Faculty: Neil Barber, Kevin Zorn and Sam Mouli

Moderator: Naeem Bhojani


Dr. Neil Barber

Appointed as a Consultant Urological Surgeon to Frimley Park Hospital in 2005, Neil Barber is Clinical Lead for Urology at Frimley Health NHS Foundation Trust and Director of the Frimley Renal Cancer Centre and the Frimley Benign Prostate Clinical Research Centre.

His particular subspecialist interests in managing waterworks symptoms in women and men, particularly for men suffering with BPH, has led to his involvement in new treatments including the introduction to NHS England of the Greenlight laser in 2002, Urolift in 2014, Aquablation of the prostate using the Aquabeam system and iTind in 2019. Neil has been involved in numerous high quality national, European and global studies as well as acting as an advisor to NICE in this field.

 

Dr. Kevin Zorn

Dr. Kevin Zorn is a dual-board-certified (US and Canada), minimally-invasive urologist, oncology-fellowship trained at the University of Chicago. As a native Montrealer, Dr. Zorn received his undergraduate and MD degrees from McGill University where he completed his residency in urology in 2005. His main focus of clinical and scientific interest is in the surgical treatment of benign prostatic hyperplasia (BPH) and prostate cancer. Other than his focus on robotic surgery with over 2500 robotic prostatectomy cases performed, Dr. Zorn is also the national Canadian surgical trainer and international proctor for the Greenlight XPS 180W laser since 2012. He has also an active proctor from residents to international urologists with integration of simulation experience. He has also been an invited speaker/visiting professor for his academic work on laser therapies and techniques for BPH management. He was the first in Canada to utilize the latest version of the Greenlight 180W XPS laser for BPH and has pioneered an enucleation-like technique to standardize Greenlight technique. Not only has Dr. Zorn helped with the national BPH guidelines, he is also an active with various other minimally invasive therapies with Urolift, Rezum, Aquablation and other cutting edge technologies including Optilume and Zenflow.

Dr. Zorn is an active researcher and a dedicated teacher to his urology residents and fellows. He has published extensively on prostate surgical care with over 250 peer-reviewed papers and 12 book chapters (http://www.ncbi.nlm.nih.gov/pubmed?term=zorn%20kc). He has received awards for his clinical work, research and teaching from the AUA and Endourological Society. He is also a reviewer for many urological journals and has been awarded Best Reviewer for Prostate Cancer in 2009 and 2010 for the Journal of Urology. He has also been a member of the American Urological Association (AUA) educational task force for the development of the laparoscopic and robotic urologic surgery curriculum and has served AUA hands-on course director for the annual AUA annual meetings for 7 years. Dr. Zorn has also helped develop and organize the University of Chicago Robotic Radical Prostatectomy Course (a symposium of the world's top robotic surgeons) which began in 2007. He has worked closely with AMS/BSCI through center of excellence (COE) training activities to foster Greenlight XPS training.  Most recently, he has been invited as a member of the CUA BPH Guidelines Committee as well as the CUA continuing professional development (CPD) Committee.  As such, Dr. Zorn has a passion for academics and peer-related education.

Over the past 10 years, Dr. Zorn has returned home to Montreal to develop the University of Montreal (CHUM) robotic and laser BPH program. He serves as Associate Professor of Surgery and Director of Robotic Surgery.

 

Dr. Sam Moull

Dr. Sam Mouli, MD, MS is an Assistant Professor in the Section of Interventional Radiology at the Feinberg School of Medicine at Northwestern University. He completed his medical training, master’s degree, radiology residency, and interventional radiology fellowship at Northwestern University.

He is the Director of the Interventional Oncology Laboratory as well as Director of Translational Interventional Radiology Research for the Center for Translational Imaging of Northwestern University’s Feinberg School of Medicine. He oversees rapidly developing translational research program focused specifically upon the application of novel therapies in the setting of image-guided therapy for GI and GU malignancies. Over the past ten years, with colleagues at Northwestern University, he has been a key collaborator in many pre-clinical and clinical research studies. His clinical interests include Interventional Oncology and Prostate Artery Embolization.

 

Dr. Naeem Bhojani

Dr. Naeem Bhojani was born and raised in Montreal. He obtained a BSc in Microbiology and Immunology and another in Physiotherapy from McGill University in 2001 and then completed medical school and urology residency at the University of Montreal. In 2011, Dr. Bhojani spent 2 years with Dr. Lingeman at Indiana University completing his Fellowship in BPH and Stone Disease. Dr. Bhojani was recruited by the University of Montreal in 2013 to build and develop Comprehensive Kidney Stone and BPH Programs. At the University of Montreal, he has the rank of Associate Professor and clinical researcher. Dr. Bhojani has published extensively in stone disease and BPH. In 2017, Dr. Bhojani was named the AUA’s Young urologist of the year representing the NSAUA. In 2019, Dr. Bhojani was awarded the prestigious clinical research scholar award from the FRQ-S.

 

Webinar Transcript 

Dr. Amy Krambeck:

Hello, my name is Dr. Amy Krambeck and I am professor of urology at Northwestern University School of Medicine in Chicago, Illinois. I will be your host today for the masterclass in endourology. This is the Endourology Society and Society of Urologic Robotic Surgeons master's class. The Endourology Society and Society of Urologic Robotic Surgeons wishes to thank Cook Medical for their grant and supported of this activity.

Dr. Amy Krambeck:

Today we have a great presentation, it's Preventing Retrograde Ejaculation as a Side Effect of BPH Therapy. I think this is an under discussed but very important topic and I'm glad we're covering it today. Our faculty is Neil Barber, Kevin Zorn, and Sam Mouli. And the moderator is Dr. Naeem Bhojani. Dr. Bhojani got his Bachelor’s of Ccience at McGill University in 2001. He completed medical school and urology residency at the University of Montreal in 2011. He then did a two year fellowship and BPH in stone disease at Indiana University. He is now the associate professor and clinical researcher at the University of Montreal. And he's received several awards including the AUA Young urologist of the year award, as well as the clinical research scholar award from the FRQ-S. So I will turn the platform over to Dr. Bhojani and he will introduce the other faculty and get us started.

Dr. Naeem Bhojani:

Thank you so much, Dr. Krambeck. So I am Naeem Bhojani and it's really my pleasure to be the moderator for this masterclass. So, we're going to begin by introducing the speakers and then we'll get started with the program.

Dr. Amy Krambeck:

I just wanted to remind everyone that this is a CME activity. And the goals and objectives of the class are listed on the website.

