Holmium Laser Enucleation of the Prostate

As a result of participation in this activity, participants should be able to:
1. Describe the basics of BPH and Holmium laser enucleation of the prostate
2. Explain the appropriate evaluation and patient selection for Holmium laser enucleation of the prostate
3. Outline the Pro’s and Con’s of Holmium laser enucleation of the prostate
Holmium Laser Enucleation of the Prostate
John Michael DiBianco, M.D.
My name is John Michael DiBianco, M.D., and I joined the department of urology in 2022. I received my bachelor’s degree in psychology from Trinity College in Hartford, Connecticut and medical degree from Ross University School of Medicine. I completed a general surgery internship and urologic surgery residency at George Washington University School of Medicine & Health Sciences in Washington, D.C. Afterward, I completed a fellowship in endourology at the University of Michigan.

I am now an assistant professor in the department of urology, and my clinical interests include general surgical urology, minimally invasive surgery and specifically the management of kidney stone disease and symptomatic prostate enlargement. My research focus includes quality improvement (QI), the goal of which is to improve the delivery, experience and outcomes of care. I aim to ensure that the choice of treatment is medically appropriate while aligning with the goals of the patient.

In my free time, I enjoy exercising to stay both physically and mentally fit. Additionally, I enjoy movies and experiencing how new movies compare to the classics.

Preroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMAP category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole, and joining me today is Dr. John Michael DiBianco. He's an assistant professor in the Department of Urology at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital. He's here to talk to us about homeo, laser and new nucleation of the prostate. Dr. DiBianco, thank you so much for joining us today. As lasers have become a real novel way to open the wider channel, improve voiding dynamics, many different techniques have evolved over the years. Can you tell us a little bit about how this has changed the landscape of BPH symptom management and lots? Describe the basics of BPH and explain kind of how this has evolved over the years?

Dr John Michael DiBianco: Thank you for having me, Melanie. It's a really great opportunity. And, you asked me quite the, question here. So might take me a little bit of time, but bear with me please. so bph, I always stress to my patients at the very beginning is that what we're dealing with here is quality of life. This isn't something like a diagnosis or a treatment for prostate cancer or anything like that. Very few patients need, or do I push them to have these sorts of therapies, because it's mostly about how much are they bothered and, is it gonna improve their quality of life?

And so BPH, for lack of a better term, is enlargement of the prostate. And what we're not actually doing is treating the prostate size or that enlargement, what we're really doing is treating symptoms. Yes, in fact that the bigger the prostate is, over time, the more symptoms will evolve and mostly patients will complain of more symptoms the bigger their prostate is. However, I've seen very small prostates cause problems and humongous prostates not cause people, any issues.

So I think that, the BPH term is the common term and the one that we utilize, but it's not the most technically accurate. But, it's currently the one that we utilize nowadays, the biggest thing that we're actually treating is bladder outlet obstruction. And so there are people who have lower urinary tract symptoms but are not obstructed. And there are people who, have bladder outlet Obstruction, but do not really have many symptoms.

And so the nature of treating BPH and bladder all obstruction is just that, we are removing the obstruction and in men, over 50% of people over the age of 50 and 80% of people at the age of 80 and, so on and so forth, who have this diagnosis. For those men, what we're trying to do is remove some of that obstruction, decrease the stress on the bladder, make it easier for urination, to occur and to allow for more complete urination so that they don't have to go to the bathroom so often and are less bothered by their urinary symptoms.

And so historically, The treatment options were quite limited for, bladder out obstruction due to BPH or prostate enlargement. The tried intrude classic very effective procedure was a open, simple prostatectomy where we actually made incisions in the skin, in the bladder itself and in the prostate, and removed the blocking tissue with our hands. Sewed everything up and put a large catheter in, and left it in for a few days.

As you can imagine, the downside to that procedure, although incredibly effective, at removing obstruction, was the morbidity, was the pain associated with specifically the blood loss. transfusions for those procedures were quite high, just due to the nature of the prostate and the operation. Then TURP came along. And so TURP trans urethral resection of the prostate is a res receptive therapy where we utilize, electrocautery and loops, these little sort of almost spoon like, devices that we use through a cystoscope. And actually just resect from the urethra outward towards the prosthetic capsule.

