HoLEP will give its patients retrograde ejaculation, but 10 years or more of durability (5% reoperation rate) within which period most patients maintain the excellent fictional outcomes produced by holep. For patients who absolutely can not accept RE, some are looking at PAE to preserve their sexual functions.
I am sorry that they may be disappointed as according to results from clinical trials, the ejaculation dysfunction rate after PAE could be as high as 56% and the reoperation rate could be as high as 20% within 3 years . An urologist has commented on one of the clinical trial results and I summarized his comments below:
Highlights (compiled by DL):
1 “IPSS after PAE and TURP was comparable” and “PAE had an advantageous safety profile”
2 “this (reliable) study showed a high rate of ejaculatory dysfunction following PAE (56%)”...... “The myth that PAE is devoid of sexual side effects (in particular ejaculatory dysfunction) has been clarified by the Swiss RCT.”
3 “Despite a favourable short-term symptomatic outcome, the main issue remains the durability of PAE. The rather poor outcomes for Qmax, PVR, and urodynamic data suggests that the long-term efficacy will be limited and ultimately a high number of patients, particularly those with obstruction, will experience failure and require additional treatments”
4v“Prostate volume reduction following PAE is in the range of 25%, similar to that achieved with 5α-reductase inhibitors .”
5 “The UK-ROPE study, a propensity-matched cohort study comparing TURP to PAE, revealed similar data and trends as the Swiss trial. The total reoperation rate after PAE (maximum follow-up 36 mo) in the UK-ROPE study was 20%”
6 “Current evidence suggests that PAE might be a viable option for symptomatic patients with no or minimal outflow obstruction or those unfit for surgery; hence, the main competitors for PAE are medical therapy and devices such as UroLift.”
7 “Finally, long-term data (follow-up 2 yr) from large-scale, high-quality, preferably randomised clinical trials are required to be able to determine the future role of PAE in the armamentarium of minimally invasive BPH/LUTS therapy. Until these data are available PAE has to be considered as experimental and should not be performed outside clinical trials.
In 2004 when I was 59 I needed to confront my bladder obstruction. At that time I chose to have a microwave treatment. I have never regretted that choice! It left me with NO side effects. Was it durable, NO. On the other hand that and my HoLEP were covered by insurance. If I were 59 again I would think long and hard before I would submit to HoLEP.
Dr. Lingeman, one of the pioneers of HoLEP in the US has been quoted saying that “the sexual experience is the same except without the mess.” What he says may be true for some men but not everyone! I wonder if he would say the same if he had experienced HoLEP? In my case the surgeon, Dr. Amy Krambeck never warned me about the sexual side effect. I guess she decided a 73 year old didn’t need to be warned.
As for the future who knows what will be available. PAE is only one of the new treatments. Al least men have a little better than a 50 50 chance of not having any side effects. As you have researched, Aquablade is available. If I were 59 again I would choose that in hope of a better treatment in the future.
A couple of other treatments that are on the horizon are FLA for BPH and HIFU for BPH. both of these procedures had their start with prostate cancer. I have talked with one doctor about FLA-BPH. His office reported that there is no prostate size limit. While the results are not instantaneous nor were my results with the microwave treatment (TUMT). The reports are that there are no side effects. I would looked into FLA-BPH but I did not find out about until after my HoLEP. Each of these will need further research but only time will tell about durability.
Who knows wheather any of these treatments will be improvements but the men coming after us may have options that are better than what we have today. We already know that HoLEP is changing. Several doctors have modified so that incontinence is less of an issue. There seems to be some research that points to the en block no touch method may result in as much as a 86% of the patients not having any side effects.
There is hope for those that come after us.
A patient from another forum just had a Simple Robotic Prostatectomy posted how excellent his results were. His excellent results seem to be an outlier to me and is against what I know. In order for readers of that forum to know that holep is the preferred selection. I posted the following. I repost here with the same purpose.
Congrats again for ur remarkably short and complicationless recovery. It seems that it could be more of an exception than a norm.
Obviously. I have had neither simple robotic prostatectomy nor HoLEP. But I also hope readers know that HoLEP is an excellent option for large prostates and is indeed a minimum invasive surgery compared to STP. Since I am not qualified nor creditable to voice an opinion, I could only cite published literature given below.
