Joey Wahler (Host): It's an effective treatment for enlarged prostate. So, we're discussing holmium laser enucleation of the prostate, also called HoLEP. Our guest is Dr. Christopher Ferari. He's a urologist. This is Curating Care, a podcast brought to you by St. Clair, health expert care from people who care. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Christopher Ferari, MD: Hey, Joey. Thanks so much for having me. I appreciate it.

Host: Same here. We appreciate the time. So for those unfamiliar with you, how about a little on your background in urology? How did you get to this point in the profession?

Christopher Ferari, MD: Sure. I mean, I chose urology because I think it has such a great variety of procedures, and there's a lot of quality of life procedures that help improve patients' quality of life, which is great for the patient, and people are usually very happy with some of the procedures that we're able to help with, especially procedures for enlarged prostate.

So, I trained at Indiana University for five years, and I'm from the area actually. I grew up in Mount Lebanon and went to Mount Lebanon High School. So, I'm happy to be back here, taking care of patients from the community I grew up in.

Host: And what brought you to St. Clair Health initially?

Christopher Ferari, MD: The group that we have here is very tight-knit, and very collaborative, and that was something I saw right away when I interviewed here. And so, the rest of the providers are incredibly supportive, and that's something that I was looking for. And also, immediately whenever I said I wanted to bring a new procedure to the group, everybody was very excited and interested in bringing something new, especially in the operating rooms. People jumped on it right away and got the equipment that we needed and everyone really jumped to establish a team to make this work here. So, we're very excited to offer it.

Host: So, a great fit there for sure. Now, you have a special focus in treating enlarged prostate or BPH as it's sometimes called. So, what are some of the symptoms patients may experience when this becomes a condition for them, and when should they consider talking with a urologist? I always ask doctors, where's that line between discomfort and I've got to see someone?

Christopher Ferari, MD: Sure. So, I tell patients you can think about the prostate is the first thing that the urine has to go through when it leaves your bladder, okay? So, as the gland enlarges, the bladder can work harder and harder, and that's where a lot of the symptoms arise from. So, there are symptoms that have to do with the urine not being able to come out as easily, so those would be like straining, things like straining to urinate and a weak stream of urination.

But then, there's also symptoms from your bladder working too hard as well. And those are things like waking up at night to urinate and also having to go very frequently and having to rush or run to the bathroom. So, those are all things that can be from the prostate causing the bladder to have to work a little bit harder.

Host: So for those patients diagnosed with BPH, we mentioned we want to get to the HoLEP procedure in some detail, which we'll do in a moment. But besides that, what are a few of the tried and true options for treatment that are available?

Christopher Ferari, MD: One of the best options that we have medication-wise, which we've had in urology for quite some time, is a medication we call Flomax or tamsulosin, and a lot of older patients are on this medication. And I basically describe it to patients as it's a way to try to relax some of the muscles that are around the area where the urine leaves the bladder.

So, it can help open up more lanes on the highway per se, and get urine to flow out easier. So, that's one of the most common things that we'll give patients first to try to see if it helps their symptoms. But oftentimes we know that patients who are on this medication for a long time, the bladder becomes more and more tired and the symptoms get worse.

So, the medication may help for a while, but sometimes it's like putting a Band-Aid on the problem, and we may need to end up doing something procedural. So, that's why we follow patients for quite some time who have an enlarged prostate to see how their symptoms change over time.

Host: By the way, Doctor, I love the analogy of opening more lanes on the highway. I think it works perfectly in this case, right?

Christopher Ferari, MD: Yep, exactly. The people respond well to that.

Host: Yes. Very well done. So, how do you determine which treatment option is right for a particular patient?

Christopher Ferari, MD: Yeah. So, that's a great question because there's many, many treatment options for enlarged prostate. If you were to look this up online, many things would come up. So, it's important to understand what procedures work for different patients and for different anatomy. So, I think prostate size is one of the most important things that we look at. We can look at that in multiple different ways. Sometimes we take a look with a camera, and take a look inside with our eyes and see what things look like, and that can tell us whether there's a lot of obstruction of the bladder or not.

Another thing we can do is we can get imaging of the prostate, whether that be a CT scan or an MRI, and that can give us a good estimate of how large the prostate is. And the reason that's important is because some procedures only work for prostates that are very, very large, and there's some that can work for smaller prostates. And kind of getting to the HoLEP procedure that, that one thing that we're proud to offer with regard to the HoLEP is that it's a size-independent procedure, meaning that it can work for any size prostate. And there's not too many procedures that, that can say that they can work for any size prostate gland.

Host: So, you might say one size fits all in this case literally, right?

Christopher Ferari, MD: Yeah. Right. So, the procedure works for any size, and that's why it's important. Because when you get to a certain threshold for how large the prostate is, there's not many options left that can be safe for patients. And so, this is one that we're able to offer. And a lot of times, patients who have a gland that large will be having very serious symptoms, and some of them even go into what we call urinary retention, where they are not able to urinate and need a catheter put in the emergency department. And this procedure is perfect for patients like that because we know their prostates are probably very, very large, and HoLEP would be a great procedure for them.

Host: And so, without further ado, what exactly is HoLEP in layman's terms? How does it work?

Christopher Ferari, MD: Right. So, it stands for holmium laser enucleation of the prostate. And what that means is traditionally when we treat enlarged prostate, we use a scope or a camera while a patient is sleeping, and take a look inside down to the level of the prostate gland by the bladder. And we have to find a way to take out a lot of the volume of that gland safely to, like I said, as mentioned previously, opening up more lanes on the highway for the patient to urinate.

