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I am in dire need of prostate surgery and it appears the best avenue is the Holmium laser.  I live in Kentucky.  Anyone have positive experiences with doctors within a day's drive of Kentucky who use the Holmium laser?  I am aware of Dr. Lingeman in Indianapolis  and he may be my choice.  But would like other recommendations.  Many thanks.

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I and my wife extensively researched HoLEP with respect to safety, efficacy, durability, post op experience, and where to have it done. I am interested in this technique because it appears to be a very viable and desirable alternative to the open prostatectomy recommended by the local urologists (130 cc prostate). We came to the conclusion that HoLEP is indeed a viable alternative to an OP but, and this is a big but, it is essential to have a very experienced surgeon. I spoke with a physician at the Cleveland Clinic to get an independent opinion from someone associated with a respected institution that does not practice the HoLEP procedure. He endorsed HoLEP but strongly emphasized the importance of using a surgeon that has considerable experience. He stated it is easy to end up permanently incontinent if the surgeon does not have the necessary experience. He also stated Dr. Lingeman at the University of Indiana has an excellent reputation and probably has more experience performing the HoLEP procedure than anyone else.

Finding a surgeon proved to be a bit of a challenge. I limited consideration to only surgeons associated with large respected academic institutions. I strongly believe the probability of receiving the best possible medical care (for any issue) is significantly degraded when using a physician/surgeon in private practice. My short list ended up with Dr Lingeman at the University of Indiana (Indianapolis) and Dr. Krambeck at the Mayo Clinic (Rochester, Mn). Both have excellent reputations but I naturally leaned toward the Mayo Clinic simply because they have such an outstanding reputation. Although there is a lot positive out there about Dr. Lingeman and nothing negative I had some reservations about him for two reasons. First, he seems to have some significant financial ties with the company that manufactures the HoLEP equipment. This means there might be a tendency for him to use the procedure in marginal circumstances. Second, his office advised me I only needed to fly to Indianapolis once. I would meet with Dr. Lingeman in the morning and the procedure would be done in the afternoon. The Mayo Clinic, on the other hand, requires two visits. The first visit requires spending two days at the Rochester clinic for evaluation and meeting with Dr. Krambeck. If they decide during this first visit the HoLEP procedure is appropriate, they will then make an appointment at some future date for the actual surgery.  This more conservative approach appealed to me even though it means I have to travel from Florida to Minnesota twice.

At this time I have an appointment for an evaluation in a few weeks at the Mayo Clinic.

Based on what I learned, it is my strong opinion you do not allow the location of a surgeon to influence your decision or even consider one in private practice. Everything I read, my gut instincts, and my face to face discussion with the Cleveland Clinic Urologist supported staying with recognized academic institutions. The risk of an error due to a minor misjudgment that results in long term consequences is just too high if you choose HoLEP.

It is not my intention to malign private practice physicians. There are certainly some very competent ones out there. However, one does not really know what to expect from a physician so it is necessary to take steps to maximize the probability of successes and minimize risk. The best (but acknowledgeably not perfect) way I know of doing this is to stay with universally respected institutions like the Mayo Clinic. As an aside, I was very surprised when I learned Johns Hopkins does not offer this technique. Since Johns Hopkins has such a highly recognized Urology department, for good reason, it really gave me pause (and still does) that HoLEP is not available there.



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How was your visit at the Mayo Clinic? This procedure is for my father and am trying to gain as much experience regarding physicians who perform the procedure as possible.



Thank you,

Doc Truth
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The evaluation was done at the Mayo on July 5 and 6. I cannot say enough positive about my experience there. The enormous clinic/hospital/administrative complex, which for all practical purpose IS the city of Rochester, is first class. Everyone, from the shuttle bus driver to the Mayo staff could not have been nicer. The evaluation was very thorough. Dr. Krambek and her entire staff are outstanding. They not only impressed me as being very competent and very professional but they are also nice people. I did not perceive one iota of the typical disrespect the medical profession usually affords its patients. interestingly, my first scheduled activity was not to meet with an administrative assistant to go over insurance etc. but to leave a urine sample at this huge collection facility with a cast of thousands. To my pleasant surprise, I was in their computer and everything went like precision clockwork for the two days I was there. It was almost as an afterthought that they asked me for some of the forms on the last day I was there.

