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Jason Hafron:  Our next topic will be the good, bad, and ugly of new BPH treatments. I would like to introduce our moderator, Dr. Gregg Eure from Urology of Virginia. Dr. Eure has gained international reputation in the treatment of BPH. He has been a leader in investigating minimally invasive treatments for BPH for his entire career. He's a recognized international expert in laser vaporization and the prostatic urethral lift. He's had the opportunity to teach and lecture in over 30 states and 13 countries.

Joining the panel will be Dr. Arpeet Shah. Dr. Shah is a partner with Associated Urological Specialists, Solaris Health in Chicago. He is the director of their APP program, and serves as a member of the National BPH Clinical Board for Solaris Health.

Dr. Zorn. Dr. Zorn is dual certified, US and Canada. He was, recently left the University of Montreal, and started BPH Clinic of Canada as kind of the king of Canada BPH treatment. One of the leading experts from Canada. Thanks for coming so far, Kevin.
And then, Tom Mueller from Summit Urology. Tom serves as the Residency Director for Rowan University. Tom, his whole career has a practice and expertise and focus on minimally invasive treatments for BPH.

So thank you, everyone. This should be a great discussion. I'll turn it over to Gregg.

Gregg Eure: All right. Thank you Jason and Gordon. I know you guys did a lot of work, so we appreciate it, and thanks for the opportunity.

So I've got a very famous panel up here. We'll get them to introduce themselves. I'm in a big group. They're my current group, about 20. We've got about 30 APPs. Josh Langston's given a little session on the success of APPs, I think tomorrow.
I do a lot of BPH. I've done everything in some form or fashion in a lot of the clinical trials. Doing a lot of the stent trials now. But kind of my main go-to is, as Jason said, is the GreenLight PVP laser and the prostatic urethral lift. But we pretty much offer everything in the practice, except currently not aquablation. So we've got Tom RP and Kevin. So if you guys go down a little bit about your practice and what you do for BPH.

Tom Mueller: Thanks Gregg. My name is Tom Mueller. I am part of New Jersey Urology, which is a part of some medical group. It's about 150 urologists. I'm a general urologist, but focusing, I guess, a little bit more on BPH and minimally invasive surgical therapies. At the present time, I guess I would say what I used to do was UroLift for prostates 0 to 100. Then I would usually TURP 150, 0 to 100 to 150. And then do simple prostatectomies for 150 and above. And now it's, for the most part, UroLift 0 to 100. And then 100 and above, I do aquablation.

Gregg Eure: Arpeet.

Arpeet Shah: Thanks for having me. First of all, I'm Arpeet Shah. I'm part of Associated Urological Specialists, which is a division of Solaris. We're out of Chicago. I do a lot of BPH and general urology, but I also do a lot of our oncology and robotics.

In terms of BPH work, I do a lot of the procedures that are out there, almost all of them. But probably my highest volume are between water vapor therapy, GreenLight photo vaporization, aquablation, and robotic simple prostatectomy.

Gregg Eure: Kevin.

Kevin Zorn: Thank you again for having me. Kevin Zorn, Montreal, Canada. Professor of Urology at the University of Montreal, and have done mainly robotic surgery. Did my fellowship that kind of grew up through the eyes of El Halali, the learning HoLEP before even TURP. And that sort of led me to my path of where I've gotten onto developing GreenLights, and some of the techniques of a nucleation with that. Onboarded Rezum, UroLift, Optilume now, for some of the office-based procedures and aquablation. So really, the only place in Canada right now doing aquablation for all Canadians. So that's my latest venture at BPH Canada. Really offering all therapies, and trying to do that personalization, which I'm sure we'll be talking about, kind of like Dr. Mueller was saying this, with regards to different sizes, but also age, their desire for recovery, and preservation of sexual function.

Gregg Eure: No, that's great. So yeah, we were tasked with talking about our workups, what we do, how it's evolved, the cutting edge of things. And then also, about the various therapies. Although being a CME, we can't mention the therapy, but we will do the best to go through that. And then we'll do some cases to highlight some of those points as we go.

