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Whether to go for Prostrate operation

Posted , 12 users are following.

nirbhar52734
nirbhar52734

I am 69 years old. I have BPH for last 10 years. I have low flow of urine, a bit of dribbling, sometimes stop and go(specially towards end of urination). Night time urination mostly 2 times but sometimes 3times. Post void urine retention about 200ml and Prostrate size 25gm as per latest ultrasound. Urine flowmetry result:

  • Max flow rate: 5.2 ml/s
  • Mean flow rate 3.1 ml/s
  • Time to max flow: 37 sec

    There is no obstruction in th passage as per RGU study done about 2 years back.

Should I go for Prostrate opeartion? if yes then whether TURP or HoLEP considering my prostrate size.

Please suggest.

What happens if I postpone the surgery? What kind of emergency may arise?

Thanks,

Nirbhar

0 likes, 31 replies

31 Replies

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  • rdemyan
    rdemyan nirbhar52734

    Posted

    I don't think I've ever heard of a prostate that is only 25 grams causing this many problems (esp. a 200 mL PVR). 25 grams is often listed as the normal size for the prostate. As some other posters have alluded to, I would question whether the prostate is the cause.

    A prostate 3T MRI would probably be helpful in establishing the shape of the prostate (particularly a potential median lobe). If that is not an option, if I recall correctly, I believe my uro here in the USA told me that a median lobe can also be diagnosed via a cystoscopy.

    You didn't mention your PSA. Have you had tests/diagnostics done that appear to rule out cancer?

    Do you have any reason to suspect that the bladder is the issue?

    I currently take dutasteride for my 100 gram prostate. I'm sure that I've read that the 5ARI drugs are not effective for small prostates.

    • nirbhar52734
      nirbhar52734 rdemyan

      Posted

      Thanks rdemyan for your detailed reply.

      I will ask the doc for MRI/systoscopy. I do PSA test regularly. Present value is a little more than 1.

      My prostrate size was 30-35 gm about 4 years back. After start of the combination drug I am taking it has come down to the present value. However, the flow has slightly deteriorated over time, and also PVR.

      Thanks for your suggestions.

      Best,

      nirbhar

    • rdemyan
      rdemyan nirbhar52734

      Posted

      Hi Nirbhar;

      Here are four typical ways that prostate size is measured:

      1. Digital Rectal Exam - can be very inaccurate and should not be trusted. My ex-uro said 40 grams for years even a month prior to other methods showing 100 grams or greater.
      2. Transabdominal Ultrasound (TAUS) - least accurate of the techniques using measuring devices. My first TAUS was 145 grams. However, should give an approximate idea and is quick and painless. Certainly better than DRE.
      3. Transrectal ultrasound (TRUS) - most accurate method using ultrasound. In my case TAUS measured 145 grams and TRUS measured 100 grams (but see caveat below).
      4. prostate 3T MRI - most accurate method short of removing the entire prostate and weighing it. After 9 months on dutasteride my 3T MRI measured 103 grams whereas a TAUS measured 70 grams. The original TRUS nine months earlier measured 100 grams. I do believe that my prostate is smaller now since my symptoms were much better after 9 months (I'm currently at 15 months of dutasteride/alfuzosin usage).

      I was told by a urologist that TRUS cannot be used if the prostate is larger than 120 grams (mine was probably around this size). When I viewed my TRUS picture, I could see that the urologist was guessing at end points, in black areas of the picture, for the diameters of the ellipsoid model of the prostate. For a small prostate like yours, though, TRUS will probably work fine.

      After seeing the incredible pictures that a 3T multiparametric MRI produces, there is little doubt in my mind that it is the best method. However, 3T mp MRI might not be available in your area at a reasonable price. The advantage is that you get a very good "picture" of the prostate in 3 dimensions and an experienced radiologist can evaluate you for prostate cancer using PIRADS. However, if all you need is an accurate measurement of the prostate size, then TRUS should work fine.

      Was TRUS or TAUS used to measure your prostate size (with TRUS a probed is inserted into the rectum)?

      You mention bladder distension: it really seems like you should determine if the bladder is the primary culprit here or not. I'm not a urologist, but with the small size of your prostate it seems that a median lobe would be the main culprit if the prostate is the problem. I believe a cystoscopy can determine if you have a median lobe. Have you had a cystoscopy?

  • pete25515
    pete25515 nirbhar52734

    Posted

    from a uk urologist - go for it. at 25g the benefits of holep arent really there over turp or even bladder neck incision- the important thing for you is to see a urologist who carries out alot of bph surgery and have whichever they are more comfortable with.

    the dutasteride is unlikely to be very helpful given the prostate size. as long as you dont mind the risk of dry ejaculation i think you will do very well with surgery.

    • nirbhar52734
      nirbhar52734 pete25515

      Posted

      Thanks for the suggestions & encouragement from an urologist point of view.

      Best,

      nirbhar

  • steven05114
    steven05114 nirbhar52734

    Posted

    Nirbhar,

    .