Obviously I made a decision for myself to travel 1500 miles to Rochester. I absolutely believe I made the correct decision and for a family member, if needed, I would encourage doing exactly the same thing.

I am scheduled to return for the procedure in September.

Hope this answers your question.
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Barry



How long did it take to get scheduled for the evaluation at Mayo once you decided that was where you wanted to go? I gather the procedure itself is scheduled for about 3 months later. I'm just curious on the overall length of time it takes to get in and out of Mayo?



Thank you!



Rob
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I don't remember exactly but I think it was only three weeks or so lead time for the evaluation appointment. If you call them they will tell you exactly so I suggest that is what you should be doing.
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Thanks Barry. Hope things go well in September!
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The following is a brief recap of my experience and thoughts from the perspective of two weeks plus after the HoLEP procedure. 

The Mayo Clinic is an awesome institution. It is one of the few places in the world where everything is done right. It is like a very fine tuned high performance precision machine. The entire staff (physicians, nurses, technicians, administrative personnel, etc.) is very customer friendly and, obviously, technically very competent.  They truly live up to the meaning of the larger central shield in the Mayo logo in both their actions and their culture, “patient care”. I was also treated with a high level of respect not typically afforded to patients elsewhere in the medical community. The collective facility is huge and extremely well equipped and very well maintained. From my perspective, insurance and other administrative issues were dealt with as a very minor background issue and certainly not as the initial and primary point of focus as I have found elsewhere. Not once did anyone make me feel anything but welcome. It is certainly not like your typical local physicians office that act like they are doing you a favor. It is a notable oasis of great customer service and technical perfection in an otherwise very imperfect medical world. 

Monday morning was the pre-surgery examination. It consisted of an EKG, some blood work, a cursory examination, and an incredibly thorough health history taken by two technicians working together. Total time was less than two hours. During this visit they explained their 0 to 10 pain scale and the meaning of each of the numbers on the scale. I suggest paying attention and understand the meanings of each of the numbers as this later proved very important in the recovery room. 

I was given a number to call after 8:15 PM to learn what time I needed to report to admissions Tuesday morning. Almost exactly at 8:15 PM the message was posted and I had a report time of 9:00 AM. I had no eating restriction until midnight then nothing but clear liquids until 30 minutes prior to admission. 

The operating room was very large, brightly lit, very well equipped, and recently renovated. It was impressive. It was also a beehive of activity. All my questions, some of which were very specific, were fully answered with respect. The Mayo uses inhalation anesthesia for this procedure. Although I am used to having a mask on my face (have been respirator qualified for 30 years), they handed me the plastic mask and had me position it on my face. I thought this was a nice subtle touch affording respect to people that might be intimidated by having a mask on their face by asking the patient to position and hold it. I remember nothing after the third breath. Virtually all the potentially unpleasant major prep, catheter insertion, leg positioning in stirrups, intubation, etc., was done after I was unconscious. 

I woke in a large open recovery room among a cast of thousands. It appeared there was a single nurse dedicated to each patient and I obviously had her undivided attention. Instantly upon achieving consciousness I was asked to scale my pain. To my surprise I had considerable discomfort from what appeared to be bladder spasms. My assigned nurse was very aggressive with zero hesitation or delay in treating this considerable discomfort with industrial strength pain meds. During my stay in recovery my nurse asked me to scale my pain every few minutes and immediately took aggressive action on my responses. There appeared to be floating nurses that would bring drugs etc. immediately upon the request of the dedicated patient nurses. They only released me from the recovery room once the discomfort was under control (based on my responses to their pain scale). There was apparently a shift change during my two hour or so stay in recovery. I noticed there was a good comprehensive turnover between the off going nurse and oncoming nurse and from my perspective it was a seamless change. Both nurses were wonderful. 

I was moved to a single room. The nurses were incredible with respect to everything. I understood each nurse was only assigned three patients. The nurses were beyond attentive and not once did they ever make me feel like they had any other interest other than attending to my needs. During the night I noticed they were as careful as possible not to wake me if they thought I was sleeping. At 5:00 AM the following morning, exactly as scheduled, they removed the catheter (see next paragraph for more about the catheter). This was a non-event with inconsequential discomfort. I was released from the hospital by approximately 9:00 AM or so. 

