Rezum Treatment for Enlarged Prostate with Dr. Richard Levin

hello and welcome everyone my name is Richard lvin and I'm going to be talking to you all today about BPH or enlargement of the prostate um I recognize a lot of people out there um so hello everyone uh some of you probably know a little bit about this procedure already and uh hope to Enlighten a lot more of you about it uh this evening so first of all um I'm a urologist I've been practicing Urology now for 26 years and um it's been an interesting change in urology over the over the last two and a

half decades in how we treat enlargement of the prostate I've seen a significant change in how we treat BPH and large prostate over the over the last 25 years and it's been very interesting in that the procedures that we do for enlarged prostate have gotten less and less invasive over the years um it used to be there was a procedure that patients like to refer to as a rotor rooter job and that was really the turp the transurethral reection of the prostate which was the gold standard of treatment 20 years ago um it was a

very good procedure it still is a very good procedure but I haven't done one in about 10 years because there's newer less invasive things that have less side effects and so I'm going to be talking about one of those today um but first i'm going to go through a little bit of background about the enlarged prostate and and uh things related to that so first of all the prostate for those of you who don't know or don't have one it's a little gland that sits below the bladder and its purpose in life is really to

make the fluid that you ejaculate so that the sperm can get to where they need to go to get a woman pregnant so after you're done that part of your life the prostate really does you no good whatsoever and in some men it tends to cause problems as we get older so that's kind of what we're going to be talking about here's the bladder the urine flows through the middle of the prostate and then out the urethra so what is BPH BPH is actually enlargement of a the cells of the prostate but they actually only

enlarge in a certain part of the prostate and unfortunately for men they enlarge in the part that travels that the urethra travels through so in other words when they enlarge they tend to close off the flow of urine so a lot of patients come to me and they tell me that they have an enlarged prostate because their internists told them so and they told them so because when they did a prostate exam they feel the prostate and it feels enlarged well that's interesting because just because the overall size of the prostate is enlarged doesn't necessarily

mean that it's causing any blockage and I have a lot of patients that have a quote unquote enlarged prostate but the urethra is actually fine and they're not having any problems then I have some patients who the overall size of the prostate is actually quite normal but they have a lot of problems because the tissue in the middle is being is being blocked so that's what we're going to talk about this problem the enlarging prostate is very common 12 million men in the US and 790,000 new men each year what I like to tell people

is that by the time you get to be about 50 about 50% of men are starting to have some symptoms are signs of an enlarged prostate and then as you know men get older it tends to go in you know percentages when you're in your 60s about 60% 70 70% and 80 about 80 to 90% of men are having some issues with the prostate so what are the symptoms well you guys could probably tell me what the symptoms are um so basically it's the frequency of urination can be either day or night the urgency meaning

when you got to go you really got to go quick difficulty to get the flow started I have some patients who tell me Doc I stand there for 5 10 minutes before things get going having to push or strain to get the flow going is not uncommon having a very weak flow of urine that takes a long time to empty the bladder and actually not emptying the bladder completely is a is a problem and then also this this dribbling afterward which we call postvoid dribbling which men tend to have some a little bit of leakage

after after urination so how do we we how do we figure this out how do we determine what's going on well there's a lot of different ways we do this uh patients of mine are probably very familiar with the questionnaire that we ask about your urinary symptoms and we ask you to grade them on a scale of 0 to five and that score gives us a a score to tell us how severe the symptoms are all those symptoms that we just talked about additionally we sometimes like to do visualize the prostate we do a procedure

called a cystoscopy where we put a flexible fiber optic telescope in through the urethra Channel and I actually look at the prostate to see how much of that tissue has grown and is causing uh the blockage we check to see how much urine is left in your bladder we do a little scan of the bladder sometimes to see how much urine remains in the bladder after you urinate the flow rate we sometimes measure we have you urinate into a special machine that tells us how much blockage there is of the flow we measure the prostate

size again size doesn't always matter in this case and the symptom score the symptom severity is what I was what I was mentioning uh previously so what are the treatment options there are a lot of options that go from less invasive to more invasive some of the options like Behavior modifications that we don't actually have to tell people to do they just kind of do it anyway when you're you know going to go to a movie people tend not to drink very much beforehand or a long plane flight or a drive people kind of tend

