How to Know in Advance if your BPH Surgery or Procedure Will Work!

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It used to be pretty much just TURP, but now there are lots of way to fix BPH, which more coming on board each day. A partial list includes: Green Light, HOLEP, Urolift, REZUM, iTind, PAE and FLA. 

But if you read the literature, or spend time here, what you will find is that all of these procedures can produce great results or not so great results. And that is often with the same doctor. 

So, in broad strokes, in many cases it's  not the procedure or the doctor that determines whether a surgery or procedure will work, but the condition of your bladder/urinary system going into the procedure.

Unfortunately, many doctors operate first and then make excuses when the operation or procedure fails. "Well, the operation WAS a success, but you really can't expect much with such a weak bladder".  

Very nice piece of information to know, after the fact!!!

The more knowlegeable and ethical doctors will test the system first to get a better idea of outcome before the surgery or procedure. So far, urodyamic testing is the gold standard here, with video urodynamics the best of the best. Still, urodynamics has limitations, and is not the genie in the bottle. 

Recently, a few of us in the self cathing group, were playing around with a way to use our catheters to open up the urethra in the way a stent might. The idea was to simulate with the catheter what a prostate reduction surgery often does, ie take the pressure off of the urethra. Problem is that a catheter is not really a stent because the catheter itself becomes part of the obstruction.

This lead me to think, what we really needed was a trial by stent. In other words, simulate a prostate reduction surgery or procedure with a temporary stent to see if indeed its worth doing the surgery or procedure.

Turns out, this has been thought of before. Problem is, as with many good idea, not much progress or effort has been put it into the idea since 2011. 

From the 2011 paper:

"An interesting application of the biodegradable stent is to simulate the situation after the TURP in patients with a combination of severe BOO and severe overactive bladder. "

The cynic in me says not to expect too much in the way of more progress and funding in this area. First, these projects need funding and most of the funding these days is coming more from the equiptment and procedure manufacturers (think Urolift and REZUM) and not from stent manufacturers for a diagnostic use. And second, a trial by stent would be added time and work for the urologist, when in fact many are really chomping at the bits to either cut, slice, dice, burn, melt or lazer away your prostate. 

However, on an individual basis, this doesn't mean someone motivated to find out before a surgery, if that surgery will actually work, couldn't hook up with a creative and enlightened urologist and do the trial by stent on their own. Not to say that may be easy, and in fact, if one does find such a urologist, please private message me their name!

I will post links to the only two studies I could find on this in my next message. They probably won't show up for a day or two until they come out of moderation.

Jim

 

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  • Posted

    One comment. I am not suggesting that a "trial by stent" is necessary or desirable for everyone. After all, stent placement in and of itself is somewhat invasive. In some cases, a good determination can be made by examination and conventional testing. 

    However, let's take the example of someone diagnosed with signficant BPH/LUTS, a large median lobe, and a somewhat dysfunctional bladder.  That person is told that the less invasive procedures like Urolift and BPH will not work, and the more invasive procedures like TURP or HOLEP might work, say 50-50.

    I would think this person would be a good candidate for trial by stent because the other option would be to submit to an invasive procedure such as TURP or HOLEP, with all the potential side effects, with only a 50-50 chance that it will work.

    This is one example, there are others. Whether trial by stent makes sense really comes down to what the individual situation is and how motivated the patient and doctor are. 

    FYI If you don't want to wait for the study links (see previous post) to come out of moderation, you can google "New developments in the use of prostatic stents" and look for the 2011 study. 

    Jim

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    • Posted

      That was a great post Jim. Very good work. I also wish I knew a Uro who would coporate with this theroy and allow us all to learn. But, most if not all Uros are only in it for the money. If you find someone please share it with me.

      John

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    • Posted

      Thanks J. From what I've read, yours would not be a case with trial by stent would be indicated. Your bladder seemed relatively intact with obstruction the culprit in your BPH/LUTs.

      I tend to agree about your uro comment. It's that but more. 

      Ever try to bring up a novel idea to a doctor? You would think they would be interested, but they are not. In almost all cases they are either dismissive or disinterested. A medical researcher once gave me a reason why. What he basically said is that most doctors are simply technicians. They follow whatever they learned in med school and practice by "current standards" which can be years behind the research. 

      The better the doctor, the more apt they are to listen, but nowadays with the insurance issues, etc, it's getting harder and harder to get time with the better docs, assuming they will even accept Medicare, which many of the top ones are starting to opt out of.

