In this episode of PodMD, Urologist Dr Kapil Sethi will be discussing the topic of surgical treatments for enlarged prostate (BPH). We discuss what BPH is, how a patient with BPH typically presents, potential risks and treatment options, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Kapil Sethi.
Kapil is a Melbourne-trained urologist with a particular focus on men’s urinary problems and enlarged prostate. He is a high-volume BPH surgeon focusing on minimally invasive treatments and Holmium Laser Enucleation of the Prostate, or HoLEP for short. Kapil completed a BPH fellowship in Hamburg and now works at St Vincent’s and Austin Health, as well as in private practice in East Melbourne.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Today we’ll be talking about the surgical treatments for enlarged prostate and how modern techniques are changing what we can offer men. Kapil, thanks for talking with us on PodMD today.
Kapil: Thank you for having me.
The topic of today’s discussion is surgical treatments for enlarged prostate (BPH). Kapill, can you describe for our listeners what BPH is?
Kapil: Sure. BPH is basically the age-related enlargement of the prostate that squeezes the urethra and makes it harder to pass urine. It’s very common. Roughly two out of three men over 60 are going to have some degree of it. So I often say to men in my clinic, if you live long enough, your prostate is going to grow. It’s not cancer, but it can really affect daily life. Slow flow, getting up multiple times at night, needing to know where every single toilet is. For some men, it’s just a nuisance. And for others, it really dominates their day.
How would a patient with BPH typically present?
Kapil: Most men don’t really walk in saying, I think I’ve got BPH. They say things like, I’m up three or four times a night. I have to stand there and wait for it to start. I can’t sit through a movie without a toilet break. I can’t go on long drives. Often their partner is the one who’s usually adding off of their broken sleep. It’s often a cluster of bothersome urinary symptoms over time, not a sudden event.
So the key really is to ask how much it’s affecting their sleep, their work, travel, and their confidence. And it’s not just how things look on an ultrasound.
How worried should GPs be about BPH? What are the risks if it’s ignored?
Kapil: So this, I’d say there’s two sides to this. So for some men, it’s mainly a quality of life issue, but that alone can be huge. Men will, you know, structure their life around toilets and sleep badly for years. But for others, the obstruction can be more serious. So these are things like recurrent urinary retention, repeated infections, bladder damage.
In the worst cases, it can impact on kidney function by long-term obstruction. So once the bladder muscle gets worn out, even the best surgery can’t get it back to normal. So I would say the message is, if symptoms are progressing or complications are appearing, we shouldn’t sit on it for years.
What are the main treatment options for men with BPH?
Kapil: I tend to explain it to patients as a bit of a stepwise ladder. So easy things are lifestyle changes, things like reducing evening fluids, cutting back on caffeine and alcohol, bladder training. These can be useful in mild cases and sufficient alone for some.
The next step up, we would look at tablets. Alpha blockers relax the prostate and sometimes 5 alpha reductase inhibitors such as dutasteride and finasteride medications can shrink it. So these can work well, but they come with side effects, cost, and the idea of being on tablets long term are common issues that I encounter.
Medical therapy, we’ve got MISTs, so that’s minimally invasive surgical therapies. These are newer, less invasive procedures. They are done in theatre or sometimes in an office setting. And these are things like Urolift or steam, resume steam ablation of the prostate.
And finally, there’s definitive surgery. So these are things like traditional TURP, laser procedures such as green light and HoLEP, which is where I spend a lot of my time. So for GPs, the key point really is once men are struggling despite medications or clearly have significant obstruction, it’s time to look beyond another script and think about procedures.
You mentioned MISTs, the minimally invasive surgical therapies. Can you talk a bit about these newer options and where they fit in?
