Median Lobe Prostate Bladder Blockage Options?!?

Hi Jim:

Here is the email I recently received from Germany:

"dear chip, 

no worries, i totally understand your cautiousness, it is a tough decision, but i hope i can put things straight and out of the way for you.

1. either i will perform the surgery or my boss, who discovered this technique. 

2. success rate hasn't changed, we perform this technique on almost all patients, because it also has a lower adverse events rate, however there are some boundaries reducing the success rate which are size of prostate, location of the enlargement, especially is it more the basis (good) or the apical (bad for success rate) parts of the prostate, the comorbidities of the bladder, that is why we perform urodynamics before surgery.

3. we perform this procedure approx. 200-300 times per year, we are only 2 surgeons which perform this technique. we use laser, as well as bipolary and monopolary resection techniques, also in combination.

our technique is getting very popular in germany, leading universities as well as high volume centers took this techniques in some cases over, also with a increased success rate.

4. yes, we had 2 patients this year from the states. and from a lot of other countries as well.

5. price for everything including all diagnostics, drugs, surgery and hospital stay (app. 4-5 days) will be 15000€.

6. we don't have a waiting list, we can perform the operation within 1-2 weeks.

why american doctors haven't taken over the technique i really don't know, because it doesn't use any new devices, it is just the interdisciplinary knowledge from andrology, sexual medicine, neurourology and surgery.

i'm waiting already  for lecture invitation…just kidding.

i hope i could help you out with some of your questions.

best regards

saladin alloussi"

 

Hi Jim:

I posted some EP TURP info.  But it is awaiting moderator approval.  

I am VERY interested in self-cath.  It scares me.  But I believe it is a worthwhile option.  

Do you have a favorite self-cath catherter?  Do you sit down?  Stand up?  Hold penis at 45 degree angle?  Or would that be 90 degree angle - haha?  How do you keep from getting UTI?  

Thank you VERY much!!!!

Hi Chip,

First, thank you very much for the information on EP Turp. It's a procedure I had never heard of nor ever mentioned by my urologist, Fortunately, my self-catherization program (CIC) is going so well, I have the luxury of waiting, an in fact unless I have a regression sympton-wise, I may have achieved similar goals to surgery already. 

For example, my International Sympton Prostate Score (I-PSS) went from 33 (severe) to 9 (mild/moderate) after 2 years of CIC. If you want to know more about the I-PSS scoring, search for my thread entitled

"What Is Your International Prostate Sympton Score?" In fact, I'll bump it up for you later but afraid to provide a link because every time I put a link in a post, it goes to "moderation" and doesn't appear until the next day or so. I also have another thread you should search for (I'll bump it up later as well so you can find it easier) entitled "Self Catherization. An alternative to Turp, Greenlight, HoLEP...?". It was from 7 months ago and covers a lot. 

As to your questions and a general overview -- Yes, I have a favorite catheter after over a dozen of the more popular ones here in the States. I tried everything from red rubber, to vinyl, to a 4 or 5 different hydrophylic ones. 

The one I like best (and it isn't even close) is Coloplast's Speedicath which is a single-use hydrophiic catheter with the coude tip. Coude Tip is very important if you have an enlarged prostate as it helps prevent any snagging as you pass over the prostate.

The size I started with was 14 French (14F) which is the typical starting size for most men. Once I got the technique down, I switched to 12F. As a general rule, you want to use the smallest size catheter that you are able to insert because a smaller diameter translates into less micro trauma. That said, I think if I started at 12F I might have been frustrated since it take slightly more skill since the smaller size means it's more flexible and therefore a little harder to handle, but only initially. I also should add that I have developed an in effect sterile "no touch" procedure where I only touch the plastic funnel end of the catheter and never the catheter itself. For this reason, I can actually do CIC quite quickly (without gloves or hand washing even) since the catheter itself is never touched. But again, this involves a little practice and is much easier with the 14F as opposed to the 12F which I use. 

