HoLEP vs. PAE: Fast Approaching Decision and Advice from Men with Experience in These
Posted , 16 users are following.
My prostate story has good news and not so good.
I just had another 3T multi-parametric MRI. It showed no lesions, nothing of concern other than thickened bladder wall and BPH with prostatitis. My PSA went from 11 to 5 in the past 9 months. My PSA density is < 0.04. My 4Kscore is 3%. All in all, little likelihood I'm looking at cancer, certainly not an aggressive cancer. But......
MRI measured prostate to be 133 cc. That is big. Two years ago, same machine/same hospital measured 121 cc. Basically, my prostate is around the same size, if you figure around 10% measurement error.
I had a trans-abdominal ultrasound a few weeks ago that measured 90 cc. I guess MRI is more accurate.
I need another surgery in the next 90 days. I'd prefer to get the BPH addressed before undergoing another operation. It is abdominal surgery. That makes me rule out open partial prostatectomy - which is a big operation.
My PVR is around 85 cc. Flow rate is good during the day, not good at night. I take 0.4 mg of Flomax every 12 hours. I void 250 cc to 500 cc (max). The 500 cc means my bladder is stretched. Not taking Finasteride or Dutasteride.
Guys who've been through HoLEP or PAE can help me.
+'s of HoLEP over PAE: should result in faster improvement in LUTS, flow rate, PVR
+'s of PAE over HoLEP: less invasive, lower complication risk (stricture, bladder outlet constriction, RE)
PAE has a radiation dose of around 50 mSv. That's equal to 5 abdominal CT scans or 40 years of background exposure. I don't know how that translates to excess lifetime risk of bladder cancer.
PAE probably doesn't require a catheter. HoLEP would require < 24 hrs with a Foley. Simple prostatectomy is about 7-10 days with a Foley.
I would rather not go through the urethra because of the low chance of a stricture forming. Also, for guys who've had HoLEP (or TURP) doesn't any intra-urethral procedure essentially core out the inner gland and by going through the urethra forms a new channel for urine to leave the bladder? That is, after HoLEP is the urethra gone??
To get to the prostate, the urethra must get damaged. What could be left of it after a TURP or HoLEP?
I understand HoLEP can lead to 2-3 months of incontinence but this can be managed with pelvic floor exercises. The risk of RE is 74-78%, which is high. But my primary concern is being able to pee, sleep through the night, sit without discomfort and pain, and be able to live a normal life (e.g., drive on a vacation, go to a ball game, sleep 5 hours straight!). Nocturia on some nights is a killer - and not good for the heart over the long haul.
I'd appreciate any input from men who've undergone these two procedures, both the good and the bad.
If I go with PAE, I think Dr. Bahtia at Miami Hospital would be no. 1, Dr. Bagla would be no. 2.
I do have an enlarged median lobe. Some guys here say PAE is not effective with a median lobe. HoLEP is not limited by a median lobe. Both procedures have been done on prostates of 400 cc or more.
Long post, but thank you to all who read it and who can help me make this decision in the next 4 weeks.
Michael
0 likes, 25 replies
glenn77 MichaelVM7
Posted
Michael,
Have you considered FLA as a third option. I have a close friend whom I steered to Houston and Dr. Karamanian.He is is very satisfied with his outcome. (I had gone the Green Laser route and had a disastrous outcome, so we had lots of long discussions before he made his decision.)
Glenn
MichaelVM7 glenn77
Posted
Yes, Glenn. I spoke with Dr K. He looked over my earlier MRI. Great guy.
Unfortunately, for BPH my insurance will cover less than $2000 of the total cost. FLA, if billed to insurance, is around $29,000. I'd be responsible for $27,000. If direct pay, FLA is around $21,000-$22,000.
I don't have that kind of money, unfortunately.
Dr K would have been my 1st choice.
Cactus_Michael glenn77
Posted
What is FLA?
I tried to look it up and all I got was legal stuff for Florida.
rdemyan Cactus_Michael
Posted
Focal laser ablation.
steven05114 MichaelVM7
Posted
@MichaelVM7 : I don't have that kind of money, unfortunately.
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I did a Rezum out-of-pocket for $2,500. It is an out-patient procedure so it is done in the doctors office without the overhead costs of an operating room.
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After over 10 months of catheters I can pee on my own again. Also no ED and no RE. The Rezum took less than 10 minutes and then I had a Foley for 2 weeks. After that there was 2 more weeks of self-cathing before I started to pee on my own as my body shed off the dead prostate material from the Rezum.
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Why not try a less expensive, less invasive procedure with lower complications and lower morbidity first? It makes sense to me.
richp21 MichaelVM7
Posted
No catheter with PAE Dr Bagla in 2017.
Also, I was told that radiation was less than one cat scan. I will post email with that communication tomorrow when i am back on my computer.
Rich
MichaelVM7 richp21
Posted
Thanks Rich,
I look forward to seeing that. From the little I could find, PAE is 50 mSV, an abdominal CT scan is 10 mSV, which is equal to 8 years of background (ambient) radiation.