Dr. Naeem Bhojani:

I would like also to remind everybody that I'll be taking questions and sending them over to our faculty. So please put your questions in the chat box. There'll also be a few polls that will be coming up on your screen, so please try to fill out the polls. And we're going to get started. So we're over 100 people now. So this is an important topic, I'm glad there's a number of people who are interested in. So again, I'm the moderator for the masterclass on Preventing Retrograde Ejaculation as a Side Effect of BPH surgery.

Dr. Naeem Bhojani:

So, this is the plan of our presentations. We're going to start by presenting our faculty. I want to mention that unfortunately right before we started, Dr. Barber had to be called into the operating room and he will try to make it but he might not be able to make it for this session. So our first presenter will be Dr. Sam Mouli, who will be presenting on preservation of antegrade ejaculation with the use of prostate arterial embolization.

Dr. Naeem Bhojani:

Dr. Mouli is an assistant professor in the section of interventional radiology at the Feinberg School of Medicine at Northwestern University. He completed his medical training master's degree, radiology residency and interventional radiology fellowship at Northwestern University. He is the director of the Interventional Oncology laboratory as well as director of Translational Interventional Radiology research for the Center for Translational Imaging of Northwestern University's Feinberg School of Medicine. He oversees a rapidly developing translational research program focused specifically upon the application of novel therapies in the setting of image guided therapy for GI and GU malignancies. His clinical interests include interventional oncology, and prostate arterial embolization.

Dr. Naeem Bhojani:

He will be followed by Dr. Kevin Zorn, who will be presenting on the preservation of antegrade ejaculation after Aquablation and Rezum. Dr. Zorn is a minimally invasive neuro oncologist with fellowship training at the University of Chicago. Dr. Zorn received his undergraduate and medical degree from McGill University where he completed his residency in neurology. His main focus of clinical and scientific interest is in the surgical treatment of BPH and prostate cancer. Dr. Zorn is the national Canadian surgical trainer and international proctor for the GreenLight XPS-180 Watts laser. He's also active with various other minimally invasive therapies including UroLift, Rezum, Aquablation and cutting edge technologies including Optilume and Zenflow. Dr. Zorn has published extensively on prostate surgical care with the return of 50 peer reviewed papers and 12 book chapters, has received awards for his clinical work research and teaching from the AUA and Endourologic Societies. He's also an associate professor of surgery and director of robotic surgery at the University of Montreal Health Center.

Dr. Naeem Bhojani:

So to kick us off just a couple of introductory slides on antegrade ejaculation. This is actually a study we did last year looking at 300 men, 150 men who had previously undergone various BPH surgeries, and 150 men who were considering undergoing various BPH surgeries. And we asked them what was most important to them, what they considered either important or very important for BPH surgery. And as you can see, 95% of them considered erectile function important or very important. And more specifically for this masterclass, 92% of the men considered the maintenance of ejaculatory function, either important or a very important consideration.

Dr. Naeem Bhojani:

What structures are important to maintain antegrade ejaculation? So, obviously, the neurovascular bundles, the bladder neck has been hypothesized as being important for antegrade ejaculation. And then of course, the precollicular and paracollicular tissue proximal to the verumontanum or the ejaculatory hood has also been hypothesized as being important for maintaining antegrade ejaculating after BPH surgery.

Dr. Naeem Bhojani:

So a couple of questions for our faculty before we get started. Which anatomic structures are most important for antegrade ejaculation, and their opinions? And then, which surgical options have the best chance of maintaining antegrade ejaculation? So with that, I'm going to now allow Dr. Mouli to begin speaking about prostate arterial embolization. Please again, don't forget to leave your questions in the chat box and fill up those polling questions. Thank you.

Dr. Sam Mouli:

Thank you, everybody for the opportunity to speak on prostate artery embolization. I'm the sole interventional radiologist on this meeting, so I'll try to cover a lot of ground as I'm sure this is a different way of looking at things than most of the other speakers are used to approaching things. So prostate artery embolization, just briefly, basically we go in through the either the femoral artery or the radial artery and thread a three, four inch or smaller micro catheter into the arterial supply of the prostate.

Dr. Sam Mouli:

Typically, we're using standard criteria for patients to undergo prostate artery embolization. So elevated IPSS score, failed medical management, larger prostate sizes. Additionally, we consider patients who are poor surgical candidates, maybe have a history of urinary retention, intractable hematuria or have very large glands.

Dr. Sam Mouli:

So the anatomy can be very complex in the pelvis. And this is just a representative anatomic schematic on the left, an angiogram on the right. And you can see that there are many vessels that enter the pelvis and many that are in close proximity to what is going towards the prostate. So understanding the arterial anatomy is critical for maintaining sexual function after prostate artery embolization.

Dr. Sam Mouli:

So, despite what the anatomic textbooks might say, there aren't always one prosthetic artery on each side of the pelvis. Additionally, the arterial branching pattern is very variable. This slide just depicts the different origins that we've seen in terms of where the prosthetic artery is coming from. It may originate from the internal pudendal artery, from the obturator artery, from the superior vesical artery. So these are all critical to look for when you're looking for non-target embolization and maintenance of sexual function following embolization.

Dr. Sam Mouli:

Additionally, as I mentioned, there is highly variable origin mostly from the internal pudendal artery or superior vesical artery. But additionally, there are multiple anastomosis within the prostate, so intraprostatic anastomosis, most often to the internal to pudendal artery. Why is this important? Non-target embolization of the internal pudendal arteries can lead to sexual dysfunction following embolization.

Dr. Sam Mouli:

So what does this look like schematically and geographically, this is just the schematic on the left showing the prostate centrally here, the rectum beneath it, and all of the different collaterals that you might see, and a corresponding angiogram on the right. Obviously, this is very complex anatomy and this all needs to be taken into account when performing the embolization to avoid non-target embolization.

Dr. Sam Mouli:

So how does it work? Basically, through embolization, we get infarction of the central gland that leads to overall volume decrease in softening of the tissue. Additionally, there's some data that indicates that infarction leads to an alpha-adrenergic denervation. Additionally, over time, which we see a path image here on the right lower screen, there is fibrosis that leads to a volume decrease with the embolic here labeled as E in the center of the screen.

Dr. Sam Mouli:

So what have we seen with the data? The most recent trials have shown subjective IPSS improvement compared to PAE and TURP, and PAE and sham in line with other MIST therapies. We have sustainable effects up to 12 months on prospect of randomized trial data with long term data from retrospective series up to five years. The critical thing I tell patients is embolization does not preclude them from future therapy, whether medical management or surgical management if needed. So it doesn't burn any bridges for them is a great first option should they decide to choose it.

