The Enlarged Prostate Playbook (Part 2): Surgical Options Explained

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2:49Jordan Runtop, man. So we had Kimora Scotland on last week and she started talking about all the micro minimally invasive office based procedures to to take a big prostate and make it somewhat manageable again. And so so much fun that I was delighted that she agreed to come back and walk us through what we do with the big fellas. So you did OK, first of all, any, you know, any quiz or, you know. No, no, that was pretty. I think the scalpels are coming out this episode. So that's when, or lasers, if I recall correctly. We could do some lasers. We could do some scalpels. Yeah. I mean, you know, again, as we talked about last episode, the field of urology in some ways was defined in the early 1900s by our reckless ability to, our wanton disregard for bleeding as urologists to want to take on the prostate.

3:41because general surgeons were like, yeah, no, we're good. We got gallbladders. You know, we got chest cavities to work on. This prostate had stuck behind the rectum, the bladder, big, big, big blood vessels that were really hard to figure out how to control back in the early 1900s. I mean, this is barely before we had coterie, where we had the cut a vessel, tie a vessel, cut a vessel, tie a vessel, and coterie came around, I think, in the early 1900s. and that allowed us to go a little bit faster. But the bottom line is the prostate's in a really tough area. So it's easy to do it endoscopically, as Kimora and I talked about last time.

4:21But sometimes we, even if we go endoscopically, we can't do those smaller prostates. So yeah, this is the trophy buck series for prostates where we're going to talk about what to do with big glands. So welcome back, everybody. And Dr. Scotland, so great to have you back as well. Can't wait to let her rip again. Well, thank you for that amazing introduction. Good morning, good afternoon, good evening, everyone. So let's talk about the big boys, like the big prostates, how can we minimally, how can we take a ship out of a bottle? So how do we go from, you know, from an 80 gram prostate to a grapefruit minimally invasively?

4:57So let's get into some of those because that's what you are known for. That's your thing. So once you get past the small prostates and the prostates without a median lobe, you're getting into the medium size to larger prostates. You've got several options. One of the newer options on the market for medium to larger prostates. And when I say larger, we're talking something all the way up to, you know, 150 grams, almost 200 grams, which sounds like a lot because it is a lot. Yeah. Okay. It's a big-ass prostate. And these are prostates. If you've got a hundred gram prostate, the chances of you not having a median lobe are very small.

5:38So we're already thinking about procedures that would probably need to take you to the operating room. The only thing that you could do for a hundred gram prostate that would not take you to the operating room is maybe resume. And even that, I think you're at the real limits there. So for a prostate that size, I'm not offering things that you can do in the clinic. So the first of those is something that's fairly new on the market. It's actually one of the newest things that's been around, and it's called aquablation, aqua standing for water. So here's another thing where you're using water. But in this procedure, you're actually, it's a little bit more high tech because you've also got a robot thrown into the mix.

6:22So what you've got... Weed. I know, fancy schmancy. So what you've got is you're going into the prostate again with your scope, but then you use an ultrasound as well. So you're putting an ultrasound in through the rectum so that you can see the prostate. And what that allows you to do is it allows you to really map out where the prostate is, what the size is, and more importantly, where the important structures are. So the ejaculatory ducts, you want to stay away from those. And so what you're going to do there is to really make sure that you're taking away that extra tissue in the prostate, but you're really being very safe or trying your best to be very safe about maintaining ejaculation.

7:05And so once you do that with the robot, then you go in with your scope and you're using high pressure water. So I tell people it's kind of like using high pressure. If you've ever seen anybody use high pressure water to clean something or to cut through things. All right. It's the same thing that we're doing here. We're using very high-pressure water, again, to cut out that extra tissue that is causing any kind of obstruction of the bladder. This is a procedure that you do in the operating room. And typically, after that, you're going to put a catheter in. You're going to put a Foley catheter, and you're going to keep the patient in overnight.

7:41And the reason you want to keep folks overnight for this and all the other procedures we're going to talk about moving forward is because it can cause some bleeding, right? You're cutting through tissue now. You're not just putting staples in or throwing some hooks. You're really cutting through tissue. It can cause some bleeding. And so what you're going to do is use the Foley catheter to put pressure. The way I explain it to my patients is, hey, if you cut your hand, what do you do? You use your other hand to apply pressure, right? So you can stop the bleeding. But the prostate is inside your body.

8:12So how are you going to stop that bleeding? How are you going to apply pressure? You got to inflate something that's going to push down on it. And so when we put a Foley catheter in, there's a balloon that you inflate to kind of keep it in place and to push down on the prostate so that you can apply that pressure to stop the bleeding. And then you also need to sort of irrigate the bladder because you're going to bleed even with that. So you want to kind of flush all of that blood out so it doesn't form clots and get stuck in there. And that's called continuous bladder irrigation or CBI. So we keep you overnight to keep you irrigated and to keep that catheter in applying pressure.

