Louise King

Good evening, everyone. Welcome to our webinar on enlarged prostate treatments. My name is Louise, and I'm your host this evening. I'm joined by a Consultant Urological Surgeon, Mr Steve Garnet. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so by using the Q&A icon, which is at the bottom of your screen. This can be done with or without your name. Please note that this session is being recorded. If you do provide your name and if you'd like to book your consultation, we'll provide contact details at the end of this session. I'll now hand it over to Mr Garnett, and you'll hear from me again shortly.

Mr Steve Garnett

Thanks Louise.

Good evening, everyone. Thanks for joining us to talk a little bit about enlarged prostates and the various treatments for that problem. I'm Steve Garnett, one of the urologists here at Benenden Hospital, and I've been treating prostates, both prostate cancer and benign prostate enlargement, for some time now. We've led a number of developments in the service both here and in the NHS, so what we're going to talk about tonight is a little bit about the causes of prostate enlargement, what symptoms it might cause, how we as urologists diagnose that, and what treatments there are in outline. In particular, we're going to be talking about the new Aquablation® treatment. a little bit about TURP, which is the sort of standard or most widely performed operation for prostate enlargement, and also a little bit about Urolift®, which is a smaller procedure that is suitable for some people as well. At the end, there'll be a chance to ask some questions, and at the end of the presentation, there's also a short video from someone who's recently been through Aquablation® treatment, just describing their experiences. So as I said I've been involved in working as a Consultant Urologist here at Benenden for about 15 years now and I work locally in the NHS in East Sussex as well so benign prostate enlargement also called BP we used to often call it and you may hear it referred to as BPH which is benign prostatic hyperplasia as well so it's a very common condition affects most men as we get older so from the age of 50 to 60 about half of men will have some degree of this and as we get older particularly sort of from over the age of 80 90% of men will have some degree of benign prostate enlargement so you know at least 3 million men are estimated to have symptoms associated with benign prostate enlargement in the UK so it is extremely common.

I think this is probably the most useful slide in the presentation which kind of tries to show you in in a pictural form what actually happens so you got the normal prostate there which it shows you the prostate is a gland usually referred to as the size of the of a walnut that's sits underneath the prostate underneath the bladder rather and as you pass urine you pass urine actually through the prostate when the prostate gets enlarged the way out of the bladder gets compressed and squeezed and the passage for the urine is much smaller so the you can see very easily there while the flow might get slower it might be difficult to pass urine and eventually you can get to the point where you can't pass urine at all so that that's really what happens when the prostate enlarges and squeezes the urethra and the way out of the bladder. We don't really know why people get benign prostate enlargements. We know that it's related to or linked to the male hormone testosterone, in that if people don't have the male hormone, they don't get prostate enlargement. But exactly why this causes the prostate to grow, we don't really understand fully.

So, what symptoms do men usually get when the prostate starts enlarging? As I said, it can squeeze or narrow down the urethra, the tube that takes the urine away from the bladder, and this might cause you to have difficulty starting to pee or maybe difficulty emptying your bladder, which can lead to needing to go more often. A reduced flow rate, in turn, can lead to getting up more at night as well, and sometimes that can lead to urine infections or possibly not being able to empty your bladder at all in more severe cases.

So for men who are worried about this and maybe have noticed some symptoms, in fact, to be honest with you, often in clinic, I see it's often patients wives or partners who've encouraged them to come for treatment because they're getting fed up with the symptoms as well, particularly if it involves getting up and going for a pee a lot in the night, which can lead to interrupted sleep for everyone, but in the first place, most people will see their GP. I know that sometimes it's difficult to get an appointment with the GP at the moment but that's usually the starting place and the doctor will usually do some tests in the community and may start you on some treatment such as a tablet however if you're referred on for further treatment you'll come to the hospital in the first place you'll have a consultation usually involved measuring your urinary flow rate which is something we do a lot of which gives us important information on whether there is a blockage and whether that's likely to be the cause of your problems because obviously there can be other things like blad problems which may also be causing the symptoms and then we will also need to assess what type of treatment is going to be best for you.

