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Medical Forum / Diseases and Disorders / Prostate BPH / January 2006Question for DR. SANCHEZ
First, thank you for your recent posts. I checked your Blog and want to say that I am glad you are responding to this newgroup. Thanks. Curiosity question: how many PVPs can one have in a lifetime and how often does one need to to a PVP? What can you add to this newsgroup about DHT levels? My DHT was extrememly high: 2,700 units when normal high was 700 units. (I do not recall what the unit measurement is.) Thanks in advance. Spread, I had my first DHT and PSA tests one month ago agfer my 3-month-old PVP. My DHT is 22 of reference range of 25-75 ng/dL done by Quest Diagnostics Inc. and PAS is 1.9 of reference range of 0.00-4.00 NG/ML. BTW, thanks for your efforts for this NG. >First, thank you for your recent posts. I checked your Blog and want to say >that I am glad you are responding to this newgroup. Thanks. [quoted text clipped - 5 lines] > >Thanks in advance. Dr. Sancha, if you search Spread's recent posts, you will find that he has been doing a lot of reasearch about what can we do after done with PVP to control the ongoing growth of our prostate instead of taking Avodart or Proscar which my uro has requested me to take after my pvp months ago. Should we take Zinc Sulfate, soy isoflavins, vitamin,...etc.? What can we do? Or waiting for the second pvp in years? Thanks in advance too. There is no theoretical limitation to the number of PVPs one could have in his life. The reoperation rate after TURP can be as high as 15% after 5 years. This includes reoperations for urethral stricture, bladder neck strictures, prostate regrowth, residual apical masses (when the operation was not performed correctly), incontinence, etc... PVP has a much lower incidence of these secondary effects, the 5 year data from the Mayo clinic showed that only two patients needed an office baloon dilatation of a soft bladder neck contracture and no patient was reoperated in five years. I had to reoperate some patients, but mainly during my learning curve, for bladder neck stricture, residual obstructive mass, and as a second stage in a very big prostate. So I guess if you have a 60-70 gram prostate and the PVP was aggressive enough, the chance of needing a reoperation should be small, or it would be many many years after a first PVP. If the prostate was very big, the biological behaviour of these prostates is to keep on growing, and although tissue removal with PVP is very good in small (60-70 g) prostates, it is impossible to remove all BPH tissue in big ones. I operated a 200 gram prostate, and residual volume after 4 hours of surgery was about 100 grams, so there were roughly 80 grams of BPH tissue left. The clinical result was excelent (good flow, good quality of life postop). My bet is that the reoperation rate will be higher in bigger prostates. But again, it all depends on many factors. For instance, removing a very obstructive median lobe could mean that the median lobe will never grow again, and thus, maybe the patient will never need surgery again. As someone posted here before, size and obstruction are not always related. I have seen patients with 200 gram prostates void reasonably well. I have operated more than 40 patients with prostates larger than 100 grams, with a follow up up to 2 and a half years I only reoperated one as a second stage. Conclusion: PVP reoperation rates are probably lower than TURP if performed correctly, we do not know what will happen with big prostates, probably the reoperation rate will be higher because removal of tissue is not as radical as in smaller ones. We know from the past that residual BPH tissue can keep on growing. PD: I have seen patients die after open prostatectomies... so If I had to operate my father, who has a 110 gram prostate, no doubt I would recommend him to choose PVP, he is 70, sexually active and if this would buy him better quality of life for some years and he ended up needing a reoperation in 8 years, that would not be a big deal, would it? a visit to theatre, a low risk op, and a relatively nice and easy postop. Regarding DHT, the prostate grows stimulated by DHT, the active form of testosterone. The only growth retarding strategy I am aware of is proscar and avidart, apart from other forms of medical or surgical castration (eunuchs and castrati singers never develop BPH) but i will see if I find something of interest. If you saw my blog, you will see I am rather busy, but I will keep it in mind. All the best, Fernando Gómez Sancha http://drgomezsancha2.blogspot.com > There is no theoretical limitation to the number of PVPs one could > have in his life. [quoted text clipped - 6 lines] > dilatation of a soft bladder neck contracture and no patient was > reoperated in five years. Dr. Sancha...Can you tell us why you think the PVP has a lower reoperation rate than the TURP (perhaps it is too early to really know for sure). Could it be due to the possibility that the TURP is more aggressive and caustic to the tissue, and therefore may be more likely to produce more scar