One of the most common benign urologic conditions faced by men is benign prostatic hyperplasia (BPH). In fact, more than 90 percent of men over 80 years of age will develop BPH, with 50 percent of men developing the condition by the age of 50. The Northwestern Medicine Department of Urology has a longstanding history of achieved breakthroughs in the understanding and treatment of common urological conditions such as BPH.
Matthias Hofer, MD, PhD, and Hayley Silver, MD, join us to share the latest advances in BPH treatment.
Recent Advances in BPH Treatment
Featured Speakers:
Learn more about Hayley Silver, MD
Matthias Hofer, MD, PhD is an Assistant Professor of Urology at Northwestern Memorial Hospital and Feinberg School of Medicine.
Learn more about Matthias Hofer, MD, PhD
Hayley Silver, MD | Matthias Hofer, MD, PhD
Hayley Silver, MD is an Assistant Professor of Urology at Northwestern Memorial Hospital and Feinberg School of Medicine.Learn more about Hayley Silver, MD
Matthias Hofer, MD, PhD is an Assistant Professor of Urology at Northwestern Memorial Hospital and Feinberg School of Medicine.
Learn more about Matthias Hofer, MD, PhD
Transcription:
Recent Advances in BPH Treatment
Melanie Cole, MS (Host): One of the most common benign urologic conditions faced by men is the benign prostatic hyperplasia or BPH. The Northwestern Medicine department of urology has a long standing history of achieved breakthroughs in the understanding and treatment of common urological conditions such as BPH. Joining me today is Dr. Hayley Silver and Dr. Matthias Hofer. They're both assistant professors of urology at Northwestern Memorial Hospital and Feinberg School of Medicine. Dr. Silver, I’d like to start with you. We know that age plays a role in BPH development. What other factors or variables contribute to it?
Hayley Silver, MD (Guest): Yes. Age is certainly a component of the symptoms related to BPH simply because as men age, their prostate tends to grow. So as time goes on, the symptoms related to an enlarged prostate get worse such that by the time somebody is in their 50s or 60s, up to 60/70% of men are having those symptoms. Besides the size of the prostate, it’s also the shape and it’s relation to the bladder that makes a real impact on whether or not somebody has symptoms of an enlarged prostate. Then there’s always the factor of how well their bladder functions to begin with and how it’s able to compensate for an enlarged prostate.
Matthias Hofer MD, PhD (Guest): I’d just like to add to what Dr. Silver said. That small prostates can also cause big problems. So just like she said, it’s not so much only the size. It’s also the way it’s shaped and so on. So even younger people can experience significant problems.
Host: Well then Dr. Hofer, how is the severity of benign prostatic hyperplasia determined? How is it determined whether it’s small or large? How do you determine the severity of what’s going on?
Dr. Hofer: The severity is usually determined by the symptoms of the patient. There is a standardized question called the international process symptoms score or IPSS that collects enough questions with which we can determine the severity of the patient’s symptoms and also track this over time. Another way of determining is whether the patient can empty the bladder well or not. The significant risk factor for urinary tract infection also for loss of bladder function is if a lot of urine is leftover in the bladder after urinating. That is another means of severity. There's a couple of tests we can do. Urodynamics, which is the pressure flow function test of the bladder that can give us objective data, but we usually don’t have to go that far. The symptoms score and what’s leftover in the bladder is, in most cases, sufficient to determine the severity. Also, the risk profile that a patient will face.
Host: Dr. Silver speak about the current standard of care. What’s unique about what you're doing at Northwestern Medicine?
Dr. Silver: Well, what I think is unique is we are a diverse group of providers with different backgrounds and experience that lends itself to a lot of collaboration and discussion of various issues that present themselves with patients. So I think that number one we are very fortunate to have such an intelligent and dynamic group here. Secondly, we are able to offer all of the tests that are necessary—as Dr. Hofer was mentioning—that we use to determine not just how well the patient empties their bladder but how well their bladder functions and how we can size somebody’s prostate with ultrasound, and investigate the shape of their prostate using a procedure called a cystoscopy where we use a camera and actually look at the bladder and the prostate from the inside. Which helps us determine how the prostate is in relation to the bladder and what the health of the bladder looks like before we offer a patient a various intervention whether it’s medications or a procedure or a more invasive surgery.
Host: Dr. Hofer, as we begin to talk about treatment options available, where does watchful waiting become the recommended strategy for patients with BPH who only have mild symptoms?
