just curious if have made up your mind to do PAE? if not what type of information u are looking for?
Gene,
When you say “Perfected (targeted ) PAE” do you mean, the new PAE procedure that blocks arteries that feed the median lobe, to shrink an enlarged median lobe ? If so, you are the first person on this forum that I know of who had the new procedure.
Can you talk more about it. Who did it and where ?
In the past PAE did not work well with an enlarged obstucting median lobe. I have an enlarged median lobe and the PAE I had in 2013 did not help me. I would be interested in hearing more about it and where I could have it done.
Thomas
Gene,
A flowrate of 14 cc per second is good
My symptoms are all over the map. Today, for example, I went 5 hrs and then 4.5 hr w/o having to pee. Other times I pee every 30 mins.
I typically void 250-400 cc, sometimes more.
I don’t know if I have a median lobe. My prostate is between 130-175 cc, depending on the scan and who measured it
Feels like I sit on a baseball .
I can’t drive > 30 mins w/o pain
I must do something
I think FLA or PAE offer best outcomes w least risk
I will probably send my last MRI to Bagla Bhatia and Isaacson and see who I am most comfortable with.
Quality of life is suffering. I hope PAE can be the answer
Michael
have not made up my mind yet but am leaning PAE over Rezum and HOLEP
I have many questions
I will see if any of the doctors I mentioned will answer them by email
Ideally, I would fly to VA NC and Miami to meet each in person but I simply cannot plan all that or spend that kind of money flying all over the country
I did not have a good feel on the phone w Bagla … felt rushed and pressured
Michael
-
medium lobe
to be prudent, no matter hat type of surgery u pick, knowing what shape ur prostate is in will ensure success, especially if u have medium lobe obstruction. Medium lobe can be detected by TRUS and cystoscopy. -
Having a balanced view and true understanding the pros and cons of the desired BPH surgical technique as well as its comparison to other techniques
it seems that almost all the responses to ur posts are from patients who have had a successful PAE. there are many posts in which PAE failed and in some cases PAE failed miserably. these patients have not responded to ur post. if i were u, i would turn every stone, chase down any lead and understand every bit of detail before deciding on using a specific technique . rushing into a decision may give u resultS which u may regret later on.
i have found that the best source of information is from clinical trials as they involves hundreds of patients and they are peer reviewed. below is a review of a 2018 paper (posted elsewhere ) of a PAE trial. u may also want to read the references cited in the review.
The purpose of the review is: “…the major attraction of PAE, at least in the public’s eyes, is its depiction as a minimally invasive procedure with less adverse events (AEs). Preservation of ejaculatory function is particularly promoted (4) . A look beyond the headlines is required to examine this image.”
Critical information from this review is on PAE ejaculation dysfunction:
“The incidence of 56% of ejaculatory dysfunction in the PAE group is rather surprising (1) . Its mechanism is uncertain. By comparison, the incidence of ejaculatory dysfunction in 84% of patients after TURP is within the expected for this procedure, its mechanism is understood, and it is an essential item on the consent form for this procedure. It therefore follows that ejaculatory dysfunction should be declared as a significant possible AE after PAE rather than the current position of promoting it as an ejaculation-saving procedure! (4)”
Source:
bmj?com/content/361/bmj.k2338/rapid-responses
(In the above link, plse replace the “?” sign by “.” that is a period.)
Comparing PAE to TURP. A critical view. Re: Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, non-inferiority trial
This article (1) is a valuable contribution to our knowledge of the value of PAE (prostatic artery embolization) in the treatment of patients with BPH-LUTs. The paper’s special value lies in the fact that it reports on the results of a RCT, thus providing a high level of evidence.
The trial results show that, at the very short follow up period of 12 weeks, PAE reduces LUTs, as measured by IPSS, but to a lesser degree than TURP, and with unproven non-inferiority. Furthermore, one has to take into consideration that, by comparison, an observation period of 12 weeks is likely to disadvantages TURP far more than PAE. The ROPE study had shown that the improvement in the IPSS is at its best at 3 month for PAE. On the other hand, for TURP patients the improvement in symptoms continues up till the end of observation period of 12 months (2).
From the functional point of view the superiority of TURP is beyond any doubt in terms of improving Qmax, PVR and Pdet at Qmax.
Since the trial did not control for any of the relevant outcomes, one can simply compare the % change in baseline measurements. The results show that the % reduction in IPSS, at 12 weeks, is approximately 48% for PAE Vs. 61% for TURP. It is worthwhile remembering that α1-blockers reduce IPSS by approximately 30-40% (3). The improvement in the Qmax is approximately 74% Vs. 211%, the reduction of PVR is 58% Vs. 85%, and the reduction of Pdet at Q max is 21% Vs 54% for PAE Vs TURP, respectively.
