Turp operation or laser ?or leave alone?

Well, he uses different methods, I assume for different conditions. I believe he said turp or laser for removing the third lobe then urolift later if there is still insufficient flow.  I know that he is one of the foremost uros in the US in robotic urology surgery and one of the more experienced in urolift.  

I can't believe all of the procedures you have endured!  Maybe you need a fresh look, a start from scratch approach.  I can see why he feels that enough surgery has been performed but maybe a different uro with a different training and experience background could take a look and see how a procedure might help with your condition. What does he expect, that you just suffer?  I know that I would want a second opinion if I had your conditions and unsuccesful procedures. As they say in New Jersey, " I'm just saying". Good luck!! 

Ron,

Best of luck and keep us posted on your progress. Like you I may have waited longer to address this than I should have. I wouldn't say I am suffering. More like I'm waiting for the other shoe to drop. All the procedures were successful at the time, but none of them lasted. 

From what my friends and relatives tell me their surgical procedures of all sorts have generally fallen short of expectations. I think we hold doctors in too high esteem. My own sordid view is that in the future they will considedr our medical procedures to be quite primitive. I think we may have been born too early for the real advances that are to come. How about some prostate eating nanobots? Well, we can hope, I guess.

Regards,

Bob

I don't think prostate eating nanobots or some such is out of the question at all in the not-so-far-out  future. Advances come closer and closer together as well. I suspect that a lot of guys my age wore diapers during the 70's and 80's as surgical solutions were much more primative. Imagine a turp procedure without a cystoscope! 

I agree.  Regardless of our medical advancements, we still remain quite primitive.  Dr. Andrew Weil made the comment that BPH procedures are still crude with the probability of sacrificing sexual function.  

Hello Ron,

Please keep us posted on your research and experiences dealing with BPH. Apparently the median lobe and total prostate size is a real barrier to doing the Urolift. Too bad because the procedure is so much less invasive than the TURP variants out there. If I were you, I would get some urodynamics done and find out what your PVR is and then determine your risk for retention. If you're like me, having put off doing a procedure for years in hopes that something less invasive came along, then knowing your PVR will help you determine how long to put off a procedure, assuming you can put up with the frequent trip annoyance. It appears that TURP side effects occur in a minority of men but if you're one of the minority then what good are percentages?

Have you looked into PAE at all? That was the other option besides the Urolift that I was researching (Prostatice Artery Embolism) I was also a heartbeat away from entering a clinical trial of NX-1207, where a single injection into the prostate has shown to shrink and relieve symptoms with no side effects. Here's the link: http://www.nymox.com/default.action?itemid=23

What's really bizrre about Nymox 1207 is that the latest report on their website that you linked to is from 2008 - 6 years ago. After reporting years of great results in trials, there has been no further development to bring this product to market. Even more bizarre, the only available products that they list on their site are Nic-alert and Tobac-alert which are urine tests for the presence of tobacco. 

PAE is also contra-indicated for prostates with a large median lobe. I also have a large median lobe that protrudes into my bladder. However it does not block the bladder neck at present. My urologist didn't address it to any great extent when he performed my GL laser turp or my bladder neck resection. I also had a very large prostate, greater than 120g.

I have posted this elsewhere but I get confused as to which bph thread I am on. You may have already read it. It's amazing anyway.

This will be the strangest BPH post you will read for a long time. I'll start with my BPH history and bring it up to date. I cannot believe this, myself. I'm almost 76 years old (July 4th) and have had bph for many years, 30 at least. Just gradually getting more urgent and more frequent pee trips, up to five times at night. I didn't seek medical help until I hit 65, 11 years ago as I had no health insurance and have been under the care   of my current uro for about 8 years or so. He put me on Flomax, and switched to another med and finally about Jan 13 to Jalyn which is a combo of two common bph meds that each address the symptoms in different ways. I began retrograde ejaculation years ago and ed began as well These damn meds do a number on your sex life in several ways. Just be prepared.

I also began in 1-13 twice monthly testosterone injections,  (1 ml)  which I administer myself in my upper thigh. Tiny needle is not painful at all. 

I began to use Viagra as soon as it was availabe then switched to Cialis later.  I then decided to try the $2 pills advertized everywhere, every five minutes on Fox News for example for Cialis generics. This stuff comes from India, I believe, and works just like the American made. I would just take it a couple of times a week or so and it made things work fairly well. It costs a small fraction of the American version. This is not a commercial, I promise.

The last time I ordered it, I got confused by the generic names and ordered the Viagra generic instead of Cialis generic. Ok, I know how stupid that is.  I even got blue pills instead of brown ones and still didn't realize I had ordered wrong. Ok, Ok, I'm stupid.

All right, I'll get to the amazing part. I knew the Jalyn was destroying my manhood so I tried a couple of times to get off of it but after a few days the urges were actually painful and right now urgent. I had to get back on the Jalyn and take the consequences or wear diapers or stay home or something. 

A couple of months ago I heard about the urolift procedure, researched it exhaustively and became a believer in it's minimally invasive usefulness. I sought out a urp who does the procedure, went to his clinic, had the scoping up the urethra and the ultrasound up the rectum routines  and determined that my prostate is 114g with a third lobe so no urolift for me, only TURP is an option.    

Returned home very depressd about my prospects of a normal life. 

The amazing part is going to be told, really!

About this time I heard about "Cialis for daily use" as a treatment not only for ED but also for BPH. Remember, now I thought my Indian generics were Cialis but were actually Viagra. Yeah, I know how stupid that is. Anyway, I started cutting my Viagra generic in half and taking one half everyday. My urgency and frequency problems improved so much that I tried again to get off Jalyn and I am actually free of any bph meds for at least a month!!!!!! 