So with mild symptoms may not need any treatment at all depends on how much these things are bothering you in fact a lot of patients I see obviously are concerned as to whether there might be prostate cancer present and if they're reassured about that then they may not actually need any treatment for symptoms but if the symptoms are more severe usually in the first place people are started on tablets and medicines sometimes these can be very useful sometimes people can get side effects or don't like them and if the symptoms are more severe or haven't responded to surgery then we to tablets sorry then we would be looking at surgery and there are different forms of surgery but the key ones we offer here would be Aquablation® which is the newer robotic treatment transurethral rection of prostate which is also known as TURP® and the Urolift® procedure another procedure that some people have is also called holap a laser procedure so let's talk a little bit about Aquablation® to start with because this is a new treatment that a lot of people are interested in it's something we've been offering here at Bon for a little while now it involves using a surgical surgically controlled robotic procedure that uses high pressure high velocity water jets to aquablate or remove excess prostate tissue and by doing that we open up the way out of the bladder and take the pressure off the urethra and improve the urine flow so this is a procedure done under general anaesthesia because we need the patient not to move at all so it's very important that they're still during the procedure because we use an ultrasound to give us real time Imaging and mapping the prostate, and once we've made that mapping the prostate, and once we've made that map the prostate, we use that to plan the treatment, and once we've made that plan, we really don't want the patient to move, so once we've made a plan, then the robot will use the high press water to oblate the prostate according to the plan that we've made. Obviously, the Surgeon is there all the time and can adjust things as they see fit, but primarily, the treatment is at that point controlled by the computer and the robot arm. This is controlled by the computer and the robot arm. This is controlled by the computer and the robot arm. This is controlled by the computer and the robot arm.

This is a shot of some of the robotic equipment; it doesn't look that exciting. I agree, but this is also the team that helps me do this procedure, and it is really a big step forward in prostate treatment because of the real-time imaging and precise way that we're able to resect the prostate or ablate the prostate.

So, what exactly happens? Well, as I said, we're able to precisely target and remove the excess prostate tissue using this high-pressure water. It's using a combination of real-time ultrasound imaging that allows us to have very accurate imaging of the prostate and then plan the treatment according to that. We use an integrated system whereby there's a camera that goes down the urethra and into the bladder and prostate area, which allows us visual inspection of the prostate, but at the same time, an ultrasound probe is placed into the back passage, which allows us to have very accurate imaging of the prostate itself, the whole prostate, through other roots. You can't always see the whole prostate; it says on their spinal or general, but we do this under a general anaesthetic, and it takes about an hour or so to do, and usually people are in the hospital for one night. Excuse me.

So I'm just going to show a little video now that that that shows exactly what happens during the Aquablation® procedure so what you're looking at here is this is the robot controlled water jet which is coming through a telescope which put is put down the urethra this is the bladder at the end here this is the prostate outlined here and the green dot here represents the ablation plan that we've already made using Imaging of the prostate here now this is the ultrasound image of the prostate and you can see at the top here the robotic arm which goes gives off this what's called an acoustic shadow so it looks very bright and you can't see well beyond that on the ultrasound but before we've got to this point we've carefully imaged the prostate using the ultrasound and set out the limits of where we want to do the ablation so what's going to happen now the video is going to play and you'll see the high press water jets ablating the prostate tissue and the image on the ultrasound as well so let's just run through this so these are the water jets going from side to side and ablating the prostate tissue and the depth of the ablation is controlled by the plan that we've set out and therefore the computer and robot are able to adjust the power used and that little image you saw there was what it looks like looking down the telescope at the same time and you can see there the water is coming out so it's continuously irrigating so the water jets there are ablating or destroying the tissue and as it's gone through the water's coming out as we get to the end of the resection here this we just resect one side at a time to or aquablate one side at a time to preserve sexual function which is can be affected by other treatments particularly at this point and the exciting thing about having the ultrasound and the robotic control is that we're able to preserve particularly ejaculation at that point there. So, it doesn't usually affect sexual function, and there's usually a quicker recovery time and less post-procedure discomfort than with other procedures. Obviously, there are no incisions or cuts, so there may well be a shorter recovery time with this system, and because we're able to use real-time Imaging with the ultrasound does allow for quite precise removal of prostate tissue, which can reduce the risk of damage to surrounding tissues and hence reduce complications or side effects. With any treatment, there can be complications or side effects, and it's quite common to have some blood in the urine for a few days afterwards. There's always a small risk of a urine infection, so we would give you antibiotics at the time of the procedure and immediately after the procedure, particularly if you've had a catheter in or tube in the bladder before the operation because you couldn't pass urine. Then there can be some difficulty starting to pass urine on the first day or so. Usually, these side effects are quite mild and settle down very quickly, and one of the nice things about Aquablation® is that people do seem to recover very quickly and have very little pain from it.