When compared to the current standard surgical treatment, namely TURP, the major attraction of PAE, at least in the public’s eyes, is its depiction as a minimally invasive procedure with less adverse events (AEs). Preservation of ejaculatory function is particularly promoted (4) .
A look beyond the headlines is required to examine this image.
In relation to adverse events the emphasis in the paper, particularly in the abstract, is on the total number of AEs rather than its significance. The really significant AEs of treatment of this condition are not the irritation, pain, discomfort, UTI, or mild haeamturia, which constitute the main bulk of the number of AEs in this study, but the serious ones as well as the long term ones. The paper did not provide detailed information regarding serious AEs to allow valid judgment, and with the very short term follow up here the long term results are unknown. However, other longer-term studies showed more concern regarding log term results of PAE, in terms of reoperation rates, etc. (2,5) . When discussing AEs context is important.
The incidence of 56% of ejaculatory dysfunction in the PAE group is rather surprising (1) . Its mechanism is uncertain. By comparison, the incidence of ejaculatory dysfunction in 84% of patients after TURP is within the expected for this procedure, its mechanism is understood, and it is an essential item on the consent form for this procedure. It therefore follows that ejaculatory dysfunction should be declared as a significant possible AE after PAE rather than the current position of promoting it as an ejaculation-saving procedure! (4)
There are also other remarks to be made about this trial.
BPH- LUTs is a complex mixture of pathophysiology, symptoms and signs (physical and investigation results). The authors chose to give symptoms the prime importance. Although, ultimately, the objective is to relieve symptoms, it is not the only objective. One will have a good reason to believe that improving functional outcomes are just as important. They are likely to result in a more durable symptomatic improvement.
The authors use the term “refractory BPH-LUTs” to describe the participants. This is not entirely accurate. Approximately 15% of patients had not even tried medical treatment.
The exclusion criteria demonstrate the limitations of PAE. The exclusion list includes many common comorbidities, e.g. Atherosclerosis, as well as common findings in patients with BPH-LUTs e.g. eGFR less than 60 ml/n
In summary, the results of this trial are unlikely to change the final conclusion of the highest level of evidence, a recent systematic review and meta-analysis on the subject (5). That had concluded “ Growing evidence supports the efficacy and safety of PAE in the treatment of BPH. However, this systematic review with meta-analysis and meta- regression shows that PAE should still be considered an experimental treatment modality. In terms of efficacy it is still inferior to standard treatment methods. Also, the persistence of improvements cannot be guaranteed.”
The authors of this paper (1) promised further follow-up extending to 5 years, and that will be another major contribution to current knowledge.
It is noteworthy that NICE’s decision to “support the use of this procedure” is based not on its equivalence to TURP, but on the basis of “the potential benefits of prostate artery embolization compared with surgery include fewer complications, avoiding a general anaesthetic and it may be done as a day case procedure” (6) . This study should not be seen as moving the agenda any further to make PAE a competitive to TURP on efficacy grounds.
The gold standard, currently TURP, is not perfect and we should continue to search for improvements. PAE will find its place. Within current evidence, it is not a replacement for TURP. It might be used as a stop-gap between medical treatment and TURP (2,7) and that will have financial as well clinical consequences; or it might be of particular value for patients in whom bleeding is the main problem, whether current and unmanageable by other means, or potential one with particular serious consequences. Time will tell.
Meanwhile, we should keep in mind the consequences of previous too enthusiastic rush to implement new and exciting treatments for BPH-LUTs. If we do, we have learnt from history that we learn nothing from history (8).
References:
1-Abt D, Hechelhammer L, Müllhaupt G, etal . Prostatic artery embolisation versus transurethral resection of the prostate for benign prostatic hyperplasia: randomised, open label, non-inferiority trial. BMJ 2018;361:k2270.
2-Ray AF, Powell J, Speakman MJ, et al. The UK ROPE Study: efficacy and safety of prostate artery embolisation for benign prostatic hyperplasia. An observational study and propensity matched comparison with transurethral resection of the prostate. BJU Int 2018. 10.1111/bju.14249. 29645352
(There are more references. Not listed here but listed in the original paper.)
Competing interests: Practicing Urologist.
The review is given at
free access.
U made a very good point. an enlarged medium lobe that protrudes into the bladder can act like a ball valve or a bar, both blocks the urine flow from the bladder to the prostatic urethra. unless the blood vessels to the medium lobe could be identified then blocked, it could not be shrink. even if it could be somewhat shrink, the blockage remains.
Wow, this is a treasure trove of info. Thanks.
I have reservations w/ PAE. I just see it as better than TURP.
FLA seems to offer me the best chance of success. Dr K has reviewed my MRI. I’m confident in him, but my insurance won’t cover that procedure based on the CPT codes.
