Prostate and Bladder Issues: What to do?

I see now how it’s done! 🙂

Thank you for your help. I’ll ask you a few questions if you don’t mind? I’ll give you a brief status on my condition. I’m 3 months away from70 years old. At this point, no cancer has been found in my prostate with an MRI. My Prostate is estimated to be about 77 g in size. I’ve had 3 laparoscopic surgeries in the past on my abdomen.

How long were you in the hospital following HOLEP?
How long did you have to have a catheter in for?
Was recovery painful?
Did you experience incontinence!
Was there significant improvement in urination?
Was it difficult to get out and about within the first three months?
Did you lose the ability to have an erection?
Did you lose the ability to ejaculate?

I appreciate your thoughts and for taking the time to respond!

My experience with HoLEP has been very positive. I had it done by Dr. Amy Krambeck at Northwestern Memorial Hospital in Chicago. She has done over 3000 HoLEPs. My research told me that is what you want--someone who has done a lot of them. To answer your questions:
I was not in hospital overnight--it was day surgery at the hospital. I got out after a few hours in recovery. The catheter was removed in the recovery room that same day. There was almost no pain in recovery. I had only a little incontinence to begin with, and now almost none. My urination is much better after many years of struggling to urinate. When I urinate now I usually have a strong stream and seem to empty much better than before. I had no problem with getting out and about after the surgery. Actually was walking around Chicago the day after the surgery--probably too much activity that soon, but went just fine. Regarding sex, no problem getting an erection. Regarding ejaculation, I do ejaculate, but it is retrograde ejaculation--no sperm/seminal fluid comes out of my penis. I believe that is because the connection is cut when you have the HoLEP. So you do ejaculate but it goes into your bladder, I think. However, you do experience an orgasm just as before with great pleasure. I believe retrograde ejaculation results from every HoLEP.

A few addition thoughts: I needed a HoLEP due to medical necessity since at that point, in 8/21 I could not urinate at all and so it was covered by insurance. That was because I essentially went into acute renal failure due to urine retention. I only found this out as I was sick and went in for testing. I have ready that this often happens as very little symptoms of kidney failure, sometimes. Had my wife not insisted I go to the doctor, who knows how much damage my kidneys would have suffered. The urine backed up into my kidneys. I had urinating issues for years due to a very large prostrate--130 mgs at the time of the HoLEP--but no one ever warned or monitored whether I was retaining urine or the possible consequences for my kidneys. So important that you ask about this to avoid this issue. I wish I had been having bladder scans during those years which would have perhaps avoided my crisis but no one ever ordered one or warned me of this danger. I now have stage 3b chronic kidney disease due to the original problem in 8/21. I am okay but my kidneys will never be the same.

These are just my personal experiences, others may have had more complications from the HoLEP. There is a lot of info on the web about this, so do your research. All I know is from what I found there and then my own results of the procedure. Best of luck!

Thank you so much for the time and effort you invested to answer my questions, I am so very grateful! Your reply is informative and helps me prepare for what’s ahead. Have a great day friend!

Thank you Paul! Thanks especially for the detail that you experienced not seen in doctors' explanations.
I would like to see others experiences - good and bad - of the various treatments for BPH. We need to be informed with the knowledge necessary when asking questions of our Urologist.

Thank you Paul for your informative post, I know it will help many of us. And yes, hearing from others and keeping this discussion going is just what we need for our bodies and minds as our condition will do a number on your mind and quality of life.

I for one have at latest count a 125 g prostate. I have been considering doing the Aquablation procedure, but at this point I seem to be ok since I went on a 95% plant based diet 9 months ago except for some fish a few times a week. I also take tamsulosin. Not completely emptying is something that happens to me at times at varying amounts from 2-6 ounces, and Paul’s post tells me to be more aware. Thank you for that.

I just wanted to point out that the first Urologist I visited said that he recommended the Rezum Procedure (steam injected into the prostate). A 2nd opinion Urologist (who performs several methods of Prostate surgery but not HOLEP) took one look at the photograph I had of the inside of my bladder showing the large bulge into my bladder from the middle lobe of my enlarged prostate….he said there is only one operation for you and that’s HOLEP. In light of my two previous Laparoscopic Colon Surgeries, and a Bi-Lateral laparoscopic hernia surgery, the Rezum procedure would not address the lobe bulging into the bladder, and that isn’t a good thing. HOLEP is my only option, but hearing another Urologist confirm this was very encouraging for me. I have an appointment with a Mayo Clinic Urologist next month and I am hopeful that he will agree to proceed with this procedure.