I'll turn to Arpeet first. This is his very well organized pathway, and at a high level, take us through what you do here.

Arpeet Shah: Now only mine, Solaris' BPH pathway, so there's a lot of people who made this possible.

Our pathway is probably pretty similar to others. Our initial visit is pretty standard. IPSS score, UA, PVR, PSA if indicated. And we have kind of a BPH brochure and introduction information that we give to our patients.

The notable part of the first part of our pathway, which is on the left side of the screen, is if you have an IPSS score of eight or above, we are recommending some sort of objective testing for bladder health and prostate health. We tend to use a lot of UroCuff in our practice. So any patients with an IPSS of above eight will get a UroCuff, and they may also get a cystoscopy and truss right off the bat, to get a better idea of what's going on. We'll obviously offer medical therapy at that point, if they're not already on it, most are on it.

On the right side of the screen. We wanted to keep things pretty broad for surgical therapy. We have a lot of great urologists in our practice, and we wanted to give them the flexibility to do the procedure that they feel comfortable with. With some restrictions, but that's why you have this long list of surgeries that are available.

The big things that I would highlight from the right side is the follow-up boxes. So whether you're observing your BPH, you're on medical therapy or you've had surgical therapy, you are getting at least annual rechecks using a UroCuff, to test for objective measures of bladder and prostate health. We want to catch the people who are on observation who need more therapy. We want to catch the people who are failing medical therapy.

And then we'll talk about this more in detail, but with the newer techniques that are out there, there might be higher failure rates that are acceptable to our patients, because there's preservation of sexual health or ease of procedure. But we need to be very honest with our patients in saying that these procedures can fail. And it is our responsibility to catch them when they fail, and before their bladder's really compromised. So I think, what I would harp out of this is importance of objective measurements for follow-up.

Gregg Eure: Yeah. Good points.

Arpeet Shah: So everybody has a pathway, but really putting it together and using it is a different beast altogether.

Some of the high points that work really well for our practice is, we really care about prompt reevaluation. Patients are there, they want answers. If you're starting them on Flomax, they should have an answer of whether it's working within two weeks, if not less. And so, we want to use this patient momentum to get them seen in our office right away.

We want to get objective evidence for their prostate and bladder health, and we want to get that to the patient. I think that's really important. And the only way to do the first thing, in terms of getting patients seen so fast, is to utilize APPs. So that's a very important part of our practice.

The follow-ups, after they've been seen by a doctor to get them in to see an APP, this also helps clear physician schedules to do the diagnostics of truss and cystoscopy. And really, the goal is to maximize the expertise of all levels of our staff. So we have navigators, we have APPs. Even the MAs are trained to do UroCuffs, and our MAs who are trained to do UroCuffs also act as our navigators. And I think, that's a really special thing in our practice.

Gregg Eure: Yeah. And that's great, Arpeet. And this is just our pathway sort of boiled down. But basically, one key point you've already heard, is just getting that patient through the pathway quicker, more efficiently. And it is hard to get guys in. Once you get them in, you've kind of got them on the hook to educate them, and really educate them about the disease process, and get them engaged with their decision-making with it.

We do very similar. We utilize APPs a lot. Lots of times, the first visit I'll have with the patient is what we call A BPH screen, that cystoscopy and prostate volume, usually with a truss. But we actually, I think, what we found too is patients love data. So whether it be UroCuff, if you're not familiar with that, it's as a single channel urodynamics with a flow. And we're using CarePath, it's not on the market yet, but it's a very sophisticated at-home flow device handle. Gives you the signal, the result to a cloud, through a chip on it, and gives, and really can navigate the patient digitally through that process.

So hopefully, that'll be available in the near future. And I know we've all played with some of these sound apps as well just to get that data. But we found that patients really respond to data. "Okay, BPH is common, how bad is mine? Give me some numbers." They track their steps, their pulse, their Peloton numbers, so, "Give me some data to see how bad I am."

And I think that really helps with the bladder health story, and we may touch on that too. But again, moving them through, really trying to get that trust in prostate volume.

