Wayne Kuang: Well, thank you all for having us, ManVsProstate. I'm a private practitioner for the last 20 years. I'm practicing in New Mexico, and this is just a passion project from the pandemic. I think it was an outreach from everyone we've spoken to around the globe on LinkedIn that this is an important truth, that bladder health matters. Because the time is now for BPH, BPO care to prioritize the preservation of bladder health. With the right dialogue, the right data, from triage, from bladder health baselines, we can de-obstruct earlier within that window of curability to prevent late-stage disease and to optimize bladder span, the number of years lived with optimal detrusor function. Sadly, the bladder has evaluated our performance, and I'm going to bring this slide up, and it has given us a failing grade, and that's the truth. Using our own AQUA registry data, we have come up short. We've been diagnosing and managing male LUTS BPH with almost like a blindfold over our eyes, obscuring our vision. We've been coming up short with even the simplest of testing, postvoid residual in only 30%. Uroflow, 3%.
Our advanced testing cystoscopy in only 3%, in multichannel 0.1%. Diagnostics are not just simply tests. They are our translator for the bladder to ensure the bladder's preferences and values are communicated and integrated into management choices. The bladder is speaking to us, but we are choosing not to listen. And that's why you see here a de obstruction rate, 7.8% single digits, and the majority are being managed with medications. Chemicals are not a mechanical solution to the mechanical problem of BPO. And we ask ourselves, why is this happening? And it's not because of indifference. It's not because of incompetence. It's because of a much subtle thing, the mind share gap. We have allowed other entities, prostate cancer affecting 1 in 8, bladder cancer, 1 in 28, colon cancer, 1 in 23, to dominate the narrative. The bladder does not have these options. Men know about their PSA way before the concept of QMAX.
They don't even know that urgency, frequency, nocturia, urgency incontinence is the bladder pleading for help. BPH. Shout out to [inaudible 00:19:35]. It is very complex. We get it, but that's why we need to simplify the complexity, and we can do that. We launched the five stages of bladder health, a community-based, patient-facing decision-making aid. Because BPH is about bladder health. You can't transplant that organ. Let's take care of it. The heart is a muscle that pumps blood. The bladder is a muscle that pumps urine through that prostate that starts off about the size of a golf ball and the shape of a donut. As that prostate grows bigger, that donut hole's going to grow tighter, causing things to slow down, stage I. The bladder muscle begins to work harder, struggle, becomes overactive, stage II. If we don't take care of it, the bladder acts out like a rebellious child causing urgency incontinence, stage III. If we really don't take care of it, just like the heart can have a heart attack, the bladder can suddenly stop working, causing the emergency of retention, stage IV. And like the heart can have heart failure, the bladder can go into bladder failure, causing a lifetime of catheter, stage V. Worst case scenario, the heart can still be transplanted.
The bladder's not so lucky. Yes, this is an oversimplification. Transitions are not distinct. Stages can be skipped, and stages can coexist, yet it highlights how this disease steadily progresses to more serious stages, and it reframes LUTS as more than just symptoms to be managed, but more importantly, this is precious physiology that needs to be protected. And it gives us a lens to look at old data. As Dr. Wein knows, the Thomas Study 2005, where we made the decision to simply observe men, 140 men obstructed, proven by urodynamics, observed after 24 years, and we showed that the real ramifications were on bladder health. Stage II detrusor overactivity increased by 100%. Stage III increased by 50%, and seven men were pushed into stage IV retention when there were none at the start. The UPSTREAM trial showed us who were the most suitable candidates. It was not those in stage V with weakened bladders, but it was those in stage I with clear obstruction where we have the best chances of saving those bladders.
If you guys can see Dr. Wein's talk on detrusor underactivity, you understand that in the Mitchell Study, 19 patients, which he taught me, atonic bladders by multichannel urodynamics undergoing enucleation. While we were able to salvage some contractility in 80%, we were too late for one in five. And this is a painful truth. We're intervening too late. We need to be better and we can. By number one, bladder health screening. We need to talk about this. AACU, NHS in Europe, let's talk about screening men somewhere between the ages of 45 and 55 with QMAX as the next vital sign for men and using symptom scores. We can also use it, intervene early with the Triangle of Triage. Identifying bladders at risk for dysfunction when they meet these criteria in isolation or in combination. Stage III, urgency incontinence, stage IV, retention. IPSS 8 and above alone, or in combination with slow flow, high residual, thickened bladders are unacceptable risk with BPHTool.com. These trigger bladder health baselines with a minimum of cystoscopy up to a maximum of multichannel urodynamics. We are replacing the guesswork with a sequence, right dialogue, right data, that drives the right deobstruction.