Hi. I have 2 or 3 posts relating my experience in a different but similar Mayo Connect thread called "Benign prostatic hyperplasia (BPH) Surgery Options". I had BipolEP (Bipolar Enucleation of the Prostate) done at the Mayo Clinic Rochester early in January 2022, so I thought I would update my experience since kayak461 seems to be in a very similar condition as I was.

Part I

Ok, some background on me. Like kayak, I am 69 years old and will be 70 in a couple of months. I have had known BPH for at least 20 years. All the doctors I have seen along the way always said, "Let me know when the symptoms get annoying enough and we will schedule you for surgery." The symptoms progress slowly and nobody ever really wants to have surgery, so we all accommodate and figure out strategies to deal with our issues and keep putting off the surgery until suddenly we can't empty our bladders. About 6 months ago, I started feeling like I was not emptying my bladder when I urinated. I live in a rural area and asked my general practitioner doctor for a referral to a urologist, which took several weeks to get. The day of my appointment, they told me to pee first and then immediately after, they did an ultrasound scan of my bladder to see if I had any Post Void Residual (PVR). The scan estimated that I was retaining 670ml of urine which surprised me at the time because I had no urgency or feeling that I needed to pee. The doctor told me that this is not good, that I was stretching out my bladder, backing up urine into my kidneys and that I needed to get this taken care of sooner rather than later. That was the first time any doctor had even suggested to me that now was the time to have surgery. He scheduled me for a follow up visit a couple of weeks later to do a cystoscopy... a tiny camera on a tube that they stick up your urethra and gives the doctor (and you) a real time view of what is going on inside your urinary track all the way up to and inside of your bladder. I have to say, I was apprehensive about having this done. But it wasn't nearly as bad as it sounds. I have had dental work done that was much more painful and took much longer. The cystoscopy took maybe 2 and a half minutes total. They use lidocaine to reduce some of the pain. The toughest part for me was when he pushed through my sphincter muscle which my doctor told me to expect as he was doing it, and it only lasted a few seconds. My prostate was quite enlarged and the urinary track through my prostate was fairly blocked so the doctor told me he was feeling quite a bit of resistance through there. But apparently there aren't many nerve endings inside the prostate because I didn't feel any "pain" as he went through there, just a general, slightly uncomfortable sensation that there was something in there. Once through the prostate, he then pushed the cystoscope up into my bladder. He was able to bend the camera around and view my bladder neck where the cystoscope had entered my bladder. That was when he saw that I had a large median lobe of prostate material protruding into my bladder. It looked to be about the size of a walnut and you could tell that if the cystoscope had not been there, the median lobe would have been directly over my bladder outlet acting as a ball valve and blocking the flow of urine out of my bladder. The doctor was watching all of this on a large monitor that he positioned so I could also see it and narrating what he was seeing in real time. I asked before hand if he would be recording it and he said he was not able to record it, but suggested that I could record it with my cell phone if I wanted to. So I did and I was surprised how well the recording came out. It was very helpful to have that recording when I later got second opinions and searched for a surgeon who could do HoLEP or BipolEP. As the saying goes, "one picture paints a thousand words". It was a real "ah ha!" moment for me... the moment I saw the median lobe on the monitor. I knew that I needed to have surgery to correct this issue. So men, if you are having serious issues trying to pee, as they say in all of the drug commercials... "ask your doctor if a cystoscope is right for you", haha. It really is the most definitive way for your doctor (and you) to see what is really going on inside of you. I also had a TRUS (TransRectalUltraSound) done during that appointment. It is a more accurate way to measure the size of your prostate, more accurate than a digital rectal exam. The TRUS estimated my prostate size at 90ml. I've noticed that some prostate size reports will use "ml" while others use "cc" or "grams". I am not sure, but I think all of those units of measurement are interchangeable.