Anybody do anything differently with their workup? Yeah, Kevin.

Kevin Zorn: It was Matt. I think I do similar to exactly what you guys are doing, and I think our key here is really catching on bladder health and progression. We know the IPSS isn't always perfect. And one of the things that I've brought into my practice and it's sort of the truss, but it's a trans abdominal, the POCUS point of care ultrasound. So I've tried the GE, I've tried Clarius, and I've tried a few others, but Clarius is kind of my go-to. You're right there at the time of examination with your rectal.

And I'm seeing patients where they're the growers. You've got guys who, for it's no good reason, they're going from 50 to 70 to 120. And I've seen, unfortunately, the other way, where they've had MRIs and no cancer three times, but no one picked up that the prostate's almost doubled in size in three years, and we missed the boat. So the question is, aside from sending people for MRIs and these expensive oncology tests, the point of care ultrasound for me in the Canadian system is so easy, and the patients think you're coming from another planet when you're showing them on your phone. It takes three minutes, and it really adds a bit more.

Arpeet Shah: How often are you doing those?

Kevin Zorn: It's part of my exam.

Arpeet Shah: But annually, or?

Kevin Zorn: Well, some patients, if it's for the med, the thing about that generic patient coming in for their yearly BPA strong meds, they're doing okay. Exactly. So annually with their PSAs and part of their Uroflow, they'll get a rec examination, just part of my physical exam. As I bring my bladder scan, the Clarius is right there. I throw it on, I click it, and there's pre-made buttons. So the workflow is already built in, so it's not like you have to sit there dictate a report at the end. It's a median lobe, yes, no. And also measure bladder wall thickness, which I think is another little metric we should be looking at, but it's going to be variable based on the bladder volume, what have you. But you do pick up those trabeculations when you see, rather than that small smooth bladder, you see that thickened coarse bladder. And I've picked up some bladder stones there too before cysto.

Arpeet Shah: That's awesome.

Gregg Eure: So we're not supposed to mention brand names, but Kevin's from Canada so different rules. But he's been using that Clarius for more than seven years, and I learned about that from him. It's a handheld Bluetooth to your iPhone or an iPad. It gives an amazingly good image. And that's another, I think, key point you'll hear throughout, is knowing the prostate volume is key to the... Because with our smorgasbord of treatments, the volume is really a key thing for that.

So this just kind of, I think, of interest. I had to put these numbers together for this past AUA and the SOBPD meeting for BPH geeks, that's a great meeting. 12 million patients diagnosed with BPH, there's another probably 12 million not even seeing a physician. But in the US, about half see us, half see primary care, and the intervention rate has never gotten above 3%. These four companies, I think probably all of them are, or at least three of them are represented here, has spent over 2 billion in the last few years, and that number hasn't budged. In fact, if anything, it went down a little bit. An intervention, really, just over 2%. And really, all the intervention is done instead of cannibalizing the medication patients, it's taken from TURP. So again, we'll show you today, going through some of the cases, different therapies.

Tom Mueller: So two things I want to add in regards to nurse navigation. When you look at that data and you see there's only a 2% intervention rate, I mean, what that tells you is very simply, we're not doing our job. We all know that this is an obstructive process, and very simply, we need to be addressing it and implementing change in our patients.

So the number one patient that walks through a urology office is a BPH patient. It only comes down to approximately 7% of gross revenue at the end of the year. Which shows us, again, we're not focusing our attention on it. So therefore, doing simple things like IPSS is somewhere that you can easily glean a lot of information from our patients with a simple piece of paper. Nurse navigation also is a way of just providing awareness of BPH that we're not necessarily paying attention to, and getting to, let's say, start to stimulate that information with our patients.

One thing I found was really interesting when I utilized nurse navigation is that, if we compared doctors utilizing nurse navigation versus doctors who did not use nurse navigation, the second visit was drastically different. In a group that we had 36 guys, we looked at guys that were not using nurse navigation, and their second visit was 52%. And for guys utilizing nurse navigation, it was upwards of, it was high 70s, low 80s percent.