Basically I unwrap the speedicath at the top, and the nice thing with speedicath is that it's already coated and ready for immediate use by it's pre-packed fluid, so no need to break any packets.

Then I either wash or spray the head of penis and meatus. I have experimented with several different methods from providone iodine wipes to antispectic sprays. 

Now, I gently pull my penis out and up (toward the ceiling) to straighten out the canal and give the catheter a straight shot going down. I do this with my left hand. At the same time I use my leftt thumb and forefinger to  open up the canal by gently pulling the head of the penis out thereby exposing the meatus, but being careful to keep a sterile field by not touching the meatus. Then, with my right hand, I hold the plastic tip of the catheter and basically "dive bomb" (but very slowly) it into the opened ureretha. If I miss and the catheter touches anything but the meatus at the opening of my urethra (maybe one out of 50 times) I throw the catheter away and start over. But if it hits the urethral opening it will stop by itself a mm or so into the canal. Then I gently push the catheter in (again, only holding it by the plastic tip) and as I push it in I change the angle of the penis from straight up to more of a 45 degree (or even less) angle as I navigate through the plumbing and into the bladder. You may find two points of resistance in the process, the second when you push through the bladder neck.

It may sound complicated and time consuming, but the entire process for me, as described, takes less than one minute plus maybe another minute or so for the urine drain. I actually spend less time in the bathroom urinating with the catheter than I did before without the catheter with my on and off dribbling!

But again, the technique as described, is my own personal technique. I believe the stanard instructions have you feed the catheter in by hand which means you should wear gloves and frankly that hydrophillic is very slippery so not sure how easy that would be. 

As for as UTI's go, I had problems the first couple of months due I think to system shock. I therefore highly recommend prophalactive antibiotics for  anyone starting CIC, but unfortunately the stock answer from the doctors is "they aren't necessary". Ha! 

After a while you may develop colonization, which basically means your urine will test positive for bacteria but you will have no symptons. This is normal and OK and you are NOT supposed to to treat this with antibiotics. 

The way to actually avoid a real UTI is with careful technique, whether my "no touch" technique, or by the more standard technique of using gloves, or thorough washing, etc.  The other way is to carefully monitor your bladder and catheter volume, at least in the beginning. 

I've read it expressed two ways. The first is that if you catherize more than 400cc, then you should increase the frequency of CIC to get the catherized volume below 400cc. Or, if you catherize less than 100cc, then you should decrease the frequncy of CIC.

The other method which is more conservative says your bladder shouldn't be holding more than 400cc of urine at any one time. Therefore, assuming you have a natural void just prior to catherization -so let's say your natural void is 150cc, and you then right away do CIC an 300cc comes out. 

Now going by the first formula, everything is good and you continue on your current daily frequency since your catherized volume was under 400cc. But going by the more conservative approach, your total bladder volume was 450cc and therefore if you had been catherizing 3X/day you might up it to 4X/day

In the beginning, I started with the less conservative approach and even then was cathing up to 6 times a day. Later, as my bladder started to regain elasticity, I went to the more conservative approach to keep bladder volume down at all time. 

Now, my average void is 150-250 cc, and my PVR is usually between 50 and 150. And this is without CIC. So, since my total bladder never holds more than 400cc or urine, I was able to stop CIC completely except for every now and then when I might take in too much fluid, too quickly.

Hope I didn't lose you with the details, but you seemed interested in technique. 

And so the important stuff doesn't get lost, I'll again repeat that for someone like yourself CIC has to advantages. First, it can buy you time until a procedure comes along you are 100% comfortable with, as opposed to picking the best of the worst available. And second, if your like me, your bladder may actually rehabilitate itself to the point where you may be able to stop CIC altogether.

Jim 

Just re-reading my "technique" primer, and forgot to mention that when you pull the penis out (a slight tug) to straighten it out and receive the catheter -- once the tip of the catheter is actually touching the meatus at the mouth of the canal, you then "loosen up" your grip (while still holding it straight) to allow the catheter to pass easily.