Part 2

The urologist who did the cystoscopy only does traditional TURP surgery, so I got a referral to a large university hospital's urology department hoping they would be able to perform HoLEP or Rezum. On my first visit to the university, I was in extreme bladder retention with a PVR of over 1,000ml and I ended up leaving that appointment with a foley catheter installed. Not fun! Unfortunately I also learned that they do not have the equipment to do either HoLEP or Rezum and the doctor I was dealing with did not know of anyone in my area who does. The university urologist wanted to schedule me for a robotic simple prostatectomy which entails making 4 incisions in the outer abdomen wall and then cutting into the bladder in order to robotically remove the median lobe in my bladder and then continuing down through the bladder outlet into my prostate to hollow it out. Obviously that is a much more invasive surgery than HoLEP or BipolEP. So I asked if I could continue to search for another urologist who does HoLEP or something less invasive and he said "of course". I found a doctor who does HoLEP, but his earliest appointment for a first visit was in February 2022 with surgeries scheduled out 6 weeks later, which puts me out to late March approaching April. My GP doctor does not recommend being on a foley catheter long term while I wait to see other urologists and I personally wanted to get off the catheter as soon as possible, but I was not interested in having a surgery that cut through my abdomen wall when there are transurethral procedures that can be done much less invasively. So I circled back to the Mayo Clinic and called the urology department and ask simply, "how soon could you schedule me for HoLEP surgery?" The person I spoke with was excellent (like everyone at the Mayo Clinic). She said she would check into it and someone would call me. I got a call from a urology resident doctor the next day who confirmed details of my situation with me and gave me some additional information. This doctor told me that Mayo Clinic had moved their HoLEP equipment from Rochester to a satellite hospital in Mankato and replaced it with BipolEP equipment. The resident doctor said she would find out when I could be scheduled for either HoLEP or BipolEP and someone would call me again. It is my understanding that HoLEP and BipolEP are similar in that they both use a high temperature cutting tool that cauterizes as it cuts and therefore reduces the risk of bleeding. HoLEP uses a holmium laser while BiPEP uses electricity to achieve the high temp, at least that is my understanding of it. (I am NOT a doctor!) The next evening I got a call from a Mayo Clinic urology surgeon. After again verifying some of the details of my situation, he told me he had an opening for BipolEP surgery in Rochester, MN on January 5, 2022. I told him to sign me up! He said he would and that his staff would set up a video teleconference call for us a few days later, which we did. In that video call I was able to show the surgeon the video I recorded of my cystoscopy which he said he could see clearly.

Part 3

I live more than 1,000 miles from Rochester, MN. I flew there on Jan 3, had a required Covid PCR test on Jan 4 and then reported at 5:45am on Jan 5 for surgery. All of the Mayo Clinic doctors, nurses and staff that I encountered were excellent. They are all so professional and pleasant. They really are a fantastic organization. The surgery went well, pretty much as planned. The doctor had estimated before hand it would take about an hour and a half. He told me after the surgery that it actually took 2 hours because my prostate was "larger than advertised". The TRUS had estimated it at 90ml back in October, but the surgeon said he actually pulled out 120grams of material which took a little longer than estimated. I had a catheter in after surgery. This catheter had an additional tube that allows them to irrigate your bladder. It slowly inputs sterile solution to your bladder to flush out any residual prostate material, blood clots, etc. I had no real pain to speak of after the surgery, just a bit of a dull ache in that area. I was in the hospital over night and in that time I was given a 500mg acetaminophen two different times which handle the discomfort just fine. I could see that there was quite a bit of red (blood) in my urine which they told me was normal and expected. The urology department sent somebody to my room every two hours it seemed to examine the output in the catheter collector. They told me each time that it looked fine. A nurse removed the catheter about 9:00 the next morning and told me that as soon as I was able to pee on my own, that I could be discharged. About 30 minutes later I pee'd the best pee I had pee'd in a long, long time! I was amazed and very pleased! To be clear, my urine was quite red still at that point, but they explained to me that "red" was okay as long as it is "clear". In other words, as long as you can see through it and there aren't lots of clots or particles blocking the view through the urine. They also said it should improve slowly over time and that it could take up to two weeks for it to be completely gone. There was a little bit of a burning when I started and stopped urinating, but it was very tolerable and subsided in a few days. Other than feeling tired, I felt good when I left the hospital. I went back to my hotel less than 3 blocks from the hospital and rested and recuperated for the rest of that day and then all day the next day, before flying back home 3 days after the surgery. It has now been about 6 weeks since I had the surgery and I am feeling great, totally back to normal... and better than I have felt in many years with regard to urinating.