The Enlarged Prostate Playbook: Your Procedure Options Explained (Part 1)

0:00This is an iHeart Podcast. Guaranteed human. Let'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. Introducing Eating Interrupted, a new podcast from iHeartRuby Studio, hosted by longtime journalist and Crohn's patient, Cynthia McFadden. 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.

0:40Are you looking for support in your weight management journey? ZepBound Terzepatide may be able to help. ZepBound is a prescription medicine used with a reduced calorie diet and increased physical activity to help adults with obesity. or some adults with overweight who also have weight-related medical problems to lose excess body weight and keep the weight off. ZepBound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligram injection. ZepBound contains terzepatide and should not be used with other terzepatide-containing products or any GLP-1 receptor agonist medicines. It is not known if ZepBound is safe and effective for use in children.

1:20Don't share needles or pens or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop ZepBound and call your doctor if you have severe stomach pain or a serious allergic reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia. If you're nursing, pregnant, plan to be, or taking birth control pills.

1:51Taking ZepBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Talk to your doctor. Call 1-800-545-5979 or visit zepbounds.lily.com. Hey everyone, it's Kel Penn. I'm inviting you to join the best sounding book club you've ever heard with my podcast, Earsay, the Audible and iHeart Audiobook Club. Every episode, I nerd out with amazing guests and dive into the best new audiobooks available on Audible. It's the book club for your ears. Listen to Earsay, the Audible and iHeart Audiobook Club, on the iHeartRadio app or wherever you get your podcasts.

2:40My name is Arnold Bogarty, and prior to me, I enrolled in Rasmussen to become a nurse. I spent 16 years in the military, 12 in Special Forces, as an Army Green Beret, and I was recommended to Rasmussen by a former student. She said she loved the culture. It was a family atmosphere. I went to visit the campus. The facilities were amazing. I knew before I left that that was the school that I was going to attend. Rasmussen University. Are you ready to be your own hero online and on campus? Learn more at rasmussen.edu.

3:19Let's talk about it. Let's talk about it, the mailroom. Welcome to the mailroom. Woo, doggy. Welcome back to the mailroom with Dr. Jesse Mills and Jordan Runtop. I have the distinct honor of sharing some time with my colleague, my friend, Dr. Kimora Scotland, who is a fellowship-trained endourologist and has been at UCLA Health for the last few years. I just, you know, the years have just gone by and by and by with how much she's accomplished. But ender urologist, just for everybody that doesn't know one, and by the way, everybody should know one because kidney stones are on the rise and they're so common.

3:58And the minute you get that crushing flank pain where you want to cry, it's good to know a good ender urologist. And that's, that is Dr. Scotland. But ender urologists are a special breed of urologists that basically are able to do wizardry through no incisions. So through scopes and lasers and a lot of skill, they're able to take giant stones out of small orifices. Or what we're going to talk about today is giant prostates out of incisionless surgeries as well. So she really is truly an amazing person. She trained medical school at Cornell and then residency at Thomas Jefferson in Philadelphia.

4:34And then did a fellowship at probably one of my favorite cities in the entire world up in Vancouver at UBC and into urology. And she's been with us since the beginning. Dr. Scotland has a PhD as well. So she's one of these rare, rare academic surgeon scientists that's able to figure out how to carve out time in the lab, as well as do an incredibly busy surgical and clinical schedule. Not sure how she does it because when she's not doing that, she's also practicing international volunteerism in urology and traveling to countries all over the continent with an emphasis in Africa on teaching local urologists how to do some of the complex cases she does so that in other words, she's not just going to perform surgeries while she's in country, but actually leaving the skills to the local surgeons behind to be able to take care of this population.

5:23So truly, I would love to unpack that as well. But it's a truly an honor to have you on, Kamara. I can go on with your introduction and how amazing you are, but I figure I should let you at least say howdy to the crowd. Oh my goodness. Well, thank you for that amazing introduction. Good morning. Good afternoon. Good evening, everyone. That's really well done. Yes. Yes. We don't know when anybody's listening to this. If it's drive time, then it's probably sometime in the morning on the 405, which always gets a special guest appearance on this show somehow with our love at Freeway. That's right.

5:57Yeah. I wish we could get sponsorship from them, but probably just oil companies and breaks. So she does, her practice really works a lot in kidney stones, but also what I want to talk with her about today is, is what I'll call prostate reduction surgeries, because there's so many different kinds. I mean, I always tell a patient when they're thinking about prostate surgery, that this isn't appendicitis, where your appendix is about ready to burst, you're miserably sick, you have to get the appendix out to save your life. And prostate surgery can be lifesaving because as we talked about in the last episode, when Jordan and I were talking about medical therapy and the history of urology and cutting for stone and Hippocrates and all of our glorious history as urologists, people did used to die from urinary retention.

