53 Edgbaston Park Road
BAUS BPH Meeting 2022
By Rachel McLennan, Urology Registrar (ST5), Monklands Hospital, Glasgow.
Over the last decade the number of treatment options for managing benign prostatic hyperplasia / lower urinary tract symptoms (BPH/LUTS) has grown substantially. Despite increased uptake of these newer modalities, equality of patient access remains an issue with some services not being offered at all in some regions. Clear patient pathways are lacking, making onward referral challenging. As a result, counselling patients on the options available can be difficult. The BAUS BPH meeting could therefore not be more aptly timed. With a programme to call on the expertise of clinicians who use each of these technologies, talks on better utilisation of day-case surgery to positively impact on long waiting lists and discussions on equality of access to treatment modalities, there was a buzz of enthusiasm about the hall from both those already involved in this field and those looking to join it. It is clear in this growing field there are ample development opportunities for any urology unit.
Tamer El-Husseiny kicked off the day with a presentation on the Getting It Right First Time (GIRFT) pathway, looking to optimise the pathway for BPH/LUTS and urinary retention patients. It was emphasised how this is particularly important for catheterised patients for whom a long wait-time to treatment has implications in terms of hospital admissions, community resources, cost and of course, quality of life. The format of one-stop LUTS clinics and the relevance of diagnostic work up with urodynamics, flexible cystoscopy and sizing TRUS was debated.
Following on from this each of the treatment modalities was discussed with fantastic talks from clinicians who had expertise in these areas.
Firstly, Rachel Morrison from Harrogate District Hospital presented on bipolar transurethral resection of the prostate (TURP). Despite plenty of evidence to support favourable outcomes for bipolar TURP compared to monopolar (reduced risk of postoperative bleeding / need for transfusion, elimination of TUR syndrome and reduced length of stay), the BAUS Bladder Outflow Obstruction (BOO) Snapshot Audit shows that there are still significant numbers of monopolar TURP being carried out and TURP in general still makes up 60% of BPH surgery. Dominic Hodgson shared the experience of Portsmouth Hospitals NHS Trust in delivering an impressive 80% day case TURP rate. Is it a process difference rather than a surgeon difference which enables these high numbers of day case TURPs? He explained the key is to manage expectations of patients and staff, ensure adequate resources, ideally with a designated day case unit (which COVID has put an end to at many sites), and lastly anaesthetic considerations such as avoiding opiates and using short acting spinals. It was felt that a template business case for day case BOO surgery would help units to benefit from where others have already paved the way. This data from Portsmouth is available for all to view on the Model Hospital website (https://model.nhs.uk/).
Discussion continued following presentations on thulium laser, holmium laser enucleation of the prostate (HoLEP), GreenLight™ laser including GreenLEP. Toby Page delivered a fascinating talk on thulium laser and showed through excellent operative videos the striking differences in plane definition in ThuLEP and HoLEP. Discussion turned to Rezūm™, UroLift®, prostate artery embolisation and Aquablation®. The technologies were presented and patient selection and suitability for day case surgery discussed. It is clear that, when considering these technologies, one must take a patient-centred approach considering the patients’ priorities in terms of intended benefits and potential risks. We were asked to consider those side-effects which matter most to the patient e.g. mortality, incontinence and erectile dysfunction vs. those which are frequently audited e.g. length of hospital stay, haematuria and number of days with a catheter. Top tips for these procedures were also shared.
It was interesting to hear the differing proportions of patients undergoing minimally invasive surgical therapies (MIST) from different units. In one unit 80% of patients underwent Rezūm™, with 20% undergoing UroLift®; in another unit these figures were the reverse. Does counselling style affect patient’s choice between these MIST procedures? The patient-centred approach was further explored with a thought-provoking presentation on the Integral study; a study on the psychology of decision making in men with BPH and talks on patient decision aids. The value of the multidisciplinary approach to exploring these issues was clear.
The afternoon witnessed a discussion on the MedTech Funding Mandate and how this applies to BPH treatments. Mark Rochester delivered a thought-provoking talk on how we can improve day case rates through four key themes – strong consistent leadership, dedicated facilities through ‘cold sites’, exploring patient factors (including the importance of separating day case patients from in patients), and looking at our own Model Hospital data. Consultants were encouraged to view their data through the National Consultant Information Programme (NCIP).
Urology accounts for over 8% of waiting lists in NHS England. John McGrath presented an overview of urology area networks (UANs) and how these could be used to assist with bladder outlet services providing patients with choice, equity and comprehensive services by increasing the flow of patients around the network. He covered what was required to take UANs forward.
The importance of training the next generation of urologists was highlighted multiple times with discussions on what options for BPH treatment training is currently being delivered and what should the competency level should be for CCT. Reshaping the provision of BPH surgery will require improved training and research in BOO surgery.
The management of BPH/LUTS needs to evolve to reflect our developing understanding of the condition and meet the needs of today’s population. Key challenges include returning to normal services following the COVID-19 pandemic, addressing regional variation and access to treatment. This meeting highlighted reasons for optimism in the showcasing of how far BPH management has come in recent years and in the ample opportunities for shaping the future management for this condition.