8:46So with aquablation, the next day you get the catheter out typically, and we're able to make sure that you're peeing on your own. We can get you home. I should take a little bit of a detour to say that this is something that happens with TURP too, because TURP is one of those procedures that has to be done in the operating room. So we will leave a catheter overnight for a TURP as well. All right. So then you've got aquablation and aquablation goes to about 150 grams or so. There are some people who push the limits, but I really don't think you should go beyond that. So then you've got something called green light.

9:22Now, green light is one of the ways that you can use lasers to vaporize the tissue. So again, everything is all about going into the urethra. You're using that laser. And again, it's sort of melting that tissue away. You're using the laser to melt away the tissue. But you're really just sort of going from side to side, you know, sort of like I tell my resident's painting from one side to the other. Green light can work for medium-sized prostates, and there's a decent follow-up that we've seen over, you know, the decades now that green light has been available. It's something where we will also leave a catheter at the end, and you're going to wake up the next day.

10:09We'll take the catheter out and get you home. I think that some people continue to use green light very often. Some people have backed away from it a little bit, mostly because, like I said, you're vaporizing the tissue. There tends to, with green light, be leftover tissue when you do that procedure. And so with some of your patients, that's an issue. If you've got a 60-year-old and you do a green light, 10 years later, you may need to do another procedure. So it's something to think about. So because you're using laser and you're able to, I imagine, coagulate or stop bleeding as you go, is there a statistically different risk of bleeding between the aquablation and green light?

10:51If a guy has a higher risk of bleeding, for example, if he's on blood thinners or anything, since a lot of these men we operate on, you know, have atrial fibrillation or something else would cause them. So talk about, you know, the ideal candidate to dichotomize if you can dichotomize aquablation from green light. That's exactly it. Now, there's not really been much in terms, because aquablation is still fairly new. There's not been that much comparing aquablation to green light. There have been lots of studies, because green light's been around for a couple of decades. So there have been lots of studies comparing green light to things like terp.

11:27And there are some studies showing a little bit less bleeding with green light. And so it was one of the things that people would think about with their patients who they need to put back on a blood thinner more quickly than others. But typically not so much of a difference, quite frankly, that it would make, you know, make the decision different for somebody who would say not on a blood thinner. Okay. So basically aquablation, for the most part, preserve ejaculation. Greenlight don't really preserve ejaculation. They do not, right. Yeah, so maybe that's why aquablation has really taken off lately.

12:08It seems to be the hottest thing. It really has. It really has taken off in recent years. Folks are able to manage larger prostates, but still, for most patients, maintain their ejaculation. I just want to say for most patients, because nothing is perfect. And so the folks at aquablation will tell you that a small percentage of people will still have retrograde or an ejaculation after the procedure. Yeah, that's critical.

12:44Let's be real. Eating is a huge part of our lives. It fuels us. It brings us together. And yes, it's one of life's great pleasures. But once a meal's over, we don't think much about what happens next, unless something starts to feel off. Because what we eat and how our bodies respond to it is complicated. From the very first bite, food kicks off a chain reaction, signals moving between the gut, the brain, the immune system, a constant back and forth we can't see and often don't fully understand. Introducing Eating Interrupted, a new podcast from iHeart Ruby Studio. Hosted by longtime journalist and Crohn's patient Cynthia McFadden, Eating Interrupted explores everything from food allergies and intolerances, and why they seem to be on the rise, to how digestion changes as we age, and what it's really like to live with a chronic GI condition.

13:36Through personal stories and expert insight, listen in to unpack what it means when your body doesn't always respond to food the way you expect, and what science is now revealing about why. Listen to Eating Interrupted on the iHeart app, Apple Podcasts, or wherever you get your podcasts. Struggling with side effects? Your genes might tell you why. The GeneSight test may reveal which mental health medications require dose adjustments, be less likely to work, or have an increased risk of side effects based on your DNA. If your medications aren't working for you, discover how the GeneSight test may help.

14:12Visit genesight.com forward slash iHeart today. That's genesight.com forward slash iHeart today. This episode sponsored by Marathon Sports. Runners know the feeling. That moment when the shoe disappears. Your stride feels smooth. Your breathing settles in. And the run just clicks. That's what Marathon Sports has been helping runners find for over 50 years. At Marathon Sports, their expert team uses the right fit process to match you with shoes and gear built for the way your body actually moves. No guesswork. No generic recommendations. Just real guidance from people who live and breathe running.

