The latest in the ‘Talk Surgery’ series of webinars shone a spotlight on to the increasingly technology driven world of benign prostatic surgery. Moderated by Surgery International’s own Editor-in-Chief and Consultant Urologist, Tim Lane, a select panel of experts were invited to join in a ‘fireside’ chat to explore the wide range of options now open to both patients and their surgical teams. In partnership with Olympus and JAV Medical, the all-female panel of Consultant Urologists taking part in the discussion included:
• Ms Stephanie Guillaumier, Consultant Urologist, Fife, Scotland.
• Ms Francesca Kum, Consultant Urologist, King’s College Hospital, London.
• Ms Christine Gan, Consultant Urologist, Lister Hospital, Stevenage.
The panel discussed the increasing number of surgical options open to patients and highlighted efforts that were increasingly focused on both improving safety and in reducing the impact on sexual function. The panel agreed that such decision making is likely to move towards MDT discussions in the fullness of time, either within or between a number of urological centers to ensure best practice.
The panel initially focused on the role of surgery in young men, with often smaller volume prostates and for whom maintaining a near to normal sexual function (and specifically relating to issues surrounding ejaculatory function) has become increasingly important. Whilst the panel agreed that a bladder neck incision and limited TURP remains a very real option for many patients, there exists a number of minimally invasive options which focus on avoiding what is otherwise inevitable retrograde ejaculation. iTIND represents a temporary implantable prostatic stent which relies on local ischaemia to re-model the prostatic urethra to improve flow. Rezum, a now widely available form of ‘steam treatment’ to induce prostatic necrosis appeared an increasingly popular choice for many. Results from the CLEAR study highlighted improved patient satisfaction with the Urolift procedure and highlighted the increasing efforts being made to focus on overall patient experiences. The panel touched on the need to undertake cystoscopy to get a better handle on the lower urinary tract anatomy before deciding upon specific minimally invasive options. Stephanie Guillaumier outlined the role of a ‘one-stop’ BPH clinic to assess minimally invasive options in their patient group and the particular importance of establishing an accurate prostate volume estimation (either transabdominally or transrectally).
The role of laser treatment for larger prostates was discussed in detail. Both ablative (such as Greenlight vaporisation) as well as enucleation (HoLEP) appeared reliable and increasingly mainline options for patients. Reliability and safety with consistently good patient outcomes appeared to place these above more recent additions to the field. Minimal blood loss appeared to be a consistent feature favoured by patients and clinicians alike and clearly favoured in those taking anticoagulants. Newer entries to this market had failed to match these increasingly gold standard procedures. Enucleation procedures were ideal for prostates 40-50g and larger with the upper limit of surgical resectability limited only by patient co-morbidity and overall operating time. TURP procedures continue to be very much routine interventions with a reliable track record based over decades of intervention. The panel favoured a gradual switch to bipolar over monopolar energy sources to minimise further the already small risk of TUR syndrome associated with Glycine irrigation.
The role of prostate artery embolisation is becoming an option in many parts of the world but radiological expertise with this particular option remains limited and its exact role in the algorithm of patient management options has yet to be defined.
The rapidly expanding expansion in the field has resulted in calls for formal Fellowship training in benign prostate surgery to allow individuals to suitably assess and deliver a whole range of options to the current generation of men with troublesome LUTS. The panel – many of whom have undergone Fellowship training themselves – warmly endorsed this new focus on an age-old problems for men.
The Webinar can be seen again here.
