How did you decide on a procedure?

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There are many different BPH surgical procedures and I believe most urologists are probably only comfortable with a few of them.  To those of you who have had a procedure, and especially if you traveled to another location or changed urologists to get a procedure your urologist could not do, how did you decide which one to get?  And how did your local urologist react when you told him you were going to someone else?

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  • Posted

    I travelled to Virginia to have the PAE procedure done by an interventional radiologist who had performed hundreds of them. Both urologists that I had been seeing at the time were, to put it mildly, very dismissive of the procedure. One of them was all set to do a TURP (the supposed "gold standard"wink. The other urologist didn't have a problem with my choosing PAE, but even after I had it continued to talk only about how the procedure could have very bad outcomes... an opinion not even remotely supported by research.

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  • Posted

    I selected PAE as it seems to be the least invasive of all the procedures, and I had responded well to Tamsulosin which was an indication that the PAE could be an appropriate choice for me.
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  • Posted

    I had been dealing with LUTS of increasing intensity/aggravation since my early 50s. At 57 (5 years ago), I was diagnosed with low-grade prostate cancer. During my research of different cancer treatments I became aware of FLA, which over time has shown some effectiveness for helping with BPH and other LUTS. I was on active surveillance for 4.5 years and continued with annual MRIs. During this time I continued to look into different treatments for LUTS, including PAE, Rezum, Urolift and all of the TUxx methodologies. I visited 6 different urologists in 3 different states and each had their own biases and prejudices (as one would expect), but only one was open minded when it came to treatments other than those offered by urologists.

    Over time, my PSA slowly ticked up and the MRI was showing some small growth of the one visible lesion. My urinary symptoms continued to be problematic as well, so in Dec 2017 I opted for the one treatment that would hopefully address both issues- FLA. My urinary symptoms are better and time will tell on the PCa. For me it was a combination of one treatment addressing both issues as well as my ruling out all of the others for various reasons (primarily due to incidence of complications, side effects and their probability of addressing my urinary symptoms [not all the same] ).  This does not mean FLA is without it's own issues. Some men do have some complications after the procedure and the number of practitioners and relatively small number of cases make tracking results difficult, but the same can be said of all new procedures.

    Since most insurance does not cover FLA there is also the issue of cost - approx 21 to 25k plus travel expenses, as such it is not even possible for many men to consider, which only increases the time for results/improvements in the treatment.

    As for your urologist question - all but the one were either unsupportive, dismissive and/or skeptical when discussing what they considered to be 'alternative' treatments. My only suggestion is learn the specifics of your situation - not all LUTS is caused by BPH, though many urologists seem to follow the same protocols for treating these symptoms (antibiotics, alpha blockers, 5a reductase inhibitors, etc) and not all treatments are best for all conditions.

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  • Posted

    If it's possible to find a urologist who has personally undergone a BPH procedure he would know what the feelings of a patient really is. Most doctors believe it is unprofessional to discuss their own medical problems with their patients.

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  • Posted

    Lee,

    As there are many different BPH procedures, the best way to decide is to rank them in terms of most effective vs least side effects. On that scale PAE is first, then Urolift, then possibly REZUM, then Greelight, FLA, Holep (the laser procedures) and lastly TURP, although TURP using the plasma buttom tip is less traumatic to the prostate tissue than the cutting loop. After most of these heating, cutting procedures there might be retrograde ejaculation that is permanent. 

    In the end, research shows they are all about equal in effectiveness. 

    The PAE is not done by urologists, but by interventional radiologists. No cutting or heating, so relatively benign procedure and fairly fast recovery. Urolift just ties the prostate tissue away from the urethra. There is recovery time and some bleeding. The various laser treatments heat the prostate, so there would be prostate swelling, some bleeding, and possibly a Foley catheter for a time after the operation. TURP is considered the most aggressive treatment, and again, depending on the type of tip used, might require an overnight hospital stay. 

    Your decision also depends on where the various procedures are performed (would you have to travel), the cost involved (would your insurance cover the procedure), and, if there is recovery time, how much time you would be able to take off from your job or normal activities. 

    So, do your research and don't just go with the first procedure your urologist recommends. It is highly likely he will NOT recommend a procedure he doesn't already do. 

    Lastly, it is possible that none of the above procedures will solve your issues if they are being caused by your bladder. Many here have had one or more of the above and their issues were not solved. So, you have to be clear about what your issues are - slow flow, can't empty the bladder, frequent trips to the bathroom at night - so you never get a good night's sleep, frequent trips to the bathroom during the day, incontinence issues. Too frequently we just assume these problems are being caused by the enlarging prostate, when that might not be the case. Try to get as much information as possible about what might be causing your problems. Is it an enlarged prostate, median lobe blocking the urine flow, or something else? if you can get your urologist to order yo a 3T MRI that would be very helpful. Many uros will just do a cystoscope. I had one and ended up with bleeding and a bad UTI, so won't do that again, so this is not necessarily a totally benign way to see what's going on. I prefer external imaging to shoving tubes into the urethra and bladder. 

    Tom

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    • Posted

      Thanks for the detailed reply.  I am pretty familiar with the various BPH procedures and based on information  available on Google (actual clinical studies, not anecdotal evidence), I don't think you can say they are all equally effective.  I have found no long term clinical studies that indicate the durability of some of the newer procedures such as FLA, PAE or Rezum.  OTOH, there are clinical studies going out to 5 years post-op that indicate Greenlight, (plasma) button TURP, and recently, Urolift, are as effective as traditional mono-polar TURP.  Urolift is not currently useful with a large median lobe (which I have) although there apparently is a study in progress that may change that.  I have read on this forum that PAE is also not effective with a median lobe (anecdotal evidence from someone who had it.)