I'm taking only the generic (50 mg) and I visit the bathroom  every couple of hours although I can actually wait a few minutes if I want. I'm up regularly one time in the night about 4:00 or so and then again when I arise around 7:00. There is another technique I use, maybe unwisely, I take two ibuprofen pm's when I go to bed. This makes me sleep so sound that I don't feel the little fake urges that I need to go, I sleep right through them. Of course, I am thouroughly dependent upon the Ibuprofen PM to sleep. Without it I won't sleep a wink. I don't know what this is doing to me, it's not supposed to be addictive but that is BS.   

I'm now dealing with bph better than I have in years, I actually think I could take the generic every two days instead of daily and I am going to try it. Maybe this will help me get off the Ibuprofen PM.  

None of this has done anything for my sex life. I think the damn meds have ruined that part of my life for good. I'm still doing the testosterone but i think it's marginally effective. It builds muscle though.

I should also say that I'm trim and muscular, take no other meds, do hard labor whenever I want to, walk five miles three times a week, etc. My uro and my regular doc say I'm a poster boy for old age.

So, that's my amazing story. 

Yes that is an amazing story. Goes to prove that there are other options besides a TURP for BPH. The only drawback to drugs are the long term side effects but the side effects of TURP are well documented.

Hope your BPH becomes a non issue over time as mine did after the Urolift. I don't think it will be long before non-invasive methods similar to the Urolift are commonplace for BPH sufferers even with median lobes...

Bob, you just missed all of the latest about Nymox nx-1207 and click on the News button. There's a number of reports there from 2014. It is also being studied for use with low-grade prostate cancer. I'm going to look into it.

Ron,

Unfortunately there is no news that's new. They have been in trials since 2006. They have been reporting positive results since 2008. Six years later they are doing the same. I have heard it can take 10 years of testing for the FDA to approve a new drug. No info has ever been released regarding the estimated possibilities and/or time frame for FDA approval of Nymox-1207 to the general public. What's even more difficult is that no other country has approved it's use. Generally proven therapies (like PAE) first became available for bph overseas. If you google nymox-1207 there are as many hits about the stock price and capitalization as there are about the procedure.

Amazing alright... It is hard to believe that a Urologist would give you Testosterone injections when you have BPH.  According to the American Urological Association, testosterone shots are contraindicated for BPH as they make the condition worse.  The medication you have been taking, Jalyn, is intended to reduce your testosterone as a lower T improves your BPH.  Jalyn is nothing more than a combination of Avodart (Dutasteride) and Flomax (Tamsulosin), and it was created for two purposes, one to allow the patient the convenience of taking one pill instead of two, and secondly to allow GlaxoSmithKline to maintain patent coverage as Flomax is already generic and Avodart will be so in 2015 (in the US anyway).

Avodart (Dutasteride) is a very slow acting drug.  It first has to lower the testosterone level and then the lower T allows the prostate to shrink thus improving symptoms.  This process takes about 6 months.  Likewise after a person has been on Avodart for a long time it takes an equally long time to flush it out of the system and allow the T level to return to “normal”.  So you have been taking Jalyn to reduce your testosterone and then giving yourself T injections to increase your testosterone back in the first place!!!  If you discontinue Jalyn, the Flomax effect goes away rapidly but not the Avodart, that is still in your system for many months.  By taking Cialis for daily use you basically replaced the Flomax with Cialis as they are both alpha blockers and work essentially the same way.

There are two types of prescription medications for BPH.  First there are the “alpha blockers” such as Flomax, Uroxatral, Rapaflo, etc., and secondly there are the “5 alpha-reductase inhibitors” such as Avodart and Proscar.  All other medications are either a combination of these two (Jalyn) or varieties of alpha blockers with different strengths sometimes marketed for other purposes (example, Propecia which is nothing more than Proscar at a lower level marketed for hair loss).

The alpha blocker category works by relaxing the blood vessels and muscles around the groin area.  This allows urine to flow easier (and also increases blood flow to the penis thus treating ED).  Flomax, the most common of these, is generic (Tamsulosin).  Uroxatral, Rapaflo and others are still Brand and obviously way more expensive.  I was on Flomax for 2 years and tried Rapaflo as it claimed to have a higher affinity for the prostate with fewer side effects.  Both improved my BPH but neither worked for me in the long run as they both gave me headaches and orthostatic problems, two common side effects.  All the other meds in this class work the same although some may work better for one person versus the other and likewise for the side effects.  Alpha blockers do not decrease your libido and they actually help with ED. Another common side effect is retrograde ejaculation and I had it with Flomax.  It was still fun however although the intensity at climax was perhaps a little less.

The “5 alpha-reductase inhibitors” work by reducing the testosterone level in your system and they take a long time to do so.  After the T level has been lowered in your blood stream the prostate begins to shrink in time (as much as 30% shrinkage but it varies by individual).  The original med in this category, Proscar (Finasteride), has been generic for a long time and it takes about a year to take full effect.  Avodart (Dutasteride), a newer med still Brand until 2015, works better and faster.  It reduces the T level further and it takes about 6 months to take full effect.  Like I mentioned earlier, if one discontinues Avodart (or Proscar for that matter) it takes a long time for it to be flushed out of your system.  Avodart and Proscar reduce your libido on account of the lower T but taking T injections to increase your libido defeats the purpose of Avodart in the first place.

Regarding surgery, the gold standard has been the full TURP as everyone knows.  Green Laser and other less invasive procedures that have been around for a while all have the same effect, recuperation time is shorter than a TURP, the risks are less, but the results are not as good.  There are always exceptions and the skill of the surgeon is key to success.  One can find people with a full TURP and bad results and one can find people with a Green Laser PVP and good results and vice versa.  However, the medically accepted consensus is pretty clear, the surgeon is able to remove more tissue with a TURP but the side effects and risks are higher.  A TURP on average is good for about 10-15 years whereas Lasers are good for 5 years or less (again exceptions abound).  A newer procedure called a Button TURP was introduced about 2-3 years ago.  It uses a Plasma instead of a Laser, I will not get into the details here, you can google “Button TURP” and get all you want, good and bad including procedures on U-Tube.  The following is a link to an NIH study comparing the Button TURP to a regular TURP and according to the study the results were similar for the two.  Other studies with the same conclusions abound on the web.  http://www.ncbi.nlm.nih.gov/pubmed/23106879

I am 68 years old and have suffered from BPH for about 10+ years.  I first started on Flomax by itself, then both Avodart and Flomax and finally just Avodart as I could not tolerate the headaches.  As the medications had run their course and the BPH was getting worse I chose to have a Button TURP 10 days ago.  According to my Uro who has done many TURPS, Lasers and Buttons, the Button is quickly becoming the standard.  The Button is less invasive with less bleeding, less pain, and faster recuperation time than a full TURP but with the same good results.   The only exception is for very large prostates.  My Uro goes in with a Button probe and if he is not able to remove as much tissue as he would like he then switches to a regular TURP.  This occurs about 20% of the time.

