Phil Orrell

Good evening, everyone. And welcome to our webinar tonight on enlarged prostate treatment.

We'll just allow a few seconds for everyone to join.

Ok. Thank you for tuning in this evening to our webinar on enlarged prostate treatment, which includes our innovative robotic-assisted Aquablation® therapy.

My name is Phil, and I'll be your host this evening. I'll be joined by our expert presenter, Consultant Urological Surgeon, Mr Steve Garnett. If you haven't joined one of these webinars before, the format is as follows: Mr Garnett's presentation will last approximately 25 to 30 minutes, and this will then 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 Q and A icon on the bottom of your screen, and you can do this with or without giving your name.

But we should let you know at this point that the session is being recorded for archiving. If you do provide your name and would like to book your consultation, we'll provide contact details at the end of this session.

Now, without further ado, I will hand it over to Mr Steve Garnett.

Mr Steve Garnett

Great. Thank you very much. Thanks for the introduction. So, what we want to talk about in this evening session is a little bit about what we have experienced, but primarily about the prostate itself, what causes enlargement, how we diagnose that, and what symptoms you might have from that. And then a little bit about treatment options, including Aquablation®, which is a fairly new treatment that isn't that widely available, but we do offer at Benenden Hospital, and a few of the other treatments that are, are also available. And there will be some time for some questions at the end. So, if we could move on, please.

So yeah, this is a little slide about me. We don't need to spend too long on this. But yeah, I have been doing prostate surgery for a long time now and have introduced some of the innovative treatments into the area where I work, including the first sort of robotic operations in Sussex. And I've been working at Benenden since 2009. Next slide.

Thank you. So, what is benign prostate enlargement? It's also called benign prostate hyperplasia, and the important word is that it's benign. So, it's a non-cancerous enlargement of the prostate, and because the prostate sits underneath the bladder, when we pass urine, we actually pass urine through the prostate. If the prostate gets enlarged, it can cause urinary symptoms. So, it's an incredibly common problem and affects about half of men from the age of 50 onward. And by the age of 80, 80 to 90% of men will have benign prostate enlargement, and a lot of those will have symptoms associated with it. So, we think there's up to about 3 million men in the UK at any given time with urinary symptoms associated with BPH. Next slide, please.

So, I think this is probably one of the most useful slides that we've got in this presentation. On the left of the screen, as you look at it, is the normal prostate. As I said, that's sitting just underneath the bladder. And you can see how when you're passing urine, you're passing urine through the prostate itself, and then when the prostate gets enlarged, you can see that it narrows down and squashes the urethra, or the water pipe through which we pass urine. So, I think this diagram makes it very clear why you would have symptoms like a reduced flow or maybe difficulty getting started passing urine. And you can see that the bladder is having to squeeze harder and generate more force to get the urine out. And over time, that bladder muscle working harder causes other symptoms, like wanting to go more often and getting up more at night. Next slide, please.

We don't know exactly why the prostate gets larger, but we do know that it's caused by the male hormone testosterone. So obviously, the vast majority of men do have testosterone in their blood. But if, for some reason, a man has had treatment or doesn't have testosterone levels, they won't develop prostate enlargement, which is exactly why some people's prostate enlarges more than others. We don't really know for sure. And there do seem to be genetic influences on that. Next slide.

So, as I said, when the prostate gets enlarged, it grows from being a small gland, typically described as being like the size of a walnut, and it can get bigger and bigger and block the way out of the bladder. So, in terms of symptoms, men often describe what we call hesitancy. That's different: getting started passing urine frequency, needing to pass urine more often, difficulty fully emptying the bladder, and reduced flow rate. And in time, this also leads on to getting up at night, needing to pee, and can cause urinary urgency or rushing to the toilet as well. Next slide.

So, if you are experiencing urinary symptoms, it's, you know, worthwhile speaking to your doctor or a specialist about this. And there can be a number of assessments that we would do to assess whether your symptoms are due to your prostate. So, it starts off with asking you about your symptoms, maybe filling out a questionnaire about your symptoms, and then examining you by looking at your prostate size.