So, this procedure uses a laser to do that. And one thing I often tell patients as well is that the prostate gland is kind of like an orange, where we have a rind on the outside, and we have all of the pulp on the inside. And we're trying to figure out the most efficient way to remove all of that tissue and leave just the rind on the outside.

And the reason that the laser is so effective at that is it can get in that exact plane between those two areas, between that shell of the prostate and the tissue on the inside, that's the glandular tissue. So, it's very, very effective in removing as much tissue as possible to prevent any regrowth, because we don't want patients to be back in our office in five to 10 years saying they have the same symptoms.

And so, if we can get out as much of that glandular tissue as we can, then the chances patients are back with us are very low. Not that we don't like seeing our patients. But if they don't come back for the same symptoms, we're very happy. So, additionally, I think the reoperation rate for HoLEP at 10 years is around 1%, is the data we have. And that's excellent to tell patients because you can tell them that only one in 100 people who get this procedure should need to have another operation for the same thing in 10 years.

Host: Well, those are the very inspiring overall numbers in terms of results. But going beyond that in terms of the way patients feel after this, before and after, why are you so high on this, Doctor? What makes it so beneficial to the patient?

Christopher Ferari, MD: I think that the patients who come back in a few months to our office will tell us just how excited they are about the quality of their urine stream, which they haven't seen that type of quality in probably 40 years or so. So, considering we see a lot of elderly patients, there's patients who have had trouble for a long, long time with their urine stream. And that's one of the things they're most excited about, is that they feel like they're able to fully empty their bladder, like they never have before.

And we can also expect that the bladder that's been very tired for a long time, as we talked about previously, those muscles can remodel themselves as well. So, we can expect some of those symptoms to improve too. The ones like rushing or running to the bathroom or waking up at night, those symptoms will also improve.

But the biggest improvement comes with the quality of the urine stream and not having to strain to urinate anymore, which is a big problem for patients who end up needing the procedure.

Host: And so, when you speak to patients about HoLEP for the first time, what tends to, if anything, surprise them most about the procedure? Do they have any misconceptions that you find yourself clearing up?

Christopher Ferari, MD: Yeah. I think that they are surprised that the vast majority of patients can go home the next day with no catheter in place, because a lot of prostate procedures require a catheter for at least one day. And the other procedure that works for very large prostates is a robotic prostate, simple robotic prostate removal, we call it, and that requires a catheter for a few days.

So, we like to tell patients that when they leave the hospital, they should be catheter-free, which is exciting for them. And then, we also like to tell them that when the catheter comes out, they should be peeing with a very, very strong stream. So, that's exciting for them. Before they leave the hospital, they're already seeing a symptomatic benefit, which is great.

And then, they'll have very minimal pain from this procedure as well, which surprises patients too. I'll see patients two or three hours after the procedure, and they have very minimal discomfort. So, that's something that excites patients as well, because I think when they think of surgery, they think of pain. And in the vast majority of cases, not a painful procedure.

Host: And so once the procedure is over, when can patients expect to be up and about and back to their old selves?

Christopher Ferari, MD: Right. the Only real restriction I have is, obviously, we want them to recover from anesthesia. So once they're feeling back to themselves in terms of not being tired and fatigued from the anesthesia anymore, they can be up and moving around as they would. But we only tell patients to not lift anything heavy over 10 pounds for around a week. And they will have some blood in the urine and some irritation with urination for a day or two, but that should improve very quickly.

Host: And then, in summary here, Doctor, you've done such a great job of breaking down some of the details here of before and after. But overall, to kind of put a bow on this, in terms of quality of life, maybe just from a confidence standpoint, from a mental aspect, how much does this improve someone's life overall?

Christopher Ferari, MD: I think that for the right patient, the patients we see for this procedure are having very significant symptoms. And it's difficult for them to go in public sometimes because they're having to use the bathroom so much, and some of that can even lead to some leakage of urine because they can't make it to the bathroom.

And also, patients who are just waking up at night five or six times a night and it's ruining their sleep, and people who are straining to urinate and having to wait for a long time to finish their urination. It can be a very, very beneficial procedure for them from a quality of life standpoint.

And I don't think we got into exactly as well that patients who can't empty their bladder very well because they have a large prostate are at risk for things like urinary tract infections and forming stones in their bladder too. And we oftentimes see patients who are getting infections and stones, because their bladder's just not emptying very well. So, this is an excellent procedure for them too. So, I think it is a great quality of life procedure, but it also keeps patients out of the hospital with infections and stones and other problems from a very large prostate.

Host: Yeah, because certainly UTI and some of the other things you mentioned, those aside from being separate conditions themselves, they can lead to even further conditions, right?

Christopher Ferari, MD: Right. Exactly. So, we're trying to prevent other problems from arising from kind of this incomplete emptying of the bladder. And there's many other things that can happen from that. So, we're trying to treat patients before they end up with multiple hospitalizations and other issues.

Host: For sure. Well, we trust you're now more familiar with the HoLEP procedure. Doctor, keep up all your great work. It sounds like many are being helped immensely by it, and thanks so much again.

Christopher Ferari, MD: Great. Thanks, Joey. I really appreciate it.

Host: Same here. For more information, please do visit stclair.org/urologic-services. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks again for being part of Curating Care, a podcast brought to you by St. Clair Health.