Dr. Hofer: If the patient is not bothered by the symptoms and he doesn’t have a significant amount of urine leftover in his bladder after voiding then there is no indication to start treatment. In this case, the treatment is simply determined by the patient himself.
Host: Really? That’s very interesting. So as you're watching them, you're just keeping an eye on the growth. So then where does the focus on prostate growth come into the treatment criteria?
Dr. Hofer: There's a couple of indications when treatment should be initiated. Again, if the patient has a high symptom score and is bothered by the symptoms. If the patient is in retention, meaning having a lot of urine leftover in the bladder because this is a risk factor for loss of bladder function and infection, as I mentioned before. There's a couple of other indications for initiating treatment such as formation of bladder or recurring urinary tract infections or bleeding from the prostate that cannot be stopped. So in these cases, we should initiate treatment either with medication and/or surgery. But as long as the patient’s emptying the bladder and is not bothered. Every patient is different. Some patients don’t mind getting up twice or three times a night because they fall asleep right away. Other patients already are bothered by getting up just once because they cannot fall asleep. So in this case we determine with the patient in a joint decision making and a shared decision making whether we initiate the treatment or not.
Host: Dr. Silver, as management of BPH has often been divided into medical and surgical options, do you feel personally that the lines between the two are not a little bit more blurred? If you would speak about some of the latest advances in BPH treatment, both surgical and non-surgical, and what you're doing there at Northwestern Medicine.
Dr. Silver: Absolutely. So I think this all comes down to, as Dr. Hofer was mentioning, what the goals of the patient are and what the specific both of the patient is. So there are some patients that come to us having had no treatment or there are a lot of patients who have already tried medications that their primary care doctor may have prescribed them and either they had bad side effects, or they don’t like the medication, they already take a lot of medications. So for maybe some patients talking about medical therapy isn’t what they are interested in. They want something that’s a more permanent or an intervention that has more durability. There are other patients—especially younger patients—who may be not ready or not in need of a surgical intervention and medication can be a good first step. So I think each patient is different and what their goals and their concerns about intervention or treatment are different. So we really try to take a look at the patient as a whole and have those discussions in detail with them.
In terms of surgical interventions, BPH is an area of urology that is constantly having new innovation. There is always new techniques and new procedures that are on the horizon. What’s great about Northwestern here is we offer everything from the most minimally invasive to what we would say the most maximally invasive surgery for enlarged prostates. So there are two very minimally invasive procedures that we offer here. Those being the UroLift procedure—which is placing almost like tacks into the prostate to open up the urinary channel—and something called Rezum that Dr. Hofer can speak in more detail about that uses steam to shrink the size of the prostate. The nice thing about these two procedures is that they don’t really come with some of the sexual side effects that patients are very wary of when it comes to BPH treatment. That’s really having dry ejaculations. Erectile dysfunction is not really a concern, although some are worried about that. It’s really the ejaculatory dysfunction.
Then, of course, we in terms of the more invasive surgeries, which are still fairly minimally invasive, we offer everything from the green light laser ablation to a traditional TURP or sort of scraping of the prostate. Then for those patients who have extremely large prostates we are able to do robotic surgery in order to essentially core out the majority of the prostate from the inside. We are, like I said, able to sort of address people from each end of the spectrum with enlarged prostate.
Dr. Hofer: Yeah. I’d like to add just one thing. That traditionally we would always start with medical therapy and then graduate, so to speak, to the surgical therapy if this was insufficient. In our professional guidelines, in a couple of years it’s equally recommended with either medication or surgical means. Like Dr. Silver mentioned, the minimally invasive procedures such as Rezum or UroLift are ideal for the patients who otherwise would be initiated with tract therapy—for example FloMax. This is a true alternative unless we understand more and more about the long term side effects of taking these drugs, mainly cognitive. I think the minimally invasive procedures have more and more of a place in the initial treatment of enlargement of the prostate.
Host: Well Dr. Hofer, as we’re talking about minimally invasive, what about office procedures? Are these more and more becoming part of that standard of care? She mentioned robotics and that sort of thing, but are office procedures very common now?
Dr. Hofer: Yes. I would say I personally treat about 50% of procedural approaches to patients in the office and 50% in the operating room. As Dr. Silver has mentioned, the UroLift and the Rezum are two procedures we can perform in the office. Both procedures take about 5 maybe 10 minutes and we can do it on local anesthesia. The outcomes are very good, very encouraging. They are not identical to what we can do in the operating room, but then the operating room is certainly also more invasive and requires a hospital stay. So yes. I could see even in the future where the addition of potentially even more innovative technologies that the office procedure will become the standard of care.