When you come to the hospital, we often do something called a flow rate, which is a test that allows us to measure how well you're passing urine and how well you're emptying your bladder. And there may be various other tests to assess which specific treatment is going to be the best thing for you. Next slide, please.

So, with benign prostate enlargement, just shorten BPE. If the symptoms are mild, you may not need any specific treatment; maybe just modify your lifestyle a little bit, perhaps reducing tea and coffee drinks, which tend to make these types of symptoms worse. But if the symptoms are more bothersome and they are affecting your life, then, as a first line, we usually look at medical treatments. So, these will be tablets, typically something like tamsulosin, and these can work to relax the prostate and allow you to pee better. But if the tablets don't agree with you or they're not working enough, then we look at surgical treatments or procedures on the prostate, ranging from a smaller procedure like Urolift® to a slightly more ablative treatment or treatment that actually removes some of the prostate, such as TURP or Aquablation®. Next slide, please.

So, let's talk about Aquablation® because this has proved very popular recently and has had a fair bit of press around it because it's a relatively new treatment and it has some advantages over some of the older treatments. So, it's a minimally invasive treatment. That is what we call robot assisted. So, while the surgeon is there, I'm there, controlling everything and checking on everything. The actual ablation of tissue is done by a robotically controlled instrument, and it uses high-pressure, high-velocity water jets to ablate or destroy the excess prostate tissue that's causing a blockage. So, it creates a nice, open channel through the prostate to allow urine to flow more freely. And that relieves the pressure and allows the bladder to function more normally. This is done under a general anaesthetic because it's very important that once we've set everything up, there's no movement, but there's no cuts or incisions, and it's all done with essentially a telescope and a robotic arm that's put down through the instrument that goes down the urethra or into the prostate that way. Next slide.

So, we're one of the first centres in the UK to be doing this Aquablation® treatment. It's still not that widely available because it's new, and the equipment is unfortunately quite expensive. But this is just a quick picture of our operating theatre, the team involved, and the equipment that we use. Next slide, please.

So, the acromegaly system is able to be quite precise and target and remove only the amount of prostate that we want. And because we use what's called real-time mapping of the prostate by ultrasound, that allows us to be a little bit more accurate and avoid areas that could have side effects. So, by using the robotics and the ultrasound, we create a map of exactly the amount of tissue we want to ablate and remove, and we can spare certain areas that may affect sexual function and things like that. So, by doing that, we can minimise side effects, whether spinal or general, but we do this under a general anaesthetic, and it's about an hour or so to do, and most patients stay for one night in the hospital afterwards. Next slide, please.

So, this is an animation that will start playing in just a second. But this is to demonstrate how the ablation actually works in a diagrammatic form. So what this is showing you is kind of a side view of the prostate with the instrument going through the prostate into the bladder, and in the little window there, there's an ultrasound image, which is what we use initially to allow us to map out the prostate very accurately, and then we plan how much prostate we want to remove, which is outlined in the green dotted line, and then what will happen is that the robot will control the movement of a robot will control the movement of a high-pressure water jet that removes or ablates the tissue to the precise depth that we have set out. So, it allows us to map things very carefully and preserve areas that are important. So, we're just going to play the video now, and that will hopefully give you a better idea of what's going on.

So, these are the water jets going from side to side, ablating the tissue, and they work their way through the prostate, destroying the tissue like that. This is a view you can see now in the window looking down the telescope. You can see the high pressure going from side to side, and the water jets are used to ablate the tissue, and then the water is aspirated continuously. So, the bladder doesn't get too full. So that's essentially what's happening. You can see that when it gets to the end, it will do one side at a time to preserve the ejaculatory ducts and areas that are involved in ejaculation to preserve that sort of function, and there we go. So that's essentially what's happening. There's an instrument in the urethra in the water pipe and another ultrasound probe in the back passage while you're asleep, and we map out the area to be removed and then set the robot going. Next slide, please.