      Jim

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    • Posted

      Hi, Jim,

      Great new thread! dHaven't read the study links yet, but is what you're suggesting similar to Itind?

      These days I avoid urologists as much as I can. So far in my urinary journey I've had consultations with 7 of them--haven't found one yet who has an open mind. I'm not sure I'd even go in for a trial by stent--I'd be too worried that he/she would mess up something in my urinary tract while placing or removing the stent.

      Stebrunner

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    • Posted

      No, not similar to iTind. The idea is to put a temporary (maybe only a week) biodegradble (or removable) stent to simulate a prostate reduction surgery. If the patient can empty their bladder during this short test period, that then suggests that a prostate reduction surgery would be sucessful. If they empty their bladder during this test period, that suggests a bladder issue that cannot be overcome with prostate reduction surgery.

      Jim

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  • Posted

    Jim,  I think you are on to something here, as I have only started self cathing recently as my Prostate has grown back in 15 months and I am told it needs resection again. One thing I have noticed is that after self cathing I can pass water for a couple days as though I have pushed the prostate back again.  Will make an enquiry of my Urologist and Urologist Nurse Practitioner on this subject as don't want this every year.

    David

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    • Posted

      Supertractor,

      I don't think it's that CIC is pushing your prostate back, but that it's resting your detrussors by decompressing the bladder. That can make a subsequent natural void easier. Longer term, it can rehab the bladder to the extent that you may be able to go off catheters for long periods of time. That is what happened with me. 

      That said, if you do want a surgery or procedure, and both you and your doctors are unsure whether it will work because of a compromised bladder -- then you do want to test further before that surgery.

      I think you might have a hard time talking your doctor into doing a "trial by stent" but can't hurt to show him the two studies I posted and ask. 

      Alternatively, you can try a CIC rehab program like I talk about in the self cath threads, and see how that works out.

      Jim

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  • Posted

    Hello Jim,

    Thanks for your post!   I am one of those guys who who fit the description of weak over expanded bladder, self cath, up to 5 times a day, (very low self voiding).

    I would be very interested in the stent as well.    However I do feel that some type of procedure will have to be done so the bladder can void with its current condition.   Even if I could get down to a PVR of 200 that would be a big step forward!

    Thanks again for your post.

    Anthony

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    • Posted

      Anthony,

      I'm not advocating the stent as a long term solution to BPH/LUTS. That would be another topic.

      What I'm saying is that stenting the urethra can mimic prostate reduction surgeries and procedures and can therefore give you a decent idea if a surgery will work. 

      If you find out from the stent test that a surgery will not work, then you save yourself the trauma and side effects from that particular surgery. if you find out from the test that a surgery will work, then you can go ahead with more confidence.

      Jim

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  • Posted

    I think that before any procedure you need a good, experienced urologist, look for review on the web or wherever and make sure you have had all the relavnt tests. Choose a urologist who has carried out a reasonable range of procedures or knows someone who has. I had a very succesful HoLep by a urologist who has av ery high success rate in this. I was referred to him by another great urologist who did most/all of the relevant tests to check the state of my prostate and bladder and offered me a choice of procedures but suggested a referral for HoLep due to the szie of my prostate. If you live in the UK and in Hertfordshire or therebaouts I'm happy to PM you with his name and the guy who did the HoLep in Cambridge. HoLep will not be the solution for everyone but for me I'm sure it was the optimum.

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    • Posted

      Dai, the point of the post is that even the best current tests, with the best urologists, have limitations in what they can predict. Trial by stent is a novel approach that needs more study and/or could be done right now with the right patient and doctor.

      Jim

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  • Posted

    Great subject! Here's my take.

    For those of us with very large prostate side lobes there is a normal narrow region at the base of the prostate called the bulbourethral gland which gets tightly compressed by BPH  and restricts our flow. Dr K showed this to me in my MRI and said it can act like a third sphincter muscle in closing off flow.

    When I would self-cath I always had a lot of trouble getting through this restriction. I used to think I was having trouble at the inner sphincter but in fact it was at this gland that I never knew existed. I would often wait 2 to 3 minutes with light pressure to get through this and then it was clear sailing into the bladder. I alsways did ny CIC right after a natural void so i could get a good estimate of my PVR.

    Recently however I found that if I do NOT do a natural pee just before the catheter but instead do the catheter first I am then able to insert the catheter with great ease and no resistance at all. I do CIC 4 times a day and in between those I have 3 or 4 NVs of about 150ml each.