You might want to ask the good doctor for specific success rates, e.g. what percentage of his patients end up impotent, what percentage end up incontinent (leaking ), what percentage end up with retrograde ejaculation. The numbers may, in fact be low and okay, but you need to know them.

Neal

Does penis stay in the "straight up" position?  Or perpindicular with floor? Or?

Jim:

Thank you soooo much!  

Chip

Hi Neal:

Success rate regarding which procedure?

There seem to be sooooooooa y options these days: 1. Self-catheterization. 2. Urolift. 3. Flomax. 4. TURP (ugh - not my favorite option) 5. The German "EP" (ejaculate preserving) TURP. 6. Green Lantern - oops - Green Laser. 7. Mini-TURP: which may preserve antegrade ejaculate. 8. Ignore the problem (not the best option). 9. HOLEP. 10. PAS? So - there are options. For that I'm grateful.

The web and sites like these are sooooo helpful.

I hope docs read this stuff.

Best,

Chip

Given my "no touch" technique, I start by pulling my penis up gently (stretching it out) fairly straight up. That way, I can place the catheter into the beginning of the canal by simply dropping it down gently. But as I push the catheter in, I then (still holding it in the streched out position) slowly start moving it to a perpendicular to the floor position, and it's pretty much perpindicular to the floor when the catheter passes over the prostate on it's way to the bladder, which is about 3/4's of the journey. BTW the whole thing will work if you keep the penis in the "straight up" position, but I just found it easier to navigate around the prostate when it's perpendicular with the floor. Your milage may vary. Hopefully, this makes sense, if not, one day I might try a YouTube Video or series of photos but to keep it GP rated, will use a soda bottle! 

When I say "perpindicular to the floor" I really mean my penis is parallel to the floor (aiming at the wall from a standing position) at the point the catheter goes around the prostate. So again, the penis goes from the tip facing the ceiling to the tip facing the wall ahead. And for those who have never self catherized, while it may sound cumbersome, the process I have described takes a matter of seconds, and becomes so second nature it's about as traumatic as combing your hair. 

Jim

Hi Jim:

That makes sense.

I haven't been "hands free perpindicular" since I was about 12 years old. Haha.

But I can do the parallel to the floor move. Ha.

I gotta laugh a little. This stuff is so awkward sometimes.

But I keep thinking of our poor aging brothers in the middle of the Amazon jungle. Maybe they use a stick to self-cath. Then they smile and continue hunting and gathering for a family of seven.

I'm so grateful to have some medical options. But I guess it depends on one's point of reference.

And I'm grateful for your share.

Cheers,

Chip

Can't wait to see your "Self-Cath" video!!!!!!

It will be a hit!!!! Huge potential audience. All us aging baby boomers.

Actually, the ancient Egyptians used catheters made from reeds and Benjamin Franklin fashioned one out of metal. Apparently BPH has been around for some time and when you got to go, you got to figure out a way to make that happen!

As you probably know, there are many self-cathing videos on You Tube. Some are professionally made by the catheter companies using either real people or animation, and some are just put up by people sharing information. My "no touch" technique difers somewhat so at some point I may put something up if I can figure out the logistics of filing and cathing at the same time! But until then, hopefully my written explanation is clear enough, but if not please ask more questions.

Use:  Tripod?  Banana?  Straw?  And two walnuts?

I was writing about the EP Turp you mentioned, and the message you got from the doc about it. He seemed to be long on generalities, which looked good, but he didn't provide statistical information on his success rates. Simply doing a lot of them doesn't mean much. I had a penile implant attempted by the head of the urology department at Upstate Hospital in Syracuse, NY. He has "done hundreds of them", but managed to cut through my urethra even though it had a catheter in it that anyone should be able to feel. Now anyone can have a bad day, and if your doctor's success rate is 99 out a hundred, you might be the unlucky one, but if your doc's success rate really is bad, you need to know about it before surgery. I later got my penile implant fixed. He did a great job, and a working penile implant is WONDERFUL(!), better than I when I was a 17.