Source:
ncbi?nlm?nih?gov/pmc/articles/PMC4446381/#!po=15.0000
(In the above, replace the sign ? by a period I.e. a dot) free access.
title： HoLEP: the gold standard for the surgical management of BPH in the 21st Century
authors: John Michalak, David Tzou, and Joel Funk
Only one section of the above paper related to open prostatectomy is given below.
“HoLEP and OP
Since the origin of HoLEP in the early 1990s, it has revolutionized the surgical treatment of men with large prostates. Men with adenomas deemed too large to resect endoscopically are often advised to undergo open prostatectomy-a surgery associated with high transfusion rates, lengthy catheterization times, and hospital stays averaging as many as 5.4-10 days [9,14].
Contrary to TURP, HoLEP is a size-independent procedure. The consequence of this is that HoLEP will eventually make OP all but a historical operation for even the largest of prostates. HoLEP has been used to successfully enucleate adenomas as large as 800 g [5]. Numerous well-designed studies have demonstrated that HoLEP outcomes, catheterization time, and hospital length of stay are independent of pre-operative TRUS volume. Lingeman, et al [1] retrospectively reviewed 507 patients who were stratified into three groups based on preoperative TRUS measurement - 125 g. They found no significant difference in hospital stay, catheterization time, post-operative AUA-SS, and post-operative Q max among the three groups. Similarly, Kuntz, et al [11] prospectively followed 389 patients who were stratified into three subgroups ( 80 g). They found no differences in catheter time, hospital stay, complication rate, or post-operative symptom score across the cohorts. Furthermore, the blood transfusion rate was zero in all three subgroups.
HoLEP and OP outcomes have been directly compared in multiple, well-designed, RCTs. Kuntz [9] demonstrated that HoLEP could be used to resect adenomas greater than 100 grams with similar efficacy as OP, but with radically decreased hospitalization stay, catheterization times, blood loss, and transfusion rates (see Table 1). Naspro, et al [14] performed a similar randomized, prospective study comparing HoLEP to OP in 80 patients with prostates 70 g at 2 years of follow up. They found almost equivocal functional outcomes but a lower transfusion rate (4% vs 17.9%), decreased catheterization time (1.5 vs 4.1 days), and shorter hospital LOS (2.7 vs 5.4 days) in patients who underwent HoLEP vs OP, respectively. Moody and Lingeman, et al [15] retrospectively compared HoLEP to OP in prostates greater than 100 gm and found that patients who underwent HoLEP benefitted from a minimal change in postoperative hemoglobin (1.3 vs 2.9 gm/dl), a shorter length of stay (2.1 vs 6.1 days) and greater amount of adenoma resected (151 vs 106 gm). Furthermore, efficiency and efficacy of the operation were not compromised; procedure duration and AUS-SS improvement between the two cohorts were equivalent.
Table 2 demonstrates the staggering reduction in LOS, catheter time, and transfusion rate that HoLEP patients enjoy.”
....................................TABLE 2................................
.................................................Kuntz (2008).......... ....Naspro (2006)
....................................................HoLEP/Open.............HoLEP/Open
Length of stay (d) 2.9/ 10 2.7 /5.4
Catheter time (d) 1.3 /8.1 1.5/ 4.1
Tissue removed (g) 93.7/96.4 59.3 /87.9
Procedure time (min) 135.9/ 90 .6 72 .1 / 58 .3
Transfusion rate (%) 0/ 13 .3 4/ 17.9
Hemoglobin loss (gm/dL) 1.9/ 2.8 2.1/ 3.1
Prostate size (g) 100/ 100 70/ 70
Change in Qmax +20.6/ +20.7 +11.4/ +11.8
Change in AUASS/IPSS -19/ -18 -12.2/ -13.5
.
Did you ever find out anything about Dr. El Tayeb in Temple? I too live in Houston and am considering using him.
Below are more proofs that HoLEP has almost the same outcomes as SPR at 12 and 24 month follow up. The complications between the two are similar. The advantage HoLEP has is in having shorter hospital stay and shorter catheter time and less blood transfusion wheres SRP has shorter operating time (this surprised me.). In the US, shorter hospital stay could translate into significant cost saving. A SPR patient said that his bill was over $110,000 whereas HoLEP is typically less than $30,000.
But both will give retrograde ejaculation. So there is no escape.
Two published studies given below compare SRP To HoLEP in details.