tissue. I want to thank you again for joining the group and I hope you will stay with us. I know you are a busy man, but it is very much appreciated by all of us, and very refreshing to see a doctor who cares enough to volunteer his time in a newsgroup. I have bad mouthed many doctors in my life (been to over 75, and I don't like most of them), but I can truly see that you are a good, kind and caring doctor, which is certainly lacking in this capitalistic world. We need more doctors who care about the patient and are able to talk to the patient in a friendly manner and not just be a chart to them. I wish you could be my urologist. Thank you so much...Pete I had to reoperate some patients, but mainly > during my learning curve, for bladder neck stricture, residual > obstructive mass, and as a second stage in a very big prostate. [quoted text clipped - 41 lines] > Fernando Gómez Sancha > http://drgomezsancha2.blogspot.com Pete, Thanks for your nice mail. It is too soon to know for sure what the reoperation rate of PVP is, but my guess is that it is lower because less patients will need reoperations for urethral stricture, incontinence, bleeding, and other causes of reoperation that happen more frequently with TURP than with PVP. You must also have into account that PVP is still a relatively young technique. There is no international consensus on how much energy should be applied per gram of prostate, how aggressive one has to be, how the surgical technique must be applied (starting at the middle lobe or the bladder neck, starting at 12.00 o'clock....). When TURP started to be used, the morbidity of the operation was much higher, and with international experience, the technique has been standardiced and now morbidity of TURP is lower than initally reported. It takes some time to really learn from experience what strategies have best results. This summer I went to India to train a group of urologists, they had done in excess of 5000 TURPs, now they are offering PVP, and probably they have done 30 by now. Also, the clinical studies comparing TURP and PVP compare the procedures done by and expert TURP surgeon and a novice PVP surgeon. Still, results of PVP in terms of morbidity are much better.... What I see daily is that the endoscopic result of PVP in prostates less than 70 grams (the size and shape of the prostatic cavity) is similar or better with PVP than with TURP, patients recover much earlier, and complications are minimal.... My gut feeling is that the results and reoperation rate with PVP in this group of patients will be better than TURP. We will need to see what happens with bigger prostates in terms of need of reoperation due to prostate regrowth. Apparently PVP causes less scarring than TURP, and that leaves a more flexible and less restrictive prostatic cavity, but this will have to be confirmed with further studies. Fernando Gómez Sancha http://drgomezsancha2.blogspot.com Dr. Sancha...thank you so much again. I would like to explain some of my problems but it would take too long, and I certainly would not expect you to diagnose me (which of course I know you can not do over the Internet, either legally or ethically). But I can tell you are a top notch physician who cares about your patients. Perhaps I will write something about my problem(s) in the future, and maybe you can offer some alternatives without going into diagnoses. I really enjoy reading your posts and haven't seen anything near as good since the doctor participation in the 1997 prostatitis newsgroup which has gone down hill, and is now almost extinct except for spammers and trollers. This group is much better, and is now even better yet with your kind inputs. I have been trying to impress [a little bit :-)] on this group the possible relationship (or crossover if you will) of BPH and prostatitis, and most recently the studies revealing the evidence of non bacterial prostatitis and interstitial cystitis being part of a "continuum" so to speak. My problems are more "itis" related than BPH, but there is a relationship I believe (my prostate is not large). Anti's and massages do not help my problems. I have urge, and a lot of CPPS if you wish - its non stop and one of the worst eating/gnawing/burning feeling type feelings you can imagine. It is hard to describe, and difficult to deal with, especially living by myself. I just had a TURP in April of this year (mainly to correct scar tissue from a previous TUIP in 1995). The uro wasn't supposed to do a TURP, but did one after I was asleep - it was on the consent form, as you may know, :-) . He said he just connected the dots from the previous TUIP cuts, and took out very little of my prostate - approx 5-10%. Bottom line is the TURP just exacerbated my prostatitis/urethritis/cystitis. I do not have diagnosed IC by cysto. I can void better during the day (after drinking a lot), but have difficulty later in day and all night (I believe it is some kind of inflammatory response), but I am not retaining. It's more complicated than that, and I didn't mean to get into it here, sorry. I live in misery and have other medical problems that are related