to know that you know you're not going to drink a lot before that so that's called behavioral modification there are medications there are a few different there are two different classes of medications types of medications and a few different medications in each class they've been around for 15 20 years or so there have been some newer ones over the past 5 years actually probably not a new one in the Last 5 Years and the medications do work for a lot of men I often would recommend that Men start with medication so at least they know

how bad they are in other words some guys these symptoms have been going on for so long and come on SO gradually that people don't even realize how bad it is they take a medication and they think aha this is what it's more supposed to be like so the medications actually do work probably for about 70% of men but typically as the prostate continues to enlarge um the medications tend not to work so well anymore also I would say a good 30 to 50% of men have some side effects with these medications that some are

not so bothersome but some are very bothersome and not very desirable so a lot of patients who try the medications that either work but they don't want to be on a medication for the rest of their life or don't work and they want to do something to improve their symptoms there are other options in the past there were really some surgical procedures the turp is what I mentioned before that was the gold standard it does work but it has a lot of side effects after that came lasers we do use lasers to open up the

channel again it works but it has some some other side effects this also requires being asleep the laser procedures and the turp require being asleep so kind of in between the medication therapies and the surgical therapies there have been developed over the last couple of years um a couple of different Therapies that are kind of in between those two extremes work a little bit better than the medications are a lot less invasive than the surgical therapies and have less side effects so I'm going to talk a little bit more about this one particular procedure resume

I'm been involved with this procedure for about four years I was involved in one of the first clinical trials that was done in the US um it was done at 10 different sites around the country and and I was one of the sites and ACW I think the most one of the most patients in the study so anyway we did this study and the results were very good and the FDA approved this procedure about a year and a half ago very very quickly so the procedure was approved his FDA approved is covered by insurance companies

in starting in November of 2015 so for a year and a half we've been able to offer this to our patients commercially not in a clinical trial what is resume or water vapor therapy so basically what it does is we use a few drops of water and heat that to steam and we use the steam to deliver the prostate to use the energy that is created when the steam goes from the liquid excuse me from the from the um the vapor phase back to the liquid phase and if anybody knows anything about the laws of

energy when you convert steam back to water it releases a lot of energy it's 540 calories per gram of water which is a lot of energy a lot more than if you were to just take you know water and cool it from let's say 99° C to 98 de CS taking it from Steam which is 100° C down to water at 99 it releases a tremendous amount of energy and that energy is absorbed by the enlarged prostate tissue and that actually treats the tissue resume uses the natural energy stored in water vapor or steam it

is a safe and effective Treatment available to relieve symptoms associated with benign prostatic hyperplasia or BPH during each 99sec treatment sterile water vapor is released throughout the targeted prostate tissue when the steam turns back into water all the stored energy is released causing the cells to die over time your body's natural healing response removes the dead cells shrinking the prostate with the extra tissue removed the UR bre thr opens reducing BPH symptoms most patients begin to experience symptom relief in as soon as 2 weeks and maximum benefit will occur within 3 months so the benefits

are that it's an alternative to medication and an alternative to surgery I'd say about 20% of patients get Improvement right away 25% of patients it takes a few weeks and about 30 to 40% of patients it takes a month or two to see the Improvement it is a very simple procedure that literally takes me about 3 to 5 minutes to do it doesn't require general anesthesia so it can either be done under a little sedation sort of like a colonoscopy or it can be done completely awake I do 70 73% of all of the ones

I do with patients completely awake they come in they walk out they can drive D home if they want it typically does not cause any changes to erection and to other sexual functions which some of the other procedures have a higher likelihood of doing so one of the big side effects with these types of procedures is something called retrograde ejaculation where when you ejaculate no fluid comes out and that is a side effect of the turp procedure about 100% of the time with the newer procedures the laser procedure that I mentioned it's it's less than

that it's about 40 to 50% of the time and in the in the clinical trials with this procedure the resume that retrograde ejaculation was about 5 to 6% of the time so it's a it's much less for patients who were concerned about that and as far as getting back to regular activities yes most of my patients get back to pretty regular activities within a couple of days some patients actually the next day they say about two hours of Total time I don't know about that I would say that if that's the case half of it

