The Rezum procedure and BPH

To Alan,

When I first look at a post it bopps up and down for several annoying seconds as the computer trys to keep up with the pop up ads, but it usually works out eventually. Now you have deleted so many posts that the software can't handle it, and I never get to see the post teased in the email I got. You are supposed to be facilitating the process, but you have gummed it up so badly that we can't see the post. Please fix the software so that it works properly, or butt out so we can see the posts.

Neal

Neal,

That happens to me on my Iphone frequently but it's not relatedto deleted posts. What seems to work for me is just to be patient and not touch the screen until the browser settles down. Then scroll up gently and the post is usually right there. In a pinch, you can do a Ctrl ""F" search of the thread using a keyword from the preview pane.

Jim

Hi Jim,

I understand about the waiting. That usually works, but after the moderator facilated the process by deleting the 93 or so posts a few days ago, the waiting didn't work. The posts referenced in the following emails were no where to be found on my Verizon phone no matter how long I waited. And while I sincerely appreciate the cylinder F hint, and I will use it when I am working on my computer, I usually use my phone to review these blogs, and my phone has no control key. Thanks for the info on cylinder F. It sometimes will be helpful.

Neal

CONTROL F, NOT CYLINDER F.

#^*[=× Spell checker.

Neal

Yeah, the phone works differently. I don't think I was using the phone the day all the posts got deleted. But in general, this forum is not the easiest one to navigate under even good circumstances.

Jim

Aquablation looks to be very promising; they had a great display at the AUA conference in Boston this year.

Early trials show it to be an efficient, safe alternative to the TURP, largely automated by a robot after the urologist programs the parts of the prostate to operate on.

We ended up not being part of the clinical trial, but will likely be one of the first practices to offer it once it (hopefully) receives FDA approval.

The trial results did look promising, although participant numbers were low, prostates were on the small size and PVRs were not all that large. But this is not unusual as trials tend to cherry pick for different reasons, not all bad. It will be interesting to see how well the procedure works with a more diverse patient group.

The one thing I did note with the thirty or so trial participants was " there was no incontinence, retrograde ejaculation or erectile dysfunction reported."  

So I would think this procedure is definitely something to keep an eye on. 

Jim

My last paragraph got cut off in the wash...

Should have read:

"So I would think this procedure is definitely something to keep an eye on. Just another example of why people should consider watchful waiting if they can. Seems like the last few years have brought a slew of prostate reduction procedures to market after a period of drought. I do not think this is coincidental to the fact that baby boomers are now reaching the age where they may have to do something, but with 70 the new 50 (I try and tell myself that ) we "50" year old's do value our sexual function. 

Jim

Jim  This is in regards to the 70 being the new 50.  My erologist and I were talking about sex and age.  You know he and I are working on something for me. He told me that he has alot of men coming and seeing him that are in there 80 and 90's that are still into sex they want to save there ejaculation.  He told me that there is a man that he did a penile inplant.  He is 92 and just got married his wife is 68.  They were going on a honeymoon and he wanted to make sure he could have a good time with his new wife.  I hope I can still have some fun at that age.  They do say age is just a number.  My doctor will help a patient with any problem they have.  He want them to be happy and that is all that matters........Ken    

"Aquablation of the Prostate for Symptomatic Benign Prostatic Hyperplasia: 1-Year Results." by Gilling et al, had 21 patients, the largest having a 102 g prostate (larger than 99% of prostates) with incredible improvement in IPSS scores and max flow rate with minimal side effects. This is just a Phase II trial, but from the folks I've spoken too, there shouldn't be a reason it won't work very well for even larger glands; treatment times are all under 20 minutes. I think it has the capacity to revolutionize the field.

For starters, we will likely offer to patients who either failed Rezum, want something that works faster, or have a very large gland. Hopefully FDA approval isn't too far away.

@JerseyUrologyGr: " had 21 patients, the largest having a 102 g prostate.."

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If this is in response to my post where I stated, "...The trial results did look promising, although participant numbers were low, prostates were on the small size and PVRs were not all that large..."  keep in mind that the 102 g prostate was not representative at all with most of the prostates on the small size. 

That said, I share your hopeful enthusiasm about Aquablation and hopefully more data will support the trial results. Zero incidence of 

retro ejaculation in the trial is very exciting to me, and again hopefully that will be replicated with a larger and more diverse patient group.

Jim

Isn't it interesting how a new unproven urological procedure might be revolutionary but another procedure is merely experimental. Just an observation.

What exactly is unproven or experimental about this?

The Rezum procedure (a procedure that is being discussed here) has had multiple peer review articles showing significant improvement in symptoms with minimal side effects. The largest study (published- more are still being accumulated) had an N=136 in the study group, with other smaller studies yielding excellent results.

