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Scott Webb (Host): Benign prostatic hyperplasia, better known as BPH, is a common condition that men experience as they get older, one that can definitely affect our quality of life. And joining me today to help us all understand how BPH is diagnosed and treated, are doctors Joseph Dankoff and Kevin Spear, both of whom are Physicians and Urologists with Summa Health.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. So, doctors, thanks so much for your time. Thanks for being on, we're talking about BPH today. So, I'll start with you, Dr. Dankoff. What is BPH?

Joseph Dankoff, MD (Guest): As men get older, the prostate enlarges and when that happens, it grows in a pattern that blocks off the urine flow from the bladder out to the outside world. And as opposed to prostate cancer, this is benign growth of the prostate. So, we call it benign prostatic hyperplasia, benign prostatic hypertrophy, and that leads to restriction in the flow of urine that comes out of a man's bladder.

Host: Yeah. And of course, as a lay person, I'm thinking, well, benign, that's probably okay. That's not a big deal, but obviously even things that are benign can be a big deal if they go untreated. And when there are treatments available, good for people to be proactive with their primaries and see specialists. So, what can we be on the lookout for? What are the symptoms of BPH?

Dr. Dankoff: As men get older, we know that their urine stream isn't going to be as strong as it used to be. And so men, as they're getting into their fifties and sixties, will start noticing that they're going to be getting up more at night. And that certain foods will make it more likely that they'll have to urinate more frequently, like drinking caffeine before they go to bed or alcohol before they go to bed. They're going to definitely feel like they're going to have to urinate more frequently. So, that's not an uncommon thing. but when men have that, if they really start noticing that it's getting just more and more difficult to get the urine to empty or that they're struggling to get it to empty, or they start having any blood in the urine or they start having leakage of urine, going, when they're not expecting to go, those are all indications that maybe the run of the mill quote, "old man's prostate" that everybody my age gets is starting to turn into something more serious.

Host: I see what you mean. And I felt like you were describing me there. I'm 53. I like to have a cup of coffee later at night. I find myself getting up in the middle of the night. So, I felt like you were describing me to a T and I think a lot of us in this age range, as we pass 50, we just chalk it up to it. Well, you know, old man bladder, what are you going to do? But obviously there are things we can do and let's talk about some of them. Let's talk about the common treatments for BPH.

Dr. Dankoff: What we'll usually start off with is medical treatment. There are medications that are designed to open up the channel from the bladder to the outside. Many times men come to our office and they just want to be reassured that they don't have something bad, like prostate cancer. And they'll say, you know, I get up once a night, but I really don't want to take any more medicine.

I just want you to reassure me that I don't have prostate cancer. This is going to be stable and they're okay with putting up with it. But then as the symptoms worsen, men will oftentimes want to be on therapy. And so we'll usually start them on medications. A class of medicines called the alpha blockers, which include things like tamsulosin, alfuzosin, medications like that. There are other classes of medications designed to shrink the prostate. So, we'll usually start people on medical therapy and that works for many men, but not for everybody. And when the medical therapy stops working, then it's time to move on to something a little bit more invasive.

Host: Yeah. And let's bring in Dr. Spear and talk about some of the more invasive options. Dr. Spear, what are the latest treatment options and who will benefit the most from surgery, let's say?

Kevin Spear, MD (Guest): First of all, there's a range of therapes, surgical therapies and the initial ones that we probably would be talking about, especially if there's more minor symptoms, as we call them more minimally invasive and over the years they've evolved. And those include something called transurethral microwave therapy of the prostate, a laser procedure of the prostate. There's even now something called a Resume, which is a steam therapy of the prostate. And then something called a UroLift, which is popular. That's advertised a lot. And that's a less invasive procedure that's very innovative and it's very functional. So, those things are looked at and men usually tolerate those very well and have good results, but there is a limitation on those and that limitatio,. One of the biggest limitations on those procedures is the size of the prostate. So, there's not one treatment really that fits every single man. And so you do need an evaluation and have to make sure the person fits in the category. And these would be for a smaller prostate, but then you get to a larger size prostate and then you move into the gold standard, which is transurethral resection of the prostate.

That's called a TURP or that's what people will call that. And that's been around for 60, 70 years and that's really the gold standard. The TURP is the gold standard, but for 40 years already, there's constantly a strive to come up with something that's equivalent to that and less invasive. And basically it really has never panned out and the gold standard, even our society called the American Urologic Society, that's the gold standard level. And so far, any of these other procedures that are minimally invasive have not lived up to that. And so they are like in a sense, a different level, but there are some that are for larger prostates and that's another level. A TURP can be done or is great for glands that we have a way to measure them, with the size in cubic centimeters or grams and a 30 to 40 to 50 to 60 is good for a TURP could maybe go to 80, but over 80 and these are getting very large and many men have these, you have to go to something different, and then now you're getting into something that's much more invasive. Those procedures I mentioned before are all through the urethra.

