Events

Vicky

Hi everyone, we're just going to give it a moment or two to allow everyone to join, and then we'll get started.

Okay, once again, good evening, and a very warm welcome to our webinar on enlarged prostate treatment. My name's Vicky, and I'm hosting tonight's session. I'm delighted to be joined by our expert speaker, Mr Steve Garnett, consultant urologist.

Tonight's session will begin with a presentation from Mr Garnett, followed by a live Q&A session. If you have any questions at any point, please do feel free to submit them using the Q&A icon, which is at the bottom of your screen.

You're welcome to ask anonymously or include your name, but just a quick note that the session is being recorded, so any names shared may be visible in the recording.

And to help us get through as many questions as possible, we ask to please keep your questions as brief as possible.

If you're interested in booking a consultation, we'll share all of the relevant contact details at the end of the session. And for now, I'm just going to hand over to Mr Garnett. Thank you very much.

Mr Steve Garnett

Thank you very much, Vicky. Good evening. Welcome, everyone. Thank you for joining us.

So I'm going to talk through this presentation on enlarged prostate treatment. There's quite a bit here, as there are more and more treatments available these days, so some of it we will have.

To skip through a little bit quickly, but it's to give you a general overview of the treatments and the kind of approach that we would take to enlarged prostate treatments. And just to sort of clarify, this is what we call benign prostate enlargement. We're not specifically talking about prostate cancer this evening.

So, a little bit about me, that is, that's a photo that needs updating, because I'm significantly older now, but this is just to say that I've been doing prostate enlargement work for a long time, and I introduced some of the newer treatments into the East Sussex and Benenden areas.

And I've been heavily involved in taking on new treatments and training people to do them.

So why are we talking about this? Well, it's a very, very common problem. Most men, certainly from the age of 50, we'll suffer some of these symptoms at some point.

Unfortunately, many of us men are not very good at going to the doctor and may suffer these symptoms without really making a fuss, without complaining about it, without telling anyone, and just try to manage our lives around the symptoms, when in fact there are a lot of effective treatments out there now. And the newer, modern treatments are less invasive.

Than some of the older treatments and can offer very significant improvements in quality of life without much in the way of side effects.

So, what we're going to talk about today is a little bit about what the prostate is, where it is, and what we're talking about when we say benign prostate enlargement, or BPH, which is another term used for this. Symptoms that may affect men.

When you should start thinking about getting treatment and what those options for treatment might be, and then we'll come on to some questions and answers at the end.

So the prostate is a small gland. It makes secretions, so it's usually described as being about the size of a walnut. So, it's fairly small in its normal workings, and it's there just sat underneath the bladder.

And as you can see, the urethra, or the water pipe through which urine passes when you're passing water, goes through the middle of the prostate. So, that's why we get men getting so many symptoms when the prostate gets enlarged, because it can block the way out of the bladder and cause various symptoms.

As you can see here in the bottom right-hand picture, as you look at the screen, that's an enlarged prostate causing some blockage to the way out of the bladder.

What does the prostate do normally? Well, it's involved in reproduction, and it makes fluid that goes into semen and helps nourish and liquefy sperm, basically, so it helps with having children. So for most men over the age of 50 who aren't looking to have more children, it becomes more of a problem than something useful.

What are we talking about when we talk about benign prostate enlargement, or enlargement of the prostate? So, you'll hear lots of different, sort of, terms used interchangeably. We talk mainly about benign prostate enlargement, or BPE.

It used to be called a benign prostatic hyperplasia, which is a pathological diagnosis, which is still used in many places, but BPH or BPE effectively refers to the same thing.

So about 50% of men over the age of 50 will start having symptoms, and for a lot of those, those symptoms can become quite bothersome and annoying.

As men get older, it becomes more and more common, and it's estimated there are about 3 million men in the UK with symptoms associated with BPH.

Just to stress the point, as I said earlier, this is not a cancerous condition. It's an enlargement of the prostate due to growth of the prostate, due to benign reasons, not cancer.

This is, I think, a useful diagram that kind of illustrates why prostate enlargement causes the symptoms that it does. On the left-hand side, you can see a normal picture of the bladder and the urethra passing through the prostate.

On the right side, with BPH or BPE, prostate enlargement, you can see that the way out of the bladder is blocked. The urethra, which is where the urine runs through, is narrowed, so you can easily see how that might cause difficulty starting to pass urine, a slow urinary flow, difficulty emptying the bladder and those sorts of changes. And that, in turn, causes the bladder muscle, which is this thick muscle, or detrusor muscle in the bladder, to become thickened.

And enlarged, as all muscles do when they have to work harder. And that causes the bladder to be, what we call it, a bit overactive, and you can get irritative symptoms, like going a lot at night, having to rush to the toilet, and wanting to go more often.

There is also a dynamic component. That means that it's not purely down to the obstruction from the prostate. There are changes seen within the bladder and some of what we call 'receptors' in the lining of the bladder, and that also has a role here.

So yes, it's benign, but it causes lots of problems and, long-term, if it's untreated, can lead to complications such as not emptying the bladder at all, which is retention of urine, and even in some cases to not allowing the kidneys to drain properly, which can cause damage to the kidneys and, in the longer term, can cause dysfunction or actual problems emptying the bladder, even after the prostate is treated.

Symptoms we touched on a little bit already, but they will be typically a poor urinary flow, although for many men, this can come on quite insidiously, slowly over the years, and people don't always notice the fact that things have slowed down a lot.

Difficulty starting to pass urine, which we call hesitancy, straining, or having to push to try and get the urine out and getting up a lot at night to pass urine.

Frequency and urgency; a strong need to pass urine; and difficulty completely emptying your bladder, which, again, people are not always aware of.

One of the biggest issues for many men who come to see me is that getting up a lot at night can cause disrupted sleep and feeling tired all the time. There can be other causes for needing to get up to pass urine at night, but certainly BPH is a big cause of problems like that.

Planning life around the toilet, always needing to know where toilets are when you go out, worrying that you might not be able to find a toilet. Unfortunately, it is increasingly difficult with public toilets not always available these days, and that could cause, obviously, anxiety, particularly when travelling in certain environments, like planes or buses.

And can even cause impacts on the ability to work and worrying about being able to get through meetings without having to rush off to the toilet. And obviously, it can have an impact on your personal relations.

Typically, it can be, you know, quite hard on partners if you're getting up a lot at night as well.

So, when would I recommend seeing help, seeing a doctor? Well, I think, you know, the first thing is, if symptoms are bothering you and it's affecting your quality of life, or you're not able to do some of the things that you want to do because of your symptoms, then that is when I would suggest you should be seeking treatment.

If your symptoms are getting worse, if you started treatment, but things aren't improving, if you're finding that, although to start off with, it was just a bit of a slow flow, now you're getting other problems, like having to rush to the toilet more and getting up more at night.

Or if you've been aware of the problem for a while, but you think you're struggling more to pass urine, we'd really prefer to initiate treatment before you get long-term damage to the bladder. There are certain situations where, clearly, you're definitely going to need treatment. These are situations where you're getting lots of urine infections.

Definitely, if you see blood in the urine, that should always be taken very seriously and investigated. Or some men get to the point where they can't pee at all and have to have a catheter put in as an emergency, and clearly that's going to need further treatment.

So I think in the first place, for most people, seeing their doctor I know it's not always easy speaking to your doctor, having an assessment, and potentially trying some basic treatments from your doctor are good places to start.

If your doctor feels that you need more investigation or initial treatments haven't worked, then you may well be referred on to a hospital; you may need to see a urologist, and what's going to happen is that you're going to come for an outpatient assessment, where there'll be some questions and possibly some

questionnaires to fill out about your symptoms. There'll probably be a urine test; make sure you haven't got an infection, and then what you can see in the picture is a urinary

Flow meter, and that's essentially a machine that measures how well or how quickly you're able to pass urine, and that's coupled with an ultrasound scan to assess how well you're emptying your bladder. And together, the flow rate and the amount of urine you're leaving behind give us a very good indication of how severe your problems are.

Often that will be combined with a blood test, a PSA test, to check for any risk of prostate cancer, and it may require further tests, such as a cystoscopy, which is a camera insertion through the urethra to look at the prostate and bladder, gives us a lot of information about the prostate shape and size and can be necessary to rule out any other problems, such as bladder issues.

What are we looking for with these tests? Well, we want to know the severity of the symptoms, and that's why some of our questionnaires are used. We want to

Assess whether there's a risk of damage to your kidneys; try and work out if your symptoms are mainly due to the prostate or the bladder, because there's quite a lot of overlap between the two. We may want to make sure there's no sign of prostate cancer, and obviously we need to understand.

What you as the patient want to get from treatment, what your priorities are, and also what your expectations are on whether we can, you know, help you with that.

We also need to talk about which treatments are going to work best for you, and that is a combination of patient wishes but also the size and shape of your prostate and your symptoms and flow, because not every treatment is suitable for everyone.

And obviously, we want to be able to give you some information about the various treatments and the pros and cons of each one.

So, we usually start with lifestyle modifications that may be reducing the amount you drink or reducing the amount of caffeine.

Maybe some medical treatments, and then we may want to consider surgical options, and those range from what we call 'ablative treatments' that help to remove prostate tissue to smaller treatments that don't actually remove tissue but may relieve things without removing tissue.

And, as I've said, the decision depends on patient priorities and wishes and general health, symptoms, but also prostate size and shape, and that's very important.

