Considering focal laser ablation and have questions

Presumably the cost of the procedure must depend on how long you are in the scanner for. Does that not make it difficult to judge how much to quote you and to schedule other patients on the same day.

To my knowledge all of the FLA practitioners quote a flat/fixed fee. 

Joe, I don't think my insurance will cover it, but I will check. My doctor feels that the "open" procedure is the best route for me. I will ask him if I TURP may work. Which facility did you go to? Florida?

Hey Gary I went to Houston for mine. And  Tim is correct most thst are doing the FLA and the PAE quote. Fixed price. Did the place you talked with not tell you a price?? 

It seems most insurance companies will not cover it. Mine paid $3,200 oit of a $21,000 charge . And thst is AFTER they gave me a pre approval in writing.

I agree with some of the other guys research PAE before you do anything radical. It really does seem to be a good option for really large prostates, plus insurance does cover it mostly. And if it does not work you can still always do something else Later.

joe

I was quoted $16,000 for the focal laser ablation procedure.

Was during Dr K trials? I'm pretty sure he charges north of $20k for FLA

I had the 3D MRI which shows the entire prostate. Aetna turned it down at first and then approved it when I sent a protest letter. Took about an hour. Very loud but comfortable. Imaging Centers of America in Boca on Glades. Didn't show any cancer or tumors but Urine in the bottom of my Kidneys. Going today for 10 day post TURP appointment with my Urologist. See story below if you have a few minutes. I outlined everything from MRI results up to today. I hope it helps.

My TURP Procedure Experience:

 After getting my yearly physical on February 16, 2018 my PSA was 6.8 up from 4.4 a year earlier. My Primary Care Doctor suggested a visit to my Urologist. Met with my Urologist on March 2 and he suggested a series of Prostate Biopsies or a 3D MRI of the Prostate. Since my brother had Prostate cancer on the back side of his Prostate we decided the 3D MRI was the best and less painful path to follow. After being turned down for the procedure by Aetna I wrote a protest letter explaining my family history and they reversed there decision and gave me the Ok. After having the MRI on March 8th my Urologist called saying he had good news and not so good news. Good news was that there were no tumors or signs of Cancer. Not so good news was that the MRI showed urine in the bottom of each of my kidneys. The MRI didn’t show the bladder so I went in on the March 12th for an Ultra Sound in his office. After the Ultra Sound I met him in his office. He said we need to get a catheter in you right now because your bladder is full and backing up into your Kidneys. This was alarming since I had just urinated before the test. He couldn’t believe I wasn’t having back pain and stomach pain with the pressure that was there. After inserting the catheter, not a pleasant experience, the nurse emptied out almost a gallon of urine. After clearing the urine in my bladder we met again in his office. He stated that he could put me on some medications for the BPH but he didn’t think they would work enough and I would be back on the catheter time and time again. So the other option was surgery of the prostate. He said that the TURP procedure would give me the most and longest relief. After thinking about it for a few minutes I decided to have the procedure after some reassurances from him. We booked the surgery for March 28th at 7:30 AM. I had to have the catheter in for over two weeks before the surgery to remove more fluids from the rest of my body and keep by bladder empty. After the first week of having the catheter in I lost 14 pounds in water weight with some blood mixed in. Blood was from the Kidneys speeding up when they realized the bladder was no longer blocked. This supposedly causes the blood in the urine. Not a pleasant way to lose weight. While waiting for the surgery I did extensive research over the internet on the TURP procedure and the other options out there. I read many horror stories posted by other TURP patients and started to have second thoughts. I met with my Primary Care Physician for my pre-op checkup. I stated my concerns for the procedures post operative side effects, Incontinence, Bleeding, Retro-grade ejaculation, TURP syndrome, Urinary infections and impotence. He assured me that my Urologist was one of the best if not the best in the area and most of his patients have very few complications if any. I decided to go ahead with the procedure.