There's not an incision or anything. But now when they get big, you have to go to something different. And there's three main treatments for that. One would be a procedure, now it's done robotically like laparoscopy and when people get their gallbladders out, things like that, laparoscopically, it would be going through the bladder and then removing basically the benign tissue in the prostate from the bladder. And then another is a laser procedure. But that is through the urethra, but that one is much more technically difficult. It takes a long time and that's called a Hol Lap. It's a holmium laser assisted prostatectomy. And then there is something you could do embolization where a radiologist does a catheterization, like when people get heart catheterization, block-off arteries to the prostate.

But that's hasn't panned out, really. And then the latest thing though, is something called Aqua ablation. And in fact, it's the first device or procedure that has equaled the TURP in comparison. And in fact, especially transurethrally, and also it could be used for really any size and shape prostate, which really there's nothing else for it.

And I'll describe that in a minute. So what that is is, a transurethral robotic platform, which is a scope through the penis. A person's asleep, but we're also doing a transrectal ultrasound and seeing the prostate and measuring it and marking out what tissue would be treated. And we have landmarks to know what that is. And then it's using a waterjet and the waterjet would be like a Waterpik if people know what that used to be, but a water stream coming out at high pressure. And then it's like a windshield wiper and it's a windshield wiper going through the prostate. And then you actually do it twice.

And that treatment after you get it all set up, the set up is the sort of the harder part, which takes time. But the machine doing this, you press a button. We have direct visualization and visualization via that ultrasound. But we could do a prostate that's 150 grams, which would be like an avocado at least. And we can do it in five to eight minutes. Now the whole procedure takes longer because of the setup and things, but that's just hard to believe actually. I'd call it less invasive and a procedure that really is going to change things.

Host: Yeah, it really sounds like it. All this technology really I wanted to ask you, what are some of the common misconceptions and is there anything you can tell listeners to dispel their worries about reaching out about speaking to their primary or seeking the advice of a specialist?

Dr. Dankoff: I guess probably the biggest misconception is that there's nothing that can be done about it. And that I'm just going to have to suffer in silence and you know, live with getting up three or four times a night, or the fear that if I go into that doctor's office, he's going to want to put his finger somewhere that I don't want it. And be very uncomfortable. And then he's going to take me to the operating room and then I'll be living in diapers the rest of my life, because I won't have any bladder control and that's just really not the case. We modify our therapies based on the size of the prostate.

Not only that, but also, the age of the man and his other associated medical conditions. So, we wouldn't necessarily do the same treatments to an 85 year old man who had a bad heart, as we would say to his 60 year old son. But also based on the severity. And if there's any concerns about kidney function, damage or things like that.

So, I guess bottom line with the misconceptions is that men should be open and should discuss this with their primary care providers and be confident that they're going to have a therapy tailored to them, that is right for them. And isn't automatically a surgical option.

Host: Uh, this has been really educational and give me a lot to think about here, especially all the lasers and robots and all of that. As we wrap up here, doctors, Dr. Dankoff, what are your final takeaways? Final thoughts. What do you most want listeners to know about BPH?

Dr. Dankoff: That they should be open and talk with their providers about this. Talk with their primary care providers, talk with their urologist, be open with what their expectations are. And also to be realistic. Nobody is going to be able to pee as good as they did when they were 20 years old. There's no device that is advertised on the internet that is realistically going to make a man pee like he's 20 years old. You know, so I guess to be realistic with his expectations,

Host: Yeah, That sounds right. It's just so great talking to you guys. And I just keep thinking about, yeah, I remember when I was 20, that was a good time, you know, in terms of the realm of what we're discussing here today, 53, not as good, but as you say, the important thing is for all of us to just be realistic, right? Dr. Spear, as we close here, last word to you. What are your final thoughts and takeaways about benign prostatic hyperplasia?

Dr. Spear: That we will definitely tailor a solution for the patient based on what their either expectations and needs, wants, how invasive or how extensive they want to go. We're not there to absolutely dictate something to someone at all. Some people, you know, don't want anything. Could we just watch this? When should I be worried? Is there something I have to be worried about? I'd rather not do this or I'd rather take the medicine or just as Dr. Dankoff alluded to earlier, I don't really want to be on a medicine. So, there is many options along the wide spectrum. And you know, we're here to help, listen and try to create something that everyone's happy with.

Host: Yeah, that's great. And it is so good as a patient, as a person and we know doctors are patients too. It's always good to know we have options be they pharmacological, minimally invasive, more invasive gold standards. I mean, you guys hit on all the touch points today. So thank you so much for your time and you both stay well.

Dr. Dankoff: Okay, thank you.

Dr. Spear: Alright, thank you.

Host: Visit Summa health.org/urology to learn more or call 330-374-1255 to schedule an appointment. And if you found this podcast to be helpful and informative, please share it on your social channels and be sure to check out the entire podcast library for additional topics of interest. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.

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