      Unlike some here, I am not afraid of retro, having had it when I was on Flomax and having recently developed it again, apparently as a result of two recent surgeries to remove bladder tumors.  Having a Foley catheter for a few days also does not bother me since I had that after both bladder surgeries.  And I've had 2 cystoscopies which were no big deal either.

      At this point, doxazosin is working well enough (especially after the recent dosage increase to 4mg from 2mg) that I do not have an immediate need to have a procedure done. I suspect I will eventually need something more than drugs and that's why I'm asking questions of those who have been down that road.

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    • Posted

      lee, don't let people pressure you into any procedures, regardless how good their intention is. Some people can get by fine with alpha blockers like Doxazosin for a long time. As long as you are not bothered with the side effects, you may never need anything else. Hank

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    • Posted

      I'm not feeling any pressure Hank.  For a while, at every annual visit my uro would give me 3 options:  1) continue Doxazosin, 2) add finasteride (which he didn't recommend), or 3) "fix the problem" by which he meant surgery.  I told him I wouldn't do a TURP (which is his recommendation) so now he no longer gives me the options.  As long as Doxazosin is working reasonably well, I will avoid any procedures.  But I still want all the info I can get in case my situation changes.

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    • Posted

      Lee,

      The reason there are no long term studies of PAE or REZUM or FLA is because they are new techniques. All studies I have seen about PAE indicate it lowers the IPSS score about as well as TURP. I download and read all the studies. I had a PAE last year with some success, but apparently have some bladder issues as well. The PAE team that worked on me recently called me and told me that they have been studying my scans and know how to correct my current issues. So, I will be going in for a second PAE. 

      I had a median lobe issue last year, but now, after the PAE, the lobe is gone, according to my uro, so maybe the PAE took care of that problem. 

      The company that created Urolift, Neotract, did a clinical study of a Urolift technique that works with median lobe. I have not seen any published results from that study yet. 

      My point was and still is that the goal is to solve whatever issues one may have with the least invasive technique possible, with the fewest side effects - bleeding, hospitals, Foleys etc. Some of these procedures can leave the patient worse off than he was before the surgery, so it's wise to be very careful about any decision that involves cutting into or burning off prostate tissue. 

      Tom

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    • Posted

      GL worked for my 75grm prostate from 2004 until it regrew to 135grms by 2013. Then Thulium/Holmium similar to HoLep . Both with quick recoveries.
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    • Posted

      I believe there is a long term study regarding PAE that was presented near DC by Dr Pisco. I'll try to remember to track it down and post a reference here tomorrow.

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    • Posted

      I found several of the PAE clinical studies.  Not sure why I had missed them in previous searches.  Operator error I guess. cheesygrin  

      Interesting about the disappearance of your median lobe.  There is as least one post on this board from a fellow who said he had PAE which was ineffective due to his median lobe.

      Was yours done by Dr. Pisco in St. Louis?

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    • Posted

      Rich,

      Although his ranking is subjective, Tom made some good points. What's missing, however, is urodynamic testing, often critical in predicting surgical outcomes. 3T MRI may be useful, but it's not a functional test like urodynamic testing. Best urodynamic testing is video urodynamics.

      Jim

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    • Posted

      Lee,

      Just because one has a procedure - any of them, it doesn't mean that the issues will be solved. By issues I mean weak flow, urgency and frequency, nocturia and incontinence. These may be related to bladder issues. 

      My PAE was done at Kaiser Medical Center in Oakland by Dr. Hastings who does this procedure for all of Kaiser in California (perhaps it's now done in Southern California, but when I had mine done men flew into the Bay Area to have their PAE). 

      The actual PAE was easy and pleasant. I was awake through the whole thing - sedated a bit but awake. The only part of the day that was uncomfortable was lying on my back in the recovery bed until the afternoon. My bladder kept filling up and I eventually requested a Foley to drain off 600cc of urine. The reason I had to be confined to the bed was to prevent bleeding, as there is a small puncture in the right femoral artery near the groin, so standing up to go to the bathroom might cause bleeding. If I had been 5'10" or shorter, they could have gone through my wrist, but as I am taller, they had to go the "short route". I also found that lying in a hospital bed for hours was extremely boring. 

      Tom

       

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    • Posted

      My son lives in San Fran so Oakland wouldn't be that inconvenient should I decide to go the PAE route (if and when I need something other than meds.)  I also suffer from bladder spasms which is part of my frequency problem.  

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    • Posted

      Did you not have a nice young lady pressing her hand on your groin as you lay there ? I did when I had my first angiogram.  Next time they went through the wrist and put a tight strap round it.
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    • Posted

      Derek,

      I was on my back for about 5 hours, so nobody was pressing on the puncture site. I was told I was too tall for the wrist. I am 6'1". I just wanted to get up out of the bed and go to the bathroom, but was told that could cause bleeding and then they would have to take me back into the operating area - big problem. So, once the Foley was put in, my bladder was OK, but I was just very bored and uncomfortable. That's another reason I don't want to have any procedure that requires an overnight hospital stay. 

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