And at the same time we cut and cauterize in order to decrease the bleeding and remove the tissue all at the same time. Now, this therapy is, some would argue that it's still the gold standard. I mean, it's been around for a very long period of time. The transfusion rate is much lower than with a simple prostatectomy and those open procedures and we still do it today. In fact, I still do it today on select patients. Downside with TURP is that while it is certainly effective at removing a large amount of tissue for very large prostates, it is been found to not be as effective at removing enough tissue to prevent further bleeding or further symptomatology.

This procedure, some people used to say, oh yeah, we'll do a tur onia and it'll buy you about eight years, eight to 10 years of, Symptom relief, to somebody who's 90 years old. that's probably sounds great. They're probably saying, that's more than enough time for me. This is a disease that affects men of all ages and younger and younger people, particularly who have a family history of it. And I think the idea of undergoing multiple procedures is sometimes not as palatable for a lot of our patients. And so, the idea of trying to figure out is there a way to mimic that simple prostatectomy procedure that enucleation of the entirety of the BPH blocking tissue, without the associated morbidity was kind of, that ideal operation.

And so the development of these high powered lasers has facilitated that outcome. And so, many years ago, utilizing these high powered lasers, we were able to do that procedure, do that simple prostatectomy, but from the inside. And, it's called a laser nucleation of the prostate where we're able to take out the entirety of the BPH tissue from the inside using some of the similar, equipment that we use for TURP and all that kind of stuff. But we do it in a different way where we actually sort of peel the orange from the inside of the rind inward instead of working from the urethra outward.

That way we know that we get the entirety of the BPH tissue. So that there's less likelihood of it growing back, and we can actually pinpoint the blood vessels that supply the prostate and therefore decrease the intraoperative bleeding and the risk of postoperative bleeding as well. So, utilizing these certain lasers, and that can be, classically the way in the United States, at least currently, the most commonly utilized laser is a home laser. So that's where the term whole up came from homeo laser and nucleation of the prostate.

There are other lasers out there like a thum laser, people who utilize that, it's called Dual up, and so on and so forth. So the catchall term that I like to use is laser and nucleation of the prostate. I am particular am trained with, the homeo laser. And so typically perform a homeo laser integration of the pro or whole up. And the high powered lasers themselves are an incredible tool that has helped us do this operation. But in fact, the thing that has facilitated even less morbidity, meaning that potentially being able to remove the catheters much earlier, sometimes the same day, but most of the time the day after, is laser modulation.

Meaning there are ways that we can alter the dynamics and the physics of the laser in order to make it one better for tissue dissection at the very beginning as well as for hemostasis. And so, those are some of the different advances, that we've utilized particularly recently in the last recent years, to kind of help make this operation even more beneficial as well as less morbid for our patients, to get them back on their feet a little bit quicker.

Melanie Cole (Host): That's fascinating, Dr. DiBianco, and thank you for that comprehensive. Answer. So since we know that men don't often seek treatment until their symptoms become quality of life limiting, and you mentioned that this is a symptom management tool, as you have more developing tools in your toolbox and you're quantifying symptom burden for these men. Please speak about patient selection because I think that that's what you were alluding to before, that it's not necessarily for everyone, that everybody doesn't just go right to some sort of surgical intervention. So speak a little bit about patient selection for Whole Up?

Dr John Michael DiBianco: You're absolutely right. Men they're not usually putting themselves first and. Looking to roll into the urologist's office all the time. That is absolutely true that I always tell people we, we typically try to, kick the can as, far as we can until we kind of have to do something. But when you understand the nature of the problem and how common it is, it's really important to understand that for a lot of us, it's just a matter of time. And the longer we wait, the bigger the prostate gland becomes or the, adenoma typically becomes, and potentially the more complicated the procedure becomes.