Dr. Sam Mouli:

In terms of adverse events, very limited. Most patients experience what we call a post embolization syndrome, which is characterized by some slight discomfort managed with over the counter nonsteroidal medications and some urinary frequency and urgency that lasts for about three to five days after the procedure. Again, that's mainly managed with fluids and nonsteroidals. And very rarely do they have more serious adverse events such as hematuria or hematospermia. Critically, sexual dysfunction is not a major adverse event we've seen in our data. And I'll go through why that is.

Dr. Sam Mouli:

So we'll go through some of the biggest studies looking at PAE versus TURP versus sham and talk about sexual function in more depth. So this was a study out of the UK, the UK-ROPE study, which was a study looking at 216 patients treated with PAE versus 89 with TURP. It was a non-inferiority analysis. And what we found was with PAE, there was a 10 point IPSS reduction versus 15 points with TURP, the gold standard. And no evidence of non-inferiority. However, sexual function was stable after PAE from an erectile standpoint. Additionally, patients who underwent PAE had a 28% volume reduction.

Dr. Sam Mouli:

However, when you dig into the data, you find out that 24% of patients in the PAE arm and 47% of patients in the TURP arm experienced retrograded ejaculation. Now, why is this? So when you look at the details of the study, many patients reporting retrograde ejaculation admitted to experiencing this before embolization since starting medication months or years before their PAE. So it's difficult to ascertain what was truly due to the embolization, what might have been their baseline because it wasn't accurately assessed at the onset of the study.

Dr. Sam Mouli:

Additionally, a Swiss trial, randomized trial comparing PAE to TURP. This looked at patients and both IPSS and sexual dysfunction. Critically 25% of patients in PAE arm were treated with unilateral embolization only which we know to be inferior in terms of symptomatic improvement. There was a 9.2 point decrease in IPSS with PAE versus TURP, so TURP was superior. However, there were no significant differences in terms of quality of life erectile function. However, again, digging deeper into the data, ejaculatory dysfunction was seen with 56% of patients with PAE and 84% of patients with TURP.

Dr. Sam Mouli:

So why is that? So looking at these two trials in conjunction, the rate of ejaculatory dysfunction range from 28 to 56%. However, there were no baseline assessments made in either case. And these were a telephone interviews following embolization, they did not use validated metrics to assess sexual function or ejaculatory function. And little detail was provided on baseline medications and the way that the embolization was performed.

Dr. Sam Mouli:

So this was a more in depth analysis by the Swiss group to look at their ejaculatory dysfunction. So in these patients, what they found was, there was infarction and expulsion of the central gland tissue, which I'll show you some images from in a few moments. And basically, this was associated with IPSS improvements, but increase the risk of ejaculatory complications. And this was specifically seen in cases where large volumes of small embolic particles were used. So smaller than 250 microns in size. Typically, we in our practice, use 300 to 500 micron particles in embolization, and this makes a significant difference. And we'll get into why that is in a moment.

Dr. Sam Mouli:

So these are just some examples from that Swiss study. The top two panels show a prostate before and after embolization with these smaller micron particles. And you can see there's almost, I would say a surgical resection like defect following the embolization. Versus a patient treated with larger particles on the bottom, you can see a decrease in the size of the gland, decreased enhancement on MR, but there isn't that defect in the tissue after embolization.

Dr. Sam Mouli:

What does this look like cystoscopically? This is a urologic audience, so I hope you'll appreciate these images. These are exposed fragments of prostate that are seen and then the corresponding pathologic specimen is showing this necrotic tissue with embolic particles in it. And then on cystoscopy, this is what you see. So two weeks post embolization you see this friable tissue. So friable tissue further up in the bladder. Six weeks post embolization it starts to break off and then it by 12 weeks you have a wide open channel. However, this contributes to retrograde ejaculation and ejaculatory dysfunction, as I'm sure you know.

Dr. Sam Mouli:

So why is this happening? So there have been a couple comparative studies looking at this indirectly and I'll dive into the data here. So this was a comparative study using 100 to 300 micron particles versus 300 to 500 micron particles. They had similar improvements in symptomatic scores with IPSS decreases depicted here. However, the authors found significantly more adverse events with smaller particles. Group A with the smaller 100 to 300 micron particles and Group B with the larger 300 to 500 micron particles. So, smaller particles increase your risk of adverse events.

Dr. Sam Mouli:

This was followed up by a randomized control trial in 140 patients with three groups looking at different particle sizes. Again, across the three groups, there was a 50% IPSS reduction with no significant differences between the groups. However, this group did not assess ejaculatory dysfunction, but we can see from their adverse event profile, there were more adverse events with patients who were given the smaller particles for embolization rather than the larger particles.

Dr. Sam Mouli:

So this is a study that we published in the Journal of Urology in 2018, from our own data. So these were patients treated with bilateral embolization with 300 to 500 micron particles. So additionally, our urologic colleagues did all of the assessments afterwards in terms of sexual function and IPSS score, we were blinded to the outcomes. And what we found in our study was significant improvements in IPSS, and quality of life and urinary flow that persisted over one year follow up. And additionally, sexual function remains stable throughout the entire follow up period from both an erectile function standpoint, and an ejaculatory function standpoint.

Dr. Sam Mouli:

Our more recent data series since our original clinical trials again validates this significant decreases in IPSS over our follow up from 26 to 10, a PSA decrease of 50%. And again, stable sexual function just slightly improved in some patients, likely given the fact that we are using larger particles, therefore avoiding that central point infarction and expulsion. Additionally, these patients are coming off the baseline medications they may be on that lead to sexual dysfunction as a side effect profile.

Dr. Sam Mouli:

This is our more recent trial looking at 39 patients treated with PAE versus 38 with sham, these patients were randomized after catheterizations or during the procedure. Again, these were treated with 300 to 500 micron particles, we saw significant improvements with PAE versus sham at the six month mark, and additionally stable sexual function. If we dig deep into the data, detailed analysis of their sexual function showed no significant difference between the PAE arm and the sham arm once again.

Dr. Sam Mouli:

So last couple studies I'll go through, looked at prospective analysis of sexual dysfunction following prostate artery embolization. So these are the first studies that really provided detailed assessment of sexual function using the validated questionnaires that are common to urologic practices. So this is 147 patients, however, they were treated with 100 to 300 micron particles. 18 months of follow up, you can see that the improvements in IPSS and quality of life were significant, significant decrease in prostate volume, and maybe a slight improvement in erectile function, probably likely again due to patients coming off the medications that they might have previously been on. And in this group 88% of men maintain antegrade ejaculation.