So again, what that recognizes, again, putting a little bit more attention on BPH. Allowing patients to recognize where their deficiencies are. And I always say an educated patient is one that's always going to want to be more involved in trying to make themselves better. They're going to be an empowered patient. And this additional information is an easy way to put it out there.

Gregg Eure: Yeah. That's a great point.

Arpeet Shah: I'd like to add to that point. Yeah, it drastically cuts down attrition rates, like you talk about. We looked at our data recently of our navigated BPH patients, and their surgical treatment rate or procedural treatment rate was 16% in our practice. So it's just an unbelievable tool that we have at our disposal. We should use that.

Gregg Eure: Yeah. We've played with the same. We had a hard time getting a physical navigator just because of space, still short-staffed. And digital navigating, with that CarePath thing I said, I thought I was killing it. So the national cysto rate for BPH, anybody know, it's like less than 10% of patients come in with the diagnosis BPH. Our intervention rate, you just saw, less than three. So I thought I was killing it. 30 some percent cysto and 15% intervention.

But now with, again, providing, doing what all these things we just said, and providing that patient the data, I've gone to 85% cysto, and half of those getting interventions. So in the mid-40s. And I think you guys are similar. But again, moving them through and doing those procedures, doing the workup.

One other thing we'll touch on before we do the cases real quick is, one of you guys mentioned bladder health. I think for patients of prostate, it's confusing, an acorn, a walnut. There's a straw in the middle, where is it? What's it have to do with me peeing? Does it have cancer? But I think bladder health resonates well in the education process. Any kind of quick snippets or soundbites that you use in educating patients? We'll go down the line.

Tom Mueller: I usually just go through very simple bladder and prostate physiology, how things work. Because most guys don't even know where their prostate is. They have no idea what the function of the bladder is. And going through how trabeculation happens, and how it represents scar. And scar is non-functioning tissue, and once it turns to that you cannot recover it. That simple snippet, which is approximately 60 to 90 seconds, it provides a lot of information such that, when that patient starts to have more urgency, or when they're on the job site and they're peeing their pants going to the restroom, or they're waking up now three times instead of two, it kind of clicks for them and says, "Ah, now I know what's going on." And that's the guy that's going to be much more prone to be seeking some sort of intervention.

Gregg Eure: And visual aids. I agree. Arpeet.

Arpeet Shah: I think our patients are familiar with the heart, and so I often use the heart analogy with the bladder. Heart's a muscle, bladder's muscle, they both squeeze. And linking retention like a heart attack, and a lot of the procedure's like getting a cardiac stent. So intervening early, and the importance of the fact that when you have a heart attack, that heart muscle is damaged forever. It's the same thing with the bladder that's damaged over time by the prostate. And early intervention in those situations is really important.

And finding out the solution. You don't go see a cardiologist, and they ask you a five questionnaire on how their heart's feeling, right? And so, we shouldn't do the same with our patients. They trust us. They're allowing us to do rectal exams on them. We all know how uncomfortable that is for our patients, so we should be giving them more when they see this.

Gregg Eure: Yeah. Kevin.

Kevin Zorn: So usually during my ultrasound of their bladder is where I bring up two things. It's the one, the Arnold Schwarzenegger effect, because it's the same idea of the muscle, and I just think that hits home. Their bladder has to work harder. It's like at a certain point there's resistance, and we know the symptoms take several years before the bladder starts decompensating. So there's BPH prior to any symptoms. Because the first thing the muscle does is it thickens, it compensates. And then it'll continue to compensate. And I talk about this sort of thickened detrusor, and explain that's not only important for getting into an earlier intervention before we get erect bladder, the too late TURP.

Everyone here at some point TURPs some guy, and they pull out their catheter and they look at you like, "What'd you do wrong? I'm supposed to urinate.", right? We've all had that patient, and we're like, "Well I'm sorry I went through the surgeon." Now have to talk about CICs, and hopefully it'll recover. We want to avoid that.

