Best Treatment for Urinary Urgency and Frequency: Greenlight Laser, HoLAP, or TURP (Rotoscoped-Rooter)?
Dr. Mistry: Hello and welcome back to the Armor Men’s Health Hour. I’m Dr. Mistry, your host, here with my cohost, Donna Lee.
Donna Lee: That’s right, board certified cohost, award-winning cohost.
Dr. Mistry: That’s right. Self award-winning.
Donna Lee: That’s right. I have the little guy on my desk. Little trophy.
Dr. Mistry: Yeah. You know, I’ve noticed that my own voice in just conversation has gotten lower and more gravelly.
Donna Lee: Because you think you’re on the radio all day long now?
Dr. Mistry: That’s right. And I love these headphones and listening to myself.
Donna Lee: I do this at home. When I’m talking to my husband, we just put the headphones on. We’re very sexy with each other.
Dr. Mistry: No, I think he’s just trying not to hear you.
Donna Lee: Well, there’s that.
Dr. Mistry: I’m a board certified urologist. This is a men’s health show. This men’s health show is really driven by your questions and something that we love to answer. For those of you that have questions, we would love your questions at firstname.lastname@example.org. That’s A-R-M-O-Remail@example.com. And if you go to the KLBJ website, you can find out how to get ahold of us. If you can access us through the webcast or the podcast and…
Donna Lee: Oh, we need a webcast.
Dr. Mistry: Maybe. I think it’s the same thing.
Donna Lee: Is it?
Dr. Mistry: I don’t understand these complicated terms.
Donna Lee: Well, you can see our cute faces on our website, armormenshealth.com or on the KLBJ website.
Dr. Mistry: And if you don’t believe that’s my real name, it is my real name.
Donna Lee: Oh, that’s right. We need to talk about that.
Dr. Mistry: M-I-S-T-R-Y, Mistry.
Donna Lee: It’s not a fake name.
Dr. Mistry: It’s a given name.
Donna Lee: Donna Lee’s my fake name.
Dr. Mistry: Isn’t that funny? I’m the one of the real name. You’re the one the fake name. And people think that it’s a gimmick sometimes. What’s somebody called that?
Donna Lee: You know my mom…a gimmicky show name.
Dr. Mistry: …a gimmicky show name.
Donna Lee: My mom’s name, oddly enough, is Tiangthong Dawan, and that’s her real name, but we called her Vena.
Dr. Mistry: There you go. Well, Donna, you got a question for us?
Donna Lee: I do. This patient said, well, it’s actually the patient’s wife, “Dr. Mistry, my 66 year old husband has BPH and had a successful TURP performed about 6 years ago due to urgency to urinate and finally several incidences of not being able to urinate at all. He is currently experiencing frequent urinating again, sometimes 5 to 6 times per night and now has a recommendation for the Greenlight laser treatment. Can you compare the two regarding success for longterm results without side effects? He’s had two biopsies at 60 and 61, both of which were negative. Also has a mild AFib which he takes medication for only if it occurs, which is only 3 to 4 times a year. Other than that, and he’s healthy and in good physical shape. Thank you.”
Dr. Mistry: That’s an awesome question.
Donna Lee: Right? What a thoughtful wife, to put all that out there.
Dr. Mistry: That’s great. There’s so much in that question, as I find an everybody’s question. You know me. Because I really love unpacking that which is not said in the question and then trying to generalize it to other people. This week alone we’ve had several patients, because one of the few reasons that people will come in during a pandemic quarantine to come see their urologist is when they cannot pee at all. And we’ve had to put catheters in. 2 of them were immediate postsurgical patients. They had an enlarged prostate for a number of years and then the anesthesia from the procedure just pushed him over into not being able to urinate at all. In our office, we’ll teach you how to at least temporarily self-catheterize so you don’t have to wear one all the time and then hopefully rapidly get you to a surgical intervention to help open you up. This patient also has what appears to be an elevated PSA, which is that blood test that looks for your risk for prostate cancer. It’s the reason that that patient had 2 biopsies at 2 different ages. If the PSA remains elevated, I usually don’t go past 2 biopsies. I’ll usually do an MRI of the prostate and if it’s negative, I don’t do much. If the PSA is still high after a TURP, which is a trans-urethral resection of the prostate, which is like a, the colloquial term is a Roto-Rooter.
Donna Lee: That’s the Roto-Rooter.
Dr. Mistry: The Roto-Rooter. That’s right. And it really involves the placement of an instrument into the penis while you’re sleeping and a loop that cuts away the old tissue and opens up the channel. It’s like, it like boars through the rock.
Donna Lee: Ah, thus the Roto-Rooter part.
Dr. Mistry: And so, that is…
Donna Lee: It sounds awful.
