Prostatic Artery Embolization procedure

While studies may show general statistical trends of certain procedures, personal experience, like politics is local. So urologists, like all of us, base their opinions and recommendations on their own immediate experience about what procedures work best. Their opinions may sometimes be at odds with statistical findings but I do believe that you are being unjustly judgemental when you accuse this urologist of "leading with self-interest". Indeed, the same accusation can be directed right back at you regarding your comment about him!s

I know men who have been helped by many surgical procedures like TURP, HoLEP, SP and others and they will highly recommend them based on their own experiences. But there are many other men whose lives have been ruined by these procedures too. It all depends on personal experience - not published studies.

For example, you had a good outcome with your PAE and so you advocate it. But I had the same procedure a week earlier by the same doctor and my outcome has been a disaster. So I do not recommend the PAE while you do even though the published studies show a high success rate for PAE. Those statistics are not much comfort while I still have to self-cath in the middle of the night.

And as far as lower complication rates for PAE vs established procedures like TURP, it is far too early to make that claim. Many millions of transurethral procedures have been performed over the decades while only a few thousand PAEs have been carried out over the past ten years. Recently I have heard that PAE make render indolent prostate tumors aggressive due to restriction of the blood supply.

To summarize, your post displays the same subjective bias you direct at the urologist in question.

Yes sir - caveat emptor!!

 

Neil, have you gotten the second opinion about your PAE outcome from Dr Bagla yet?

Hi Rich - not yet. I want to get my MRI results first and then send them to Dr. Bagla for his opinion. I was to have had my MRI this past Monday but the wide bore machine did not boot up so I am now rescheduled for the end of Sept. How are you doing? Thanks. Neil

Pretty good. Just about to pull the trigger on having a PAE with Dr. Bagla. The tamuslosin is driving me nuts, even taking it every other day. Wake up in the middle of the night not able to breathe, blowing my nose for 45 mins. Based on all the incredible help in this forum, I've decided that whatever choice I make to deal with my LUTS, there is a potential for unkind results. Just have to place my bet and hope for the best.

End of Sept is today. When will you have the MRI? Totally hoping that Dr B can shed some light on what's going on with you.

Rich

We all have our right to opinions, including yours, and personal experience validly shapes it. Your PAE did not go well. Reseach shows you are in the minority. 

It works for around 80% of those who undergo it, according to short and mid-term research results of 3-5 years post procedure. No sexual side effects. No post-surgical catherization. There are cases where procedures other than PAE may be the best course of action.

I have made sure never to claim that anyone should do a PAE.

When I chose PAE, it was in the context of giving a few months to see if it worked, if not, then to consider other procedures that were more invasive.

Frankly, your personal opinion matters litte to me, and so should mine to you, since each experience, yours or mine, is simply one anecdote. Some value, but not much.

However, it can be part of a learning curve. That is why we are here sharing. In my sharing, in my initial post, I gave a reference for a meta analysis of PAE because my personal experience is just one, but peer-reviewed research gives the reader a better picture as to possiblities.

However, a professional rendering an informed opinion, such as this urologist, has a responsibility to share with the patient what well-established research shows, in this case, that peer-reviewed studies demonstrate no improvement in Bipolar TURP is not safer or yields better results that Unipolar TURP, absent what I had previously mentioned.

He may have a personal opinion about his personal success rates, and consider his results particularly wonderful, but he has a responsibility to share what the research shows,  - after all, perhaps someone else would do the TURP.

As for me advocating PAE, you miss the point: at the end of my post I noted that there were other procedures other than PAE that had lower complication rates and were showing good results, so no advocating was done.

I have never said that people should do PAE, only to read the reseach and consider it as an option. No objective bias here.

Hi Rich - I meant that my MRI is the end of October - not Sept. Sorry. Then I will talk with Dr. Bagla for a second opinion. Have you considered trying Xatral for your alpha blocker - as it has none of the sinus congestion issues you experience?