My case in brief:  Button TURP at noon on 8/21, overnight stay in the hospital with a catheter, pain at 7-8 out of 10 when first waking up in recovery (nothing like my rotator cuff surgery 4 years ago, pain at 10/10 for a very long time), when I got to the hospital room with morphine pain at 5, blood irrigated out with saline IV, pain overnight varied between 3 to 6 depending on morphine cycle.  Not able to sleep due to the constant nurses coming in to change IV, take vitals, drain catheter bag, etc.  Next morning pain down to 3-4 without morphine, catheter out by noon (painful to take out but short lived), blood clots made it hard to urinate at first but once I started flowing I had no further problem and was discharged.  They gave me an Rx for hydrocodone but only took it for 2 nights to sleep better.  The pain pretty much went away after 2-3 days except the burning sensation when I urinate which I still have.  Blood in the urine also pretty much went away after 2-3 days (one clot passed yesterday with a small amount of blood).  It has only been 10 days so any comments I make about results would be premature.  I will see the Uro in a week and have been told (and have read) that recuperation takes about a month and full results in 3 as the prostate has to grow a new lining and the bladder has to readjust.  I expect to have retrograde ejaculation and was warned about it.  A TURP (full or Button) makes more than an opening, it removes some of the surrounding tissue in order to have room for future growth and retrograde is one of the consequences.  At my age kids are a non-issue, sex is but I have to urinate.  Flomax gave me retrograde anyway and Avodart greatly reduced my libido so to me retrograde would be preferable (if it happens).  I don’t know what the final outcome will be, time will tell, but surgery wise this one was a piece of cake. 

CS123,

Thanks for the detailed explanation of how the bph drugs work and also for the info on your own button turp. I'm also 68 and had the GL 2 years ago, and a bladder neck resection and stones removal after a hematuria 9 months ago.  Best of luck on your recovery and successful outcome for the button turp. I had a very large prostate, more than 120g, and my uro said he removed 70g of it in 70 minutes with the GL. I often think there might be a correlation with the prostate size and the relative success of the procedure. Do you know how large your prostate was before the button turp and approximately how much was removed? My uro said that regardless of how much is removed, the capsule doesn't shrink, so I don't think there's an objective way to measure the new size of the prostate after a procedure, unless it is subsequently removed.

Also, do you know if tamsulosin reduces T? I was on it for about a year and my T is below the low line for normal. Although I have ED, my libido (desire) has never suffered, and sex is always satisfying. I also wouldn't take T shots, having heard it makes bph worse. But an erection is not a requirement for a satisfying sex life, so I'm not sure why men are concerned about low T levels. Maybe I'm missing something?

Bob120, I will try to answer your questions as best as I can.  I do not know how large my prostate was except that my PCP and my Uro both said that it was moderate, not large.  When the Uro came to see my wife after the surgery he told her that it was larger than he expected but he was able to remove enough tissue and create a good channel.  I had hoped that the Uro would drop by the next morning but his partner showed up instead and he did not know the details of my case.  I will see my Uro on Monday Sept. 8 and will know more then.

You mentioned that according to your Uro the capsule does not shrink with surgery.  This makes sense to me, although I have no real evidence.  The pictures/drawings I have seen depict the hollowed out interior with no change on the outside.  But this is only anecdotal evidence.

Regarding Tamsulosin, it does not reduce testosterone.  It is simply an alpha blocker (like some blood pressure meds) that relaxes/enlarges the smooth muscle walls of the arteries.  Some blood pressure meds like beta blockers affect your libido (but not by decreasing testosterone).  Avodart does reduce testosterone, or at least testosterone conversion into dihydrotestosterone, that is specifically what it is intended to do, and it is well know to decrease libido and increase the chances of ED.  Tamsulosin has a stronger affinitiy for the prostate than blood pressure meds and thus it is used for BPH.  In years past they used to use Hytrin, a blood pressure med that was not very good for BP but helped with BPH.  Tamsulosin is far better.  Tamsulosin also should help with ED but only a little, Viagra etc. are far more effective and will not make your BPH worse.  For anyone having ED and BPH I think Viagra, Cialis and Levitra are the answers if their physical condition otherwise allows.  These meds will not make BPH worse, they actually will help but only briefly with the exception of Cialis which is long acting.  Cialis for daily use is just a lower dose of Cialis taken everyday.

My understanding is that testosterone levels generally decrease as men age.  The problem with injections is that as men age they also develp BPH and testosterone shots will make BPH worse.  I suppose each of us should answer if the BPH or the low T is worse.  In my case BPH was bad enough to impact my life.  My sex life is not what it used to be but it has not been bad and I hope it returns even better after the surgery and particularly after I get off Avodart.  As I mentioned it will take months to flush out the Avodart.  I also know for some men its effects tend to be rather permanent (hope not me).

Regarding my own case the BPH symtoms seem to be improving but it is too early to really tell.  I have no pain, no blood, and just some burning when I urinate.  Time will tell...

CS,

Thanks for the addl. info. I find that 10mg of Cialis about 45 minutes before going to bed works well enough for me. I tried the daily cialis 5mg but started to notice I was often in a bad mood (maybe the lack of a sexual release while the cialis was in my bloodstream caused it, I don't know). Taking it before sex with some whiskey seems the magic formula for me.

