Dr. Gill discusses clinical impact of the new wave of BPH treatments

Urology Times® is celebrating its 50th anniversary in 2022. To mark the occasion, we are highlighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, Bradley Gill, MD, MS, discusses the development of minimally invasive treatments for benign prostatic hyperplasia (BPH). Dr. Gill is a urologist with Glickman Urological & Kidney Institute at Cleveland Clinic.

Please summarize the development of minimally invasive surgical treatments for BPH over the past several years.

I'd like to think about where we've come over the past 50 years and where we are now. We really started with open simple prostatectomy and transurethral resection of the prostate [TURP] as the basis of maximally invasive and minimally invasive BPH treatment. We know historically that those procedures carried risks of bleeding, stricture, of TUR syndrome if you were resecting for too long, but many of those things are afterthoughts now. We know with simple prostatectomy we can approach that robotically. We can use a single-port transvesical approach to the surgery and we can get patients home the same day with clear urine and get their catheter out within 3 to 5 days, with minimal blood loss and minimal risk. We know that with transurethral procedures, now, we can do much the same. Patients are able to go home the same day, often with clear urine, and in some cases—for instance, with [holmium laser enucleation of the prostate (HoLEP)]—get their catheter out the same day. Putting these two modalities together, combining robotics and transurethral surgery, robotic imaged-guided water jet ablation or Aquablation of the prostate can now also facilitate a same-day discharge for patients, with the addition of preserving ejaculatory function—something not possible with simple prostatectomy or anatomic endoscopic enucleating procedures.So we really have made strides. I think in part that’s due to technologies, but also, it’s how we apply those technologies.

So if we take another step forward and think historically, we’ve had office-based and other minimally invasive approaches to BPH treatment; for instance, transurethral microwave therapy or transurethral needle ablation—TUNA and microwave, as they were called. We know that those treatments may not have been the most effective, but they were an option for men to do—often in the office—with the hopes of preserving sexual function.

If we fast forward to where we are now, we think about options like water vapor ablation therapy or Rezum, the prostatic urethral lift or the UroLift, or implantable intraprostatic devices like the iTind. Those devices are the modern equivalents where we're able to treat BPH and help a man try to preserve sexual function. They're very different than their predecessors, but in some elements are still the same. So if you think about what we're doing there, we're bringing men in, treating them in the office, having them be able to get home the same day, and then get back to life, often with a short recovery and usually no impact on their sexual function.

Lasers are another big part of what we're doing—lasers with transurethral resection and vaporization, also with enucleation, with HoLEP and [thulium laser enucleation of the prostate] and all of the different varieties there. Those have been a great stride forward in transurethral cases because of the ability to use saline irrigation. Once we've stepped away from monopolar, even to the use of bipolar energy, we've been able to perform safer transurethral resections, often on bigger glands, with the use of saline that doesn't risk electrolyte abnormalities or the dangers those cases historically did. So lasers have been another large part of our development. We can effectively ablate and vaporize and coagulate tissue with those. We can also very nicely enucleate and clear a gland with laser energy. So the use of energy, whether it be monopolar, then on to bipolar, now on to laser, I think of as another parallel development in BPH management. Again, it's a technology that's evolved, but it's also our application of that technology.

Why do you think that these treatments belong on a list of innovations in urology?

It’s very clear; these have drastically changed the treatment, recovery, and [adverse events] for BPH that men experience. Not only that, but they involve a lot of different technologies. When I think about innovation, I really think about technology and then also the patient experience and outcomes. With the array of things here—water vapor therapy, prostatic implantable devices, lasers, bipolar energy, devices to reposition the adenoma, the application of robotics, imaging, focal therapy—we run the gamut of technologies, but we also see how those technologies can provide drastically different outcomes for our patients. Now, by appropriately applying treatment, we can not only address their BPH symptoms, but we can also maintain their ejaculation and erections, so we're able to treat BPH while preserving sexual function. It’s pretty clear that over the past 50 years we've seen innovations in BPH treatment both from the utilization of technology and also from the patient outcome and experience standpoint.