It's called "evidenced based medicine."

You referred to aqua Latin.

Aquablation

Aquablation?

Yes, there are currently 12 peer-reviewed papers on this; it is new.

However, June 2017 Journal of Urology has an article with statistically significant results (great improvement in QMax and IPSS)

It is currently in an FDA sponsored study; anyone who meets criteria to enter it will have their treatment fully compensated. 

But it's nevertheless still experimental isn't it!

How do you define experimental? Once you go beyond Phase I, passed a Phase 2 with flying colors, you're in Phase 3; ("This phase II study provides early evidence to support the safety and effectiveness of aquablation for symptomatic benign prostatic hyperplasia."

The safety and early efficacy has been proven; an epidemiologist would consider this a completely different level of "experimental" vs something that has had no studies whatsoever.

Ross,

I'm routing for both FLA and Aquablation. They currently seem the most promising, and will be following both closely.

Jim

I would guess that anything unapproved still qualifies as experimental.

Deepends what your bias is I guess!

I 100% agree Jim. 

Ross,

I don't know if you've been following aquablation closely, but one unique aspect is that it's performed by a "robot" and actually described as a "urologist free" procedure where the doctor basically only programs the computer. In theory this should greatly diminish operator error. Because let's face it, how many doctors in the world do you think currently have the skills for FLA of Dr. K., S and W?  

Jim 

Jim

It's not bias, it's biostatistics.

Phase III is different than Phase II is different than Phase I is different than something that is not being actively studied.

It's not quite "urologist free", although the actual ablation is performed by the computer.

The urologist reviews the ultrasound and performs cystoscopy and programs the area of the prostate to be treated. The machine does the ablation; the urologist then performs a second look to assure that there is no active bleeding, etc... But in general, I think once AI gets to the right place, human error in many procedures will be greatly diminished.

Aquablation certainly does seem promising; safe and effective based on early trials, and minimal cost to patients. We hope to be offering it to our patients by the end of this year, assuming it is FDA approved.

"urologist free" -- No disrespect.  That is how the literature I read, described it. Personally, if I were the manufacturer, I would have used a different marketing term to my target audience  

Jim

How would Aquablation match up to someone like Frank who is in retention and say compare to button turp?  Same question with Rezum. 

Jim

For a nice description of the procedure, see, "How I do it: Aquablation of the prostate using the AquaBeam system"  by MacRae in the Canadian Journal of Urology from 2016. The surgeon programs and has direct visualization the whole time.  

Some of the key benefits I see for my patients:

1- Operating time is minimal, reducing anesthesia and other risks

2- Ablation is programmed and performed by machine, but with direct and ultrasonic visualization by a urologist the entire time, maximizing safety

3- Hemostasis can be performed upon completion

3- Catheterization time can be minimized

in addition to the results seen in the studies.

Assuming upcoming studies are as successful, it has the potential to be big.

It depends on size and extent of symptoms and detrusor pressure seen on urodynamics.

Generally, the TURP is considered the "gold standard" (unless the gland is really large, in which case a suprapubic prostatectomy would be the "gold standard".)

Aquablation should approach the results of a well-done TURP.

Rezum is a nice, minimally invasive procedure which has some drawbacks- it takes some time for the tissue to die off (vs a TURP type of procedure where the tissue is removed in real-time.) We have had some success with Rezum with retention patients, but it really depends on the factors mentioned above.

So Aquablation would be more agressive/turp like than REZUM. What about Holep as a "gold standard" for larger prostates versus a suprapubic prostatectomy? As to the rest, I have told Frank to get a second opinion on his urodynamic study and/or get another, as from what I have seen here it can come down to who reads it.

Jim

HOLEP is performed by relatively by relatively few physicians;

for those who have had training using it for exceptionally large glands, it can be performed in lieu of an open or robotic simple prostatectomy.

Of course, Aquablation could end up replacing it; such is the way of technology.

Hi Jim,

I want to be sure that we all agree about the definitions of the terms we are using.

As I have always understood it, EJACULATION is the forcing of seminal fluid out of the prostate. ORGASM is the constellation of wonderful feelings that we feel a few seconds after EJACULATION.

I have wonderful ORGASMS after EJACULATION, and can't tell that I have RETROGRADE EJACULATION unless I am looking at the end of my penis at the time. ( I do have RETROGRADE EJACULATION). It's no big deal unless one is planning to have more children, and even then, there are work arounds.

Please, let's not confuse the two. No one wants to lose the ability to reach ORGASM, and some of the medications and surgical procedures the doctors are selling can do this, and we need to be careful about that; but RETROGRADE EJACULATION of seminal fluid is, for most of us, no big deal.