Kapil: Yes. Now, this is a space that a lot of men are hearing about. So MISTs are procedures that are designed to be less invasive than traditional surgery. They’re often shorter procedures, sometimes with quicker recovery. And in some cases, they aim to preserve sexual function by preserving ejaculation, which is important for many younger men. Examples include implant-based procedures, steam-based therapies. From a patient point of view, they often sound very attractive. It’s a quick procedure. You’re home the same day. There’s minimal sort of cutting involved. But there are some important caveats. I would say they’re usually best for smaller to moderate-sized prostate glands. They are also ideal for men with mild to moderate symptoms, not those with advanced disease such as retention or with other big complications. And the long-term data is getting there and it is improving, but it’s still not as mature as it is for TURP and HoLEP.
What we are tending to see though is that retreatment rates can be higher than more invasive surgeries. So I would say that missed a really reasonable option for carefully selected men who value a lighter touch procedure and are prepared to accept that they may need something more definitive down the track. When I see a patient, I often talk them through it and I just say, look, are you the sort of person who wants the least invasive option now and might accept a possible second procedure later? Or would you prefer that you just have one big definitive fix and be done? That conversation can help determine whether we lean towards missed or go straight towards something like a TIP or a HOLEP.
What is HOLEP in simple terms and why are you such a fan of it?
Kapil: So HOLEP stands for Holmium Laser Enucleation of Prostates. It’s a keyhole laser operation done through the urethra. The easy way to explain it is that instead of scraping away the prostate like you would with a TURP, we peel out the whole blocked inner part of the prostate, almost like taking the orange out of its rind. So for patients, what that means is that it can work for prostates of almost any size where there is very strong long-term flow, low bleeding risk, even on men with blood thinners. There’s also short catheter in a hospital stay in most cases.
So I’ve focused a big part of my practice on HoLEP because it gives men a one-off definitive fix in most cases and the retreatment rates can be extremely low. I can offer this safely to patients who previously might have turned away from surgery.
Have there been any important developments in BPH surgery in recent years?
Kapil: So yes, great question. I’d say there’s two real big trends. The first is that there’s the rise of mists, giving men that more light touch approach when they’re not ready for major surgery, but want something more than tablets. And then there’s also a shift towards these full enucleation techniques like HoLEP for men who want a durable one-off solution, especially with large prostates or more serious obstruction. With both modalities, we’re seeing shorter hospital stays, often overnight, better safety for older men and those on anticoagulants, and more focus on durable outcomes rather than quick fixes that need repeating.
Are there any warning signs a GP or their patient should look out for that suggest they shouldn’t wait any longer?
Kapil: Definitely. The ones that would really make my ears pre-cop are recurrent urinary retention, post-void residuals that are consistently high on a bladder scan or ultrasound, repeated urinary tract infections, if there is any visible blood in the urine once we’ve excluded bladder cancer, and any suggestion where renal function is getting worse or there’s upper tract dilatation that’s sometimes seen on ultrasound. So those men shouldn’t be watched. They really need a timely specialist review.
When should a GP refer a patient with BPH to a urologist?
Kapil: I would say refer earlier than you think, especially if symptoms are moderate to severe or impacting on life significantly, medications failed or is causing side effects, the prostate either feels large or imaging suggests a large gland, or you’re seeing any complications such as recurrent retention, infections. And finally, sometimes a patient might just say, look, I want this sorted. I just don’t want another tablet. So even a one-off opinion can just clarify whether a candidate for any of the MISTs or something more definitive like a HoLEP, we can just plan the timing together.
Could you please identify the three key take-home messages from today’s podcast on surgical treatments for enlarged prostate, BPH?
Kapil: Sure, I’d be happy to. So the first one would be that BPH is extremely common and often an inevitability with age. So if a man lives long enough, his prostate is going to grow. And for many men, it will be more than just an annoyance. Now, the second is that we’ve got a massive spectrum of options. So from tablets and mists through to definitive surgery like HoLEP, the art really would be to match up the right patient and the right treatment at the right time. And the final thing I’d say is early referral would make a difference. So once the bladder is damaged, the results are never as good. So you don’t want to wait for repeated retention or kidney issues before sending them in?
Thanks again for your time and the insights you’ve provided.
Kapil: Thanks again for having me.
