195: HOLEP - The Prostate Procedure Changing Lives

Scot: John, I've got a question for you.

Dr. Smith: Yes, sir.

Scot: As a man, not as a doctor, because you actually know this answer since you're a urologist, at what point do you think a guy should start worrying about how often he's peeing? How many trips to the bathroom before it's an official problem?

Dr. Smith: I mean, that's a tough one because if it doesn't bother you, a lot of times guys won't come in. And so I usually tell guys when it starts to bother you. But I would say any time it becomes more frequent than every few hours, or you're waking up more than a few times at night, that's something to start to have the conversation about.

Scot: All right. And Mitch, how long do you think a guy should wait before the stream starts? I mean, you're all ready to go and you're just waiting. How long?

Mitch: Am I comfortable at home or am I at a very busy urinal?

Scot: Busy urinal.

Mitch: Oh, it's going to take a minute. It's going to take 30, 45 seconds.

Scot: Yeah. Well, there are a lot of things guys will talk about. We'll talk about sports, grilling, the best way to cook a steak, but what's not on that list? Prostate problems. And prostate problems can cause what I just talked about right there.

Nobody wants to talk about it, but too many guys deal with it. You're waking up three, four times a night to pee. You're standing at the toilet for what seems like forever. Then when you're done, it still doesn't feel like you're done. I mean, it sucks. And at some point, the meds and the quick fixes just don't cut it anymore.

That's where a procedure called HOLEP comes in. It's a high-powered laser that clears out the problem. Only a handful of doctors in this region even do it. And we're going to talk to one of them today.

This is "Who Cares About Men's Health," with information, inspiration, and a different interpretation of men's health. The whole crew is here. I'm Scot. I bring the BS. The MD to my BS, urologist Dr. John Smith.

Dr. Smith: Howdy.

Scot: The "I care about my health" convert, Producer Mitch.

Mitch: Hey there.

Scot: And I think John Smith called our guest a rockstar when we were talking about doing this topic, urologist Kelli Gross.

Dr. Gross: That's awfully nice. Thank you.

Scot: You had to hesitate and pause. Were you thinking, "Is this the same John Smith I know that said that?" Is that what was going on?

Dr. Gross: John's always very nice and complimentary, and I promise I didn't pay him off, but I don't know if I truly deserve it.

Dr. Smith: Kelli's a very, very good urologist. She does a procedure that only a few people do. And I am complimentary of her, but again, a lot of people who get those compliments don't like to necessarily own them. I think Kelli may be playing down her talents and her skill level a little bit because I get to see her patients before surgery and after surgery, and so I've seen . . . There's no magic in medicine, but if there was, I've seen the magic.

Scot: That's cool. So, yeah, I think that's worth bringing out. John, you see a lot of these patients. You kind of do the preliminary workup for these patients, and then Kelli takes over and does the surgery? Is that accurate?

Dr. Smith: Yeah. You give me credit for being a urologist all the time on the show, which is partially true. I'm a non-surgical urologist in our office, where I don't go to the operating room. I do a lot of the workup for all these patients, I make sure they're taken care of, and then I pass them to my partners who are very proficient and do high-volume, high-quality surgery for folks. And Kelli happens to be one of those great urologists that I have the ability to pass patients to.

Scot: Kelli, not a lot of urologists perform this necessarily in the region, for sure. What does it take to become really skilled in this procedure? What is it that makes you such a rockstar doing this?

Dr. Gross: That's a good question. I guess it's doing a lot of them. I don't know if "fortunate" is the right word to say, but we get a lot of referrals from urologists in the area, not even just this state, but a lot of different surrounding states. And we get a lot of really complex patients with unusual situations, or particularly large prostates. To be modest, I guess, we're good at handling the more complicated situations.

Scot: Got it. So if you walk in the room, I know that I've got a large prostate issue if you come in and . . .

Dr. Gross: Well, I see people for a lot of different things, but that's one of them.

Scot: Sure. Fair. Do you remember the first time you did this procedure? Was there a point when you were doing this procedure and you were like, "Wow, this could be kind of a game changer for some guys"?

Dr. Gross: The biggest thing is seeing people in follow-up in clinic, and I definitely still have patients who message me, call, etc., and just are like, "Hey, my life is different."

I think I had a gentleman send me a message recently. I did his surgery, I think, in 2020, and he wanted to tell me he was still doing well, and definitely changed how he was dealing with his daily life.