Neal

Hi Neal,

I think we are using the same terminology. I've had both antegrade (where the semial fluid comes out of the penis) and retrograde (where it doesn't) ejaculation. The retrograde ejaculation happened when I was on Tamsulosin. I also intentionally induced it maybe half a dozen times when I was experimenting with tantric yoga many years ago. And I agree, for some people it's no big deal, and actually for tantric practioners it's preferred. But as you have read here, some people prefer the feeling of antegrade ejaculation. I'm one of them.

Jim

@nealpros: "No one wants to lose the ability to reach ORGASM, and some of the medications and surgical procedures the doctors are selling can do this, and we need to be careful about that"

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I just caught this part. I do know some meds (or even alcohol in excess) can make an orgasm difficult or impossible. But curious, what specific meds and "surgical procedures" are you referring to? 

Jim

Do the urologist program the machine that does it.  What are the side effect..Ken

Neal  Very happy for you that you have the same feeling but sometimes that is not the case.  I don't want mine going up I want it going out.  At 61  I may have a little problem getting a good erection ( ok for oral and mastubation Working with my doctor  But my oragsm are very intence and I can shoot 4 to 5 time.  Just because I'm not having kids I still want it.......HAve a great day  Ken

Neal  That is why when they tell you about a procedure they tell you everything will be the same.  Because all men have a orgasm.  They do not consider the male ejaculation a sexual function  Ken

Side effects should be similar to other ablative techniques such as TURP.

The urologist programs the machine, watches the procedure to assure the correct tissue is ablated, and then gains hemostasis.

Can it be done like a FLA where the tussie that is only casuing the problem is removed and leave the other stuff alone where you don't have retro.  I guess your you guy just made another surgery to castrate us men I throught things were going to get better to me that is worse  Not for me  Sorry

I think it is a bit of a misnomer that only certain tissue causes the problem. Obstructing tissue can be ablated with any procedure, regardless of energy source. That one procedure somehow is safer has no scientific merit.

I do not understand your accusation that we are "castrating us men" (?) as this is nothing of the sort.

But in a way you are.  There have been so many men on here that have been forced into a turps and not told of the out come of it.  You here the same thing All will be the same.  9 out of 10 procedure cause retro. So you are castrating men. Men in there 30's 

Kenneth, I'm really not sure what you're referencing.

Castrating means to remove a man's testicles.

Men in their 30's rarely (if ever) have TURP procedures.

I'm not "forcing" a man to have anything, and I (and most urologists) are up front with what the risks of a given procedure are.

I'm not saying you are but this man ended up having a turp done by a doctor and the doctor did not tell him that he would have retro.  He got a lawyer and taking him to court after the doctor laugh at up and told him there would be less clean up.    ( I do know what castrating but with retro you get the same out come no kids.  To me it just a sham that we can come up with treatment for us men that are better and not take anything away from us.....I think sometimes a urologist forgets he is a man and what he is doing to another man in the way of helping help.  It just to bad we have come to this..Ken

There are plenty of doctors (in every field) that don't necessarily do the right thing for their patients; thankfully, they are a small minority.

I cannot comment on the particular case you mention as I do not know the details.

I am happy to offer my services as a practicing urologist and voiding specialist to answer any questions anyone may have regarding treatments available for these issues.

Of  course there are.  That is why we try to tell the men on here to get a second opinion.  I have been on this site for over 3 year and I have heard it all.  I hate to see a man have there prostate cut because that is what he was told by the doctor and then find out it's not his prostate it's his bladder.  I do not feel we should have to choise between peeing better or our ejaculation.  There are also alot of mis treatment.  You go for a holep surgery 3 month later you have the same problem you have another one. they 6 month later you have more problems they got worse.  You have a turp to clean of the mess from the 2 other surgery.  How much of the prostate are they going to take.  It is a same that we have to go through this.  I have allway told men on here to make sure thay have all the test and get all the information before they pic a procedure.  I have writing many letter to many hospital protesting many of the procedure that we are talking about ( Mostly Turp That is a horror )  I have gotten some letters back  One nice one was from a urologist from the mayo clinic  I don't remember which one I have it in a file and it late.  Thanking me for taking the time to do this.  He said also he will try to work on it for me.  He said he agreeds with me.  He told me that he had a Turp when he was 58 and his sex life was never the same.  I do thank you for being on here and putting up with us men and answering our question.  Sometimes we can go in a circle on a subject.  But we are all on here to help the men in this world.  Life is to short to give up anything.  God gave me my ejauclation and no man will ever take it away..  Take care  Ken 

JUG said:

"I think it is a bit of a misnomer that only certain tissue causes the problem."

Can you point us to any peer reviewed studies confirming this or is it just your opinion?

"Obstructing tissue can be ablated with any procedure, regardless of energy source. That one procedure somehow is safer has no scientific merit."