6:41They died from kidney failure. They died from stones that got infected in the prostate or in the bladder. And they died obviously from not being able to urinate at all, which again, led to horrible kidney failures. And so prostate surgery really defined the field of urology in the early 1900s. And so with that in mind, though, it's a tough organ to get to, you know, to make an incision, to get down to it. There's a lot of real estate that is near and dear to humans, such as nerves that control erections and muscles that control urination. To go through the penis to get to the prostate, which is what we're going to spend today talking about, also has a lot of complications, side effects, and risk benefits.

7:23And so what I think I want to do to you today is I want you to kind of define for the listeners, what are all the mousetraps out there? What's a terp? What's a holep? What's a green light? What's an aqua ablation? I'm just rattling things off because a lot of our listeners are probably thinking about one of these. And so, and then I'm going to, I don't want you to get like traumatized that you're going to go back to your oral boards here, Kimora. But I'm going to give you case scenarios and where I'm going to say, ah, this is a 55-year-old guy that, you know, has failed medical management. and probably throw different prostate sizes out, right?

7:56Because you're going to tell me that as much as we say it doesn't, you're going to tell me that size matters when it comes to the prostate. Does that sound like a fun way to have a conversation? There you go. No, I want to start, and I'm sure you've already had this discussion maybe in a previous podcast, with just briefly trying to level set about what this all is. So we're talking about folks who have large prostates. and the prostate by and large is an organ that in most men is not absolutely necessary. And I say that because I'm sure you're going to talk about prostate cancer at some point if you haven't already, but I say that because a lot of the folks who come to my clinic are really worried that I'm talking about taking away tissue that they need.

8:45So I want to kind of start with that. And I also want to say that not everybody who has a large prostate needs to have surgery. I tell all of my patients that apart from that, let's say 5 % or so of people where having a large prostate is really something that could be potentially life-threatening, most people with large prostates nowadays, it's really a quality of life issue. and so beyond talking about medication when we start thinking about what the surgical or procedural options are i just try to tell everybody to just sort of take a deep breath we'll go through it there's about exactly i'm a man of a certain age now

9:30several options and it can get sort of overwhelming but you know at the end of it all You just sort of remind yourself that this is a quality of life issue. And it's certainly something that we want to make better, but it is something that you have some time to make decisions about, ask questions about, and really feel comfortable before you make a decision. I like that. That's a very good way to do. I still feel, you know, my population, we talk about patient populations. Most of my population still thinks their prostate is an incredibly important and necessary organ because what we're going to talk about, I think a lot is the idea that you're right.

10:11We, we've covered this last episode with the prostate essentially does a couple of things as, as we get older, which is either get cancer or get enlarged and cause trouble that way. But the one thing it does in the world is it makes semen and then it allows you to ejaculate. And it turns out a lot of guys really like to ejaculate. And so that's what I want you to kind of dispel, right? To say that, well, okay, you're going to still have an orgasm, but your ejaculation may change. And that may help us make some decisions when we're looking at our surgical armamentarian. Yeah, sure. I was going to say that, you know, because there are some options that allow you to keep your ejaculation and some that do not.

10:49But I just wanted to sort of, you know, get us all on the same page. And one of the things that I tell my patients is this, I'm a woman, but But most of the people who are talking to me about enlarged prostates have already sort of had families and have made the decision that they don't necessarily want to add more biological kids to their family. Because most people are around that age where they're, you know, of course, there are always people who may be thinking about adding to their family, but most people are not. And so what I tell most of my patients right from the beginning is let me know if expanding your family is something that you're still considering.

11:30Because if that's not the case, then I tell them, hey, listen, I know that ejaculation is something that is very important. But what the prostate does is it helps, right, provide some of the fluid around semen that helps with ejaculation for the purpose of having, you know, new family members. Or a good time. Sure. Sure. And so what I tell a lot of my a lot of my patients is this, hey, listen, you're still going to ejaculate. You may not have that fluid. And, you know, depending on, you know, where you are in life, it may be good not to have that fluid. You know, it's easy cleanup. And, you know, certainly your partner is not going to be upset about that.

12:11So, you know, sometimes it's it's just about some level setting. But I understand that. Lots of folks want to have ejaculate, and I am completely supportive of that. So, you know, I'm happy to start talking about what some of the options are. Yeah, let's break it down because I think that's what we're going to do is we're going to give people almost a cafeteria list of the various options. And then we're going to kind of paint these patient scenarios so that we'll probably hit a lot of guys in the audience that, oh, yeah, that's me. I'm 72. I was told I have a big prostate. And then, yeah, let's get into it.