I checked into the hospital on March 28, 2018 at 6:00 AM for my 7:30 AM Surgery. I was taken back and prepped with an IV. I met with Anesthesiologist and then my Urologist right before the surgery. Lots of the same questions about my health history. They then wheeled me into the operating room and I moved my body onto the operating table. I asked them what the large monitor above the table was for and that’s all I remembered until I woke up in recovery. After a couple of hours in recovery I was moved up to my room for the night. I now had a catheter in me that was a third again the size of the one I had originally. Not a pleasant experience. Thank God I was under when they put it in. The reason it’s bigger is because besides the drain tube there is a return line for saline wash solution to drip back into the bladder to remove blot clots from the Surgery.  There was a two bag hanger for the solution an intravenous drip and an antibiotic drip. I was starting to feel old. I felt a little tightness in the Prostate area but really no pain to speak of. I felt pretty good. I had Salmon for lunch and visitors. Around 4:00 PM I started to feel nauseous. They gave me some anti-nauseous medicine through my IV and I felt a little better and fell asleep for a couple of hours. They brought dinner in but I ate very little because I was still feeling a little nauseous. My visitors returned but I wasn’t much company because of the continuing nausea. They said they couldn’t give me anymore medication for it until 2:00 AM. My company left and I rolled on my left side to try any get some gas out of me. Worked pretty well and relieved the nauseous feeling quite a bit. Didn’t sleep much I dosed off and on until about 4:00Am still fighting the nausea. When the nursing group came in to attend to my roommate on the other side of the curtain they also gave me another shot of the nausea medicine. They said it was probably the anesthesia that was making me sick and it usually passes in 10 to 12 hours for most patients. Finally the nausea subsided around 5:00 AM. My Urologist came in around 7:00 Am and said everything went well. There was a little more tissue in my Prostate then he had anticipated so the Surgery took 20 Minutes more than the normal one hour. He said my bladder looked clear of any blood clots so he was going to release me to go home with my buddy the catheter. He wanted it to stay in over the weekend to make sure I was clear and he would see me on Monday to remove it, oh joy, and test my ability to urinate without it in me. That would be exactly three weeks with a catheter in. Monday didn’t come soon enough. I had a little blood in the catheter through Saturday but Sunday was clear. Made sure I took laxatives daily to relieve constipation. My Urologist said my constipation would clear up after the catheter was removed. I showed up for my appointment at 10:00 AM on Monday April 2, 2018. I was taken to a procedure room for testing urine flow. After undressing I laid down on a table and the nurse poured 300cc of saline solution into the port on my catheter. She said it was going in quickly so I didn’t have any blockage there which was good. My bladder started to feel a lot of pressure from the solution. She then said to hold on because she was going to pull out the ½ inch diameter catheter from my bladder back through my penis. I almost came off the table. I thought going in was bad but this was twice as bad. She said there wasn’t much lubrication left and it was a large catheter. The last three or four inch pull was the worst part. This so far was the worst pain through the whole ordeal. Not so bad considering the alternative of not urinating or renal failure. She had me stand up over a portable potty and try to urinate into a container with cc markings on it. I needed to give her back the 300cc she poured in before I could leave. They need to make sure I could empty the bladder completely. Nothing was happening. It seemed like a daunting task considering I hadn’t urinated on my own for over 3 weeks. Finally my Urologist said I could go into another room and hang around until I produced or go home and come back if I couldn’t empty. I moved to another room and finally felt the urge and filled the 300cc plus an additional 100cc that probably was in me when I arrived at the office. Success, I can now go home and without a catheter. My Urologist prescribed some antibiotics for a week and rescheduled for Monday April 9th. Hopefully that will be my last appointment for awhile.

My urine stream is like that of a teenager. I almost overshot the toilet bowl. I empty fast and completely. Hooray!!! Don’t seem to have any bad side effects from the Surgery. No pain urinating, no dribbling and no leakage. I do have blood spotting in the pad up against my penis and a little blood at the start of urination. My Urologist told me to expect that for a couple of weeks so I wasn’t alarmed at all. SOOOOOOO happy! I am a little sore under my scrotum but hardly noticeable. I slept great the last two nights but still getting up twice. No real urge to go just getting up. I tend to get easily tired if I do too much which he said is normal because of the blood loss and the procedure. He said my strength will come back over the next two or three weeks. So far I have no negative feelings about the TURP procedure and would definitely do it again.