Depends what you mean by safer doesn't it? Many men here are clearly concerned by the potential of collateral damage done by the less accurate ablation techniques. I mean you would use Rezum style steam ablation in the brain would you? Therefore there must be scientific merit as to the safety of MRI guided, fine tunable accuracy over a more generally applied unguided technique. Whatever your opinion, it's just common sense!

Ross:  you are simply working with incorrect information; one cannot simply determine the exact tissue which is causing someone's problem; generally the "middle" tissue (transition zone) is often thought of as obstructive and the peripheral tissue isn't- this just isn't necessarily correct in all cases. There are plenty of patients who had this tissue resected yet still have symptoms; it's not a simple "clog in the plumbing" as There is no magic, "OK, this millimeter of tissue is bad, this millimeter is good".

I don't think there is a question regarding safety based on FDA trials.

Also, the studies demonstrate that there is no significant change between the study and the control group in terms of multiple parameters we follow for this disease state (sexual function, etc...) It's a great procedure we are now able to offer.

I hope this clears up some of your misconceptions.

As an example, "The effect of complete transurethral resection of the prostate on symptoms, quality of life, and voiding function improvement" by Milonas, et al, looked at the amount of resection performed in the transitional zone as well as total prostate volume; unsurprisingly, the resected tissue/total volume ratio was important (not just transitional/resected) in determining IPSS improvement. Not a surprising study, as that's textbook information.

So, you can't just suddenly say, "ahhh... this mm of tissue needs to be treated, but THIS mm of tissue does not"; it doesn't work that way.

I hope this helps your understanding.

Good morning Jersey.  Isn't there a test that you can do. to see what is the problem.  Example.  You have a man that come to you and you find after a scope that the prostate is about 40cc but the median lobe in blocking the bladder neck.  Can't you just go in and get rid of that portion of the prostate and leave the rest alone.  Not distroy the whole prostate.  Ken

Absolutely; and I think we're splitting hairs at this point (as I'm hoping you're not going to try this at home  

Having an intravesical prostate certainly has a high correlation with symptoms, and an attempt can always be made to treat that area first; with the understanding that, just like everything else in medicine, there is no guarantee that it is the sole cause of the voiding dysfunction.

In men who have urinary retention with severe bladder decompensation, for example, a complete resection down to the capsule may be warranted.

But some men Not all think that you are taking away there quality of life when you stop there ejaculation.  You may make me pee better and save my life but with you stopping my ejaculation you are killing be in another way.  I know doctor are here to help us with our problem but sometimes they don't listen to us.  (  Not all doctor but some )  Ken

I have a full understanding thank you. I think the break down in communication is happening because Kenneth and many other men are concerned about collateral damage due to the lack of accuracy of most if not all urologocal procedures approved for the treatment of BPH. The "safety" of a procedure for most patients correlates to its ability for example, to ablate the problem areas around the bladder neck withouth causing retrograde ejaculation. What is so hard to understand about that?

I had two urologists tell me that my treating my problem areas all but guaranteed retrograde ejaculation. I had another Manhattan urologist suggest a full prostatectomy.

Clearly, as my IPSS score is now < 5 and I have full sexual function, accuracy and safety was in play. 

You dismissed MRI real time heat maps as just marketing but made no acknowledgemnt of your error. Of course if it makes no difference what tissue you ablate, it may as well be random!! But try listening to what people are telling you, they want to have a procedure that relieves their chronic symptoms and keeps them in tact. The safety and accuracy of a procedure is therefore of the utmost importance. No matter what you claim!

 

No not going to try this at home.  I may be set in my ways but I do see the whole picture.  Let me ask you same patient you tell him what you want to do and he ask you to just get rid of the medien lobe Let see if that works first.  If it doesn't we can allways go back.  Now with doing just the center lobe will that man still end up with retro being you have not gone into the whole prostate.  Thank you for being a good guy  Ken.

Thank you Ross.  You said it much better they I.  I think alot of doctor don't listen to there patient about there concerns.  They just want to do it there way.  There has to be protocol to any procedure I know but they has to be a way to ajust a procedure to what the patient is asking for.   Ken   

Ross:

I am not sure what you mean regarding an error?

The "MRI real time heat maps" does not have a place in benign prostate disease at this time. I also didn't claim anything beyond what the literature states, so I'm not sure what you mean.

I think we are again getting off track; you can think of me as a resource for your forums (i.e. like the show, "The Doctors"; an MD who is an expert in this field who can try to navigate and discuss treatments for men's health issues for those who have questions.

It sounds like you've already had treatment and you are doing great; I'm very happy for you, but I'm not sure what advice you need from me or why you would need it at this point.

