My HOLEP Experience

Ken,

Can you please elaborate?  What do you mean the prostate "acts as a plug" for the bladder?  Is this based on anatomical fact or is it something guys who have been through various prostate procedures discuss on this forum?

I'm curious to understand this better.

My prostate has grown a lot the past year - at 175 cc if the ultrasound measurements can be trusted.  My PSA density is < 0.05.  I've declined a second biopsy because my high PSA is due too a very large prostate, not cancer (I have had a negative biopsy and clean multiparametric MRIs).

Right now, I'm considering HoLEP, FLA and PAE.  I can go to one of the best prostate surgeons in the US and he can core out much of the enlargement/inflammation.  But that is major surgery.

PAE is not invasive but its best results are 6-12 months out.  And since it cuts off blood to the prostate, what if I need a biopsy at some point down the road, and cannot take Cipro to prevent infection to the prostate (since the drug would have no way of reaching the prostate with the prostate artery blocked off)?

FLA is promising but not covered in the US.  That's 25-30K out of pocket.  That's a lot of cash.

HoLEP is more invasive - a TURP with a laser.  There are two great doctors - one at Indiana University, one at Vanderbilt University - who have very good outcomes.  But I did not know incontinence was common with HoLEP.

Seems like the best bet is FLA.  But  with a kid in college I'm strapped for cash.

I think insurance covers HoLEP.  I know it covers major surgery, but that is a long recovery.

Thanks Ken.

Michael

Geezer,

May I ask a personal question?  With HoLEP, can you ejaculate?  Or is that lost?

Also, how are you peeing 2.5 months after you had HoLEP? 

I'm 60 and in otherwise good health.  My prostate is very big.  Honestly, life is very difficult.  I cannot sit for 10 minutes without pain and burning.  I probably have chronic prostatitis from the biopsy to go along with BPH.

I need to do something.  My Uro doesn't want to put me on Finasteride.  I know it has side effects but if it can shrink my prostate enough to give me relief, then I can go with a procedure.

I want to look at FLA but my wife will not co-sign with me to get a second mortgage.  I'm suffering a lot but she is not going to go into debt.  It's basically my health and too bad, I can go for open partial prostatectomy (major surgery) because our insurance will cover that.

I think insurance covers HoLEP so that is an option for me.

But I want something that will let me pee again like I was when I was 45 (I'm not asking for 16 or 18 - just 45), and I don't want to wait 12 months for PAE to show results.

Thank you.  I hope you are out of the Depends soon and fully heal!

Michael

indeed, 175cc prostrate will be a tough and long operation and thus potentially would have more complications than a smaller prostate.

I have also looked at HoLEP seriously as my insurance also covers it.

No HoLEP is not TURP with a laser. It differs in at least two ways. The holium laser coagulates while it is doing  the resection thus it has less blood loss. Secondly, it uses enucleation: a kind of cut a rectangle then peel off the tissue inside the rectangle  then push that tissue into the bladder.

the three loop technique is most common. The first retangle or loop is from the bladder neck to in front of the verumontanum and including the middle lobe. This step removes the whole middle loop Verumontanum is  the most important landmark in the operation. What is left is the left and right lateral lobes and that are dealt with by diving into two parts. Each is peel off and push into the bladder.  Then the laser is withdrawn and r place by a morcellator , which has an rotating blade to cut the enucleated tissues into small pieces and suck out by vacuum.  A complex surgery that is why  requires an experienced surgeon.

or Incontinennce 

Ask  your urologist is you can do CIC.  I think it will at least buy you time.  I've been doing it for almost two years, and it's the best!  I can now empty my bladder completely.  It's easy once you do it a few times.  Just got to slide that catheter into the penis, and move it down towards your bladder.  Once it reaches the bladder, your bladder, will drain completely.  It feels great to walk around with an empty bladder.

More:

If u goggle HoLEP complications u will find that Incontinence and retrograde ejaculation are too major complications. The former is about 10-20% and the latter is 70-80%. And to a lesser degree blood in urine is also an issue. If u go to steadyhealth  HoLEP enucleation experience thread and read those over a thousand posts, u will see how people are suffering from incontinence, some wear pads for many months.