We call it the Duality of Deobstruction. What is the most you can do? Well, that's your maximal approach, or is it some fraction thereof, your fractional approach? The bladder applauds having all these tools in our tool belt and also celebrates the right surgical choice based on the right size, the right shape, and the detrusor function. That's our trifecta. And we do this at the table of shared decision-making where we seek compromise when one size does not fit all. When patients want to live their best lives with the best physical, intellectual, emotional, social, sexual, spiritual health, when bladders want the best health with the maximal approach, when healthcare wants to reduce the burden of BPH, and when urologists want the greater benefits and durability of a maximal approach while balancing risk versus reward. Surgical choice is a two-step process where we choose a technique based on the approach. For a fractional approach, we choose from the categories of LIST, least invasive surgical therapies, and MIST, minimally invasive surgical therapies.
And for the maximal approach, we choose from invasive surgical therapies as we all know. So I'm going to stop my share and I just have one final word. The preservation of bladder health is our true north. Let us work together with the expertise and wisdom of folks like Dr. Alan Wein, where let's find the right dialogue, the right data. Let's triage, obtain bladder health baselines to deobstruct earlier within that window of curability to prevent late-stage disease. And my promise is that together we can affect positive change away from that prostate-first approach to a data-first, pro-diagnostic, bladder-centric paradigm so all of our patients can live their best lives incontinence-free and catheter-free. We need to lean into protecting bladders. We are defenders of the detrusor. Let's go save more bladders. And this concludes what I have to say, Dr. Wein. I just want to wish to add that sharing this time with you all and UroToday gives us hope and I look forward to similar interactions frequently in the future.
Alan Wein: So thanks so much for that. That was very energizing. So when do you think men should start to be screened and what should we be on the lookout? In other words, something, simple evaluation that might be able to tell us who has already started on the path to having a lower urinary tract that's not going to function well unless they do something about it before they get to, let's say, old age and they have urgency urinary incontinence, they're pretty much in retention or are in retention, et cetera?
Wayne Kuang: The answer there is let's not reinvent the wheel. Where can we learn from? We can learn from hypertension screening. They have a vital sign, blood pressure checks. We have one, too, QMAX, maximum flow rates. China looked at their data. We know that around 60 years old, there's an inflection point after which scores, IPSS scores 8 and above start to really rise at around 60. Then if we look at the Benner studies, as you know, for men, around age 60 for urgency incontinence, about a little more than one in three men will have that as an issue. Then if we look at the retention rates, probably around 60, it's a little less than 1% per year. Now, in my book, I wrote that I thought ages 45 to 55, depending on the healthcare system, was the best time. But I think talking to primary care last week out at Arizona, 45 to 55 might stress the system too much and increase burnout and overload the system. So actually, I'm thinking maybe a little bit around 60, because I test out the system, beta tests, see how it works, how do we interact and interplay with primary care?
The second thing we need to do is be willing to listen to the bladder, but we have to use the right symptom scores. Choose the one that fits your healthcare system, ICIQ, the LURN, the IPSS. Some people are actually using the community-based, non-validated IBPSS. I might've sent that to you already, Dr. Wein. It's basically IPSS reordered to mirror stage I, stage II with voiding subscore, storage subscore. Then we added a question for urgency incontinence stage III for the LURN, and then we used ICIQ for a question about retention. So now we have a way for patients to auto diagnose themselves. They can see where they are themselves in the present, stage II, stage III, and it ignites them to do what it takes not to let their bladders enter the late stages of disease. And now the conversation is starting. I just met with the American Association Clinical Urologists on Tuesday to really look for public policy initiatives on the Hill to try and help us initiate this dialogue and start talking about screening just like we do for hypertension. So that's where I'm hoping we're going, and we're trying to just now spread that message across the Atlantic and the Pacific, and we're gaining momentum right now.
Alan Wein: If you turn up someone, let's say, that has a QMAX peak flow rate of 15 mls per second, which is low. I mean, low, but not terrible, not awful. And yet they have minimal residual urine, probably, let's say, I don't know, 50 mls, something that's very minimal. And they have, I would say, modest symptoms. So, how do you manage that person? Do you automatically say, "Wow, we ought to do something. We ought to follow you. We ought to try and treat you with something that's minimally invasive, non-surgical, et cetera?" I mean, how do you manage someone like that within this paradigm of stepwise progression to disaster?