The post surgical catheter is something to behold. It wasn’t quite a garden hose but relative to the seemingly small portal available, it certainly appeared that way. It was big (22 French I think) because it is required to provide two way flow. Until the catheter was removed, they had a big 3 liter bag of saline continually dripping in and flushing the bladder.  Except for some minor soreness where the catheter entered, the catheter presented no real problem. Nevertheless I was impressed by the size of it. 

I was completely mobile with no consequential discomfort when released from the hospital. We walked back to the hotel (only a couple of short blocks). During the course of the day we limited lunch and dinner to the hotel restaurant and I generally chilled. Late afternoon we took a two block walk to the drugstore but came right back to the hotel.  I never had any consequential pain. However, there was a low level of discomfort in varying degrees but never to the point of being distracting. I can’t say I felt great but I also can’t complain about feeling bad either. We flew 1600 miles back home the next morning and, in spite of my wife’s objections, I drove our manual shift car the 40 miles from the airport to home. At no time during our full day of travel (the day after I was released) did I ever feel bad. Over the next few days at home I had to be careful about what I did because I was limited to lifting a maximum of 10 pounds for a week or two.  Mostly I behaved as it appeared to me even minor indiscretions resulted in more bleeding. 

I am now 15 days post procedure. I went back to work (an office desk– but a moderate amount of walking) the following Monday morning (6 days post procedure) without any consequential issues. I did find by mid afternoon I was really exhausted but by Wednesday this was no longer a consequential problem. The first week I seemed to need to pee with a strong sense of urgency about every 50 to 60 minutes. The first few days after surgery the flow rate appeared restricted to a small extent. Now, two weeks later the flow rate is great but I still need to pee frequently and each pee is only about 10 seconds of flow. The bleeding appears to be slowly decreasing now but the amount of bleeding varies a lot from one extreme to the other. Overall, there is a lot more bleeding than I expected (my expectation was unrealistic – the bleeding is indeed expected). Each pee is accompanied with some minor discomfort at the start of flow and a quick but tolerable burst of discomfort at the end. This is not yet improving. Leakage never has been a significant problem and is easily dealt with using a small thin pad that has a light adhesive backing. The diapers and “cups (one size fits all)” they give you when released from the hospital are huge overkills but without knowing what to expect the first few days they did provide a good comfort factor, especially knowing I was going to be on two long flights with a significant layover in Chicago on the way home. 

My very unrealistic expectation going into this was to mostly have no symptoms within a week or so after the procedure. Although there is no visible external incision, almost an entire organ was thermally mutilated by somewhat continuous blasting with a high energy laser, finely diced up (morcellated) in the bladder, and then flushed out through a tiny opening never intended for anything more than a thin fluid stream. There is a lot of unseen internal healing and repair left for the body to take care of. At two weeks plus I am still sore, I pee frequently (every hour or so) with some discomfort that does not really go away, I am still bleeding to one degree or another, and there is still leakage. I also have some internal soreness that I sense is originating from what remains of my prostate. However, none of this represents any consequential level of discomfort, limitation of my activities, or a reduction in quality of life. Also, without any question, HoLEP is a much more desirable alternative to the open prostatectomy the local urologists were focused on doing. 

I am certainly not a member of the medical community but my suggestion for anyone considering any type of surgical procedure is to avoid surgery until the risk of retention or kidney damage gets to a point that requires it being addressed. I was hoping much more elegant solutions, now in late phase III trials, such as direct injections of Botox or Nymox Pharmaceuticals product, would become main stream but this has not yet happened. 

I cannot speak for any other institution but I cannot say enough positive about Dr. Amy Krambeck, her entire staff, and the entire Mayo Clinic. Virtually everyone we encountered was pleasant and helpful. The only one thing I would avoid is giving Mayo your email address. I now get an almost unending stream of offensive SPAM from them. 

I hope this provides some insight as to what to expect.

 

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Barry, I truly hope you improve over the coming weeks.  Reading between the lines it appears you are a bit disappointed so far with your recovery.  Kudos for being so diligent in keeping us informed.   I am the one that started this thread and will go into more details at a later date.  Briefly though,  I have visited personally with several doctors who perform the HoLEP procedure as well as speaking on the phone with staff of other physicians proficient in HoLEP.   Boy do I have some stories.  I can't say I felt comfortable with any except for Dr. Nicole Miller at Vanderbilt.  My surgery is scheduled with her on November 5.  I am confident she is the best of the best.  Below is a link from one of her patients.  He seems to have come through with flying colors.  With post more details about my surgery as well as some of my experiences with doctors (won't mention any names though) that really disappointed me.