And then potentially the less options you have. Smaller prostates have a much, wider variation of the available treatment options, than do very large prostate. So, it is a fine balance and it is very difficult to. Catch everybody at that exact moment. when we're talking about patient selection, the AUA, the American Urological Association guidelines, several years ago came out with an updated guideline recommendations for physicians because all these procedures, began to emerge pretty rapidly actually in simultaneously.

The idea of coming up with some sort of framework as which to identify which patients were ideal for which procedures, and first and foremost, understanding what the patient's symptoms are. Are they mild? Are they moderate? Are they severe? That's an initial classification. Understanding the patient quality of life currently, as well as the patient as a whole. Are they very ill? Are they on blood thinners? Do they have, heart disease? All sorts of things that can go into, selecting which operation is the best one. The next one is understanding the procedures themselves in the absence of medication. So, medication's a whole, other topic.

And, and most patients come into the urologist office already on something, whether it's an Alpha blocker or Flomax or Soin, all these different ones that are out there that really do help with symptoms. But Typically that's, a little bit outside of the realm of the urologist nowadays because they are so safe and effective and common in primary care doctor use when they come to the urologist office. Our job is to understand more of the procedural and surgical aspects of all these different options in order to be able to counsel our patients into, which one suits them best in our opinion, and then which one do. Hear, understand and say, yeah, that aligns with my goals that aligns with what I'm thinking of, as far as an outcome.

And so the prostate itself, the goal of the prostate is to sort of store and, act as a conduit for semen and the fluid associated with ejaculation. As well as it assists us in holding back our urine over time. The problem is that we can't get the urine out, well enough because of the obstruction or the blockage. So those muscles and those nerves that hold our urine back don't get utilized very often, especially when we have an enlarged prostate. So what I typically tell my patients is that, when we treat that area, it's gonna take some time for our muscles and those, nerves to kick back into gear and remember what they're supposed to do.

So Not only does it, deal with ejaculation, but it also deals with continents that holding of our urine. So the downsides to any treatment potentially deal with ejaculation and with continence. The balance is always with surgical efficacy, meaning how well does it work, as well as durability, meaning how well does it work, and then how long does that last for versus the side effects. And so side effects can include, short term pain, some bleeding, potentially infection, time with a catheter in your bladder, as well as retrograde ejaculation, which is sort of the ejaculatory problems. And I always stress that it's not the same as erectile dysfunction or erectile function.

Erectile function in BPH therapy, are. Very well correlated, meaning that just as you have surgery on your prostate, for cancer and so forth, that's what people always hear about issues with erectile dysfunction. But in reality, the problem is with the ejaculatory function, meaning that when you have retrograde ejaculation, the semen, the fluid may come out the end of the penis, but it may not, it may also just go back into the bladder because that tissue has been removed and therefore there's no backstop to project it forward.

So that is certainly one of the complications or the potential downside to any BPH surgery as well as incontinence. So the concern about having some short term, meaning the first few months versus long term issues with urinary leakage or incontinence, those are things that are potential downsides. If you put that on one side of the balance, then you have the symptoms that the patient is having. And for every patient it's, different. How much do they weigh the potential downsides versus how bothered are they with their symptoms? And so what we have is we call them less minimally invasive procedures.

And more minimally invasive procedures. Because whole up sounds like a very aggressive procedure, and we are removing a lot of tissue, but there's no incisions, bleeding risk is very low. the risk to injury, to the urethra and the bladder are quite low, especially in comparison to open procedures or laparoscopic procedures and so forth. So we always refer to them as sort of more minimally invasive. So the less minimally invasive procedures have less chance of all those side effects that we talked about, but their efficacy and their durability are lower, and they typically are not well studied or indicated for patients who have very large prostates.

It's typically reserved for small to normal size prostates, maybe a bit of an enlargement. Because we know that the nature of doing less to the prostate may not affect the prostate tissue in such a way that it allows for good flow afterwards, then we move on to more invasive, minimally invasive procedures. And that is more the classic turp. some of the newer. Vaporization procedures of the prostate, and then we're getting into, whole up and so forth. The other categories, like the patient factors, the minimally invasive, the less minimally invasive or missed procedures as they're sometimes referred to, can be done in the office.