And at the same time, part of the dysfunction of the bladder is the FUN, the frequency, the urgency, nocturia, which sometimes co-associates with that. So I explain that, not only to get them into therapy but also after the therapy. Because we all know we do a TURP or whatever BPH surgery, we don't make IPSs of zero. It's all like PSAs after a prostatectomy. Some people are going to have some of that FUN after, and explain that may take several months after the de-blocking that they're going to have some bladder recovery as well.

Gregg Eure: I think that's great. And again, the bladder health. I tell them the bladder has two functions stores urine and empties, the work of that muscle is squeezing urine through your blockage. Like any muscle, it gets stronger, but you overuse it, you can burn it out. And then you're one of the dudes on the catheter commercial. And I think that resonates too, they don't want catheters.
So let's do some cases. You may or may not be able to tell, these where somewhat made up. We'll take the first one. Severe IPSS score, some post void residual prostate volume, 50 ccs. And just a sort of straightforward by low bar looking prostate. Tom, what would you do with this one?

Tom Mueller: For me, I mean, this would be a minimally invasive surgical therapy. I tend to prefer prosthetic urethral lift, but this guy definitely needs treatment. I think a very important point with this guy is, meds have failed him. And most would I think argue that not waiting for the IPSS to get to 24 and to start to implement some sort of disobstructive technology, I think, would improve this patient dramatically.

Another important thing, is that when we talk about minimally invasive surgical therapies, I mean, these are not comparators to TURPs, they're not comparators to GreenLights, et cetera. They're comparators to medicines. And when it comes down to it, we, as urologists as a whole, do a very poor job at trying to get these guys off of medicines. More and more data comes out, whether it be with the five ARIs or the alpha blockers, that they're just not as fantastic as we once believed them to be. And now that we have therapies that have very minimal side effects, we should start to implement them a little bit more in our practices.

Gregg Eure: Yep. Anybody do anything differently? Any other thoughts?

Arpeet Shah: Yeah. I'm thinking parallelly in terms of how I would treat this. If he really cared about ejaculatory function, I would probably do a prostatic urethral lift. If he didn't, then I would lean towards water vapor therapy.

Gregg Eure: Yeah.

Kevin Zorn: One of the points that I didn't see here was the age of anticoagulation status, and this sexual function as the SHIM is three and he's got no partner.

Gregg Eure: No. And those are all key things, and obviously, to tease out with them. So Kevin, I know you and I have some experience with some of the new things on the horizon, the stents, would this be a patient a candidate for one of those?

Kevin Zorn: So again, no middle lobe, under 80 grams, iTIND could be another type of stent to look at. Especially for those if you scope them, I like to scope these gentlemen beforehand, aside from just having the bilobar. Which again, I'm not sure if you guys have the same issue, you get another from another partner or someone else and it's just normal bladder. I'm in Canada, where it's like two lines and maybe I can read it, normal bladder. They're looking for bladder tumors bilobar, but is it a high neck?

And I think, what we don't appreciate with flexible, again, for those in the room who used to do rigid, you get down, or when you're doing a TURP, and you're taking a knee because you got to get up off that high neck. That may be a good candidate for an iTIND, where you'll make that higher commissary. You're really not making the prostate bigger as you would with a HoLEP, but with the iTIND you're really just going to increase the length of the channel. Kind of like if you're trying to get into your suitcase, you forget something, but if you open the zipper a bit longer, you increase that length, though it's a little easier to get in there. That's really what the iTIND is doing. So it's something else to consider, if you're looking for something where there's minimal catheter amount of time, and the recovery is quite quick.

Gregg Eure: All right. Same dude, Aladdin, but this time he's got a moderate median lobe. Your partner scoped him the first time and called it bilobar. Or you look in and see a decent little middle lobe there. Tom, could he still have your prosthetic urethral lift?

Tom Mueller: Yeah. I mean, thankfully, there have been advancements as far as prostatic urethral lift, and the new advanced control device, which can manipulate the tissue much more easily. Just as long as there's a nice sulcus that's within the prostatic urethra, that we know that we'll be able to get into that sulcus and push that tissue over to the side. I've had tremendous improvements still with the minimally invasive approach, still maintaining all the ejaculatory function, et cetera.