So, is this the right treatment for you? That's very difficult for me to answer just for everyone. I think you know we need to work out exactly what your prostate size, shape, and symptoms are, but it is suitable for a wide range of people, particularly people with moderate to severe symptoms, and you know you would need to have a full assessment to know if it's exactly the right thing for you. But the nice thing about this procedure is that it can treat most sizes and shapes of prostates.

I'm going to move on and talk a little bit about some of the other options briefly. TURP® is probably the most widely performed operation; it's been around for a long time. 40 years or so now, and doing this, during this procedure, the prostate is what we call resected or scraped away from the inside using this instrument, which is essentially a camera that is put down the urethra, and the Surgeon is then able to directly inspect the inside of the prostate and guide cutting away the prostate in small little bits at a time, which will core out if you like. That's probably the easiest way to think of it. the obstructing tissue, it's a very effective operation at improving urinary symptoms. We know that, but it does have some well-recognised side effects, particularly on sexual function and particularly ejaculation, and a small risk of incontinence, which is generally very low. I would say it's a very effective operation, but it does have these documented side effects, and usually people are in the hospital for a couple of nights after this procedure. This can be done under spinal or general anaesthesia.

The other procedure I wanted to talk about a little bit tonight is the Urolift® procedure this is a smaller procedure than some of the other procedures we do on the prostate this involves putting little implants in that essentially pull the prostate open so we fire through the prostate a little clip that's then deployed on the outside and then that's tensioned against a clip on the inside of the prostate which pulls the sides of the prostate open so because there's no sort of damage to prostate tissue it has relatively few side effects doesn't have any effect on sexual function or continence what I would say is with like many things in life because it's a smaller procedure it does have perhaps less dramatic Improvement in symptoms compared to some other things and probably it has less durable results in that you know you may be more likely to need further treatment in the future. I'm just going to show a little video of that because it's a little bit difficult to necessarily understand just from that picture, so what this video is going to show is a schematic diagram of the prostate.

Louise King

I'm not sure if Mr Garnet's frozen or if it's my screen, but I can see someone's put their hand up.

I think he's just frozen, so I think they're just going to rejoin. Sorry about this; it shouldn't take too long.

Mr Steve Garnett

We're just logging back in. We've frozen.

Louise King

I wasn't sure if it was me at first.

Thank you for your patience.

Everyone, in the meantime, while they're doing that, I just thought I'd let you know everyone that's joined this session. Well, we see 50% off the value of your consultation for joining the session. You also get a call back from our dedicated private patient advisor, and tomorrow you'll have an email with a recording of this talk, so if you want to go back and kind of revisit any information that Mr Garnet went through, you can do that, and you also get a new loyalty scheme, and you'll get loyalty points by attending this webinar.

Perfect, great.

Mr Steve Garnett

Sorry about that technical issue there. Okay so what I was talking about was Urolift® procedure and just going to show this quick video to outline exactly what happens with the Urolift® and I think I was just at the point of saying that this is a schematic representation of the prostate here narrowing or squeezing the way out of the bladder the urethra and we'll just run this through and show how the implants are placed so we put this instrument down the urethra and then fire these little implants through the prostate after compressing the prostate tissue and here you'll see the implant going through to the outer part of the prostate and then being pulled back to tension and compress the prostate tissue therefore widening the way out from the bladder and the number of implants we put in depends on the size of the prostate and also the shape of the prostate and not all prostate shapes or sizes are suitable for this but on average we put about four of these implants in now obviously this doesn't remove any prostate tissue and it doesn't stop the prostate from growing so it is possible over time that these will become less effective but it is a very small and quick procedure and it can be repeated in the future so as a sort of before and after showing how this is improving the flow rate and this is an image of what we see when we look down the telescope towards the bladder good. So hopefully that made a bit of sense, so that's usually done as a day-case procedure. Usually, to be honest, we do it under a short general anaesthetic because it's a bit more comfortable. Most patients don't need a catheter and go home the same day. People having this done do get a few days’ worth of stinging and discomfort, but generally the side effects are quite mild, and people get back to normal activities very quickly.