Scot: So five years later, this guy felt compelled to send you a little message to just let you know, "Hey, things are still good, and this has been life-changing for me"?

Dr. Gross: Yeah. I appreciate those, though.

Scot: Yeah. Can you give us some other stories, a little bit more detail, like how this actually changed somebody's existence?

Dr. Gross: I mean, I hear it all the time. I had a gentleman recently who was saying how . . . This sounds very dramatic, but it really was, I suppose. But he was saying that before the date of the surgery . . . He wasn't suicidal or anything, but wasn't sure if life was worth living with all the stuff he had to deal with, with his urinary symptoms. And then after, his life was completely changed.

I mean, of course, everybody's got a different experience and some are easier than others, but I think there's a number of people whose lives really change when they don't have to deal with the urinary side of things.

Dr. Smith: There's something to be said for a good night's sleep, Scot.

Scot: Amen to that.

Dr. Smith: I mean, we have our Core Four, and that's one of them. Kelli hasn't been around the podcast long enough, but we have a Core Four for health, and sleep is one of them.

And a lot of these guys come in . . . I mean, imagine you're waking up every hour on the hour at night to go pee. Just set an alarm and try it tonight. Let me know how you like it. These guys have been doing it for 5, 10 years and they're at their wit's end. They're like, "Man, I don't know if I can live like this anymore."

Then they go through and they have this surgery, Dr. Gross takes care of them, they get their catheter out a few days after the surgery, and they go home, they pee for the first time like they're 21 years old, and they go, "Oh my gosh."

Then within three months, they're sleeping through the night with maybe waking up once. I mean, it truly is life-changing for these people, because I get to see a lot of them after surgery too and they make these statements like, "Man, I didn't know I could have it this good again."

Mitch: Wow.

Dr. Gross: Yeah, I had a guy recently, a couple weeks ago, who . . . We ended up taking the catheter out the day of surgery for various reasons. And even then, a couple of hours after his procedure, he was like, "I don't think I've felt my bladder empty like this in years."

Scot: Wow.

Dr. Gross: So it was an immediate change for him.

Scot: We should have a Core Five. Taking a good pee is probably . . .

Dr. Smith: Let's add that in. I like that.

Scot: Right? There's nothing better than . . . That's something I never would've considered, just what it feels like to have your bladder feel empty.

Well, the HOLEP procedure sounds like it can be just a game changer for guys. Why don't you go ahead and let us know a little bit what this procedure is all about? What's going on? What happens?

Dr. Gross: Yeah, so a HOLEP is a Holmium Laser Enucleation of the Prostate. There are a lot of different procedures that can be done for an enlarged prostate or urinary symptoms related to the prostate, and HOLEP is just one of them.

So what it is, is if you think of the prostate more like an orange, it's an orange with a hole in the middle. That's the tube that goes through the urethra. So the prostate itself makes up the urethra.

Basically, what we do is peel that orange from the inside, meaning using a little tiny scope through that urethra or the urine tube there. And then that big orange pieces, we push into the bladder and use a special machine to break that up and take out the tissue fragments.

So what that leaves is the outer rim of the prostate and removes all the blocking prostate tissue. So that ends up leaving most people with a pretty normal-sized prostate at the end.

Scot: And then that gets rid of all the issues that we talked about?

Dr. Gross: Well, in general. It could be a little complicated. If you've had urinary symptoms for decades and decades, you can start having bladder changes, for example. Or you've been getting up at night for decades, you may still get up at night. But for the most part, I'd say for most patients, they go back to pretty normal.

Dr. Smith: I'll plug in for 10 seconds. Everyone over the age of 50 to 55 wakes up, on average, once a night. So when Kelli brings that up, that's why we say that. Everyone is still going to wake up once a night, on the average, but those four trips to the bathroom are going to become one, maybe two. That is the goal.

Scot: And the other procedure . . . So you're just a handful of people in the area that do this. The more common treatment, when it gets to surgery, is something called TURP. Is that how you pronounce that?

Dr. Gross: Mm-hmm.

Scot: What does that mean and how does it compare to the HOLEP process?

Dr. Gross: Yeah, TURP is Transurethral Resection of the Prostate, like you said. And if you think of that prostate again, this time you're thinking of it a little bit more like a donut. Again, there's that hole in the middle. You're opening up that donut hole by removing little bits of tissue at a time. And that just opens up that channel, similar to a HOLEP. It's been around for a long time because it works pretty well.

