Urology webinar transcript
Louise King
Good evening, everyone. Welcome to our webinar on treatments for enlarged prostate. My name is Louise, and I'm hosting this session.
I'm joined by our presenter, Mr Steve Garnett, our Consultant urological surgeon at Benenden Hospital.
This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation. Please do so by using the Q&A icon, which is at the bottom of your screen. This can be done with or without giving your name. Please note the session is being recorded. If you do provide your name.
If you'd like to book your consultation, we'll provide contact details at the end of this session.
I'll now hand over to Mr Steve Garnett, and you'll hear from me again shortly. Over to you, Steve.
Mr Steve Garnett
Thanks, Louise, good evening, and welcome everyone. Thanks for joining us this evening.
Sorry. I've got a little bit of a cold like lots of people at the moment. But hopefully, you'll be able to better understand what I'm saying. So, if we move on to the next slide, this is a little bit about me. Looks a bit younger in that picture, but I've been leading on prostate services and urology in East Sussex for over ten years now, and I help bring in both the Urolift® and the Aquablation® services to Benenden Hospital. Next slide, please.
So, what we want to talk about this evening is a little bit about prostate enlargement, what it is and what it isn't. Then we're going to touch on Aquablation®, which is kind of the newest prostate ablation treatment. We'll talk briefly about TURP, which is the most widely done and longstanding operation on the prostate, and we'll briefly talk about Urolift® as well, which is a smaller excuse me, or minimally invasive treatment and then we'll be able to take some questions at the end next slide, please so prostate enlargement, or better known as benign, prostate, enlargement, or bpe, used to be called bph.
This is a benign that means a non-cancerous condition affecting the prostate and it's really very, very common. So it affects at least 50% of men from the age of 50 onwards, and by the age of 80, about 90% of men will be affected by benign prostate enlargement. So you know, probably about three million men in the UK will have urinary symptoms due to BPE.. Next slide, please.
I think this is a really important slide. This shows very clearly what we're talking about. So on the left of the screen. As you look at it, you've got the normal prostate, which shows that the prostate is this gland that sits underneath the bladder there, and when you pass urine, the urine comes out of the bladder and actually come through the middle of the prostate, or through the urethra or water pipe which runs through the prostate and then on the right side, you can see, as the prostate gets enlarged, it grows and blocks that way out of the bladder, so the urethra or prostatic urethra there is constricted, and you can understand quite easily, I think from that diagram how your flow might be reduced. The bladder is thickened because it's having to work harder to try and get urine out, and that causes other symptoms of bladder irritation like wanting to go more often and as the bladder muscle starts to fail, you may not empty your bladder very well, may start leaving urine behind. Then you get further symptoms like having to get up more at night and kind of dribbling when you're passing urine. So I think that's a really important diagram there. That kind of explains the crux of the problem. Next slide, please.
So we don't really know exactly why people get BPE. It's definitely linked to male hormone testosterone.
But exactly why people get these problems we don't really understand, and I think it's important to say very clearly that it's separate from and not related to prostate cancer. So you know, enlargement of the prostate is very, very common, due to benign, prostate, enlargement, and prostate cancer whilst can cause some of the same symptoms is a totally separate condition. New slide, please.
So the symptoms that you get really, as I just talked about from that picture of an enlarged prostate it blocks away out of the bladder, so it can be difficult to start passing urine. We call that hesitancy or frequent need to pass urine frequency, difficulty emptying your bladder. So it's incomplete bladder emptying and, as I say, also getting up at night and actually also, another common symptom is urgency, a strong desire to go to the toilet that's difficult to hold off.. Next slide, please.
So what to do if you're experiencing some of these symptoms? Well, in the first place, you can contact your GP. Talk to your doctor about that. Maybe have some basic assessments, or come and see us at Benenden, or get referred by a doctor to come and see us and we'll want to do things like checking your urinary flow rate, assessing your prostate.
Maybe some blood tests and assessing what sort of treatments might work for you, and whether whether that sort of thing we can offer you here at Benenden, which in most cases it is. Next slide, please.