(I) Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis
Patrick Jones, Laith Alzweri, ..., and Omar M. Aboumarzouk
Results
In all, 310 articles were identified and after screening abstracts (114) and full manuscripts (14), three randomised studies (263 patients) were included, which met our pre-defined inclusion criteria. All these compared HoLEP with OP. The mean transrectal ultrasonography (TRUS) volume was 113.9 mL in the HoLEP group and 119.4 mL in the OP group. There was no statistically significant difference in Qmax, PVR, IPSS and QoL at 12 and 24 months between the two interventions. OP was associated with a significantly shorter operative time and greater tissue retrieved . However, with HoLEP there was significantly less blood loss , patients had a shorter hospital stay , and were catheterised for significantly fewer hours . There were no significant differences in the total number of complications recorded amongst HoLEP and OP.
Complications
There were no significant differences in the total number of complications recorded amongst HoLEP and OP. The commonest Clavien–Dindo Grade I complication in the HoLEP group was dysuria (27.7%) and in the OP group it was transitory urge incontinence (23.2%) (Table 4). In the sub-analysis of complications according to Clavien–Dindo Grade, the only statistically significant difference was seen amongst Grade II complications, where the results of the meta-analysis favoured HoLEP. For Grade I complications, the results favoured OP; however, this was not statistically significant. For Grade III, IV and V complications, the trend in results favoured HoLEP, but again this superiority was not statistically significant. There was one death in the OP group, with none in the HoLEP group.
Discussion
The results of the present meta-analysis suggest that HoLEP and OP possess similar overall efficacy profiles for both objective and subjective disease status outcome measures. The present review shows these improvements persist to at least the 24-month follow-up point. However, in the perioperative period, patients undergoing HoLEP spend significantly fewer hours in hospital and are catheterised for a significantly shorter period.
Efficacy and safety
While OP retrieves greater tissue volumes and carries the advantage of a shorter operative time, it is associated with a significantly greater drop in haemoglobin. Elshal et al. reported that 24.5% of patients had required a blood transfusion after OP in a retrospective analysis of 163 patients at their institution. Such are the haemostatic advantages associated with HoLEP, Tyson et al. [18] determined it to be a safe alternative to TURP for patients on oral anticoagulation therapy.
(II) Holmium laser enucleation versus open prostatectomy for large volume benign prostatic hyperplasia: a meta-analysis of the therapeutic effect and safety].
Article in Chinese
Chen H1, Tang P, Ou R, Deng X, Xie K.
OBJECTIVE:
To compare holmium laser enucleation (HoLEP) versus open prostatectomy (OP) for large volume benign prostatic hyperplasia.
METHODS:
The randomized controlled trials (RCTs) pertaining to HoLEP and OP for management of large volume benign prostatic hyperplasia were retrieved from Medline and Embase. Meta-analysis was performed using Review Manager 5.0 software.
RESULTS:
Three RCTs were included in the analysis. No significant differences were found in IPSS or Qmax between HoLEP and OP. Compared with OP, HoLEP was associated with significantly less blood loss, a shorter catheterization time and a shorter hospital stay, but a longer operating time. HoLEP and OP were similar in terms of urethral stricture, stress incontinence, transfusion requirement and the rate of reintervention.
CONCLUSION:
HoLEP and OP have similar therapeutic effects in the management of large volume benign prostatic hyperplasia. Although with a longer operating time and less resected tissue, HoLEP causes less blood loss and requires a shorter catheterization time and a shorter hospital stay. HoLEP has a comparable safety to OP in terms of the adverse events.
1) how many paper underwear reinforced with guard should I bring to the hospital and for a 3 hour trip from hospital to home? Obviously, don’t want to overload my backpack. Talked to the hospital, it will not provide any pad or underwear. It is my responsibility for supply.
2) how much water I have to drink to continue flashing the bladder during a 3 hr trip to home?
Do I need to bring some bottle water?
3 ) during trip home, do I need frequent access to toilet to change paper underwear?
4) I can go home either by train or by car. Which one is the best? Train is preferred as it will be rush hours both in the city and on interstate highway.
5) I am scheduled to stay in the hospital for 23hours after holep. Can I convince the hospital to discharge me without a family member showing up? The train station is only a 4minutes walk from the hospital. If I am able to walk 24hr after holep and capable to ride a train, don’t see the necessity to drag another person along if she is needed only for formality.
6) a hospital staff told me that the catheter is typically stay on for two days after holep. But the surgeon told me that because I am “out of town”, he will remove the catheter before I am discharge from the hospital that is in 23hrs after holep. Medically, is there a downside for removing the catheter in one day instead of the typical two days? How to judge when it is safe to remove the catheter? What is the consequence of removing it too soon and later a problem occurs?