14:51Whether you're training for your next marathon, getting back into running, or chasing a better everyday run. Marathon Sports helps you find what works for you. Visit MarathonSports.com or stop into a Marathon Sports store today and experience the difference the right fit can make. Well, it's that time again. Backpacks, first day of school outfits, and the low-key anxiety of, am I even doing this right? Good Mom's Bad Choices is diving into the back-to-school season the way only we know how. unfiltered, funny, and full of the moments other shows won't touch. From surviving morning drop-offs to the guilt of missing the first bake sale.

15:29I already told me that next season she wants to join a club team that's by your house. So I was like, so you want me to pick you up from school? I'll take her by my house. But then I have to take her there, and then I have to drive back. And then some days I'm here, and I have to go pick you up at school, and then bring you back. I was just like, hell no. This is a space where moms treat their highlight reel for the real real. Whether you're a new mom, a veteran mom, or just trying to make it to pick up on time, this season of Good Moms Bad Choices is for you. Listen to Good Moms Bad Choices from the Black Effect Podcast Network on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

16:16all right so we've got our coblation and now we're gonna get to the truly big boys which is folks who have really large prostates okay you're talking your grapefruits you're talking your pomelos um you know 200 gram prostates 300 gram prostates i mean you know which is really large. And really for that, you've got one option that's minimally invasive, where we're still going in and not making any incisions. And that's called the HOLEP, or Holmium laser enucleation of the prostate. I should say here that when I say HOLEP, I'm also including something called THULEP, which is Thulium laser enucleation of the prostate.

16:57The whole idea is that you're using a laser to enucleate the prostate tissue. So what does that mean? If you think about what the prostate looks like, it's really got three what we call lobes. Okay, so we've got a left-sided lobe, a right-sided lobe, and for people with prostates that size, a medium lobe. And those are just the areas where the tissue has grown over and they look like little balls of tissue. So with inucleation, what you do is you actually use the laser to get underneath that ball of tissue and scoop it out. So you take the whole thing out, you know, wholesale, basically. With all of the other procedures, you're either sort of chipping away, cutting pieces or trying to burn through tissue.

17:50But with this one, you're scooping them out. Okay, so that's the inucleation part of it. That procedure is something that can really get you down to capsule and empty out all that tissue. Now, I haven't mentioned capsule before. What I tell people is when you're doing this surgery for BPH, as compared to doing a prostatectomy for prostate cancer, the difference is that with a prostatectomy, you're taking the entire prostate out. You're taking the prostate out, you're taking out the seminal vesicles, which are these two organs that sit right by the prostate, and you might even be taking some of the nerves in that area.

18:29When you have BPH, this is not a cancer procedure, so you don't have to take all of the prostate out. You're just taking all the extra tissue. And the way I tell people to think about it is thinking about an orange and thinking of BPH or that extra prostate tissue as being the actual tissue of the orange. right so the the rind is what we call the capsule that's kind of the skin of the prostate and what you want to do with all these procedures to get all the tissue of the prostate out right and leave that rind so holep comes closest to doing that really of all of the procedures that we do so with holep you're able to get you know the large um prostates out and holep actually can be used for small prostates all the way up to larger ones.

19:20Most people tend to use it for medium-sized to larger-sized prostates, but you can use it for the whole gamut. With whole-ups, you do lose your ejaculation. And again, it is one of those things where you're going to keep the catheter overnight. There is a chance of incontinence with whole-up that can last around the time of the procedure, and in some patients, can last a little bit longer as well. So that's something to keep in mind when you're thinking about these procedures. Yeah. Okay. Just maybe spend a couple minutes on the suprapubic, retropubic, incisional prostatectomies. Is there still a role for what made us urologists, what distinguished us from general surgeons in 1906 or so?

20:08Absolutely. Absolutely. So the final thing that you use for the really large prostates is called a simple prostatectomy. And that is the one procedure where we're going in and we're making an incision, typically a small incision. And that incision is going to be up in the abdomen, but down where the bladder is. So, you know, really near the pelvis and you're going in to the bladder and then you're basically trying to scoop out the prostate. So starting in the bladder, going into the urethra, scooping out the prostate, taking all that tissue out. And there are various ways you can do that. So as Jesse said, that's sort of, you know, what made urologists urologists because we would do this procedure.

20:49We would do that open. Nowadays, we don't do it open. Open meaning that I'm going in with, you know, a blade and making that incision. Nowadays, we do this typically using the robot. And so the robot goes in, makes very small incisions, and the robot goes in and is able to take that prostate tissue out. And then once you're done with that, you're able to close up the bladder, close up the skin, and keep the patient in the hospital for a day or two. Because it can be a procedure that causes quite a bit of bleeding. And so we want to keep you in there, make sure that we're, again, putting pressure, and we're, again, giving you that irrigation.