Dr. Smith: Now, Kelli mentioned size. When I work these folks up and you talk about size, I'll make dumb analogies all the time, and one that I use for guys all the time is I say, "The guy that comes in that you can sell a two-seater Porsche to usually doesn't have four kids with him. Those are the guys you're showing the minivan to."

And so a lot of times, if the guy comes in and his prostate is really large, he probably needs a HOLEP, and he's going to do better with a procedure because the HOLEP tends to take care of larger prostates much better than a TURP.

And so, like Kelli mentioned, it's not really that one is worse than the other, but it's which one is more amenable to your prostate? And so we usually get a workup done where we look at the size and shape of the prostate to figure that out.

When I'm working them up, what's the best patient for me to send to you? What's your ideal HOLEP?

Dr. Gross: I've probably done enough that I feel like I could probably do a HOLEP on almost everybody if they needed one. But I think as far as versus other procedures, the guys that are really going to benefit the most are anybody who's on the younger side, because it's got a very low re-treatment rate as far as surgeries go. I usually quote 1% to 2% at 10 years versus pretty much every other surgery, except for simple prostatectomy. We haven't gotten into that. It's going to be a lower re-treatment rate than any of those.

Other guys that just other procedures might not benefit them quite as much are men who have had very large amounts . . . urinary retention where they can't go to the bathroom at all, but large volume is what we call it. So they've had two liters, for example, in their bladder when your bladder is supposed to hold about half a liter.

A real stretched out bladder, that's usually a sign that the bladder isn't working. So if we do a procedure that is not taking out as much prostate tissue, we'll tend to still need a catheter. So a HOLEP can get them to the point where they're emptying their bladder in a way that other surgeries can't.

As well as guys with a bit bigger prostates, 80 grams and up, those guys aren't going to do quite as well with a TURP or one of the more minimally invasive options, which I'll argue aren't necessarily minimally invasive versus the old-fashioned TURP or, for example, HOLEP.

Dr. Smith: That's exactly the way that I look at it when I try to get stuff done for you. But I know that if you're a guy and you're out there and you're seeing your urologist and they're like, "Hey, your prostate is X," in general, a HOLEP is reserved for larger prostates. Correct, Kelli?

Dr. Gross: I mean, I think you can do a HOLEP on pretty much any prostate size, but that's one big category where it's going to benefit you if you have a bigger prostate.

Dr. Smith: So do you feel, and I know we've kind of talked about this before, but a TURP and a HOLEP, in that 40- to 80-gram range, are equivalent is kind of my understanding. Is that how you look at it?

Dr. Gross: Maybe a little lower re-treatment rate, I would say, over the long term for those 40- to 80-gram size. But it does carry a higher rate of incontinence or leakage of urine than a TURP.

So 40- to 80-gram range, it's just going to kind of depend. If you're 50 years old, you're less likely to have incontinence of urine and more likely to need another surgery at some point. So that might be a good trade-off as far as what are the pros and cons to each surgery. But I don't think there's always a clear winner from that prostate size range.

Dr. Smith: And I think the smaller prostates are a little bit more technically challenging, from my understanding, on the HOLEP. Is that right?

Dr. Gross: Yeah, I'd say under about 40 grams, it gets pretty tough. And I'd say there, you probably really start seeing less of the improvement as far as re-treatment rates.

Dr. Smith: Kelli, I do a lot of these. Referrals that you get from other doctors for these HOLEP surgeries, what's the one thing you wish they would do differently in the workup process that would make your life easier in order to practice the way that you would like to and the best?

Dr. Gross: That's a good question. I think the biggest thing for me . . . I mean, I think this is true for any physician. I just want to make sure that a patient comes in understanding the options.

So I am happier when I know a patient has already had a discussion as far as, "These are the lifestyle changes you could make. These are the medications that you could try. These are all your surgical options," so that they're not coming here, often traveling really far, and I'm like, "Well, you could do meds if you want to." They traveled for me to talk to them about medications or something like that.

So that's the most important thing for me, is just making sure that they've had that conversation.

Dr. Smith: And so what do you think is the most important thing that they need to hear before they get to you?

Dr. Gross: Yeah, for me it's pros and cons of each of their options. That includes a HOLEP. I like to give people the percentages of what the risks are for all sorts of different procedures. And I like to tell people why certain procedures aren't great for them and certain ones would also be an option if I'm seeing somebody for a HOLEP consult.