And things that we don't recognize as far as median lobes. Everyone's looking for that perfect channel. For one, I think you can provide that, but you have to recognize also that with median lobes, there's two reasons why they're having lower urinary tract symptoms. It's not just about the obstruction, but it's also about the mobility of that median lobe. And what something like the prostatic urethral lift does is, it does push the tissue over, which creates a channel that this guy has never had before. But it also immobilizes that median lobe as well, which is a huge, huge part of why these pipe people have such dysfunctional voiding symptoms.

Gregg Eure: No, that's a good point. All right, let's go to Buzz next. So moderate IPSS. Not much post void residual. But a good size prostate, 145 ccs, just a trilobar, not a huge middle lobe but all components there. Kevin, what would you do with this one?

Kevin Zorn: Again, I think you'd have the same discussion. I can do a laser TURP. I can do aquablation if he's young and really interested in maintaining ejaculatory function. And I would be adventurous to say I would step off and do Rezum on this gentleman. We've actually published, Elterman and I published on a large series of over 80 ccs, and they do just as well. There's another McVary paper, I think it's in press, coming out looking at over 80 ccs and that IPSS reduction's impressive.

Gregg Eure: Yeah. Arpeet.

Arpeet Shah: Yeah. I agree. You could do a Rezum on this. I would probably lean towards aquablation. And with that type of therapy you can preserve ejaculation pretty well, if that is an important factor. But it is a quick procedure, and the most amazing thing about it is that it's reproducible, despite surgeon skill, right? So you use the technology to your benefit. And we should start looking at that as a society more and more. And that's one of the benefits I think of Rezum as well, is that it's reproducible despite surgeon skill. Because you're letting the technology do the work for you. For me, I don't feel comfortable doing UroLifts with median lobes, but I am sure that you're good at it, but I've never been taught how to do that correctly, so I can't provide the same benefit that you might with that technique to your patients. So that's why I kind of like the ones that are reproducible using the technology.

Tom Mueller: It's a great point. And the fact that, I think that is one of the real downsides of the prostatic urethral lift is that, you have to think, you have to be a little bit creative. And that sounds crazy, but I speak of what's what I say translatability, the ability to take a product and send it into middle of Idaho, and that normal everyday urologist is able to do it, and that's really, really important. That's where something like aquablation really does translate really well.

HoLEPs are fantastic procedures, but there's three people that can do them. And if that is the case, is it really a great technology? Something like aquablation does normalize and standardize things. So it does allow the everyday urologist to be able to treat a wide variety of prostates.

Gregg Eure: Speaking of procedures, we need no skill for, who's doing prostate artery embolization and would you offer it to this patient?

Kevin Zorn: It is interesting. I just got interviewed outside about this, and I acknowledge that it is there, and I think, let's look back at the history. When was it available? It preceded 2015. It was when we didn't have these missed. We have surgeons, as you said, there's only about 5% of urologists who've taken time from their life to go do a fellowship. Because that's what it's become, a fellowship training skillset to do this. And then you have in your community practices, patients who are anticoagulated, 200 gram prostates. Well, what else can I do? Well, it seems easy, but at the end, it's no one in this room is an interventional radiologist. But if you really sit there with a watch and study what's being done radiographically, in terms of radiation exposure, how much contrasts been done? It's not a 10-minute procedure.

Gregg Eure: No, it's not.

Kevin Zorn: Not a 30-minute procedure. It's like a two hour procedure. And at the end of the day when you look at the ROPE trials and so forth, you're not really doing that much for IPSS. And again, coming back to surgic agnostic, technician agnostic, even the radiation oncology gentleman, I don't know if he's still here with us. But he just said there's a bandwidth of experience, and you're going to get some interventional radiologists who only do one side, but that's a successful procedure. And the amount of CPT codes, I've been told, is very impressive. But regardless, what doesn't impress me is the data.