13:00Let'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 iHeartRuby Studio, hosted by longtime journalist and Crohn's patient Cynthia McFadden.

13:39eating 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 through 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. Are you tired of spending money on trial and error for mental health medications? According to a large study, on average, patients who received GeneSight testing saved over$1 ,000 on their total annual medication costs compared to traditional approaches.

14:25Discover how the GeneSight test may help you with medication costs. Visit genesight.com forward slash iHeart today. That's genesight.com forward slash iHeart. Are you looking for support in your weight management journey? ZepBound Terzepatide may be able to help. ZepBound is a prescription medicine used with a reduced calorie diet and increased physical activity to help adults with obesity or some adults with overweight who also have weight-related medical problems to lose excess body weight and keep the weight off. ZepBound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligram injection. ZepBound contains terzepatide and should not be used with other terzepatide containing products or any GLP-1 receptor agonist medicines.

15:12It is not known if ZepBound is safe and effective for use in children. Don't share needles or pens or reuse needles. Don't take if allergic to it. Or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2. Tell your doctor if you get a lump or swelling in your neck. Stop ZepBound and call your doctor if you have severe stomach pain or a serious allergic reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia.

15:44If you're nursing, pregnant, plan to be, or taking birth control pills. Taking ZepBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Talk to your doctor. Call 1-800-545-5979 or visit zepbounce.lily.com. My name is Arnold Bogarty, and prior to me enrolled in Rasmussen to become a nurse, I spent 16 years in the military, 12 in Special Forces, as an Army Green Beret, and I was recommended to Rasmussen by a former student. She said she loved the culture. It was a family atmosphere.

16:21I went to visit the campus. The facilities were amazing. I knew before I left that that was the school that I was going to attend. Rasmussen University. Are you ready to be your own hero online and on campus? Learn more at rasmussen.edu.

16:40Cool. So, so yeah, let's do a little alphabet soup. What's a terp? So a TURP or a transurethral resection of the prostate is a procedure where we, and again, most of these procedures, we do not make any incisions, no cuts outside of the body. So they're almost all going to be us going into your urethra, which is the tube you urinate out of. So we're going into the penis, into the urethra, and then getting to the prostate and treating it there. So the TURP is what I call the, a lot of people will still call the gold standard, but what I call the thing most people know, because it's been around for 50 years.

17:21And what a TURP is, is we go in with an instrument, and then we use heat to basically cut out the extra tissue in the prostate that is causing the obstruction. So again, the whole reason for these surgeries is because as the prostate gets larger, just because the prostate happens to sit right underneath the bladder, as it gets larger, it can start to block the bladder so that you're not able to empty as well. And that's what gives you all of these urinary symptoms. So when you go in with the terpia, you're using some heat to cut away that extra tissue so that, you know, what I think about when I think about the urethra is sort of like a tunnel.

18:03and the prostate is, you know, just extra tissue that has now grown at the end of that tunnel and made that channel a lot smaller. So when you go in and you cut out all that extra tissue, you open up the tunnel again. Nice. Yeah. Yeah. I think the, uh, the Terp, and we're not sponsored by Roto-Rooter, but that is what exactly what a lot of our guys say is that you're basically coring out that tunnel. And by doing that, then we talked a little bit about this too, but you're basically decreasing the amount of force that the bladder needs to evacuate urine. So who's a good candidate for a TURP then?

18:38What's your ideal? So the candidate for a TURP are folks who have large prostates, but not too large. So I'll take a little bit of a meander just to kind of make sure everybody's on the same page. The way I look at all of these procedures for treating prostate is, like Jesse said, all about size. So when men have BPH or an enlarged prostate, it's because their prostate is a little bit larger than normal. And so your doctors will throw numbers at you, but somewhere over 30 to 35 grams, if you're having symptoms, is considered BPH. And so you have some procedures where you're able to really have success with prostates that are large, but really not that large.

19:24And then we'll go into what that all means and, you know, what portions of the prostate are causing problems with those procedures. And then you have those procedures where you can sort of go from small to medium. And then you've got procedures where you are really treating very large prostates. So for a TURP, you can go from small prostates all the way through medium prostates. And what I mean by that is a prostate that's about 80 grams or so is considered a medium-sized prostate. And that's important only because with a TURP, you want to get that done in a certain amount of time. And once you get into larger and larger prostates, it really doesn't become a good idea to do TURPs.

20:07It takes too long and you can start to have some concerns about what that means for the patient under anesthesia for that long. Got it. Do you play the nut and fruit game with your patients where you say, well, normal prostate should be a walnut or an apple. So an 80 gram prostate is like a large apricot or a small peach. Exactly. I sometimes do that. And, you know, sometimes we're having to talk about, you know, much larger things, grapefruits, pomelos, you know, whatever it is that folks are able to. A cantaloupe? If you have a cantaloupe prostate. A cantaloupe would be a bit much, but, you know, whatever people can visualize, because it's really tough sometimes.