That does not result in any significant increase in lifetime risk for all cancers combined, given the risk for males in the US is 1 in 2 of developing cancer in a lifetime.
I could not find much, admittedly, and continue to look.
Since you had PAE with Bagla, can you tell me how quickly you notice improvement in urine flowrate and reduced night time visits to the bathroom? How big was your prostate prior to PAE? Have you gotten a measurement since then?
I'm pressed for time because I need surgery (other than prostate) and don't want to risk acute urinary retention from the anesthesia. With a prostate > 130 cc, it is very large.
richp21 MichaelVM7
Posted
Hi Michael,
Here is the initial communication I rec'd from Dr Bagla's office in August of 2016:
I imagine that different offices use different equipment and different procedures, and therefore might have very different radiation exposures.
I continued the conversation with Dr B's office. I will post the follow-up messages in a second post.
I have had some improvement from the PAE, just not as much as I would have hoped for. It did allow me to stop all meds, which was a huge benefit. Nighttime "trips to the bathroom" (I use a portable urinal, so I just get up and pee right next to the bed... very little disruption of sleep) have stayed much the same.
It didn't happen all that quickly. It seemed to improve well beyond the time limit when Dr B said there wouldn't be any more improvement (I think that was 3 months).
Prostate was approx 95 cc prior to PAE. Not sure about afterwards.
Rich
richp21 MichaelVM7
Posted
Here are the follow-up communications:
I wrote on 09/21/16:
Dr. Bagla said the procedure would take about an hour. My understanding is that if some difficulty is encountered, it could take several hours. If that occurs, is there a concern for an increased radiation exposure?
Julie's reply:
I wrote on 01/16/17:
I know from a previous email that you said that the radiation involved for the procedure is less exposure than a typical CT-scan study. I'd be interested in knowing what modifications Dr. Bagla has developed (or uses) that allows for the reduced radiation. I assume that he uses some form of Fluoroscopy.
Julie's reply:
I have deleted the link as the moderator would not allow it to be posted. I can send it to you by PM if you're interested.
Rich
chuck68670 MichaelVM7
Posted
Michael,
I am tentatively scheduled for PAE with Dr. Picel, Stanford University Medical Center (he used to be at UCSD) May 16th. Just had a CT scan, because my insurance wouldn't cover the 3T MRI, so Dr. Picel informed me he needed the CT scan as a "minimum" to get a fairly accurate picture; short of the MRI 3T.
While discussing BPH in general, the subject of median lobe came up. I stated I had heard that PAE might not be effective with a median lobe issue. Dr. Picel said that PAE can be very effective with the median lobe "IF" the IR Doc knows prior to the PAE procedure of the median lobe; then that can be effectively addressed at the same time as the prostate itself.
Overall, I prefer the PAE option as a first-choice because of its low invasive nature; and it thereby leaves open the option for HoLEP or TURP should I not receive adequate flow enhancement and reduced PVR. If HoLEP or TURP are done "First" there is No "option" of PAE. Just my thoughts.
Good Luck Brother.
Chuck
MichaelVM7 chuck68670
Posted
Chuck,
That is a very good point. PAE is less invasive and it leaves open other options. HoLEP enucleates the prostate and not much is left.
I would agree that a skilled IR would be able to target the artery to the median lobe. I've come across Dr Picel's name in my research. Being associated with Stanford, one of the top hospitals in the US, speaks highly of his credentials.
rdemyan MichaelVM7
Posted
I haven't had any procedures, so I'll only comment on the urethra question. HOLEP, TURP, Greenlight and some others (however, not Urolift, PAE or Rezum) essentially destroy the section of the urethra that goes through the prostate. So the prostate urethra is gone, and the remaining prostate contains the urine and keeps it flowing to the downstream urethra and out the penis. At least that is my understanding.
MichaelVM7 rdemyan
Posted
rdemyan,
Yeah, that makes sense and is perhaps the best explanation I've seen.
I wonder if the interior of the prostate grows an entirely different cell layer to accommodate the urine, which can have a varying pH.
Thanks 😃
rdemyan MichaelVM7
Posted
I asked my uro once about what keeps the urine from leaking through the prostate and eventually into the abdominal cavity. I didn't fully understand what he said and I was pressed for time to ask him other questions, so I didn't take it further. But he said that a lining is formed (which I guess would be the cell layer you mention). He said something about it being similar to the inside of the mouth, which I didn't fully get. It was my first office visit with him and I had to continue on with my powerpoint presentation 😃
JerryR MichaelVM7
Posted
Last week I met Dr. Chandler Dora at the Mayo Clinic, Jacksonville, FL. (Google: chandler dora holep youtube - and watch him perform the procedure.) I was very impressed, though he advised me my prostate was a little too small (39ml). I'm thinking about FLA for me. My impression of PAE is that the success rate depends on the anatomy of the arteries supplying your prostate - but I'm not a urologist. Good luck to you.