Dr. Sam Mouli:

Lastly, a group looked at 50 patients treated with 300 to 500 micron particles, and again demonstrated significant improvements in IPSS, QOL, urinary flow, but no significant changes in both erectile and ejaculatory function. Again, likely due to using the right size particles, larger particles, no central gland infarction.

Dr. Sam Mouli:

So the take home points, PAE can provide similar symptomatic improvements to the newer MIST therapies, but sexual function must be assessed prior to treatment. And this is where collaboration with neurologic colleagues is critical. The risk of adverse events increases with the use of smaller particles and preservation of sexual function is contingent upon technique. So you need to protect collaterals to other organs to eliminate non-target embolization. And you need to use the right particle size. In our own experience at Northwestern and over 400 patients and across two clinical trials with our urology colleagues, meticulous technique has resulted in an excellent safety profile with no significant sexual dysfunction or ejaculatory dysfunction. So in conclusion, symptomatic improvement does not have to come with significant tradeoffs. Thank you.

Dr. Naeem Bhojani:

Excellent. Thank you, Dr. Mouli. We have a little bit of time. So I'm going to ask a few the questions that we have in the chat box. There's also a polling question for you to respond to please. So first question is, which artery do you target for PAE?

Dr. Sam Mouli:

So we typically want to target the prosthetic artery on either side. Now, I show the angiogram and there's a lot of collaterals to other organs. And so what you need to do is not only get into the prosthetic artery, but kind of skeletonize it. What I mean by that it's typical. Similar to surgical therapies you want to when you do an open resection of the prostate, you want to skeletonize the vessels. And so you want to put coils and block off any collaterals to the penis, the rectum, the bladder to avoid non-target embolization. That's the first step.

Dr. Sam Mouli:

The second step is to use the right particle size, as I mentioned, so you don't cause that infarction. So the prosthetic artery is not similar between the two sides of the pelvis, it only is and maybe 10, or 15% of cases. So on one side, it might have its own origin, on the other side, it might come off the superior vesicle or the obturator or the pudendal artery. And so you need to take that into account to protect those other organs when you're doing the embolization.

Dr. Naeem Bhojani:

Are there any issues with post-operative retention due to large pieces of necrotic exposed tissue from PAE?

Dr. Sam Mouli:

Yes, and that can be a major issue. And so that's why in that study that was published by the Swiss group, they saw these patients in retention, and that's why they were scoped and they had to evacuate the tissue. In our experience, as long as you're not using these very small particles causing that central gland infarction and expulsion, you should not have issues with post-operative retention if a patient comes into you not already in urinary retention.

Dr. Naeem Bhojani:

So we think that that central infarction caused by the smaller particles is what is causing the retrograde ejaculation?

Dr. Sam Mouli:

Correct. Because as you saw from the images that I provided, and the cystoscopic images, you're basically resecting that tissue that you want to preserve, as you mentioned in your intro slides, that tissue at the apex, the tissue at the bladder neck, and that is being exposed. Basically, you have it's almost a surgical defect, I'd say. And that's not the goal and should not be the goal of embolization.

Dr. Naeem Bhojani:

Interesting, okay. Can PAE be done in presence of patients who are in retention? And if yes, how long does it take to see a response and do a trial avoid?

Dr. Sam Mouli:

Excellent question. So we do do a lot of PAE for catheter dependent patients, specifically the ones that might not be amenable to other surgical options, elderly men with other medical comorbidities, maybe on anticoagulation and such. Typically, our practice has been embolize with a catheter in place, and give them about two weeks to three weeks after embolization to kind of get them through that post embolization syndrome that I mentioned, the dysuria, the burning, et cetera, the frequency. And then do the trial avoid.

Dr. Sam Mouli:

In our experience, the vast majority of our patients and I mean 95% have become catheter free at that two to three week mark after embolization. Granted, this is dependent on adequate patient selection, you've ensured that this is a prosthetic origin of their voiding dysfunction and that's why they're in retention and not neurogenic bladder, or stricture, or something like that. And so on the carefully selected patients, we can get them catheter free at the two to three week mark after embolization.

Dr. Naeem Bhojani:

Okay. Another question from the chat box is, any complications encountered early in practice? And just to follow that, do you think that there some sort of experience required to maintain antegrade ejaculation, or you really think is just the particles?

Dr. Sam Mouli:

So, I think it's twofold. I think, just like any other surgical therapy, there is a learning curve. And I think the learning curve for prostate embolization is, and this might not be a popular opinion amongst my colleagues, but it's at least 50 consecutive cases, over a short amount of time. Really to understand the anatomy, everything that I showed you in terms of the variable origins, the arteries, if you don't want to analyze the arteries then you want to protect. And then that will lend itself to preservation of sexual function. So by avoiding the non-target embolization, by avoiding the use of the smaller particles, and really just targeting the prosthetic tissue that you want to treat, you can really decrease the incidence of dysfunction.

Dr. Sam Mouli:

I think reports of early erectile dysfunction following PAE and ejaculatory dysfunction is mostly due to non-target embolization or inadvertent embolization, causing that necrosis of tissue you don't want to treat. Additionally, it's very experiential, you need to have done enough cases to recognize the variance in anatomy and what you need to watch out for. These collaterals occasionally appeared during the course of embolization. They are not there right away when you see them as I've heard other talks about HoLEP and such, when you're resecting tissue, you might see one bleeder and then another one pops up when you're doing the resection. Same as prostate embolization, new collaterals appear during the course of embolization. And you need to be able to recognize that and recognition comes with experience.

Dr. Naeem Bhojani:

Excellent. What percentage of patients are not candidates for PAE based on vascular anatomy?

Dr. Sam Mouli:

So it's basically what we're looking at is we consider at our group technical success is only seen with bilateral embolization. Unilateral embolization is not considered technical or clinical success. And as patients get older, and they have atherosclerosis and such, that it becomes definitely more challenging. And there is probably a specific patient group that you can imagine, who have a history of coronary disease, peripheral arterial disease that we know upfront that they're going to be more challenging and you can get screening studies, CTA, MRI that show significant atherosclerosis. And in those patients, the success rates can be lower in the 60 to 70% range.

Dr. Naeem Bhojani:

Excellent. Thank you, Dr. Mouli. There's still a bunch of questions. But we're just going to get to Dr. Zorn, so we give him enough time and then we'll circle back and get back to these questions. Take it away, Dr. Zorn.

Dr. Kevin Zorn:

Thank you, Dr. Bhojani. Thank you colleagues and the urology society for the opportunity to present. Alright, so I have been deeded the task to present on both Aquablation and Rezum water approaches for BPH management approved. And the goal here is really the assessment of the antegrade ejaculation maintenance for both these therapies. So here are my disclosures I've trained first by a halali how to do HoLEP, grew onto GreenLights and helping out with some of the GreenLight training with Rezum, biorobotic prostate for Aquablation. And finally, some of the new studies we're doing with Zenflow, Optilume, for my disclosures.