    So now when it is time to CIC I wait until I feel the need to pee and do CIC right away. What is interesting here is that if my bladder is really full the pee will actually flow around the outside of the catheter and into the toilet. If I hold the catheter at that position until the pee stops and then continue the remaining 6 inches into the bladder there is very little pee left in the bladder.

    So as Jim indicate, the catheter is acting like a stent right at this narrowing of the urethra which in my case anyway is in fact acting like a third sphincter muscle.

    If however my bladder is not all that full when I CIC without first doing a natural pee then I still get into the bladder with ease because the added bladder pressure is still dilating that narrowing of the urethra, but I do not get flow around the catheter at the bulbourethral stricture. Instead all the pee just comes out when I enter bladder.

    So it would seem that when the bladder is under sufficient pressure a stent catheter just inserted up through this bulbourethral gland could be enough to empty the bladder without actually penetrating the bladder itself.

    More in a minute ....

     

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    • Posted

      Darn - I got another UTI and did not want to lost the post.

      Continuing ..

      This all relates to PAE and othe rprocedures. I had a PAE last summer and it was a resounding technical success but also a resounding clinical failure (my IPSS is still 30).

      Dr. K walked me through in 3D (and actually 4D  if you include the dynamic contrast time part) mp3T-MRI from a few months ago. he showed me where my PAE successfully embolized many small arterioles in my prostate and killed a lot of tissue. In fact my prostate size was reduced from 280gm to 180gm over 3 months.

      But the problem was that the necrosis was very spotty throughout my prostate and distributed randomly. In particular there was no tissue removal by necrosis in the narrowing region of the bulbourethral gland which is where most of my peeing problem comes from. The PAE proceudre dare not try to embolize blood vessels close to this region for fear of embolizing the urethra so it seals off arteries outside the prostate and "hopes" the effect will propagate down to the desired region. This is probably why some guys have great results with PAE and others don't (assuming they are good candidates for PAE). It really is the luck of the draw in an uncontrolled process.

      Dr K showed me where he would ablate the tissue around my urethra if I ever did FLA with him. While my prostate volume reduction would be minimal my symptom improvement would be immediate and dramatic. So this shows that prostate volume reduction is not always a good measure of PAE clinical outcomes.

      Neil 

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    • Posted

      Neil,

      You said: "...So it would seem that when the bladder is under sufficient pressure a stent catheter just inserted up through this bulbourethral gland could be enough to empty the bladder without actually penetrating the bladder itself."

      I think we're on the same page, but the above is only true if the bladder itself is strong/elastic enough to properly empty. And that is the reason for "trial by stent".

      ------------------------------

      Regarding your theory that it's easier to pass the  bulbourethral gland with a full bladder -- an alternate theory is that a full bladder will loosen up the internal sphincter. So, it's possible that multiple things are going on. 

      If you really want to know, video urodynamics during CIC should be able to give you the answer. You would want to do CIC with both a full and empty bladder and then compare films. Finding a urologist who is interested/motivated in doing such is another story. 

      As a side note, I recently purchased a portable bladder scanner, which might also work for you in that you should be able to see the whole CIC process from the inside in real time. Of course this may require three or four hands, although I did notice at the Bard site a device that holds the penis during CIC which would free up two hands.

      If you have any comments or interest here, let me know on one of the self cathing threads so we don't get too much off topic here.

      Jim

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    • Posted

      Forgot to add .. when we have to pee and hold it in our brain has given the signal to pee so the inetrnal sphincter has opened involuntarily but the external sphincter is kept closed by sheer will as w bare down to wait. So when it is time to CIC, if we resist the urge to natural void and insert the catheter through the external sphincter the pee should start to flow around the catheter unless the BPH is keeping the bulbourethral gland stricture closed. So until we penetrate that region there should not be any pee flowing. It depends on the bladder pressure and how much pee there is to dilate the constricted region. It is unlikely that any pee will flow out of the catheter itself because the small eyelets are closed by the urtheral lining which is pushed up against it. Also if we used a larger catheter like a 16 (I use 14), this whole process would be inhibited somewhat.
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    • Posted

      Not 100% sure, but it does seem that if there is sufficient bladder volume signaling urination, then the act of releasing the external sphincter (voluntary muscle) will automatically open the internal sphincter (involuntary). However, that does not necessarily mean that if you pierce the external sphincter with a catheter that the same will happen. I believe Frank tried this and was unable to get a flow started and I would love to try the experiment but since I have no need to catherize these days I will beg off. Again, I think video urodynamics would give some interesting data here but first you would have to find an interested urologist. 