An unexpected side effect of the GL turp was a lowering of my PSA. I was up to about 6.9 before the GL and it was down the following year to 6.5. It was the first time in decades I had a decrease in PSA. It normally rose by a fraction of a point every year.

Sounds like you are doing very well in a short time. I had bleeding, urgency, frequency and pain for about 9 weeks after the GL. Best wishes.

Bob

CS123, I was diagnosed with BHP about 4 years ago and had a PSA of 5.4. Uro did a biopsy that time and no cancer was detected. He put me on Flomax to impove bladder retention although I had no typical symtoms (stop/start or dribble peeing) and got up only once a night. I stopped the Flowmax after a year's use because I could see/feel no benefit and it lowered my libido (luckily no ED). PSA tested 7.4 this year and uro said another biopsy is necessary - did that and still no cancer. Been put on Uroflow since the last biopsy (still get up once during the night). Went on two week antibiotic course and went for PSA a month later - PSA increased to 8.4. Waited another month and did another PSA, which increased to 9.3. Uro recommended another biopsy, but now want to include a TURP. Went for a second opinion and uro said the previous two biopsies could have missed the cancer and also recommended a biopsy/TURP (scheduled for mid November 2014). He implies the TURP, together with another biopsy (7 core left portion and 11 core sampling right part of prostate) should improve the (cancer) sample rate and to explain the monthly increase of PSA.

There are both good and bad reports about the TURP procedure and I'm left with a choice of either to wait and maybe then decide at a later stage to do another biopsy OR alternatively do the TURP and biopsy now and get more a accurate sampling to determine whether cancer is present. Many men are having a low grade of cancer and possibly die with it rather than from it, but I guess it will be unwise to be able to detect it early and get treatment than rather to wait until it is too late.

I'm just worried by choosing a safe option to detect cancer (which two biopsies showed not to be present) and in the process will bring problems such as incontince and/or ED upon oneself. I was hoping that this kind of operation (TURP) would have been sorted out, but from forums like this it still seems way off a 100% success rate.

At age 55 and given the growth rate of my prostate over a 4 year period it is most likely that a TURP will have to be performed (or not?) in future. What I established from reading various articles, the high urine residue (40%) in my bladder can possibly cause kidney problems and considering that, it might be a good enough reason why a TURP should be performed.

I would like however some opinions about performing a TURP for the sake of improving cancer detection ? I always thought a biopsy was good enough, but it seems not?

CS123, I was diagnosed with BHP about 4 years ago and had a PSA of 5.4. Uro did a biopsy that time and no cancer was detected. He put me on Flomax to impove bladder retention although I had no typical symtoms (stop/start or dribble peeing) and got up only once a night. I stopped the Flowmax after a year's use because I could see/feel no benefit and it lowered my libido (luckily no ED). PSA tested 7.4 this year and uro said another biopsy is necessary - did that and still no cancer. Been put on Uroflow since the last biopsy (still get up once during the night). Went on two week antibiotic course and went for PSA a month later - PSA increased to 8.4. Waited another month and did another PSA, which increased to 9.3. Uro recommended another biopsy, but now want to include a TURP. Went for a second opinion and uro said the previous two biopsies could have missed the cancer and also recommended a biopsy/TURP (scheduled for mid November 2014). He implies the TURP, together with another biopsy (7 core left portion and 11 core sampling right part of prostate) should improve the (cancer) sample rate and to explain the monthly increase of PSA.

There are both good and bad reports about the TURP procedure and I'm left with a choice of either to wait and maybe then decide at a later stage to do another biopsy OR alternatively do the TURP and biopsy now and get more a accurate sampling to determine whether cancer is present. Many men are having a low grade of cancer and possibly die with it rather than from it, but I guess it will be unwise to be able to detect it early and get treatment than rather to wait until it is too late.

I'm just worried by choosing a safe option to detect cancer (which two biopsies showed not to be present) and in the process will bring problems such as incontince and/or ED upon oneself. I was hoping that this kind of operation (TURP) would have been sorted out, but from forums like this it still seems way off a 100% success rate.

At age 55 and given the growth rate of my prostate over a 4 year period it is most likely that a TURP will have to be performed (or not?) in future. What I established from reading various articles, the high urine residue (40%) in my bladder can possibly cause kidney problems and considering that, it might be a good enough reason why a TURP should be performed.

I would like however some opinions about performing a TURP for the sake of improving cancer detection ? I always thought a biopsy was good enough, but it seems not?

SD,

How man ml is your PVR (post void residual). You say you have 40% urine residual but don't say how many ml's that is. As far as i know, once you pass 250ml  to 300ml post void resdual, you need some sort of procedure, either to the prostate or the bladder neck or both.

To the best of my understanding, some procedures like holep (holmium laser) examine all the tissue removed for cancer because the procdure basically grinds it all up and then removes it as chum. It seems this would be a better way to detect PC during the process of a turp type procedure.

High PSA isn't necessarily proof of cancer. PSA can rise just based on a cystoscope exam, infection, stones or prostatits. Maybe it is even reflecting your high pvr. My PSA has been higher than normal and is presently 6.5 but has come back as high as 8.9. After my last surgery to remove stones and resection the bladder neck it actually came down from 6.7 to 6.5. I've never had a biopsy.

 

Forgot to mention that ha high PSA could also be the result of an enlarged prostate. How big is your prostate? Mine was over 120G before my GL, which removed about 70G.

Hi Bob,

 My PVR is 160 ml and the flow rate is 16ml/s. According to the uro a flow rate of 14ml/s is considered as bad. (Not sure about the per second but I remember the 16 & 14. You don't get a report or printout of such detail - maybe I should have asked for it. According to me if as long as the flow is continues it is okay, but the uro said it should peak high at the start and then drop away - realy would not have bothered me.