Thanks for sharing Rich. Glad it went well for you. Most likely you will not need anything for years since Turp is well proven to be much longer lasting. Hank

Why do you think PAE would be so much radiation? I'm thinking its probably less radiation than FLA

No radiation from MRI.

This is just silly. I would suggest you google radiation exposure and PAE, as I just did and found doses around 400 mGy.

I think you are off by a factor over 1000

Sam I would love to be off by 1,000. Please let me know where on the internet you found 400mGy. I think we would all like to know.

My bad angelic field with MRI.

Meant to say magnetic field

Angelic field 

You feel like you are in a tomb after being in there for a while.

Hi Derek, the one I was in was not so enclosed which did not leave one feeling trapped which was where I had my FLA with Dr K in Houston it was much easier to deal with and no pain at all during or after my FLA  and very successful  

How open was it?

I need a standing MRI scan on my lower back when it has pressure on it. There are not many here and only two in London. I need my MRI compatible pacemaker reset for the procedure and they cannot arrange that.  

Hi Derek, sorry I don't know perhaps someone else does, kind regards Brian.

How much of you was in the scanner and how far away was doctor K from you?

Hi Derek, I traveled from New Zealand to have Dr Karamanian in Houston Texas to do my FLA for me as I had bph  (median lobe) and was told by 1 out of 4 urologists if I had turp I would definitely become incontinent, 2 said nothing and 1 said I would not become incontinent but later said its usually the second turp that results in incontinence, so I traveled a long way and it was well worth it as there were no side affects and no pain at all and all is well thanks to Dr K, you also asked about the mri machine D K has, it has a larger opening at both ends compared to the more tighter narrow ones I had been in before here in New Zealand so I did not have that trapped feeling, yes all of me was in the mri but DR K's excellent assistant Donnie was always checking up on me to see how I was doing.

The equipment had a long way to go to when being used inside you. How does he manage to control it.

I have mentioned on here before that users can google "FLA vs. Green Light Laser: What’s the Difference?" for explanations of the procedures.

One of the main difference is you will never hear a Urologist support Focal Laser Ablations as they first cannot perform the treatment and second there is a lot about it they will never understand as they have no training in the Interventional Radiology field. For the most part they are scared of the IR's getting in the play pen with them and offering MRI's instead of biopsies and focal laser biopsies and focal cancer removal. 

They really need not worry as there are about 150 to one urologist verse interventional radiologist and then just a hand full that have dedicated to Prostate treatments in the US. Hard to fight those medical bureaucracies as they have the power.  

 

Hi Derek, you asked how does Dr K control FLA?, with mri guided laser ablation, a needle guide in the rectum is adjusted to the appropriate angle then a cooling catheter is placed through the needle guide into the prostate. After confirmation of the appropriate position the laser fiber optic is placed inside of the cooling catheter. A light "test dose" is applied and seen on the mri,and the laser fibre optic is again adjusted. Once it is confirmed in two separate planes with real time mri heat mapping that the laser fibre is positioned correctly then the laser power is increased to treatment temperatures. This is a meticulous process which allows for tremendous precision, with Dr K's BPH patients he will usually go through that process between 5 to 12 times(depending on the size of the prostate), once for each ablation zone. Where as with green light it starts vaporizing through the urethra and keeps going until the urologist thinks they have gotten enough also green light laser power is approx ten times that of FLA it is much more aggressive, and the procedures are completed more quickly. With green light the urologist can only see what is visible in front of the camera which is located in the urethra, where as with mri guided FLA Dr K can see all of the anatomy in multiple planes, kind regards Brian.

Thank you but I still see the procedure being carried out from a distance as you are in the scanner and he is outside. Surely he does not have the same control as someone doing a GL or HoLep where they are close to you.  My last urologist said that I had ruined his back as he was crouched between my legs for nearly three hours :-)

What position are you in during the procedure?  