I don't think you have much to lose trying the PAE. It has little downside (except for the cost) but in my case anyway, it also had little upside. When you are planning to do your PAE? Please keep us informed. Take care. Neil

The studies and statistics you mention regarding PAE trials have no objective significance because they all contain a hidden placebo effect. Only when this effect is quantified by properly designed double-blind control group trials can any claims regarding PAE efficacy be made. A hidden placebo effect is already hinted at in these studies because most of the improvements are only seen in the subjective IPSS scores while objective measures like prostate volume, PVR, PSA are largely unchanged. So for you to state that I am "in the minority" is a specious assertion. Indeed I was told that I am a "prime candidate" for PAE and that my procedure was tetbook perfect.

Recently two very promising prostate injection Phase 3 trials for BPH went down in flames due to placebo. Yet both these therapies had shown outstanding clinical benefits to hundreds of men following phase 2 a few years ago. It was very similar to PAE where the IPSS scores had dramatic imrpovements but the physiological improvements were nil.

Our responsibilities as professionals is to give the best possible advice to our patients based on our own directly-verifiable experiencs. This does not include confusing them with reference to suspect trials on experimental procedures which may have been published in peer-reviewed journals. We all know that getting research published is based more on political merit than scientific merit.

I have tried to gain access to the raw data for most of the published PAE trials so I can break out the relevant trends on clinically important parameters (prostate size for example). Yet I was denied access in all cases even though the studies were performed at publically-funded schools. I wonder why? In our Freshman statitistics classes we all studied "how to lie with statistics". But every man on this forum and every patient who puts his trust in us is not a statistic and as such deserves better information than placebo-saturated means and variances.

 

I can only imagine your frustration at what you are going through. I hope things work out well for you.

It is outside the scope of my correspondence or time, to break down for others the volume and quality of data available.

Suffice it to say, however, in contrast to what you wrote, that the PAE research, whether or not it is the best procedure for any one person, does show ample data in multiple peer-reviewed journals demonstrating objective changes such as reduction in prostate volume, increased Qmax, PVR, and other uroflometry parameters....as well as significant reductions in subjective results.

Some of this information is found in journal magazines that require a subscription, however, your local friendly reference librarian can obtain copies.

For anyone that has an interest in this or any research regarding the efficacy and drawbacks of urological procedures, I mentioned google scholar, which is free on the internet, a few posts ago. There is a lot of information there that shows statistical analysis of data for a number of procedures.

However, let's not get away from the reason why I posted.

Professionals have a responsibily to share with patients what research demonstrates about procedures, good and bad, in a neutral way, while adding their personal experiences with the procedure if they want to.  That was the only point I was making.

 

Hi Neil,

    There are a few reasons that I haven't been inclined to try alfuzosin (Xatral).  My uro doc suggested it, but said that it would only be marginally better for the sinus symptoms. I looked on the web and found

that stuffy or runny nose was a common side effect. Viagra affected my sinuses also, I think I'm just wired that way.

    Alfuzosin also has possible cardiac implications for men with heart issues. My heart is fine but I'm not thrilled about taking a medication for the rest of my life that can affect the heart. It also lowers blood pressure, and I do have bordline low blood pressure, so probably not a wise choice for me. Have you taken it? What has been your experiece with it?

    Re: PAE. I'm of the school of staying away from meds and medical procedures unless I absolutely have to take care of something. I've had relatively good health and a few too many experiences of being seriously misled by medical professionals. With that said, aging is rearing it's head (I'm 69), and the ol' prostate is definitely impinging on the pipes, so I think it would be wise to go forward with this. Especially after hearing that ignoring it could lead to kidney and/or bladder problems. And the excellent reviews that I've read on the forum about Dr. Bagla (and Dr Isacsson) alleviated some of my concern. But bottom line is that like all the other BPH treatment options, PAE is invasive, and there could be unfortunate side effects. Whew, hope this wasn't too much of a rant. Apologies if it was.

    I'm looking at Nov for the procedure, but have a few things to take care of at home to allow my wife and I to be away for a almost a week, so that timing is not certain. I haven't checked yet with Dr B's office to see what availability they have.