***this post is edited by moderator *** *** web addresses not allowed***Please read our Terms of Use

 

 

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Hiyield.
Have you investigated "button" electrovaporization and greenlight?
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Fiddler, if you google greenlight you will find long threads on the subject and almost uniformly negative. Years ago, I decided I would never undergo that procedure. Not saying there aren't competent doctors out there that perform greenlight, just it's something I would never consider. I am not aware of button electrovaporization but checking it out it appears to be some form of Turp. And anything Turp related is also not on my agenda.
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Hi Barry, Thanks for letting folks know how you went about this. How are you doing now? It's the end of October. I'm trying to make similar decisions that you faced.
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Now just shy of six weeks after procedure. -Bleeding mostly stopped after 3 to 4 weeks. Even though I am back to my 325 mg aspirin a day, there is no bleeding at all now even after active physical work. -Internal soreness was never more than mild at worst and only intermittent but it was totally gone after a week or so. -Discomfort when peeing is still present but I noticed over last week some signs of improvement. -Still have minimal leakage but nothing a very minimal pad cant easily handle. Expect this to take a long time to resolve but is really practically inconsequential. -Still have to pee every hour or two (a true pain in the butt). Great flow but only 7 or 8 second of flow. Do not know if completely voiding but feels as if I am. Over past week, might be seeing some marginal increase in duration of flow as a few times had 10 to 11 seconds of solid flow. Prior to my first BPH symptoms 20 years ago a typical pee took 30 to 35 seconds so this is the standard I compare to. -If put off peeing long enough, sense of urgency eventually escalates to a high level of discomfort (pain to some). Never a concern for loosing control but high level of discomfort drives a very high level of need to get to a place to pee quickly. Being a guy means the world is my urinal but, when there are a lot of people around or at work, a rest room becomes a practical necessity. This symptom has, so far, shown no real sign of improvement. With respect to all symptoms improvement is certainly not a continuous thing but symptoms cycle to better to worse to better but negative peaks continue to slowly show a decreasing trend. Alternative to HoLEP was an open prostatectomy. Absolutely no question HoLEP is the much smarter alternative. Post procedure symptoms I described are inconsequential with respect to quality of life and nothing compared to what a patient has to deal with after the major trauma of an OP. I also would highly recommend the Mayo to the exclusion of everyplace else. Never have I encountered a medical facility as outstanding as the Mayo in all respects and I doubt there are any although some probably come close. This comes from someone that demands a lot from the medical care industry and not just with respect to competent doctors and other personnel. Also, from reading others posts it seems to me some guys are stressing out over having this procedure. Trust me, as I said in another post I cannot quite classify it as a non-event but the overall experience is mostly a figurative pain in the butt rather than being a traumatic medical event. The only one time I experienced any consequential level of discomfort was when I awoke in the recovery room. The Mayo recovery room staff was on top of of it instantly and I had a recovery room nurse 100% dedicated to me and only me while I was in the recovery room. So, guys, stop stressing, there just is nothing about it that will warrant any real concern but you will pee like the proverbial racehorse, albeit not for very long, at least initially.

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Barry,

I am trying to get a general idea of what this procedure costs because I am on a Medicare Advantage plan and they won't cover it. It sounds like your procedure was covered by your insurance, but do you have any idea what the total of the costs is ? Thanks.

By the way, best of luck in your ongoing recovery.

 

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I do not know the cost. I suggest you call Dr. Krambek's office at the Mayo and tell them your a candidate for HoLEP. Ask them if they can work with the insurance you have. I would be surprised if you do not get a positive response. All travel and lodging expenses will be out of your pocket no matter the insurance unless you live near Rochester or the Mayo Arizona facility and don't need to travel there.

In addition, tell your insurance company the alternative is an open prostatectomy. The cost of five days hospitalization and the much more extensive procedure will be much greater. There is also more risk with an OP, such as infection, that they would have to deal with that to.
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