Brian, that is an excellent explanation of the process and very accurate. What you described is the way dr. Kay does the procedure other doctors doing f l a do not go to the painstaking time-consuming procedures that dr. K goes through. That is why his procedure takes longer amounts of time. Additionally, he uses conscious sedation while other doctors performing the same f l a use Valium and a pain shot. There is a big difference in the anesthesia used by dr. K. These are all things that any person considering f l a should research through a conversation with the different potential practitioners they might use. Great explanation though and good detail thank you

You are prone on your stomach with some support under your hips so your buttocks are raised.

They slide you in and out of the MRI to verify positioning of the laser and to monitor the ablation.

My procedure was 4+hrs, but I recall almost none of it other than the beginning and the end.

There was no pain nor discomfort.

I assumed that you would need to be positioned like that.

Is it always a standard charge or is dependent on the time taken.

Tim, I was the same way with regard to not remember anything and no discomfort. I was not as long in the procedure as you. I do remember waking up though on my stomach once during the procedure and thinking I was in a dream. I opened my eyes slightly and about 18 inches from my face was Donnie Sartin's face with his head laying on the platform and he was staring straight at me. I did not know if it was a dream or not and I went right back to sleep. I woke up after the procedure when I was in recovery and I told Donnie I had a weird dream and I thought I saw him on the table in front of me. He laughed real big and said that was not a dream. He said in most of these procedures he sticks his head in from the front of the table to watch the breathing patterns of the patient during the procedure. He said it was not a medical requirement but something he likes to do from his years of experience. It helps him monitor the patient. 

Brian, I think a difference in the FLA that should be pointed out is that this procedure is accurate in the point of tissue removal up to 1 mm of accuracy. Of course that also has to do with the quality of the Doctor preforming the procedure and is why again Dr. K takes a long time in the process. He is very calculated before starting and checks the numbers many times during the procedure instead of just pulling the trigger in a designated direction as in done in most tissue removal. He is a strong believer in the physician oath of beyond all other "do no harm". 

This precise accuracy capability is what gave me the confidence that I would not lose any sexual function from the FLA procedure.

AFAIK all quote a flat fixed price in the range of 21 to 26 k   

Yes john Dr K uses a conscious sedation as in my FLA with him  I was conscious but very relaxed with the exception of my bad shoulders so I asked his excellent assistant Donnie (who was always nearby to keep an eye on me)  to give me more sedation to overcome my bad shoulder complaint which he promptly did and all was well, yes FLA in Dr Karamanian's hands is outstanding hense all the excellent feed back, I have never in my lifetime met such a devoted medical professional and one who is happy to help and often without charge, where do you find that these days! I am so very glad I refused turp with all its barbaric risks and I am pleased to say I still have my prostate urethra, I still have my bladder neck valve, I still have a complete prostate as if it was not even touched!,everything works well with no damage! so what about the cost it was well worth it!

I agree with you. Sometimes now after a year and a half I seem to forget how bad it was because I am now so use to being back to something that is livable. I feel guilty that  I forget how desperate I was and how it felt hopeless at the time.

My wife sure reminds me from time to time how bad I had it and how good I have in comparatively now. After all, she also suffered in this process. She fell and broke her knee cap in half on one of my exploratory trips to research the PAE procedure when we went to Chapel Hill NC to interview Dr. Isaacson and the day before her accident we were in Virginia to see Bagla. I drug her around to talk to 9 different Doctors in 7 cities. A broken knee cap is the worse break you can have. It has taken her 24 months to fully recover. I know it was not my fault but it was another situation caused by my bad BPH. 

But she claims it is all worth it to her because of the success I got. I hope it last a lifetime.

I am sure glad it all went so well for you also. 

 

Yeh sometimes I remember how desperate I was - even though FLA in my case was not a resounding success I'm in a better place than I was for sure. I can function normally and had I done any other procedure I'd probably have RE and otherwise not much different to what I have now.

Your wife sounds like a saint!

When you say 'something that is liveable' does that mean that you still have some symptoms remaining ?

So the question is what does livable mean? To me this means I do not get up 8 times at night to urinate anymore and then while doing so I would not completely void. That was unlivable.

It means I no longer urinate on myself at work in front of other employees because I could not hold the urge to go any longer and I waited too long to go to the mens room. 

It means I do not get stuck in traffic jams and pee on my self in the process of using a bottle while having to drive. 