@JerseyUrologyGr: "you can think of me as a resource for your forums (i.e. like the show, "The Doctors" [wink] ; an MD who is an expert in this field who can try to navigate and discuss treatments for men's health issues for those who have questions.

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First, I want to say that I am somewhere in between your stated views on FLA and Ross'. I also found the deleted discussion between the two of you infomative. Both of you made some excellent points but it seems the off topic nature and the repetitiveness doomed it to the junk pile. 

I think you have every right to answer or not answer any questions you want, and to "define" your role here. However, this is not anything like the show, "The Doctors",  nor should it be. In fact, if the men here had that much confidence in what their doctors tell them, this forum would not exist. 

So, if you do continue to post here -- and I hope you do because you're bringing a professional point of view and some really good information -- please expect your ideas and advice  to be challenged from time to time, just like we challenge the ideas and advice of non professionals to promote a more useful dialogue for everyone. We treat "arguments from authority" here just like any other argument. 

As to why Ross is posting here, given he has been successfuly treated, probably for the same reason I'm posting here. To share our knowledge and experiences with others suffering from BPH/LUTS. 

Jim

Hi Jersey,

1. Can urologists actually determine exactly what tissue is causing a specific man's BPH?

2. If so, can that specific tissue be removed?

3. Is the " best" method to remove that tissue determined by its location, or better, what determines the best method to remove that tissue?

4. Are which methods of removal are more precise, and less likely to cause collateral damage?

Thanks,

Neal

Hi Neal;

It's a good/loaded question, and not one that has a straight-forward answer.

When looking in the cystoscope during the procedure, you can see the "obstructing" tissue; in many/most cases (depending on pre-operative urodynamic parameters) this tissue may be all that is needed to treat; several studies support the theory that an intraprostatic median lobe is a primary culprit of voiding dysfunction; that being said, I've  seen men who could've benefited for more extensive resections. Particularly men with acute urinary retention and a decompensated bladder, the literature generally supports resecting down to the fibers of the prostate.

Technically, a TUR-style procedure (such as a PlasmaButton) allows you to have direct and exact visualization of the tissue removed. However, treatment of the lateral lobes and staying within the anatomic confines of the prostate with most procedures allow you to avoid "collateral damage".

Nut to me it seams like you do more that what you need to do just because protocal tells you do do so.  If the median lobe is what is causeing the problem leave the rest alone.  All that does is maybe cause more problems.  I feel sorry for any man that has to go through this.  I have a friend that is 80  when he was 60 he had his prostate remove because of cancer.  He told me know that if he had to do it agin he would not have done it.  He lost his sex life his wife and he still have to ware a pad.  I guess that is what you call helping the patients..Ken

Ken, I've always appreciated your posts on the forum, but I do feel this last post was rather disrespectful. Perhaps I read it wrong.

Rich

And I will add to Jim, who is usually so correct and doesn't need any additions,  that you present yourself as a self proclaimed expert.

That been appreciated, I for one would love it if  some of the men you have peronally treated with these protocols would join our discussion and provide some realistic testimonial of the symptomic relief they recieved under your care. I will note that in adding up the time and amount of post in the last week on this site, well you must be working nights. Thank you for not billing us!!! (Relax, It a Joke). 

HOLEP was my first choice if I was going to have BPH surgery. Great track record only bad side effect was RE. Last Summer my  symptoms were real bad. Mostly urgency and occasionally (every 3 nonths) pretty bad blood in urine. Figured I would have surgery in  December and recouperate during the Winter months when the snow was flying. I was taking fernasteride & tamsulosin. By late Fall my symptoms had improved so much that I decided to hold off on surgery. Then j12080 came along with his great FLA  success. Was contemplating FLA but I'm doing so well right now I hate to upset the apple cart with any type of procedure

I started out with one of those type of uros. He was hell bent on doing TURP but would tell me exactly how the tissue wouyld be cut away. He said maybe laser, heat, how wire etc. Then I did some research and realized he wasn't doing any of the newer procedures. I walked out and never went back

If you are doing well brother then ride it out BUT be prepared. Ross will tell you about that one. Congradulation and I hope the success stay. It can. You have a good plan. 

Hang in there. 

Unckle,

If it ain't broke too much, stay with the devil you know. I'm in that position right now myself. Not willing to risk a marginal improvement for the inherent risks of any procedure. The bph/luts store will only get better with time should that time come.

Jim

I fully expect my BPH symtoms to return. $ got a little tight with a rather large and unexpected home building project.  I had hoped to have $ together for FLA by June but it hasn't worked out that way. So I emailed Dr K to let him know I couldn't participate in his study group. 