Just to stress that not everyone's going to be suitable for every treatment.

In terms of medication that often people get from their doctors,

We usually start with medications called alpha blockers, and these are medicines like tamsulosin and alfuzosin, and they relax the muscles in the bladder neck and prostate and can help you pass urine more easily. There's another class of drugs, of which finasteride is one, dutasteride is another, and these help to reduce prostate size, but they can have certain side effects.

They are useful, but they need to be. You need to be aware of what the potential side effects are before you start on those.

So there are good, you know, first-line drug treatments, but long-term, they can have complications and side effects, and the alpha blockers in particular don't stop the prostate from enlarging and symptoms getting worse. And often, people may find them effective to start off with, but not over time the symptoms may get worse.

This is quite a complex slide, but it's just trying to indicate the different interventional treatments available for BPH at Benenden Hospital. There are other treatments that we're unable to offer here, but there are very, very few hospitals that can offer absolutely every single treatment.

And as you can see from this slide, we do offer an awful lot here. And that ranges from what we would call minimally invasive treatments, which at Benenden we offer, iTind and UroLift®, to treatments that are what we would call ablative, because they remove some prostate tissue.

So, that ranges from TURP, which is a long-standing treatment, to laser to Aquablation®, being the newest, ablative treatment around, which uses a robotic approach to help, carefully remove prostate tissue.

So, they all have different pros and cons. The iTind and UroLift® can be done as day cases.

And don't usually require a catheter or a tube in the bladder afterwards. The more ablative treatments are, usually done with

An overnight stay in hospital, occasionally two nights in hospital, and would usually have a catheter in afterwards.

The common side effects of all the surgical treatments can be effects on ejaculation because of the role of the prostate, and that can be affected by any treatment. And

Occasionally erections can be affected. That's not a common issue, but occasionally that can happen, and that can happen with the drug treatments as well.

Other issues, such as we would always have to caution people that there's a very, very small risk of incontinence or leakage with prostate surgery. It's extremely rare, but it can vary from procedure to procedure.

So we offer all of these at Benenden. Not every funding route applies to every treatment, I'm afraid, so it is slightly complicated, and not all treatments are available to NHS patients, and not all treatments are available to Benenden Health patients.

So I'm going to talk very briefly about iTind, which is a new minimally invasive treatment.

And I think these minimally invasive treatments are probably best thought of as an alternative to ongoing drug treatments, because they don't have the same impact as more invasive treatments or bigger operations, but they don't have the side effects of tablets.

So, iTind is essentially a small metal cage or metal wire device that's placed into the prostate.

And over it's placed in a collapsed state, and then it expands once it's in position, and then over the course of 5 to 7 days, it slowly expands by that pressure expansion causes the prostate to enlarge and allows you to pass urine better.

There's no heat or direct cutting or burning, so it has very few side effects. But clearly, during that five to seven days, there is a metal implant inside the prostate, and that can be uncomfortable, and some men do find that uncomfortable.

So the way this is done is that the iTind is inserted into the prostate through the urethra in a collapsed position. Then that's released, and it slowly enlarges over five to seven days, causing what we call remodelling of the prostate.

After seven days or so, that device is removed, with another small procedure, which causes that device to collapse down and be pulled out through the urethra.

So, it's a fairly new treatment, but it has been around for a little while, and it has shown good, good benefits. It can be done as a day case. As I say, there are no cuts or stitches and no catheter is usually placed.

And it does cause good improvement in symptoms, but it can be a little bit uncomfortable for those five to seven days while the device is in place.

TURP is a more invasive or ablative treatment where we, under general anaesthetic or a spinal anaesthetic, we put an instrument down the urethra and use what's called a loop or electric wire current, to cut through the prostate and slowly cool that out and remove tissue. Now, this has been around for a long time. Excuse me, it's a very effective operation. It's been done for at least 40 or 50 years now.

Excuse me, we use some modern variations on the TURP procedure. So, in fact, at Benenden, we do something called CHRIS, which is a slightly more modern procedure with slightly fewer side effects.

But it is, in essence, a similar procedure with an instrument going down, coring out the prostate, and afterwards, you would have a catheter in, usually for a couple of nights, and often you would be in hospital for a couple of nights.

So it's very effective, but it does have high rates of causing ejaculation problems. A small number of men can get erection problems with it, and there can be other longer-term complications, such as scarring on the inside, where the operation's being done. But as I say, it's a very effective and proven treatment that we know is durable and works very well.

So this is just another slide to sort of, again, indicate what I've been talking about, that we can look down through the camera and see on a screen, and then at the tip of this telescope, there is a loop that cuts through the prostate using an electrical current to core out the prostate material.

So, in hospital for 24 to 48 hours with the catheter in, you will get some blood in the urine for a couple of weeks after this procedure.

And definitely some stinging and burning when the catheter first comes out and you start passing urine. But as I say, this is the most commonly done procedure nationally for prostate problems and remains very effective.

The UroLift® procedure is another minimally invasive procedure where we put these little implants in that look a bit like treasury tags, and they are fired through the prostate through a needle, and then they pull the prostate open. So again, this has been around now for quite a long time. It's safe and effective.

But, like the ITIND, it has a slightly less significant impact on symptoms than the other procedures but it is a day case.

We don't actually do it under local anaesthetic very often, because patients have found that a bit uncomfortable, so we generally use a short general anaesthetic. And I think we've got a little video here that just shows how this works. So, essentially, this is a

schematic representation of the prostate, and this is a camera going in, and this is fire, and we're going to fire the UroLift® device out through the prostate, so the prostate is compressed or pushed to one side.

Then the device fires the implant out, which anchors on the outer side of the prostate, and then the inner plate is deployed, and usually about four of these are placed through the prostate to pull the prostate apart and improve the urinary flow.

This does give a good improvement in symptoms, but it doesn't, like the ITINs, give long-term improvements, and further treatments may be required.

The benefit of these two minimally invasive treatments is they have very few side effects and very little effect on sexual function.

So that's just going to show you a before and after picture, indicating how the flow is improved with this treatment.

So, I'm going to move on now to talk about Aquablation®, and this is a relatively new, robotically controlled treatment that uses high-pressure water jets to remove excess prostate tissue and open up the prostatic urethra and channel. It is done under a general anaesthetic.

But because there's no heat, or other heat-inducing energy source uses. It has perhaps fewer side effects than other treatments, and it's the only treatment that uses real-time ultrasound imaging of the prostate to help plan the treatment and allow us to know exactly how much prostate tissue to remove.

Because of this, it does have less of an effect on sexual function, particularly ejaculation, and extremely low rates of incontinence or other serious side effects. So we're able to precisely target and remove the enlarged prostate tissue.

It is a robotic and computer control procedure, and it uses an integrated camera with also an ultrasound probe.

Inserted into the rectum to allow imaging of the prostate.

It takes about an hour, and it's usually done with a one-night stay in hospital.

This is going to show a little schematic video as well, just to indicate what happens during the treatment. So, in this picture, in the main picture, what you can see is the prostate here in the lighter colour, and this is the enlarged prostate zone.

The bladder is here. This is the robotic arm placed through the urethra into the prostate, and you can see the prostate bulging into the bladder here.

This area here is what we call the bladder neck, or the edge of the bladder. In the insert picture here, what you'll be able to see is this is the ultrasound image that we see and use when we're doing the procedure in real time.

So, using the ultrasound, we've mapped out on the image, this green dotted line shows the tissue we want to remove, and then the computer guides the robot-controlled arm to remove just this amount of tissue and nothing more, which helps preserve other structures and reduces the impact on sexual function and reduces the side effects. So if we run this, you'll see a high-pressure water jet coming out of the tip of the robotic arm ablating the tissue, and you'll see that it goes from side to side to remove this tissue.

So let's just run that. So, in the bottom screen, you can see the prostate being ablated in real time.

And in the bigger picture now, you can see how the high-pressure water jet goes from side to side, ablating the tissue, and by controlling the power of that water jet, we can control how very precisely, actually, how deep it goes.

And what you can see in the insert is, whilst we're ablating the tissue with high-pressure water, we're also sucking water out so the bladder doesn't fill up.

So this is contoured to the shape that we want to remove, and now as we get to what we call the apex of the prostate, the water jet will just be on one side, and in a minute it will go to the other side and do the other side. And by doing that, we're sparing the middle area, which is primarily involved in the ejaculation process, so it's very good at preserving sexual function.

Okay, so Aquablation® is, as I say, a very new treatment with perhaps a little bit more precision and image control, and it is a robotic procedure.

Slightly reduced recovery time and post-procedure discomfort; no cuts required; and because we're able to map out the prostate and use this robotic system, it's a little bit more precise, reducing the risk of damage.

And finally, this evening, I think I'm going to talk a little bit about laser treatment for prostate enlargement. So, ThuLEP, there is another type of laser treatment called HoLEP, and the ThuLEP, or HoLEP, just refers to the type of laser used, and essentially they're very, very similar.

ThuLEP uses a thulium laser. HoLEP uses a holmium laser. They do the same thing. They're very good for very large prostates, because they cause slightly less bleeding than other treatments. They are required and are carried out usually under a general anaesthetic, and we put a telescope, again, a bit like the TURP, through the urethra, and the surgeon uses the laser to cut through the prostate tissue and core out the prostate tissue.

Hole, and then that's placed into the bladder, and then a separate machine is used to chop that tissue up into small pieces so that it can be removed through the telescope again.

