HoLEP vs. PAE: Fast Approaching Decision and Advice from Men with Experience in These

Men's health
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My prostate story has good news and not so good.

I just had another 3T multi-parametric MRI. It showed no lesions, nothing of concern other than thickened bladder wall and BPH with prostatitis. My PSA went from 11 to 5 in the past 9 months. My PSA density is < 0.04. My 4Kscore is 3%. All in all, little likelihood I'm looking at cancer, certainly not an aggressive cancer. But......

MRI measured prostate to be 133 cc. That is big. Two years ago, same machine/same hospital measured 121 cc. Basically, my prostate is around the same size, if you figure around 10% measurement error.

I had a trans-abdominal ultrasound a few weeks ago that measured 90 cc. I guess MRI is more accurate.

I need another surgery in the next 90 days. I'd prefer to get the BPH addressed before undergoing another operation. It is abdominal surgery. That makes me rule out open partial prostatectomy - which is a big operation.

My PVR is around 85 cc. Flow rate is good during the day, not good at night. I take 0.4 mg of Flomax every 12 hours. I void 250 cc to 500 cc (max). The 500 cc means my bladder is stretched. Not taking Finasteride or Dutasteride.

Guys who've been through HoLEP or PAE can help me.

+'s of HoLEP over PAE: should result in faster improvement in LUTS, flow rate, PVR

+'s of PAE over HoLEP: less invasive, lower complication risk (stricture, bladder outlet constriction, RE)

PAE has a radiation dose of around 50 mSv. That's equal to 5 abdominal CT scans or 40 years of background exposure. I don't know how that translates to excess lifetime risk of bladder cancer.

PAE probably doesn't require a catheter. HoLEP would require < 24 hrs with a Foley. Simple prostatectomy is about 7-10 days with a Foley.

I would rather not go through the urethra because of the low chance of a stricture forming. Also, for guys who've had HoLEP (or TURP) doesn't any intra-urethral procedure essentially core out the inner gland and by going through the urethra forms a new channel for urine to leave the bladder? That is, after HoLEP is the urethra gone??

To get to the prostate, the urethra must get damaged. What could be left of it after a TURP or HoLEP?

I understand HoLEP can lead to 2-3 months of incontinence but this can be managed with pelvic floor exercises. The risk of RE is 74-78%, which is high. But my primary concern is being able to pee, sleep through the night, sit without discomfort and pain, and be able to live a normal life (e.g., drive on a vacation, go to a ball game, sleep 5 hours straight!). Nocturia on some nights is a killer - and not good for the heart over the long haul.

I'd appreciate any input from men who've undergone these two procedures, both the good and the bad.

If I go with PAE, I think Dr. Bahtia at Miami Hospital would be no. 1, Dr. Bagla would be no. 2.

I do have an enlarged median lobe. Some guys here say PAE is not effective with a median lobe. HoLEP is not limited by a median lobe. Both procedures have been done on prostates of 400 cc or more.

Long post, but thank you to all who read it and who can help me make this decision in the next 4 weeks.

Michael

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Michael,

Have you considered FLA as a third option. I have a close friend whom I steered to Houston and Dr. Karamanian.He is is very satisfied with his outcome. (I had gone the Green Laser route and had a disastrous outcome, so we had lots of long discussions before he made his decision.)

Glenn

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No catheter with PAE Dr Bagla in 2017.

Also, I was told that radiation was less than one cat scan. I will post email with that communication tomorrow when i am back on my computer.

Rich

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Michael,

I am tentatively scheduled for PAE with Dr. Picel, Stanford University Medical Center (he used to be at UCSD) May 16th. Just had a CT scan, because my insurance wouldn’t cover the 3T MRI, so Dr. Picel informed me he needed the CT scan as a “minimum” to get a fairly accurate picture; short of the MRI 3T.

While discussing BPH in general, the subject of median lobe came up. I stated I had heard that PAE might not be effective with a median lobe issue. Dr. Picel said that PAE can be very effective with the median lobe “IF” the IR Doc knows prior to the PAE procedure of the median lobe; then that can be effectively addressed at the same time as the prostate itself.

Overall, I prefer the PAE option as a first-choice because of its low invasive nature; and it thereby leaves open the option for HoLEP or TURP should I not receive adequate flow enhancement and reduced PVR. If HoLEP or TURP are done “First” there is No “option” of PAE. Just my thoughts.

Good Luck Brother.

Chuck

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I haven’t had any procedures, so I’ll only comment on the urethra question. HOLEP, TURP, Greenlight and some others (however, not Urolift, PAE or Rezum) essentially destroy the section of the urethra that goes through the prostate. So the prostate urethra is gone, and the remaining prostate contains the urine and keeps it flowing to the downstream urethra and out the penis. At least that is my understanding.

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Yes, Glenn. I spoke with Dr K. He looked over my earlier MRI. Great guy.

Unfortunately, for BPH my insurance will cover less than $2000 of the total cost. FLA, if billed to insurance, is around $29,000. I’d be responsible for $27,000. If direct pay, FLA is around $21,000-$22,000.

I don’t have that kind of money, unfortunately.

Dr K would have been my 1st choice.

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Last week I met Dr. Chandler Dora at the Mayo Clinic, Jacksonville, FL. (Google: chandler dora holep youtube - and watch him perform the procedure.) I was very impressed, though he advised me my prostate was a little too small (39ml). I’m thinking about FLA for me. My impression of PAE is that the success rate depends on the anatomy of the arteries supplying your prostate - but I’m not a urologist. Good luck to you.

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Thanks Rich,

I look forward to seeing that. From the little I could find, PAE is 50 mSV, an abdominal CT scan is 10 mSV, which is equal to 8 years of background (ambient) radiation.