I'm not sure in terms of gram how big the prostate is - it has just been described as "mildly enlarged" on the report to my GP. On the ultrasound it is forming a slight dent in the bladder, but it is difficult to say whether it is a severe case. I seem to experience a slight discomfort (like a half full bladder) when jogging, but nothing major to complain about.

I agree that a high PSA (9.3) is not an indication of PC, but the frequency of change the past few months which increased by 1 every second month (7.4, 8.2, 9.3) is a worrying factor. I made sure to avoid sex 2-3 days prior to a PSA test as that will have an effect on the count. Prostatitis or some inflamation could well have an effect, but I'm very healthy and was hoping if it was due to the aforemention inflamation it should improve and show on the subsequent PSA's taken.

If the success rate of a TURP was higher without the possibility of incontince and ED, it would have been an easier decision, but as we know that is a real possibilty.

From my limited experience, I would consider your PSA as high enough to be very worrisome and increasing half a point monthly as downright scary. I hate the idea of a needle biopsy and have never had one but I would be in the Doctor's office demanding a biopsy if my PSA was increasing like yours. 

I would say that the increasing liklihood of PC far overshadoes any concern about the rate of urine flow.

I would nail that question down in the next few weeks if it were my problem. PC is nothing to trifle with!

If your urologist is not concerned about this I would immediately find another urologist and while you are at it find a uro who has done the new urolift procedure numerous times as that procedure would work beautifully for someone with a smaller prostate. 

Good luck and keep us posted. Oh, I almost forgot to add;  the urolift procedure should keep you from needing the BPH meds. If you value your sex life do not get on the slippery slope to ED and no libido. Surgery, I have come to realize is much preferable to demasculinazation by medication.  

Hi SD,

A pvr of 160ml is not that high. Before my GL my PVR was between 250 and 400ml. I was waking up in full retention in the early morning hours every night, where it took a shot of whiskey and 10 minutes of walking around the kitchen with severe kidney pains to try to get my stream started. When I had to cath, being in pain and unable to pee more than a teaspoon, I'd void around 400ml. After my GL my PVR ranged from 25 to 250ml based on my cathing and emptying into a urinal with ml markings. Average was 125ml.  My uro actually told me 250ml was OK for me. A year later he widened my bladder neck and removed bladder stones, which was likely part of the problem all along. 9 months after my bladder neck and stones surgery, my flow remains decent. I need to get a sonogram soon to determine my PVR. But in the last 2 months I have developed nocturia and insomnia.  I am up all night a couple of times a week peeing 2-1/2 to 3-1/2 liters in 8 hrs. in my bedside urinal. During the day I go very little, then wind up peeing every 20 to 30 minutes from 1AM to 8AM or even 10AM before getting an hour or two of sleep. To me the model of an enlarged prostate stopping flow and causing retention and a high PVR makes sense. But there can be more to the story. 

It sounds to me like you barely have a bph problem. I also used to feel like I was sitting on a sock, but the prostate swelling didn't make my PSA jump like yours. What you have is a PSA problem. I imagine all you can do for that would be to get more biopsies to try to determine why the PSA is rising. Can the biopsy itself raise the PSA? Maybe you need a second opinion. Have you had a cat scan of the prostate and bladder to look for tumors or cysts? I have an adrenal cyst and a protruding median lobe which may be the cause of my bladder irritation and nocturia, but doesn't cause my PSA to rise that fast. It goes up about a half a point a year. 

Bob

Hi Ron, Yea, that increasing PSA is outright scary and I am scheduled for a biopsy (and TURP) at mid November. The uro explained that it is possible to miss PC with biopsies (had 2 so far, one in April this year, which indicated no PC). That's whay he recommended a limited TURP to get a bigger sample around the core of the prostate.

Haven't found an experienced uro yet that has performed enough Urolift ops and would have definately considered that. I've gotta find out what the rising PSA is all about so the TURP "sampling" seems to be the way to go.

Hi Bob, Yes, according to literature a biopsy can raise either the prostatitis level or cause inflamation, of which both can contribute to a rising PSA. I went on an antibiotic course (10 days i think) after the biopsy and then went for another PSA check after another 2 weeks to let the biotics do its job & the body settle down, but that still showed and increased PSA.

What I derive from this whole situation is that prostatitis can play a significant role in PSA levels, but the problem seems 1) that it is difficult to cure/contain, or maybe cureable up to an undefined level and 2) that there are no specific marker to determine the level of prostatitis. Maybe the latter statement is not correct, but none of the uro's so far indicated to check for prostatitis other than describing a dose of antibiotics and hoping for the best?

Hi SD,

From what I have read there's bacterial and non-bacterial prostatitis. The non-bacterial doesn't show up on tests and isn't affected by anti-biotics. I always came up as neg. for bacterial prostatitis. Non-bacterial is a catch all meaning they don't know. In fact it has been renamed LUTS (lower urinary tract symptoms). Yet despite it never showing up on a blood test, when my uro did the Greenlight laser he said there were numerous pus filled abcesses all through my prostate. So if those weren't bacterial, I can't imagine what they were. I've come to believe the prostate is a mysterious sort of organ.

SD1959, sorry for the late reply. I am not an MD by any means but I have followed BPH issues closely. Some of what I will say below has already been stated by others so I am just reiterating their comments.

Your post addresses two issues, the possibility of prostate cancer and BPH. IMO (and as RonTexas said) you need to address the cancer possibility right away. You are only 55 and at that age cancer can be a real concern. If you were 75, a high PSA would not be as much of an issue as older men often have low grade prostate cancers that grow slowly. The general consensus is that at advanced ages men with prostate cancers tend to die of other causes. However at 55 I would find out the reason your PSA is increasing and I would so ASAP. Prostatitis, etc. can indeed cause a high PSA and that may be your case so you may have nothing to worry about. Regardless, I strongly urge you to find the best Urologist in your area and find out the cause. If you are not pleased with the first Urologist go to another one until you are satisfied with their advice.

