A Surgeon's opinion on BPH "Success" Factors

In my last post I talked about bladder symptoms of frequency, urgency and nocturia (night-time voiding) and how to address them with habits. I started off the post with the statement that 15% of men who get BPH surgery are dissatisfied despite objective improvements in flow parameters. These link together because people who get BPH surgery for "irritative" symptoms like listed above sometimes do not get better after BPH surgery that best address "obstructive" symptoms (weak stream, poor emptying, feeling of incomplete emptying)

A couple people added that picking the correct surgeon is important - so I thought I'd chime in about this. Points not necessarily in order of importance.

1. Picking the Correct Surgeon - this is absolutely true but probably for reasons you are not considering. The best surgeons will under-promise, over-deliver. The patient will have a great pre-surgical understanding of the best case, worst case, and most likely case scenario of the outcome - so the patient is never surprised. Working at Mayo, one of the things I value most is having ample time to discuss these things with my patients.

Taking it one step further, sometimes the correct advice from a surgeon is to not get surgery, at least not this go around. This is the core principle of my previous point, sometimes irritative symptoms will not get better after even elite prostate surgery from the best surgeon, because the symptoms are coming from the bladder or brain (not prostate).

Technical skill of the surgeon is of course important. A good laser surgeon needs to use enough energy to open the channel but minimize complications. Also, enucleation surgery is quite technically demanding and frankly the world does not have enough great enucleation BPH surgeons - We have two in Rochester - and I'm thrilled to announce soon we will have three. See my previous posts on relative outcomes of different BPH procedures. Which leads to:

2. Picking the Correct Procedure for your needs - Different BPH procedures have different trade-offs - considerations include durability, incontinence risk, sexual dysfunction risk (both erections and ejaculation), post-op catheter time, post procedural symptoms (sometimes you get worse before you get better), and other complications risks. Again, a great surgeon will refer you to the surgeon who has the most experience in the procedure that you pick to be best. It is very reasonable to ask your surgeon what their preferred BPH surgery is. It's rare for a BPH surgeon to offer every different surgical approach as there are so many options.

3. Managing your own expectations - Patients will often go to their health care provider with something they are excited about because they saw a video or an advertisement on it. After I produced some videos about Rezum (steam therapy of the prostate) on the Mayo channel people came to me asking for it. The current trend is for patients to come in and ask for Aquablation. But Rezum is not a great option for men with a history of infections or who leave a ton of urine behind. Those men are probably best served by enucleation surgery but also have to understand the trade-offs. I am lucky to be able to send these patients to my colleagues in Rochester or other sites in our system. There are similar scenarios for Aquablation that make it a sub-optimal choice too - small prostate size, blood thinner use etc. Shared decision making with your surgeon about 1. if you need surgery 2. picking the correct procedure with the correct proceduralist 3. having appropriate expectations about both good and bad outcomes is critical.

At the end of the day, remember it is always reasonable to get a 2nd opinion from a different surgeon or doctor if you don't feel comfortable.

Tobias Kohler, MD, MPH
Professor of Urology
Head of Mayo Men's Health