Bradley Gill: Firstly, thanks for the opportunity to join you. So urodynamics in men, there's really a lot happening. And one of the things you alluded to is the intravesical bladder monitoring device is commercially available. And that's actually something way back in training and in my engineering days I worked on in the early stages. It's really remarkable the technology and what goes into that device because it allows you to measure detrusor activity and pressure. And there's algorithms in there that can break down complex things, contraction frequencies and whatnot to help tease out the abdominal component from what's actually being recorded. So it gives you a pretty good insight into what the detrusor is doing. And from a male standpoint, very easily allows us to see if there's obstruction. The same for detrusor underactivity and when you're interrogating BPH symptoms and retention and those type of things. Overactive bladder, it's rather insightful as well, you can see detrusor overactivity and phasic contractions.
And I think compared to prior state-of-the-art catheter-based urodynamics, it's a big step forward because you're not sitting in a room with a bunch of people staring at you in tubes in different orifices and folks saying, all right, "Try and pee. Try and pee. Can you pee on command?" This allows the patient to actually get up, move around, have a cup of coffee, go to the bathroom in privacy. It gives much more real-world data.
Alan Wein: I heard that you were on your way, you collectively, to developing a rectal pressure monitor so you could make the record look more like what we consider at this time a conventional record. Do you think that that's going to add a lot or do you think the way it sits now is pretty sufficient for people who are experienced in urodynamics, perhaps with the aid of some gizmos inside what already exists to help you tell what's a contraction as opposed to what's just an intraabdominal pressure increase?
Bradley Gill: Yeah, I think that's a great question. We're creatures of habit. We're used to looking at the tracings that look at a certain way. We're used to diagnostic tests that we've always used so there is a learning curve there for sure. As to what's being developed and worked on right now, I can't really say much to that, but to the point you make, it wouldn't be very difficult to develop another pressure sensor to use along with. And again, it could be something that's ambulatory and easy to move around with. But depending on the clinical question that you have that you're using urodynamics to answer, the intravesical device itself is really helpful for a lot of what we see in men, our BPH, our retention, urge incontinence, those type of things. Stress incontinence, when I see guys for complaints of stress incontinence, that good old-fashioned standup and cough.
Alan Wein: Yeah, exactly.
Bradley Gill: You get it very clearly, and if you're not careful, you get it on you.
Alan Wein: Yeah. So do you think that this method, which is obviously more physiologic than what we do now. What we do now is totally unphysiologic. The bladder fill rate is like, was it one to 2 mLs per minute or something? And so do you think that this is going to change what we consider to be the norms as far as bladder capacity, as far as pressures, as far as compliance, as far as even flows without people staring at you or listening at the bathroom door to see whether you're going to be out of the bathroom quick enough?
Bradley Gill: Yeah, I think there's a lot to be learned there still. You fill the bladder quickly with cold water, you'll probably induce some artificial contractions. And will that cloud your determination of capacity and what the bladder's doing? Absolutely. At the same time, having something that's inside the bladder may also roll around and tickle the bladder, so to speak. So I think there's potential for some artifact on both sides. The other thing you bring up is the role that volume plays in all this. And again, that's a paradigm change and a thinking change for how we look at and we interpret that data. We don't have a way to measure really volume with the device and the technology in its current state, and that becomes something you just have to take into context. Flow rates right now, you use an external uroflow device to correlate with the pressure measurement. So you can do a pressure-flow study, but the volume measurement becomes a little bit of a challenge with that device.
Alan Wein: Right. So there's a lot of controversy about just urodynamics and in which areas it's really useful. So it sounds like for men, you think the study is really valuable in looking for the parameters we consider to be characteristic of obstruction, which may have to change with this device. And looking for involuntary bladder contractions, I guess, although if somebody leaks involuntarily, they usually know it and it's hard to imagine it's due to anything but a bladder contraction.
So do you think that urodynamics should be used in men with BPH? And the reason I ask is all these reports now of people making bigger and bigger holes with HoLEP and with aquablation and people who even carry over a liter of urine in their bladder have a big residual, which was supposed to be like, "Wow, they must have an awful bladder. Don't do anything to these guys." But a substantial number of them, certainly lower than if they have pressure flow indicating obstruction, but a substantial number void... They may have a residual, but they get off of catheterization and they're pretty happy. So suppose somebody said, "Well, what about these people?" Doesn't that mean that maybe we ought to just operate on pretty much everybody in retention?
Bradley Gill: Yeah, it's a very great question. And if I look at my own practice and how it's evolved over time, I use less urodynamic testing now than when I first came into practice. And I think some of it is experience and clinical gestalt and those type of things. But I think some of it also is the conversation with the patient and understanding the patient's goals and that in voiding dysfunction, bar none, that's what we work for. It's patient goals, quality of life, and it's getting everybody on the same page.
So I pull the old football analogy out when I have that guy come in with retention, say, "Hey, you've got a really big prostate. Chances are it's probably your prostate that's causing you the issue. We can do some testing, we can check your bladder function, we can see what's going on. And if you have a little bit of bladder function, we go in and completely clean out the prostate, there's a real good chance you're going to urinate again. Even if you don't have much bladder function, you can still void and have a permissive post-void residual. Or if you want to do something, you're tired of using catheters, you have to try something. It's a relatively low-risk procedure to do an enucleation either robotically from above or with a scope from below. We can throw the Hail Mary," and that's my football analogy. We'll throw the ball to the end zone, hopefully our team catches it.
Now, if we talk Cleveland football, Miami football, there's some differences there, but we won't get into that. And a lot of patients will look at you and go, "Yeah, I really want to do something to try to be able to urinate again." And you counsel them to the procedure and you go through with it.
Alan Wein: So last question, do you think that urodynamics in general or this device is particularly useful in a woman that comes in with pretty characteristic stress incontinence symptomatically?
Bradley Gill: It's a very good question. I'll tell you, it's probably been about six years since I've had a female in to see me in the office aside from kidney stones on call. But I go back again to the clinical examination, the discussion in the office. If there's demonstrable stress incontinence, that's case in point. If you can't reproduce it, then that's where some other information may be helpful. It's always possible it could be bad overactive bladder in the patient, just they're not noticing their contractions, but then you get into the weeds of the utility of urodynamics in overactive bladder and false positives, false negatives.
Alan Wein: Yeah, yeah, yeah. Well, listen, it's been great to talk to you. Everybody who watches this watch the trajectory on this fella, because it's going to be like, "Whoa, 45 degrees or more acute." So it's been great talking to you. I'll see you at the AUA.
Bradley Gill: I appreciate it. And thanks for the invite. I look forward to seeing you.