Once you have addressed the cancer risk, be it by biopsies, TURP or what have you, then you can address BPH (moot if you have a TURP in November). I have not heard nor read of anyone having a TURP just to determine if a person has cancer. That is not to say that it is not done, just that I have never heard of it. I just don’t know, but it surprised me. I have several friends with prostate cancer and none of them had a TURP solely to investigate cancer. So this needs to be further researched either by you on the web or far better by the best Urologist you can find. I have a good friend with PC, detected by PSA and biopsy, treated with targeted radiation and doing quite well 10 years later (he is now about 75). I also had a good friend who died last year at age 68 because the cancer had spread so again go to the best Urologist you can find and determine if you have cancer and if so if it is the type you need to be concerned  about. Pardon the diatribe above but the possibility of cancer is the top issue.

That being said, if you find out that you have no cancer and your BPH symptoms bother you enough then give yourself the standard IPSS test and if you score 20 or more you need drugs or surgery. Some drugs will seriously impair your sex life (Avodart and Proscar), others less so (Flomax and similar alpha-blockers, but even these will impair you to some degree). The gold standard for surgery has been the conventional TURP (the typical roto-rooter) but this gold standard is quickly being replaced by the Plasma Button TURP, technical: Plasma Vaporization of the Prostate (you can do web research on this yourself and even see it done on YouTube). I am 68, scored 21 on the IPSS, and had what was described by my Urologist and two PCPs as a moderately enlarged prostate (PSA was 0.9). I had been on Avodart and Flomax (discontinued the latter because of headaches like all alpha-blockers). Drugs had run their course and in August I had a button TURP. It has been a success. My IPSS is now at 8 and I expect it to be at about 5-6 in 2-3 months after frequency improves further. It has improved already but more to go. The Uro (and the web) warned me that it will take about 3-4 months post-surgery for the bladder to adjust and retrain and that frequency is the last issue to improve after a TURP. My experience is typical for a button TURP, studies showing similar results are available by googling. Like others have said the real key and this cannot be overemphasized, is the ability of the Uro. A good Uro with lots of experience is extremely important and is the key to good results.

I disagree with RonTexas on Urolift. I would not do a Urolift even if I could as it will not last as long as a TURP (why go through a second procedure later). Urolift just compresses the side lobes. What determines the lifespan of a procedure is how much of the prostate (the removable portion) is actually removed. The button TURP has been reported to be equally as good on tissue removal as a regular TURP but with less side effects (bleeding, pain, etc.). My button TURP was a piece of cake. I had rotator cuff surgery on my shoulder in 2010 and I was concerned that a TURP would be very painful. My apprehension was way overblown. Yes I had pain (8 out of 10 the first night, the shoulder was a 10 out of 10 for over a month and 8 or so out of 10 for 2 additional months).  I spent one night in the hospital on morphine so no big deal - by the next morning pain was down to 3-4 without morphine, was sent home with Norco for 5 days and I took it two nights only to sleep better. Urination burned for 2-3 weeks (took pyridium). Blood disappeared after 3 days. My only regret is that I did not have the surgery sooner. As it turned out I had a large prostate after all. The prostate can grow laterally on the side lobes and this is detectable by the usual rectal exam. However it can grow into the bladder as a third lobe and this was my case. The growth into the bladder is not detectable by rectal examination, only by cysto. The Uro told me that he removed essentially all of the third lobe and 80-90 % of the lateral lobes (of the portion that can be removed by a TURP, they never touch the outer capsule which does not grow anyway).

I think those of us who have a successful and easy procedure tend to not post on these websites, they are happy with the results and go about their way. So take all comments including mine with a grain of salt and form your own opinions. Hope this helps…

Hi John;  I had "PAE" surgery on September 10th of this year.  So far Iam "Not Impressed".  The main reason I had it was to get rid of the 4 to 5 nightly times to the bathroom.  Nothing has changed yet in that category.  The Doctor who did it is one of the best in the world and a pioneer in this field.  Obviously he is a interventional radiologist.  He is with Inova Hospital in Alexandria, Virginia and has done the PAE 116 times.  The reason I know this is because he told me I was number 116 .  Anyway,  Iam also having a hard time keeping an erection now but did not have that problem before the surgery.  You have to understand he is "closing off the arteries and veins" that lead into the prostate.  Not a simple thing. 

Tamsulosin doesn't reduce testosterone it is basically a muscle relaxent and is pretty ineffective if you have a greatly enlarged prostate as I found out. I would go for TURP rather than mess around with drugs particularly if you have retention probs. An erection is not a requirement for a satisfying sex life?? I think a lot of us would take issue with that!

NX-1207 currently has failed to meet endpoints in phase 3 of clinical trials. In other words, it hasn't met expectations.  

I cant seem to find much info on the internet about the plasma button turp

do you know of any surgeons doing this procedure in the RI / Boston area?

or is there a web site you can direct me to?

thanks

Ed

ed, practically all urologists perform the button turp procedure. Probably at least 75% of all procedures to relieve urine flow restriction by removing prostate tissue are the button turp procedure. It is called the "gold standard" by urologists because it is accepted by all insurance companies, Medicare, etc and because it is quickly and easily done. it also usually works failrly well with pain and blood for only a few weeks although there are plenty of examples where it doesn't work at all and many more where repeat procedures are necessary. In summation you can say that it usually works fairly well.

There is a far better procedure called the Holmium Laser Enucleation of the Prostate (HOLEP) performed by a dozen or so Urologists at major university medical centers, the Mayo Clinics, Johns Hopkins and possibly a few others. These are the best medical centers in the US.

In my opinion, backed by facts readily obtainable on the internet, it is a superior procedure compared to button turp, green light laser, PAE,  urolift, open prostatectomy or any other procedure for the purpose of removing prostate tissue in order to increase urine flow.

Fair warning: very few urologists who perform turp or any of the other procedures will recommend HOLEP. They are not trained to do it, do not have the equipment, and since the other procedures may work out ok and are accepted in the industry they will strongly advise against HOLEP. 