20:46to understand what it is that I'm talking about when I talk about what we're going to do. Yeah, I use a pickleball a lot now since everybody in my head have BPH. We're all playing pickleball. So you got a pickleball-sized prostate, then you know what you're dealing with. Okay, cool. So that's a term. I do appreciate what you said about the risk of anesthesia. And yeah, you can fluid overload somebody, even with saline terps these days for the urologers out there that are listening. And so, yeah, you got to be really fast. Like everything in surgery, it's good to be good, and it's even better to be good and fast.

21:21And TURP is one of those things where you just have to keep what we say resecting or getting tissue out. Okay, cool. All right, so what else is out there after TURP? If TURPs have been around for so long and they're so good, then what else do we got, and why is what we're going to talk about next either better, or who's the better candidate for kind of the next level of what you're going to talk about? Sure. So what I should talk about first is, you know, so why don't we just continue to do TERPs, right? Yes. It's been around for a while. Seems like it works. Well, there's a couple of things. One is that a TERP is certainly one of those procedures where you're not going to have any ejaculate when we're done.

21:59It's just because of the way that we take the tissue out and some, you know, some of the effects of the heat that we use in order to do the Roto-Rooter. And then with terps, you can sometimes have other unexpected side effects. So you can sometimes have incontinence where people will leak a little bit. And that may be something that lasts for just a day, a few days, a couple of weeks. And then in a small percentage of people, unfortunately, it can last for longer. So, you know, obviously that's not necessarily something that folks are signing up for when they're going to do a procedure to help with their problems urinating.

22:37There is sometimes in very small percentage of patients, some issues with libido that can be associated with getting a TURP procedure. Again, very small percentage of patients, but not zero. And so over the years, it's been a helpful procedure for lots of men. But certainly if there are things that are a little bit less, I don't want to say dangerous because a TURP is not dangerous. But if there are things that have fewer side effects, then certainly people want to consider them. And so some of the options that have come up in recent years, again, like I said, have to do with size. So I'm going to talk about those procedures that you may not necessarily even need to go to the operating room to do.

23:20Oh, good. And there are a few of those. You know, lots of men do not want, obviously, to have procedure, have to go to have anesthesia. They'd like to have something that they can just get in clinic and head home that same day. And so most of those types of procedures are things that deal with smaller prostates up to medium-sized prostates. But for most of those procedures, except for one that I'll go into, you have to have a certain type of prostate. And what I mean by that is this. So the prostate, as I mentioned, grows underneath the bladder, but if it continues to grow, sometimes it can push into the bladder, forming what's called a median lobe.

24:00And then there are some procedures where if you have a median lobe, it really doesn't work. So I'm going to talk about those first. So for those guys who have smaller prostate, no median lobe, got a few options. One of them is something called Urolift, which I tell patients is basically a procedure where you go in again through the urethra with your equipment, and then you basically use staples to push the prostate aside. That's basically what you're doing here. You have these clips that basically push the prostate once to each side, and that opens up the channel for you. It's a very quick procedure, okay?

24:38And it's something that you may have already seen being advertised online and on TV. It is a procedure, like I said, that should be for a smaller prostate. Okay. And it should be a procedure in somebody who's never had another procedure before. Most patients do fairly well after a Urolift. They're able to go home that same day. There are some side effects, mostly having to do with irritation. And then the jury's out about how long Eurolifts actually last. So as the years have gone by, you know, there's sort of less and less success in terms of just having that be your only procedure you ever get done.

25:20Yeah. So that's the Eurolift. Then you've got a bunch of things that are on the market and on their way to the market that have to do with putting some equipment into the prostate that lasts either for a few days or more permanently. So the first of these is something called itined. So with itined, you go in again with a scope and you've got these nitinol. Nitinol is a type of metal, basically. And they're basically little spokes. They look like kind of hooks that you put into the prostate and you leave the hooks for a few days. And the reason you do that is because the hooks will basically sort of push through the prostate and create little grooves within the prostate.

26:09So you come back to the clinic a few days later, your urologist will take those hooks out. And what that does is by creating those hooks in the prostate is allows you to empty the bladder a little bit better. As you can imagine, it's not getting rid of any tissue. And so also there's some question about, you know, what the follow-up time is, how long this is going to last. But most people do okay during the procedure and again are home that same day. Then there are a series of things that look like stents. Now, stents are basically tubes that hold to stent open the prostate. So there are tubes that push open the prostate.