My urologist is at a major center and is ranked among the best in his field, is widely published and a major cancer researcher. I know he is very skilled, but cutting me open to resect part of my prostate is major surgery. If I had an aggressive cancer, I would have him remove my prostate w/o needing a 2nd opinion from Johns Hopkins. But BPH is not life threatening…it simply robs a man of life’s quality.
I will research PAE more. If my insurance will not cover FLA next year, I can look to HoLEP.
Would an MRI reveal a median lobe?
I didn’t ask Dr K if I had a median lobe.
I might just ask my GP to prescribe me Finasteride and then tell my Uro I am taking it. Maybe that can buy me time.
I was wondering if Serrapeptase would be counter-indicative w/ PAE since it attacks all sources of inflammation and foreign material in the body. I doubt any IR would even remotely be able to answer that.
btw, my knees, neck and low back all feel much better after two months on Serrapeptase. 
I appreciate all of your help. I have a lot more reading to do.
Michael
When I am on schedule w/ Flomax (0.4 mg AM and 0.4 mg PM) I urinate well, especially in the day. Flow is slower at night.
When I skip Flomax, urine flow is much slower.
During the day I can go 4-6 hours w/o needing a bathroom. But some days (especially if I have 2 cups of coffee), I have to pee 2x/hour.
My output has been as high as 500 cc, but usually is around 320 cc. My PVR is between 55 cc - 85 cc.
So, I am left to wonder: if I had a large protruding median lobe that blocks the bladder neck would I be able to urinate as well as I can because of Flomax? Flomax only relaxes the muscles around the urethra - it doesn’t relieve obstruction.
I suppose I can try to find my MRI report to see if it mentions that.
I don’t know if FLA targets the median lobe. I can ask Dr K that question.
Michael
Thomas,
After your failed PAE in 2013, did you have another procedure? How are you today?
Thanks,
Michael
Gene,
You just said something that never dawned on me: “depends how fast the vessels will grow back.”
If they do grow back, that would seem to ensure the need to repeat PAE at some point.
The only procedure that would never need to be repeated is probably radical prostatectomy. But that is a last resort for BPH.
Michael
As far back as 1995 a urologist told me that now we would never now do a radical
prostatectomy for BPH.
Derek,
I don’t think insurance would cover RP for BPH. A partial resection (cutting out the inside of the prostate, or a TURP with a scalpel) would be covered based on CPT codes.
But even that is a last resort as it is major surgery.
If I had a Gleason 7 or 8 tumor, I’d schedule RP. But there are other options for prostate reduction short of major surgery.
Michael
Thomas,
Are there only select medical centers that will treat a median lobe with PAE?
Perhaps over time IRs have figured a way to target the ML that was not known in 2013?
Michael
Sorry, I meant my reply and comment to dl808 " enlightment " comments on PAE long time effects and side effects. I didn’t mean to reply to lpr user.
Michael,
I read about a PAE procedure to block arteries to the median lobe in one of the discussions on this Patient web site, but it would be difficult to find it again. I vaguely remember it may have been Dr Bagla, in VA. The best thing to do is call some of the doctors and ask them if they do it. The person named gene97713 posted something in this discussion that sounds like he had the procedure and it worked for him. I asked him about it but he has not replied.
Thomas
these are good numbers. ur symptoms seem to be mild under the control of flowmax, which seems gives u no side effects. just curious why do surgery.
From other threads, i noticed that Gene seems to have a lot of experience in PAE, well read and knowledgeable. u may be interested to check out his other posts for more info and also more Q&As in those threads.
statiscally, there bound to be success and failure of PAE and will be reflected in the replies u receive. papers on clinical trials will give u the statistics as well as complications. if u have identified PAE is what u want, i am wondering why u are hesitating and what type of further info u are looking for.
according to gene’s post above, the durability of PAE seems to be not well established yet. something to think about.
Michael,
I have not had another procedure. I stayed on .4mg dose of Flomax, and in 2016 I started double dose of Flomax .8 mg. In May 2018 started CIC . August 2018 I stopped Flomax and was OK with just CIC. In October I went on a 3 day trip so started .4mg Flomax again, and was able to dribble out about 100mL of natural void which was helpful while traveling because CICing could be put off.
I am now looking for another procedure, and considering Urolift for enlarged median lobe, however the metal clips interfere with MRI images, so need to find out more about that. I am also looking into Rezum. Also considering a second PAE for enlarged median lobe.
Thomas
just posted a reviewer’s comments on a PAE clinical trial results in the thread “My horrible PAE experience” if interested.
I had a PAE with Isaacson 2.5 years ago. Incredible success. Changed my life. With a large prostate like yours, you are a very good candidate. Mine was 122. PSA dropped from 10.3 to 4.8. A simple elegant procedure with a few days of urgency which are addressed with pain pills. Can’t recommend it highly enough.