to this in my opinion, and I can not get any doctors to help me, and going out of town to a tertiary care center (Baltimore, MD) is not an option because I don't have any one to help me. Have been to both John Hopkins and Univ of MD for non uro stuff in the past, with nothing to show for it. Thanks again, and I look forward to reading your posts in the future...Pete > Pete, > [quoted text clipped - 36 lines] > Fernando Gómez Sancha > http://drgomezsancha2.blogspot.com Pete, Sorry to read what you are going through. The truth is that we do not know much about pelvic pain and "chronic prostatitis". I must say that as a doctor it is usually frustrating to try to help patients with pain symptoms that do not respond to any strategy. We are at a loss. The typical patient has already visited a high number of urologists trying to find improvement without much success. I try to help them understand they suffer a chronic problem and to learn to live with it and to try strategies to improve at least a bit their situation. There is a world leader in this kind of problem, though, at the Department of Urology, Queen's University, Kingston, Ontario, Canada. jcn@post.queensu.ca, his name is Dr. Nickel, JC (for Curtis). You might want to visit them... or at least try to contact them to see if they could help you. This department is always researching on new diagnostic and therapeutic strategies and latest treatment options. Fernando Gómez Sancha http://drgomezsancha.blogspot.com Thank you Dr. Sancha...I can see you are on the same page with me (I am called a "problem patient" -which you were too kind to state). I have many problems and have bad malaise much of the time (I mean real bad - imagine the worst flu type symptoms - washed out feeling, achy all over, head is swimming, bad nausea, rectal discomfort, and it is damn close to intolerable). I believe I have some kind of virus that won't let go, and it is compounded by my uro problems. It is indeed systemic, and there is no doubt that it is related to my serious T-4 cell deficiency (non-hiv, cause unknown). I also have sarcoidosis, stomach problems, and enlarged lymph nodes and definitely believe I am at high risk for cancer (if I already don't have it) due to my T-4 cell deficiency. I appreciate your comment about Dr. Nickel in Ontario and have read some of his stuff (along with Dr. Lowell Parsons) on IC. There is no way I can travel to Canada, I can't even go to Baltimore MD which is 90 miles away (I told you I live by myself and don't have anyone to help me). I am a retired 58 year old engineer with good health insurance, but effectively I am no better off than the homeless person in the street, since I have no one to help me. When I do need a procedure its difficult at best, and like pulling teeth to get the one person I know to take me, and I have to pay her. Sorry I strayed with my personal problems. So I am stuck locally in western Maryland. If I needed major surgery, I don't know what would happen. As far as my CPPS type pain goes, it is hard to describe like I said (urge, eating, gnawing, burning, and a razorblade feeling from my bladder through my urethra when I tighten any muscles - e.g. cough, bend over, even walking sometimes). When I try to let out an additional amount of urine after already stopping it is like a plow effect (with the razorblades). It is terrible, but the worst is the constant feeling that I can not describe, plus it is transferring into my rectum also (pressure, pain, feeling of having to have a bowel movement). I use a heating pad on my belly/groin area much of the time to try and help get it off my mind. I believe it is an inflammatory response which could also be related to my immune deficiency. Can I ask you if you have any experience with inflammation (without infection) causing serious malaise (or any kind of malaise). I believe it can. I can get no help from any of my doctors on this. I am afraid to have another cysto right now (since it will just irritate me more) but I guess I will ask if I don't get better (all the uro's are in the same office and I am afraid they will abandon me). Maybe I need another look to see how the TURP from last April healed (do you agree). I have stopped my massages with the PA at the uro's office, and have quit the Elmiron that I asked for as a last resort (takes 3 months to a year to work, if it works - and I have not been diagnosed with IC). I took it 3 weeks and quit recently because I have been to sick (to see if that would help). I apologize to all for wandering from the original post...Pete > Pete, > [quoted text clipped - 16 lines] > Fernando Gómez Sancha > http://drgomezsancha.blogspot.com Dear Pete, We are used to see monotonous patients and symptoms all the time. 95% of our patients are straightforward and present with the most common complaints. They also respond to treatments in a fairly predictable ways. "Problem patients" as you say usually have different mechanisms of disease, and it is very probably that you have a general inflammatory response, as you suggest. Or that this relative immune deficiency condicionates your clinical