Okay, so I think that's a quick overview of prostate enlargement and the treatments that we've got on offer here at Benenden. We're now just going to play a quick case sort of report of a patient who recently underwent Aquablation®, just outlining his experiences, and he's very kindly given his time and obviously his identity and allowed us to show this, which we very much appreciate. So, I haven't seen this yet, so it'll be interesting to see what he says. I hope he says good things, but we'll see.

Philip Ralph

My name is Philip Ralph, and I was a self-payer for Aquablation®, which was completed on December 11, 2023, which is a matter of chance. I saw some information about Aquablation® that I felt was only available in America, and to my surprise, I saw some information that Benenden Hospital in the UK actually offered this procedure, which was robotic and offered fewer side effects and a better recovery chance for me, as I was concerned that I did not want to have a catheter for the rest of my life.

Aquablation® has brought my life back to normal. It has given me my life back. I no longer have a catheter. I don't have any symptoms. I don't have any incontinence; I'm able to urinate absolutely perfectly; I don't have to go to the toilet frequently; it is as if I'd never experienced any problems; I am fully recovered; and I am so happy I chose Benenden and Aquablation®.

Mr Steve Garnett

Well, it sounds like a positive experience. That's good. I mean, I think you know people have had very good experiences with the Aquablation® and do seem to recover very quickly, which is really nice to see, and obviously Philip there had gotten to the point that he couldn't pass urine at all and had a catheter in, so it's quite a severe sort of case, and most patients, don't you know, were seeing before that, so they haven't gotten to that point, but even in that severe case where he's had a catheter in beforehand, he's done very well with the Aquablation®, so that's nice to see.

So, I think we're going to move on to a question-and-answer session now, and I think, Louise, are you going to post this and fire some questions at me? Hopefully, I don't know what I'm going to get, but hopefully I'll say something useful.

Louise King

I'm sure you will be okay. We have some questions already, so we have some, and if you are thinking about posting some questions, please do so.

The first one asks if Urolift® or Aquablation® can be performed if already catheterized, which I think is kind of a case study.

Mr Steve Garnett

So you know, as in that little case report, yes, Aquablation® can definitely be performed if you have a catheter in already, and Urolift® can technically be performed, but there's not a lot of it's not commonly done; there's not a lot of evidence out there as to how well it works, to be honest, and I think if you've got to the point of needing a catheter in because you couldn't pass urine, then probably you're going to be better off with a slightly bigger procedure than Urolift, but it can be done.

Louise King

Okay, and that person also asks, How does the new procedure, ITIND, compare to Urolift®? Is it a good alternative?

Mr Steve Garnett

Yeah, so this is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. This is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. This is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. This is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. This is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. This is quite a new treatment that involves essentially putting a little collapsible metal cage into the prostate, which is left there, which is then cut into the prostate over a couple of weeks and is then removed. I think the evidence for it at the moment is still there, but there's not a lot of evidence for it as yet. I think it's early days; it's not something that we're performing at this hospital at this time, and it's not very widely available currently. I think quite a few urologists have a few doubts about it, but we'll have to see.

Louise King

Thank you. We've had a question around the risks of the operation, but of course you didn't mention a couple, so I guess if you just mentioned the risks of all three operations, I guess, and is there still a need to take medication afterwards, and can the prostate grow back again?

Mr Steve Garnett

There are quite a few questions there, yeah, and there's a cat behind you.

Louise King

Yeah, sorry.

Mr Steve Garnett

So, in terms of whether you need to take medication, now the whole point of having an operation is so that you don't need to take medication anymore. Can the prostate grow back? Yes with any procedure the prostate can continue to grow and as I said we've got the because it's been around the longest the TURP® has been done for about 40 years we have the most sort of long-term follow-up on that procedure we know that about 20% of men after TURP® will need a second procedure by 10 years so 80% don't but one in five do by 10 years after a TURP® if you look at Aquablation® the figures for retreatment are very similar to TURP® if not a little bit better at five years but because it's fairly new we don't have 10-year data so I can't directly compare it at 10 years and with Urolift® we tend to find that the retreatment rate as I say is a bit higher than that because it's not actually removing any prostate tissue in terms of side effects I think I sort of alluded to that, but with a TURP, the majority of men will find that the ejaculation is affected, and some men will get erection problems. A very small number of men can get incontinence problems with Aquablation. Most men do not get any sexual side effects, and incontinence is incredibly rare. With Urolift®, there are essentially no significant sexual side effects, and inconsonance is not an issue.