The truth is that button turp is the gold standard for the Doctors while HOLEP is the gold standard for BPH patients. The results from the patient's point of view is far superior in every way.

I think that my case is fairly typical; I had HOLEP performed in October, 2014 at the Mayo Clinic by Dr Humphreys. I had NO pain, NO blood other than a bit of pink urine for seven days. As my prostate was very large it protruded into the bladder and when removed from the bladder neck left me incontinent for a short time. This would have resulted from any procedure that removed the prostate from the bladder neck. I have been free of incontinence for some time now and have no symptoms of BPH, have taken no medications and I am as normal as i was as a teenager.

I have documented my experience in several forums on patient.info  and you can find my comments there as I progressed from persueing urolift as a solution and eventually settling on HOLEP as the best possible procedure. 

From my research prior to the procedure I expected the best possible result but the whole experience with the Mayo Clinic, Dr Humphreys' staff and the results of the procedure were beyond any expectation. As i have stated before, I have had sprained ankles that injured me worse than the HOLEP procedure. In adddition, Dr Humphreys advised me that less than 1 or 2% of patients ever have a repeat surgery.

Other factors effecting the outcome have to be my age: 76 and the size of my prostate 114 mg. I also am in excellent physical condition for a man of any age, take no medication, all my vital signs are excellent, my weight is normal and I was therefore an excellent prospect for surgery. There's also the factor that HOLEP is the only method where the size of the prostate does not matter.

I don't know how a surgical instrument, a viewing device and a water tube, in and out,  can be inserted through the penis and manipulated for several hours without any soreness, very little blood, no pain, etc. This technology is simply unbelievable and I say that without reservation.

I stayed in the clinic overnight and two days later toured the mountain town; Jerome AZ on foot for five hours or so and then flew home the next day.  

Do yourself a huge favor, continure to do your own research, the facts are readily available and realize that your health is secondary to urologists who do not perform HOLEP and they will not recommend it. It is YOUR life, YOUR future is at stake and NO ONE else will care about you as you care about yourself.

Best of luck to you and keep us advised here. Many thousands of BPH sufferers may benefit from your experience as I hope they have from  mine.

RonTexan      

Ron,

I think you are confusing the classic TURP -Trans Urethral Resection of the Prostate - the so called gold standard performed for years by most urologists, with the Button Turp which is actually called the bipolar plasma vaporization of the prostate (BPVP) with "button-type" electrode. All the articles and studies I have read have declared the HOLEP, Thulium laser and BPVP to be superior in safety and outcomes to the classic TURP. I agree with your assessment that the HOLEP may well be the best. In my case I was more concerned with sticking with my urologist, at the time so I went with the GL which is the only procedure he did. The downside was that it was only partially siuccessful. The upside was I didn't get retro, and when I needed emergency surgery for hematuria, he was right there, and while he was inside he removed bladder stones, trimmed some more off my median lobe, and did a resection of the bladder neck, which did the rest of the job the GL didn't do.

Bob

Hi Ron,

Isn't retrograde ejaculation a certain outcome with HOLEP?  Also, I think there's some incontinence risk.  I think PAE is the only technique that has risk of impotence, incontinence, or RE.

Oops.  I meant to say, "no risk of...".

Well, I don't know, my long-time uro told me several years ago that he no longer does the standard turp and now does the button turp, the latest innovation. He recently called it the the Gold Standard. When i mentioned that i had been researching on my own and wanted to have the Holep method done I'm not sure he had even heard of it. his reply was that if so few uros are performing the procedure doesn't that tell you something. i replied that yes it does, it's very advanced, very difficult and requires extensive training and experience. He recommended that i have an open prostatectomy as my prostate was too large for any Turp procedure. I told him that it is not too large for Holep and that would be my choice. After the Holep was done I sent him a very detailed letter about the Holep and the Mayo Clinic and the unparalleled success I had experienced. I received no reply. You would think after ten years of treating me he would express some joy that it turned out so well. But no reply. it's the "not invented here" thing.

I'm glad to hear that your various urinary troubles are being solved. best of luck to you!

Ron  

I agree. Because PAE doesn't use the urethral route, these risk factors aren't a problem.  I still think PAE has the best upside and the fewest downside risks.  

Hi Ron,

I think you may be doing a bit better than me. It sounds like your prostate problems are behind you. Mine are about 75% behind me. I have no problems during the day, but still get up 2 to 5 or 6 times most nights. Using a bed side urinal I can go in the dark and get back to sleep quickly. But since last September, about 7 or 8 nights a month I void more than 10 times, usually voiding between 2 and 2-1/2 liters. On those nights (last night was one) I'm only getting an hour or two of sleep the next morning when the water works stop. Since my PVR was only 7ccin October, my urologist said there's nothing more he can do for me because I am not blocked in any way. My GP is stumped and I'm being evaluated by a nephrologist who so far has found my kidneys to be working fine. Next stop is a cardiologist and doctor of internal medecine. But so far it is looking like I'll be one of the millions for whom no cause or solution is found for their medical issues. Best wishes,

Bob

PAE may very well be the method of the future. We read a lot that it hasn't caused new problems and that's something that can't be said about any of the tissue removal methods, including Holep, assuming that you don't have retrograde ejaculation already before surgery. The problem with PAE is that it doesn't hurt you but it may not help you much either. It seems to be a method still under development. Am I wrong? Those who have experienced PAE speak Up!! 

Ron, have you read the testimonials on Dr Pisco's site?  They're quite impressive.  He's done over 800 of them.  I think 10-15% may not have any improvement.  However, they are not worse off except for paying $5,000 or so.  (I think the price in the US is much higher.)

Mike ..and Ron

i'm following this discussio because i have the same problem.  can you tell me who Dr Pisco is and what is his site name ?  where is he located ?  

Robbie 

Hi Mike, do you know if PAE is covered by Medicare in the US?