Maybe aquablation will be approved by then and you can compare data from both. Or maybe your prostate will not meet your expectations and stay behaved

Jim

I am sorry that you feel that way.  I did ask my friend Jack if I can put him on this post He told me yes and if it helps someone not rush into a procedure he will be happy.  I would never say a thing about anyone that I don't get permission to do so first  Have a good day  Ken. 

Jim aquablation is just a new way for them to do a turp  Did not like what I read  Ken

Ken,

I thought I read that the aquablation trials had no incidence of retro ejaculation which would be a major difference from TURP, however I can't see to find that citation anywhere now so maybe I was wrong. All I can find is this: "Superiority in ejaculatory function (MSHQ-EjD) and incontinence scores (ISI) at three months" which to me is unclear whether there is any incidence of retro or not. Something to look into because if aquablation has the same incidence of retro as TURP then it's not the breakthrough I thought it might be.

Jim

Still can't find it Ken, they seem to just skirt around the issue with verbage like I quoted before. I hope I'm wrong, but looks like it's not the antegrade ejaculation preserving TURP like procedure I thought it might be. 

Jim

What I read was something like the aquablation was the same but with water and it would have the same out com.  Going to have to find that again  And your that is no breakthrough.  I think it's a step back.  I will look for it later just having dinner been a long day  Ken

I qam tired of the % of the trails why can't theysa y  out of 200 men 20 had retro.  It would be easier to understand..I will let you know later if I find it  Ken

Maybe the marketing department is writing up the trial reports. They know exactly what they are doing.

Thje prostate is mapped and the actual tissue removal is done robotically. I assume areas such as the ejaculatory ducts can be avoided.

I had thought that was the case but I can't seem to find a citation on that anymore. Don't want to read to much into the quote in my previous post, but you would think that if they didn't have retro ejaculation they would just say it. Something to look into.

Jim

That may be true but I want to talk with the patients first.  They have more control of the water jet but they do the same with the Button turp.  And most men end up with retro  Ken 

Ken, Unless the study data says no retro ejaculation, I think we can safely assume there is an incidence of retro. I'm sure they can avoid the ducts but the issue is can they avoid the ducts and still get the results they need for symptomatic improvement. 

Jim

Jim this is where I read it.  PROCEPT Biorobotisa presents Phase 2 data on treatment of benign Prostatic Hyperplasia with Aquablation using the Aquabeam  Ken

I read that as well, but the wording is still unclear to me if there's retro or not. 

Jim

I think it's the same as FLA but with water.  They can avoid the ducts but do they want to.  I still say the problem is that doctors to not think of the male ejaculation as a sexual function.  That need to chance.  I sent you a PM and another onee where I read somethings you may find ok.  ken

thats change

It is very misleading.  To me Aquablation is like the FLA procedure  but with a TURP procedure outcome....Ken 

Hi Jersey,

Thanks for your answer. It covers many of my questions, but in one case ,I wasn't clear, so your answer wasn't responsive.

By collateral damage, I was referring to side effects. For example, bleeding, incontinence, impotence, inability to ejaculate, RE, etc. I wasn't referring to side effects outside the prostate.

Please address that issue, now that I have clarified it. As an aside, the site for the company selling the equipment to do a button turp doesn't list these things as possible side effects, except for bleeding. That's just a bald face lie, as we have had many men post on this site who have had TURPS, and who now have these,as life long side effects.

Thanks for your help,

Neal

Any procedure on the prostate has the potential for the side effects you listed. If you limit the treatment, you can reduce the risks, but nothing is 100%. Nothing. Not even Urolift. "There are no guarantees in life... Or surgery."

I'm not sure what you mean by the risks on the site for the company; while I have not read the statement you are referencing, the company's lawyers vet whatever they list, and I'm sure in that case they decided the onus of the risk would be on the surgeon, not the device manufacturer. The responsibility is on the surgeon to entail the risks he feels are involved for whatever procedure he offers a patient. Just like a scalpel company doesn't need to state that a risk is "loss of your nose", if a surgeon decided to cut off a nose, it certainly would be a "risk"! In that case, the blame would purely be on the surgeon, but not the device manufacturer.

I hope that clears this up for you.

Neal and Jersey.  I'm going to put my nose into this.  It is true that the company can't be blamed,  The surgery is only as good as the doctor doing it.  Now because as we get older we need more information and a guarantee.   

Hi Jersey,

Your answer is very helpful, but do I understand you correctly? Can it be inferred from your answer that all of the procedures themselves are equally safe from the side effects i described earlier, and all of the risks of those side effects are really caused by the competence, or incompetence of the surgeon?

I had my urethra cut into, even though it was catheterized, by the chairman of the urology department of a major hospital in upstate New York trying to do a penile implant, since repaired and revised, so I am admittedly sensitive about "complications". That said, the men, and the few women on this site seem to have 2 concerns, the effectiveness of the procedures, and the side effects of the procedures. If there really is no difference in the side effects of the procedures, then it comes down to the doctors involved, and that is important information. But is it really that simple? Is a TURP as " safe" as a PAE?

