We ended the last installment with a Fusion MRI prostate biopsy to rule out any cancer, noted by a slow but steady increase in PSA, prostate-specific antigen, a protein made by the prostate that can be an indication of prostate cancer. This is an outpatient procedure that takes a few hours from start to finish, with mild sedation and a brief post-procedure recovery.
That study was negative, which in medical-speak, is a good thing, as it means nothing was found to get excited about, other than the fact that I just had a large prostate, which wasn’t too surprising based on the symptoms I’d been managing for some time. I continued to do reasonably well, meaning I was having some symptoms of urgency, but nothing I couldn’t deal with, and my quarterly visits to the urologist were basically just to monitor my I-PSS, the International Prostate Symptom Score, a subjective questionnaire used to determine the level of dissatisfaction with qualify of life with BPH. I was doing well enough that I wasn’t really interested in doing anything more aggressive than the Terazosin, which was still working “OK,” although the efficacy was beginning to wane just a bit. However, I knew that sooner or later I would have to make a decision, so I began to research different treatment modalities, and there are numerous options, I discovered.
The gold standard for treatment of BPH is the TURP, Transurethal Resection of the Prostate, which has been around for decades and hasn’t really changed that much over the years. A cutting instrument called a resectoscope that is lighted and has a camera is inserted into the urethra and the surgeon can visualize the prostate and the surrounding anatomy to carve out small pieces of the prostate and evacuate the excised tissue through the scope.
TUMT, transurethral microwave thermotherapy, uses microwave energy to reduce prostate tissue volume to relieve pressure on the urethra to increase urine flow. High-energy laser therapy marketed as GreenLight Therapy also removes overgrown prostate tissue and is suitable for some cases where the prostate is not extremely large. There are also water vapor treatment options that convert water to steam that breaks down the prostate tissue.
Open surgery is also an option for very large prostates, but it is an invasive procedure that requires hospitalization and there is a higher risk of blood loss. Back in my days as an OR Surgical Technician, I assisted with a number of these procedures, and they were brutal, to say the least! Fortunately, that option isn’t done that much now.
In my online research, I discovered a newer and less well-known non-invasive technique that showed promise, Prostate Artery Embolization, performed by an interventional radiologist in the cath lab. I was intrigued by this technique, which involves a radial or femoral artery catheterization and use of a tiny catheter that is threaded from the artery, up and through the aorta, then down through the iliac vessels to the prostatic artery that supplies blood to the prostate gland using guided computer tomography angiography (CTA). When the radiologist identifies the tiny prostatic artery, the embolization, the disruption of the blood supply to the prostate, is accomplished by injecting extremely tiny (100-300 microns) gelatin or silicon beads, called “microspheres,” into the artery to impede the prostate blood supply while not completely stopping it. Over the next few weeks, the prostate gland begins to “atrophy” or shrink in size, relieving the compression of the urethra and reestablishing normal urine flow.
I’m far from an early adopter in most things, but the concept fascinated me, and I traveled to Christiana Hospital in Delaware for a consultation and was found to be a good candidate for the procedure. Unfortunately, my health insurance didn’t recognize the feasibility of the procedure and denied coverage, which was a disappointment. Just for grins, I inquired what my cost would be if I paid out of pocket for the procedure. I was shocked, but not too shocked, to be told the cost to me would be $169,000! That narrowed down my options to what my health insurance recognizes as “efficacious, and medically prudent” treatment options.
Five months later, things changed as I reached “critical mass” and my urethra became obstructed totally and I had to begin self-catheterizing, a humbling experience in itself, so it was decision time.
On my next follow-up with the urologist, we had an earnest discussion about treatment options, and TURP, the procedure I least wanted to have, became the best option. Five weeks later, in April, I was wheeled into the operative suite, the lights went out, and I woke up three hours later with a Foley catheter in place. Following discharge from the Post-Anesthesia Care Unit, I spent the weekend with the Foley until Monday, when I had the pleasure of deflating the balloon and untethering from the rubber device that had been the source of my brief love/hate relationship.
As explained in the post-op instructions, I had a moderate amount of bloody urine for a week or so post-op, but I was peeing normally, and that was and is a wonderful experience! After about five weeks, I feel fully recovered. There was little if any pain post-op, and once the catheter came out, the recovery was almost a non-event. I had some fatigue for a couple of weeks, probably more from the anesthesia effects, but looking back, my apprehension was overly dramatic. I understand now why TURP is still the gold standard for most cases of BPH.
As far as medical certification is concerned, for a TURP or other prostate procedure, a status note from the urologist at the time of your next FAA medical exam should allow your AME to issue a medical certificate if you are otherwise qualified.