problem. I would agree that a look inside with a cystoscopy might help to rule out problems that might cause or agravate your symptoms. How do you feel if you take antiinflammatory drugs? Fernando http://drgomezsancha.blogspot.com > Dear Pete, > [quoted text clipped - 8 lines] > might cause or agravate your symptoms. How do you feel if you take > antiinflammatory drugs? They don't help...plus I have stomach problems and can't risk taking them long term. I am screwed. I appreciate the time you have spent communicating with me...Pete > Fernando > http://drgomezsancha.blogspot.com Dr. Sancha, I e-mailed Dr. Nickel yesterday about PVP Clinics in western Canada. He responded quickly this morning and stated that the only clinic in western Canada (in Vancouver, British Columbia) had closed because of "poor results" !! His one-line response did not explain what he meant by "poor results". Perhaps, he meant that the clinic could not survive without making a lot of money ?? or because their PVP surgeries resulted in 'poor results' for the patients. I don't know what he meant and I hesitate to bother this busy expert in eastern Canada anymore. My own city (Edmonton, Alberta) has an eduated and well-to-do population of about 750,000 people, and NO PVP clinics ! Of course, in Canada we have national healthcare (run by the individual provinces). Each family in Alberta pays (if they are not indigent) approx $90/month for complete healthcare. I believe British Columbia also charges a similar modest amount per month. In any case, perhaps PVP operations cannot be sold to patients because they are run thru private healthcare providers. People in Canada expect *all* their healthcare costs to be paid by the provincial governments. Anyway, I'll have to keep looking for a PVP clinic somewhere ... -Mel Smith (currently in Mesa, Arizona for the winter) >Dr. Sancha, > [quoted text clipped - 12 lines] > My own city (Edmonton, Alberta) has an eduated and well-to-do population >of about 750,000 people, and NO PVP clinics ! Interesting that the Vancouver clinic has closed. Rather academic for me, actually, because when I contacted them about a year ago, they said they would not do a prostate over 60 g in size (and I'm around 150). There are two centers in Ontario that do PVP, and the procedure done there should be covered by Alberta Health Care. There is Dr. Baldwin in Scarborough, highly respected, but did not recommend PVP for me... he has had problems doing PVP on such large prostates. The second location in Ontario is north of Toronto somewhere. I have not contacted them. Ed Ed, Thanks for the further info. When I get back to Canada in early April, I'll contact them. Thanks again, -Mel Smith Ed, PVP can be performed in very large prostates like yours, but if you want to get a good clinical effect you have to be extremely aggresive. This means operating during three hours or more, using three fibres or even four, and delivering 600.000 to 800.000 Joules. I have had wonderful results in patients with big prostates with this approach (followed up for almost three years, their flow is better than mine!!). It is certainly much more expensive, as laser fibres are costly, and it is imperative that the surgeon has had extensive experience with big prostates. In some centers in Europe they prefer to do it in two stages. They do a first PVP and schedule a second stage two weeks later. I always advise my patients that a second stage might be necessary, but I am very aggresive in the first go, so it is very rare that a second stage is needed. I guess not very many surgeons are able to perform PVP in such big prostates nowadays. If someone claims he can do your prostate in half an hour with one fiber, you should not listen to him. Fernando Gómez Sancha http://drgomezsancha.blogspot.com Ed, >PVP can be performed in very large prostates like yours, but if you >want to get a good clinical effect you have to be extremely aggresive. [quoted text clipped - 9 lines] >necessary, but I am very aggresive in the first go, so it is very rare >that a second stage is needed. This probably explains why many have less than desirable results. In the U.S. Insurance companies and Medicare probably specify a fixed amount that they pay for a procedure regardless of how long it takes. I suspect that most or at least many doctors that receive their compensation in such a way, limit their procedure time and use one fibre. Many paitients probably take the results as "good enough". If not they go back for a second or third procedure. A retired physician told me that a friend of his was having PVP. When he woke up he became very upset. He found that the laser had broke and instead of stopping the procedure where they were they finished off with TURP. So when I go for a PVP and sign the wavier allowing TURP I will be certain to specify that it be only if medically necessary. I suppose they can always say it was medically necessary. > Ed, > [quoted text clipped - 19 lines] > fibre. Many paitients probably take the results as "good enough". > If not they go back for a second or third procedure. Rich...This is a good point. I