They're quick. They have low risks of bleeding, retrograde ejaculation and so forth. the nice thing for some patients, especially those who have concomitant heart failure, lung disease, so forth, they can be done under local without anesthesia. And so from an anesthetic perspective, they're definitely enticing for sicker patients. Patients who are on anticoagulation or who have a high risk of bleeding, There are some procedures that can be done on full anticoagulation. We try not to do them if there's any, we talk to the patient, talk to their cardiologist or whoever has them on the anticoagulation and figure out the exact risk.

But typically they can restart those anticoagulants pretty quickly. And if we have to, we actually can do, what's called photo vaporization of the prostate or whole up on patients who have active platelet or coagulation, at the time of the operation. although studies do show that if you can hold it, then it's definitely safer. But we certainly can do it and that's for sure. and then additionally, we can do pretty much any trans urethral procedure under an epidural or a spinal anesthetic. We just communicate with our anesthesiology colleagues about which we think is safest for the patient and go from there.

Melanie Cole (Host): Wow. Thank you so much for outlining the pros and cons of Whole Up and speaking about the services that you offer, as we wrap up Dr. DiBianco, is there anything else you'd like providers to know about treating patients with BPH and when you feel it's important that they refer to the specialists at UF Health Shands Hospital?

Dr John Michael DiBianco: Absolutely. So thank you again for the opportunity. The biggest thing that I think the most recent guidelines has forced both, primary care doctors as well as, urologists who treat BPH to think about and to at least, keep in the back of our minds is that this is a chronic, progressive disorder, disease, if you will. We know that if somebody's already symptomatic and there's evidence that their prostate is enlarged, that it's not gonna get better with time. So the understanding and the counseling of that is important. Back in the day, we used to just do our rectal exam and figure out, oh yeah, it feels pretty big.

He's got enlargement. Nowadays with the advent of, prostate MRI, we've realized that we're not as good as we think we are. Some of us are, but most of us aren't. And so the idea of obtaining an objective size measurement of the prostate is very important. And so a lot of times patients already have, whether it's a transrectal ultrasound, a CT scan for some other reason, of their pelvis. Or prostate MRI, because they previously may have had an elevated PSA or, something. those are all incredibly valuable for both one surgical planning as well as patient counseling.

A lot of times they don't have that. And that's one of the things that we do, is we will obtain some sort of, imaging study depending on the, patient and so forth. So, we can also do what's called a cystoscopy, where we actually look inside the urethra to understand the prostate anatomy and look for other, pathology that might be going on or contributing to their symptoms. But I definitely recommend that if you have a patient that you're treating for BPH or you've tried some medication, whatever it may be, and they're just not really, benefiting from it.

You may Specifically ask, did anybody in your family have any problems with their prostate or need to have a, procedure on their prostate? great deal of patients will have, you know, my dad had it, my uncle had it, that kind of stuff. And it's actually more familiar than, prostate cancer is. And so it's a really good indication that potentially they might need something down the line. And, I think counseling and patient empowerment and earlier referral is really critical. if you think about it, a guy in his fifties who's got some symptoms already, has already kind of taken some Flomax, still not very happy.

Think about the average life expectancy for him at least another 30 years or so. That's a lot of medication. It's a lot of potentially new medications, a lot of, potentially small, less minimally invasive procedures and so on and so forth. Where you nip that thing in the bud deal with the actual problem at, earlier stage where the bladder is at maximum health, where he's at maximum health, where his pelvic floor muscles are at maximum health. And you can prevent this from ever being a problem that he'll ever has to deal with again.

And so again, some sort of objective imaging, or size assessment of the prostate. As well as, early referral and patient counseling, in order to empower them to understand that this is a real problem that is very, very, very much, able to be dealt with, with pretty minimal side effects if done appropriately.

Melanie Cole (Host): Thank you so much, doctor, for joining us today and sharing your expertise on all of these new advances. What an exciting time to be in your field and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org.

And to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/mema. And that concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole.