Jan Chaseley

Good evening everybody. I hope that you're well and welcome to our webinar on UroLift®, a procedure for enlarged prostate my name's Jan Chaseley. I’m the clinical nurse specialist at Benenden and I’m your host for this evening. The expert presenter is Consultant Urologist Mr Steve Garnett.

The presentation will be followed by a question and answer session. If you'd like to ask a question during or after the presentation please do so via the question and answer icon, which is at the bottom of your screen and this can be done with or without leaving your name. If you'd like to book a consultation, we'll provide a phone number at the end of the session and please note that this webinar is being recorded. I’ll hand over now to Mr Steve Garnett and you'll hear from me again shortly.

Mr Steve Garnett

Good evening everyone. Thank you for joining us to hear a little bit about the UroLift® procedure, which is a relatively new treatment for prostate enlargement causing urinary symptoms in men - which is a very common and widespread problem.

And what I want to do is just talk a little bit about the procedure; what it involves, what the benefits are and talk briefly about the some of the studies that have shown that it works. Because I want you to know that it's been around for a little while and it's a tried and trusted treatment. And briefly to explain some of the tests we do to know if it's going to work for you.

So, let's start a little bit just talking about the prostate. So, the prostate is a small gland that sits underneath the bladder as you can see in this diagram here. So, this is the normal prostate, which is about the size of a walnut, and this is the bladder. And obviously the bladder fills up with urine and then, when you pass urine, you actually pass urine straight out through the prostate.

The prostate's actual function in in life is really to do with having children and it makes secretions and things that help with the semen and things like that. So, as you get older and you're not so interested in having children its actual function is not usually so important in that regard.

As the prostate enlarges (it does in the majority of us as we get older) it can enlarge to a degree that actually blocks and narrows down the urethra - the water pipe through which we pass urine. And if it gets very blocked and narrowed, you tend to develop obviously a slow flow. It might be difficult to start urine passing urine, you might find that the flow becomes a bit stop/start-ish and you get secondary changes in the bladder, because the bladder is having to squeeze really hard to get the urine out through the blockage in the prostate.

The bladder becomes thickened and then the bladder starts to become what we call ‘overactive’. It can start squeezing on its own without you wanting it to and you might feel that you have to pass urine more often. You might find that you're not actually emptying your bladder very well and you might often find you're having to get up at night to pass urine.

So, these are all typical symptoms of prostate enlargement. And the most common form of prostate enlargement is what we call benign prostate enlargement, which is nothing to do with prostate cancer. So, it's a very common problem and there are, you know, long-standing treatments including medications and surgery, but they do have a number of potential side effects with them.

So, the UroLift® is a relatively new system that offers the opportunity to sort this problem out without a lot of the side effects the existing treatments have.

So what is it? Well it's, as I said, it's an alternative to medication or slightly larger surgery and it offers a rapid symptom relief and better, what we call, risk profile so fewer side effects than existing treatments. And importantly it doesn't have any effect on sexual function, it doesn't have any risk of incontinence.

So, what we're looking at in this screen here is the actual UroLift® itself. It’s a little implant that goes in; it's put into the prostate and it pulls the prostate open. So, this is the view that we have - as a I would have as a Urologist - looking through a telescope, down towards your prostate. And you can see the sides of the prostate here are meeting in the middle and causing a blockage. And with the UroLift® implants, we pull those sides apart to create a nice opening through which you can pass your urine.

And again, in this one the lobes are nearly together and touching and we pull them apart to create a wider channel which allows relief of the symptoms. How is that done? Well we do it what we call ‘cystoscopically’, which is using an endoscopic approach, so there's no cuts or anything. It's all put down a tube as is generally done under a short general anaesthetic procedure. It takes about 10 minutes and we put these implants in that to pull the sides of the prostate open. On average about four implants are put in

I’m going to show you a video in a minute that makes it a lot easier to understand this, but what you can see here is that - after the procedure - the sides of the prostate are pulled nicely apart and there's a bigger open channel through which you pass urine.

It's worth pointing out at this stage that some people actually grow the middle part of their prostate and develop a lump of prostate here, bulging into the bladder. And that's why it's not suitable for everyone and we have to do some tests to make sure that you don't have that middle lobe, although that's not so common. The majority of people do have just enlargement of the sides of the prostate so we use a what's called a retractor or a delivery device and you can see the actual implant itself looks really very much like (to be honest) a treasury tag doesn't it!

You've got this one bit that's fired through the prostate and then we tension it to achieve the desired amount of retraction of the lobes of the prostate so you get an immediate effect which you can see when you're doing the procedure. And again, these are the sides of the prostate and you can see them being pulled open.

So what this little diagram is trying to show you is that the implants are put in up here at sort of ten o'clock, two o'clock which is well away from any of the nerves or important structures that have any role in in sexual function so that there's very low risk of any damage and it's a very safe procedure.

So, what I want to show you here is a video that gives you an animation of what's actually happening, because it makes it a lot easier to understand. So, we'll try and get this running and hopefully this will come up and we can go here.

So, what this will show you in a second is the view that I would see as a doctor, looking through an endoscope, down through the urethra. So, this is a telescope being put down the water pipe or urethra coming up to see the prostate and these are the lobes of the prostate on either side, which are meeting in the middle and causing a blockage. So that you can see very clearly why there's a blockage there.

And this is what happens with the UroLift®; we push the lobes aside and fire the implant through, which goes through the prostate and then is pulled back to anchor the prostate. And then we tension it to the desired amount to pull the prostate lobes on either side apart and we do that - as I said - on average about four implants. But it just does depend on the size of the prostate. For bigger prostates, you might need more. For smaller prostates you may only need two implants. And I think this video sort of neatly explains what happens and how we do it, and you can sort of see very clearly how the opening or the channel through which you pass urine is much enlarged afterwards.

There we go. So that's how we do it and that's what it looks like down the telescope when I’m when I’m looking at it. So that's a nice sort of demonstration of how that works. I’ll go back to my presentation.

So that's in broad outline what the procedure is: putting these implants in to pull the lobes of the prostate open and, in summary, the advantages that because there's no cutting like other surgery there's less risk of bleeding and other side effects. It doesn't affect sexual function, it can be done as a day case - in and out of hospital the same day - and the majority of patients don't need a catheter or anything like that, which is needed with most other surgical treatments.

I’m going to just run through quickly some of the evidence behind UroLift® because I think it's important that you know that it's been studied quite a lot now and it's safe and reliable. So, in fact the first sort of studies published on the UroLift® go back ten years now. So whilst it's still relatively new in this country, it has been around for quite a long time and there have been safety studies back ten years ago and then real world data, which is doing it in patients nine years ago.

Now - and the most important sort of point of view from the UK - was that it was approved by NICE actually in 2016 so it has been approved by NICE as a safe and recommended treatment for benign prostate enlargement symptoms for at least five years and it is actually available in some places in the NHS, it's just unfortunately that availability is quite patchy and with the current problems related to COVID it's actually very difficult to get these type of symptoms treated in a timely way in the NHS at the moment.

So the most important study was this L.I.F.T. study which was done mainly in America and Australia and they looked at a lot of patients and it was - and this is unusual for a surgical treatment, for surgical study - it was what we call a randomised study against a sham or pretend treatment. And that's important, because it's important to know whether there's a placebo effect.

And what the study showed was good and reproducible results with good outcomes at four years. So, it's durable. And you can see here a rapid improvement in symptoms. So, this is what we call a symptom score as a rapid reduction and results were maintained for the length of the study, which was four years.

So, then it was extended to five years and showed really a very good, sustained treatment up to five years. Now that's the length of the studies, so I can't tell you right now whether it goes whether it remains working really well after five years but, you know, these are good results up to five years and importantly it was safe with very minor side effects (usually some short term stinging or burning that went away after a week or two after the procedure) and as it says at the bottom there were no sexual dysfunction problems identified with this procedure.

Equally importantly, it showed a very low need for other treatments after you've had a UroLift®, so not many men required anything else doing - which is another important factor.

As I said, it's a relatively small procedure and the studies have repeatedly demonstrated a quick return to work, with minimal time off work (if you're working). But, if you're not working, equally less time away from the golf course or whatever it is you want to do. So good recovery, very quickly, and this this is comparing it to TURP, which is a sort of standard procedure that's done for prostate enlargement. And actually, this showed very favourable outcomes, with the UroLift® showing that there's good improvement in urinary symptoms and a very quick recovery and it was very safe.

Again, I think this is a nice summary of what I’m saying is that the UroLift® has very mild or moderate - what we call - adverse events or side effects with very good improvement in symptoms and it's often compared to TURP, which is this other type of surgery - which does have a greater risk of complications.

But I would also say to you: look at this section here, which shows that actually lots of men get treated with drugs for their prostate enlargement and prostate symptoms and I think that, you know, we tend to say all - you know - drugs are safe but actually they do have a lot of side effects. So, these are quite significant side effects whereas there are very few side effects with the UroLift®.

So, I actually see a lot of men coming to see me saying “Oh I’ve been on this medication or that medication for a number of years for my prostate and I don't feel it's working very well”. Well, we can see on this slide UroLift® is much more effective than drugs. Or “I’m getting dizziness” or “I’m getting sexual side effects” or “I feel tired” which is quite common on a lot of these medications or “I’ve got sinus problems”. These are all medication-related issues and we don't always think enough about them, because if you're taking drugs long term for your prostate and you're feeling terrible, then that is not a good outcome.

So that is another area. Rather than just thinking “Oh it's a for a different form of surgery”, I think we should think of it in relation to not having to take drugs all the time. So, you know, UroLift®, I think the drugs I was talking about commonly prescribed are these alpha blocker drugs, but this slide’s sort of saying - you could have your lift instead of drug treatment or instead of other surgery. And it's a good treatment, so it's suitable for potentially for all men with prostate enlargement and symptoms - particularly men who might be frustrated by the side effects of medication treatment, or are not getting enough relief from their medication, or if you're worried about more invasive surgery that might have other side effects.

So, it is a really good option. It isn't suitable for absolutely everyone and we do have to do some tests to work out if it's going to be suitable for you, but it is suitable for the majority of people. More recently there have been some longer-term studies reported with more data showing again good reduction in symptom scores, very few side effects and increasing data that's going on showing that this is a self and consistent and reliable treatment.

So just briefly, I mentioned about further tests and things and - you know - not to be crude, but we have to be a little bit blunt, this is really describing what a lot of us experience as we get older as men and I’m sure any men listening here will remember being at school and being able to pee up here and having your competition with your mates. But, as we get older, I’m afraid the flow does get slower and this is a sort of graphical representation of what happens. And if you're finding that the flow is getting down, well actually here and certainly if it's getting closer to your toes or if you feel it's safer to sit down to pee because of this, that would indicate you have likely got a significant problem with your prostate.

And so when you come to see us about that, we would want to do a flow test and that is getting you to pee into a funnel which measures how well you're passing urine and gives us a more exact form of this really.

So what does that look like? This is what a flow test looked like and - in a man without any prostate problems - you'll see that his flow test is this shape. He pees very quickly with a good flow over 15 mls per second as a maximum flow and then finishes quickly and that's it done. In men with prostate enlargement and prostate problems, you see the flow is slow, doesn't get up much above 10mls per second and it's prolonged. It might stop/start stop start and it's got this bit that goes on at the end that we call (lovely word) it's called terminal dribbling. But I’m sure some of you watching will be able to relate to that! So that's an important test that we need to do to see if the prostate is the cause of your problems. And - if it is - and we're thinking that UroLift® would be suitable for you, then we would need to do a further test to look in at the shape of the prostate to know if it's the right shape for UroLift®. But, as I say, the majority of men do have the right shape but it's something we do need to check.

So, in summary, the UroLift® is an exciting and a good new treatment that has been around for a little while but can be difficult to get, certainly now in the NHS. It offers what we call rapid symptom relief. And the IPSS here is the International Prostate Symptom Score; so, the studies have shown a good reduction in the symptom score, so much improvement in symptoms with good improvement in flow. And that improvement is rapid - by about a couple of weeks after the procedure.

And there are mild side effects only, like a bit of stinging, a bit of going to the loo more often - they've usually gone by a couple of weeks. There's no sexual side effect, it can be done under local anaesthesia (although to be honest we usually do it under a short general anaesthetic), there's good evidence to support it for five years and no reason to think that it's suddenly going to stop working. And I do think that it has been shown across the world in a number of studies now to be a safe and effective treatment.

So, I’m going to stop talking there. That's what I wanted to say about the UroLift® and I think we're going to have some questions now.

Jan Chaseley

Lovely, thank you very much Mr Garnett. That was a very informative presentation.

So, I’ve got a couple of questions on here. So, I have an enlarged prostate which is causing embarrassing urinary issues. I know the UroLift® device is placed through the urethra to access the prostate, and I’m worried how painful that will be.

Mr Steve Garnett

So, as I was saying in the presentation, we would usually do it under a short general anaesthetic, so you're asleep, so it's not painful. The actual procedure and afterwards, as I said, most men get a bit of stinging and burning, particularly - you know - the first day or so and you might get a bit of stinging for a week or so, but it's not severe.

People do not require lots of painkillers and you can see from the studies showing quick return to work and quick return to normal activities, people wouldn't be able to do that if they were in pain. So, it's not, we don't see people getting lots of pain from this procedure.

Jan Chaseley

Lovely, thank you. And a similar question. I’ve had two bladder neck incisions before, and I’ve found the catheters extremely painful. I’m guessing that with the UroLift®, a catheter is also inserted and - if so - is it possible to have this done under an anaesthetic?

Mr Steve Garnett

So, with the UroLift® actually we do not normally put a catheter in, which is for many men a big advantage because it is true that the catheter can be uncomfortable.

A catheter is - for those who aren't completely sure - the is the plastic tube that's put down the urethra, into the bladder to drain the bladder. And if you have a cutting procedure, like a laser operation, or - this man's referring to a bladder neck incision, which is a cutting operation on the prostate and bladder neck or a TURP operation because they involve cutting, which can cause bleeding - we have to put a catheter in because the catheter helps stop that bleeding by pressing on the area.

With the UroLift®, because there's much less bleeding, much less risk of bleeding we do not normally need to put a catheter in. Occasionally we do and, you know, I can't guarantee that you'd get away without a catheter - but most men do not require a catheter, so much less painful.

Jan Chaseley

Thank you, the next question. If I’ve had prostate cancer does this increase my chance of experiencing incontinence and - if so - would the UroLift® procedure be available to me?

Mr Steve Garnett

Well there's quite a lot in that question actually because I think really it depends a lot on the type of treatment you've had for prostate cancer, whether it's radiotherapy, brachytherapy, hormone treatment, so there are lots of different aspects to that. But the bottom line with UroLift® is you can have a UroLift® after prostate cancer and again, because there's no cutting, there is no risk of incontinence - where there is a risk with other cutting treatments like TURP which is commonly done after prostate cancer.

Jan Chaseley

Thank you, next question. Of the several non-invasive treatments for BPH available, why have you chosen to perform the UroLift® and do you have any experience of other procedures including Rezum (which is obviously the steam treatment).

Mr Steve Garnett

So Rezum is a steam treatment and is a newer treatment than UroLift® and the bottom line is UroLift® has been around for longer with more evidence to support it; more data, more experience with it. And I think when you're looking at a new treatment, I think what I look at as a professional is “Is there good evidence to support it? Is there, you know, minimal side effects, minimal complications with it” and UroLift® ticks all the boxes in that regard. So, I think it's safe and reliable and because it's been around longer, I’m more confident in it than some of the newer treatments.

You know it's not to say that some of these newer treatments might not be good, but because they haven't been around quite so long, we don't know if they stop working after a few years. So that's why I do UroLift®. I think it's a very good treatment.

Rezum may work for some people but the other thing about Rezum is because the Rezum works by destroying prostate tissue, patients will need a catheter in usually for about a week after the treatment. And - as we've just referred to actually - a lot of patients are having this treatment because they don't want a catheter in. So that's another thing that I think UroLift® has an advantage over Rezum.

Jan Chaseley

Thank you and a really good question. Next, is there a shelf life for the implants?

Mr Steve Garnett

Well that's kind of what I was alluding to in the in the data. So, in the studies, there is good - there are good - results up to five years. But on an evidence-based approach what I mean is I haven't got proof to tell you that it will work for ten years because the studies haven't been that long.

So, the studies are longer for UroLift® than other treatments, other newer treatments, but the studies have only been done for five years now. There's no reason to think it will suddenly stop working, but with all prostate treatments the prostate can grow further, or things can get worse over time.

So, it is possible you might need another treatment in five years, six years, seven years. Difficult to know. It is possible but, then again, if it's a relatively straightforward, small procedure that doesn't cause you a lot of discomfort that might not be - you know - thought of as the end of the world if you did need a re-treatment.

So, the bottom line is there's good results at five years. I’ve got no reason to think that it's suddenly going to stop working, but I can't tell you there is proof because we don't, because it hasn't been around long enough.

Jan Chaseley

Lovely, thank you. And slightly going along with that: what happens after the five years if it fails? Does it need removing or replacing or repeating?

Mr Steve Garnett

No, it doesn't need removing. If things change and you needed a more, a bigger procedure like a TURP or a laser operation, then you can still have that. And in that situation, the clips or the implants are removed during that operation; they just come out as part of that operation.

But then the other option is potentially you could have a UroLift® again if it was still suitable for you and, in which case, no - they wouldn't be removed, they would be left there.