Thanks for spending so much time helping us with these issues.

Neal

I found the aquabeam citation. "How I do it. Aquablation of the prostate using the Aqua Beam system Catriona MacRae, MBBS, Peter Gilling"

33 trial participants total. NO cases of retrograde ejaculation. I am trying to get more information but this sounds very promising.

Jim

 

As I mentioned before, the prostates so far as a whole with aquablation were on the small size, the PVRs on the low side and the numbers still relatively small. Following is the conclusion of the Gilling article cited earlier. I also suggest anyone interested to read the entire article. It's actually written mostly in English as opposed to Medicalise.

Conclusion

Aquablation is a new method of prostate ablation

showing functional improvement that compares

favorably to other BPH technologies. The safety

profile of the procedure is also favorable, with no

grade III-V adverse events. At this time there have

been no reports of retrograde ejaculation or sexual

dysfunction, with most men reporting improvement

in IIEF scores postoperatively. Longer term data with

larger patient numbers are required, but this technique

shows promise to improve LUTS with the potential for

less morbidity than traditional TURP

 

Thati s great.  I saw that one but could not get it to open for me going to try it aagin and print it.  Ken

Ken,

It's on the web as a "pdf" file. It should just open by clicking on it. Very readable. Promising, but as the conclusion says " Longer term data with

larger patient numbers are required". Maybe some of that data is already in as the article is from last year. Of interest is that the 2017 citations, posted earlier, do not mention "retrograde ejacultion" directly. I am hoping this is just a wording/terminology issue and not that they have had cases of retro since the 2016 article here was written.

Jim 

@JerseyUrologyGr: "...Having an intravesical prostate certainly has a high correlation with symptoms, and an attempt can always be made to treat that area first"

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

In this hypothetical, how might you go about treating the median lobe alone? And, related, in addition to a cystoscopy and ultrasound, would more precise imaging such as a 3T MRI be useful in visualizing the 

obstruction if you were not going to perform a complete resection. Thanks.

Jim

Jim

 

There are many ways to treat it; we have had very good success recently with Rezum. Standard would be TURP.

MRI doesn't really play a role in the management of BPH (but we have found it very helpful in the prostate cancer realm.)

It won't give you any useful data beyond a cystoscopy and ultrasound, but is very costly.

Gilling's Phase II Aquablation trial included someone with a 102 g prostate; that's roughly 99th percentile; 

Incidentally, I just saw a patient back today who is 2 months after Rezum with 130 g prostate who was in retention. His max flow rate is 15 and emptying. Happiest he's been in years!

Are you saying then that you could perform an ejaculating sparing TURP by treating only the median lobe? If so, have you done any such procedures and how were the functional results? Thanks.

Jim

"but is very costly" (MRI)

I think mine cost $700, which I did not think was too costly. The real question is whether it is valuable in the diagnosis and treatment, which you are saying it isn't.  

I know but that is one prostate out of 33. Most of them were under 50 g by memory. Gilling himself I believe said larger studies were needed. That seems to be a nice result you got with the Rezum. Congratulations!

Jim

Moto and JerseyUro,

The reason I asked about MRI is because every time I asked a uro about my obstruction I always got a vague answer like "yes, you're obstructed, yes you have a large median lobe." But I would think that an image showing the actual obstruction like the men were shown by Dr. K. (FLA) would be helpful for more targeted procedures which minimize tissue removal compared to say a traditional TURP.

Jim

I agree Jim. I would think an image of the area would be valuable to see what is going on. $700 seems cheap compared to a mistake. I don't remember how much the ultrasound cost that I had done to determine the size of my prostate was, but I bet it was close in cost to the MRI, with less information, and quite uncomfortable!

I mean before the uro says "show me the money" I want them to show me the urethral restriction! And it has nothing to do with trust, I would just like to see exactly what we're talking about. Again, with traditional TURP, maybe not so important since they are taking out a lot, but with more targeted procedures you would think better imaging will give you more precise targeting. 

Jim

A cystoscopic (direct) picture would probably be more obvious. 

$700 is about 1 1/2 week's pay for the average American; consider yourself lucky you can afford it! Most of my patients could not.

It is not useful for the treatment of BPH, but is very useful for managing elevated PSA's, for which I have gotten insurance to pay for it  in many cases.

Overall good; you can easily limit the amount you resect/ablate.

All Phase II trials need larger studies; Aquablation is certainly no different! Remember, you probably don't want to be the first few hundred having a procedure performed! (That's why they are generally fully subsidized for those in the studies.)