So I think it's important to say that if if you do have just quite mild symptoms that are not really bothering you that much, you may not actually need any treatment and some, you know, some of those treatments can resolve with simple lifestyle changes like watching what you drink, cutting down on caffeine that type of thing, but for more severe symptoms, particularly, I always think that if it's really starting to bother you and affect your quality of life so that you know, if you're always wanting to know where toilets are, you don't feel confident going out, that that type of thing. Then there are a number of different treatments available now, ranging from tablets to procedures, and particularly here at Benenden. We are going to talk about what we offer, and we'll talk briefly about Aquablation® tup and Urolift® procedure. Next slide, please.
So Aquablation® is the newest treatment, really, that's on offer and it's not that widely available at the moment. But we do offer it at Benenden. It involves using a minimally invasive robot assisted procedure whereby high pressure, high velocity, water jets are used to ablate or destroy the prostate tissue that's causing a blockage and by doing that we relieve the pressure on the urethra or remove the blockage and allow better urinary flow. Now it is performed under general anesthetic, but there are no cuts or incision. It's all done with instruments down the urethra, and because we use real time live ultrasound imaging. It allows us to be very precise and only remove the tissue we want to. Next slide, please.
Quick picture of the team and the equipment we use. That's some of it there, and that's that's in the operating theaters at Penndon, which, very pleased to say lovely, shiny new theatres, which very nice to work in. Next slide, please.
So what happens? Well, we're able to precisely target and remove the prostate tissue that's causing a blockage because we're using a combination of computer controlled water, jet ablation and ultrasound imaging. So we use an ultrasound to map the prostate. Looking at the size and areas of the prostate that are causing a blockage and then we map on a computer sort of design program the area that we want to ablate or remove and then the computer helps guide us do that and the process usually takes about an hour or so and usually is a one.
Sometimes a two night stay in hospital and I think we've got a slide coming up that makes that all a bit more understandable. Yes. So this this next slide gives us a, a real life, not a real life. Sorry, a diagrammatic image of what's happening during the acquisition. So what you can see in the main picture is the Aquablation® arm or probe. So that's going down the urethra into the prostate and at the end of that probe you can see a high pressure water jet coming out and what that's going to do is ablate or destroy the prostate tissue mapped out by that green dotted line. Now in the little tile or window in there. What you're looking at there is the ultrasound image that we can see in real time, and we've used this ultrasound image to map out the prostate and the area that we've basically drawn on in green dotted line is the area that of prostate tissue that we want to remove. So what we're going to do in a minute is just run this video, and it will show you essentially what's happening during Aquablation® with this high pressure water jet going from side to side, and the depth is very much controlled of how far we ablate by by the computer based on the green dotted line that we've drawn on. So if we play the video now.
So this is the water jet going from side to side and removing that prostate tissue and you'll see that we're able to be very precise. It's a little bit less deep there and then. We're going deeper again now, and that's the image There was down the telescope to see and what this is showing you is water coming out as we're as we're putting water in to do the ablation.
So that's essentially what happens with Aquablation® and because we're able to use the real time imaging and be a bit more precise, we're able to avoid some of the side effects which other procedures may have, particularly on sexual function. So we have lower risks of affecting things like ejaculation. That's a real time image of the water jet coming out and ablating the prostate tissue.
So essentially, that is what happens in Aquablation®, and it is as the name said, it is high pressure water ablating the prostate tissue. So by doing that you can see that we will have removed a lot of the prostate tissue, and there'll be a nice open channel through which this patient can pass urine with a good flow next slide, please, so it doesn't usually affect sexual function, there's a reduced recovery time and reduced time in hospital, and because there are no cuts, there's less risk of complications and bleeding and infections and because we're using a robotic computer controlled system, we can be a little bit more precise and that really the ultrasound really helps us with that, and we're able to map out exactly what we want to remove and not affect the rest of the prostate. Next slide, please.
So any operational procedure will have some risks. Any operation particularly has risks of infection, so we generally give an antibiotic. With this there may well be, and in fact, normally, there is some blood in the urine for a few days afterwards and to start with, it's going to be a bit stingy or burning passing urine. That's that's normal. But these are usually mild and will settle down in the first ten to 12 days or so after the procedure. Next slide, please.
So we'd need to assess you to know if it's right for you as an individual. But acquibration is good for many different sizes and shapes of prostate. So it is very adaptable, so it will be suitable for a lot of men with BPE, particularly those with moderate to more severe symptoms and we can look at the options and and do various tests to assess what's gonna work best for you. Thank you. Next slide.