21:31Okay, so that is something that actually, you know, more and more urologists are offering to their patients if they have larger prostates. amazing jordan you've kept your color so far uh before i he gets a little he gets a little woozy with like blood and gutty things but it's pretty good i'm gonna i'm gonna go into the just ask her a couple of case scenarios but do you have any uh thoughts or anything about all of the surgeries we went from clinic based to you know civil war surgery based at the end uh with a robot though so it's definitely a modern civil war surgery yeah yeah but talk to me anything came up with um you know that for the common guy out there listening yeah i had a few things i uh you know i'm the only one on this call who does not have a background in medicine so i i kind of specialize in the in these stupid questions and uh all you've answered all of the pre-written stupid questions i have so now these are probably very stupid because they've just come up from things that um you mentioned lasers i aquablation i understand i understand water i can visualize that.

22:38That makes a lot of sense to me. I am sort of by nature more of a worrier. Can you talk more about this laser, the green light? Because that's something that just for me, and obviously I know that's been, you mentioned that it's been used for decades in medical procedures, but can you talk a little bit more about what the laser actually is and what it does to the tissue? Because that just seems like a frightening thing to have going on inside my body. Right, absolutely. And I think Most people, when they hear laser, you're just thinking of a laser pointer, right? Or James Bond, yeah. Yeah, James Bond laser or James Bond, right.

23:15So if you think about James Bond, actually, one of the things that you'll see is they're using a laser and that laser is like cutting through something. It's cutting through some metal, trying to blow up a ship, something like that, right? So we're doing something similar with HOLEP, at least, right? Of course, it's not at that kind of energy. You're talking about much smaller energy, but you're using the energy from the laser to really cut through that tissue. With green light, like I said, it's a little bit less about cutting through the tissue and more sort of vaporizing the tissue. So one of the things that most energy that you use has to go into some other kind of energy because that's just sort of how the world works.

24:02Like nothing disappears, right? And so what happens with laser energy is that a lot of laser energy actually will give off heat. So with the green light, you're actually, you know, going around the tissue with the probe and you're lasering. But what you're really doing is you're vaporizing the tissue because you've got the laser produces heat. And so you're using that heat to vaporize the tissue. And so, you know, it sounds scary, but it's actually really safe because we're using it right at energy levels that are safe for the tissue that we're working in. And again, thankfully, we have, you know, lots of experience with this.

24:44One of the good things about the prostate, again, is it's sitting in the urethra outside of the bladder and there's lots of tissue. I'm doing this procedure because you've got lots of tissue. So there's lots of tissue to go through. So harder for us, not impossible, obviously, but harder for us to, you know, cut through anywhere we don't need to. Thank you. And we have a section of the show. So probably I'm kind of jumping the gun here called You're Probably Going to Be OK that we do towards the end. You mentioned earlier, you know, if you're in my office and you're 38 years old and we're doing one of these procedures, we're probably going to see again in five to 10 years.

25:14I'm 38 years old and it just got me thinking, and I know this is a very broad question, but what can someone in their mid to late 30s do to ensure that they don't wind up in your office, at least at that age? Are there any broad strokes? Yeah. What's the expression? Prevention is better than the cure or something like that. Though I love Robert Smith. Yeah. How are we going to be OK? Yeah, no, that's a great question. And I get that a lot. And I will say this, there are some, you know, articles that have been written about this. And what I will say is that eating healthy is going to help anything that you could possibly, you know, throw at you.

26:01Right. And so it's always good to eat healthy. You know, have lots of fruits and vegetables in your diet, drinking lots of water, staying really well hydrated. beyond that there's honestly not really very much that i can tell you about anything that you can eat or anything that you can do to not have your prostate grow larger and the reason for that is because the prostate is one of the few organs in the body that continues to grow as an adult and so some men yeah sorry i had to get the great cure yeah that's very good Sorry, go ahead, Gamora. We did a lot of rock and roll on this show. There you go.

26:46No, so some men will have larger prostates than others. And that's where we get into, you know, you could have a 65-year-old who has a 35-gram prostate. That's not causing any problems. You could have a 65-year-old that has an 80-gram prostate. And you can have a 65-year-old that has a 300-gram prostate. And, you know, we don't really quite know why, you know, some men grow their prostates faster than others. You know, some of it is genetic. Some people will tell me, you know, yeah, my dad had this procedure, as did my brother and my other brothers talking about having the same symptoms. And so, you know, it's something that unfortunately we can't quite predict necessarily.

27:26And but, you know, staying healthy, drinking lots of water, that could help a little bit. but just because you're 65 doesn't mean you have to have pph and so you may never have these problems i also want to just basically say again it's a quality of life issue and so you may have guys who come into my clinic who have an 80 gram prostate but they're telling me hey listen doc i have zero problems i'm not getting up at night i'm not running to the bathroom i don't feel like i'm not emptying my bladder and you know there are tests that we can do in clinic to check those they fly, you know, pass those tests with flying colors, I leave them alone, right?