Jan Chaseley

Thank you, next question. Recently I’ve been needing to rush to the toilet without much warning and I sometimes struggle to pass urine. What advice would you give me?

Mr Steve Garnett

Come to Benenden (Hospital) and get sorted out! It does sound like you need to have some tests done. It sounds like that's becoming a real problem. As I sort of suggested in the first slide, when the prostate enlarges, the bladder then has to work harder to get the urine out and that can cause you to have these symptoms of wanting to or needing to rush to the toilet first thing.

I would say is there are some things that will make that rushing worse, so particularly caffeine. So, I would cut caffeine out, because whilst it's not the cause of the problem it can make things worse. So, cut out caffeine - you can have decaf coffee if you want or herbal teas - but avoid the caffeine, because that often helps quite a bit more than you think.

But then potentially look at having some treatments for your prostate, because if you're having to rush but you're also finding it difficult to pee that's a classic symptom of prostate enlargement. So yes, get it get it looked at.

Jan Chaseley

Thank you. And somebody here says I’ve already had a urodynamics test two years ago and a TURP surgery was recommended. Will I need to have this test repeated?

Mr Steve Garnett

Not necessarily. We probably want to do a flow test to see how things are at the moment, but that's a non-invasive test. But the most important thing really is - as I said - to know what the shape of your prostate is like. So, I probably would need to have a look at the prostate, but I wouldn't think you'd need to have the urodynamics repeated.

Jan Chaseley

Thank you. I’ve had green light laser treatment, which cured the problem to start with but I’m now experiencing problems again - particularly at night. Daytime seems to be fine. Would UroLift® help?

Mr Steve Garnett

Possibly! I would have to have a look. You know it's difficult to advise a little bit on these specific cases because it depends a lot what your prostate shape and outcome after the green light laser surgery is. But it certainly is a possibility.

Jan Chaseley

Thank you. I’ve been taking alpha blockers now for over a year, but I’m still up in the night more times than I would like. I am interested in the UroLift® but is there any impact on sport, particularly running or going to the gym?

Mr Steve Garnett

No, I mean I'd advise you to not go running for a few days after the procedure but no, there is no impact on sport. You can get back to that quickly.

Jan Chaseley

I think that's the advantage, isn't it, of the UroLift®? You can get back to your normal life much quicker.

Mr Steve Garnett

That is absolutely it.

Jan Chaseley

Can this process be used if low-level prostate cancer has been identified and I’m under active surveillance?

Mr Steve Garnett

Yes, potentially it can. There are some issues we'd need to talk through about that because these little implants will have a little impact on an MRI scan, which might be used as part of your active surveillance for prostate cancer. But yes, there are plenty of men with active surveillance for low-grade prostate cancer who have the UroLift® - so yes it can be done.

Jan Chaseley

And another question: my prostate nurse has suggested that there's a prostate size limit on the UroLift® is this the case?

Mr Steve Garnett

Yep it is the case. So, to put this into context, a sort of normal size prostate is about 20 mls in volume. As we get older, it does get bigger, so - depending on your age - it might go up to 25 or 30 mls. Over 30 mils we'd say is enlarged, over 40 mils we'd say is quite enlarged. The UroLift® is suitable up to 100 ml in volume now - that's a pretty big prostate. But if your prostate is over 100 mils in volume then that would be too big for the UroLift®.

But to be honest most men's prostates, even with prostate enlargement, are not that big.

Jan Chaseley

Thank you. A patient here says I’ve previously had bladder neck incisions and two TURPs. Would this procedure now help me?

Mr Steve Garnett

Well that's quite a bit of surgery already and I wouldn't rule it out but, to be honest, you'd need some careful looking at an assessment because you may have some scarring from your previous surgery. But quite possibly you could have a UroLift®.

Jan Chaseley

Lovely, thank you very much. I’m just checking out; I think we've answered all of the questions. I’m sorry if we haven't answered your question today but if we haven’t, we will do so after the event and get back to you.

If you'd like to book a consultation, please contact the number on your screens between nine to five Monday to Friday.

You will receive a short survey and I’d be really grateful if you could please spend a few minutes to let us have your feedback on today's webinar.

Our next webinar is on the 9th of December at 6 o'clock with Consultant ENT Surgeon, Mr Henry Sharp, who will be discussing treatments for blocked ears and noses.

So, on behalf of Mr Steve Garnett, myself and the team at Benenden Hospital, I'd like to thank you very much for joining us tonight. We hope you've enjoyed the webinar and we look forward to seeing you soon. Thank you.