Wayne Kuang: What we're trying to do is first educate, pre-educate. "Mr. Smith, did you actually know it's really about your bladder that we're worried about? You only have one, so let's take care of it." Then we want to educate that it's really about the data. You and I both know all these symptom scores are actually rather subjective and have a lot of recall bias. And so what we're trying to educate, "Hey, you're right on that fringe. Let's get a bladder health baseline. Let's choose data in your journey so we know where you are with shared decision-making." Let's say they do choose to pick something like try a medication, but now you have a baseline bladder health assessment that you can track.
And now is the golden era where we have the ability to track very easily with all the advancements with QMAX uroflowmetry, whether it's ProudP, Maniflow, MenHealth, IO urology, at home or in the office, we have the ability now to track and get these bladder health baselines for guys. And I think that's really just the message because all men want to live not just longer, but better. I mean, think of us, we all have our smartwatches. We want our data. The modern man wants to be involved with making those decisions based on their data. It's very easy for them to see and it's very easy for them to buy in, especially with the IBPSS. When you say, "Hey, Mr. Smith, you're already in stage II." "Whoa." They don't want to get to stage III, IV, and V. How do we know? Well, let's get the data and then let's talk.
Alan Wein: So what about the use of 5-alpha reductase inhibitors? I mean, do you think that slows this progression along with alpha blockers, or what do you think the actual role of medication is somewhere in what you perceive as the early stages, and how early do you really treat someone, or how early do you recommend? Because a lot of patients will say, "It doesn't bother me that much. It's okay." I mean, what do you tell those guys and do you try and manage them medically before you clear out all the stuff there?
Wayne Kuang: Wow, there's so many good points there, Dr. Wein. Number one, I just want to talk about men. Men, every day they put on this armor of masculinity, and we need to pierce that armor and invite them to take it down and have an honest, vulnerable conversation that's based on data. And it's very hard. I tell guys, "Most guys suffer from I'm fine syndrome. Oh, doc, I'm fine." But they're actually just fearful because they don't understand what's going on and what's at stake, their bladder health. I think we got into a bad habit in general in America. "You got a problem, Mr. Smith? Take a drug. Still got a problem? Take a second drug. Still got a problem? Take a higher dose." We need to understand that BPH drugs from a ManVersusProstate perspective, this is controversial, they are temporizing measures. They do not treat the mechanical problem of benign prostatic obstruction. We're not anti-drug. Antibiotics treat sepsis.
Like brain tumors, shout out to defender Ricardo Gonzalez, where we use medications to temporize the symptoms and surgery to take care of that brain tumor, surgery, deobstruction is the mechanical solution for the mechanical problem of true benign prostatic obstruction as you and your colleagues really clearly defined by multichannel urodynamics. And people ask me, "Well, what about the COMBAT trial?" We applaud it. It did a great job of demonstrating of temporizing and reducing risk by 66% out to four years as compared to tamsulosin. However, by inductive reasoning, if you take those curves and you spread them out to 10 years, the risk is never eliminated. We're essentially just sweeping the problem under the rug to deal with it later once the disease has progressed. And as I talk around the country, I say, "What's the largest retention volume you were called about in the emergency room?" "1 liter, 2 liters, 4 liters." "What percent of those men were on BPH drugs, alpha blockers, 5-alpha reductase inhibitors?" And it's most of those men are on those BPH drugs. They are temporizing, not treating for true obstruction.
Alan Wein: So one last question. How do you follow these people from year to year? Let's say you established a baseline, patient says, "It's okay. Why don't you let me come back and see you? Just pick a time and we'll do some studies and see if I'm getting worse, staying the same, et cetera." How do you follow these guys?
Wayne Kuang: At a minimum with the symptom scores as well as Uroflow and a PVR. I'm very lucky that I have access to pressure flow studies with a cuff test. And so, I can actually check that a year later and just make sure there's not progression. I have a lot of guys who I have to be very careful with because I have this guy, a Vietnam War Vet, tough as nails. He's never going to be like, "Hey, this is bothering me." So I have to really use the data to drive good decision-making, not just for him, but also for his bladder.
Alan Wein: Got you. Well, as always, I enjoyed the presentation. I enjoyed the answers to the questions. I wish you luck in this, and I hope to see you on the circuit again very soon.
Wayne Kuang: And your thought... Okay, be well.