However, I would not suggest ruling out  HoLEP because indeed it is the best for large prostrate and that benefits outweigh complications which are to be expected from any minimum invasive and resecting surgical intervention.

U may want to know some said HoLEP is the new gold standard. But the morcellator prolong the operation time and perhaps it causes more incontinence, which I understand is transient but from steadyhealth, some seem to last more than 7 months, but they could be a minority.

If u are in the east coast I also know that dr das in Philadelphia appears to be a competent HoLEP surgeon as he worked with Peter Giling, HoLEP's inventor , 20 years ago and has since then has been doing HoLEP. Lengiman(?) had also worked with Giling.

Hi. My understanding is that RE is the norm with HoLEP so not the best technique if you are younger. Tev Aho in the UK who did my op and the poster's said incontinence was not common and I believe this is where the surgeon's skill comes in. Certainly I'm fine on that front. He did say strictures could happen presumably due to some damage during the op but he said that could be fixed (?). My flow rate was amazing after the op. It has slowed in the 3 years that has followed but still very good and I can control it. My prostate was 140gm and Mr Aho said HoLEP was the best solution for very large prostates with GL being an option for smaller ones. I'm not sure I agree with or understand the 'plug' comment. Many of us have had the median lobe projecting into the bladder causing a 'plug' and restricting flow. The skill of the surgeon is in making the right cuts etc to remove the plug but leave the right sphincter function. It is a complex and long op but in the right hands it appears to generally have good results. I wish the guy who do did my inguinal hernia op had the same skill level! Ensure you have a surgeon who does HoLEP as his main technique and has been trained by others associated with the guys who originated the technique in New Zealand.

Dennis

My symptoms are all over the map. 

Some nights I wake up 1-2 times to pee, other nights 3-5 times. 

Some days I will urinate at home, go to work and then pee for the first time 6 hours later.  Usually, after that first time I will go every hour.  I drink a lot of water.  

Then there are days - especially if I drink coffee - where I'm in the bathroom every half hour. 

Yesterday at home, I went about 250 cc.  I was drinking water and orange juice while working at home.  An hour later I peed about 325 cc.  

Some days I feel like I empty well; other days not so.  

Last week during my ultrasound, I knew I didn't empty well.  I had been constipated and foolishly used a Fleet enema 3 hours before the procedure.  When the technician told me to try and pee, at first it came out with a good stream. Then, I "leaked" some of the ckear enema solution from behind.  I had to clamp my urine flow and wipe up.  I was nervous and frustrated and when I got back to urinating, I knew I didn't empty.  I had a PVR of 85 cc.  I drank more water.  When I got home an hour later I peed over 300 cc and felt good. 

I do depend on Flomax 0.8 mg per day.  

For HoLEP I have considered Dr Lindeman at Indiana University.  He's done over 2000 procedures. 

I want to do FLA, which is less traumatic but that's about $25,000 cash.  My wife will not sign papers for me to draw off equity in our house.   I would pay it back and I have plenty of life insurance if I die.   But she won't do it.  

I suppose RE is no big deal.  I haven't had sexual relations with my wife since I was 55.  

I don't think I can do CIC.  The very thought is frightening.  

I'm still not sure on PAE.  

Thank you,

Michael. 

Since RE is not a big deal I think you should look at some kind of Turp and get the job done quickly not wait for weeks or months hoping that it worked - I think there is one called "button Turp" My Urologist used to do Green Light and he said button Turp is less bloody and painful. He also does Rezum but that is one of those "wait 6 weeks and hope that it works" FLA as well like that. I've spoken to at least two men who had Turp or Green Light and were really happy with the results.

PAE in my opinion is like a gamble - I had it twice and it did absolutely nothing except it probably contributed to damaging my bladder since post surgery I couldn't pee for a week and did not know about CIC.

Flomax helps but if you do the procedure you probably can get off that.

Michael I'm not sure but maybe Ken is thinking about what causes RE. When a man has an orgasm the smooth muscle of the bladder neck contracts and blocks the semen forcing it to go through the urethra. If you have surgery which reduces the size of the prostate by a lot there will be a gap where the prostate tissue used to be, so even when the bladder neck contracts it doesn't shut the entry to the bladder and the semen just flows into the bladder. The body is a miraculous thing.

