Turp or laser....MRI vs biopsy

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I am 64, very active, ran the Phoenix marathon on February 25, 2017 and had a acute urinary retention thereafter. Eventually due to my protein and green powder mix before the race. Possibly irritated the prostate more than it could take. Followed the visit at the urologist, tests, PSA in the 7 range, he recommended a biopsy, then i did a MRI which came out clean, the 4K test showed 60% chance of risk to get prostate cancer. Due tomthe mid lobe i cannot do a Urolift. What is best now? Do Laser or a Turp? Do a biopsy or not? What are your thoughts and concerns?

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  • Posted

    I've been doing CIC since I went in to AUR in July 2014.  I tried the PAE, which I thought was the best option, in 2015.  I also have enlarged mid lobe and, at the time, they thought the PAE would still work, but it turns out that it didn't.  I've only seen 1 of hundreds of cases where the PAE helped for those w/ enlarged mid lobes.  At present, I don't see anything out there that seems better to me than CIC'ing. I'm watching FLA and HIFU, but it is very early days and they have mixed results.  I would like to do something because I'm having to catheterize a bit more often thatn before.

    Good luck!

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  • Posted

    First - hopefully you don't end up with cancer. If you do, they can score its aggressiveness and you can make decisions from there. Most prostate cancers (95%) will never cause a problem, so statistically, you have about a 3% chance of getting a prostate cancer that could hurt you.

    I would suggest avoiding laser and TURP. Probably the best option for you right now is Rezum. THey spray your prostate with steam, it kills the tissue and your body absorbs the dead tissue over time. This can be done in a docs office, does not require anesthesia and they can direct the spray where your prostate is obstructing things such as a median lobe. Almost no chance of incontinence or impotence from it, while both are possible with TURP/Laser. THey claim about 3% chance of retro ejaculation with Rezum - based on anectodatal eveidnce on this blog it could be as much as 10%, but still lower than the 100% with TURP and 50% with Greenlight. TURP is outdated and should almost never be performed - if your urololgist suggests it, find another doctor. Too many risks, complications, too long a recovery, ect. Greenlight can cause real problems too - use it as a last resort IMO.

    If Rezum doesn't work, it doesn't preclude doing anything more extensive and for most men, it does work. You could also look into FLA (Focused Laser Ablation) which has been a cancer treatment where people kept reporting it helped their BPH, so they are now experimenting with it for BPH. ITs done by interventional radiologists (like PAE is) and doesn't have the track record Rezum and Urolift do, but might be worth looking into.

    Meanwhile, stop using that powder mix and get set up to self cath (cic) so if you go into rentention again, you can deal with it without a trip to the ER or foley catheter. Until you make a decision about treatment (assuming that retention wasn't a one-off due to the powder mix) it will buy you as much time as you need and let you live pretty normally.

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    • Posted

      Hi Oldbuzzard, thanks for your thoughts.I will check this with Rezum, haven't heard before about it. FLA I have heard and was considering with a fine doctor in Houston. The urologist prescribed me Flomax or the generic Tamsulosin. As for now I don't need any catheter. My prostate according to the MRI is 56 grams and is pushing in to the bladder. Would you do a biopsy? I have read that with 12 holes in to the prostate, it is like shooting in the dark. You probably can see as much on a MRI. Now, from the doctor I understand that the MRI is 90 % secure and so is the biopsy.....so nothing is for granted...which it is not in any case!

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    • Posted

      There is a type of MRI (the name escapes me right now) that is more accuarte than a biopsy and carries none of the risks - I would do that and follow up with a PSA test every 6 months. The real issue with the PSA isn't the size, but the change in % over time. Hopefully someone who remembers the name of that MRI procedure will chime in.

      Also - because you have a 60% chance of developing cancer, dont' rush into an invasive treatment if you get the diagnosis. They can guage whether a cancer is an agressive one or not. If it isn't, you can just watch it with a very strong probablity that nothing will ever come of it.

      I don't think they let you post URLs, so just google Rezum and there's a doctor locator that can point you to docs that can do it. But if you're peeing OK right now and that retention was a one off due to that training mixture, you don't have an urgent need to do anything.

      I'd get set up to self cath, so that just in case it happens again, you can take care of it yourself and not deal with the ER or a Foley catheter. Before Rezum, I had a bad retention episode and was shown how to do CiC by my urologist. No problems bad enough to cause retention for 2 1/2 years, until one night on a business trip just before bed. Having that cath in my bag turned what would have been a 1 AM trip to the ER in a strange city to a 45 second self cathing. When I woke up, I could pee normally again. I was very happy to have had that catheter in my bag...