    Back to your experience with PAE. I thought I read that your symptoms actually got worse for a while?

Hi Neil,

    Could you pint me to the studies where you think that the placebo effect might have been the cause for the good results?

Thanks so much for your posts.

Rich

Hi Rich,

I tried to point you to some of the relevant studies but the moderator would not let me name names - sorry.

I had also written that I have been on alfuzosin for 13 years now with none of the side effects you mention. Why not give it a try - you can always stop it.

Honestly - please don't worry about adverse consequences of the PAE procedure itself - it seems invasive but it is quite benign. Dr. Bagla has performed over 500 - the most of any US doctor. But if you are concerned about procedures in general you could just self cath indefinitely to avoid bladder/kidney issues until a truly non-invasive treatment for BPH, like an injection, becomes available.

The week after my PAE, after all the drugs wore off, my BPH symptoms did worsen in terms of retention and have not returned to pre-PAE levels. I was told I was the ideal candidate for PAE and that my procedure was perfect - somtimes I wish I were more suggestible so that the placebo effect would work for me! Improvement is improvement whether real or perceived. Neil

If PAE has achieved such efficacy in terms of objective measures then why has the FDA not even considered it yet for the most rudimentary level of acceptance? Every year SIR puts out their position paper regarding possible acceptable objective measures to assess PAE. Yet little progress has been made in this regard which is why the procedure is still designated experimental. The position papers read like arguments at the UN!

I would point you to a recent paper by Pisco where he presents data on 630 men followed over 7 years. Yes it does show statistical improvement in the clinical measures you mention but the variances are so large that these perceived improvements in the data could easily be accomodated by a placebo effect. Clinical data, as with all experiments should always be presented with error bars. So no - PAE is not there yet and wouldn't be until it meets FDA testing standards for a valid treatment of BPH.

To my mind, having read all published studies, the reason PAE has to be redone every so often is that the placebo effect has worn off. Perhaps this is why I saw no benefit from the procedure notwithstanding my lack of any complicating factors which could be used as an excuse.

Before I had the PAE I was convinced as a scientist that there was no compelling fact-based argument to support its efficacy. Hence I was not susceptible to placebo. Had PAE in fact been a valid treatment for BPH my skepticism would have been irrelevant and my pathological condition would be history. Or perhaps I am the victim of a reverse-palcebo effect?

 

Hi Neil,

   Thanks for your support and encouragement. At this point in terms of the possible downsides and upsides of both choices, I'm 95% leaning towards PAE rather than the Alfuzosin.

    Even with the Alfuzosin, your symptoms are worse after the PAE? I'm assuming that your symptoms would be even worse w/o the Alfuzosin.

    Re: the info on the studies, perhaps you could private message that to me. Thanks!

Rich

 

Hi Rich

You are very welcomed. You are correct about the alfuzosin - if I miss even one day I pay a heavy price. I must say it has been a good drug for me with minimal side effects and a lot of benefit. This is in contrast to the dutasteride (Avodart) which has taken a heavy toll on my quality of life. Dr, Isaacson told me right after the PAE that I could stop taking the Avodart right away but I dare not with no symptom improvement. He has pretty much jettisoned me in the follow up - I think the fact that my procedure was a technical success was all that mattered to him but I could be wrong. He has certainly not shown any interest since then - maybe I bugged him too much. Anyway I understand that Dr, Bagla is much more people-oriented. But Dr. Isaacson is good technically and he has a wonderful support staff. I will try to send you a private message with the links. I tried once before for someone else and even the private message was blocked. Take care. Neil

HI Rich -

I was blocked from pasting links into the private message, as well as attachments so if you would private-message me your email then I can send you the relevant info w/o the moderator. Thanks. Neil

HI Rich,

When you ask for anyone to send you studies, if they do it as a link the software will flag it. What I have done is note the name of the article and the name of the lead author/s. If a journal name is available even better. It goes through that way.

That info should suffice for someone to look it up on the net.

Just sent it.

