“...brings a knife to a gunfight.”
― The Untouchables (1987)
Just because we did a prostate procedure doesn’t mean we relieved a man’s obstruction
Our hubris. A patient's poor outcome. The surgical trend is to do less. The reality is, if you do less, you get less. It is the reason that so many men who have undergone conservative TURP, Urolift, and Rezum are not satisfied with outcomes. In this era of proof by questionnaire, you are led to believe they are all doing great. You are led to believe success is all about some arbitrary percentage improvement from baseline. Success on paper, but not in reality.
Case: A 90-year-old man was referred to a urologist for overactive and obstructive voiding symptoms. Workup identified a 130+cc prostate; he was then treated with Rezum steam therapy but continued to have overactive symptoms including incontinence. This led to intravesical Botox therapy. Subsequently, he was hospitalized numerous times for urosepsis from increasingly resistant pathogens. He was referred for a second opinion.
The thought process of the first urologist: Because he did a procedure, Rezum, he assumed he relieved the patient’s obstruction. In fact, the voiding questionnaire was better. Therefore, in his mind, lingering urgency and incontinence represented an independent problem, so Botox was performed.
The reality: Rezum didn't adequately alleviate prostatic obstruction. The gland was too large. The overactive symptoms, which were a consequence of longstanding obstruction and prostate inflammation worsened from the resultant devitalized prostate tissue. Botox hastened the deterioration further by causing incomplete bladder emptying. The resultant infections were inevitable.