So in contrast to that TURP or transurethral resection of the prostate has been around for 40 years or so now, and that's because it's an effective treatment. It is still the most widely performed operation for prostate enlargement in the Uk and what we do is we use a telescopic instrument down the water pipe, and at the end of that there's a small metal loop which has an electric current that runs through it, and we use that to cut through the prostate and remove the prostate piece by piece or little chip by little chip to remove all the blocking area. Now, when we're doing that we don't have the benefit of an ultrasound scan and computer guidance, but it is a very effective operation, but it does have higher rates of sexual dysfunction compared to Aquablation®, particularly affecting ejaculation. But it is, as I say, very effective and works well, and it can be done under a spinal rather than a general anesthetic.
It would usually be a two night stay in hospital, and it's common again to have some blood in the urine for a couple of weeks or so afterwards, and there are some additional risks of other small complications like scarring afterwards, which are rare, but can happen.
There are some size limitations on this, so if your prostate is very large. It may not do so well with a turp. We may not recommend that. Okay, next slide, please.
So the Urolift® procedure is what's called a minimally invasive surgical treatment. So this is, it kind of fills the gap, I guess, between medication and more invasive treatment. So many men don't want to come and stay in hospital, or have anything that has risks of affecting their sexual function, and in this treatment small little implants are placed in the prostate to pull it apart to pull it open, and this improves the flow and bladder, emptying and urinary symptoms. Although it says local anesthetic procedure under there. We don't usually do it under a local anesthetic because it is a bit uncomfortable. So it's quite a quick procedure, usually only takes about ten min, so we do it under a short general anesthetic or sedation. Usually I think it's important to say that with the Urolift®, like lots of things that it is quicker, more easily done with fewer side effects, but it has a less durable or long lasting effect, and many patients do get a good result from this for a few years, and we'll then need further treatment in the future. There aren't really any recognized sexual side effects or incontinence problems with this. So it does have few side effects. Next slide, please.
So this is just we're going to run this video in a minute just to show you exactly what happens with the Urolift®. So what you're looking at at the start is a diagram of the prostate or two lobes or sides of the prostate meeting in the middle and causing a blockage to the way out. So what you'll see in a moment is the Urolift® instrument goes in, and we fire a little clip through the prostate that anchors on the outer part of the prostate, and then we tension the inner plate or the inner part of the clip to pull the prostate lobes apart and create a nice channel to pass urine through. So if we run the video now.
So that's the diagram of the prostate and in a minute. That's the telescope, the instrument coming in down the urethra and what happens is we deploy the little clip. We compress the prostate fire, the clip out which deploys on the outer part of the prostate, and then we tension that and employ an inner clip, and you know you might be thinking these look like treasury tags. That's what everyone kind of thinks and they do. That's essentially stitch material and little metal end plate and by doing that by pulling and compressing the the prostate, pulling it apart, compressing each lobe it opens it up like that, and depending on the size of the prostate that will affect how many clips you need to put in. Typically, the average number is four. So that's what it looked like before, with a narrow way out of the bladder, and afterwards you'll see a nice open channel. So that's how the Urolift® works, and it is a good sort of medium term option, but it doesn't give as lasting an effect, and doesn't give as great an improvement. So I think if you've got more severe symptoms, I would generally encourage men more towards more slightly more invasive treatments, like Urolift®, sorry like Tup or Aquablation®. Next slide, please.
So we're coming to the end of the session of of me talking, but there will be options for questions and answers, so I think you can submit your answers in writing, and you don't have to put your name on it, and then Louise is gonna come back and host some of the questions and I'll try my best to answer them. I'm not able to answer some really individual questions about you personally, but I can give answers about the treatments and what may or may not work in certain situations and obviously on the slide. There you can see that these treatments are available at Benenden, either potentially through your membership. If you're a member or through other options, such as paying for them.
So, Louise, if I hand back that to you now.
Louise King
Of course. Yes, okay, thank you very much for the presentation. Really interesting and we do have some questions which we'll go through. If some are kind of similar to other people's questions, I won't ask every individual one. Just so, you know.