Louise King

Thank you, okay. This person said they'd had a procedure about five years ago. It was very effective, but the symptoms have recurred. Sorry, they understand that a repeat is not so successful. Would Aquablation® therefore be appropriate as an option for them?

Mr Steve Garnett

Yeah, so as I said, it's very hard for me to say in specific cases whether it would absolutely be the right thing, but there's no reason you can't have Aquablation® after PAE, which is prostate artery embolisation where the blood supply to the prostate is blocked off by little implants that are put into the blood vessels. While that can be a good treat, the problem with that is that often new blood vessels form, the prostate does start growing again, and the symptoms return over time. But yes, further surgery such as Aquablation® is possible after that.

Louise King

Okay, thank you. What is the longevity of the Aquablation® procedure?

Mr Steve Garnett

Well, I think I've just been talking about that, really, at five years, the results are as good as, if not better than, TURP, which has been around the longest, but we don't have 10-year outcome results because it's a new treatment, and that's always the problem with a new treatment, yeah.

Louise King

Can this person make any lifestyle or dietary changes to reduce prostate enlargement or maintain prostate size?

Mr Steve Garnett

Yeah, that's a good that's a good question obviously a lot of people are interested in diet and effects of that so I think the first thing to say is that we do know that caffeine will make symptoms worse so if you drink a lot of tea and coffee consider cutting down on that or switching to decaf tea and coffee and the remember there is quite a lot of caffeine in tea as well as in coffee in terms of the prostate itself there isn't you know there isn't much evidence-based sort of research in terms of things that can help reduce prostate size relating to your diet there is some evidence that something called lupin which is found in tomatoes may help reduce prostate enlargement but I think the thing with diet is it's really probably a bit late by the time you've got symptoms to think of dietary things that might help because really diet is more a preventive thing than a treatment thing so it's difficult to give you know an answer that has much sort of evidence or scientific basis on that.

Louise King

Thank you. Does Parkinson's disease affect eligibility?

Mr Steve Garnett

Well, Parkinson's disease It doesn't directly affect eligibility, but Parkinson's disease can cause urine symptoms themselves, so if you have urinary problems and you've got Parkinson's disease, it may be that some of your problems are related to Parkinson's rather than prostate enlargement. Clearly, having Parkinson's disease doesn't mean that you can't have prostate enlargement as well, so it's a bit more complicated when you have other problems like that, but that absolutely doesn't mean that you can't have Aquablation® or other treatments just because you've got Parkinson's.

Louise King

This person says they have a metal hip. Does this affect the scan that would be required?

Mr Steve Garnett

No, because we're using an ultrasound for Aquablation®, and that's not affected by metallic implants. MRI scans and some degree CT scans are, but the way we're using a scanner with the ultrasound, no, it's not affected.

Louise King

Okay, so I'm just going through various ones here; they're all quite similar. This person's waiting for prostate cancer radiotherapy, and they may need prior treatment for flow restriction. Currently, TURPs are suggested. Can this new procedure be used rather than TURP?

Mr Steve Garnett

Yeah, there's no reason that you couldn't have Aquablation® prior to radiotherapy. Yep, that's absolutely fine.

Louise King

Thank you. Another person said, Can you speak about Rezūm? Do you hear of the Rezūm procedure, which seems to be very common in the USA?

Mr Steve Garnett

Rezūm treatment is a treatment where essentially the prostate is injected with steam, so as you'll sort of notice, there are a lot of treatments for prostate enlargement now, and it's very difficult for any one hospital to provide every single treatment. So Rezūm is not a treatment that we offer at Benenden Hospital; it's a treatment that involves injecting steam into the prostate with a telescopic instrument that's put down the urethra again, and that steam destroys the prostate tissue, so it's not suitable for particularly large prostates. I would say it's similar to Aquablation® in terms of it's a fairly small quick treatment but it has perhaps limited Improvement and the kind of the downside of Rezūm treatment is that you do need to have a catheter in afterwards because the prostate takes a bit of time to be affected by the Steam and most patients have a catheter in for a week or so and particularly if you have a slightly big prostate you may well need more than one treatment so you tend to have a treatment with a catheter for a week and then go back a few weeks later and have another treatment with another week of the catheter so it's a treatment that's available but not at Benenden Hospital and I think for many patients the Urolift® is you know offers similar benefits Okay, without a catheter, yeah.

