Prostatic Artery Embolization procedure

Men's health
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Thanks 333health for your response. I don't know if you noticed but I started another thread recently on PAE failures titles "PAE Disappointment Journal". The idea is to compile experiences of "failled" PAE procedures and look for trends as you discuss here. So far the response had been very good.

I myself have been on alpha-blockers (Xatral) for over 10 years and it has been extremely effective (much more so than the 5-aplha reducatse inhibitors). All signs pointed to me being an ideal candidate for PAE but now at over 5 weeks my BPH continues to worsen.

I wonder if it could be related to size? I am trying to get statisitcs on PAE qualitative score measures vs initial prostate size. Also could the TRA vs the TFA entry be a factor in the outcomes? I wrote Dr. Isaacson about this.

Have you yourself ever tried as an experiment taking a steroidal anti-inflammatory to see how it affects yours BPH symptoms? I had some prednisone (50mg) tablets left over form last's asthma bout and tried as an experiment taking just one tablet and then getting my PSA measured. Three days after taking the pill my BPH symptoms disappeared totally and PSA had dropped from 10.5 to 0.5!! But a week later I was back dribbling again. Also steroirds are very dangerous but as a scientist I could not resist doing this experiment to confirm that my problems are all autoimmune/inflammatory related.

Have you been screened for PCa? I did two liquid biopsies last year (Apifiny and MiPS) which are easy and cheap and I recommend them to all here.

All the best and thanks for your response. Neil

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Aetna Insurance, my insurance company, has a long list of prostate treatments listed on their website plus the results and success of clinical trials on those...,The REZUM and PAE appeared to be the Most Successful, offered the Quickest Recovery, had the Fewest Complications & Side Effects. as well as, the Least Pain...I talked to Dr. Isaacson about performing a PAE, but he stated the REZUM was more appropriate for my medical condition due primarily to a small, 29 cm prostate, but other reasons too, ie. a low 3.3 PSA, small medium lobe obstruction, etc...Thus, my remaining best choice was the REZUM which I had ~ 3 weeks ago....

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If the prostate's size is not reduced, it seems its pressure on the urethra would continue and, thus, you would still have trouble voiding, ie. totally empting your bladder which causes more frequent attempts to void...

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Dear 333, you seem as one of the more knowledgeable people on this site, I'd like to ask you a question. I've been on Finesteride/Tamsulosin for a few years with a prostate of 220 in size. After my PAE in June 2016, I experienced immediate relief from the urinary stuff associated with BPH> From the med's I incurred retrodgrade ejaculation. I still have that condition, even with the PAE in June. My recent visit to the Uro guy, he said he thought it would take another month before I could expect normal ejaculation, mostly because of Tamsulosin.

Any thoughts on this.

gary

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What was your PVR prior to PAE and how did it change after the preocedure?

My PVR has been 500-600ml, prostate size 100g.  I have multiple bladder stones and a ureter stone. I have a combination stone removal, bipolar TURP scheduled for Monday, 9/19 at Kaiser Santa Clara.  Surgeon said that there is a chance that a second TURP procedure might be needed, depending the outcome of the first.  I am currently catheterized.

I could have a stone only surgery and then PAE, but I am concerned about the amount of disobstruction realized, and the time to realize it, since my bladder is stretched (500ml).  I am thinking that TURP will give faster and better disobstruction than PAE, needed because my bladder is so stretched out.  Of course, I hate the idea of RG ejaculation, TURP recovery, risks, etc.  But with such a large PVR, I am aftraid for my bladder function, and I do not like the idea of catheterization for a long period.  Need to get the PVR down quickly so that my bladder can have the best chance to recover.

The urologist did not do any urodynamics testing.  PSA has been stable at about 17 since neg biopsy 5 years ago.  Mark

 

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Mark, this is not medical advice; I will share what I would likely do in your situation: you have a PVR of 500. I assume that you had a CT scan with contrast done by the urologist to ensure that there was no retrograde flow to the kidneys.

Assuming that is the case, that is no retrograde isues: it would be highly unlikely that I would allow them to do a TURP.

Kaiser, unknown to many because the urologists at Kaiser are not in the habit of telling patients about PAE, has an interventional radiologist at Oakland that has been approved by Kaiser to do PAES.

He has been doing them at the Kaiser facility in Oakland for two years, and getting research-level results. His name is Jeffrey Hastings.

In your shoes, which I am not, and can't tell you what to do, unless you have an urgent, can't wait a few weeks need to have a procedure (I had much higher PVR level than you and no retrograde flow), I would STRONGLY consider POSTPONING the surgery until you get a referral to Dr. Hastings in Oakland and see what he thinks.

