Shammai Rockove, MD, FACSFounder and senior surgeon, Center for Urology, Oregon
“...brings a knife to a gunfight.”
― The Untouchables (1987)
Just because we did a prostate procedure doesn’t mean we relieved a man’s obstruction
Our hubris. A patient's poor outcome. The surgical trend is to do less. The reality is, if you do less, you get less. It is the reason that so many men who have undergone conservative TURP, Urolift, and Rezum are not satisfied with outcomes. In this era of proof by questionnaire, you are led to believe they are all doing great. You are led to believe success is all about some arbitrary percentage improvement from baseline. Success on paper, but not in reality.
Case: A 90-year-old man was referred to a urologist for overactive and obstructive voiding symptoms. Workup identified a 130+cc prostate; he was then treated with Rezum steam therapy but continued to have overactive symptoms including incontinence. This led to intravesical Botox therapy. Subsequently, he was hospitalized numerous times for urosepsis from increasingly resistant pathogens. He was referred for a second opinion. The thought process of the first urologist: Because he did a procedure, Rezum, he assumed he relieved the patient’s obstruction. In fact, the voiding questionnaire was better. Therefore, in his mind, lingering urgency and incontinence represented an independent problem, so Botox was performed.
The reality: Rezum didn't adequately alleviate prostatic obstruction. The gland was too large. The overactive symptoms, which were a consequence of longstanding obstruction and prostate inflammation worsened from the resultant devitalized prostate tissue. Botox hastened the deterioration further by causing incomplete bladder emptying. The resultant infections were inevitable.
Chronic congestion, edema and inflammation from Rezum done on a large gland
How we stabilized the situation: At this point his family members were leery and would not consider surgical or catheterization protocols. They did agree to prostatic artery embolization. This, along with methenamine suppression, early recognition of infection symptoms, and hygiene protocols, has translated to no episodes of hospitalizations for urosepsis in well over a year. He’s not cured, but he is much better than when we started. Message 1: We need to honestly assess our personal outcomes: Did we accomplish our objective? With noncancerous prostate procedures, we must prove that we relieved obstruction. It can't be an assumption based solely on validated but extremely limited questionnaires. Treatments are not the endpoint; accomplishing the intended goal is. Questionnaires may have some role, but without going on a tangent, the role is minimal.
Message 2: Don't bring a knife to a gunfight. Rezum can work but under much more limited circumstances. Minimally invasive is best for minimal problems. Worse, as in this case, when poorly used, they cause more harm than good. What could work with such a large gland? If a person can tolerate them: robotic simple prostatectomy, transurethral laser enucleation, and modified Aquablation.
