Shammai Rockove, MD, FACS

Founder and senior surgeon, Center for Urology, Oregon

Introducing our newsletter

“Facts are stubborn things, but statistics are pliable.”

― Mark Twain

“Evidence based medicine” is harming us. It’s leading to protocol-based medicine. It limits thinking, doesn’t allow for introduction of nuance, falls prey to poor data, and restricts constructive dialogue. Bridging the gap is essential. We must understand the evidence, but also recognize when it is not applicable or simply wrong. Urology is caught up in the trend, and we need a workaround. Our newsletter will address common urologic issues realistically. The first issue focuses on some treatments for BPH (benign prostatic hyperplasia). Corporate America aggressively markets many procedures. Some are very effective, but others… not so much.

Aquablation Computer Console

One of the most important additions of 2023: Aquablation

Bladder outlet obstruction from prostate enlargement is a major health issue in aging men. Data is accumulating supporting the notion that addressing it sooner in its evolution is beneficial. Data is also accumulating casting concerns about long-term harms from medications such as tamsulosin and finasteride. In 2023, we became the first center in Oregon to offer Aquablation, with the advantage of more rapid healing and better preservation of ejaculation compared to conventional TURP. Our large experience already has allowed us to introduce important procedural modifications that benefit men even more.

In essence the pendulum is shifting. Prolonged treatment delay and pharmaceutical intervention is giving way to consideration of procedural options. The onus: We better be sure the procedures we offer actually work.

A rare glimpse of the aquabeam in action

Urolift has a safety problem

Once a treatment gains traction, even if it doesn't work well or is harmful, removing it from the market is difficult. Urolift has serious complications, and despite poor objective performance, its presence persists. Teleflex, the company that owns Urolift, is focusing considerable resources to spin safety concerns, as public databases are filling with at times life-threatening reports. I hope the trend of primary care providers discouraging their male patients from undergoing Urolift further strengthens in the new year.

Robotic contouring during the Aquablation procedure

The new issue: How to fix those with
Urolift. Many surgical options successful with
Aquablation high up on the list

With over 400,000 Urolift procedures worldwide, a problem arises: How best to remove the incorporated Urolift metallic clips from the prostate while also finally relieving men of bladder outlet obstruction. The best tool depends on the prostate size. Greenlight laser and Thulium/Cyber lasers are good for smaller glands. For larger glands, Aquablation has proven effective. For the largest glands only robotic simple prostatectomy and transurethral laser enucleation should be entertained.

The obvious question now being routinely asked: Wouldn’t a man be better off going through these effective procedures primarily instead of detouring for a poor initial procedure such as Urolift?

We're emotional not objective.

We physicians are not as objective as we think.

As any good salesman knows , and for what Kahneman and Tversky won a Nobel prize, it is emotion not cold hard data that drives our decisions. In fact, we selectively use objective data to support the emotional conclusion. If we recognize this truth, we can overcome its inherent limitations.