So, the benefits are that it has fewer side effects than some of the other treatments. So, it doesn't usually affect sexual function. Most of the other treatments will very commonly affect ejaculation and have some risk of erectile dysfunction. It's a minimally invasive treatment, and there's a shorter hospital stay than typically with a TURP and other procedures. And obviously, there are no cuts or incisions on the outside. And because we're able to be very precise, the risk of damage to other tissues is reduced. Next slide, please.

With any treatment, there are potential risks or side effects. So, there's always a small risk of a urine infection, and you'll be given antibiotics when you're having this procedure first. A few times afterwards, when you're passing urine, it will sting a bit, and you may well see some blood in the urine. But after a few days, these things will settle down, and I would say that after a couple of weeks, people are getting back to normal. So it is; it is a very effective treatment, and the studies now have shown it to be as effective as the standard treatments with fewer side effects. Next slide, please.

So, is it the right treatment for you? Well, we would need to see you, assess you in the clinic, and perhaps perform some further tests. Certainly, a flow test and possibly an ultrasound, and review your symptoms and see exactly what problems you are getting. But this could potentially be a treatment for most men with prostate enlargement. So, it's not particularly restricted by size, which some treatments are, or prostate, or shape, which some treatments are. So, it is widely suitable. Next slide, please.

So, the operation that's been most commonly performed is still the most widely performed. is called the TURP, or transurethral resection of the prostate. And this is an operation that's been around for 40 years or so now. Now it is very effective. But it essentially uses instruments again down the urethra, but to core out or remove the inner part of the prostate that's causing a blockage, using what's called a loop through which an electrical current passes, and we're able to remove bits of the prostate at a time and then flush those out. Now, as it's a sort of bit-by-bit procedure, it can take a longer time, particularly for the big prostate. But it is effective; it's very good at improving symptoms, but it does have certain significant recognised side effects, particularly affecting sexual function. You know, there is a small, very small risk of incontinence, but it remains a very good, well-tried, and trusted operation that is possible and also available at Benenden Hospital. Next slide, please.

Another newer treatment that's been around now—a little bit longer than Aquablation®, I would say—but is a very small procedure that is attractive to a number of men is the Urolift®. So, this is a very minimally invasive treatment that, I would say, fits in between medication and surgery. It's not necessarily the right treatment for men with very severe symptoms. But if the symptoms are not too bad, you don't like taking tablets, or you're getting side effects from tablets, then this may be a very good treatment for you. It's a small procedure that's done on a daily basis. So, there's no stay in the hospital, and in most cases, a catheter isn't required. It involves putting these little implants in the bladder and firing them through the prostate to pull the sides of the prostate apart to improve the flow and empty the bladder that way. Just one point: it isn’t we don't usually do it under local anaesthesia. Next slide, please.

So, this is a schematic video again showing you what really happens with the Urolift® because it's much easier to demonstrate it than to talk about it. So, if we play this now, please.

So, what you're going to see in a second is the instrument coming in. This is a diagram of the prostate. The two sides of the prostate which are enlarged and pinching down the urethra in the middle. So, what happens is that we push the lobes aside, and then fire this implant through which there is a clip on the outside and is then tensioned by length and a clip applied on the inside. So, by doing that, it's compressing the prostate and pulling the sides or the loads of the prostate apart. So, there'll be depending on the size of the prostate a variable number of these implants placed. But by doing this you're opening up the channel through which you pass urine and improving the flow rate. Now, as you can appreciate because there's no cutting. or destruction or removal of tissue. It is minimally invasive and doesn't have many side effects. It doesn't affect sexual function, and there's no risk of incontinence. The downside of this is you can't actually improve the flow as much as you can with the other procedures. So, as I said, it's not ideal for men with severe symptoms. And also, some men develop enlargement of what we call the middle lobe of the prostate. So, as you can see, this is the view looking down the telescope towards the bladder, and you can see on the left and right where it says before that those are the lobes of the prostate, and afterwards, the lobes have been pulled apart, but some men have what we call the middle lobe of the prostate. Whereas right in the middle of the picture would be a lump of prostate, and that can't be pulled very easily to the sides. So that is less suitable for a urolith procedure. Next slide, please.