Thanks!

Ah, good to know!

When you say,

"Professionals have a responsibily to share with patients what research demonstrates about procedures, good and bad, in a neutral way, while adding their personal experiences with the procedure if they want to.  That was the only point I was making."

but precede this by accusing the doctor in question of "leading with self-interest", you yourself are violating the very principle you advocate. It would be irresponsible of any doctor to discuss an experimental procedure for which even the basic mechanism of action is not understood.

Lord knows that as specilaists we all have little time to even keep up with recent advances in our disciplines, let alone be sufficiently aware of experimental procedures in other fields like IR to discuss them with patients. Only in the case of terminal patients should such discussions occur. Otherwise we would be violating our oath of "do no harm".

This urologist in question was being responsible in informing his patients about the procedures with which he has direct experience and which would help them in known predictable fashions. It is impossible for him to be even handed on both his own expertise and research procedures. This is why the FDA exists - to ensure that new procedures have passed the efficacy requirements before presenting them to the doctors to discuss with their patients as viable alternatives.

You really do owe this physician an apology for your ad hominen attack on him. He was being responsible in looking out for the best interests of his patients and following his oath.

It's your choice as to how you see things, and a waste of time for anyone trying to change others opinions.

Medicare covers PAE  for research purposes, and FDA approval is given at tail end of a number of procedures that, while waiting approval, have shown to work. FDA did not approve TURP until years after it was being performed in a number of US hospitals and clinics.

There are other posts here about some urologists not being forthright with alternative procedures. Note that urologists cannot perform PAEs. IRs do that. 

But urologists can do TURPs. It has been the experience of more than one person on this thread that they were not given alternatives that research shows have promise, based on clinical data. Urologists have in the past and do engage in practices that have not met FDA yet, this is part of the experience curve.

People are people, and so is human nature. It is not a negative comment about urologists in general, there are thoughtful and superlative practitioners in every profession, including urology.

But we are all under pressures of sorts. Government research demonstrated that physicians who owned or had a financial interest in imaging centers ordered invasive testing much more often than physicians with no financial interest.

Caveat emptor.

First do no harm -the Hippocratic oath. Any doctor needs to make sure they are sharing alternatives that have merit, at least to give the patient the opportunity to make choices, even wrong ones.

First do no harm -the Hippocratic oath. A doctor, as in this case, who minimized the harm that an approach he  likes when his profession's most prominent journal shows studies proving otherwise is not practicing his oath.  He at  the least needs to let the patient know the risks and that he feels his particular approach is safer than other urologists throughout the world doing the same thing.

He needs to be even handed.

I am not here to change opinions, including yours. Continuing this particular thread is not constructive, and brings my participation in it to an end.

I know that you had a tough time with your PAE. Its human nature to color what we see through the lens of our experience. I wish you well.

I wish you well you too and regret that an honest debate will force you to disappear into cyberspace - you should reconsider. In any case your thread will continue.

You realize of course that your last statement:

"Its human nature to color what we see through the lens of our experience"  applies equally to you as well.

My PAE experience really had nothing to do with my reaction to your specific post. It was your personal attack against the urologist in question because of his reluctance to entertain a procedure he opposed. You introduced yourself at the start of this thread as a "medical professional". Part of being a professional involves respect for those who disagree with you. Had you just discussed this urologist's attitudes dispassionately as a teaching moment for those us on this thread , then that would have been great. But it was your ad hominen questioning of his motives that I really objected to in my reaction.

The history of Science is replete with examples of people who have gone against published studies based on their own personal experiences. Very often this is where quantum jumps in our understanding originates.

There is no requirement to be "even handed" when it means advocating an approach which contradicts our experience. To suggest that this urologist's motives were anything but sincere because he disagreed with you is to impose your own subjective bias on his intentions - not exactly being even handed - notwithstanding mountains of published evidence to the contrary - he still deserved the benefit of the doubt and not the dressing down you gave him. That is what angered me - the unfairness of your position as a professional in dealing with another professional.

All the best to you.

Neil