NICE make Greenlight PVP the preferred UK option

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The case for adopting GreenLight XPS for treating benign prostatic hyperplasia is supported in non-high-risk patients. Please see the guidance for details.

We estimate that around 13,600 people with benign prostatic hyperplasia are eligible to have GreenLight XPS. Uptake of GreenLight XPS will be steady from year 2 onwards with around 6,800 people having the procedure each year.

Savings range from £1.3 million when 36% of procedures with GreenLight XPS are done as day cases, to as much as £3.2 million when 70% are done as day cases.

Based on 53% of GreenLight XPS procedures being done as day cases, the guidance is estimated to save the NHS around £2.3 million per year (or £4,200 per 100,000 people 

https://www.nice.org.uk/guidance/mtg29/resources/resource-impact-report-2541401533

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  • Posted

    Thats interesting to see just as the UK -ROPE trial for PAE ends which was funded by Nice I think.

    So more men will continue to be butchered. Avoid at all costs, insist on PAE.

    I was offered Green light laser and am very glad I refsued and did my own research.

    I had mine done as part of the Uk trial, but there are UK centres that will do it privately. Namely Dr Nigel Hacking at Southampton.

    Any thoughts anyone?

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    • Posted

      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
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    • Posted

      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.

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    • Posted

      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.
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    • Posted

      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. 

       

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    • Posted

      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. 

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    • Posted

      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="">

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    • Posted

      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.

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  • Posted

    One big down side to this is that with more men having Green Light PVP than the standard TURP or HoLEP the incidence of PCa being discovered during a "rebore" will drop.

    The Green Light PVP procedure does not produce any viable tissue to be examined for the presence of prostate cancer whereas the other two procedures do.

    I think the percentage figure for TURP and HoLEP of previously undiagnosed cancer being discovered during the procedure is approx 15% (could be as much as 20%) and the majority of these were found in men who were symptomless i.e PSA not raised and DRE unremarkable.  Having their cancer discovered before it became a problem was a big bonus for those chaps, something that will not happen with Green Light PVP.

    My low grade PCa (Gleason 6) was discovered following a HoLEP procedure and I am glad that I resisted the urge to have a Green Light PVP which had a shorter waiting time.  

    Having read the detail of the NICE decision, it was made I believe on purely cost saving measures when the cost comparison between GL and HoLEP was made.

    I saw no mention of the potential cost made of how easier it would be to treat men who had low grade PCa discovered at an early stage during a HoLEP over the cost of treating men who's cancer had been left undiagnosed following a GL and whch had advanced.

    If you throw that cost into the equation I suspect HoLEP would come out on top.

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    • Posted

      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..

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  • Posted

    Just doing the "back of a fag packet calculation" based on 6,800 men a year having a GL procedure.

    I just 10% (680) of those "cancer symptomless" men go undiagnosed with PCa following the procedure and need significantly more treatment for a more advanced cancer at a later date, the quoted potential savings of between £1.3m and £3.2m will be meaningless.

    Radiation treatment, chemo, brachytherapy, prostatectomy either open or Da Vinci, hormone treatment plus all other meds that go with managing the condition and not forgetting end of life care, I doubt if you'd get much change out of £5m for the treatment of 680 men based on a best case scenario.

    Oh well, the NICE "bean counters" will always have persuasive arguments to put forward and conveniently "overlook" the bigger picture.

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    • Posted

      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"

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    • Posted

      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.

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    • Posted

      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. 
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    • Posted

      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.

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    • Posted

      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. 
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    • Posted

      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.

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    • Posted

      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:-)

       

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    • Posted

      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.

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    • Posted

      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).

       

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