Mike asks, how can you tell if your problem is benign or cancerous?
Mr Steve Garnett
So, yes, I mean, that's a good question. The vast majority of people with urinary symptoms due to prostate enlargement will have benign prostate enlargement as a cause for their symptoms. But essentially, you're going to need to have some tests like a PSA test which is, prostate specific antigen which you may have read about which has been in the news a lot recently, with various high profile, people being diagnosed with prostate cancer. But an elevated PSA will give an indication or raise concerns about possible prostate cancer and also you will need your prostate usually to be examined by a specialist, but that combination will give us a strong idea, and if anything is suspicious, then you would need further tests to look for prostate cancer.
Yep.
Louise King
David asks, is there a type of scan that can be administrated to see if TURP or HoLEP procedure is advisable? If not, what types of tests are being used today for that objective?
Mr Steve Garnett
Well, I mean, essentially, HoLEP is holmium laser enucleation of the prostate, which is another form of prostate surgery which is similar to TURP in that it uses laser energy to core out the prostate, but has very similar side effects to TURP in terms of sexual function. But essentially the only the only thing that would differentiate as to whether you could or couldn't have one of those would be the size of the prostate, and that would usually be assessed by ultrasound scanning or possibly your specialist just examining you now for most people they would be able to have both of those procedures. It's only if the prostate is very large that TURP wouldn't be recommended. In that case HoLEP, or possibly Aquablation® would be options.
Louise King
Thank you. Okay, a slightly longer question now from an anonymous attendee, they said at the beginning of last year they'd been taking Finasteride for a long time, but it's not working. They also prescribed Solifenacin.
Mr Steve Garnett
Yep.
Louise King
And dried Tamsulosin. Unfortunately, they had side effects due to these and the first one made him impotent to stop taking it.
He's now having to get up four times a night and is trying to decide if she'd ask for alternative drugs or have a prostate operation. He's worried. Some of these drugs increase the risk of dementia as well. Could you advise?
Mr Steve Garnett
Yes, so just like operations, there are pros and cons to tablets and a lot of them do have side effects. Particularly on sexual function. I think you've basically tried all the tablets from what you're saying. So you would really need to consider, I think, prostate operation you. We would definitely need to do a few further tests. You know I can't. I can't say you definitely need an operational which operation based on what I know right now, but I think it's unlikely that any further tablets are going to be any more effective for you. So I think you would need to consider whether you need a prostate operation.
Louise King
Kind of related to that question. Another person has a similar question, but their last part is, would you need to carry on taking prescribed medication, after having an operation such as a TURP or Aquablation®?
Mr Steve Garnett
No. So you know that's part of the benefit of having these procedures is no. Once you've had them, you don't need to take medication.
Louise King
Great. Thank you.
Does prostate hesitation become more pronounced at night? Nick says.
Mr Steve Garnett
Yes, it's quite common that people find their symptoms particularly passing urine and their flow and difficulty getting started typically gets worse at night, or lots of patients find that.
Louise King
Great, thank you. Does the prostate still enlarge after these treatments?
Mr Steve Garnett
Yes, the prostate does continue growing for a lot of well for many men. It does continue growing. But you've got to remember we are removing quite a lot of prostate during these operations. So even if it does continue to grow, the vast majority of men don't need any further treatment in the future. It is possible for your prostate to grow back enough to need further treatment, but the majority of men do not need further treatment.
Louise King
That relates to Alan's question when he says. Is there any benefits or not, or to seeking corrective treatment earlier rather than waiting until symptoms are worse?
Mr Steve Garnett
I think I'd never sort of try and rush people into an operation. But you don't want to. I think the problem is, you don't want to leave it too late. So if you get to the point where you're not emptying your bladder very well, and you've already got what we would call sort of bladder failure or bladder problems. You can get to the point where you can't pass urine at all and obviously you want to avoid that. But you know, if you're leaving it, if you leave it too late, then the bladder function may not improve even with an operation. So there's two things you really need to pass urine. Well, you need a good squeeze from your bladder, and you need no blockage from the prostate.
If you leave it too late, and the bladder is not working well, even if we remove the blockage, you may not pass urine. Very well. So yes, you don't need to rush into it if your symptoms are mild, but don't leave it too late.