would like to ask Dr. Sancha the following if he reads this. Do you charge by increments of time when you do your PVP's. I know that's how hospitals charge for use of the OR/ER in the U.S. And then there is the standard five levels of office visits, etc. If you do charge by increments of time, how do most of the insurance companies (in Spain) pay you. Is it a fixed amount like Rich suggested, or is it incremental. I would like to think that all the uro's who perform a PVP would do what was necessary to achieve a good result , and not short change the patient because the insurance companies only pay a fixed amount (which very well could be true). So if doctors are short changing the patient because of the "good old dollar", then that is a slam on the doc's, as far as I am concerned. Please tell me you don't do that Dr. Sancha. You said you were always aggressive (which takes more time)...Pete > A retired physician told me that a friend of his was having PVP. > When he woke up he became very upset. He found that the laser had [quoted text clipped - 3 lines] > medically necessary. I suppose they can always say it was medically > necessary. > > Ed, > > [quoted text clipped - 43 lines] > > medically necessary. I suppose they can always say it was medically > > necessary. Pete, I am a bit of a capitalist and I my opinion is that it is a more a slam on the insurance company. Just as those from other countries say their socialized medicine selects the cheapest method or that which is "good enough". I would not expect a doctor to work perhaps three times longer without extra compensation. And, you know for sure that the hospital isn't going to tie up their operating room for two hours extra without pay. That is unless the patient is unable to pay. Then they have to make up the difference on the next patient. But it might be something to bring up with the surgeon before he does a procedure. A TUMT always takes about the same time and Medicare has a flat rate the the doctor is required to accept if he wants to deal with Medicare patients. Then there are those doctors who will not accept Mediare payment. They will accept Medicare patients but the patient will have to pay the extra cost above what Medicare allows. I would not be surprised but what the HMOs that cover Medicare patients give the doctor even less. They charge the insured less and still make a profit. Doctors that accept medicare patients on a "non-participating" basis cannot charge more than 15% over the medicare approved amount. >> > Ed, >> > [quoted text clipped - 73 lines] > the HMOs that cover Medicare patients give the doctor even less. They > charge the insured less and still make a profit. Hmmm...I wonder what happens if they refused to accept the patient period (ie pay up front, or on a payment plan, or I am not going to be your doctor). I guess that is their perogative. I don't think medicare patients get any special consideration just because they are senior citizens :-) . > Doctors that accept medicare patients on a "non-participating" basis > cannot charge more than 15% over the medicare approved amount. [quoted text clipped - 74 lines] >> but what the HMOs that cover Medicare patients give the doctor even >> less. They charge the insured less and still make a profit. > Hmmm...I wonder what happens if they refused to accept the patient > period (ie pay up front, or on a payment plan, or I am not going to > be your doctor). I guess that is their perogative. I don't think > medicare patients get any special consideration just because they are > senior citizens :-) . Oooops. That's prerogative :-) . > > Hmmm...I wonder what happens if they refused to accept the patient > > period (ie pay up front, or on a payment plan, or I am not going to [quoted text clipped - 3 lines] > > Oooops. That's prerogative :-) . A couple years ago my family physician announced he would no longer accept Medicare assignments. He has more patients than he wants. The difference is not great so I have continued using him. His basic cost is not all that far from the Medicare assignment. I think perhaps less than 10%. Medicare pays 80% of what they assign. You or a supplemental policy pay the 20%. With supplemental insurance I pay the doctor less than $10 of a $100 fee. I will have to discuss with my URO what services he gives in a PVP. I still expect that he would go with the standard (one fiber?) treatment. If it is not "good enough" he will then perform a 2nd one and of course Medicare or Insurance would pay for that too. I will wager that they would not pay for a double session the first time. Well it could be worse. Some countries someone decides if you are worth a given treatment. If not, no doctor in the country is allowed to treat you even if you can pay. They say that would be giving special treatment to the rich for something that is supposed to be available for all. In those countries, those that can afford it go outside the country to get the treatments. Unless there is a possibility of making a profit companies like Laserscope are not going to do the necessary research to make their equipment's. It is a risky