NICE make Greenlight PVP the preferred UK option

I had GL PVP and was more than happy with it. Many are even happy with TURP it all depends on the outcome and with reason the minority it does not work for are vociferous and try to put others off. PAE will take years to get off the ground as there is not the capacity to do it

I do not agree with you there, although I take on board the cancer detection advantage ofnTurp and Holep, verses pae and Gl laser treatment. 

Pae is far less invasive and destructive and succeeds in 80% of cases, there are other methods of PC detection, full Mri scans and pcae urine analysis.

Now if I needed a procedure for the first time I would elect forPAE.

Quote: " there are other methods of PC detection, full Mri scans and pcae urine analysis" but what about when you are PCa symptomless and only present with BPH symptoms, picking up early signs of cancer with a TURP/HoLEP is a no brainer.

I had PSA 16.92, DRE was clear,per cent free PSA was 5% (a new fancy-pants test to supplement PSA), so had high res multi-parametric MRI with gadolinium for enhanced contrast at Nuada, it came back with 80% chance of a tumour but the report also equivocated and said might just be inflamed prostate.  It said prostate volume 22 cc (about 22g), small, so high PSA is worse than if big.  MRI-guided transperineal needle biopsy came back with inflamed prostate, no cancer, on 13 cores.  Now, if you google "Individualized Risk Assessment of Prostate Cancer" (recommended by my own uro's little firm, and many others on net), and at base of that site click "continue" button-box, and enter DRE clear, biopsy negative, no family history, age 55, and my PSA, it cheerfully says I still right now have 12% risk of high grade PCa based on that data.  Which is why I await with interest, the histology from my holep last Monday, 9 days ago (seems to take 2 weeks or so to come through, unlike needle biopsy results which take 4 working days).  Of course, 70% of PCa is in outer layer and wouldn't be picked up via holep/TURP histology specimens, so after the minimum time for stuff to settle down, 4 weeks, I am having a PSA test; if it is <2.5, all="" well="" (i="" am="" 49,="" but="" had="" to="" put="" 55="" in="" the="" calculator="" as="" it="" is="" not="" calibrated="" for="" younger="" ages="" than="" 55="" -="" so="" my="" stats="" shouldn't="" be="" as="" bad="" as="" it="" said="" !). ="" if="">2.5, kind of annoying  I might ask for that urine test (you mean PCA3, not PCAE, I think).  Not many uro's offer that, I believe; my expensive private one, hasn't/didn't.  If it was a miracle test that was accurate, PCA blood test would immediately be redundant.  But I'll give it a go.  The cancer research page on PCA3 tests, says "The PCA3 test isn’t yet accurate enough to be used on its own as a test for prostate cancer".  It adds that NHS doesn't offer it; privately it's about £400.  It's apparently used alongside PSA and % free PSA and MRI, as yet another (inaccurate) "indication".  I believe they spend a lot less on prostate cancer research than on breast cancer research, which is why our tests are all rubbish. 

 

The Free PSA Test has been around since about 1997.

My local NHS hospital were doing it until the accountants decided it was too expensive.

I paid £25 then for one myself. My GP took the blood and sent it off to a Lab in Sheffield. 

Thanks, interesting.  My PSA was 16.92 and free PSA 5%.  MRI-guided TP biopsy clear on all 13 cores (biopsy said inflamed prostate). And I just heard this evening that the histology from HOLEP samples is clear.  So unless the biopsy was wrong, it looks like the % free PSA wasn't that effective in discriminating between (non-bacterial ???) chronic prostatitis, and  PCa.  Uro' says it can be the case for PSA and %free PSA to mislead like this, all of them are merely indicative and prone to inaccuracy. 

I'll have PSA re-tested (and % free) by private uro' in 3 weeks (=4.5 weeks after Holep), hopefully getting a low post-HOLEP result as a new baseline, and then I'll be 50 and can try to get GP to give me one each year (she refused point blank in April when sudden LUTS-y symptoms began - I was 49 then and still am; you're SUPPOSED to be able to insist on a PSA test from age 50 from your GP once a year, even if not symptomatic, but I think they often don't want to if <60). would be interested to hear how long other men left it after their turp, gl or holep before a new stabilised baseline psa reading ? would="" be="" interested="" to="" hear="" how="" long="" other="" men="" left="" it="" after="" their="" turp,="" gl="" or="" holep="" before="" a="" new="" stabilised="" baseline="" psa="" reading="">

There seems to be a reluctance due to loss of faith in PSA test results. I eventually took the attitude big prostate high PSA.

Biopsies seem to be rather hit or miss as well.

Be sure to get an "MRI guided biopsy". Anything else IS literally "hit or miss ".

Neal

If ever needed again.