Michael, your void volume of 250 and 350ml is normal. So is PVR of 85ml. As far as nocturia, you might be consuming too much fluid. Try cutting it down, especially in the evening. You'll be fine. No surgery nor CIC is really needed, unless you want to get off the meds. Hank

Michael, please try CIC.  I was the same as you about not wanting to stick a tube, down into my penis. It doesn't feel bad at all!  Just go slowly, and you will be fine.  I used to try and see how fast I could do it, and my best time was 3 seconds.  I stopped doing that, because once when I was trying for speed, I started to bleed.  It wasn't a long bleed, but I thought to myself, I better stop being foolish.  Now I take a couple of minutes to do it.  I go really slow, so as not to injure myself. This is the catheter that I use:  SpeediCath  28494 Tiemann   Male  FR 14/4.7  Coloplast.  You can let you urologist know about it, then he has to order it, and it will be sent to your home.  When you start using it, you will be amazed at how great you will feel, with an empty bladder, all the time!  I've  been doing it for close to 2 years, and I wish I had  started doing it 13 years ago.  I am 69 years old. By the way, I forgot to mention that I order the coude tip, and not the straight tip.  The coude tip, has a little curve at the end, for better insertion. You are probably wondering how can a curve tip, be better than a straight one. Well, the catheter, has to pass by the prostate, and the curve tip, helps when the catheter, gets to that curve in the passage way.

Aloha,

Dennis

Hank,

I know some men here are being helpful by recommending CIC.  I realize I need to do something, but I'd reserve CIC for last and would pursue surgery before then.

Last night I went to bed early.  I woke up at 10:20 pm and 12:30 am, and voided 500 cc each time.  I then got up around 3:30 am but did not measure - I was too tired and just sat on the toilet, but it was probably much smaller, like 200 cc.

I crave salt and eat a lot of salted pumpkin seeds, which makes me drink a lot of water. I should cut back on fluids after 8:00 pm.

With Flomax in my system, the stream is good during the day. When the Flomax tails off - about 20 hours after my previous dose - the stream slows down, and at night it slows more than during the day.  I was surprised at how easily I voided last night after midnight.  My flow is still slow - probably around 5 mL/sec.

I've seen men on this forum who've ha failed PAE, but I don't think I've read of a single failed FLA.  I talked with a doctor who specializes in PAE, but he seemed too pushy - like he already wanted me to schedule surgery and fly out.

I dread self-cath and running the risk of infection, and the cycle of antibiotics and more infections and more antibiotics, etc.

It's good to read of men who've had great success with HoLEP and FLA.  It would take me at least 6 months to get the resources to avoid FLA.  I want to ask my doctor to put me on Finasteride to see if my prostate (anywhere from 130 cc to 175 cc) can shrink a little before I dive into FLA.

I guess I'm not too confident PAE will work. 

As for HoLEP, I'd consider it at some point, even if trading RE to save my bladder + kidneys is part of the deal. 

I admire the guys who can do CIC.  I don't have the stomach or the courage.

Michael

Hi. Some people find CICs fine including my Son. I used one for a few weeks and hated it but be aware that if your median lobe is very protrubent, like mine was, the CIC can hit a brick wall. I failed completely one day to insert one and had to visit my excellent Urologist's nurse. She also failed, called my uro and he performed a suprapublic op there and then to insert a SP catheter which I had for 3 months. I found that easy. I then had the HoLEP and the SP catheter was removed before I was discharged. I know nothing about FLA so can't comment on that but the HoLEP has been brilliant.

You won't get infections from CIC if you use pre-lubricated. In fact if you have a lot of stagnant urine constantly in your bladder you'll probably get more infections that way.

Having said that, from what you are writing you naturally voided 500 then another 500 so I doubt whether CIC would buy you much, maybe it would mean an extra hour between having to get up anyway.

I know PAE works for a lot of guys but after 2 failed ones I am skeptical. I also had FLA, it improved but did not solve the issue, perhaps because when I saw the surgeon I was in a bad way plus the 2 failed PAE's had an effect, FLA would still be my first choice if money is not a consideration. I have the large dreaded median lobe, could be why PAE outright failed and FLA not as good as some others' results. There was one guy I know of who had a bad experience with FLA, people speculate because his prostate was quite small to begin with. He told me he is waiting for Aquablation to be tested. Lots of buzz about Rezum as an alternative, in a way Rezum sounds a bit like FLA to me, I know the entry point is different but the idea of killing some tissue and the dead tissue getting absorbed and discarded by the body over a period of 6 weeks or so is similar.