It means I do not have to think about the route I will be traveling for the day and process a chart where the rest rooms will be along the route. 

It means I can now play golf and only stop to urinate one time in 18 holes. 

It means I do not have to carry extra changes of underwear in my truck.

It means when I do go now, I start immediately and I void completely. And the stream is full.

It means I now urinate like the normal 66 year old man should and it does not control my life. My voids are now between 300 and 400 cc  each time.

This is my definition of "livable". I control my life again and my urination does not control me. 

The mistake I made is I, like so many other men waited too long to do anything about this condition. But for many years the alternatives were not worth what would have happened. Sustaining my sexual ability was the most important thing to me. It may not be number one to some men and in that case the traditional offerings by the Urological doctors would be fine and work. 

I believe I damaged my bladder in waiting too long and I made it weak. I cannot push and get the same increase in flow I got when I was young but my flow is good and it is strong enough for a 66 year old man. I am sure you remember youth when you could actually feel your bladder push? BPH will weaken that and I don't think it will come back. I waited 9 years and that was too long. But I am not sure how many 66 year old men feel their bladder  in a pushing sensation anyway? Age is an evil mistress.

I just dare not get in a pis...g contest as I can't push it like a fire hose anymore. But guess what? You are not suppose to do that at 66. So when I say Livable I should maybe change that to NORMAL for my age instead of livable.  To put it another way, I feel I spent $20K and got more than I expected and definitely my money's worth. I am now hoping it will last me 25 years then color me up, I am out of here. 

I hope this answers your question. 

Well said!

Wow, you were in a worse way than anyone I've ever met. Liveable gave me the impression of some but not enough improvement. You certainly show what can happen to anyone who does not go for treatment soon enough. 

I had my FLA in June with Dr. K. Prostate was 185CC with median lobe and a large benign cyst protruding into my bladder. I had all the same issues as you. My whole life revolved around my prostate. Is my life perfect after this procedure, no, but I am no longer on meds and now have control over my bladder. I would gladly pay $100,000 if necessary to be in the shape I am now in. This procedure changed my life far more than I hoped! There is a reason we have a K club, Dr. K is the finest Dr. I have encountered in my 66 years of life.

The MRI can distinguish between a cyst and a nodule on your prostate ? Did Dr K say how much of your problem was related to the cyst as opposed to the prostate. My cousins husband had a large cyst on his prostate that was otherwise pretty normal. At that time the only option was a TURP that fortunately did not cause him any later problems.

I had a cystoscopy in 2015 two years after my second laser procedure and they noted a small nodule  that they guess is non malignant on my median lobe. Without having any present problems I'm not inclined to ask for it to be checked again.

Steve, I could not agree with you more. And you are right on the mark about Dr. Karamanian. It is difficult to tell other men about what you and I have found in him. His expertise and skills in reading the facts on the MRI are in my opinion unmatched by other Interventional Radiologist. His accuracy with the laser is superb. His attitude toward healing is in fact the way we all hope and wish all doctors would be. We go to the doctor for anything and we go in with hopefulness that a caring, wise and technical doctor will treat us with compassion and give us the time due with superior communication and compassion. 

I was in bad shape for about two years and that is the time I went around the country looking for an answer. After nine trips, I was shocked and in disbelieve when I found Doctor K. I had already been to four other Interventional Radiologist about PAE or FLA and his was going to me my last IR visit. The difference between him and the others was actually surreal. I could not imagine he was actually that way. I also told him after my procedure that because he is a younger man, I was afraid time and the system would change him. He told me he came from a family of Armenian Doctors and,NO, it will not change him and if it does, he would get out of medicine altogether.

I have heard people ask on this thread why he takes twice the time in a procedure, I have tried to explain but you and I know why he does it and you are right he is worth five times the money in my opinion.

Hope versus hopelessness was what I feel I got the most from him not just in BPH treatment but in medicine. Treatment wise, I no everyone did not get what we got and I know that we are all different. To a fault he wants to help someone much more than turn them away and he does that also.  