I had two biopsies in years prior to my GL in 2005 and at that time my PSA was over 9.0.After the procedure it came down to 5.0

The hospital (Freeman Newcastle)  where I had it debated about five years ago whether to stay with GL or go over to HoLep and opted for for HoLep

My prostate regrew over the years and in 2013 it was 135grms and PSA around 7.8. I had Thulium/Holmium laser surgery. The first part saves tissue and the second tidies it all up. I had 37 grms sent of to histology that was clear and this time my PSA was 0.74..

http://www.p-international.com/article/S2287-8882%2815%2930076-3/fulltext  ; : it says that greenlight is provided to NHS hospitals for free anyway, based on a contracted committment to buy so many fibres a year from the providing firm at £570 a go.  A bit like Walls giving a small shop a free freezer, or some offices being given free coffee machines but flavia's proprietary sachets are rumoured to cost up to 50 pence each.  I wonder if the Holmium laser is provided like this ?

Results : that URL conclides, "PC was identified in 13.4% in men aged ≤ 65 years, compared with 28.7% the older group. The younger group had a lower proportion of Gleason score ≥ 7 (30% compared with 40%)" - So I think that means 4% or so of the under 65's had aggressive(ish) PC.  For anyone that does, I am sure the extra cost of more treatment due to late diagnosis makes HOLEP a superior overall choice; NICE's cost-benefit is based on ONLY comparing GL with TURP re : hospitalisation time.  As that study says in conclusion :

"Incidental PC in men aged ≤ 65 years is not uncommon. Our results suggest that TURP specimens in men aged ≤ 65 years should be completely assessed. Under-identification of cancer may occur as a result of increasing use of [GL, not HOLEP] laser prostatectomy and the consequent loss of tissue for pathological examination"

Does Non high risk patients mean ones very unlikely or known not to have cancer?

That's the billion dollar question!  How other than previous biopsy, rising PSA, DRE, familial risk can you say that someone is 100% cancer free before having a GL (or TURP/HoLEP).

The men that do not present any prior PCa symptoms and are then diagnosed with a highly advanced cancer (small cell for instance) are those that will be the losers in the GL lottery.

Lost opportunities will mean lives lost earlier than necessary but that's how it is unfortunately in the UK when it comes to doling out a decreasing amount of money on an increasing amount of patients.

It must relate to cancer, as it specifically (click in the NICE guidance in URL at top of this thread, on "Please see the guidance for details" then click on to actual report ... section 1.2, says GL is better than TURP who have an increased risk of bleeding.  All intuition screams they must mean, to not use GL for high risk of PCa - and use TURP or HoLEP, the operation they dare not mention, instead.  But if you google "nice holep", you find their recommendations of 2015 and 2010 around holep.  They want you to try meds first, before TURP or HOLEP or GL.  But alpha blockers, even if you only ever take ONE pill, can complicate later cataract surgery (albeit not making it any more likely) - see interactive floppy iris syndrome (doesn't affect you at all unless you need a cataract op).  70% of those who ever took alpha blockers get it to some extent, it is manageable and usually just makes the cataract op harder and potentially more painful as pupil dilators and stuff (the internet says) may be needed; in an unlucky few cases it makes it a lot harder. 

Tell me about it, I've got permanent pin point pupils because of Tamsulosin and I'm stuck with them for life and all down to the iris muscles becoming weakened due to the drug.

I was hoping that when I came off Tamsulosin 8 months ago following my HoLEP my irises would start dilating again but it isn't going to happen.

Yikes, I didn't know it had any effect BEFORE a cataract op ... even more glad now that I declined it (I was just worried that both parents had cataracts, so maybe I will later).  I did read that it binds super-well to the A1 receptor in the Iris, which is the only other A1 receptor than the weaker one in the prostate.  It is "tuned" to those two.  You can take non-selective alpha blockers instead (avoiding most of the iris effect, and probably the permanence of it), but only if your blood pressure is highish to start with, as they might make you faint.  Mind you, an awful lot of men take alpha blockers for BPH so the effects for most people, can't be too bad.   Eye surgeons only figured out the link about 15 years ago, and then wrote a lot of papers on it.  Most internet articles about tamsulosin, do not mention this iris effect. 

The surgeon doing my cataract operation said to the nurse, Why do they give me all the difficult ones?

I also had deposits forming on my corneas from having taken Amiodarone.

It is called Flopy Iris syndrome. Only Tamsulosin causes it the other alpha blockers are OK.

I once asked the nurse at my GP's surgery which drug she had most complaints about. She said Tamsulosin and I said only from men. She said No mainly from their wifes:-)

 

Agree with you completely. Of course the Health Editor in the Times does not know that from his article.

In the early days with Laserscope the rods were £3K each.

Thanks Paul, you've done a better job of explaining it than I did and thanks for pointing the way to the article (how did I miss that one when it was first published).