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  • Posted

    You should do what you feel is right. If the MRI was clean, I would think that PC isn't an issue and if it is, then it is small, so small in fact that it is unlikely the cause of the enlargement. Probably BPH. I am 48 years old and I have trouble urinating, so bad in fact I am having kidney pain at times and I nearly needed to go to the hospital to be cathed. Eventhough my PSA is still very low at .32. I doubt I have PC, but my dad has BPH, with no suprise, a low PSA. Seems to be a patern here, at least in my family. I may need PAE, but I am not sure where my prostate is enlarged. In your case I would ask my doctor what they thought would be the best action and if you are not ok with Biopsy or even if you are, please get a second opinion. That could change everything. Some times a fresh perspective is what is needed and if both doctors say Biopsy, then maybe it should be done. For me, I would say no to a biopsy, but I have other health conditions that make a biopsy more risky for me. Good luck to ya.

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    • Posted

      Craig, BPH is a huge problem in our western society and I am afflicted as well. According to my lifestyle I should not have it, but still got it...Good luck to you as well.
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  • Posted

    This is my considered advice based on my own experiences.  As your MRI has come ouu clean as you say then a biopsy even a template biopsy is highly likely not going to find anything.

    Given that the 4K test gives you a 60% risk of developing PCa, then I would suggest a 6 monthly PSA testing regime and if and when you get into double figures have another MRI and if a lesion is detected I would then recommend another MRI.

    In the meantime and if you are not already doing so, radically change your lifestyle.  Exercise regularly, loose weight if you are obese, change your diet to no read meats, no processed meats and no dairy products plus more veg and fruit.

    I started all of the above over ten years ago and I'm still on an active surveillance routine.

    TURP or Laser?  Laser everytime!  HoLEP is by far and away the best and being one who has experienced it I would recommend it.  Out the same day without a catheter can't be bad or following day if you are operated on late in the day.

    Good luck.

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    • Posted

      Hi Rogcal, thanks for your advice. I do exercise regularly and have done so for decades, I am slim, athletic, eat a lot of fruit, have now radically reduced red meats, no processed meats and reduced dairy products, alcohol and coffee. We'll see if that helps...

      Good luck to you as well!

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    • Posted

      I excercise like an idiot, eat really healthy and still developd BPH. Doing all that is nothing close to a way to avoid it, although it may help and there is no downside to trying it.

      You may need to do something if it gets bad enough - but get a full workup and go from there.

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    • Posted

      I would also make sure you are getting enough Vitamin D as this seems to be an issue for most of us. They have linked low D levels with a high risk for PC. Also those with low Testosterone are also at an increased risk annow they are finding strains of HPV present in agressive PC. All bad news for me, but I still doubt I will have an issue with PC, but there are things we can do to help prevent it and the rest is out of our control.
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  • Posted

    Outside of the marathon, was this your only incidence of acute urinary retention (AUR)? I assume they catherized you right after. Do you know how much fluid came out? Have you had your post void residual (PVR) measured under normal conditions. It should be part of any urologist's visit with someone with BPH, especially given an episode of AUR. Have you had a bladder/kidney ultrasound study? This is important, not only to examine the bladder but to see if there is any kidney issues from retention such as hydronephrsis. What are your other symptons besides the case of AUR? Do you know your IPSS score (you can google it and take the 5 minute test).

    Unfortunately, urologist's often short course the route from symptons to surgery, especially when presented with a case of AUR. I say, unfortunately, because the right course of action only becomes clear after thorough testing and analysis. You may not need a procedure at all now, or if you do, it's important that the intergrity of your bladder is tested first. That test is called urodynamics, the best being video urodynamics? Have they mentioned that to you. Also, I would think cystoscopy should be done prior to any surgery.

    Jim

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    • Posted

      Hi Jim, thanks for your thoughts and advice. This has been my only AUR experience. Releasing water has been slow for many years. My IPSS score is around 20. Accordingto the cystoscopy, the urologist determined that the bladder is aged, probably due to storing urine more than normal. I can sleep up to 4 to 6 hours on a good night. Usually go up once, maybe twice. The maximum of water I can release is around 200 ml, which seems very little if you read that a normal person can hold between 400 and 600 ml. Probably the enlarged prostate (55 grams) is the main cause. I have not had a bladder/kidney ultrasound study, but I will take your advice and check it. The urologist has not mentioned anything about urodynamics, but seems logical to me to test before doing any surgery. Thanks again and good luck to you!

      Emil

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    • Posted

      The older bladder generally holds less than the younger. My voids are generally no more than 250ml, yet I'm not in retention. You should find out how much retention (PVR) you have if any. Again, your urologist should have done this in his office with a simple bladder scanner. 

      Depending on your results, there are several things you can do before considering surgery. Tamulosin (Flomax) or 5 Mg Daily Cialis sometimes can be quite helpful symptomatically. 

      As to surgery, still think that should not be your focus now. If it does come to that, there are newer and less invasive approaches than TURP or Laser. Unfortunately, most urologists only suggest a surgery or procedure that they actually do. And most only do one procedure, or two at most. So it's really up to you, the patient, to do your own homework if it comes to that. 

      Jim

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