Yeah, we can move on. Yeah. So that's a quick overview of the treatments that are available, particularly at Benenden Hospital and Aquablation® TURP. There are a number of other treatments, but I don't think you know that it's very difficult for anyone centre to drive every single treatment these days. I think the treatment options available at Benenden offer you the most up-to-date and best-tolerated treatment with the best outcome. We're going to have a little quick patient feedback video. Now from a patient who had Aquablation® with us a few months ago and who kindly agreed to tell us his story.

So, if we play this now, I'll be quiet for a bit.

Philip Ralph

My name is Philip Ralph, and I was a self-payer for Aquablation®, which was completed on December 11, 2023. By chance, I saw information about Aquablation® that I felt was only available in America, and to my surprise, I saw some information that Benenden Hospital in the UK actually offered this procedure, which was robotic and offered fewer side effects and a better recovery chance for me. I was concerned that I did not want to have a catheter for the rest of my life.

Aquablation® has brought my life back to normal. It has given me my life back. I no longer have a catheter. I don't have any symptoms. I don't have any incontinence. I'm able to urinate absolutely perfectly. I don't have to go to the toilet frequently. It is as if I'd never experienced any problems. I am fully recovered, and I am so happy I chose Benenden and Aquablation®.

Mr Steve Garnett

Ok. Yeah, next slide.

Ok. So that's a brief outline of the treatments and options that we have here at Benenden. I think what we're going to do now is just move on. If any patients or sorry people have any questions, I'd be happy to answer them.

I think Philip will just take over hosting again now. Thank you.

Phil Orrell

Ok. Thank you, Mr Garnett, for that clear overview of the treatment options. We can take a few questions from the attendees, as mentioned.

So, the first attendee asks, Is Aquablation® limited by the size of the prostate? Is it not suitable for a large prostate?

Mr Steve Garnett

No, it is suitable for large prostates. I say that with the psych caveat because obviously there are some, some absolutely huge prostates that we wouldn't necessarily do it on, but for the vast majority, it's not particularly limited by size. So, for example, the TURP is definitely limited by size, as is the Urolift®. We can't do that on very large prostates at Benenden. Without going into specifics about your case, I would say that for most people, Aquablation® is going to be absolutely fine. There will be a few people with exceptionally large prostates who can't do it.

Phil Orrell

Ok, thank you. This next attendee, Peter, asks, Is there a danger that the high-pressure water jet in Aquablation® destroys healthy bladder tissue?

Mr Steve Garnett

No, because we're very carefully mapping out the prostate, and we put safety checks in place before we start to make sure that we're not going to be damaging the bladder or any of the other structures nearby. So, no, it doesn't damage healthy bladder tissue. You've got to also realise that although the water is fired out very fast when you get further away from the jet itself, the power of that water jet is massively diminished. So, yes, it's very powerful and very close to the jet, but away from the jet, you know, it doesn't cause damage. In fact, going back to the previous question, if you have a very large prostate, we may have to do what we call two parts, to do the Aquablation® twice while you're asleep, to reach the outer parts of the prostate. Simply because that water jet doesn't reach far enough down in one pass. And that's another reason why other tissues are protected.

Phil Orrell

Ok. Thank you. The next question is: where does the ablated material go?

Mr Steve Garnett

So, the ablated tissue basically goes into the bladder and then is evacuated from the bladder through the telescope that's down the urethra, and that tissue is syphoned off and removed. Sorry, I would say a small amount of that will be looked at under the microscope. Just routinely check for any signs of prostate cancer. But this is not an operation like the other operations. This is not an operation to try to diagnose prostate cancer. That would be a different thing.

Phil Orrell

Ok. Thank you. This attendee asks, Can an enlarged prostate affect sexual function? If there is a problem with sexual function, will this procedure assist in recovering that function?

Mr Steve Garnett

So, in general terms, the answer to that is no; we don't, and we don't generally find that enlarged prostates affect sexual function. Of course, both prostate enlargement and problems with erections are very common in men as we get older. So, it doesn't mean that one causes the other, but both are very common. Unfortunately, I can't make any promises that prostate treatment with any of these treatments would improve sexual function. Occasionally, people say it does, but it's certainly not the aim of the treatment or anything I would like to claim.