That does not result in any significant increase in lifetime risk for all cancers combined, given the risk for males in the US is 1 in 2 of developing cancer in a lifetime.

I could not find much, admittedly, and continue to look.

Since you had PAE with Bagla, can you tell me how quickly you notice improvement in urine flowrate and reduced night time visits to the bathroom? How big was your prostate prior to PAE? Have you gotten a measurement since then?

I’m pressed for time because I need surgery (other than prostate) and don’t want to risk acute urinary retention from the anesthesia. With a prostate > 130 cc, it is very large.

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Chuck,

That is a very good point. PAE is less invasive and it leaves open other options. HoLEP enucleates the prostate and not much is left.

I would agree that a skilled IR would be able to target the artery to the median lobe. I’ve come across Dr Picel’s name in my research. Being associated with Stanford, one of the top hospitals in the US, speaks highly of his credentials.

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rdemyan,

Yeah, that makes sense and is perhaps the best explanation I’ve seen.

I wonder if the interior of the prostate grows an entirely different cell layer to accommodate the urine, which can have a varying pH.

Thanks :slight_smile:

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I asked my uro once about what keeps the urine from leaking through the prostate and eventually into the abdominal cavity. I didn’t fully understand what he said and I was pressed for time to ask him other questions, so I didn’t take it further. But he said that a lining is formed (which I guess would be the cell layer you mention). He said something about it being similar to the inside of the mouth, which I didn’t fully get. It was my first office visit with him and I had to continue on with my powerpoint presentation :slight_smile:

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RE: the PAE
News from here (Arizona) is not very good.
My urologist “sort of” heard of this procedure; my PC had not, so he would not even give me a referral, saying that he can’t refer me for something he knows nothing about. That alone made him suspicious.
Meanwhile, my urologist had staff meeting with the 10 or so doctors in his urology suite to ask more questions. The BAD news: among all the doctors a total of 8 patients had the PAE procedure done. Sadly, all 8 reported negative or worse results. So much so, that my Dr. thinks the procedure could get halted and/or banned until more research is done and outcomes can be proven to be better. Buyer beware - it is a VERY expensive procedure: The only interventional neurologist in Arizona says it’s about $20-30 K.

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I had the PAE 3 yrs ago with Isaacson in North Carolina. The guy is great. Procedure took less than 2 hrs. In one week I was like a new man. No sexual side effects and can be redone in the future if prostate grows. To me it’s a no brainer. Holep screws with sex life. Now covered by Medicare. I think by now Isaacson has figured out how to fix the middle lobe issue but that is a guess. You can find his info on line and he will promptly call you if you email him. Good luck

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Furthermore the docs talking about banning PAE are simply trying to protect their surgical livlihoods. They are medievel idiots. Talk to the experts like Isaacson, Baglia , etc. Urologists are to be avoided at all costs. They don’t seem to mind screwing up your sex life.

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What is FLA?
I tried to look it up and all I got was legal stuff for Florida.

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doesn’t any intra-urethral procedure essentially core out the inner gland and by going through the urethra forms a new channel for urine to leave the bladder? That is, after HoLEP is the urethra gone??>

I’ve brought this up in this forum before. Evidently, no one here knows the answer to that or maybe its a dumb question. I don’t see how though. The way to cut down the prostate is through the urinary tract. Funny how this is rarely mentioned on here, even by those that know a lot about it. I’ve concluded that it just isn’t that big of a deal as the urethra is actually, even though lined, nothing more that a natural passage. Reaming it out as most of these procedures do doesn’t seem to cause problems in the long run.

1 Like
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Focal laser ablation.

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Hi, Michael,

Sounds like you are concerned about urinary retention after the general anesthesia for your upcoming abdominal surgery. I did, too, and they put in a Foley catheter for 24 hours. You could also learn to do Clean Intermittent Catheterization (CIC). Some men on this forum learned to do that in case of retention.

My prostate measured 90 cc when last measured and has a large median lobe. I also was choosing between HoLEP and PAE. I went with PAE because it’s less invasive, and if it didn’t work, I could try other procedures. Maintaining sexual function is important to me, and that also played a part in my decision.

I should say, too, that before I had a procedure done, I had acute urinary retention. At the hospital they drained 7 liters from my bladder. All the urologists I met with told me I would never void on my own again, because my retention was so extreme, but each suggested a surgery. The surgery was always their specialty. Urologists will usually advise against PAE, because it’s something they do not do. I learned how to do CIC to buy time to make my decision.

After my PAE, I came down with a urinary tract infection, making CIC almost impossible. My IR had a Foley catheter put in for 7 days. After the infection cleared I started to make progress with my natural voids. Before PAE I could only pee a few drops. About 6 months later, I could pee about 200 ml at a time. Prior to PAE I had to CIC 5 times a day. After PAE, I still had to CIC 5 times a day, but PAE made CIC much easier. And I was still making progress, until I had bladder stones removed. After that procedure, my natural void volumes dropped, and haven’t come back.

In the meantime, I’m happy with CIC. It allows me to live a normal life, and I don’t feel rushed to make a decision. When some studies are done on FLA, or if it’s covered by my insurance some day, I might go with that.

Stebrunner

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I have been told the instruments for GL, HoLep and Turp go through the urethra to the prostate and then selectively laser/burn prostate tissue. The urethra is not lasered as it has no need to be but it does suffer some trauma from the instruments that causes swelling. The urethra is evidently spongy and also absorbs blood and fluids used in the procedures and eventually settles down.
There are plenty of YouTube videos and demonstrations of the various procedures and the companies will send you links to them.

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Hi , Can you do CIC? Its not all that bad. I have been doing this for 3 years.
frank