So, for people who have particular problems, like a very large prostate, or what we call chronic retention of urine, where people can't empty their bladder very well, this is a very good treatment.

And, also for perhaps people who can't stop taking tablets that thin the blood, like antiplatelet medicines that some people are on for heart problems because there's a lower risk of bleeding, this is a good option.

So, if you've not been to Benenden Hospital, I can certainly, you know, recommend it. It's a really nice place, very, very clean, very modern, with excellent levels of care; it's very, sort of, personalised, all the staff are very committed to providing you with an excellent experience if you come there, and the waiting times are very short, and the level of experience is very high.

And you have experienced consultants delivering all the treatments themselves.

So, that is where I'm going to come to an end. I'm going to leave this slide up for a minute because it talks a little bit about options and offers, and I think Vicky will come in there and just explain a little bit more about this, but please do get in touch if you've got questions, and we'd love to see you at Benenden and help you with your symptoms. Thank you.

Vicky

Lovely, thank you, Mr Garnett. So I'm just going to move on to our Q&A session now. We're delighted to have so many of you join us this evening, and hopefully we'll try and answer as many questions as possible. If we don't answer it, we will be in touch afterwards if you leave your name.

Okay, so we're going to start with Paul, and Paul says, Is it true that travel sickness tablets are not allowed if you have an enlarged prostate?

Mr Steve Garnett

So there are various tablets which can have slight side effects of affecting how well you pass urine. So, you get warnings on quite a few tablets, because they can affect the way the bladder contracts.

If you have an enlarged prostate, that doesn't necessarily mean you've got any symptoms, and it certainly doesn't mean you've necessarily got any trouble emptying your bladder.

So, it's a bit of a blanket statement, and I wouldn't say that just because you've got an enlarged prostate, you can't take those tablets, but if you are known to have a poor flow or trouble emptying your bladder, or you find it difficult to pee, then I would avoid them.

Vicky

Okay, lovely, thank you. That's useful, Paul. Next question from Jeff. Jeff's got a couple of questions. Is there an upper age limit for any of the procedures, or does it depend on someone's general health?

Mr Steve Garnett

Yeah, there's no age limit; it just depends on how well you are and how fit you are to go through anaesthesia if you're having a surgical treatment, but there's certainly no age limit.

Great. And Jeff's other question is, how soon after Aquablation® can I start physical exercise and running again?

Yeah, so we generally advise avoiding strenuous physical exercise for two weeks.

And then you can go back to things, gently. You probably want to build up to things. The main issue, the main concern, is lifting weights, and I don't just mean going to the gym, but I mean you know, around the garden, anything like that.

We really want you to avoid that for three or four weeks, just because there's a risk of causing a bit of bleeding from the prostate. So, a couple of weeks after the treatment, you should be getting back to most activities, but avoiding heavy lifting for another week or so. Running, you could probably do about three weeks after treatment.

Vicky

Right, lovely. Hope that was helpful for you, Geoff.

The next question is from Gary, and Gary says, is there any treatment not recommended for those with severe flow restriction due to both prostate enlargement and a restricted bladder neck opening and thus needing a catheter?

Mr Steve Garnett

Yeah, if you're in that situation, you really need an ablative treatment, so forget about Urolift and ITIND, and there's another minimally invasive treatment called Resume.

You need one of either, I would say, a laser, a TURP, or Aquablation®. They would give you the best chance of being catheter-free, and they would all treat the bladder neck as well as the prostate.

Vicky

Okay, lovely, thank you.

The next question is from Bruce, and Bruce says, Would I still need to take Tamsulosin after these procedures?

Mr Steve Garnett

No, the idea of having these treatments is that they are, you know, they stop you needing to take the tablets. So, definitely, after the more ablative treatments, which are the bottom three on the screen, you would not need to take tablets.

Vicky

I hope that was helpful. And on a similar topic from Nicholas, Nicholas asks, I went on Finasteride last year for 6 months.

I stopped using it in March because of depression and erectile dysfunction and restarted in May and have been on it since then. His question is, how long should he continue using finasteride 5mg?

Mr Steve Garnett

Well, you've just, thank you, nicely illustrated some of the side effects of that medication, which is why I was quite careful to say that you need to discuss it with your doctor before starting and be aware that there can be side effects.

The longer you use finasteride, the more effective it is. It tends to reduce prostate volume by about 20% per year, but some people do get side effects, and those are mainly erectile dysfunction, breast enlargement, and depressive-type symptoms, which are rarer but can affect some men.

You know whether it's helping you.

Vicky

The medication seems to be doing the trick, but should I investigate any of the recent treatments available? I've also stopped drinking alcohol and reduced caffeine intake since having a catheter.

Mr Steve Garnett

I mean, I don't, you know, these questions are always slightly difficult without knowing full details, but I think you've got a very large prostate there at 150cc's, or 150 mils.

A normal prostate is about 30 cc, so it's significantly enlarged. You'd certainly be suitable for a laser procedure or an Aquablation® procedure.

If your symptoms were bothersome and now you would need further tests, what we don't know, really, is it sounds like you've managed well on the Tamsulosin, but are you emptying your bladder? Are you leaving a significant amount behind, which would mean you're at risk of further episodes of retention.

The tamsulosin tablet can help with symptoms, but it doesn't really reduce the risk of you ending up not being able to pass urine again. So that might be a consideration.

So you know, you potentially might benefit from treatment, and one thing a lot of people sort of worry about is

Perhaps getting treatment before things get too bad, or perhaps getting treatment before they do, older and less fit to have treatment. So, those are all issues you need to think about. Tamsulosin also can have side effects. If you're not getting them, that's great, but a lot of men can get slightly low blood pressure, and a lot of men can feel a bit tired on tamsulosin, and it can also have sexual side effects as well.

So, you know, it's difficult to advise you further than that, but again, it's a balance.

Vicky

Okay, lovely, thank you.

The next question's from Andy. If there is time, which there is, could you please explain how retrograde ejaculation results from some medication?

Mr Steve Garnett

So retrograde ejaculation is associated with Tamsulosin and a lot of the other surgical treatments, and it's, with the tablets, we think it's more to do with affecting the way the bladder neck contracts during ejaculation that then stops the ejaculation from going backwards into the bladder.

So that's what happens normally, the bladder neck contracts, but with the tablets, it seems to affect that.

It's not everyone who gets that; it's about one in 10 men on Tamsulosin, and then the bladder neck doesn't contract because the Tamsulosin prevents that.

With the surgical treatments, it seems to be a combination of damage to the bladder neck but also more damage to the ejaculatory ducts, which run through the prostate and come out near what we call the apex, the sort of weigh out a bit of the prostate.

So, there's a combination of things there, and it's probably not fully understood, because it's quite a sort of complex thing, and for a long time, people thought it was entirely down to bladder neck issues, but it doesn't seem to be, actually. So, it probably has something to do with the ejaculatory ducts as well, where they come out.

Is an area called the verumontanum on the prostate, and that can be damaged in a lot of these surgical treatments.

Vicky

Okay, thank you very much.

The next question is, I suffered a UTI recently. Would this have been caused by my large prostate, and if so, could I expect UTIs to become a more regular occurrence?

Mr Steve Garnett

Well, a urinary tract infection can have many causes, but in men, prostate enlargement is a common cause because often men don't empty their bladder properly, so then they have chronic stagnant urine left behind, which predisposes to urine infection.

So not for everyone, but for a number of men, it can be a cause, and for some men, that can become a recurrent problem. So, you know, again, difficult to predict the future, particularly without further information, but certainly for some men, that does become a recurrent problem.

Vicky

Okay, thank you.

Are any foods particularly beneficial or harmful to prostate health?

Mr Steve Garnett

Yeah, I mean, dietary advice is a difficult one, because there isn't that much evidence. There are a few things that seem to be helpful, so there's a group of, I guess, uncertainty, but there is some evidence that pumpkin seeds may help with bladder health and bladder symptoms, but then getting into the realm of, kind of, anecdote rather than serious evidence for a lot of these things.

Vicky

Okay, thank you. Does cycling have a negative effect on your prostate?

Mr Steve Garnett

Well, if it's cycling, it's using, you know, a fair bit of hard work.

saddle and cycling long distances, that does cause a lot of pressure on the perineum and pressure directly onto the prostate.

I wouldn't say it does have a direct impact in causing prostate enlargement, but it can cause discomfort and nerve-related symptoms in that area, but it shouldn't specifically cause urinary symptoms, I would say.

Vicky

Okay, hope that's helpful.

Our next question is from Paul, and Paul says, Do the benefits of ITIND decay over time, or is it a permanent treatment?

Mr Steve Garnett

No, it's not a permanent treatment, so ITIND and Urolift are what we call minimally invasive treatments.

And the benefit is for a limited period of time, so after a few years, it seems to wear off, and you would need further treatment, so

You know, that's probably 3 to 4 years, approximately, of benefit, and for some men, slightly less and for some men, slightly more.

Vicky

Okay, lovely, thank you. And on a similar theme here, Colin's asking, Where's the evidence for how long each of these treatments lasts before the symptoms return?

Mr Steve Garnett

Yeah, so as I've just said, the Urolift and the ITIN are not destroying or removing prostate tissue, and they have a limited duration of effect, probably 3 to 4 years on average. The TURP, Aquablation, and laser treatments are all removing varying amounts of tissue.

We know that about 80% of men have not needed any further treatment at 10 years after initial treatment.

Vicky

Okay, lovely, thank you.