Robbie, Dr Pisco pioneered the prostatic arterial embolization (PAE) technique.  He's in Lisbon, Portugal.  I can't include links in posts, so I'll send you a private message.

Ron, I think I read someone on the forum said it was covered by Medicare.  I'm not certain, though.  If not, you could make a short trip out of it to Portugal.  The euro has weakend recently against the dollar, so it's cheaper now.

The embolization has been updated so the success rate may be higher.  The Perfected Technique is being used, proximal first, then distal embolization.  I was told by Northwestern University that PAE was covered by Medicare in their clinical study.  RIA Endovascular in Denver said it was covered my Medicare with an additional diagnostic code.  

Just wanted to add, an additional diagnostic code would be blood in the urine according to RIA Endovascular.  The nurse there told me last month that they were doing 10 PAEs a week.  I said, "You mean a month."  She said, "No, a week."  She said there is demand because men are looking for something without sexual side-effects

Camster, did you get PAE at RIA?  10 a week is impressive.  They'll surpass Pisco's 800+ in no time.

I did not get PAE done yet.  This was part of my investigation.  RIA charges $13000, up from $11000 one year ago.  I told the nurse that it is cheaper for me to go to Lisbon and see Dr. Pisco.  She said the hospital charges are steep.  

Even with a flight to Lisbon and hotel, you'd save about $7,000.  As PAE grows in popularity, more people will find out about Pisco and places like RIA will have to re-negotiate the facility fees or lose out on business.  What's really galling is that most hospitals are "non-profit" and still gouge their patients and get billions in dollars from taxpayers in the form of "uncompensated care" rebates.

My last hospital stay of a week at a highly rated for-profit hospital generated a $68,000 bill (in addition to what my surgeon and anesthesiologist billed). But Medicare only paid $6,500, and I and my secondary insurance paid about $600 each.  I'm thinking if I had no coverage the hospital would have been able to write off the $68,000 amount on their corporate income tax. It seems it would be fairer for the taxpayers if they were limited to writing off just the amount ($7,700) they settled for. That said, it seems there's no way most people can afford hospital care without insurance coverage. One way or another, either through taxes or insurance, we will pay.

Bob, I don't know how for-profit hospitals work but so-called non-profit hospitals use accounting shenanigans like the one you mentioned.  They know they won't get $68k but they bill for it anyways.  They know they'll only get a fraction.  In your example, they would claim $60k in uncompensated care to the federal government.  Of that $60k, they would get a nice chunk back at the end of the year.  So, the more they claim to lose, the more they make in terms of rebates the federal government.  That's also why they gouge people at emergency rooms without insurance.  Those "losses" turn into huge profits at the end of the year.

If you want to see what pricing without government interference should be, Google "Surgery Center of Oklahoma."   They list their pricing and it's all-inclusive.  Plus, it's about 1/10th to 1/5th of the pricing of competing non-profit hospitals.

Mike, Those prices are all for day surgery, they don't include overnight stays. Still they are approximately what surgical costs are in NJ without the anesthesia, and they include the anesthesia, so it's a good price. Still, for anyone on medicare it's a no go. For anyone with employee healthcare, it's a no go.For anyone needing non surgical care it's a no go. Since most medical treatment is probably done on seniors, and they are all covered by medicare, I'm not sure who would benefit from this setup. The thing about taxes is you will always pay them. They never go down. If costs go down in oe segment, like health care, you can be sure your taxes will go elsewhere. They won't come back to you if you are part of the 99%.

Well, if places like the Surgery Center of Oklahoma can provide most surgeries for 1/10th to 1/5th of the price of hospitals, something is seriously wrong with hospital pricing.   You can get a TURP for $3600 and a laser TURP for $4900. The rates are all inclusive and there are no price surprises.  I didn't see a greenlight one but they can often arrange surgeries not listed on their site for a fraction of hospitals.

Hi Mike agreed. When you look at a hospital bill and see they charged $5 for an aspirin you know the pricing is off the wall. My Greenlight was done in my urologists office and it was about $6000 including anesthesia. The procedure took just 2 hours. But Medicare paid all but a few hundered dollars of it. Does the Surgery Center of Oklahoma take Medicare? I think the problem is that if you have Medicare you pretty much don't care about the cost, since you aren't paying it. There's no incentive in the system for price reductions or savings. I will still pay the same $120 a month or so for Medicare coverage whether I incur zero expenses or a million dollars worth.

They don't take Medicare.  They'll help you file regular insurance claims but they're primarily cash/credit.  That cuts down on their costs as they don't have hire a  staff to process the claims.  It also reduces uncertainty of payment. 

The center signed a deal with the county last year for county employees and saved taxpayers over $570k in just 5 months.

Oklahoma City is now a medical tourist destination.  More and more surgery centers are converting to the transparent price model.  People who don't even live in Oklahoma have been able to show hospitals in their towns the pricing and get discounts locally.

Even though they charge a fraction of the price, the surgeons who work at Surgery Center of Oklahoma make more money.  The surgeons own the facility and charge reasonable facilty fees.  They even give you aspirin for free!

The way my medicare supplemental insurance works (Cigna) if Medicare doesn't pay, they don't pay at all. I think most Medicare supplemental insurance works like that these days. So no one on Medicare could afford to go there. It's a good business model as they just specialize in surgery for people under 65, so they have a healthier population as a customer base. And if they make deals with employers they can make some real money. If an employer pays premiums for 30 years, it's not likely employees will need as many surgeries as retirees would.

I emailed Dr. Keith Smith at the Surgery Center of Oklahoma a few months ago about doing PAE.  He said he would pass it by the urologist.  I told him that a urologist doesn't do the procedure and may not be favorable to it. PAE is not being offered there yet.  

Interesting.  That guy is a pioneer.  You can get most surgeries there for a few thousand.  Hopefully, he adds it soon. 

Maybe send him an email too.  Maybe he needs to hear it from others.   He was not familiar with it when I contacted him.  

How do you "know" Urolift will not last as long as a TURP?