Host: Dr. Silver, as we discuss some of the most innovative technologies that are supporting your work, I’d like you to also mention what other providers might be involved in treating BPH. It’s not only urologists these days is it?
Dr. Silver: Well, yeah certainly most patients—certainly the older patients—have already begun therapy with their primary care doctor. So we spend time actually going and speaking with primary care doctors to help them better assess and treat patients and know when to refer to a urologist, but the majority of primary care doctors will feel very comfortable initiating medical therapy for this issue. So I do see most of my referrals from the primary care folks. Geriatricians, I would say, are included in that as well. Then occasionally we do have nephrologists—the medical kidney doctors—who will refer patients to us who they follow for kidney disease or patients who may need kidney transplants because that is a concern for those patients who may also have an enlarged prostate prior to getting a kidney transplant. So there are some other specialists that we do work with. Then, of course, the patients who get urinary tract infections, sometimes we work a lot with the infectious disease doctors for those patients as well.
Host: Dr. Hofer, tell us what you and your colleagues at Northwestern Medicine are doing to advance the treatment of BPH. Is there any new research clinical trials that you're working on that you’d like other providers to know about?
Dr. Hofer: The clinical trial that we are doing currently is with the department of interventional radiology with Dr. Riad Salem about prostatic artery embolization which is an alternative treatment which is also offered at Northwestern University. Other than that, the technologic advances Dr. Silver and I, I think we are proud to say that we offer every technology that is currently employed in BPH treatment at Northwestern and have ample experience with all of these technologies.
Host: Dr. Silver to wrap up, what would you like other providers to know and take forward to help their patients, when you feel it’s important for them to refer to the specialists at Northwestern Medicine.
Dr. Silver: I think that it’s important for providers to know that it’s never to early to send patients to have the conversation with us about their bladder and prostate symptoms. Now more than ever we are able to offer these new technologies and advances earlier on in the patient’s journey with this issue. I think knowing that we could have alternatives to medications upfront is a good discussion to be able to have with a patient as opposed to seeing them after years and years of struggling and not doing well on medications. So I frequently tell primary care doctors that it’s never too early to send somebody to us. You don’t have to start patients on medical treatment before you send them to have a consultation. Because like Dr. Hofer said, some of these younger patients or patients who would probably be okay with meds but don’t really like the side effects, we can offer them these minimally invasive procedures upfront. I think that it’s never too early. I like to develop a nice long-term relationship with these patients because that’s what we end up doing. We follow them for years. Being able to sort of start with them in early part of the journey helps us intervene maybe in a more timely way when they start really getting bothered by these symptoms.
Host: Well, thank you so much, both of you, for coming on and sharing your expertise. It’s really such an interesting topic and such an exciting time to be a physician in this area. So many technologies. Thank you, again. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicines, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I'm Melanie Cole.
Recent Advances in BPH Treatment
Melanie Cole, MS (Host): One of the most common benign urologic conditions faced by men is the benign prostatic hyperplasia or BPH. The Northwestern Medicine department of urology has a long standing history of achieved breakthroughs in the understanding and treatment of common urological conditions such as BPH. Joining me today is Dr. Hayley Silver and Dr. Matthias Hofer. They're both assistant professors of urology at Northwestern Memorial Hospital and Feinberg School of Medicine. Dr. Silver, I’d like to start with you. We know that age plays a role in BPH development. What other factors or variables contribute to it?
Hayley Silver, MD (Guest): Yes. Age is certainly a component of the symptoms related to BPH simply because as men age, their prostate tends to grow. So as time goes on, the symptoms related to an enlarged prostate get worse such that by the time somebody is in their 50s or 60s, up to 60/70% of men are having those symptoms. Besides the size of the prostate, it’s also the shape and it’s relation to the bladder that makes a real impact on whether or not somebody has symptoms of an enlarged prostate. Then there’s always the factor of how well their bladder functions to begin with and how it’s able to compensate for an enlarged prostate.
Matthias Hofer MD, PhD (Guest): I’d just like to add to what Dr. Silver said. That small prostates can also cause big problems. So just like she said, it’s not so much only the size. It’s also the way it’s shaped and so on. So even younger people can experience significant problems.
Host: Well then Dr. Hofer, how is the severity of benign prostatic hyperplasia determined? How is it determined whether it’s small or large? How do you determine the severity of what’s going on?