The next question is from Fred, and Fred's asking, how do you assess the size of an enlarged prostate?

Mr Steve Garnett

So that can be a combination of various scans, maybe involving an ultrasound scan, maybe involving a cystoscopy, which is a look inside the bladder and prostate, and maybe involving, in some cases, an MRI scan, but the most commonly done assessment of prostate size, would be an ultrasound.

Vicky

Okay, thank you.

The next question is for Michael around when can you drive again after any of these treatments?

Mr Steve Garnett

So after the operative treatments, certainly Aquablation, we'd say after one week you can drive.

Sometimes we recommend leaving it for two weeks, but it's one to two weeks for the ablative treatments. For the smaller treatments, it's 24 hours.

Vicky

Okay, thank you; that was helpful.

The next question is from Paul. Paul had a TURP op in 2012, and his concern is the risk associated with not clearing all the urine.

He can't take finasteride or tamsulosin since both or either cause severe depression.

His prostate is very large, but he's been coping. What happens if he delays treatment with a very large prostate?

Mr Steve Garnett

Well, again, I think you need a bit more assessment on your flow and how much you're leaving behind. But, you know, if you had your initial operation 14 years ago.

So, you know, it's not surprising that over time the prostate has grown back. Doesn't happen in everyone, but if you had a large prostate, a very large prostate to start with, then you're clearly someone who tends to grow their prostate quite, quite quickly, and it's grown back.

The risk of leaving treatment, if you're already getting significant symptoms, is that if you're already not emptying your bladder, then the longer you leave it, the more damage you can do to your bladder, and you can get to the point where you're not passing urine very well at all and leaving a lot of urine behind.

And then, you can get into a situation where you have a treatment on your prostate, such as an operation, and even after that, you still can't empty your bladder very well because the bladder doesn't work.

It's not the prostate anymore; the bladder's been damaged by that long period of slowly getting worse and worse, so that would be the concern, so it depends a lot on how much you're leaving behind; that would be the sort of key factor there.

Vicky

Okay, thank you. I've got a couple of questions here about the effectiveness of finasteride and tamsulosin. Roughly how long do they stay effective for?

Mr Steve Garnett

So, yeah, I mean, unfortunately with these things, it is quite a personal response to treatment, so it's quite different and difficult to generalise.

Vicky

Okay, another question on that theme, how often should you get your medication checked?

Mr Steve Garnett

Well, I think if you're not getting side effects and it's working well, then you can probably leave things alone and carry on.

But if you find that the medication is no longer effective or your symptoms are getting worse, then I think you should get reassessed. So, it depends on the response to treatment and how you're getting on with it and whether you've got side effects.

Vicky

Okay, thank you.

Next question is from Roy. Roy had a Rezūm procedure 3 years ago and the next is now suffering the usual prostate symptoms, flow, retention, and urgency. He's now on Tamsulosin. Could he have a UroLift®, or should he have something more permanent?

Mr Steve Garnett

I mean, honestly, I would suggest you have something more permanent. I mean, this is a classic thing we see after a resume that

Somewhere in the region of three to four years later, the symptoms recur.

And, you know, you're back needing further treatment.

And you know, you would need, obviously, a bit of assessment to see what your flow is like and how well you're emptying your bladder and discuss with you what your absolute priorities are. You would potentially be suitable for these other treatments, like UroLift® and iTind, but if you've had one minimally invasive treatment and it's not lasted that long.

You may be better off looking at a slightly more effective treatment.

Vicky

Okay, thank you. I've got time for a couple more questions, so we're just trying to group some of these together. Paul asks, How do we know if the bladder has emptied completely?

Mr Steve Garnett

Well, it's very difficult for you as a patient to know that, but that's why when you come and do a flow test with us, we do a scan of your bladder afterwards to see how much you're leaving behind.

Vicky

Okay, and if pressure on the bladder is causing you back pain, can that be relieved by having treatment?

Mr Steve Garnett

I'd be very cautious about saying that pressure on the bladder's causing back pain, because there may be, obviously, many, many, many causes of back pain, and it's rare for prostate enlargement to cause back pain. But if your bladder were not emptying well.

And if that was causing back pain, then having surgical treatment should relieve that pain.

Vicky

Okay, thank you.

Next question. Sometimes ejaculation is less than normal, or rarely nothing at all. How is this best fixed, please?

Mr Steve Garnett

Very difficult to treat, I'm afraid.

Vicky

Thank you.

Next question: My PSA is going up. What can I do to control it or slow it down?

That's a really difficult question to answer, like, in this situation, I'm afraid. I don't know why your PSA is going up. Obviously, the concern with a rising PSA, if it's going up fairly quickly, would be prostate cancer, so I think you need to find out why your PSA is going up. I can't really answer that right now.

Vicky

Okay, thank you. And the last question, with a large prostate, are the benefits for the last two procedures on the listed ops, Aquablation® and the ThuLEP, similar, or are there differences?

Mr Steve Garnett

No, I would say that the benefits are similar. Probably depends a little bit on prostate size, and if you have a very large prostate, certainly, you know, if your prostate's 180 ml or more, I would

steady towards a laser procedure. If it's not that large, then I think they both offer very good, similar improvements in symptoms.

Vicky

Okay, lovely.

I think that's just about all we've got time for in terms of questions. If we haven't covered your question, and you provided your name, we'll follow up with you via email.

Would you mind moving to the final slide, Mr Garnett, please?

That's great, thank you.

So thanks again for all of your questions, and this evening we're really pleased to offer 50% off the value of your initial consultation, and that's if you book during August, but you can book a consultation any time up to the end of October.

Callback from your dedicated private patient advisor, an email with a recording of this session, as well as treatment information and loyalty reward points if you're a member of our scheme, and updates on future events and health news as well.

We'd really appreciate it if you'd take a moment to complete the short survey that'll appear at the end of this session, as it helps us to improve and tailor future webinars to your needs.

If you'd like to speak to somebody to book your consultation, our private patient team's available until 8pm this evening and from 8am to 6pm Monday to Friday, and you'll find the contact number on your screen.

We've got some more webinars coming up on a range of topics, including hip and knee replacement surgery, Arthrosamid® injections, plastic and cosmetic surgery, and shoulder pain, and you can sign up for these on our website.

So, finally, a thank you from all of us here at Benenden Hospital and from Mr Garnett for joining us. We hope to hear from you very soon. Goodbye.

Mr Steve Garnett

Goodbye.

Damien

Right, once again, well, good evening and a warm welcome to you, on our webinar on large prostate treatment. Now, my name's Damien, and I'm hosting this session. I'm delighted to be joined by our expert speakers, Mr Karl Spiteri, Consultant Urologist and Lucy O'Donoghue, Market Development Manager at Olympus.

Now, tonight's session will begin with a presentation from Mr Spiteri and Lucy, followed by a few questions at the end. Now, if you have any questions, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously, or include your name. Just a note, though, that the session is being recorded, so if any names shared may be visible in the recording. To help us get through as many as possible, please keep your questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session. And let me hand you over to Mr Spiteri.

Mr Karl Spiteri

Hello, good evening. So first of all, thanks for joining us. I'm glad I was invited to give this presentation.

It's a presentation which will be focused on the symptoms and the management of enlarged prostate, which is a very common problem, but it's gonna have a heavy focus on an innovative procedure, which we have recently introduced here at Benenden Hospital, which is called the iTind procedure.

I won't talk about it much just as yet, because I'd like to go through a more generic presentation about prostate enlargement first, and then zoning onto the heightened procedure later on.

So, just very briefly about myself. I'm Karl Spiteri, I'm a consultant urologist, did all my training in both general surgery and urology in Malta. I then moved into the UK around seven years ago to train in robotics, robotic kidney surgery, which is my main specialty.

But of course, I also do lots of core urology. Which I practice both in the NHS and as well here at Benenden Hospital.

So, why are we doing this talk on prostate enlargement? Well, urinary symptoms are very common in men, and most of us might associate this with symptoms of getting old, but it is not always the case. It can be pretty common even in younger males.

And in fact, we are very known to suffer silently. Men typically leave it until it's very late before they seek help. But the truth is that effective treatment exists.

And as time goes by, we are seeing more and more modern procedures which are less invasive than ever.

This is just a bit of an overview of the webinar, so we're going to talk about the prostate itself, the enlargement of the prostate, what symptoms to look out for, when you should seek help.

And the various treatment options available, and as I said, we'll then hone in onto the iTind procedure.

Right, so, very briefly, prostate. It's a small gland which is located just beneath the bladder. We like to describe it as the size of a walnut.

And it forms part of the reproductive system, but as you can see on the diagram, the urethra, which is the water pipe, passes or pierces straight through that prostate gland, which is why it tends to be so related to the two urinary symptoms that men can experience.

Its function is mainly related to the production of seminal fluid and as you can appreciate on this screen already, how an enlargement of the prostate can constrict on that urinary tube, which passes right through it.

So, what is benign prostate enlargement? It's first of all, it's a benign condition. This is a non-cancerous growth, and I highlight this because Of course, I meet many patients who have lower urinary tract symptoms whose main concern is that there might be prostate cancer.

Now, actually, the very vast majority of lower urinary tract symptoms have nothing to do with cancer, they are to do with benign prostate enlargement.

it can be called various things, benign prosthetic hyperplasia, benign prosthetic enlargement, BPH, it's all the same thing, essentially.

And it's very common. It affects around 50% of men who are between 50 and 60. Having said that.