The urologists will not be happy about it. But doctors where unhappy back when patients started not allowing routine tonsillectomies with appendix removal thrown in for good measure, or when a number of them started saying no to routine antibiotic use for colds.

You are about to do permanent, irreversible changes to your prostate with a TURP, and you have been told you will likely need another.

PAE changes are usually seen, including decreased post void residual, 4 weeks after the procedure. Often less. Why not consider it, and if you meet the parameters, do one? If it does not work out doing a very conservative approach, then you can always do the TURP.

My two cents. Hope it helps. Hastings has a very good reputation. It's the resistance from your urologists that may be a challenge. Ask your primary treating physician, not your urologist, for a referral to the interventional radiology dept. in Oakland. You dont need the urologist to do so.

Once you have it, you can call that dept and ask for an appt with Dr. Hastings. Since it is Kaiser, he will have access to all your records, urologists' notes, and imaging.

Good luck whatever you choose.

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Actually, I have already consulted with Dr Hastings and he feels that I would be a good candidate.

The complication that I have is bladder stones, about 25 of them up to 9mm.  Also, a ureter stone stuck at the ureter/bladder junction.  I am scheduled for combination stone removal and bipolar TURP surgery on Monday.

Last Thursday, my PVR spiked to 670 and I gave in to the urging of the urologist to have a foley installed until surgery, to protect my bladder from further damage and a rest.

Dr Bagla suggested doing PAE, try removing the catheter in 4 weeks, and then wait for the stones to pass naturely.

Or, I could have surgery to remove the stones, followed by PAE.

In either case, I would need a foley for a long time.

Do you work at Kaiser?  Mark

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I attempted a self-cath on Thursday with the San Jose Kaiser uro-nurse assisting/teaching.  It was not succcessful.  The catheter would not go in all  the way and was removed with a lot of blood.  I then asked for a foley, but it was lunch time and everyone left for an hour.  I was left with a foley and instructions to go to ER for instllation, or wait an hour for them to return from lunch.

I decided to go to the urology dept in Santa Clara to have the foley installed.  There a uro-nurse unsuccessfully tried a 14fr which did not go in and was removed.  Then a 16fr.  Then a urologist tried a 18fr, all unsuccessful.  Finally, the urologist successfully installed a 18fr via cystoscopy.  I was given no ABs.

I was told that I had jammed the self-cath through my urethra and into my prostate (false passage).  This caused the next 3 attempts to likewise follow.

The foley bag was bloody and I felt a constant urge to pee, so much that I could not sleep.  I finally decided to go to ER Sunday morning, where they confirmed via US that the foley was functional.  The ER doctor recommended a urine culture test.  This came back positive for UTI on Tuesday night and I was started on ABs.  By Wenesday afternoon, the urge to pee was gone and no more blood.

On Monday, my surgeon sent me an email saying that catheters are not as bad as I described (unable to sleep) ending with "see you for the procedure".  It is a good thing that the ER doctor ordered the urine culture test, otherwise it seems that I would be going to surgery on Monday with an active UTI.  Scary.  Don't know what to do.  Mark

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Randy I wish you luck with the procedure you had you should do great.  I wish more men with pick other procedure then tupr.  That is a very old and needs to be put out to pasture.  Take care  Ken

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Holep is less blood but why deal with the side effects if you don't have to.  I'm 61 and sex is still pat of my life I don't want retro.  It is part of the orgasm.  And when a doctor tells you all will be the same.  They don't know.  They are just telling you what they learned in a book.....Get all the information you can before you pick one.  Have you even had retro.  some man can't deal with it and stop sex all together because it does not feel the same  Ken 

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Dr. Bagla is a pioneer regarding PAE in this country. If he and Dr. Hastings opine that PAE is good for you, even with stones, I would strongly consider it. I had a diverticulum with stones prior to the PAE, but unlike you, they did not cause obstruction, so I see why the foley is a good idea.

I consulted a second urologist who said the stones can be taken out as needed after the PAE. If it were me, I would very strongly consider to have the PAE, leave the foley for a few weeks, as Dr. Bagla suggested, then take it out and see what happens.

You can monitor PVR closely after taking out the PAE and see how it goes. You said your largest stone was 9 mm. People  pass kidney stones that are 10 mm or more fairly often. Some can't. Most of yours are smaller.

Maybe consider giving nature a chance first before they drill your prostate - twice. Maybe TURP is your best choice, I don't know, but remember that urinary retention issues respond very well to PAE according to research. It's one of the most dramatic changes that PAE has to offer, statistically.

Have you gotten a second opinion from other urologists? I would do that before any surgical procedure, especially if it will forever change sexual dynamics, and possibly other side effects. 