field and many endeavors fail. I was just following the progress of another company that had a promising new procedure. It failed and they went bankrupt. Investsors lost everything. Thanks Rich...see my in-line comments...Pete >>> Hmmm...I wonder what happens if they refused to accept the patient >>> period (ie pay up front, or on a payment plan, or I am not going to [quoted text clipped - 11 lines] > or a supplemental policy pay the 20%. With supplemental insurance I > pay the doctor less than $10 of a $100 fee. Rich...I see what you are saying here, but that is not really what I meant by refuses to accept the patient. You apparently mail the bill into Medicare and continue on from there, versus the 15% overage that "jay1000" mentioned in his post for doctors that accept Medicare on a "non participating" basis (and apparently the doc still mails in the paperwork to Medicare). What I meant was the non affluent person on Medicare who needs something more expensive (like surgery), and the doc won't see the poor bastard unless he pays up front in full or on a payment plan (i.e. the 15% rule jay1000 mentioned doesn't apply), and the patient can not afford to pay the difference. I guess we are kind of talking the same thing, except you can pay for your situation with little impact...Pete > I will have to discuss with my URO what services he gives in a PVP. > I still expect that he would go with the standard (one fiber?) [quoted text clipped - 8 lines] > available for all. In those countries, those that can afford it go > outside the country to get the treatments. Rich...this is interesting. Do you have an example of what countries, and what kind of procedures...Pete > Unless there is a possibility of making a profit companies like > Laserscope are not going to do the necessary research to make their > equipment's. It is a risky field and many endeavors fail. I was > just following the progress of another company that had a promising > new procedure. It failed and they went bankrupt. Investsors lost > everything. > > A couple years ago my family physician announced he would no longer > > accept Medicare assignments. He has more patients than he wants. [quoted text clipped - 10 lines] > participating" basis (and apparently the doc still mails in the paperwork to > Medicare). The Dr. does the mailing. Then Medicare pays their 80% share of the mediare allowable, my supplemental pays the other 20% and then the doctor sends me the bill for the 10% or whatever it is that he charges above the allowable. > What I meant was the non affluent person on Medicare who needs something > more expensive (like surgery), and the doc won't see the poor bastard unless > he pays up front in full or on a payment plan (i.e. the 15% rule jay1000 > mentioned doesn't apply), Some work only that way but I have found that most will accept Medicare. Those are not doctors I would be going to anyway. > > Well it could be worse. Some countries someone decides if you are > > worth a given treatment. If not, no doctor in the country is allowed [quoted text clipped - 5 lines] > Rich...this is interesting. Do you have an example of what countries, and > what kind of procedures...Pete Norway for example. I don't have proof but have been told the above. All medical care is free but they can turn you down. A doctor can opt out of medicare for a minimum of two years by filing an opt-out affidavid with medicare and having his medicare-eligible patients sign a contract that they will not file a claim with medicare. But the physician cannot accept any medicare patients during the two years, i.e., no "cherry-picking". There are exceptions for emergency treatments. > Thanks Rich...see my in-line comments...Pete > [quoted text clipped - 50 lines] >> new procedure. It failed and they went bankrupt. Investsors lost >> everything. > A doctor can opt out of medicare for a minimum of two years by filing an > opt-out affidavid with medicare and having his medicare-eligible patients > sign a contract that they will not file a claim with medicare. But the > physician cannot accept any medicare patients during the two years, i.e., no > "cherry-picking". There are exceptions for emergency treatments. When I have encountered the "the doctor is not accepting new Medicare patients", I wonder if he continues to see his previous ones. I can understand them wanting to do that if suddenly their practice is overloaded with Medicare people. It's a tough field and they should be rewarded for the long time they spend in preparation and that in just keeping up with the state of the art. The one time I was in the hospital for a week I saw my personal physician there early in the morning and late at night every single day. I had been put there by a specialist surgeon but the family doctor still came by every day making his "rounds". The field keeps getting more complicated with more medication and methods of treatment. Not like it was even 50 years ago when open heart surgery was an experimental thing. And 70 years ago there was not much a doctor could do about most illnesses. Pneumonia was most often fatal, polio was a horrible