Good presentation on newer BPH procedures

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Google "Treating BPH: Comparing HoLEP, Rezūm, UroLift, and Aquablation" and you'll find a 30 minute talk on YouTube given by DR Mitchell Humphreys of Mayo Clinic giving an overview of some of the common minimally invasive procedures. Lots of good info.

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15 Replies

  • Posted

    i've watched most of these and my opinion is they dont come close to reality

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  • Posted

    "Aquablation is a next-generation surgical therapy that involves an image-guided, robotically-controlled, high-velocity water jet that provides precise and rapid removal of tissue. Results from a trial comparing aquablation to transurethral resection of the prostate (TURP) favored aquablation in terms of maximum urinary flow rate, anejaculation rate, and mean resection time. This technique demonstrated feasibility, safety, and a relatively short mean operating time when treating large prostates as well. "

    Sounds like there is a new "Gold Standard" in Town.

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  • Posted

    Thanks. I'll watch soon. I'm guessing that Dr Humphreys is a urologist since PAE is not included (at least in the title).

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  • Posted

    Thanks for posting this. Very informative.

    The thing that really surprised me is how surprised Dr. Humphreys seemed about the effectiveness of using imaging for BPH procecdures (when he discussed aquablation). Even TRUS which is almost exclusively done by urologists.

    Really?? Maybe I'm missing something but it seems very logical to me that being able to get a whole perspective/view on what a urologist is doing is likely to produce a better outcome than only being able to see a few inches ahead. Knowing exactly how close the ablation, enucleation tool is to sensitive structures is clearly a major advantage.

    Except for urology, I can't think of many medical specialties that are resistant to using MRI, for example. I guess it must have something to do with whether or not a procedure can be done in the office or in the hospital. Probably a lot more profit with office procedures. I'd be curious to know what others think about this.

    Finally, I was starting to lean towards aquablation as a procedure I might do down the line, but he brings up a very good point about how do you stop the bleeders when there is no heat. Apparently, they have to go back in with another tool to cauterize the bleeders.

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    • Posted

      You're welcome, I thought it was very informative too.

      I've read and been told directly by a Dr who does aquablations that you can't precisely locate the ejaculatory ducts in 3D on TRUS. It is easy to calibrate where the proximal end (end closest to center of the body) of the veru is because the hand piece used in the aquabeam system has a camera at a known distance from the fully extended nozzle/tip. So the uro just lines up the camera with the proximal end of the veru by watching on the TRUS video and the camera video to see where that part of the shaft of the hand piece is. That is the critical landmark in any transurethral surgery as if you resect much distal to it (further away from the center of the body) you risk damaging the external voluntary sphincter and incontinence. While the ejaculatory ducts exit into the urethra from the veru and are thus fairly easy to protect at that point, they have to get to that point from the posterior side of the base of the prostate where the vas deferens and seminal ducts meet and join the ejaculatory ducts on each side. Those ducts which I believe run through the central zone are evidently not readily visible on TRUS so there is some guesswork involved in avoiding them in any transurethral procedure. Also, the veru is very easy to locate when doing a TURP or other transurethral procedures. They can also see the bladder neck on TRUS and of course on a camera used in any transurethral procedure.

      What would be very informative is if as part of the randomized controlled trials they had compared the ablation map used by the surgeons on the 10% of patients who ended up with RE with the ablation map used in the other 90% of cases to see if there were any obvious errors in setting up the ablation maps.

      Just a guess but I suspect the lack of use of MRI in BPH procedures may be due to cost. I suppose it is justified in MRI-guided prostate biopsies in order to increase the chance of obtaining cancerous cells that are there and visible on high rez imagery. Is that not why FLA is so expensive compared to others? It may have more to do with CMS and insurance companies than the profit motive of the uros.

      What he said and what you can read in the paper on the WATER I trials is the early procedures they did they used some type of cautery but eventually shifted to using a balloon tamponade with a tensioning device for a few hours post op to close the bleeders. I think that's the main reason it requires an overnight hospital stay. Basically they put a balloon that's part of a specialized Foley catheter as the last step of the procedure and inflate it so that the pressure it exerts on the cavity that was ablated stops the bleeding. The tensioning device used looks a little like some kind of medeival torture device but I guess if that's what you have to do then that's what you have to do for a few hours post-op.

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  • Posted

    yeah they are trying to make every penny in house. too cheap to even learn how to twilight sedate

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    • Posted

      To add another thought to the discussion about TRUS imaging to assist in the location of anatomy in the prostate, I recently read an abstract of a paper in which the authors devised a mathematical model of where the ejaculatory ducts were most likely to be in any prostate gland as a function of its width. I thought that was fascinating.

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    • Posted

      Fitting experimental data to mathematical models almost always shows some data points several standard deviations away from the model line. It would be a bummer for those who match those data points.

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    • Posted

      Totally agree, but I assume if a surgeon knew where that mean location is, he/she could establish a safety zone around it to account for the spread. The trick would be knowing when you reach that point if you're operating blindly from inside the urethra.

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  • Posted

    it's only urologists view on treating BPH

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