A HOLEP is often a procedure of you can do it on almost everybody versus some procedures are just not good options for some people. So I prefer when people understand some of the subtleties in their decision-making.

Scot: I think when a guy hears about prostate, they get a little nervous to begin with, especially prostate surgery. And one of the first things that I think . . . You can tell me. Do men worry about their manhood, their sexual function, that sort of stuff, when you start doing operations and procedures in that area?

Dr. Gross: We definitely hear that, and I think all prostate procedures or medications or whatever it is are going to carry some kind of risk.

Now, that being said, having an enlarged prostate also carries plenty of risk as far as leaving that untreated and the things that can happen down the line with that. But all of it is going to have some potential side effect.

Now, most procedures don't cause much issue with sexual function except for retrograde ejaculation, which is when, if you ejaculate, it just goes backwards in the bladder. It's harmless. Most people don't care, but some people really do care about that. So a lot of those procedures will cause that, but it's very rare for any procedures to cause erectile dysfunction.

Scot: One of the things I think I really got from this . . . I think we're probably ready for some takeaways. Is there anything else we need to be discussing, John, when it comes to this procedure?

Dr. Smith: I mean, I think we've hit a lot of the high points. A lot of the nuance are things that people are going to have when they get to the doctor and they're going to nuance those conversations. I think we've nailed a lot of it. Kelli, anything that you think we missed that you would want to make sure that we had out there?

Dr. Gross: I'd say not podcast form. I mean, we can talk for forever. I'll talk to people in clinic for a really long time about pros, cons, post-op, all that.

I think one thing I do want to stress is I know a lot of guys are nervous to address their prostate issues or they think it's normal and they don't want to live with it. I encourage people to at least see a urologist, talk about medications, at least monitor it. We can work with you. If you don't want to do something, we'll still work with you, but we can monitor kidney function, for example, or how well you're emptying your bladder and where your symptoms are.

And I think in the long run, that helps prevent those bladder changes that I was talking about, and your results from a long term. I think people really just wait too long sometimes, and they've got terrible symptoms and it's a lot harder to come back from that than if we've been working with you, stayed on top of symptoms, and then eventually you're like, "Hey, this isn't controlled."

Scot: I think one of my takeaways . . . I always want to make things like, "This is the best procedure," or, "That's the best procedure." And it was really fun listening to you two talk because it really brought into focus the fact that we're talking about HOLEP primarily on this particular episode for people considering that, but there might be an instance where that isn't the best procedure and actually your outcome might not be as good.

I think you were talking about leakage, and if I understood that correctly, if you're not kind of in the right patient profile, you might actually have some side effects that you wouldn't want to have. Did I process that correctly?

Dr. Gross: Yeah, and I think also with any surgery and medications, any situation, we just can't 100% predict some of those rare side effects that people end up dealing with.

So, for example, if I had an 80-year-old guy with a 30-gram prostate, I don't think it's worth that potential higher risk of incontinence. But if he really wanted one, then we could do it. But we will at least talk about, "Hey, what does that mean?"

Scot: Mitch, what did you get from today?

Mitch: One of the things that I found interesting is I want to challenge your original assumption that guys don't talk about prostates because my . . . So I have had a very strange career path, and before you, Scot, most of my bosses I worked very closely with, average age 76. And there was a lot of conversation about prostate problems and what was being done about their prostates, and, "It just happens when you get old, blah, blah, blah."

What has been appreciated is just sitting and listening that there are options if you're having these symptoms. It's not, "It's just going to happen and that's just what's going to happen." It's very reassuring to say I don't love the idea of lasers by my bits, but hey, at the very least, there are people out there that can kind of talk through symptoms and are open to talking through those symptoms, and there are a lot of options available.

Again, love when I hear people talking about this kind of stuff that is usually reserved for not being talked about with guys.

Scot: Dr. Kelli Gross, thank you so much for being on the show. As another illustration of what a rockstar Kelli is, looking at her reviews here on University of Utah Health, out of 5 stars, she's like a 4.8. You can't even tell that that fifth star has anything missing. It's just a little bitty part that's missing right there. So thank you for sharing all of your knowledge and expertise and doing everything you do for men's health.

Dr. Gross: Yeah. Thank you for having me. It's been great.

Scot: If you have any thoughts or would like to share any of your stories, we would love to hear from you. The email address is hello@thescoperadio.com.

Thanks for listening, and thanks for caring about men's health.