Dr. Kevin Zorn:

So I think more than ever, aside from either hat of dealing with prostate cancer and the complexity of managing patients, I think now the discussion we have for a BPH patient has become like going through a menu of restaurants. So there's quite a few options to offer to patients. And I think that's our job to inform and discuss and enter in the discussion, as Dr. Krambeck said, and under touched or under the rug entity of the sexual ejaculatory function is now become something patients are coming to seek us for. So in the area of surgery, I think Aquablation has that unique role of creating a pre determined area that protects some of the organ structures we're going to talk about for preservation of ejaculation. And as well in the MIST category, the Rezum, which actually does shrink and treat BPH versus displacing it and protecting some of the ejaculatory structures depending on position of injections.

Dr. Kevin Zorn:

So here we go, Aquablation. So we'll start on Aquablation as most people know on the conversation already. For the last few years, the Water I, Water II data's been presented. The actual technology is what we see here is a robot, which is guided by ultrasound imaging, this computer system. And then the handpiece, the robotic handpiece, which you can see here is really the disposable component that is manipulated and executed by the robot. So it's actually, compared to DaVinci, a master slave robot. This is a fully automated delivering robot, so it executes the surgery and takes out of the equation the learning curve. And especially in large prostates given our environment, Dr. Bhojani would attest, we have a lot of large prostates over 80 grams. And we know they're complex because they take longer to do and across open osteotomy, PVP, HoLEP. Dr. Krambeck and everyone who does HoLEP, it's a long procedure. There's higher risk of complications, the bigger the prostates if you do TURP, the more transfusion, the more chance of surgical revision. So we know that.

Dr. Kevin Zorn:

And then I think the whole skill equipment development, and deeded on what was just mentioned before is the learning curve is the execution over a short period of time. So if you're going to go to the gym and do legs and you're willing to do legs once a month, you're probably not going to gain much because there's a forgetting curve. So the importance of doing something repetitively, so for those who've done HoLEP, it's a little hard to do on your own but if you're going to dedicate a fellowship to repetitive multis cases day after day, you'll more likely retain and develop that expertise.

Dr. Kevin Zorn:

So Aquablation, we've published on this before, demonstrating that across these larger prostate volumes, you can see in the bottom blue, the almost not a complete horizontal but just under an hour of dealing with this prostates over 200 grams is quite impressive. So again, I think the abilities of Aquablation to be quick is very minimal. Most people are very excited about this. Question of some, the bleeding in the Water I, Water II studies, we didn't use any hemostasis, it was a traction balloon.

Dr. Kevin Zorn:

So as you can see here, one pass taking under four minutes to execute up to a seven centimeter length urethra is quite impressive. So once that's done, we will go ahead and suck out the clots, replace in a catheter with a balloon and protraction. Nowadays the new session is to go in and to use a loop and to actually cauterize, especially at the bladder neck, which has reduced transfusion rates in these larger prostates from 5% to under 1.5%. So I think that's something that's going to be getting out there.

Dr. Kevin Zorn:

And as you can see here, the idea that without using cautery, I think at one month the epithelialization is quite impressive. Across the boards from the Water I to Water II, Dr. Bhojani was another co-author on this paper, really, almost mirror images. If you look at the IPSS, the quality life, it's efficacious. At the end of the day, I think we're able to deliver for both up to 30 to 80 from the Water I to the larger prostates, a comparable outcome in a very quick amount of time. And it's safe, especially in these large prostates.

Dr. Kevin Zorn:

And as mentioned, the preservation of ejaculatory dysfunction, at least in the Water I series of 30 to 80 grams, over 89% of patients maintain ejaculatory function. In the Water II series 82%. In terms of transfusion rates that was, I think, the Achilles tendon to those initial series. Just like everyone on this conversation, if we looked at the first DaVinci robot surgery by Binder in Germany that took over eight hours, most people will say, "Well, I will never do that." But with evolution and practice, as we can see, moving to the right here, those transfusion rates have dropped down considerably, especially in high volume executors like Thorsten Bach and a few others in Germany.

Dr. Kevin Zorn:

So again, dealing with large prostates, we can do them fast, and the hemostasis seems to be coming along the way. With regards to failure rates, again, some people would be concerned that these larger prostates, what's the failure rate, very small percentages. So let's get into the idea of the precision that no matter who you are, if you can get onto Aquablation, there's are very short learning curve. You can pre program what I think is the predictable anatomy that you'd want to achieve, which is to get down a capsule up until the apex and preserve both pericollicular tissues, as you can see here, and I'll play the video momentarily, and the verumontanum without injuring any of the structures beneath it as well. Which I think doing lasers at some point you may cauterize and you may either deliver some energy down that direction, which with Aquablation, you actually never aiming the water beam in that direction.

Dr. Kevin Zorn:

So here's a cystoscopic view of less than a month and a half out after surgery, you can see very open like defects almost like a HoLEP like defect down a capsule, already quick up the embolization. But the key element here is that the apex and the verumontanum are intact. Again, allows for consistent outcomes and allows a tailored apical treatment for the preservation of those structures and the wise words of Dr. Dasgupta, in this, the Aquablation finally democratizes BPH surgery. So if anyone here from any country or so forth wants to get involved, we can be comparable surgeons altogether.

Dr. Kevin Zorn:

The butterfly cut. I think this is the magic word that's unique to Aquablation. That during the treatment, there's a sagittal view as you'd see here, where there is a demarcated area of two centimeters, or you can choose this that is behind the verumontanum. Well, how do we know where the verumontanum is? Well, during the procedure, you actually have your scope in with a cystoscopic view parked in front of the verumontanum and on ultrasound, it's quite clear you are located. So you can identify precisely where that verumontanum is and then choose a distance behind where there will not be water treatment downward toward the verumontanum. Not injuring the veru, nor injuring the ducts beneath the verumontanum. Which people don't really talk about, it's more of the veru. But the structure is kind of like the ureteric orifice, but beneath the ureteric orifice are the tubes that emit through that orifice.

Dr. Kevin Zorn:

And here you can see there's a treatment and ipsilateral on one side that will treat only the apex on one side, it'll stop, retract the water beam and treat on the contralateral side. So here you can see an animated view of that ipsilateral, the patient's right side apex being treated with a fast rotating water beam. And it's coming back, you can see the ablation, it'll stop, it'll retract and then deliver to the other side. I think you get the point, I'll jump ahead here. At the very end, you can see the veru is intact, you'll see some blood on the other side. But nonetheless, the veru is intact.