epidemic, all children usually had measles, chicken pox, whooping cough, etc. My question is how much can we expect from doctors under present conditions? Free enterprise results in more and more new innovations and cures. Socialized medicine seems to stagnate the treatments. Under it you get what is available as long as there is not a cheaper alternative. It seems to me that most countries have their free enterprise physicians that will give the newest treatment for a price whereas the public gets what is "good enough" and they wage complaints that they don't get the "good" stuff for free. I am "rambling". >> A doctor can opt out of medicare for a minimum of two years by >> filing an opt-out affidavid with medicare and having his [quoted text clipped - 33 lines] > > I am "rambling". Rich...you are not rambling. I understand and agree with what you are saying. I live in the U.S. which does not have socialized medicine (for other non U.S. readers in the ng), and that can be just as bad (I'm not saying socialized medicine is bad, but there are certainly pros and cons for each). Doctors will drop your insurance in the U.S. if the ins company's allowed rates are too low, and it becomes a damn vicious game that the patient gets caught it in the middle, like I said. And then there are the dreaded lawyers with the malpractice suits. My over all complaint is that there are too many doctors (except for our Dr. Sancha of course) that don't give a damn about the patient, and we are just a chart, and they don't have any personalities and won't call you by your first name (which they don't know anyway), and make you feel more comfortable when you are talking to them. They give you 10 minutes (that's becoming the standard appointment time these days), and start walking away from you before you're finished asking your questions, so they can see the next patient (incidentally patient scheduling should never be less than 15 minutes IMO - and I usually take longer than that). My old pulmo at my last residence used to schedule half hour appts. (he was a good person and a good doctor). Boy those days are gone. And there is no way you can talk to doctor on the phone anymore, with *very* rare exceptions, and then you get caught up in the miscommunication link between the receptionist and the nurse (who usually won't get on the phone either) and the doctor, and then back on down again (usually the nurse calls you on the way back down). You have read some of my bitches about doc's before. I know doctor's are busy people, but if they become so busy they lose sight of what is going on with the patient (or they don't care enough), then we are in trouble. Doctor's tend to gloss over stuff real quick and IMO miss stuff (did you ever watch how they scan through your chart while you are talking to them (kind of in a daze), like they are trying to figure out who you are. I don't believe they can be listening to you and scan your chart at the same time (I'm sure some people in the world can do that, but I don't think too many). Did you ever try getting all your records from a doctor (you should, or at least get copies of your lab tests and scan reports and procedure notes - most people don't care enough and are not into researching their conditions (like some of us), and they may have more straightforward problems that are easily solved. You would be amazed at all the things you will see in your records that are not things you said (they could have been misinterpreted of course) and all the mistakes the transcriptionist made in typing dosages and dosage instructions because she didn't interpret the dictation correctly (especially for "sound alike words"), or the doc dictated them wrong. I went to a bad pulmo previously for my sarcoidosis, and he kept blindly hand writing (no dictation) that my pulse/respiration were 72/18 (i.e. normal) each office visit, and I have tachycardia and my pulse is always over 100, especially in the doctor's office. In most cases the doc probably scans the transcriptionist's typing quickly, initials it, and in your dreaded chart it goes. I have seen statements in my records from my current uro's (both the PA and the surgeon) that made reference to doing an exam (e.g., abdominal exam is benign, no CVA tenderness, liver and spleen non palpable, etc.) when none was done (other than my digital massages from the PA). I confronted the PA on this very diplomatically and basically told him they never touched me except for my digital massages, and I thought I was going to lose them (there were also several misstatements about things I never said). We had a nice talk and the PA kind of weaseled out of the stuff. Perhaps they were mixing up my dictations with other patients - who knows - but it happened on three or four visits. You don't want to know about my misread catscans. I'm sorry, but I believe the docs are going to fast, and god knows how many surgeries may have turned out better if the surgeon might have taken a little more time (although I understand being quick is very important in many critical procedures, where time is of the essence). Sorry...now I am