Neal

Also, you need answers to those specific questions, and some others, not just overall number he does, and success rate,

Neal

Hi Neal:

I believe Jim answered this.

EP TURP has a success rate over 90%.

But it would cost me $20,000.

Best,

Chip

You're missing my point, which is that more information is needed. A "success " might mean that the guy on the operating table lived. The question is, what was his life like after the surgery, and we're there any complications, what were they, and what were the rates for each type of complication? Maybe those numbers are all good, but we won't know unless they are given to us, will, we?

Neal

No, "success" was defined in detail, and the results were impressive in that they were consistent with regulart TURP but without retro in 90% of the cases. No one is pushing EP Turp, or saying it's better than another procedure, just pointing out that there is another option out there that many are unfamiliar with. I know I was. You can find all the details of the study in my first post of the thread entitled "Ejaculation Preserving (EP) Turp -- Anyone have it done or familiar with it?". If you click on the box (upper right) entitled "full text links", you can read study in entirety.

Jim

"Regular turp" has many possible complications besides retrograde ejaculation. There's impotence, and incontinence, to name two. These serious complications also need to be researched and evaluated by anyone considering turp. Neither urolift nor PAE seem to have retrograde ejaculation, nor these other two complications. In fact, they don't seem to have complications at all except some post op pain, and maybe a catheter for a few days, unless done by a complete idiot, though we can't ever ignore the possibility of idiocy. I'm suggesting that EP Turp may not be a panacea. We need to be cautious and carefully evaluate ALL the possibilities.

Neal

Again, no one is trying to sell EP Turp over any other procedure. Just trying to point out that it has the advantages of TURP without the high incidence of retro. And yes, Turp (or EP Turp) has it's own unique set of complications that anyone contemplating it will look into. But keep in mind that not everyone is a candidate for PAE, and not everyone is comfortable with having a foreign body permanently embedded in their urethra as with Urollift. 

As for myself, I'm not thrilled with any of the current options (including EP Turp) and that's why I self-catherize instead. But self catherization isn't for everyone either, so at some point many of us have to pull the trigger on one procedure or another, and the more information we have on everything that is available, the more informed decision we will make. 

Jim

That is sooo cool about the Egyptians and Ben Frankiln.  And a relief to hear.

I wonder of Charles Darwin would think the human male species will eventually have smaller prostates?  In the year 4515?

I agree with you.

Neal

Hi JIm,

Hope you are well. Do you have anymore info or heard about anyone having the EP Turp from Germany? I am considering it. I'm in the US. My prostate is now 120 and have a large median lobe. Had a PAE which shrank it a little but not enough.

Hi Chip. My 65 year old husband has just started to self cath (approx 2 weeks). He resisted taking this action as he was quite scared and anxious about the whole procedure, so much so that when the nurse showed him how to do it, they laid him on a bed because they thought that he was going to faint!

?Husband had prostatitus which prevented him from peeing at all - hence need for catheter. He found the first few days very uncomfortable - but he was not relaxed at all! Not surprised it was uncomfortable! However now 2 weeks in to cic and he has discovered a great deal more about his body. He now knows what works for him i.e. what position, when to change position, how to counter any resistance. He is also able to cic standing over the loo which is really much better than having to lie down. All I would say to you is GIVE IT A GO! My husband is a real wus when it comes to medical procedures and if he can learn how to do it and learn how to relax after just 2 weeks, then anyone can do it!

?We are considering our options at the moment and the cic is giving us time to do that without any pressure from our urologist who is a TURP maniac!

?I know that it is easy for me to say as a woman, but don't be scared! I live with the cowardly lion and he has coped really positively with cic.

Not had any UTI in 2 months and in moving from permenant catheter (fitted by nurses) to cic - for last two weeks. Hope this helps.?