Dr. Kevin Zorn:

So just to jump ahead here, so the published results, and this is something that just was published by Dr. Bhojani and the team. Looking at what structures across the board was the most important, looking in univariate and multivariate analyses, really the key element was the depth of the treatment beyond the verumontanum. So if you were to treat very deep, rather than the length of the apical tissues, more the depth of treatment that even though you may have preserved the veru, if you get deeper down to the structures below the verumontanum, seem to have the most significant violation of the anatomic structures which lead to the failure of having ejaculation. So I think the key element is if you are doing your treatments, making sure not to treat below or at a course behind the veru. That was what was found to be the major factors in those less than 20% of patients who did not have antegrade ejaculation.

Dr. Kevin Zorn:

So I guess the contour, the planning, this is getting come in the learning curve as we evolve in this technology. That like a Tesla, you can plug in what you want. I think we're all going to only be learning more and more from Aqua, which is teaching us what are the key structures, one of the questions that are of the session, what structures are important for maintaining ejaculation? So the key element is when you do create your planning that you do not want to go too far below the verumontanum. And this is where the idea of tailoring around those structures at the apex in verumontanum, such as you're going too deep may preclude outcomes that we're aiming for. So is the key element is those elements of the tissues below the verumontanum.

Dr. Kevin Zorn:

So let's just jump ahead here. So again, the other aspect I think that may not be covered as well as the bladder neck and I think some of the benefits of Aquablation because there's no thermal, there is some preservation of the collagen. So while it kind of blows the leaves off the tree stems, it preserves a lot of the collagen structures without cauterizing and damaging those structures. So partly, possibly is there any elements of the bladder neck that's less injured with Aquablation than we would see with thermal treatments, with the water cavity cavitations.

Dr. Kevin Zorn:

So complete my Aquablation discussion there, I think the literature is pretty clear. Most members already know this. We'll discuss more at the end. Let's jump into Rezum, which is a different population. Aquablation really opens the fossa, we've seen that clearly. And that's really for men in retention large prostates. The Rezums sort of fits the 30 to 80 program prostates, at least in my practice, here, it's an office-based procedure, we can do it under a local sedation, or a prairie prosthetic block for like a biopsy. It's quick to do and really has the disposable delivery this piece through a 30 degree scope. We do this with, as I mentioned a periprosthetic block. Dr. Dean Elterman uses a pethrox, inhaled sedation. And others have used infusion or if you have an anesthesiologist help with a nitric oxide.

Dr. Kevin Zorn:

But the elements are I think the periprosthetic block with the use of lidocaine has worked quite well in our series now. I'll use 40 cc of lidocaine, I'll do the standard between the prostate and seminal vesicles, that kind of triangular injection of five cc. I'll puncture through the seminal vesicles and do the, if you do robotic prostatectomy, that's where a neurovascular bundle enters into the prostate and probably interface better in the transition zone. So you get 10 cc per side on that area. And then at the apex to get the afront vessels coming in at the apical areas and let wait for 20 minutes to do the anesthesia, step out and then come back into the treatment.

Dr. Kevin Zorn:

Just a little overview of the treatment for those who don't know too much about Rezum. It involves a cystoscopic guidance of a one centimeter projected motorized needle that's protruded through the mucosa. There's not much talent aside from aiming at the lateral borders nine and three o'clock and coming back to the apex side and aim more anterior not to get the steam down too much into the lower apical structures, similar to what we've learned for Aquablation. And again, doing those treatments and retracting back every centimeter, sort of a five centimeter length the urethra. My treatment number will depend on your retention or not, or the length of the prostate where for every centimeter I'll do a treatment. So looking at the sagittal ultrasound view during my periprosthetic block, it will help guide me and the number of treatments to deliver.

Dr. Kevin Zorn:

So again, the steam is transformed into an aqueous phase, that energy is transferred over to the cells. And as we know getting it up to 70 degrees centigrade, those cells will undergo apoptosis. So each treatment is nine seconds long. So technically, the gun is aimed for 15 nine-second treatments. MRI data shows a reduction of over 30% volume. So we're actually unlike UroLift doing a single purchase of a $1200 gun, doing up to 15 treatments and actually shrinking and causing BPH shrinkage. We can also treat median lobes. The UroLift unfortunately has a higher cost and coming from a Canadian perspective at $950 per suture, rendering it very difficult to insert five, six, 10 sutures. The math that adds up as very costly expense compared to a single cost Rezum or I think, cost effectively Dr. Ulchaker has published it's a quite a cost effective therapy.

Dr. Kevin Zorn:

The data, unlike the Aquablation, I think there's a time dependency effect. So I explain to patients, it'll take at least three to six months for us to get there. The first couple of months is going through the inflammatory phase, the expulsion phase, the atrophy phase of the adenoma. And here we can see the presence of a median lobe that was treated for this patient where injections were done into the median lobe. You can see on the right the regression and shrinkage and the shortening of the urethra consistent with adenoma atrophy. Those with and those without median lobes did fairly well, it was of comparable data from the inaugural studies done by Dr. Claus Roehrborn and Kevin McVary, demonstrating the efficacy on median lobe. That five year data now running out to 4.4% retreatment rates for these prostates, with a 5% of returning to medication, I think fairs very well. And seems to be a little superior to that of the UroLift.

Dr. Kevin Zorn:

The downside, as mentioned, the first one, I explain to patients, you pretty won't like me, this area you're going to have some inflammation, we'll need you use the catheter for a week. And then thereafter, the dysuria, some of the irritative symptoms, which most of these, as you can see are short lived and dissipated within three to four weeks. Here's the all recur paper looking at cost and comparison to combination therapy and UroLift and GreenLight and Rezum having a really big drop in IPSS with a relatively lower cost compared to some of the other competitors.

Dr. Kevin Zorn:

So here, this is sort of comparing the MIST and the way I explain to my patients, very low, if any erectile dysfunction, the ejaculatory, there are some probably advantages between three and 5%, especially the larger prostates, men who are due more treatments, especially at the apex to get them out of retention has the higher risk of having those dysfunction. But more or less, I'd say over 90% of patients are going to have maintenance of ejaculatory function, and the surgical failure rate being in favor of the Rezum, as well as the medical failure as well. So that's why I tend to favor Rezum in those patients versus the UroLift.

Dr. Kevin Zorn:

So that said, I think the six month outcomes and this is some of the data that's put up in literature and demonstrated to patients is there is a defect as you can see quite a noticeable one as you back to the verumontanum, you can notice the verumontanum is intact, its pristine. For that reason, more likely to do well. Here's a GreenLight two years out on the right, demonstrating there is some degree of a veru, but it's not as preserved, or diffuse and heterogeneous regrowth. Just as comparative to show.

