Scott Webb (Host): Men of a certain age, and I am in that group, often experience an enlarged prostate, also known as benign prostatic hyperplasia, and the symptoms are annoying and definitely affect our quality of life. I'm Scott Webb and joining me today to tell us about a revolutionary procedure to treat BPH called Aquablation is Dr. Christopher Girasole. He's a urologist at Elliot Hospital and Manchester Urology. This is Your Wellness Solution. The podcast by Elliot Health System and Southern New Hampshire Health members of SolutionHealth. I'm Scott Webb.

Doctor, thanks so much for your time today. As I mentioned, I'm 53 and have a little bit of a vested interest in this topic. So, some free medical advice for me and everybody else who's listening. And as we get rolling here, what is benign prostatic hyperplasia?

Christopher Girasole, MD: So, benign prostatic hyperplasia or BPH as we commonly call it, benign basically means not cancerous, prostatic basically means of the prostate gland and hyperplasia is just a pathology term referring to growth. So, it refers to the completely natural and normal benign growth of the prostate in men.

It’s important to point out this is a gland that only men have, so it doesn't affect women. And so BPH simply refers to benign growth of this gland as men age, which is a normal process, affected by genetics. You know, most guys who say, oh yeah, my dad had an enlarged prostate, they start feeling the same symptoms. And so, it's very common. If you live long enough, you will probably experience some symptoms of BPH. Most men, by the time they get into their fifties and certainly sixties, are going to start to see some symptoms. And, you know, the question is how significant are those symptoms going to be? And to what extent will they worsen as that patient ages?

Host: Let's talk about what brings men into the office. Like what are the symptoms that they're experiencing that get them to either first go to their primary and/or skip over and get a referral and come right to you?

Dr. Girasole: Great question. So, the typical symptoms that we associate with BPH are, you know, we can divide them into two categories: the obstructive symptoms or what we call the irritative symptoms, and the obstructive symptoms are relatively intuitive. And they're caused by the fact that as the prostate gland grows, it is obstructing the bladder. The prostate gland lays right outside the bladder. And it surrounds the urethra as it's coming off the bladder. And so, as that gland grows, the tissue gets in the way and now the bladder is having a hard time emptying. And so, the obstructive symptoms that we tend to associate with BPH are a weakened urinary stream, caliber of stream, and some hesitancy of urination, meaning maybe it takes a little while to initiate the stream.

Some patients can experience intermittency, which means that they're stopping and starting several times in the middle of their stream. Those are the most common, or having a severe case, a man who literally can't pee. And so, the obstruction gets to the point where the patient really can't empty the bladder. They eventually started having significant discomfort associated with the bladder stretching, and then those patients need more urgent attention. But that's obviously the worst-case scenario. Interestingly, the more annoying symptoms to patients tend to be the irritative symptoms.

And those really refer to the frequency and urgency of urination, waking up at night to pee. Especially waking up at night is probably the thing that irritates people the most. They may pee no more frequently at night than they do during the day, but during the day it's no big deal cause they're up and they walk down the hall to the bathroom, but when you wake up to pee every 90 minutes, it’s hard to get a good night's sleep. And so that tends to be probably the symptom that patients focus on the most. And as I said, it's pretty intuitive why an enlarged prostate would cause obstructive symptoms.

Now, why would an enlarged prostate make a patient have to pee more frequently or have more urgency of urination? And the answer is that the bladder is just like the rest of us, it doesn't want to work any harder than it has to. And so, it doesn't like the fact that it's having to generate such a strong contraction to get that urine out, to get it through that prostate tissue.

It manifests this displeasure with the situation by being irritable and holding less urine. And so, the bladder is just basically responding to the fact that something's wrong, and it doesn't know what, and the bladder is kind of like a baby; it doesn't have that many things it can do, you know. It can go more frequently. It can cause a little burning when you pee. But the bladder just tends to let you know that something's going on. And so, if you treat the enlarged prostate with medications or procedures to relieve that obstruction, then you know, that secondary aggravating frequency and urgency of urination gets better as the bladder forgives and forgets.

Host: It's so interesting listening to you because, in my mind, I was picturing it. What if somebody were animating this conversation and your answer, and I'm just picturing the animated bladder with the angry face. And it definitely, I'm in tune, I'm in touch with some of what you're describing here. The little bit of the angry bladder, bringing out those symptoms, waking up every couple of hours during the night. And you're absolutely right doctor. It is super annoying. It's really annoying. And now I have a better understanding of why my bladder might be a little angry with me and why and when and all of that.

It is so great to have your expertise today to try to picture and explain this. And I know there are some new treatment options for BPH. I want to have you talk about Aquablation and why this is such good news for men like me.