Louise King

After the procedure, does the prostate resume its normal size? Please, and thank you. An example client was very helpful, they say.

Mr Steve Garnett

Good so I'm not sure which treatment that was referring to but I have I have kind of already sort of mentioned that the prostate can start growing again and I think particularly with you know smaller treatments like Urolift® or Rezūm if you have a very large prostate and you tend and you tend to grow or your prostate tends to grow a lot then it is likely that you will find that your symptoms return after a few years and even after bigger treatments it is possible although most patients don't need further treatment it is possible for the prostate to grow back again.

Louise King

Okay, thank you. This person says they're sitting there and thinking Aquablation® looks like a no-brainer. Then, whether now or further down the line, at which point would it be advisable to take action? This person, 62, is taking tablets and currently getting up three to four times per night and on the short fuse when feeling the need to urinate.

Mr Steve Garnett

So I think that's a very common situation and as to when to have treatment you know these are very kind of personal decisions I think because you know clearly we're not talking about something that is you know I'm not I'm not we're not saying or you you've got to have treatment because you've got cancer or something it's not like that so it's an it's a treatment to improve your quality of life now when do you do that that depends on how much your symptoms are affecting you now I would say if you're getting up three or four times a night you're probably getting quite tired and if you're having to go to the toilet without a lot of warning that might affect your confidence in social situations or going out in that situation personally I would what probably be thinking about treatment but you know that's depends a lot how you feel about it and if some people find that they've got used to it and they manage very well in that case it's probably less urgent but I think the thing to do is if you've got problems that are particularly if they're issues despite being on tablets I would suggest getting an assessment sooner rather than later because what you don't want to do is end up getting to the you know leaving it too long and getting to the point where you can't pee at all and then having to go to a& an emergency and having a catheter placed and that's all very uncomfortable and not a sort of route you really want to go down and I would say get an assessment see what the options are for you see what's going to work best for you and then make a decision you know Aquablation® may well be a good choice for you but until you until we've seen you and assessed you we can't really advise you further the other thing to say is some people get a very good response to tablets like tamsulosin other people find that less effective and some people just get side effects so a lot of people are on tamsulosin which is a drug to relax the prostate a little bit and open it up and improve flow but some people get dizziness or light headedness some people feel quite tired or weak on it some people get some sinus congestion these are all quite common side effects and other people also get sexual side effects and erection problems on these tablets and to be honest a lot of people just don't want to take tablets long term which I can understand so the answer to when to have something done I think is quite a personal one but I would definitely relating to the question or the person who asked the question the symptoms you're describing I would certainly think about getting an assessment sooner rather than later and then making a decision.

Louise King

Thank you, and I think this question relates to something I can't say properly: Is there a link with dementia? With it, there isn't a clear link to dementia. Some of the other tablets that we use for urinary problems have been associated with dementia.

Mr Steve Garnett

The problem with these things is that association doesn't mean a cause, so as you'll appreciate, a lot of older men will be on tablets like this, and a lot of older men will at some point develop dementia. It doesn't mean that one causes the other, but it does mean that there is an association because these older men are on these tablets. Now, proving cause and effect is much more difficult, and there isn't any that actually shows that any of these medicines are causing dementia, but I think you know there's a similar population that is taking them.

Louise King

Yeah, that makes sense. This person has been diagnosed with mild prostate cancer. Can Aquablation® still be performed in these circumstances?

Mr Steve Garnett

Yeah so what we call low risk prostate cancer is often a very you know benign form of cancer slow growing type of cancer and would often not actually need any treatment but that doesn't mean that there isn't benign enlargement of the prostate as well and you're very much able to have Aquablation® or other treatments if you've got early low-risk prostate cancer and in some ways it can make actually follow up of those cancers a bit easier because the PSA should come down after these treatments and be a little bit easier to monitor related to that if someone doesn't know if they have cancer but can a biopsy be carried out at the same time as you doing the operation so when you have an Aquablation® a small amount of tissue is sent off to be looked at to see if there's any sign of cancer but it I wouldn't it's not a test for prostate cancer and in fact for all of these procedures although tissue will always be any tissue that's removed will always be checked for cancer Prostate cancer tends to affect a different part of the prostate, more the outer part of the prostate, and when we're treating prostate enlargement, it's more the inner part that causes the problem, so it's not a very reliable or useful way of checking for prostate cancer.