Dr. Kevin Zorn:

So I think there's that consistency that when you deliver steam, the steam is doing the work, you don't need to have as much training and talent. And so again, I think the Rezum itself is office-based. It could be a one hour door to door very little learning curve, the more the inconsistency, I think of the number of treatments people do. So, Dr. Bhojani and I, and Dr. Elterman, mentioning that in the literature, there's no standardized method of reporting the number of injections. So if Mr. Jones goes to 10 different urologists, I think there's going to be 10 different a number of injections and treatments and angles that will be delivered. So there's not that necessarily consistency as we would see for perhaps the Aquablation.

Dr. Kevin Zorn:

So in the current 2021 era, BPH treatment, which is crowded, I'm sure everyone will agree to that, we need a personalized, that's the special word. We look at Aquablation on the left here with we can treat large prostates, there's an immediate cavitation, it's consistent, an image plan robot executed. So across the board, you don't have to do two year dedicated fellowships, I think this will be the way of the future. I really think so. In the next 1020 years, I expect this to be sort of across the board way we treat BPH. Short learning curve, the downside, maybe those who are anticoagulated, getting through the hospital stay, especially a lot of these Mr. Office outpatient procedures. Looking at cost and availability, this robot is another issue.

Dr. Kevin Zorn:

Looking at Rezum, it's an office-based. It's really dedicated for 30 to 80 grams. We're missing data on the over 80 gram prostates. The recovery takes little bit longer, there's a four week recovery. Most patients say it's mild symptoms and they get through it. The question again, the issue is the time delay to getting to outcomes, men in retention. And then the variability depending on who's doing it, that number of locations and treatments is also a big factor. And that may influence some of the ejaculatory dysfunction if you're treating below the horizon near the veru for treatments. So both offerings optimize ejaculation, there's no 100%, explain to patients. Patients selection and expectations are of paramount importance. So with that, I thank you for your attention, and we can screen some questions.

Dr. Naeem Bhojani:

Thank you, Dr. Zorn. So in terms of Aquablation, you mentioned that we've learned some lessons from Aquablation namely, not going too deep. Do you think you could use that information for other procedures? For example, I know you do a lot of GreenLights. So is that information that you could use when you do GreenLight for someone who wants to maintain antegrade ejaculation?

Dr. Kevin Zorn:

Yeah, so I've had a handful of patients where I've done what I call sort of a partial trap where you're going to open up the floor only, save the lateral lobe. So Dr. Kaplan's published on that as well, looking at bipolar, he just said floor only, for those with the median lobe and the floor, he just cavitated between, let's say, five and seven got a capsule, clear the floor and stopped maybe a centimeter in front of veru, kind of enucleated. I would wonder if you guys have done the same, that ability to sort of tailor into the equation that treatment. But I would think most often enucleated you're not enucleating a 45 gram prostate on a 52 year old, newly married gentlemen. You're dealing with the 80 year old gentleman who can't urinate 1.2 liters of retention bladder diverticulum, you just want to maximize residual. He probably wants his ejaculation to be removed too, but it's important. But I think in the categorization of what's important is getting that catheter out, protecting renal function being important.

Dr. Kevin Zorn:

So yes, I have done GreenLight cases like that. I've had outcomes where they're favorable. There's been some reported GreenLights as well. We haven't had any excellent, let's say randomized control study with post ejaculate urine analysis or sperm counts, post procedure to validate. It's mostly a question of the MSHEQ that we're going to capture. We don't have more objective ways of evaluating ejaculation.

Dr. Naeem Bhojani:

Looks like your presentation did pretty good. So if you had 100 gram prostate and a patient wanted to maintain their antegrade ejaculation, 50% of our audience would recommend Aquablation. What would you recommend? 100 gram prostate, Dr. Zorn, patient really wants to maintain their antegrade ejaculation?

Dr. Kevin Zorn:

Yeah, so I think if that's the most important thing, and they're not retention, and we really want to optimize, I think the MISTs can be discussed. We have to say that it's 100 grams or that don't have data, the FDA approval is 30 days for Rezum. UroLift is again, 30 to 80, they expanded to 100 in median lobes, but I don't know if everyone's doing that, especially for median lobes. I think those are the things that we put on the plate. The Aquablation, again allows that more certainty. And again, you see it, you witness it, you're the one designing that let's say the CAD, you're trying to make a model. You design a CAD, you press a button, the plastic printer designs you have 3D reconstruction, this is the inverse of exactly that. I think there's nothing else that provides that consistency and regularity that you can preserve. So for that reason, I think Aquablation would be the way to go.

Dr. Naeem Bhojani:

Dr. Mouli, how about you? 100 gram prostate, patient wants... And you can only say PAE now. And patient really wants to maintain their antegrade ejaculation. But I'm assuming for this, you would probably recommend PAE.

Dr. Sam Mouli:

Yeah, I think there is a urologic adage that size doesn't necessarily correlate with symptoms. But I would say the converse, a patient with a very large gland with significant symptoms would benefit from something like embolization. Certainly all the other neurologic options are available, but in that patient category, I think embolization probably does the best versus a patient with a smaller prostate.

Dr. Naeem Bhojani:

Great. How about for 50 gram prostate, Dr. Zorn? You would prefer Rezum, I'm assuming, to maintain antegrade ejaculation?

Dr. Kevin Zorn:

So right now we're just kind of bucketing it into the volume. And I think that's another factor. If you have 100 gram prostate, more likely you're going to be at least 10 years older than the 50 grammer. I mean, I think there's an age factor has to be discussed. But yes, I think if we're going to use the 50 gram, most likely you're not going to be in retention, and I would think that would be the probable case. So if it's a median lobe, 50 gram, I think the Rezum is the way to go. I really think that they are younger, to do an Aquablation on a 50 gram, I know we've done the data, but to a patient, I can do it in the office here and they'll go home within 40 minutes with a catheter. Or we'll do Aquablation where they'll have to be kept overnight potentials for transfusion or what have you. So I would think the 50 gram would be the Rezum ideal patient.

Dr. Kevin Zorn:

But again, there's a lot. I'm sure everyone here has a lot of different, the anticoagulation. So, that's the advantage, if he's on Plavix and Coumadin, I can do a Rezum. It's really very minimal, it just mucosal bleeding, pretty straightforward. To do Aquablation, obviously not the case. And the medical community, I think the factor of the PAE is exposure to radiation, time on the table. I don't think they're done in 30 minutes or an hour. I think some of these patients are on table for quite some time. So that has to be factored into the equation as well.