Glad to hear that, however this option isn't frequently offered with TURP, both from personal experience and the experiences of others here. In Europe, I believe some centers offer what they call epTURP (ejaculation preserving TURP) with functional results similar to standard TURP and with around a 92% chance of preserving antegrade ejaculation. It has been around since 2014 so why this hasn't been offered in the USA?  

Per "Ejaculation-preserving transurethral resection of prostate and bladder neck: short- and long-term results of a new innovative resection technique."

Jim

I'm not sure why you think it isn't offered in the US. It has been around a lot longer than that. It's just a simple variation of the technique. I've done them since 2003.

Saying the MRI is not useful for the treatment of BPH makes more sense than saying it is expensive. I doubt there is a huge difference in cost between the MRI cost and say a urodynamics study, and a cystoscopy. And don't forget the ultrasound through the rectum, I bet that isn't cheap either. 

I had all of those tests done, with inconclusive results. In fact, I was diagnosed with an Atonic Bladder after the urodynamics test. 

But when the Dr saw my Bladder via the MRI, he said it looked fine. And it is working fine.

And I would think most people have insurance, so it is really more a matter of is it useful to have an MRI than one of the other tests, and the Dr ordering that test instead, and the insurance agreeing to pay for it. They did pay for it in my case, so there is that too.

 

When I asked my extremely well credentiled uro at a major teaching hospital about the incidence of retro from his proposed TURP, he said I would probably get it. I asked the same question to my next uro (he did button turp) and his answer was "If I do it right, you will have retro". Also, here on the this forum, I haven't read of anyone being offered an ep TURP, or even having that discussed. So if "it's just a simple variation of the technique" and if ep TURP only has an 9% incidence of retro, how come most of the men here and elsewhere have retro from TURP? If the functional outcomes are similar per the citation, why wouldn't EVERY uro offer epTURP over traditional TURP?

Jim

An ultrasound can be performed without going through the recturm, and is less than $100; cystoscopy is several hundred dollars, and urodynamics are at least several hundred dollars, but they are all reimbursed by insurance for voiding ICD10 codes, as they are established diagnostic tests for voiding dysfunction. An MRI is not.

MRI's may not be reimbursed by insurance; NJ certainly won't pay for an MRI for a BPH code. Also, a bladder can look fine anatomically on an ultrasound/CT/MRI, but those are not functional tests. 

There are no guarantees in life; as I mentioned, ejaculation dysfunction is always a possible risk factor of any procedure performed on the prostate.

Understood, but the question is if the retro rate is 90% (traditional TURP) as opposed to 9% (epTURP), and if the difference is "just a simple variation of the technique" with similar functional outcomes -- then why isn't everyone being offered an epTURP?

Jim 

I can't vouch for what you've been told by others in the past. I would guess that if it's brought up by a patient, it would be discussed by most younger/recently trained urologists.

@JerseyDoc: "Also, a bladder can look fine anatomically on an ultrasound/CT/MRI, but those are not functional tests."

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

And conversely. The doc who did my cystoscopy said my bladder looked "all beat up like the surface of the moon", so I can only imagine what an MRI would look like. But it does function OK now. 

Jim

The two docs mentioned were pushing or in their 60's. I asked a third uro (probably his 40's)  about two years later, if he could do an ep version of GL (that is what his hospital offered) and he said, "I can do it if that is what you want".  Honestly, it was not as confidence inspiring as if he said, " That's what I alway do", and I also was left with the lingering thought, why woudn't I want that!! Anyway, thanks for your input on this. 

Jim

Paid for all three of my past ones and are about to now pay for another as a follow up. 

But it does look promising.  There at least taking the time to spare the bladder neck and the verumontanum so the men will not have retro ejaculation.  That is why this study is going on .  To many men have been   upset with the Gold Standerd Surgery.  Maybe there is hope for our special group  Ken

I think that is way they came up with Plasma Button Turp.  The urologist has more control over the button and can avoid the bladder neck the duct also the sphincter and only get rid of the tissue that he need to.  My doctor said it take longer to do it  About 3 hour or longer   Ken  

Yes there is no guarantee in life.  That is why we have to fight the battles we think we need to fight.  Doctor don't offer the EP Turp because it is a newer procedure and it is done by the younger doctor.  The older ones do not want to go back to school. In your other post to Jim you said that if the patient bring it up then you will talk about it.  That should brought up by your doctor.  He should ask you if retro is a problem for you but doctor don't feel we need it because we are old and are not having kids.  Thats grap.  Ken.  Also the EP TURP takes longer to do and if your doctor does not care enough he just want to go in and cut away and be out in 45 minutes.    

It really depends on the size of the gland;

conventional thought is that an experienced resectionist should take about 1 minute per gram of tissue.