is spent doing paperwork probably 5 minutes doing the actual procedure and maybe another 10 minutes of me talking to you afterward the procedure again it's 9sec treatments of delivering the steam how many treatments depends on how big the prostate is so if you have a small prostate it's probably two or three treatments I'm talking treatments meaning 9sec treatments done at that same time um if your prostate is very big it might require 8 10 or 12 treatments some patients have to have a catheter a lot of patients go home without a catheter and oral medications

some patients take a little medication to reduce anxiety beforehand if they're going to be awake [Music] you need to know where every bathroom is within a f mile radius of wherever you are you know I remember there was a time when we were in Spain and the people we were traveling with were saying you know he's always going to find the bathroom and I always had to I had pretty well uh was resigned to the fact that I would have to take medication forever well first of all it was really expensive you know even though

I you know I'm I have Medicare Part D it still was an expensive thing plus you know it makes you dizzy and um I'm not so sure I wanted all that stuff in my body and so then I made an appointment and said you know I've read your brochure and I'd like to consider this so had a um a conference with uh the uh physician and uh you know he didn't push me at all he said you I want you to think about this and so you know I I did that went home I talked

about it with my wife and uh I said I don't see where this is going to lay me up um you know this should be uh something that's going to work really pretty well for me and so I uh uh went back to the the doctor made an appointment and you know I don't I don't think I was at the clinic for more than an hour um it didn't hurt um it felt weird but it didn't hurt I first started feeling uh relief from the symptoms uh probably uh three weeks after the surgery because I

had to uh gradually get off of the uh Flomax and start taking those pills every other day and until because you just can't stop with those uh for two weeks and uh uh the Avodart uh my urologist said take it until it's gone so when it was gone I was free U since my resume procedure uh I've been able to be free of having to know where the bathroom is right away I don't have to take pills and um I don't have to pay for them when I do get up at night which is about

once a night and I think that's pretty normal um I'm not dizzy I don't feel like I have to hold on to something uh um just kind of really works uh beautifully uh and there have been no side effects my God to have the freedom but this is this is really what what has uh uh been the end result is freedom freedom was is a big thing I would really say this sets you free and when you're 75 like I am um that becomes a really important issue I would say to uh to my friends

friends and have about the procedure it's easy and if you're thinking about it do it it gives you the freedom that you never thought you would have [Music] again basically it's a it's a very good procedure it's not for everyone um certainly you know you need to be evaluated by a urologist to determine if we think that it's a good idea a good procedure for you um you know some people with these symptoms actually the symptoms aren't related to just the prostate but there can be other issues as well if you're not happy with the

symptoms you're not happy with the current treatment medications then certainly this is something to consider so at this point I think what I'll do is I'll take some questions I also want to say that one of my patients who had this procedure gracefully volunteered to come here tonight to possibly answer some questions my name is Chris hampson I'm a delightfully young 68 years old I had the procedure done a little over a year ago IID initially come to Chesapeake Urology and I had an appointment with another doctor and I was going to have the microwave

procedure and then he told me that Dr Lin was involved with his recently approved procedure which I had done I had my yearly checkup two weeks ago I think it was something like that um mine was more like the Goodyear blimp I was in the the nine and I know on there that looks like man that's got to hurt like hell it it doesn't doesn't doesn't hurt at all and he's true about the procedure it if it was more than five or 6 minutes I was trying to recall on my way over here how how

long it was and I knew it wasn't long but it had to be somewhere in that range before I had the procedure I put up with the symptoms for probably a year and uh the night that finally did it I'd gone to dinner at a restaurant out at the White Marsh Mall and before I got to McDonald's I had to pull in a street open the door and go in the street that's how good that was I was going probably 10 12 times a day and one time it always seemed to be the same so

don't tell my wife I took a measuring cup went in the cup and it was 2 oz 2 oz 2 oz 2 oz 2 oz 2 oz uh after the procedure he showed me how to use the catheter I didn't need it I really suffered no after surgery pain uh I went back to what I do uh two days later and uh didn't really need the medication and since then there has been no backlash no side effects he knows what he's doing were you put to sleep or did you have sedated or no nothing so

actually believe it or not when I did your procedure I did a little bit different technique in terms of the numbing medicine I I changed that a little bit and actually it's even less painful now than when you had it done he asked that if you're getting these symptoms is it possible to have prostate cancer yes it's possible but these symptoms are not specific for prostate cancer so in general prostate cancer has no symptoms which is why we recommend the PSA blood test and the yearly rectal exam so I I kind of alluded to when