It's usually about 30% of men in this age group that actually have bothersome symptoms from it. So one can have an enlarged prostate, which gives no symptoms at all, which is fine.

It gets increasingly prevalent as we grow older, and in fact, it's estimated that about 90% of men older than 80 have benign prostatic enlargement.

Again, this is another visual representation to sort of depict How this benign growth of the prostate can cause a constriction of the urine that would need to pass through this tightened pipe over there.

But there's also what I call a dynamic component, so it's not if I go back to the previous slide, this is you can see the growth causing an anatomical obstruction. The growth is compressing, but there is also a dynamic component to these symptoms.

which relates to the to the musculature in the prostate and at the base of the bladder. So, if someone has a high tone of this masculature, it does cause a constriction around the bladder and neck, and what these little blue dots are representing are the intensity of receptors.

which will cause constriction of the smooth musculature in that area. And as you can appreciate in this image, there's quite a high density of them at the base of the bladder, which we call the bladder neck, which is where the bladder joins the prostate.

I wanted to highlight this slide, because when we later on talk about the iTind procedure.

This is an area which is particularly targeted by the iTind procedure, and we do see quite a fair few of men who have symptoms.

Whose problem is not so much the actual enlargement of the prostate, but more this tight bladder neck.

So why is it a problem? It's I already said this is a benign condition, so why is it a problem? It starts off as a bother, and it tends to remain a bother for quite a long time, but slowly but surely, it can lead to more sinister or difficult problems, such as chronic retention of urine.

And a more end-stage result is having obstructive kidney failure when if one had to reach a stage where the bladder is just constantly in retention and causing back pressure onto the kidneys.

But there's also an important aspect, which is bladder dysfunction. So, imagine This bladder, which is constantly having to generate a high pressure to squeeze urine out through that enlarged prostate.

Over time, this bladder is going to become increasingly dysfunctional, so causing lots of frequency and urgency and kind of contracting on its own accord. And this is something that is not easy to reverse.

So, we have changed our notion nowadays, where we don't really like to allow things to be too far gone. There is a sweet spot where one needs to have an intervention so that one can prevent having these more reversible bladder problems.

What are the symptoms that one would get? So, the earlier symptoms tend to be a reduced or a poor flow.

a difficulty in starting the piece, having, like, kind of having to wait a whole minute before the P actually starts.

And, getting more and more have a need to strain, to squeeze that urine out.

As time goes by, then, there tends to be more of these what we used to call the irritative symptoms, so waking up to pee at night all the time, lots of frequency of urination, and having a really urgent need to pee. Once the signal comes, you just have to go.

And also difficulty to fully empty the bladder.

And how might this affect one's life? Of course, it can result in lots of disrupted sleep, poor rest.

What we see a lot is people planning their life around toilet availability. Of course, anxiety when traveling. And it can even have an impact on work and relationships.

So, when should one seek help? I think one of the more important things is the first dot there, if the symptoms are bothering you, because effective treatment exists.

As I said, these are benign conditions, so if the symptoms are particularly mild, and they're not bothering you, yes, they can be left alone, and perhaps with some lifestyle modification, you can avoid medication and even avoid surgery altogether.

But especially if there are progressive symptoms, and even more so when the symptoms are progressive from those earlier-type symptoms that I mentioned, to the more irritative-type symptoms, the frequency, and the urgency.

I think that would be the time where you're willing to start thinking of seeing whether you need to have something done.

And again, the big notion here is to protect the bladder from having long-term damage.

From years and years and years of unmanaged symptoms.

Other reasons to seek help is if there's recurrent infections, which can be associated with an incomplete emptying bladder.

And also, visible blood in the urine. I mentioned it's not a direct symptom of benign prosthetic enlargement; it's just one of those symptoms that we never ignore. Visible blood in the urine, that's something that needs to be seen, too. So I always like to mention that.

And it's not too complex to diagnose and do a workup for prostate enlargements, and it can it's something that can be easily done as an outpatient, and it is something that we routinely offer here at Benenden.

So what would you expect if you are referred for these symptoms? First of all, we take a detailed history about the symptoms and how these are affecting you.

It's quite common that we do a digital rectal examination to get a bit of a gauge of the size of the prostate, but also it's a good screen for any overt prostate malignancy.

We quite routinely do a urine dip test, and a urine flow test, and also a bedside ultrasound to assess how well one is emptying the bladder.

We do not always do a PSA, and we do not always do a cystoscopy, but they are quite common investigations that we do as well, so you will be guided by us whether you need these or not.

And what are we looking for? The severity of symptoms? Are there any signs of back pressure on the kidneys?

We try to establish whether this is mostly a prostate or a bladder issue. We also want to understand whether there's any prostate cancer underlying, but importantly, we need to understand your wishes, priorities, and expectations.

Also, we then need to find out which treatments are the most likely to work for you. So, this is where we start looking at the specific anatomy in your particular case, and the particular physiology in your particular case, to counsel you about the procedure which is the best one for you.

I'll briefly go through this. So, there's, Various things that can be done, so lifestyle modifications, then, sort of.

We escalate to medications, and then it can be escalated to surgical intervention. And as we will see, there are the more classical radical interventions, and nowadays there's a couple of minimally invasive options.

And there's a various amount of factors that we use to guide you as to which one you should undertake, including the symptom profile, the anatomy of your particular prostate, but also your wishes and your priorities.

So medications are very well established. We used to consider these the first line. There's the alpha blockers, which relax the bladder, neck, and the musculature in the prostate. And there's also finasteride, which shrings the prostate. But of course, these would be long-term medications, and I meet quite a lot of men and understandably unkeen to be on long-term medication, or they have tried them, and they have too much side effects, or the other thing that can happen is they start to work initially, but then the symptoms progress and they're not working anymore.

The more radical surgery, I use the term radical loosely here, this is not some barbaric surgery, it's radical compared to the more modern, minimally invasive ones.

But since there's the transureter resection of the prostate, where we physically core out that obstructive internal prostate tissue.

There's the laser enucleation, which does the same thing, but in a different way, and it's designed for those particularly large prostates.

There's also the aquaablation, which is a more modern way of removing that obstructing tissue, using a high-powered water jet, and that is actually something that we also offer here at Benenden Hospital, so all these three procedures are available here.

They are very effective, because these are literally removing chunks of tissue from the prostate, and they have stood the test of time. They're durable, but of course, being more radical, they come at the expense of other potential effects of having removed all that tissue.

So there's quite a high rate of retrograde ejaculation, which means that when one has an orgasm, there's no seminal flu being ejected. Essentially, it goes back into the bladder. Completely harmless.

Quite a few men are not bothered by it, but other men are quite sensitive to the loss of ejaculates. So this is something that we do factor quite seriously now that we have other options.

I should mention at this stage that even though the more radical surgeries are associated with a high rate of retrograde ejaculation.

The Aquablation is one of the more disobstructing procedures that actually has a higher chance of preserving retrograde ejaculation, so I need to specify that with Aquablation, there's a higher chance of protecting that.

They are associated with an inpatient stay, and most of them need a temporary catheter, and of course, there is a higher risk of bleeding and a higher recovery time, because it's more radical surgery.

And this now leads me on to the minimally invasive procedures. I've listed these two, because these are two that are offered here at Benenden. There are others as well, but it will be a whole night of talking if I had to go through each and every procedure.

So the Urolift is also a procedure which has stood the test of time. It's the one it's the procedure, which is represented by the diagram that you are currently seeing, where it involves permanent implants, which essentially pull the prostate lobes apart to open up that channel.

And the other minimally invasive procedure, which will be the highlight of today's talk, is the iTind procedure.

Which I will start talking about now, and this is a slide I like a lot, because It depicts how iTind is kind of designed to hit a sweet spot between not being too invasive.

But, not doing anything at all. So, as you can see on the left-hand side of the screen, there's watchful waiting, which means when we decide that we are going to tolerate the symptoms as they are, and just bide our time.

escalating to medication, and eventually all the way up to the permanent implants and the more radical surgical options. And iTind is designed to be there right in the middle for people who do not want to be on medications, but either don't have Sort of severe enough symptoms for a more radical operation, or are not ready to have that more radical procedure.

So, what is the iTind procedure? It's quite an innovative way of of opening up the prostate, so it uses this Like a cage, made of, made of wires, and it is placed in the prostatic ureter as depicted in the image here.

It's deployed into the prostate, as a day-case procedure, and it then stays there for around a week.

And whilst it's there, those three lines of wire will start working their way into the prostatic tissue, and slowly but surely, they will reshape the prostate.

So that they it will it will afford it a much wider channel for the urine to passes.

After a week, the device is removed, and once the device is removed, there's quite rapid relief of symptoms, without requirement for any permanent implants.

And, as it's written there in the text, there's no cutting of tissue, no burning, no destruction, so it's a quite sleek way of opening up the prostate.

I put this image here just to see to show you how it looks after the device is removed. So you can see on the first image when it's first introduced, the second image is then showing how it works its way through the prostatic tissue to open it up, and then it's removed to leave that, open channel here.

I have a similar slide, which I'll I just want to highlight that What is quite different in this iTind procedure compared to the other is that it does quite a lot of work at the bladder neck, and you might remember I showed you that slide earlier on where quite a few men have an issue not so much with the prostate enlargement as itself, but with a tight bladder neck. And this is a procedure that can really directly target that tight bladder neck.

And replace the need for long-term medications that relax the bladder and neck.