Dr. Girasole: Yeah. I mean, historically, when we talk about treatment for BPH or the enlarged prostate, we can divide that into medications or procedures, and you know, medications are effective. There's plenty of them out there. Some men, they work well. In other men, they can cause side effects or just not work. Even in men where the medications help, there's no question that procedures tend to do a better job at alleviating symptoms than the medications. And then, given some of the long-term sexual side effects and other side effects that some of the medications can cause, a lot of men gravitate towards a procedural option. The newest and greatest procedural option is called Aquablation, and aqua refers to the fact that it uses water.

And ablation is basically a medical term for destroying tissue. And so, we're using high pressure, high PSI waterjets to destroy prostate tissue, and the way it's done is the patient is placed under anesthesia, whether that's a general anesthetic or a spinal anesthetic, this is done in the operating room. It's not done in the office. So, the patient does have to go to the hospital to have it done. The patient is placed under anesthesia and then a scope is placed through the natural urinary opening. There are no cuts, there are no stitches. The scope is placed through the urethra. And then by definition, if we're going into the bladder, we have to go through the prostate.

The part that is going through the prostate is a specialized part that can shoot those water jets in a kind of circumferential fashion and just destroy the prostate tissue around the scope by using 800 PSI water jets. The interesting thing is that while the patient's asleep, we also have an ultrasound probe, and we put that in through the rectum while the patient's asleep, and it shows us a picture of the prostate. And so, we can actually map out within that patient's prostate, what is the target zone? Where's the tissue that we want to destroy? How deep do we want to penetrate? And so we can really customize the treatment to the unique shape and size of the patient's prostate, which is one benefit of Aquablation.

The other benefit is that we can control things, as we are using that technology to use the water just to destroy the tissue. I'm doing that with a foot pedal, and the robotic machine is doing the work, but I'm visualizing on the ultrasound what's happening. And so it allows us to be more precise and to make sure that we're only going to hit what we want to hit, that we're not going to get through the capsule of the prostate, into surrounding tissues, which can lead to potential complications.

And so, when we think about our traditional surgery for the enlarged prostate, that is called a TURP or a transurethral resection of prostate. And sometimes you can do it either using an electrified cutting loop, or it can be done using a laser to destroy the tissue, but either way, you're going in with a scope, and you're destroying that tissue.

The risk is if you are too aggressive and get through the urethra into the sphincter muscle that wraps around the urinary channel, there's always a chance we could cause incontinence or the involuntary loss of urine when you cough, laugh, or sneeze. Now, this is very rare. I mean, this is one in many hundreds of patients, but that's not reassuring if you are that one patient.

And so, one of the benefits of Aquablation, because we can be more precise, it really takes that risk down to pretty much zero. Because we know what we're doing, we're watching it happen. And we know that we can avoid those problem areas. One of the other potential complications of a TURP is that if we're too aggressive when we're resecting and we get through the capsule of the prostate, or we're using electrical energy right near the capsule of the prostate, the nerves just outside are running by on the way to the penis and they bring the signal to get rigid in response to stimulation. And so, again, it's not a common complication after a TURP, but some patients, you know, a small percentage of patients could experience erectile dysfunction after a traditional procedure for the enlarged prostate.

And so again, by making sure that we're mapping out where we're going and not getting too close to the capsule, we take that risk down to zero. The other benefit is that many of the medications for enlarged prostate, as well as the traditional surgery for prostate, tend to lead to loss of a ejaculation, and the ejaculatory ducts plug into the prostate, and that's where the ejaculate plugs in. So, when you have an orgasm, that's how all that stuff kind of gets into the urinary tract to come out. It's right there in the prostate. And when you would do a TRUP or a traditional surgical procedure for the enlarged prostate, that area gets gummed up if you will.

And so it's very typical and even expected that the solid majority, I mean, at least 90% of men who have a TURP when they have an orgasm, nothing's going to come out anymore. And so that doesn't hurt you, and it doesn't necessarily take away from the sensation of climax, but it's a little different, and some men are very bothered by that.

And so, the other benefit of Aquablation is we can map out and avoid that area of the prostate, where the ejaculatory ducts are plugging in and spare it. And so, it lowers the risk of ejaculatory issues to roughly 10%, which is pretty darn good. And so, it's just a more precise way to do it. It's just a different way to skin a cat, if you will. Whether we do a traditional surgery, or we do Aquablation, we're creating a nice open cavity that the urine can exit the bladder through. And so, it's going to relieve those BPH symptoms, but Aquablation does offer some advantages over a traditional surgical approach, just because of the precise nature of the procedure.

Host: Yeah, it absolutely. does. I mean, it sounds a little like science fiction between mapping and robots and all the advantages and benefits to patients. And I'm sure you're hearing a lot of good things, right? So, you're seeing those frowny faces when they come in and those smiles when they leave; maybe you can share what patients are saying about the outcomes and the joy, if you will, the success of this new procedure.