7) I am only a 2-3 hr train ride including a transfer from the hospital or the doctor’s office. Is there any medical necessity that after hospital discharge , I stay in a hotel near the hospital? I do not mind the inconvenience of traveling, just want to know if it is medically necesssary.
8) while I stay in the hospital, could I take ambien and go to sleep or I have to be awake all the time so that the nurse can continuously flash the bladder?
9) where can I find a video with good instructions for Kegels?
10) did I miss anything?
I did not bring my own underwear but used the hospital provided. I will give my best guess.
1 First be careful about your fluid intake postop.
I was an hour and a half from the hospital. I would suggest that you take two guards and to pair of underwear that should give you a backup.
2 don’t bring a lot of water. You will be well flushed with the catheter that sends water into you during your hospitalization. The catheter is large so don’t be surprised if it is uncomfortable. It too me from about 1pm to about 8pm to get comfortable.
3 I was comfortable on the way home and did not require a stop but I was not drinking any fluids on the way.
4 Seating is important you will be very tender in the pernium area. I could not sit comfortably on a hard surface for a week or more.
5 I can’t really advise you on this as my wife was there to drive me home. Remember you will have a weight limit that is imposed by the doctor. Personally I would like to have an adult there.
6 there will be a lot of swelling so it is possible that the urethra would be close by the swelling. If it does happen be prepared to get to an ER. I don’t know of anyone that has such an experience. I only stayed overnight. The nurses came in at 4am on the day after the surgery and removed the catheter. I had to urinate twice before they would let me go.
7 I can’t think of any thing.
8 the use of drugs is strictly controlled so check with the doctor’s office. I was not allowed to take my blood pressure meds. As for the flushing there is a bag that is filled with fluid that simply uses gravity to send fluid into your bladder through your catheter and a second tube that comes out into a urine bag. The staff will look for small tissue particles that may not have been removed during the morcellation. The urine will be discolored with blood but that will go on for several days.
9 I need to go through my notes but start by searching “kegels” on YouTube.
10 As always you are very complete.
What is your surgery date?
For better results search “kegels for men” on YouTube.
Samples
youtu.be/HKNQx5EXHOU
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I have a document on the subject that I will scan and pm.
1) Since your stay will be much shorter than mine, I'd bring about 10 shields (just to be safe) and 3-5 underwear. I had a 3 hour drive home and as Buster suggested I wore the pants and a shield together and that is all I needed BUT I spent the previous night in a hotel which gave time for my incontinence to settle some so if I were you, I'd be prepared with an extra set or 2 of pants/shield for the trip home just in case. Dr Das advised me to stop and urinate every 2 hours max (I made 1 stop in a 3 hour drive).
2) I was advised to drink normally. They did not want me over-drinking. I'd think you can make a 3 hour trip with no drinking at all but Dr Das and/or his intern/staff will advise you accordingly.
3 ) Per #1, unless your leaking a lot you should not need to change, just be ready in case you do. Those pants and shields can hold a lot of urine, you'd be surprised.
4) Well I'd prefer car for privacy but if you can sit on a train near a restroom in case you have to change that'd be your best bet.
5) I don't think so, but you'll need to discuss this ahead of time to be certain, don't leave it to chance. Darlene his nurse practitioner may be able to help there. If there is any way you can have someone accompany you that is best.
6) My situation is probably much different than yours due to the size of my prostate and the duration of my procedure. My catheter stayed in for 3 days "to help things heal" per Dr Das so I can only surmise he does not think you will need that same length of time.
7) I stayed at a hotel for my convenience only and for the length of time I had to be in Philly (from DC). Don't see any medical necessity for this but the more walking you do, the more chance you will leak DL so bear that in mind. Less activity = less leaking, more activity = more leaking.
8) As Buster said they will monitor drugs very closely. You don't need to be awake for the flushing (It's all done with a 2-way catheter, they just check the color of the urine, look for chunks, and change the bags every 3 hours or so) but I think they want to make sure your conscious when they come in and take BP, temperature (for possible infection signs) etc. so I doubt ambien will be an option,
9) I'll defer to Buster's reply.
10) If I think of anything else, I'll post again but this is pretty thorough. If you have any other questions don't hesitate.
I really didn’t get much sleep between my roommate’s cpap machine and the typical poking and prodding. The main thing I remember was how uncomfortable the two way catheter was.
The document may be proprietary so I will pm it.