This is showing the same thing, but in a cross-sectional view. So you can see on the image on the left.

The constricted urethra with tight bladder neck, and after a week of implant, those three wires will open those 3 channels into the prostate tissue to allow the urine to pass easier.

And this is more of a real-life image now, showing the end result of those incisions that the device would have done over the course of that week.

So, as an overview, the iTind device was innovated and designed to specifically give a rapid symptom relief.

With a rapid return to daily life, and preservation of sexual function. By sexual function, again, what I refer to here is the maintenance of the anti-grade ejaculation, so that one doesn't lose the ejaculate.

And also, of course, designed to support durable results and specifically designed to avoid the need of a catheter following the treatment.

Designed to avoid, or getting off prescriptions, for long-term medications.

It is designed to avoid general anesthesia. Having said that, the insertion tends to be done under general anesthetic.

We are looking at eventually getting the insertion done also under a local anesthetic, so that both the insertion and the removal are done under local anesthetic. And again, is designed to avoid sexual dysfunction and designed to avoid the need for permanent implants.

In medicine, we are quite fixated about having evidence about all we do, so I thought I'd present some evidence about this device to support its use, and why we've decided to start offering this procedure.

I'll start by presenting this, one of the earlier studies which was done so it was a what we call a prospective study, which is sort of gives a higher quality evidence.

And that showed that, over the course of 2 years, you can see this graph depicting the improvement in the flow rate. So, generally speaking, the flow rate doubled following the heightened procedure.

And, I mean, as urologists, we're all, we give lots of importance to the flow rates, but actually, from a patient perspective, perhaps what you would be more interested in is not necessarily the number, the flow, but actually how it's affecting you. So this is perhaps an even more important slide.

IPSS is the International Prostate Symptom Score, which essentially, it's a scoring system which covers a myriad of symptoms relating to the prostate. So this is what really will be affecting you on a day-to-day basis.

And, as you can see, the symptom score effectively halves following the insertion.

Of the device, and over the course of the two years when the study was performed, the results were sustained, which is quite important.

Again, similarly, this is a quality of life score. The higher it is, the more terrible it is, and as you can see, with the device, it went from an average of four to an average of two, and it was quite well sustained over those two years. So this was one of the earlier studies.

Of course, as time went by, we got more and more data so that we can get a better idea of its durability.

I've got this next, so this is just showing the volume which, as you can see, has also gone down. This is the amount of urine that remains in the bladder following a urination. You might note that it was not too high to start off with.

And the reason for that is people who have a very high urine residual are not ideal candidates for iTind in the first place. So that's why it was not too high to start off with, but as you can see, it went down following the iTind insertion.

So this is the slide I was referring to, which is now showing the trials, but, after four years, because, of course, we got very excited with those two-year data, but we wanted to see how long, how durable, these effects are going to be.

And, actually, the improvements were sustained at over 4 years, and actually, I don't have the slides here with me, but there's newer data showing that the benefits are sustained even up to six years. And as time goes by, we'll have more and more data to see how fair their durability is going to be.

The other reason I wanted to show this slide is that it is showing, side by side, different trials. So this is not just one trial, but there are here are three different trials, which were done independently, all of them prospective and all of them multicenter.

And they're pretty much showing similar results across the board, so improvement in the symptom score, and improvement in the flow rates, which were sustained.

So, what would you expect from an iTind procedure? Mentioned some of these, so it's inserted as a day case procedure. It's removed as a day case procedure a week later. No cuts involved, no stitches, quick return home.

I would need to highlight that during that week, it will be uncomfortable, yes, because there is going to be this device which is pressing internally on your prostate.

So, I would suggest that if one is having such a procedure, you would stay probably best to stay off work for that one week while the device is doing its job, but then once the device is removed, within a few days, literally, you're up and running again.

And as I said, there is no requirement for a cater in the very vast majority.

So the key benefits, it is minimally invasive, truly minimally invasive.

There's no permanent implants, rapid recovery, rapid symptom improvement.

Now we can say that they are also durable improvements.

Importantly, preserve sexual function.

And no need for a post-operative cater.

To be completely candid, the rate of categorization after items is around 5%, so that's pretty low.

Regarding safety and side effects, I've already alluded to the fact that once the device is doing its job, it's gonna be pretty uncomfortable, and you'd need to be at close proximity to the loo for that week.

So there will be short-term urinary symptoms whilst the device is doing its job.

But he has very low complication rates, very low cauterization rates, and understandably, the symptom improvement is going to be less dramatic compared to the more radical surgery. And this, I mean, this stands to logic, because of course.

The more radical procedures are physically removing whole chunks of tissue from the prostate, so you cannot compare a minimally invasive prostate procedure to the more radical ones. They're just two different they're achieving different things.

So, if one has very severe symptoms, or his bladder is already having dysfunction, lots of urinary retention then iTind is not the procedure for you. In that case, we'd be advising to have a more radical procedure.

Yeah, so who is suitable? People who have mild to moderate symptoms.

What we call smaller prostate, so what I mean to say here is that the prostate enlargement is a progressive thing, and someone who has, say, a, I don't know, 30 gram prostate, that's, for us urologists, is considered a small prostate compared to the huge ones that we tend to see. But it is still an enlarged prostate compared to when one is younger.

It's suitable for people who want or need a rapid recovery, a rapid return to their daily routines.

People who are seeking an alternative to long-term medication to manage their prostate symptoms.

Suitable for people who want to preserve their sexual function. Again, by this, I refer to preserving the ejaculatory mechanism.

People who prefer to avoid a catheter after the procedure, and people who have a good baseline bladder function. So this is not designed for people whose symptoms are already too far gone.

And in fact, it is unsuitable for prostates which are just too large.

Prostates which have a middle lobe, this is an anatomical detail, which we assess when we do a camera test of the prostate.

And it is not suitable for people who have established bladder dysfunction.

So why would one choose to come and see us here? We're a group of very experienced urology consultants, we work very well together, and we have access to the latest technology, including iTind, which I've now spoken much about, and also aqua ablation.

We value a lot giving personalized care, and especially when it comes to prostate, because as I mentioned earlier in this talk.

Quite a lot of it has to do with how the symptoms are affecting You in particular, how they're affecting your life.

And of course, there are shorter waiting times, over here at Benenden.

So, if I had to sort of choose, like, two key takeaway messages is that BPH is very common, but it is treatable, and the iTind offers a minimally invasive option, which works well, durable, but preserves your sexual function.

So yeah, sorry, I've been babbling for quite a long time. I think now is a good time to hand over to my colleague, Lucy, from Olympus, who's been has helped us out to introduce this new procedure here at Benenden.

Lucy O’Donoghue

 Yeah, so thank you, Mr Spiteri, and to Benenden Health for having me here this evening. I'd be pleased to share with you some real patient experiences of having the iTind procedure. I work for Olympus, which is the company that sells and supports the use of the iTind device here in the UK.

So firstly, I just wanted to acknowledge the patient's journey. Many will have been managing their symptoms for quite some time. We often hear about frequent trips to the bathroom, especially at night, disrupted sleep, and that constant feeling of urgency. And also, of course, the emotional side, the fatigue, frustration, and sometimes even embarrassment.

And that can really have an impact on people's daily routines, their social activities, and their overall quality of life. And in my role at Olympus, I've had the privilege of hearing some of these patient stories, which I would like to share with you this evening.

There are three of them. This is the first gentleman; his name is Chad. He's a 44-year-old man from Liverpool, and he generously shared his story with us, which was then featured, as you can see, in the Sun news outlet. Chad was diagnosed at just 28, so he had been suffering for a long time. He learned that his father had suffered from the same condition, and so he went to see his GP about it.

Chad said that, Over the years, I tried medication to improve flow, but it felt like sticking a plaster over a larger wound.

Helpful for a short time, but the less effective the longer I took it. He also had a surgical procedure called a bladder neck incision, which is where cuts are made in the bladder neck to relieve the obstruction. But again, it didn't provide him with lasting relief.

Sleep was his main issue, and he said it became an endless cycle. That level of exhaustion wasn't sustainable, especially with a high-focus job. I reached the end of my tether, and I knew I needed something that really addressed the problem.

So, Chad underwent the iTind procedure, in a hospital near Liverpool. He said, Before I could be discharged, this is after having the procedure, I had to empty my bladder. The flow shocked me in a good way. I hadn't experienced anything like that for years.

He also said that he understands why some men hesitate because of the intimate nature of the exam and the treatment, but he said he was treated with absolute dignity and professionalism throughout, and any initial embarrassment quickly gave way to feeling safe and cared for.

And he concluded by saying, if you're experiencing similar symptoms, don't put it down to pride, or assume it only happens to older people.

There's no shame in asking for help. Be in tune with your body, speak to your GP, and find out what options exist. You don't have to manage this alone.

The second gentleman is a GP. He's 58 years old, and he doesn't wish to be identified due to the nature of his work, so we'll call him John, and this isn't his real name, and this is not his image either.

John said that at night he was having an urgent desire to urinate on a very frequent basis, almost every half an hour to an hour. I would have to get up and go to the toilet, and I wouldn't necessarily pass much urine.

This was having an enormous impact on his life and work, because I'm a GP, and it was disrupting my clinics.

His symptoms really disrupted his life, sleep, and working hours. Working in the medical field, he said that he knew there was a problem from the beginning, but he continued to struggle with the symptoms for about 10 years.