I get patients that say their internists you know did the prostate exam and said their prostate is big I tell my patients that's great but that doesn't matter because when I feel your prostate I'm not feeling for the size I'm feeling to see if there's any hard nodules that would indicate a risk of prostate cancer but all these symptoms that we're talking about they're not symptoms of prostate cancer they're more symptoms of an enlarged prostate and enlarged prostates you know they're both have to do with the prostate but actually they happen in different parts of

the prostate so prostate cancer actually happens in the very outside of the prostate so that it's more likely we can feel it with our rectal exam the BPH happens on the inside of the prostate which is why when the the prostate enlarges on the inside where the urine flows that's why it causes these symptoms so they're separate and no they're not related you know any procedure that we do you might need another one done 5 10 years down the road my experience with the laser procedure which we've been doing now for about 11 or 12

years is that about 10% of men need something done between 5 and 10 years later you know this procedure the the clinical trial now the patients are um a lot of them are coming back for their three-year followup and they're still doing very well so you know will they will some patients need to have something done again yeah probably depending on if your prostate continues to grow now there are actually medications we can put you on to prevent the prostate from growing but I don't typically recommend them because they cause lots of side effects most

of my patients come off their meds and he was if I I look back at your chart you were on the Flomax twice a day and your symptoms were pretty bad and now he's not on any medications the rectal exam again primarily we're feeling for cancer once men get to a certain age the studies show that press a cancer is not going to cause you any problems because it's such a slow growing tumor um so yes I often tell my patients that you know I can forgo that a very unpleasant test if you would like

U and so but as far as the urination symptoms again that's a whole different different aspect of the prostate so most patients if they can come off the warrin I recommend they come off of it if they can't I have done this procedure on morphine the patients that I do awake I have them urinate right after the procedure if they can urinate then most of them don't need a catheter if they can't then they have an option of either having a catheter in for a few days or learning how to put a catheter in which

is called intermittent catheterization and as Mr hson told you I taught him how to put a catheter in in case he had any problems but he never needed to do it so people some people get swelling of the prostate from the procedure and it takes a few days for the swelling to go down and some people it swells so bad that you just can't pee at all so PSA is for those of you who don't know is a is a blood test that measures a protein that's made by the prostate it stands for prostate specific

antigen we use that to try to identify men that at at risk for prostate cancer but it's not a perfect test and some of the PSA is made by normal prostate tissue so we're getting rid of some of the normal prostate tissue and so the PSA therefore does tend to go down somewhat a little bit um there are some medications some of you may have been on called Avodart and proscar and they really lower the PSA by 50% this procedure I haven't seen it that low I've seen some patients who it doesn't go down at

all and I've seen some patients who it does come down some but that's kind of a you know I look at it it doesn't really matter whether it does or not I mean it just is what it is now to be honest with you I have not done this I've not needed to do this procedure twice in somebody yet until about a month ago um and that was a guy who was in urinary retention he couldn't urinate at all typically I recommend a more aggressive surgery for somebody like that but his heart was so bad

that he couldn't have anesthesia so his only option was a procedure awake so I did the procedure on him and and a year ago and unfortunately he still was never never able to urinate but he decided he wanted to try it again A year later well guess what this time he's urinating so well the green light is the laser I've been referring to that's a more um invasive procedure um it has to be done asleep I'm not going to say it's better or not better um sometimes I recommend one to a patient sometimes I recommend

the other sometimes I recommend you know you could choose whichever you want um that procedure like I said has to be asleep the chances of retrograde ejaculation are much higher about 40 to 50% compared to 5 to 6% um so it's you know it's just different and you kind of got to choose um with the laser procedure the the urinary symptoms tend to improve more quickly for some patients than they do with the steam but for the steam you know I think the average for the steam is probably more in the three to four week