Louise King
Thank you. What are the risks of incontinence for each of treatments?
Mr Steve Garnett
The risk of incontinence. You know, this is something that obviously men are very worried about with any surgeon. I understand that, but the risks are really very low. So with a tup, the generally accepted risks are about two% two people in a hundred, and that tends to be more men with prostate cancer who may have this operation, or men over the age of 80 are slightly more prone to that with Aquablation®. The risk is much, you know, is is even lower. I've not seen it at all. But you know, even if we say it's, it's just under one%. It's very low with Urolift® because there's no ablation or cutting at all. It's it's not. It's really not seen in terms of this. In that regard. So the risks are very low. I would say.
Louise King
Thank you.
Paul's heard that for a very large prostate only laser is used. Can you aquablate the largest prostates?
Mr Steve Garnett
Well, it's all it depends. You know what we're talking about here so very large, so a normal prostate volume would be about 30 mils in volume. Over a hundred over approximately a hundred mils in volume. We would consider it pretty large, and we wouldn't usually do a TURP Aquablation®.
We would not usually do over about 150 for those very large prostates, over 150 mils in volume, which is not common. There are not that many people who have prostates that large laser has advantages because it is able to remove, remove more tissue with less bleeding at that very large size but for the vast majority of men they'll be suitable for TURP or Aquablation®.
Louise King
Okay.
I've got lots of questions here. I'm just trying to find a variety. This person had Urolift® a couple of years ago. But unfortunately, it didn't work out for them, and they're wondering if they could still have Aquablation®?
Mr Steve Garnett
Yes, there's no problem having further treatment with Aquablation® after Urolift®. That's fine.
Louise King
Okay, thank you.
Similar to that. If someone's already had a TURP, is any further treatment possible for hardly enlarged 82 CC. Prostate.
Mr Steve Garnett
Yes, so 82, as you know. Or going back to my previous answer, I said over 100 would be considered very large. So, 82, whilst it's large. It's not huge, and you'd be suitable for further treatment for any of the treatments we've discussed.
TURP, Urolift® or Aquablation®. You could have any of those. Yep.
Louise King
Okay, does age matter? This person's asking a question. They're 81 years old.
Mr Steve Garnett
Well, that would be considered young in prostate treatment terms. So, no age, age isn't an impediment. The only the only issue to some of these treatments would be your physical health. So, if you have lots of breathing problems or heart problems which may make an anesthetic an issue that would be a concern, but not age.
Louise King
Okay, sorry. Yes. I froze there.
Mr Steve Garnett
Yes.
Louise King
I wasn't sure it was just me. It was me.
If you're on blood thinners. Are any of these procedures suitable?
Mr Steve Garnett
For any prostate operation, I'm afraid you would have to stop blood thinners. Unfortunately, the prostate has a very vascular structure, so it does bleed a lot, and we can't do any of these procedures on blood thinners.
If you're on blood thinners for many things, you can safely stop them for a short period of time, so the most common indication would be atrial fibrillation, and you can easily stop them for a couple of weeks with atrial fibrillation, and then go back on them, but you would have to stop them. Yes.
Louise King
Thank you.
This person's been prescribed Tamsulosin. Might that prevent the need for intervention?
Mr Steve Garnett
No, so Tamsulosin works by relaxing the prostate and improving symptoms. So it's good at helping with the symptoms, and that may be all the treatment you ever need. But it doesn't stop the prostate from growing so over time a lot of men on tamsulosin will find their symptoms slowly get worse. So, it's quite common that that helps to start with. But after a couple of years or so the symptoms may deteriorate. Not always, but that tablet does not stop the prostate from increasing in size.
Louise King
Okay
Okay, if there's a history in the family of prostate cancer, how often would you recommend that a PSA test be undertaken?
Mr Steve Garnett
Well, it depends on the age at which your family members were diagnosed with prostate cancer, because that can increase the risk. So, if you have a first degree relative. So that’s whether a father or a brother diagnosed before the age of 65, that more significantly increases your risk of prostate cancer. But so, for most men with a family history of prostate cancer, we would recommend an annual PSA test over the age of 50.
Louise King
Great. Thank you.
What is the normal size of a prostate? Lots of messages about varied sizes.