Dr. Girasole: Absolutely. I'm going to mention one other benefit of Aquablation over a traditional surgical procedure. A traditional surgical procedure can somewhat be limited by the size of the prostate. So, if the prostate is too big, people like to say, oh, the prostate's about the size of a walnut, you know, in a young man. But then as you get BPH, it might turn into a lime or a lemon, or maybe even a grapefruit, you know? And so, they can get really big. And if it's an enormous prostate, you really can't adequately get rid of enough tissue and do a good enough job with a TURP. And so, there's a limit, there's a size limit to doing a TURP and doing a good job.

Aquablation, one of the other benefits of the technique is that you can do it even in very large prostates. And so that's an advantage. As far as what the patients are saying about their outcomes, yeah, the outcomes as you might expect, mirror those of a TURP or a traditional surgical procedure. Patients are going to typically first notice an improvement in the strength of the stream because we're relieving the obstruction. But as we mentioned before, that frequency and urgency is usually the bladder responding to the situation. And sometimes it does take a little while for that bladder to forgive and forget.

And so, some patients can have a little bit of a delay in the resolution of those symptoms, but the long-term effect of the procedure is yes, stronger stream, easier to start, easier to empty, less frequency, less urgency, less waking up at night. Most patients are gonna have a little bit of blood in the urine intermittently for about a week. Some burning with urination is pretty typical for several days as part of the healing process. But this is not the type of procedure that patients need pain medication afterward. People aren't even taking Tylenol. I mean, nothing, maybe a little something to help numb the urinary tract to help take care of the burning when you pee. That can be a common complaint for a few days. But patients certainly tolerate the procedure well. As I said, there are no cuts or stitches. It's a relatively non-invasive procedure. And from an activity standpoint, patients are really, you know, up and at ‘em doing normal things right away. But I usually recommend that they hold off until the urine is clear on any kind of heavy exercise.

Host: Well, it's really amazing. And it is music to my 53-year-old ears. So, as we wrap up here, doctor, so educational today, so informative, who's a good candidate for Aquablation? And what would be your takeaways?

Dr. Girasole: For most men, when we talk about treating the enlarged prostate, you know, we're talking about a quality-of-life disease, right? And so, you can have one man who has what I would think, and maybe you would think would be severe symptoms, who might sound miserable in terms of waking up every hour and struggling to pee; where are they saying this isn't going to kill me. I don't want to take medication for this, nevermind a procedure. And you got another guy who comes in and has what seem to be very mild symptoms, and yet is clearly terribly bothered by them. And so, what drives treatment here is typically the patient's perception of their quality of life.

And not me telling a patient, you need to do this. Now, there are some exceptions to that. You know, some patients who have more significant obstruction of the bladder, can potentially have some problems from a long-term standpoint, in terms of if they're poorly emptying the bladder due to obstruction, those patients can develop stones in the bladder that can lead to issues, pain, and trouble that can lead recurrent urinary tract infections. If patients are emptying poorly and in the worst-case scenario, if that pressure that is being generated in the bladder is too high, that can get transmitted up to the kidneys and cause kidney failure. Now, those are very rare patients since BPH is so common. In the overwhelming majority of patients, what drives treatment is just the patient's desire for treatment.

But there are patients that can have more significant issues. And so, on those patients, we tend to be more aggressive about doing more aggressive treatment plans. Now, as far as who's a candidate, as I said, it's really anybody who is bothered enough by their symptoms. Most men start with the medication, but you know, a lot of men decide that medications aren't for them and those patients might choose a procedure. And really, medications for the enlarged prostate can be prescribed by most primary care doctors. Other primary care doctors will defer to the urologist. But if the patient is concerned about these symptoms, they can certainly come to see us, and we evaluate patients using a urine test.

We do a little ultrasound to see how well they're emptying. We do a physical exam to gauge the size of the prostate. We ask patient to fill out a symptom survey that details the severity of the symptoms. And then we just simply have a discussion. For some patients we'll do an ultrasound to measure the size of the prostate if it seems like it's quite large, for other patients we'll opt to take a quick look in with a scope to look at the anatomy, because certain procedures that we do for the large prostate are really dependent on the shape of the prostate. And so, the evaluation for a patient with enlarged prostate really depends on the patient's goals, the patient's anatomy, and the severity of their symptoms and other problems.

Host: Yeah, goals, anatomy, severity. And it also seems like it really comes down to, you know, what an individual patient's sort of threshold is for the annoyances, for the irritation, they get up during the night or not being able to go, and so on. This has been so educational and informative today. Great free medical advice from an expert, which I'm sure we all appreciate it. I definitely do. Doctor, thanks so much for your time. You stay well.

Dr. Girasole: You too. My pleasure.

Host: And for more information, go to Elliothospital.org. If you enjoyed this podcast, please be sure to tell a friend and share it on social media. This is Your Wellness Solution. The podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.