How have these treatments improved outcomes for men with BPH?

First and foremost, they’ve given men the option to think about what matters most to them and allowed them to get out of a “one-size-fits-all” approach. Historically, prostate enlargement was treated with simple prostatectomy and TURP, and you were really limited in what you were able to offer patients. With the advent of needle ablation and microwave, those things changed a little bit. Granted, they may not have been the most effective treatments in terms of outcomes, but they were able to offer patients the potential to preserve sexual function. So you fast forward to where we are now, and we have the in-office procedures that are able to preserve sexual function in the vast majority of, if not all, men, and also do that oftentimes with the avoidance of general anesthesia. So we can do procedures that are more convenient for patients, they can drive themselves to and from [the appointment] if you do them with local anesthetic, we can do procedures that are able to preserve sexual function, procedures that have a very low risk of bleeding or scar formation or other complications. Not only that, we have the ability to really get good, durable results with many of these treatments.

Of course, the literature shows a number of comparisons between them; some appear to hold up better over time than others. But what it boils down to is having an informed discussion with your patient and saying, “Here's your prostate; here's what options would be good for a prostate like yours, and here's what options would be good based upon your preferences and what you want to get out of therapy”. If a man understands that his treatment of choice is likely to need to have something else done in a few years but it meets all of his criteria, then I consider that to be the right decision for that patient. Other men may want to look at durability and their treatment holding up over time, and if they're willing to sacrifice ejaculation and sexual function in that regard, then that's the right decision for them. We're in a good place where we have options. We have different things available. We can really have a good conversation with our patients about treating BPH and doing it in a way that sits well with them.

What future innovations do you anticipate emerging in the BPH space over the next several years?

That's a very thought-provoking question. I honestly don't know because we've come so far in the past 50 years, there's no telling where we may go. One thing that I do think is going to be a game changer will be image-guided therapy. As we move forward in medicine, not only in BPH, but in other areas, we're going to see growing attention to focal therapy and image-guided treatments. If we're able to only treat the part of the prostate that's causing problems, and leave alone the other high-stakes real estate—for instance, where the nerves are on the outside—that really is the best way forward. We'll alleviate symptoms, we'll hopefully be able to preserve other function like erections and ejaculation, and using imaging guidance may be one way of doing that.

That being said, I think we'll grow to understand more about why certain treatments preserve ejaculation and why it disappears with others. I think being able to reproducibly maintain ejaculation while clearing adenoma will be something that we'll see happen. I think we'll also see much more granular data coming forward that are going to help us understand more about the durability and expected outcomes of procedures. So we'll be able to have better conversations with our patients about the need for potential retreatment and what to expect going down the line. This area is still very ripe for innovation. That's something that we see now; there are a number of very promising devices—intraprostatic implants and temporarily placed devices—that are being investigated around the world. I think we'll start to see those come to market as well and understand how they differ from each other and what the risks and benefits are for those.

Otherwise, I think we'll just continue to refine and improve the treatments that we have. We've seen HoLEP become a same-day, in-and-out procedure. We've seen things like Rezum and UroLift become procedures done under local anesthetic that men can drive themselves to and from, and we've seen robotic prostatectomy become something that can be done as a same-day surgery with minimal catheter time. I think we'll continue to see our steadfast procedures that we always use continue to improve as well.

Is there anything else that you would like to add?

In summary, what I would give as a take-home point is we've come a very long way over the past 50 years—seeing procedures developed, seeing technologies emerge, and learning how to optimally apply those to the treatment of BPH. If we step back and we look at where we are now, and we look at the guidelines, again, I fall back to the same few things. We need to match the right procedure to the right prostate and the right patient. So understanding as we go forward what procedures are the best for certain shapes and sizes of prostate and how those procedures can meet a man's goal—often, that involves maintaining sexual function—is really critical for us in determining how to best treat BPH. That has been in itself a huge innovation over the past 50 years—learning how to optimally apply the array of treatments that we have.