Phil Orrell

Ok, thank you. This next guest asks: Is Urolift® reversible?

Mr Steve Garnett

Well, the thing about the Urolift® is that it's not so much a reverse. It's difficult to take the clips out unless you're having further surgery on the prostate. So, you can go on and have a lift done again; you can go on and have Aquablation®, TURP, or other things done to the prostate in the future. And the internal clips that you saw being placed will be removed as part of that procedure, but the clips that get placed on the outside of the prostate will stay there permanently.

Phil Orrell

Ok. Thank you. The next question is, are there any incontinent risks with Aquablation®?

Mr Steve Garnett

You know, it's really hard to say it's impossible for something to happen because incontinence can happen for many different reasons. People have continence problems. But what I can say is that the risk of incontinence with Aquablation® is exceptionally low, and I would put it at under 1% chance, but I don't think it would be fair to say anything is impossible.

Phil Orrell

Alright, thank you. This next question obviously means this person is talking post-procedure. Do prostates continue to grow and end up needing retreatment?

Mr Steve Garnett

Yeah. So, with any prostate treatment, there is a retreatment rate, and the prostate can continue to grow. Obviously, the factors to take into account are the age at which you're first having treatment for the prostate. Obviously, if you're a relatively young man with a very large prostate, that suggests your prostate does grow very quickly, and there's probably an increased chance of you needing further treatment in the future. If we look at the sort of long-term data that we do have, we know that about 20% of 1 in 5 men who have had a TURP in the past will need a repeat procedure by 10 years after the operation. But you know, if you turn that around, that means that 80% of people do not need further treatment within a 10-year period. So, we haven't got 10-year data on Aquablation® yet. But the five-year data is, if anything, slightly better than TURP. So, we'd expect it to be similar.

Phil Orrell

Ok, thanks. The next question is: Is there any risk of the Urolift® implants being dislodged or moving into the urethra?

Mr Steve Garnett

Well, the urine implants are, so the urethra and prostate are really one; they're not separate. So often, people are sort of given the idea that this picture of the urethra is like a tube running through dough or something, but it's not like that the urethra and prostate are fused together. It's one and the same. So, the implants that are placed are in the urethra. That's where they're supposed to be, and they pull the prostate apart that way. It's very rare, but occasionally the clips can become dislodged, in which case. They were usually just passed out in the urine. They're actually quite small. Patients have occasionally noticed passing them out when they have a pee. It's rare, but occasionally it can happen.

Phil Orrell

Ok. The next question is from a gentleman called Nigel, who says I am 80 and I've had two TURPS. The first was not fully effective five or four years ago. I'm now experiencing incontinence, and sexual function is severely affected. Is either Aquablation® or Urolift® possible?

Mr Steve Garnett

Yes. Both Aquablation® and Urolift® can be possible after a TURP, you know. Obviously, I can't answer specifically about you without further tests and investigations. I think so, because when you've had two procedures already, it starts getting a bit more complicated. But in principle, yes, you could have an Aquablation® after a TURP, you could have an Aquablation® after a Urolift®, and you could have a Urolift® after a TURP as well. So, yeah, both are potential options for you.

Phil Orrell

Ok. Thank you. This next attendee asks, having been advised to take Tamsulosin. I think that is, excuse my pronunciation, Tamsulosin five years ago and not so far used it and still perhaps only goes to the toilet once a night or not at all. I do have urgency sometimes during the day. Am I doing any damage to my bladder?

Mr Steve Garnett

Well, again, I can't really answer that without doing what's called a flow test, where we see how well you're passing urine and how well you're emptying your bladder into it. From what you say, it doesn't sound like you're likely to be damaging your bladder because your symptoms don't sound bad. But without doing those tests, it would be really difficult for me to answer because what can happen over time is that the bladder can increasingly struggle to generate the force to get the urine out, and you can slowly be leaving more and more urine behind, placing yourself at greater risk of not being able to pee at all. Now, it doesn't sound like that's happening, but without doing the flow test, I wouldn't really know for sure. So, I think you need a few more tests.