Just the fact that he could look in my prostate and show me what was my specific issue, then explain and show me on the film exactly how the problem would be alleviated was so much more than any Urologist can do. They will show you nothing. When I saw the sexual components of my gland and how far away from my 3 problems they were, when he showed me the route he would take with the laser, I knew then that FLA was my best most logical shot at getting my life back. And I knew I had found a Doctor who was different. He was very special and unlike any other doctor I had ever met (Except for the ones on TV). 

I am so glad to hear you are better and living life again. You are now 8 months out. I can tell you in my case, it continued to get better after 8 months. The longer the time the more the prostate settles and reforms it's shape. 

Here to your continued good luck.

After my procedure, Dr. K actually had the whole procedure he did on a disc. He showed me the areas he ablated and explained how they would improve my urinary issues. He did make a point that the cyst was protruding into my bladder and was probably a big part of my problems. He actually show me the laser being placed in the cyst and then showing the cyst disintegrating after two injections of the laser.

Thanks for the kind response. I probably like you go on these blogs to see what other people are experiencing with FLA or what questions they might have. As I said  earlier my experiences were very similar to yours. I peed my pants twice on airplanes, would have to stop on car trips to urinate in places that exposed me to probably a criminal complaint. I had to go to the emergency room twice for retention. For three years I went to over six urologists and was always told the same thing, my prostate was to large for Urolift, Rezum and only a TURP was available. After looking at the TURP procedure on utube and the Urologist actually being very honest on the possible complications, I decided to look for other options. This is the main reason I still go on these blogs. Without this blog I would have never found Dr. K. I hope anything I can offer may help a person that is going through the same issues I had. What I went through was the most frustrating and hellish experience I have ever gone through. Before I agreed to the procedure with Dr. K, the Dr. asked me what my expectations were. I said I hoped I could get off the meds and have bladder control. He said there would be a 70% chance that this would happen. Dr. K is on the conservative side, so I liked my odds. Since the procedure is my life perfect, No, but instead of 70% better, I would say I am closer to 90%. I listen to my body and can tell you what affects my prostate in an adverse way. Alcohol in moderation is fine, coffee is hit or miss, I now drink tea. Spicy foods are out unfortunately. I will continue to come on these blogs to tell my story if could possibly someone help someone. I believe I have this responsibility.

You are a good man Steve to remember what this condition does to men's lives and even though you are better, you want to help others as you know how they feel.  I agree completely with you. No urologist will show you what is wrong and then after the procedure, show you the evidence that they did what they said they would do and here is how it worked. I look at all the procedures and I just kept on finding no answers. You will improve more and I look forward to hearing about it like you, if my story can help someone then so be it and I will participate. In the end we all get to make our own decision. But I would tell everyone to just do lots of homework and understand the whole process and make someone show you. If they can't show you then chance are they are just shooting in the dark and taking out what ever they happen to hit.

FLA is precision accuracy to 1mm in the hands of the right person. Typically this level of expertise would take twice a long and that is why he does it that way. And it is not the all with all in treatments for everyone but I know a lot of people now that got the same results you and I got. It is a shame that there is only one Dr.K. I wish we had 1000 of them but we don't.

You are fortunate you were in America when you were desperate to go. When we were on in Botswana a Guy on one of our safaris twice asked the driver to stop the jeep so he could go. He said he was so desperate he did not care if there was a lion behind him.

Steve thanks for sharing. Before FLA, what meds were you on ? Were the meds helping ? Did you have FLA just to get off them ? Thanks. Hank

Hi Derek, what you said about the guy in Botswana is the cruel reality because before I had FLA if I had to wait too long too pee I was in excruciating pain but when I finally got to pee the pain was actually worse than the unbearable pain of trying to hold on, it was so painful that I felt like screaming and wondered how on earth men in the past must have pondered suicide, thank God I found Dr Karamnian and by the way I don't have that horrific pain anymore.

I was on high dose rapaflo and finesteride. They did help, but the side effects for me were awful. I am a changed man since I got the meds. it has taken me almost 8 months to get this crap out of my body. I am now starting to feel my old self again. the meds were toxic for me.

This was less than a year before my prostate started to bother me so when I was first diagnosed I was concerned but never got to that  stage in my years of uneasy waiting for alternatives to TURP.