Dr. Hofer: The severity is usually determined by the symptoms of the patient. There is a standardized question called the international process symptoms score or IPSS that collects enough questions with which we can determine the severity of the patient’s symptoms and also track this over time. Another way of determining is whether the patient can empty the bladder well or not. The significant risk factor for urinary tract infection also for loss of bladder function is if a lot of urine is leftover in the bladder after urinating. That is another means of severity. There's a couple of tests we can do. Urodynamics, which is the pressure flow function test of the bladder that can give us objective data, but we usually don’t have to go that far. The symptoms score and what’s leftover in the bladder is, in most cases, sufficient to determine the severity. Also, the risk profile that a patient will face.
Host: Dr. Silver speak about the current standard of care. What’s unique about what you're doing at Northwestern Medicine?
Dr. Silver: Well, what I think is unique is we are a diverse group of providers with different backgrounds and experience that lends itself to a lot of collaboration and discussion of various issues that present themselves with patients. So I think that number one we are very fortunate to have such an intelligent and dynamic group here. Secondly, we are able to offer all of the tests that are necessary—as Dr. Hofer was mentioning—that we use to determine not just how well the patient empties their bladder but how well their bladder functions and how we can size somebody’s prostate with ultrasound, and investigate the shape of their prostate using a procedure called a cystoscopy where we use a camera and actually look at the bladder and the prostate from the inside. Which helps us determine how the prostate is in relation to the bladder and what the health of the bladder looks like before we offer a patient a various intervention whether it’s medications or a procedure or a more invasive surgery.
Host: Dr. Hofer, as we begin to talk about treatment options available, where does watchful waiting become the recommended strategy for patients with BPH who only have mild symptoms?
Dr. Hofer: If the patient is not bothered by the symptoms and he doesn’t have a significant amount of urine leftover in his bladder after voiding then there is no indication to start treatment. In this case, the treatment is simply determined by the patient himself.
Host: Really? That’s very interesting. So as you're watching them, you're just keeping an eye on the growth. So then where does the focus on prostate growth come into the treatment criteria?
Dr. Hofer: There's a couple of indications when treatment should be initiated. Again, if the patient has a high symptom score and is bothered by the symptoms. If the patient is in retention, meaning having a lot of urine leftover in the bladder because this is a risk factor for loss of bladder function and infection, as I mentioned before. There's a couple of other indications for initiating treatment such as formation of bladder or recurring urinary tract infections or bleeding from the prostate that cannot be stopped. So in these cases, we should initiate treatment either with medication and/or surgery. But as long as the patient’s emptying the bladder and is not bothered. Every patient is different. Some patients don’t mind getting up twice or three times a night because they fall asleep right away. Other patients already are bothered by getting up just once because they cannot fall asleep. So in this case we determine with the patient in a joint decision making and a shared decision making whether we initiate the treatment or not.
Host: Dr. Silver, as management of BPH has often been divided into medical and surgical options, do you feel personally that the lines between the two are not a little bit more blurred? If you would speak about some of the latest advances in BPH treatment, both surgical and non-surgical, and what you're doing there at Northwestern Medicine.
Dr. Silver: Absolutely. So I think this all comes down to, as Dr. Hofer was mentioning, what the goals of the patient are and what the specific both of the patient is. So there are some patients that come to us having had no treatment or there are a lot of patients who have already tried medications that their primary care doctor may have prescribed them and either they had bad side effects, or they don’t like the medication, they already take a lot of medications. So for maybe some patients talking about medical therapy isn’t what they are interested in. They want something that’s a more permanent or an intervention that has more durability. There are other patients—especially younger patients—who may be not ready or not in need of a surgical intervention and medication can be a good first step. So I think each patient is different and what their goals and their concerns about intervention or treatment are different. So we really try to take a look at the patient as a whole and have those discussions in detail with them.
In terms of surgical interventions, BPH is an area of urology that is constantly having new innovation. There is always new techniques and new procedures that are on the horizon. What’s great about Northwestern here is we offer everything from the most minimally invasive to what we would say the most maximally invasive surgery for enlarged prostates. So there are two very minimally invasive procedures that we offer here. Those being the UroLift procedure—which is placing almost like tacks into the prostate to open up the urinary channel—and something called Rezum that Dr. Hofer can speak in more detail about that uses steam to shrink the size of the prostate. The nice thing about these two procedures is that they don’t really come with some of the sexual side effects that patients are very wary of when it comes to BPH treatment. That’s really having dry ejaculations. Erectile dysfunction is not really a concern, although some are worried about that. It’s really the ejaculatory dysfunction.