He said, I was reluctant to take any medication. I have patients myself who react to lots of medications, or are hesitant to take anything, and I'm sort of like that.

But 8 years into his suffering from BPH, he did try medication, but he found that it didn't particularly help, so he decided he wanted to consider some surgical interventions. He discovered that he could be a good fit for the iTind procedure.

He said that the great advantage of the iTind procedure, compared to other options, was that it was a temporary device. The device would only need to stay in for about a week.

It's a really low invasive procedure. I also didn't want to stay in hospital overnight. I didn't want a catheter afterwards. Plus, there's a low risk of incontinence with the iTind. I just thought all of that sounded perfect.

John underwent the iTind procedure.

He said that as soon as I had the procedure, I noticed an improvement. My flow rate was much better. I was emptying my bladder within 30 seconds compared to the prolonged time before, and this has been maintained.

He said that he was completely fine after having the iTind removed. He remarked that he was advised not to ride his bike for the first week, but he could go for runs, and he was pleased to be back on his bike the following week.

When asked if he would give any advice, he said, by going to your GP, You will be able to find out much more, as well as the options available. I would also say, if you're thinking about having surgery for this condition, inquire about the iTind and see if there's something they think could be helpful in your case. I also encourage patients to seek help.

Partly because most people do not know or can't always tell the difference between BPH and prostate cancer and other conditions.

He goes on to say, I truly do not know if I would have gone forward with any sort of surgery. My other option was to have an incision on my bladder neck with a scalpel, and then come out of the hospital with a catheter. It's definitely worth trying the iTind, because if it doesn't work, then I'm sure there are options. But I do think this is a brilliant non-invasive option.

And finally, this is Mark. He's a 66-year-old from Hampshire, and he's a retired pharmaceutical marketing manager. He owns a camper van, and he likes to volunteer with Oxfam at summer festivals. He first noticed a problem with his prostate in his mid-50s. He used to wake every hour or two at night to pee.

He needed to be near a toilet at night with a clear walk from the toilet to his bed, which isn't ideal, as you can imagine, at a festival in a muddy field.

It also meant that nights away from home, staying with his parents, overnight with his friends, he had this extra layer of stress.

And it also impacted his relationship. He'd often wake his wife at night because he was restless.

Also, he felt it was embarrassing for her sometimes, as he often needed the loo, frequently when they were out and about.

He took Tamsulosin, which is a BPH medication, and it worked well in the beginning, but as the years went on, he began to struggle with dizziness, which was quite worrying for him.

So, he went to see his GP, who referred him to a urologist.

And he underwent the iTind procedure.

Mark said that it was uncomfortable for the week that the iTind was in. He said that he had to take painkillers and be near the loo constantly, but once removed, the discomfort disappeared within a day or so.

I was able to go on holiday two weeks later.

He was very satisfied, saying, I rarely have to go to the loo more than once a night now, and sometimes not even that. So I sleep better and I'm more rested. He concluded, I'm looking forward to not having to wade through a muddy field in the night to get to the toilets.

So, these issues can carry a lot of fear, and that can stop men from seeking help, but the condition's very common, not just in older men, but in those even in their 40s and early 50s. But it is treatable, and there are now less invasive options, such as iTind, which takes around 15 minutes, with no overnight stay.

So our message is to know your flow. If something doesn't feel right, when urinating, I encourage you to speak up to your friends, family, or doctor to get it checked. And if I tinned, If your doctor thinks that iTind could be suitable for you, as Mr Spiteri described, there are benefits in increasing your quality of life, providing quite rapid symptom improvement. It's quite a straightforward procedure, and has been shown to preserve sexual function.

The results have been shown to be durable, and it is routinely catheter-free.

So with that, I will hand you back to Damien. Thank you for your attention.

Damien

Lovely, thanks, Lucy. Really interested to hear those cases, and thank you, Mr Spiteri as well, for that for that initial presentation.

What we're going to do, we're going to move over to the questions, the Q&A session now. We're really pleased to see so many of you today, so we're going to answer as many as we can. If we don't get through all of them, if you've left your name, we will get back to you via email after the event.

So, actually, during your first presentation, Mr Spiteri, Keith was quite quick to ask a few questions here. First, he actually wanted to know what cystoscopy was.

And then, second to that, whether the iTind could resolve his urgency issues.

Mr Karl Spiteri

So, in fact, I should start by apologizing for not saying what a cystoscopy is. Yeah, cystoscopy is a it's a diagnostic procedure where we use a telescope that goes through the P-hole so that we assess The urinary retract from the inside, so we assess the urethra and the prostate and the bladder from the inside.

We do this quite commonly for people who have lower urinary tract symptoms from a large prostate that we think might need a surgical intervention. And the reason we do it is, as I said, there's Quite a big variety of options nowadays.

And we would seek to identify which intervention would be best suited for for you, for your symptoms, but also for your prostate. So, looking literally at the anatomy of your prostate to see which one is the most likely to be of benefit to you.

Regarding the second question, does iTind resolve the urgency issue? The answer is yes, but there's some key issues here, so regarding when it comes to the urgency of urination, this can happen as a result of an enlarged prostate and the subsequent effects it has on the bladder.

But it is not uncommon for people to have frequency and urgency, not because of a prostate issue, but because of a primary primarily bladder problem, where the bladder is hyperactive, overactive and in these latter circumstances the interventions to the prostate tend to not do so much for the frequency and the urgency. But if these are if frequency and urgency are as a result of the obstructive prostate, then yes.

The iTind, and similarly, the other procedures, not just the iTind, will improve the urgency.

What I always like to highlight is that when we have whatever procedure we do, not just the IT and even the others, we typically see that the flow is the flow rate and the ease of urination is the first thing to improve.

The frequency and the urgency tend to lag a bit behind, and in fact, it's not uncommon for the frequency and the urgency to become a bit worse before they become better, because this long-term obstructed bladder all of a sudden has its obstruction taken away, and you're left with this unopposed overactive bladder. And it takes a couple of weeks for the bladder to readjust to that.

Damien

Yeah, fantastic, thank you. So, we've got a few similar questions here. Maybe you could remind us as to how long we believe the iTind can last, but on top of that, whether the procedure could even be repeated.

Mr Karl Spiteri

Yes.

So, as the years roll by, we are getting more real-life data to show us that the item is indeed durable, and this is very important to us, because as I said earlier, we know we can't compare a minimally invasive procedure to a more radical one. The radical ones, we know, they can last for even decades, sometimes even two. But so far, we have data of up to six years, which is showing that the results are indeed durable.

Of course, there's no guarantees. A minority will need either repeat intervention or perhaps a more radical procedure down the line. And this is the reality with the minimally invasive procedures. They do improve symptoms, but the improvement is not as dramatic as the more radical procedures, and yes, it might be the case that later on down the line, you might need either a repeat intervention or potentially a more radical procedure. Can it be repeated? Depends. I mean, let's say the symptoms Start progressing again, and they're they become a bit too much.

We would need to redo the investigative process, including the cystoscopy, to see why the symptoms have recurred, and if it's something that if it is we find that the item can be repeated, yes, well and good, but if we find that actually the prostate has just continued to grow all over the place.

We might probably be telling you, listen, there's no point repeating the items. Now is the time for you to have a more radical procedure.

So that's something I stress quite a lot, that the iTind and the other minimal, not just the iTind, but even all the other minimally invasive procedures, they are not for everyone. It depends a lot on the symptom profile and the anatomy of the prostate as it is.

Damien

Lovely, thank you. We've got an anonymous question here. This gentleman's been prescribed, Tamsulosin 400mg released by capsule, but they seem to have no effect, and he's still urinating frequently. Should he stop taking them? He's been on those medications for a year now.

Mr Karl Spiteri

Well, this is actually a very common scenario that we encounter quite a lot.

My take on this, first of all, you should always seek, sort of, advice from someone who knows your case in much more detail. I can't give formal advice based on a one-liner. But, just to give you a general idea, my take on this situation is that If a medication is making absolutely no difference, then there's no point in taking it, especially if this is for a benign condition.

Where the aim is to improve the symptoms.

Having said that, it is not at all uncommon that people who feel that there's no benefit at all when they stop taking when they then stop the medication, they feel that actually things are even worse than they were. And this is normally because the prostate enlargement is a progressive thing, and The Tamsulosin, even though you might feel that it's not doing much, it might be slowing down that progression.

So, what I usually advise in these situations is that, I mean, if you've been on it for a year, and it has made no difference at all, you can try and come off them. It's a short-acting medication, so within a week, even less.

you will know whether there's a difference or not. And if you find that on stopping the medication, you know worse, then the answer is easy. Don't take them.

Whereas if you find that things have actually become even worse than they were, you probably ought to continue them, but you may or may not want to seek advice on Having other medications or surgical intervention, because the medications are not enough.

Damien

Yeah, absolutely. Perhaps maybe we'd be seeing that gentleman in the future, in the future. So William's asking William's also on, on a form of medication recommended by one of our colleagues here. He said that it's for a, if he's nocturnia worsened by the next step would be TERP.

Do you think it's likely that his benign prostate has gone beyond the option of less invasive things like the, like the iTind?

Mr Karl Spiteri

Yeah, it is possible. Again, I can't judge by by by so little information, obviously. But this is something I was trying to allude to earlier, that's iTind is not a magical solution for everyone. If the symptoms are too far gone, there's bladder dysfunction, there's lots of urinary retention, we ourselves would be telling you a minimally invasive option is not is not good for you. It's not just going to work. And in that case, you would need a more radical procedure, such as TURP. And I know, I mean, I've been praising iTind, but I will be very honest in saying that all the other options they're also very good. These are all very good options. The UTRP, the Urolift, there's plenty of options. It's just finding the one which is the best for your particular situation.