range of getting good Improvement and I look back at your notes and at your one month checkup you really didn't have much change at your three-month checkup you were like amazed so he asked um if this kills the cells of the prostate what does it do to the cells of the urethra and that's a very good question and it does absolutely nothing and the reason for that is so the prostate has different zones okay different areas and and I already explained to you how the middle area where the urethra runs through is where the enlargement

occurs so here's the middle area is where the enlargement occurs the outside area is more where the cancer occurs so what we do is we the needle penetrates into this area that is where the enlargement occurs and the steam is released directly into that area you know the steam is is water vapor so if you breathe okay onto your hand okay your breath is going to go beyond where your hand is correct because it's a there's a barrier well the same thing with the prostate there's a barrier right here between the prostate and the urethra

and so that steam stays in this area where the enlargement is it doesn't actually go into the area where the cancer is and actually this treatment I mean I don't know how much I'm allowed to talk about this but in the future this treatment might be used for prostate cancer by injecting the steam into different zones of the the prostate so basically it's because of the it's called the zonal anatomy of the prostate that the steam stays where you put it and we put it in the area where the prostates enlarged so these little puncture

sites heal within a day or two yeah the water just gets resorbed by the body and it's I mean it's actually so do you know what a milliliter is pretty small pretty small so each each steam injection is42 milliliters so it's not very much volume each injection is a different yes a different area in the prostate you know there are there are different modalities for treating this problem and some doctors have decided to you know just do one or the other um you know it's really not a very difficult procedure compared to some of the

procedures that we do so it's it's very easy to get trained in if somebody wants to but you know it's just like anything else you kind of do what you like doing you know they're all procedures that work and it just depends on the individual patient what the prostate size is what the important factors are to that patient so this first study was done with prostates from 30 to 80 gram which is you know an enlarged prostate they're planning on doing an extra large uh prostate study from 81 to 150 grams um the largest prostate

I've done personally is 151 gram and he's doing very well currently it's not designed to treat cancer cells but certainly if the steam hit a cancer cell it's going to get rid of it it's going to destroy it but again like I said most of the time the cancer is in the outside part of the prostate and the enlarged prostate is in the middle um and they're trying to do they're doing studies right now actually outside of the US in prostate cancer with this I think that you know a couple patients have had some difficulty

urinating for a little bit longer a few weeks um a few um I've had a couple of patients who did get the Improvement that they thought they would but I'd say 90 90 plus% do so yeah I mean it you know there's nothing that's perfect um and so yeah but there has there have really to my knowledge have been no I mean the the most serious side effect that there is is that it doesn't give you the Improvement that you thought it would I mean there's been really no bad side effects no serious complications with

this procedure I don't believe anywhere well like I said um the gentleman who asked about the kumaden I would prefer that patients stop their blood thinners but I have done this procedure with patients continuing blood thinners there's just a there's just a little bit higher risk of having some bleeding and patients do have some blood in the urine after this procedure which typically doesn't cause any problems I'm sure you had some blood one time that's it one time the one that I recall because it it looked more like um grape juice juice or there might

have been a few drops later on but it I didn't believe that much okay I mean typically patients have a little bit more blood than he's describing you know a little blood in the urine on and off for a week or two is pretty pretty typical somebody on blood thinners it might be more than that there's a correlation between the size of the prostate which increases the number of treatments which I think increases the need for the use of a catheter some men prefer to have a catheter and learn how to insert it themselves when

they if they couldn't urinate that's called intermittent catheterization there are other men who don't want to mess with that and who just want to leave a catheter in for a few days I teach people how to do whichever they're more comfortable with I think that the differences in effect are minimal and most people don't notice much difference between Rapa flow and Tami loen or Flomax but I'm not opposed to it I mean I'll I I don't put I don't ever push anyone toward having a procedure patients come to me and say all right I'm ready

to have this done I give the options I talk about it but I don't ever tell someone okay you you know we really need to do this procedure now I don't do that unless it's for cancer but if it's for something like this patients tell me when they want to do it if you want to try another medication sure all right well I really do thank everyone for coming uh I really appreciate it um hope that we uh learn something