Then, of course, we in terms of the more invasive surgeries, which are still fairly minimally invasive, we offer everything from the green light laser ablation to a traditional TURP or sort of scraping of the prostate. Then for those patients who have extremely large prostates we are able to do robotic surgery in order to essentially core out the majority of the prostate from the inside. We are, like I said, able to sort of address people from each end of the spectrum with enlarged prostate.
Dr. Hofer: Yeah. I’d like to add just one thing. That traditionally we would always start with medical therapy and then graduate, so to speak, to the surgical therapy if this was insufficient. In our professional guidelines, in a couple of years it’s equally recommended with either medication or surgical means. Like Dr. Silver mentioned, the minimally invasive procedures such as Rezum or UroLift are ideal for the patients who otherwise would be initiated with tract therapy—for example FloMax. This is a true alternative unless we understand more and more about the long term side effects of taking these drugs, mainly cognitive. I think the minimally invasive procedures have more and more of a place in the initial treatment of enlargement of the prostate.
Host: Well Dr. Hofer, as we’re talking about minimally invasive, what about office procedures? Are these more and more becoming part of that standard of care? She mentioned robotics and that sort of thing, but are office procedures very common now?
Dr. Hofer: Yes. I would say I personally treat about 50% of procedural approaches to patients in the office and 50% in the operating room. As Dr. Silver has mentioned, the UroLift and the Rezum are two procedures we can perform in the office. Both procedures take about 5 maybe 10 minutes and we can do it on local anesthesia. The outcomes are very good, very encouraging. They are not identical to what we can do in the operating room, but then the operating room is certainly also more invasive and requires a hospital stay. So yes. I could see even in the future where the addition of potentially even more innovative technologies that the office procedure will become the standard of care.
Host: Dr. Silver, as we discuss some of the most innovative technologies that are supporting your work, I’d like you to also mention what other providers might be involved in treating BPH. It’s not only urologists these days is it?
Dr. Silver: Well, yeah certainly most patients—certainly the older patients—have already begun therapy with their primary care doctor. So we spend time actually going and speaking with primary care doctors to help them better assess and treat patients and know when to refer to a urologist, but the majority of primary care doctors will feel very comfortable initiating medical therapy for this issue. So I do see most of my referrals from the primary care folks. Geriatricians, I would say, are included in that as well. Then occasionally we do have nephrologists—the medical kidney doctors—who will refer patients to us who they follow for kidney disease or patients who may need kidney transplants because that is a concern for those patients who may also have an enlarged prostate prior to getting a kidney transplant. So there are some other specialists that we do work with. Then, of course, the patients who get urinary tract infections, sometimes we work a lot with the infectious disease doctors for those patients as well.
Host: Dr. Hofer, tell us what you and your colleagues at Northwestern Medicine are doing to advance the treatment of BPH. Is there any new research clinical trials that you're working on that you’d like other providers to know about?
Dr. Hofer: The clinical trial that we are doing currently is with the department of interventional radiology with Dr. Riad Salem about prostatic artery embolization which is an alternative treatment which is also offered at Northwestern University. Other than that, the technologic advances Dr. Silver and I, I think we are proud to say that we offer every technology that is currently employed in BPH treatment at Northwestern and have ample experience with all of these technologies.
Host: Dr. Silver to wrap up, what would you like other providers to know and take forward to help their patients, when you feel it’s important for them to refer to the specialists at Northwestern Medicine.
Dr. Silver: I think that it’s important for providers to know that it’s never to early to send patients to have the conversation with us about their bladder and prostate symptoms. Now more than ever we are able to offer these new technologies and advances earlier on in the patient’s journey with this issue. I think knowing that we could have alternatives to medications upfront is a good discussion to be able to have with a patient as opposed to seeing them after years and years of struggling and not doing well on medications. So I frequently tell primary care doctors that it’s never too early to send somebody to us. You don’t have to start patients on medical treatment before you send them to have a consultation. Because like Dr. Hofer said, some of these younger patients or patients who would probably be okay with meds but don’t really like the side effects, we can offer them these minimally invasive procedures upfront. I think that it’s never too early. I like to develop a nice long-term relationship with these patients because that’s what we end up doing. We follow them for years. Being able to sort of start with them in early part of the journey helps us intervene maybe in a more timely way when they start really getting bothered by these symptoms.
Host: Well, thank you so much, both of you, for coming on and sharing your expertise. It’s really such an interesting topic and such an exciting time to be a physician in this area. So many technologies. Thank you, again. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicines, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I'm Melanie Cole.