Louise King

Okay, thank you.

Mr Steve Garnett

Sorry, I would say that can be part of the assessment before coming to any treatment, which may involve tests for prostate cancer. Yeah, do any other conditions, such as type 2 diabetes, mean that a person would be unsuitable for them? Aquablation® again a bit like the Parkinson's question now that having diabetes or other conditions doesn't mean that you're not suitable for Aquablation® or other treatments but it may be that those other conditions may be causing or responsible for at least some of the symptoms that you're getting because we know that diabetic control is very important in terms of urinary symptoms and if you've got high sugars that that aren't well controlled that will make you pass urine more often it will obviously make you drink more as well and get up more at night and can of effect the bladder as well so diabetic control is important for urinary symptoms but it doesn't it certainly doesn't mean you can't have Aquablation® or other treatments now.

Louise King

Okay, I've been asked a question, but I'm not sure what procedure they mean when they ask: will they cycle without aggravating the prostate?

Mr Steve Garnett

I mean, I assume that means post-operation. Yeah, if you have something like an Aquablation® or a TURP® or a procedure that's removing some prostate tissue, I would advise you to leave it for a few weeks before you go cycling because when you're cycling and the saddle is pressing right on the prostate area, it might cause you to bleed a bit, but certainly with Aquablation® after four weeks, you could certainly get back to cycling. 

Louise King

Normally, would Aquablation® aid erectile dysfunction?

Mr Steve Garnett

No, I don't think anyone can make that claim. It's not a treatment for erectile dysfunction, although what we do see quite often is that people have prostate problems and are on tablets for that. As I sort of mentioned a little bit earlier, those tablets can cause erection problems, so if you have an operation that allows you to stop taking those tablets, that might help. But no, none of these operations can be claimed for themselves; they actually improve that side of things.

Louise King

I've been asking questions for quite a while now, but one is: What's the difference between the HoLEP operation and Aquablation®?

Mr Steve Garnett

Yeah, so HoLEP laser and nucleation of the prostate, the most essentially that is using a laser to core out the prostate, so the best comparison with that is a TURP, so TURP® uses electrical energy to cut through the prostate. HoLEP uses laser energy to cut through the prostate because they're both cutting through the prostate and removing tissue; they both have similar side effects; they both have high rates of affecting ejaculation; they both have similar rates of incontinence; and they're both done using a camera rather than any other Imaging means that the Surgeon is using visual inspection of the inside of the prostate to guide what they do, whereas with ablation, we're able to map the whole prostate, image the whole prostate using the ultrasound, and then map the treatment using the computer-controlled robotic arm. So, I would say, TURP® and HoLEP are quite similar, just using different forms of energy, and Aquablation® is a very different type of treatment.

Louise King

How does Aquablation® or other surgery not damage the urethra?

Mr Steve Garnett

​So this is a common question that I get asked, and it's really because the information that you're given and those diagrams don't make it clear that the urethra is not a separate structure from the prostate, so the urethra itself is part of the prostate; it's not a separate tube going through a donut or something; it is just part of the prostate, so in that way, it's not something that will damage the urethra; it's just the lining of the prostate, and that will regrow after treatment.

Louise King

Okay, thank you. I think that's all the questions we have time for today. We have a few more, so I'm not sure if we can answer them afterwards. I'm sorry if we haven't gotten through all of your questions, but yes, I think that will be all the questions we'll go through today.

Could you please move on to the last slide? So I went through some of this information earlier on while we had some technical difficulties, so I won't repeat myself, but after we finish this webinar, you will have a survey pop up, and I would really appreciate it if you could complete this survey as it helps us improve and shape future events, and it also gives feedback to Mr Garnett, which is really helpful.

If you'd like to discuss or book your consultation, our private patient advisor, Chelsea, is on the phone until 8pm this evening at the number on the screen, or you can speak to her and anyone in her team from Monday to Friday. 6am, sorry; 8am to 6pm again on the same number.

Our next webinar is on shoulder pain treatment, which you can sign up for via our website, and then, on behalf of myself, Mr Garnett, and our expert team at Benenden Hospital, I'd like to say thank you for joining us this evening. We hope to hear from you very soon, so thank you very much and goodbye.