Damien

Lovely, thank you. We got another anonymous question here. Oh, and this is an interesting one. Can the iTind be performed after the UroLift, which was actually performed about 5 years ago for this gentleman?

Mr Karl Spiteri

Yes, it can. I mean, the iTind, there's a is a sorry, the Urolift is a permanent implant. But I don't see why the item shouldn't work if there was a previous Urolift.

Assuming that the anatomy is right for an item.

Lucy, can I ask you to intervene on this one? Am I correct in stating this here?

Lucy O’Donoghue

 Yeah, so, the company I work for, Olympus, has not run a clinical trial using patients who've had Urolifts and who've had a, you know, not enough of an improvement in symptoms and who want something else to then have an iTind to say that it works. So I suppose from my perspective, we can't advise that it will work, and then we would sort of pass it over to your clinical expertise.

Damien

If the gentleman's attending, there's, you know, symptoms are coming back, take advantage of the offer and come and see Mr Spiteri, I guess would be probably the best advice, do you think? And we can take us from there.

Mr Karl Spiteri

Yeah, yeah, yeah.

Damien

Okay, great.

Mr Karl Spiteri

It's a very niche situation. There's not going to be any trial specifically looking at that specific situation. So it would boil down to clinical judgment and having a look inside, and making a clinical decision.

Damien

Okay, great. Jeff's actually got a question here about aquablation, and this is whether he could actually drive himself home after the procedure.

Mr Karl Spiteri

I mean, not immediately, because it involves a general anaesthetic, and you shouldn't be driving yourself home immediately after a general anaesthetic.

So, typically, you would stay the one night after an Aquablation, and I would still generally recommend that someone drives you home the day after the operation, but technically, yes, you can, technically.

Damien

Okay, great. And actually, I hadn't noticed this second question from Jeff, and I think this is quite an important one across the different modalities, is there an age limit for any of the procedures, or is it just determined by general health?

Mr Karl Spiteri

Very good question, and I would very much view towards the latter, which is general health.

Of course, we do look at age. Age is an important factor, but there's what we call the age, and then there's the physiological age. So, we see people who are in their 80s and 90s who are super fit, fitter than myself, and their physiology is really great. Equally, we see people who are 50 years of age who have, unfortunately, terrible comorbidities, and they don't do well with surgical intervention. So, the general health, I would say, is even more important than the absolute age when determining whether one can withstand or do well with a surgical intervention.

Having said that, even the fittest of elderly people. The reserves, the physiological reserves, are not as good as they used to be when one is younger.

So this is still something we factor in, okay? Because, you might be as fit as a fidel, but following an intervention or a general anaesthetic. You one would struggle to recover compared to someone who's younger.

I would have to say that this is where the benefit of these minimally invasive procedures comes to the fore as well, because they are minimally invasive, the tissue trauma is less, they're short procedures.

So, there tends to be a quicker, better recovery for people who have more limited physiological reserves.

Damien

Lovely, thank you. We've got Keith asking again, a good question, Keith. So, for the 5% who do require catheterization, and this was related to the iTind, how long would that be required for? I don't know.

Mr Karl Spiteri

It is not permanent, luckily so essentially, in the unusual circumstances where this happens, we we can introduce a catheter through the device, so device would be their implant, and then we just put the catheter through it, and it's a temporary catheter.

Until the swelling and the inflammation settles down, and then we take the catheter out. So, it is not a permanent cater. I would say it would probably if that happens.

We'd leave it for the week whilst the implant is doing its job, and then we take it out at that stage. But it's no, it's not permanent.

Damien

Lovely, thank you. And an anonymous question here, do we get to choose which procedures we have?

Mr Karl Spiteri

To a significant extent, yes. So, what we do is we do that full assessment that I spoke about earlier, take the history, we do the cystoscopy, we do the flow rates.

And based on all those, we will then narrow down the options for you. Now, there will be occasions where we'll tell you, listen, there's this this is the procedure for you, this is the if you're going to have something, this is the one that you should do.

But it is quite common that we tell you, actually, based on your symptoms, your anatomy, you can have this procedure, or this procedure, or this procedure. This has these benefits, this has that benefit, and we then allow you to choose which one you'd like to proceed with.

Damien

Lovely, thank you. Mike's got a couple of questions here. So, firstly, he wanted to ask whether the iTind surgery was under a general anaesthetic, but secondly, he was inquiring about whether MRI is ever used in the part of the diagnostics.

Mr Karl Spiteri

Sorry, yeah, good question. So, regarding the general anaesthetic.

The insertion, yes, it's done under a short general anesthetic.

But we are very keen that we then we are looking at shifting that into a local anesthetic insertion. To be very candid, we're quite keen to get more, sort of get more fluent, because this was quite a new procedure. And once we get even more fluent with it, I would be very keen if we start doing the insertions under a local anesthetic as well.

But currently, the insertion is under a short general anesthetic.

The second question regarding the MRI, not routinely, no. So, we don't routinely do an MRI as part of the diagnostic workup.

We do recommend an MRI if we have some suspicions, or we want to rule out prostate malignancy. That's where the more the power of an MRI is, to look for prostate malignancy.

So let's say we do a digital rectal examination once you're in clinic, and we feel a bit of a nodule which you need to look into further, or the PSA is particularly high, then yes, we'd include an MRI as part of the diagnostic process, but it's mostly To to confirm or rule out cancer, rather than as part of the workup of the lower urinary tract symptoms.

And regarding the bladder scan, that is essentially a bedside ultrasound, where we measure the amount of volume of urine that remains in the bladder after having a pee, to see how efficiently the bladder is emptying.

Damien

Okay, lovely, thank you. John actually asks, why does the prostate return oh, sorry, why doesn't the prostate return to its original shape after the iTind removal?

Mr Karl Spiteri

So, in fact, the way the device was designed is so that it doesn't return to the original shape. So, those three Metal wires will be applying a constant pressure so that they slowly but surely cheese wire over the course of a week through the prostate tissue.

And because you're not just, you know, just slicing through deposit, that doesn't just reheal and close it back up. The fact that it keeps on cheese wiring over the course of the week, it essentially remodels the prostate, so it retains the shape that the items does.

Damien

Okay, great, thank you. You might have a better idea of off-the-cuff anatomy like this for David Smith's question here. Can iTind be suitable for a prostate five times bigger than normal?

Mr Karl Spiteri

I would say no, unfortunately, because it again, it depends what you classify as normal. Yeah, well, yeah, but Let's say when we are very young, the prostate is about 20cc, so 5 times as larger, implying 100cc prostate, which is not suitable for an item, no.

Damien

Okay, lovely, thank you.

We got Mike here. How many patients were surveyed to give the results of the success of the treatment?

Mr Karl Spiteri

I think there was quite a few different studies there, I don't know. Yes, there's quite a few. I think the perhaps the more the one I spoke about the most, and the one which has those durable which show the durable results over, over the years.

The number of people which went through the entire follow-up, because people drop off, of course, during these studies, people unfortunately die of other things, or they just don't follow up. But I think it was 48 people, which were followed up up to 48 months.

Damien

Yeah, no, fantastic.

Oh, excuse me.

Yeah, Kevin's asking, have I sorry, I have been taking various medications again for 5 years now. If I had the iTind, could I stop taking these medications?

Mr Karl Spiteri

Yes, in fact, that is one of the reasons for the iTind. It's for people who are on medical management of the prostate, who and either the medicines are not working enough anymore, or they'd like to come off the medications.

So the answer is yes, assuming that the diagnostics show that iTind is the right procedure for you.

Again, depending on the symptoms and the prostate anatomy.

Damien

Fantastic, and I think we've got time just for one more, because This might actually relate to a new procedure here that has just been introduced as of a few days ago. And this gentleman is asking, can iTind be carried out on an 84cc enlarged prostate, and how does the operation compare to a HOLEP laser?

Mr Karl Spiteri

Yep. So, again, I would say that 84cc is a probably a bit too much for right, and it's unlikely to work with a native force, you see.

And, for that size of prostate, again, depending on other factors, but generally speaking, it's gonna be either a TURP or an Aquablation, or, in fact, the HOLEP procedure.

So, the whole procedure, essentially, I won't steal it under, because it's, as Damien said, this is a procedure that's sort of now newly being introduced here, but essentially it uses a laser to enucleate all that internal core of obstructing tissue. So this is designed, sort of, to maximize the amount of tissue removal to really get a really big wide channel.

So it's particularly suitable for the very large prostates, including 84 cc's, but, you know, HOLEP would be suitable even for prostates which are 150cc, 200 cc's, you know, these sort of big, big prostates.

8 to 4 cc's, hole up is a good operation, but equally could have a TORP or an Aquablation.

Damien

Good, good, good. No, it's good to hear that we've got such a large portfolio of procedures and offerings that could cover pretty much, or not, almost everyone.

All right, grand. Well, thank you, everyone. Thanks again for your questions and being part of this evening's session. If we haven't covered your question, if you've provided your name, we'll follow up with you via email. As a thank you for attending, we are pleased to offer 50% off the value of your consultation.

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Finally, thank you for, both our guests here, Lucy and Mr Spiteri, and good evening to you.

Thank you very much, and good evening.