Phil Orrell

Ok. Thanks. The next question is: Is it advisable to consider Aquablation® if you have taken Finasteride for a number of years?

Mr Steve Garnett

So, finasteride is a drug that's taken to reduce the size of the prostate. It is an effective drug. It can have some side effects, but it's an effective drug. Just because it reduces or works to reduce the size or stop the prostate from going in general terms doesn't mean that it works brilliantly for everyone. And if you've got worsening symptoms despite being on Finasteride, then certainly a probation could be a good treatment for you.

Phil Orrell

Ok. Thank you. This is quite a broad question from a gentleman called Peter, who asks, At what point is it worth considering treatment of any form?

Mr Steve Garnett

Well, I would say, yes, that is quite a broad question, but I think it's, it's, it depends on you. I mean, if you've got symptoms that are annoying you and bothering you and affecting your quality of life, and that might be, you don't really want to go out to the theatre because you're worried about it, or to the cinema or whatever, or to a concert or whatever it is you, because you're worried about having to get to the toilets, or you're worried about your water works, or you don't want to get a bus, or you don't want to go on holiday, or you start worrying about your round of golf or whatever it is. If it's affecting your life or you can't sleep because you're getting up a lot and you're getting tired, if it's affecting your life and your quality of life, then I would say that's when you should be looking for treatment.

Phil Orrell

Ok, thank you. Martin asks, I'm currently taking Tamsulosin after chronic UTIs at 65. Should I delay Aquablation® or go for it?

Mr Steve Garnett

Now, again, I think, you know, it just depends on how you are with it. If you're taking Tamsulosin, you're happy with the medicine; you've got no side effects, and your symptoms are all fine. Then I don't think you need Aquablation®. But if you're getting side effects from the medicines, if you're still getting symptoms despite the medicines, if you're, some people feel quite tired of Tamsulosin. If Tamsulosin is just not doing enough and you're still having some of the problems I just talked about, then yeah, that would be the time to have treatment. So, it depends on how you feel about it.

Phil Orrell

Ok. Thanks. Apologies. If this revisits some of your answer from earlier, Mr Garnett, somebody asks, How is this achieved? I'm assuming this gentleman is referring to the Aquablation® procedure. How is this achieved without making a hole in the bladder?

Mr Steve Garnett

Well, because we're able to map the prostate very accurately and guide the pressure and the depth of the water jet, it is only treating the prostate and not the bladder. So perhaps the video has confused people because that's the second question. But it's got nothing. It's not; it's not damaging the bladder.

Phil Orrell

Ok. And I think we've got time for one more question. I think this is a follow-up question from the gentleman earlier who asked, Is there not an increased risk of incontinence if one has a third procedure?

Mr Steve Garnett

Yes, the more treatments you have, the greater the risk of incontinence. So, yes, if you've had two TURPS and you're having a third one, the risk of incontinence will be greater than it was the first time you had the treatment. Yes, that is true.

Phil Orrell

Ok, thank you very much. I'm sorry if we didn't answer all your questions, but if you've provided your name, we will answer yours via email, and as listed on the screen here, we offer an exclusive offer for those attending this webinar. So that includes 50% off your initial consultation. As a thank you for registering this evening, you will receive a call back from your dedicated private patient advisor and an email tomorrow with recorded treatment information, pricing, and loyalty reward points via email. If you're registered with our loyalty programme, you will also receive updates on news and future events. Following this webinar, you'll also receive a survey. If you could complete that survey, and if you take a few moments to do that, we would very much appreciate it. It helps us to inform and improve future events of this type.

If you would like to discuss or book your consultation, our private patient team can take your call this evening until 7.30, or they're also available, as listed on the screen, between 8am and 6pm Monday through Friday at the number listed.

All that remains for me to say is that our next webinar is on hip and knee surgery. You can sign up for that via our website and on behalf of Mr Garnett and our team here at Benenden Hospital. I'd like to say thank you very much for tuning in today, and we hope to hear from you very soon. Thank you, and goodbye.

Mr Steve Garnett​

Thank you.