Last year, I participated in the French Urological Association (AFU)/AUA scholar exchange program. A few years ago, AFU and AUA began a partnership, offering to young urologists in training (fellows) travel to a US academic center for 3 weeks for an immersive experience with benign prostatic hyperplasia (BPH) experts. Being in my third year of fellowship in Paris (focused on BPH), and working on my PhD thesis (focused on BPH, too), I had no hesitation when I was offered a trip to Houston Methodist Hospital (Figure 1) with Dr Ricardo Gonzalez, ending in Chicago for the AUA Annual Meeting.

Figure 1. Houston Methodist Hospital.

More than good timing for my personal course of study, I am convinced that we are living in the perfect time to participate in exchange about BPH to help find the best use of each of the many novel technologies at our disposal. I welcomed this eye-opening international exchange and opportunity to share ideas with like-minded and innovative surgeons.

Simple prostatectomy and transurethral resection of the prostate were described in the 1930s, remaining as gold standards for 70 years.^1,2 As holmium laser enucleation of the prostate (HoLEP) was starting to rise in the early 2000s,³ innovative surgical technologies were emerging, improving safety of procedures. In the past 10 years, we have been experiencing the climax of innovation, and minimally invasive surgical therapies (MISTs) are now changing the approach to treat many of our patients.⁴

In this period of fast progress, we can get “analysis paralysis” with the diversity of techniques. Sharing with experts or even just discussing communal experiences with our colleagues seems a logical way to navigate in this new field and master the techniques.

Figure 2. Enjoying a Texan dinner with Dr Gonzalez’s family after a day of work.

As a concrete example, while recognizing that the American and French markets are different, Aquablation remains rare in Paris. At Houston Methodist, I could observe many procedures, and was impressed by the automatization of the technique, improving reproducibility and decreasing the learning curve. In particular, the ability to treat a > 200-g prostate, preserving the apical ejaculatory hood, in less than an hour raised the question of the place of enucleation for these cases. However, general anesthesia and the necessity of bipolar coagulation leave the debate open in the era of even less invasive office procedures (ie, MIST).

Regarding MISTs, technical feasibility cannot be the only concern. For example, regarding vapor thermal therapy (Rezu¯m), the patient pathway was even more insightful than the technique itself. During this procedure, which was done completely in the office setting, the patient was prepared by the nurse patiently and reassuringly. Everything was ready when Dr Gonzalez came to perform the brief 5-minute procedure, and the patient could take his time in the room afterward when the clinic activity kept going in the next rooms. I was very inspired with this system, involving nurses and all the team directly with the patient, making them comfortable for procedures purely under local anesthesia. Interestingly, the technique of local anesthesia that we discussed during the trip has allowed me to improve my technique for in-office transperineal prostatic biopsies, proving one more time that sharing with others is always an asset.

Of course, technical aspects remain an essential end point in this kind of topic for an exchange program. To cite just one of many discussions, we both have experience with placing UroLift implants, and we could debate about management options for median lobe obstruction. Indeed, data about UroLift for median lobes recently emerged,⁵ and the specific way to fix them on the lateral lobe remains somewhat controversial in the community. In fact, the debate about the relevance of this indication of treatment, in particular to treat storage symptoms, remains unclear and should be further studied.

The main topic of this exchange was BPH and was not limited to MIST. The enrichment concerned every aspect of the practice, including systematic techniques to perform prostate enucleations. For example, I was trained in HoLEP during my fellowship and managed the preservation of ejaculatory function with enucleation of the median lobe alone when possible. Sharing with Dr Gonzalez (Houston Methodist) in the operating room (OR), it appeared that the side-fire MoXy fiber of the GreenLight laser was much more efficient for the median-lobe–only enucleation. When I came back, I decided to export Dr Gonzalez’s technique. I am using it now every time that I can, saving time and energy during enucleation and coagulation, and allowing us to multiply procedures in a day as we don’t use HoLEP kits that necessitate morcellators for these patients. This is an example where doing enucleation can vary depending on what the patient’s goals are; for patients who do not mind the idea of retrograde ejaculation, HoLEP remains a mainstay at both of our hospitals.

Outside of the OR, it was an equally enriching experience. We would “debrief” about what was done in the OR over a beer. I enjoyed meeting his family over Tex-Mex dinner realizing that we enjoy the same quality time on each side of the Atlantic (Figure 2). I was able to go to the NASA (National Aeronautics and Space Administration) Johnson Space Center on the weekend to see where space flight was developed and designed, much the way innovation continues inside of the ORs of the Texas Medical Center.

Ending this trip in Chicago for the AUA Annual Meeting was a perfect “grand finale.” I met many people involved in BPH, attended the meeting of the Society of Benign Prostatic Disease, and shared experiences, ideas, and visions of the future with surgeons who are game-changers.

I came home from this trip with ideas, motivation, and new friends, and I started by sending abstracts of my work to meet them again in San Antonio.