I would not get a second opinon from the same organization that gave you the first one. 

The urologists at UNC in Chapel Hill that work with Dr. Isaacson have a lot of experience with PAE and different presenting conditions, in part because they joined forces while doing research. Dr. Borasky is one of them, and is excellent.

No,I don't work for Kaiser, I see a lot of patients in my clinic that have HMOs and are looking for other options, and many of them are from Kaiser.

Nothing against Kaiser, there are a lot of wonderful folks there, just that no one organization can best help everyone.

No that you have the foley, and I assume PVR numbers have dropped dramatically, I would think it means you have time to look around, and make sure your next step is the best step.

Let us know what you decide and how it goes, we are rooting for you!

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Mark, I received your last email about the catheter fiasco after I sent you my last reply.

So sorry to hear that. Catherization can give you an UTI, especially if you have stones, because the stones can serve as a hidding place/nest for the organisms, even if you take ABs. So can a cystoscopy. I never had a UTI until my cysto. The culture showed multi-organ colonization, typically indicative of infection while getting the cysto.

I'd be scared too. And if I inferr correctly that you would like some feedback, I sure as heck would not get that procedure, or if I had to, would likely not do it with that surgeon.

Your foley, after much anguish, is functional. You are draining well. You have time, it seems - I can't say for sure since I cannot give you medical advice, and cannot tell you for sure you should not have the TURP, but, man, if were me, I surely would be looking around for as long as clinically feasible for other options that made sense.

 

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Mark.  What are you going to do.  If both Doctors tell you that your a good candidate.  Cancel the surgery and have the PAE first and then worry about the stones.  I think you have a better chance with the PAE they the Turp.  There going to core out the whole prostate and then get the stones what happens if the shell of the prostate collapses your going to be screwed  You will be in bad shape   Cancel now before it to late  Ken

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Thanks.

I do not know, actually, if the stones are causing obstruction.  The stones may be only the result of obstruction.  The foley is to prevent my bladder from 'dying' from the high PVR.

What did you do about your bladder stones?

Dr Hastings suggested larposcopic bladder stone removal followed by PAE.

The surgeon said that there was an "unlikely" chance that 2 TURPs would be needed.  Probably, just 1, followed by 1 week of catheterization.  With any PAE alternative, I am looking at 5-6 weeks of catheterization, and PAE does not always work.  I do not like the idea of a foley long-term, with recurrent UTIs.

And, I am not sure if I might need a very strong disobstruction improvement in order for my distended bladder to recover. I believe that TURP more reliably gives faster/better disobstruction.

But Kaiser, the surgeon, and TURP all make me uncomfortable.  The surgeon is the only one locally that would accept my challenging procedure, but he seems too busy to pay much attention to my case.

I would be very interested to know how high was your PVR and how quickly did it change post-PAE?

Thanks.  Mark

 

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My PVR was not a short term crisis, no need for a foley, my urologist said I could wait months before having to do a TURP.

TURP does have more of an effect with obstructive issues, at least initially, and the catheter would come out quicker. PAE could give you, as it has me, more than enough clearance to go easily and drain. But you might be waiting a month or so.

Or have the stones taken out then the PAE. That could be done close to each other.

In answer to your other question, within a week of the PAE i was urinating as much as 400 ml at night in one urination. By the 9th day, I was off the tamsulosin because my daytime urine flow was now reaching close to 200 ml each time, enough to drain most of my bladder by going a couple of times to the bathroom.

Cost/benefit short-term versus long term, you have to figure that out.

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Thanks Ken - They would first remove the stones and then do the TURP, in the same procedure.  I should then be catheter-free about 1 week later.  Mark

 

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How high was your PVR when the urologist said that you could wait months?  At 500-670ml, they were saying that my bladder could die any day and then I would be permanently catheterized.

If only I did not have the catheter put in.  Now, I do not know how severe the false passage is.  I wonder if it went through the capsule.  

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half of yours. If you did not have the catheter put in, you may have had a crisis with your bladder in these days, who knows? You now have a catheter that drains, it's functional;  you can take ABs to prevent possible recurrences of UTIs, you can use D-Mannose as well, which has good research for it, and can decide without hurry whether you want the TURP or a PAE.

I think that taking a strong look down the road, at long-term possible issues, as Ken mentioned, is wise.

 

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Ken - Do you have reason to believe that they will core the prostate first and then get the stones?  Mark

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What are the sizes of your bladder stones?  Have you passed any yet?  Are you worried about AUR if a stone(s) gets stuck in your urethra (I have heard of that happenning after PAE)?

Do you have Dr. Borasky's phone number?

Thanks.  Mark