      Jim

       

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    • Posted

      Hi Jim - thanks for your reply.

      I think the 2 sphincters work independenly. This is one of the reasons that holding it in when you really have to go can lead to prostatitis and an inflamed prostate which could eventually cause BPH. That is, if there is a very strong urge to go and we keep the external sphincter closed then the acidic pee will backflow into the prostate gland causing all sorts of trouble. Dr. Nickel wrote a lot about this years ago as one of the primary causes for acute prostatitis.

      On another topic, do you think a new thread just dealing with UTIs would be useful?

      Take care.

      Neil

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    • Posted

      Agreed that it's also important WHERE you remove the obstruction. But also important is whether the bladder is strong enough to completely empty even if you precisely remove the offending obstruction as with FLA. Trial by Stent covers both those bases. It precisely opens up the urethra and therefore give the bladder a good chance to work. If it works, then we know that at least a precise prostate reduction surgery would work. If it doesn't work, we know it may not. 

      Problem is that most docs are more focused on expensive surgeries or procedures to try and fix the problem as opposed to less expensive procedures (like trial by stent) that basically are diagnostic. 

      What's with the UTI? Sure, start another thread on UTI's we don't want this thread infected smile

      Jim

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    • Posted

      I've noticed that if I use my detrussors while CICing that I empty my bladder better than if I just let the pee flow out on its own. That is, I seem to have a residual after CIC of about 75 to 100ml in the base of the trigone (my continence nurse confirmed that a few weeks ago ). But this morning while she was here I did a self-cath and used my detrussors to keep up a good flow stream through the catheter. She then measured 0 ml in the trigone (and elsewhere). Also after I cath, if I press up against the kitchen counter I usually feel a little pressure but I don't feel any pressure if I use the detrussors through the cathing process. Also it makes for a nice looking flow stream!

      I will be having the Gat Goren procedure in early May. It is entirely experimental but it is the only treatment which attempts to address the source of BPH which is Free T spraying the prostate at 300 times normal concentration thus driving the hyperplasia. It was confirmed that I have bilateral varicoceles which is consistent with the GG theory. I will start a new thread on this as it gets closer. It is done by VIRs on the venous side of the blood flow so is much less risky than PAE and it never gors near the prostate.

      Neil

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    • Posted

      Are you saying you have 75ml to 100ml left over after you cath if you don't use your detrussors? If so, it may be just an individual thing because of your individual bladder architecture. In my case, I have a diverticulum that can start emptying into the bladder almost immediately after either a natural void or CIC, so it's near impossible to tell if I ever reach empty with CIC unless I'm on a bladder scanner real time during CIC. I did similar once with my new bladder scanner at home, but it was with a natural void not during CIC. Now if I just had an extra hand or two smile

      Are you going to Israel for the gat Goren?

      Jim

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    • Posted

      Yes - I seem to retain a residual after CIC of 75 to 100ml w/o using my detrussors but if I bear down with them during CIC then my residual following CIC, at least this morning was zero ml. In both tests my CV was about 450ml since I did not do an NV immeditaely beforehand to make it easier to get the catheter in.

      Maybe you could get a continence nurse to come by and try out your new diagnostic setup while doing CIC?

      I will be doing GG in Detroit. I convinced a VIR there who specializes in infertility to try it because if it is successful in curing BPH then he would be on easy street. He is very keen on it. I told him I had bilateral varicoceles but he did not believe me so when the color doppler ultrasound came back on Wednesday he was very impressed. The challenge will be to occlude the right ISV.

      Oddly enough I was going to go to Cyprus last summer where GG now perform their procedure since the urology lobby in Israel forbade them to treat BPH and forced them to stick to their infertility treatments.

      But in collecting the required diagnostic info for them I found out that my prostate had grown to 280gm. GG would not do it on me then because they said GG takes about a year to work and by then I would be in kidney failure. That was when I decided on PAE and after that failed I learned CIC thanks to you which has given me the luxury of time to do GG now and wait for it to cure my BPH.

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    • Posted

      The VIR in Detroit sounds like an experimental kind of doc. Maybe he would give you a "trial by stent' per the links I posted. Sort of a preview of what you might expect, or not expect, from the Gat Goren. 

      Jim

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