Dr. Naeem Bhojani:

If you look at our poll results, actually, so about 50% of the audience would do a MIST procedure for a 50 gram prostate. And about a quarter of them would do a PAE. Just a question for you Dr. Mouli, since we also have Dr. Krambeck, how do you guys decide? You're at the same institution, how do you decide between PAE and HoLEP?

Dr. Sam Mouli:

That's a great question. Dr. Krambeck just recently joined us in January. So it's very new, but the success of our program to date has been contingent upon a great collaboration with urology, we get the two FDA approved ID clinical trials to study PAE. In those settings, the patients came through urology, they did all the follow up. So we were coming, as I mentioned, blinded to the results. And I look forward to continued collaboration with the group because that's really why we've been successful. So it's going to be a shared decision making process, I think, it's, let's say it's driven, as we all know, and quality of life is a primary concern.

Dr. Sam Mouli:

And so for every patient, you got to weigh the invasiveness, the return to normal activities, the preservation of sexual function, and every patient's going to weigh that differently. And so having shared decision making with them is critical. And that'll kind of guide you towards which therapy might be the best for them. Some, the urinary symptoms might be first and foremost, and they want to get relief right away, then you need something that resets the tissue. Absolutely, I won't argue with that. However, if they're really worried about having a catheter, they want to go back to work as soon as possible, they want to try something minimally invasive, to start, knowing that you might need further therapy down the road. I think PAE is a good option in those patients.

Dr. Naeem Bhojani:

I guess also, I was talking to Amy before with enucleation. Basically there's very little chance they're going to maintain their antegrade ejaculation. So I don't know, maybe that would be something you guys could discuss, Amy. Maybe if your patient really wanted to maintain their antegrade ejaculation, you'd send them over to Sam.

Dr. Amy Krambeck:

Yeah, and so the patient population in Chicago, they're very knowledgeable, and they know what they want. So the benefits, we all know the benefits of enucleation and the nice thing about enucleation now is there is no catheter. I mean, they may have a catheter for a few hours, and that's it, they go home the same day. 200 gram prostate, 50 gram prostate, doesn't matter. So I mean, there's huge benefits to that, but the big downside is retrograde ejaculation. So, if the patient is unable to accept that they will have retrograde ejaculation, then we have to talk about other options. And in those patients, I will discuss PAE, or Rezum, or UroLift, or whatever fits their size prostate in their clinical scenario. So if you are going to treat BPH, you have to have an open mind, and you have to be able to understand that it's not one size fits all for all patients.

Dr. Kevin Zorn:

No, just a question because I know that some of the GreenLight people with the side firing laser have tried to do these adaptive techniques. Does anyone in the nucleation world try to create like what we've seen with Aquablation, with GreenLight use, instead of starting at the veru and doing that peri-veru deception. Start a centimeter back, get the capsule, then move forward. Any thoughts, or trials, or anyone ever thought of that?

Dr. Amy Krambeck:

Yeah. We were just talking about that, Naeem and I, before we started the webinar, and I think a few people have played around with it. The problem with enucleation is it's like peeling an orange. There's one way to peel an orange. And if you don't stay in that plane, you've got juice everywhere. Yeah, it's kind of the same thing with the prostate. Like if you deviate from that plane, then it no longer becomes an enucleation it becomes an ablation and then trying to control bleeding and so on. Some people have toyed around with median lobe only. And I think if it's a median lobe only, and they have significant lateral lobe, you can potentially preserve ejaculation if you move far enough away from the veru when you do it. Then I think their data shows maybe a 50% retrograde ejaculation rate. But nobody's really tried to fully change the technique to make it better.

Dr. Naeem Bhojani:

One quick question, Dr. Zorn, there some data to suggest that UroLift preserves ejaculation better than Rezum. Any thoughts behind that? And why that would be?

Dr. Kevin Zorn:

Well, I think, I didn't put up some of my slides, but some of my patients kind of what we saw with Sam's discussion too, where once you've done some thermal impact, it's like you got a sunburn, right? You don't want it the next day, it takes some time. And the same, we devaporize, in this case, do a pop those with the heat. And these patients will slough off big chunks of tissue over the next couple of weeks. Well, you can't predict as surgeons we're placing these things, and what we can predict is the inflammatory phase, or the degree or amount of sloughing. So that's going to be a component of where those objections are made near the veru for those patients.

Dr. Kevin Zorn:

So yeah, I think the UroLift is you're just putting a suture deep through to the capsule, you're hitting an anchor at the capsule, you're compressing you're firing your other suture. So really, all your treatments are up toward, let's say 10 and two, you're nowhere near those structures. You don't want to be putting one near the sphincter nor the bladder neck. And you're not treating men with median lobe, so most likely you're a younger, smaller prostates that are being done. And so there's nothing thermal, you're compressing transition zone and the ejaculatory system is beneath on the floor. So there really is no treatment beyond the puncture. So in the Rezum, you puncture, but the steam goes one to two centimeters in a circular spherical treatment under the mucosa, you don't see where you're treating. Whereas the UroLift, you're in trajectory with your needle, there's nothing else going any direction elsewhere than that. That makes sense.

Dr. Naeem Bhojani:

Excellent. All right. Thanks, Kevin. Thank you to our faculty, it's a great session. Thank you to the audience for attending, thanks to the Uronology Society for inviting us. And if there's anything else, Dr. Krambeck?

Dr. Amy Krambeck:

It was a wonderful discussion. I think I learned a lot personally, I always do with these meetings. So thank you Dr. Bhojani for a great moderation. Join us on February 19th 2021, where we have a debate on, Can Focal Therapy Replace Prostatectomy in Men with Localized Clinically Significant Lesions and a Negative Standard Biopsy? The faculty is Dr. Emberton and Dr. Carroll. On the panel will be Dr. Klotz and Herb Lepor. And then the moderators will be Dr. Abreu and Dr. Polascik. So I think this will be a wonderful presentation.

Dr. Amy Krambeck:

Remember, you will get CME credits, you will receive a survey from Michelle Paoli, indicate which seminars you attended and you will get the CME certification sent to you in your email. Please fill out the evaluation questionnaire at the end of the seminar. And all upcoming webinars are listed on the Endourology Society website at www.endourology.org. We encourage everyone who is not already a member to join the Endourologic Society. Your membership dues provide you with many membership benefits, including the full text online access to the Journal of Endourology, video urology and case reports. So please again, go to the www.endourology.org website. And finally, we are all keeping our fingers crossed for September 21st through the 25th in Hamburg, Germany, for the World Congress of Endourology 2021. I hope to see everyone there. Thank you