Michael, HoLep is great. However, there's high risk for RE and some risk for incontinence. So far for larger prostate like yours, FLA is probably perfect, as reported on this forum.

CIC won't help you much currently. Cutting down on salt and fluid intake will. How about unsalted seeds ? Hank

Do you mean about in the Urethra or the site of the wound?

Philip.

Mr Aho told me that there was a risk of strictures i.e. in the urethra which he said could be fixed (?). I've not had that problem and no scarring at all.

BPH surgeries could leave behind scar tissues is all new to me so I don't know what I was talking about. I read a post, the poster said that he had a retreatment, the surgeon removed "scar tissues left behind by ALL previous procedures". So surgery removes blockage, but scar creates new blockage? 

DL  This is the way I have taking it.  I was told by a doctor that any surgery will cause scar tissue.  You can have surgery to have the scar tissue removed but that can also cause scar tissue so your back with the same thing.  But with some surgery you have to move up to other surgery's to remove the results from the first surgery.  Example :  Rezum being it using steam to melt the prostate tissue.  It can cause scar tissue.  They have use a Turp surgery to clean that up.  I have a stricture just before the prostate I got it from Kidney stone surgery.  They can cut it out but it can still grow back  Have a great day  Ken 

Philip.

This may appear trite, but why do you refer to Tev Aho as "Mr. Aho"?  Is  he not an MD?  Or is it convention in the UK to refer to MDs as "Mr." and not "Dr." as we do in the US?

Just curious to know.  Thanks.

Yes, this is one reason why I look more favorably at BPH treatments that do not enter through the urethra - chiefly, PAE and FLA.

I think, in time, FLA will probably become the gold standard but this is only if the FDA in the US approves it and insurance companies cover it, otherwise the volume of patients will remain low because it is cost-prohibitive for most.

Thanks Hank.

I think, in all honesty, I cannot steel up the courage to self-cath, and will undergo surgery before choosing CIC.  Perhaps if I were braver.....

I'm consistently voiding 400-500 cc.  I only got up 2x last night between 10 pm and 5 am, so I praise God for a pretty good night's sleep. 

I need to better schedule my major fluid intake......and cut back on salt! 

I think FLA holds promise.  I can't get over this mental block I have regarding PAE - the cutting off of blood supply to an organ.  PAE is the least invasive of all options but that keeps me from diving in.  And, I've read enough accounts of failed PAEs on the internet but have only found men happy over FLA.  Also, experienced HoLEP practitioners can open things up and flow improvement is immediate. 

Michael

Michael, in the UK we refer to consultants as "Mr" and other levels of medics as "Dr".

It depends, in my case the neck to my bladder was bent by the growth of my prostate. Therefore, a certain amount of checking during the procedure was done to make sure this we reversed during the procedure. 

If the PAE had worked and my prostate had shrunk, this may not have fixed my bent bladder neck. This was explained to me after my surgery.

I am going to find out more when I see Mr Aho in 3 months.

I hope we get more, less invasive procedures for men, the stop any form of damage to their bodies, that is my real wish.

Philip

Michael:

I wish I had your quantitative results.  Being able to urinate 250+ each time during the day time would be great (I typically average 125 to 140 during the daytime).  Your PVR doesn't seem all that high, so maybe some of the suggestions to try some lifestyle changes might help at this point rather than surgery.

Here's a few ideas:

1) Buy a prostate cushion.  I have the Allman cushion and I actually place it on top of two other thin cushions.  My pelvic floor is well of the chair when I sit (I can place my hand between my pelvic floor and the chair.

2) I believe you mentioned in one of your posts that at night you think your flowrate might be 5 ml/sec.  There is a cheap device for getting a rough idea of what your MAXIMUM flowrate is during urination. It is called the Uflow Meter by MDT and you can purchase it on Amazon for aboout $11.  I have a post on the device, so if you are interested you might want to check it out.  Since you're already measuring your urine output, checking the max flowrate with this device will add almost no additional time.

Good luck with your symptoms.