Mr Steve Garnett
Yes, so I did refer to that earlier, but about 30 CC's is routine which is normal.
Louise King
Thank you.
What's the waiting time for an operation?
Mr Steve Garnett
Well, I mean you'd have to come up and be assessed to see if the operation is suitable. So obviously, there's that. But if if you come up and are assessed and fill an operation suitable, then the wait time. Obviously, it does vary at different times of the year. But currently I think it would be about roughly four to six weeks.
Louise King
Thank you.
Okay, we'll just do a couple more questions.
If this person has a prostate size of 200, what treatment would be recommended?
Mr Steve Garnett
So that goes back to me sort of saying that over 150 would be considered very large. So, 200 is very large. So, the best treatment for that would be a holeep procedure. That's a laser procedure that we don't do at Badminton.
Louise King
Okay, does taking finasteride reduce the size of prostates?
Mr Steve Garnett
Yes. So, finasteride is a medication that works to shrink the prostate down and it reduces it by about 20% over a year. It takes a long time to work, and the longer you take it the more effective it is. But yes, it works by shrinking the size of the prostate.
Louise King
A couple of MRI related questions. I'll just cover off this person's referred for an MRI in relation to this, but they are claustrophobic, what kind of alternative form of diagnosis is there? And can an MRI identify if enlargement is benign or cancerous?
Mr Steve Garnett
So, this sort of webinar is really about benign prostate enlargement, and MRIs are really used to look for prostate cancer so slightly different topics. But what MRIs are useful for and good for is looking to see if there's signs of prostate cancer. It can't tell you for sure. If you've got prostate cancer, but it can see if there are abnormal areas that look worrying and if there are, then you would be recommended to have a prostate biopsy or a sample taken.
Unfortunately, if you're claustrophobic, while some scanners are bigger than others, there aren't any alternative scans that are useful for diagnosing prostate cancer.
So yes, that's it. You may. Some people who have claustrophobia are able to go through a scan if they get a sedative medicine like valium or something. Sometimes people are able to do that, but there is no other test that gives us the information that MRIs can in terms of looking for prostate cancer. I'm afraid.
Louise King
And what's the typical recovery time for Aquablation®?
Mr Steve Garnett
Usually one night in hospital. First couple of weeks, you may have some ongoing you know, stinging, burning, and you probably wouldn't want to be committed to doing anything too much in that first couple of weeks and I would say a full recovery by about four weeks.
Louise King
Thank you and let's go for the last question. I'm afraid if we haven't got through to your questions, we have your name. We can answer them via email afterwards.
So, the last one will be, can the prostate be removed completely?
Mr Steve Garnett
So complete removal of the prostate is called a radical prostatectomy, and that's an operation for prostate cancer so that can be done. But it has quite high risks of incontinence and very high risks of sexual dysfunction and would not be done unless it was for prostate cancer.
Louise King
Thank you.
As mentioned, I'm afraid we didn't get through all your questions. We just had so many, and we had such a popular event. So, thank you very much for sending them in and if we do have your name and email address, we will contact you. Can we move on to the last slide, please?
So as a thank you for joining this session, we're offering discounts on your treatment and consultation.
Free consultations are happening right now until the end of February for non-members. Members may get this consultation included, but we suggest that members go down the Member route as your diagnosis could be included as well.
We're offering 20% off Aquablation® treatment for anyone who's joined this webinar, and that offer is valid for a short period of time and 20% off TURP procedures for Benenden Health members. A callback will take place from your dedicated prior Patient Advisor and there will be an email with the recording and treatment, information and loyalty reward points that will follow up afterwards and we'll keep you up to date with our future news and events.
At the end of this you'll be sent a short survey at the end of the session, and we'd be really grateful if you could complete that, as it really helps us to shape future events and get feedback.
If you'd like to discuss or book your consultation, our private patients team can take your call until 8pm this evening, or they're available normally from 8am to 6pm, Monday to Friday. Use the number on the screen.
We have more events, and webinars coming up on varicose veins, knee and hip surgery and hernia repair and you can sign up to any of these via our website.
On behalf of myself and Mr Steve Garnett and the expert teams here at Benenden Hospital. We'd like to say thank you very much for joining us today, and we hope to hear from you soon. So, thank you very much, and goodbye.