Dr. Mistry: …that is a very effective way of opening up the prostate if you are in urinary retention–that’s when you cannot pee at all. And it works very well. The fact that it only worked for 6 years bothers me because usually it works for longer than that. And the fact that the PSA didn’t drop some more substantially also bothers me because when you remove that volume of tissue, usually the PSA will drop substantially. That leads me to believe, I wonder what happened the first time? Most urologists are very good at the Roto-Rooter or TURP procedure and it usually won’t fail after so many years…just six years. And if it did fail, either something else is going on–current urinary symptoms are not due to an enlarged prostate–or the first procedure was inadequate. What the questioner was asking though, getting back to what they were asking, was whether or not the Greenlight procedure is an effective salvage procedure after a TURP? And what the Greenlight procedure does is it uses a laser energy that penetrates the lining of the inside of the prostate where it abuts the urethra, and it kind of melts it away to open up the channel a little bigger. Now I will tell you that my experience with using Greenlight in this salvage environment has been very poor. Because of the previous surgery that’s been done in the prostate, there’s a lot of scar tissue there, and that scar tissue isn’t going to respond to that wavelength of laser energy quite like cutting it might. Now there is a procedure called a HoLAP or a, let’s just say a Greenlight laser enucleation of the prostate that works in a different way. Instead of just going straight through the lining and trying to ablate or evaporate or eviscerate that tissue, you actually cut the tissue out using a laser beam. But if the first TURP was done properly, there may not be enough tissue to do that type of enucleation procedure. So in our clinic you would get what’s called a urodynamic study. It is a study where we actually look for evidence that your bladder has a lot of strength to it to make sure that the urine can get pushed out even if we open up the channel. We can also measure whether your bladder is blocked or not, because if it’s not blocked then unblocking it with a Greenlight’s not going to help you anymore. And we want to make sure that’s the right diagnosis. I mean, sometimes even urologists and surgeons, we have a limited number of hammers in our belt, you know, and everything looks like a nail, you know? And there’s a lot of quote unquote “Greenlight specialists” in our town here in Austin. And so if you’re…the same thing happens for all of them. If your urologist is a Urolift like expert that everything looks like it’s the right thing for a Urolift, and if your urologist is a Rezume expert then everything looks like the right thing for a Rezume. I tend to try to really mold the treatment to the patient. So if you are a redo prostate person, then a Greenlight is not going to be the hammer that I pull out of my belt. I’m going to be looking to make sure you need something, first of all, because taking you to the operating room and it not working is not a joyous experience for anybody involved. And so first I want to make sure that there’s some value to taking you to the operating room, and then if there is value, making sure that we make sure you have a procedure that is going to last the next 15 or 20 years, and that’s what the TURP should have done. But every situation is different. Some people may regrow their prostate. Some people could have had a very, very large prostate that really the TURP may have been just inadequate to take enough tissue out, and it just regrew quickly. And there might be just more than one way to skin that cat.
Donna Lee: Is that the right analogy?
Dr. Mistry: I don’t know.
Donna Lee: I don’t know. I don’t think so. You’re talking about regrowing your prostate like a worm when you cut a worm in half?
Dr. Mistry: I’m telling you, skinning cats…this coronavirus we’re really trying to gain a lot of new hobbies, and I got all these knives. I don’t know what else to do with my time!
Donna Lee: Oh my goodness. What else can we share with that lovely wife?
Dr. Mistry: That’s a great question, and we would really encourage wives, especially if your husbands are reticent to kind of talk about things–we’ve gotten lots of great questions on Peyronie’s disease, but this is a great question on what I would consider recurrent urinary symptoms after what was supposed to have been a very longterm treatment.
Donna Lee: Right? And we highly recommend second opinions.
Dr. Mistry: Yes, that is a big, that is a big thing around here mainly because we love sharing kind of our, what I think is a unique perspective on how we practice urology. I try to have always try to do it in a more holistic way, without just one treatment that try to fit everybody into that box. We have pelvic floor physical therapy in our office. We have sex therapy in our office. We nutrition in our office. We have practitioners of different experience levels and ilks that have different areas of expertise. Dr. Yang is an excellent, very gifted Greenlight surgeon. I do tons of Urolifts, Rezumes, and TURPs. We have practitioners who deal with kidney stones, we have just an incredible breadth of experience here, but always to take you to the next level. You know, if you’re complaining of low testosterone, we’re going to not just give you testosterone, but also try to help you make more of your own and get healthier.
Donna Lee: Wow. Yeah. Wouldn’t that be nice? To do it naturally?
Dr. Mistry: That’s right. Because you know a lot of patients out there, they have a sneaking suspicion that doctors are trying to keep them sick. Just so they stay on the medical teet. That is not true, first of all! We have absolutely 0 interest in keeping you sick, but how do we show that? We show that by giving you the tools to make you better. Now the diabetic that comes into the office, and we give them a great nutrition plan and a great workout plan and give them every tool he needs to lose weight and he doesn’t lose weight–he can’t blame us for keeping him a diabetic! You know, we’ve done our best.
Donna Lee: He’s back on that medical teet!
Dr. Mistry: Well Donna Lee, tell people how to get a hold of us.
Donna Lee: You can call us at (512) 238-0762 and we will tell you all about the medical teet. And you can send us questions to firstname.lastname@example.org. Keep sending these questions. We’re keeping you from going into the doctor’s office and paying that copay for at least an hour. We’ll answer them for free right here: email@example.com, and check out our podcast wherever you listen to podcasts. We will be right back.
: Dr. Mistry wants to hear from you. Email questions to firstname.lastname@example.org. We’ll be right back with the armor men’s help hour.