So if I have Mr. Jones here who I can say, "Look, I can bring you to the office.", to point in hand, a guy from a month ago, 93 years old, no one wants to touch him, he's got a catheter. 200 gram prostate in retention, we brought him for a Rezum. No one else can take him to anesthesia, and three weeks later he is catheter free. Is he urinating like great? No, but he's catheter free. And to me, for him that was his greatest success.

So coming back to the whole idea of agnostic techniques and democratizing procedures, the idea of these aquablation, anyone in those room, if anyone says, "I have an aquablation.", chances are that patient will have had the same procedure. Versus a UroLift, I think there's the number of sutures, the angle of suture placement, the tension on a suture. It's a bit of a dartboard.

Gregg Eure: Yeah. All right. Let's try to hit on a few more points before they kick us off. So Mr. Pinocchio, lying to himself. He says, "My IPSS is just five. My quality of life is great." But he's been in retention twice. He walks around with a residual 350. Prostate's 80 grams, and bladder looks dreadful. We all see these guys who we should have worked on five or 10 years ago, or see them from partners. What do you do with this fellow?

Kevin Zorn: I was going to say, this guy is, we don't really pretty much, we talked about it at the beginning, but the emphasis here of the PVR, the last one 45, he's got a good bladder, just is emanating poor bladder function. We know, and we as cardiologists, we don't have digoxin for the bladder. It'd be great. So we don't have that. The best we can do is reduce the resistance. So flow is pressure of resistance. Everyone here in the room can reduce resistance. This patient needs reduction of resistance. And for that volume, nucleation, laser, or aquablation, depending on anticoagulation status. Do you want sexual function? And costs.

Tom Mueller: I think it's also important to note, that guys that have compromised function too, you want to do a little bit more for these guys. So a minimally invasive surgical therapy may not be in his best interest. You want to maximally disobstruct this patient, or to maximize whatever functional bladder tissue that he does still have leftover.

Arpeet Shah: Yeah. I would certainly use urodynamics pre-procedurally to better counsel a patient on what their outcomes might be. Yeah.

Gregg Eure: Yeah.

Kevin Zorn: And my spidey senses are flickering, because he's got an IPSS of five.

Arpeet Shah: Yeah.

Gregg Eure: Yeah.

Kevin Zorn: That's why the name.

Gregg Eure: Again, patient. Patient administer. All right. So I put an age on this one. 93-year-old gentleman, cath. Comes in with his catheter he's had for months. On a couple anticoagulants, and had an MRI along the way. Somebody biopsied his prostate for a PSA of 4.2. What would you guys do with Tommy here?

Kevin Zorn: It just sounds like me from a month ago, where he just went to four or five other people saying, "Look, you've got a catheter CIC or Foley forever.", and I did a Rezum.

Arpeet Shah: I would do a Rezum.

Kevin Zorn: You get a 34% reduction, or an average 30 reduction, percent reduction in prostate volume. It's just that you have to explain that this is not your Amazon Now. I like to use that expression. If you're looking for the Amazon Now, you're not going to necessarily do well with this, but I would offer that.

Gregg Eure: Tom, would you get him off anticoagulant and do a prosthetic urethral lift?

Tom Mueller: Possibly. I mean, I will say it is a very common question as far as anticoagulation is concerned, and everyone complains of it. I got to be very honest with you, there's very few patients that can't come off of it.

Gregg Eure: Right.

Tom Mueller: There's very few. I mean, there's mechanical valves, that's about it. And I have very safely been able to take them off and get them back on without any repercussions. Now, the board question's always going to be, this guy needs some sort of laser TUR. Rezum is going to be a great option as well. But yeah, you want to try to do the least amount as possible, but getting him catheter free.

Gregg Eure: They won't let him off the aspirin 81 milligrams. Is everybody okay with that-

Tom Mueller: Fine.

Gregg Eure: ... proceeding? No issues with aspirin at all.

Tom Mueller: Yeah.

