is another question, I suppose on the same line, if my prostate continues to grow, would any of these procedures need to be repeated?

Mr Steve Garnett

I think that's the pros and cons of Aquablation® over laser surgery. yeah so there are different forms of laser treatment but holp is laser nucleation of the prostate and that is doing a very similar thing which is just using a different form of energy to core out the prostate so with the TURP we use electrical energy to remove the prostate chip by chip bit by bit with a holp procedure laser is used to core out big lumps of the prostate which are then chopped up in the bladder and then removed so the holp and the TURP have very similar side effects particularly in terms of sexual function so they both have high rates of retrograde ejaculation and they can both have rates of incontinence although that's not common it can happen so I would say with the aqua ablation the rates of sexual side effects are significantly lower and they’re very low rates or risks of incontinence

Jan Chaseley

Thank you, and if I take blood thinners, is there a procedure that would be better for me?

Mr Steve Garnett

It really depends on what you're taking blood thinners for, because the most common reason for taking blood thinners is a heart condition called atrial fibrillation, which is an irregular heartbeat. For that reason, it's generally considered safe to stop anti-coagulation or blood thinners for a couple of weeks, so all of these procedures would involve you having to stop your blood thinners, so if you stop them, it doesn't really make a lot of difference which procedure you have.

Jan Chaseley

With Aquablation®, do you take samples that can be checked for cancer?

Mr Steve Garnett

We do take a small amount of tissue to check for cancer, but it's much less of the prostate that's sent off to be looked at because the amount that we're actually able to send off is quite small. I would say that all of these procedures are not really necessary while we check the tissue removed for cancer. We're not doing them because we think there's cancer there, and to diagnose cancer, a different approach usually involves prostate biopsies rather than these types of procedures.

Jan Chaseley

With regards to recovery from Aquablation®, is a recovery time quicker than a TURP with regard to exercise and getting back to normal activities?

Mr Steve Garnett

Yes, I think that the recovery time is a little bit quicker. I think with both procedures, the first couple of weeks you're going to be taking it fairly easy, not doing an awful lot, and trying to avoid heavy lifting, but people do seem to feel back to normal and more comfortable a bit quickly. I think after a lot of prostate procedures, people do have some sort of stinging and burning and a bit of discomfort, and that can go on for, at least, the first few weeks, and it seems to be less with Aquablation®.

Jan Chaseley

The next question is: if I had surgery done and Aquablation® done now at age 50, do you think it would need to be repeated again at age 70?

Mr Steve Garnett

That's probably a difficult one because, as I said, not always well, any prostate procedure may need to be repeated in the future because if you've needed an operation on your prostate at the age of 50, you've clearly got a sort of quick, quite early enlargement of your prostate, and it's likely that your prostate will continue to enlarge, so I would say whatever procedure you have, unfortunately, there is a chance of you needing something again in the future.

Jan Chaseley

A question: If you do have prostate cancer, can it be treated with Aquablation®?

Mr Steve Garnett

So Aquablation® is not a treatment for cancer. Okay, if you have urinary symptoms because of prostate enlargement and you've got prostate cancer, then you can have the Aquablation® treatment to treat your symptoms, but it's not a treatment for the cancer, so you would still need other treatments for the cancer.

Jan Chaseley

Thank you, and a patient here says they had a TURP about 10 years ago, but they now feel that they're getting more urgency and urinary problems. Would Aquablation® or TURP be best for me?

Mr Steve Garnett

Again, well, on the face of that, without more information, either treatment would be suitable for you, and you may not feel that the benefits of Aquablation® are particularly useful if you've already had a TURP, but both treatments would be suitable for you, and it sounds like you probably do need some treatment with the way you're describing things.

Jan Chaseley

Yes, and where does the removed tissue go with Aquablation®?

Mr Steve Garnett

I suppose it's just yes. A lot of the tissue that's ablated just goes into the waste, but some larger bits are removed and sent off to be looked at.

Jan Chaseley

Thank you very much. Are there any other questions further down, Ollie, or are we just reviewing the questions? a question somebody's just saying: What does rectal discomfort mean with Aquablation®? Did you mention?

Mr Steve Garnett

I mean, I'm not sure, so when we do the procedure, we do put an ultrasound probe into the back passage. I think that's the only thing I would think that the rectal discomfort refers to. Most people don't really see the problem. I mean, that's done for prostate cancer diagnosis with people awake, and it's usually not pleasant, but it's not painful.

Jan Chaseley

Thank you, and another question about whether it could be repeated, and I think we've already answered that one. Both TURP and Aquablation® could be repeated with any of these treatments. Is there an ongoing risk of incontinence?

Mr Steve Garnett

So with any treatment to the prostate there is a potential risk of incontinence the risks are very low in fact and I know people worry about it an awful lot but even with a TURP it is pretty uncommon so TURP rates of incontinence are generally quoted is around 1 to 2% but that so that's one to two men in 100 having the procedure and that tends but that does tend to be people who actually have prostate cancer which affects the anatomy and with Aquablation® it's generally less 1% so very uncommon good perfect and obviously here at Benenden Hospital if you're having any of these procedures your post-op follow up is done with us as a specialist nurses so obviously we'll cover things like pelvic floor exercises and help you with all of that

Jan Chaseley

Thank you very much. Could you just move to the last slide for me? Mr Garnett is lovely. Thank you very much. I'm sorry if we didn't answer all of your questions today. There have been a couple of questions specifically around the procedure, so obviously the private patient advisers will be able to give you more information about that. Tonight, we're offering you a 50% reduction on your initial consultation. You will get a call back from your dedicated private patient advisor, and you will receive the recording of this webinar tomorrow. This will also help you stay up-to-date with any upcoming news. If you would like to book a consultation or discuss this further, please contact the private patient team at the number that is now on your screen. They are here tonight until 8:00; otherwise, they're available Monday through Friday between 8 and 6:00 p.m. And again, if they have any queries, they can always check those out with Mr Garnett and myself. We would be grateful if you could complete the survey when this session closes to help us improve our future events. The next webinar from Benenden Hospital will be on ENT treatments, and you can sign up for this webinar on our website. Sorry on behalf of Mr Garnett today and the expert team here at Benenden Hospital. I'd like to say thank you for joining us today. We hope you found it informative, and we look forward to hearing from you soon. Thank you very much.