    "What happens if I postpone the surgery? What kind of emergency may arise?"

    .

    If your PVR's are 200 ml, then when you are "empty" you are only half empty so when you are full, how full are you? If you are often over 400 ml, then you may be stretching out you bladder and damaging the bladder wall muscle (trabeculation).

    .

    This is a damage that slowly develops over time from BPH bladder outlet obstruction (BOO). That was my case so even after a successful Rezum to clear the obstruction, it took many months for my PVR's to drop below 100 ml into the normal range.

    .

    As far as emergencies go, there is always acute urinary retention (AUR) where you can get a big buildup of pee in you bladder. I went into AUR and they took 2 liters of pee out of me. You can also get pee backing up into your kidneys which may cause kidney stones which are very painful. I had them too.

    .

    I understand that in India, your options may be limited but I would not do a TURP or HoLEP as they both result in permanent sexual damage (RE) to the prostate. I had a Rezum to minimize the chance of that. As a fast outpatient procedure, I would think that Rezum would be easily adopted in very populous India.

    .

    Regards,

    .

    Steve

    • nirbhar52734
      nirbhar52734 steven05114

      Posted

      steven, thanks for your detailed reply.

      As you mention about bladder, I saw the last USG report & found that distended bladder was mentioned.

      Thanks again.

      Best,

      nirbhar

    • steven05114
      steven05114 nirbhar52734

      Posted

      Nirbhar,

      .

      My report said distended bladder too. A distended bladder means that you have been holding over 400 ml of pee and stretching your bladder. This also means possible bladder damage that may be hard to recover from. Do a Google search for the following:

      .

      The Detrusor Muscle: An Innocent Victim of Bladder Outlet Obstruction

      Vincenzo Mirone, Ciro Imbimbo, Nicola Longo, Ferdinando Fusco

      .

      I would say that if your bladder is distended, the sooner that you have a procedure to remove the blockage from your BPH, then the sooner that you stopping further bladder damage. In hindsight, I should have had my BPH corrected much sooner.

      .

      Finally, have you been put on Tamsulosin (Flomax) or similar and Finasteride (Proscar) or similar to see if the combination will let you pee better, provided that you can live with the side effects?

      .

      Steve

    • nirbhar52734
      nirbhar52734 steven05114

      Posted

      Thank you so much, steve for suggestions. Ofcourse I will google the article.

      I had atleast one of the two drugs you mentioned but without any appreciable outcome.

      Thanks again.

      Best,

      nirbhar

    • steven05114
      steven05114 nirbhar52734

      Posted

      Nirbhar,

      .

      First, good morning to you! It is evening for me in the U.S.

      .

      The combination of Tamsulosin and Finasteride did nothing positive for my BPH too. The Tamsulosin gave me blurry vision and the Finasteride filled in my bald spot. Both are known side effects. After my Rezum, I decided to stay on the Finasteride to prevent prostate regrowth.

      .

      Here is another classic study on drug combination therapy for BPH:

      .

      The effects of combination therapy with dutasteride and tamsulosin on clinical outcomes in men with symptomatic benign prostatic hyperplasia: 4-year results from the CombAT study.

      Roehrborn CG1, Siami P, Barkin J, Damião R, Major-Walker K, Nandy I, Morrill BB, Gagnier RP, Montorsi F; CombAT Study Group.

      .

      There are a bunch of spin-off papers on the original CombAT study. It even has a Wikipedia entry. I don't know if the citation above is for the original study.

      .

      Steve

    • nirbhar52734
      nirbhar52734 steven05114

      Posted

      Good morning steve.

      Many thanks for detailed info on combination therapy.

      Best,

      nirbhar

  • dai12345
    dai12345 nirbhar52734

    Posted

    Hi. That's a very small prostate. Mine was 130gm hence my very successful HoLep. My bladder was struggling and twice normal size due to the back pressure. I wonder whether a weak bladder is part of your problem? I had urodynamic tests and a scan to show where the problem might lie. HoLep is normally reserved for very large prostates and Green Light for smaller ones. I had my Holep 3 years ago so there may be other approaches now.

  • russ_777
    russ_777 nirbhar52734

    Posted

    Hi, there is a critical piece of information that you apparently don't have. Your flow rates are very low and residual high. But from that data alone you cannot tell whether the primary issue is obstruction in the bladder neck/prostate or if your bladder isn't functioning correctly.

    The data that tells your urologist that can only be obtained by having a urodynamics study done. Among other things, it will measure the pressure in your bladder when you are emptying it after it has been filled with saline solution to the point you tell the technician you can't hold any more.

    If the pressures that are measured during the test while you're voiding are above a certain value then that tells your urologist that obstruction is the only problem and that something needs to be done to reduce the size of the prostate tissue internally that is causing the obstruction.

    The test is not the most pleasant thing to do, not because it is painful, but because some people consider it to be embarrassing.

    • ramblin
      ramblin russ_777

      Posted

      It was quite painful for me. I'm beyond embarrassment at this point.

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