Gregg Eure: Okay. So how about this one? Shifting gears a little bit. 65. Minimal IPSS. PSA is 1.5. Not much residual. He's happy on his tamsulosin. What do you do with this? Just real quick one line, what would you do with this fellow? Tom?

Tom Mueller: I would intervene. Minimally invasive surgical therapy.

Gregg Eure: He's happy. He doesn't want anything.

Tom Mueller: I don't think medicines improve patients' underlying symptomatology at all.

Gregg Eure: Okay.

Tom Mueller: I think it's something that we, again, we over utilize, and should be starting to intervene a little bit more.

Gregg Eure: Arpeet.

Arpeet Shah: I would do objective testing like a UroCuff to get a clear picture, and then present that information to the patient one way or another. If it is flow patterns and his bladder curves look great, I mean, that's fine. He can stay on medical therapy, but I would be watching him closely.

Gregg Eure: Yeah. Kevin, any Canadian tips?

Kevin Zorn: I would've had the POCUS, to see what's his prostate volume is, and perhaps annually check to see if there's growth. And also something that's probably not talked enough and probably not well studied prospectively, is the use of daily Cialis. Which aside from helping with better LUTS improvement, and improving dizziness in some other side effect profile. But some of the cardioprotective stuff that's emanating now, and hope not to see or predict it. But I think the future, then we'll see some cardioprotection, some of the studies that have been coming out as of late. Versus the other medications which we're talking about, Alzheimer's, post-finasteride syndrome. But I've not heard anything to... Aside from poverty in Canada. I tell them what's the biggest side effect of daily Cialis? I tell them it's poverty.

Gregg Eure: And we do similar. We'll get a UroCuff or something usually, to try to give them some numbers. But if it really looks pretty good, we're now cutting these guys loose. Say, "Go back to your primary care." Because it doesn't progress in all patients, more than half it does. But some, if they're stable, fine, we need room for the others. So go back to your primary care. If it gets worse, come back to see us.

So winding down conclusions. So I think these are kind of the points you heard today. Cysto, early in the pathway and often. So get that patient to cysto sooner. I think we'd all agree.

We heard the bladder health message, very good presentations for those. And again, the patients want the data, show them that prostate size. I think most are visual. Prostate size,. Give them some numbers, how bad it is.

And then when I trained there was open prostates in TUR. Now, we've got a whole smorgasbord of things. So I would say, pick a minimally invasive or two, get good at it. Pick some ablative procedures, get good at it. And be able to offer those to patients, and get them off the pills. Any last comments, anyone?

Tom Mueller: I just say safety, safety, safety and safety. Just because we can do it doesn't mean it's necessarily good for the patient. So efficacy these days, I think, is taking a little bit of a... It should be down on the list as far as how we implement our technologies in our patients. We will take a little bit more safety and a little bit less efficacy, and I think patients are going to be much more willing to try to treat their underlying symptoms.

Gregg Eure: Yep.

Arpeet Shah: And then to expand on that, with the new technologies that are coming out, it's important for kind of a shared decision making model. So you have to be pretty blunt and clear to the patient, that some of these new technologies may not be as efficacious, but that can be acceptable. And using all forms of testing afterwards, and following them afterwards to define and then catch the failures is important.

Kevin Zorn: Just the take home message for me would be, as much data gathering as we can as quickly as available. So the POCUS point of care ultrasound, your choice of devices, but one price. And for me, it's just something that adds tremendously to the patient encounter, and gets me with more information that makes those judgment decisions, bladder health and prostate volume.

And secondly, education to the patient in decision making. So typically, for prostate cancer you have radiation, you have surgery. Well, with BPH, you now have this menu of different options. Kind of like your slide there, that crowded right corner. You have a lot of these options. So we've developed, through the Canadian Urological Association, the CUA patient navigation. So the patient go in, put in their prostate volume, we send them the link, and then they can go through it. So when they come back, they'll have further knowledge of the different techniques.

Gregg Eure: And the patient education. Awesome. All right. Great job, guys. Thank you very much.

Arpeet Shah: Thank you.

Gregg Eure: Thanks to the audience. Appreciate it.