rambling (once again)...Pete > My over all complaint is that there are too many doctors (except for our Dr. > Sancha of course) that don't give a damn about the patient, and we are just [quoted text clipped - 5 lines] > next patient (incidentally patient scheduling should never be less than 15 > minutes IMO - and I usually take longer than that). This reminds me something told to me by a woman I know who works for Kaiser Medical. She said she was having lunch with one of their female doctors. The doctor broke down in tears because she was not allowed enought time to properly treat her patients. A few years ago I was visiting in my little home town in Minnesota (3500 people). My son got water in his ears when swimming so we went to the town Dr. We spent about a half hour just chatting. He like most small town doc's was a big wheel in town ("Let's ask the Doc about that!!). However, it will be difficult to get a URO who has done 100 or more PVPs to find time to stop and talk. He is in too much demand, patients backing up trying to get in and he has a lot of expensive equipment to pay off. But the guy down the street is more than willing to find time to give you a "roto-rooter job" (Good enough for my daddy, good enough for me). >> My over all complaint is that there are too many doctors (except for >> our Dr. Sancha of course) that don't give a damn about the patient, [quoted text clipped - 11 lines] > female doctors. The doctor broke down in tears because she was not > allowed enought time to properly treat her patients. God bless that doctor!!!! She sounds like she may even be nicer than Dr. Sancha :-). > A few years ago I was visiting in my little home town in Minnesota > (3500 people). My son got water in his ears when swimming so we went > to the town Dr. We spent about a half hour just chatting. He like > most small town doc's was a big wheel in town ("Let's ask the Doc > about that!!). Wow!! That almost sounds like Marcus Welby (the TV show in the 50's). I know the small town docs may have done that back in the 50's/60's, but apparently there are still a few left. Interesting. I was born and raised in a small "village" (approx 2000 back in the 50's) and the one or two docs made house calls for 10 or 15 dollars as I recall, and my mother would pay them later on when she could. We also had a milkman deliver our milk. My father made 50 dollars per week and there was no such thing as medical insurance (i.e. very rare) and supermarkets weren't even around yet, and we didn't have a car till I was about 15 or so. But now the world is new and improved - LOL . > However, it will be difficult to get a URO who has done 100 or more > PVPs to find time to stop and talk. He is in too much demand, > patients backing up trying to get in and he has a lot of expensive > equipment to pay off. But the guy down the street is more than > willing to find time to give you a "roto-rooter job" (Good enough for > my daddy, good enough for me). Rich...If you may recall I had a TURP back in April and it just exacerbated my prostatitis and I have all kinds of groin/rectal/malaise problems as well as other medical problems. The only reason I mention that is, I live in an approx 35,000 community (small by city standards), and the uro's are all in one room and are basically "rednecks" (but its a huge practice - 6 docs plus staff of about 35), because they don't even know what a PVP is, like I have said in the past. Anyway they are not high tech as you imply by the PVP docs not having the time to stop and talk. But they don't want to spend a lot of time with you either, and they often can not answer my questions anyway (so I read and study on the Internet and newsgroups, like we should - not that it necessarily helps, because most docs get pissed when you tell them that). My point is I think most doc's these days (whether primary care or specialists) tend to blow you away, and there are very few exceptions. > Wow!! That almost sounds like Marcus Welby (the TV show in the 50's). I > know the small town docs may have done that back in the 50's/60's, but [quoted text clipped - 6 lines] > didn't have a car till I was about 15 or so. But now the world is new and > improved - LOL . That little town is the home of Sinclair Lewis. It was the model for his book "Main Street". It is also has to be right close to the mythical town "Lake Wobegon". There is even a Lake Woebegon trail right outside of town. A fellow I know in London had heart problems a year or so ago. He checked with his doctor and was told he needed an EKG. They scheduled him for one in nine months!!! He went to a private clinic and had it done immediately. Fortunate, as he could not have lived for nine months. However if he had kept his original appointment, look at how much money they would have saved. Gives me the impression that might be one of the reasons they can operate at lower cost. I have the theory that if in the U.S. one wants to see how a socalized medicine facility operates, go to a VA hospital. You get reasonably good care but don't expect the personalized you might get from your family doctor. If you have to stay it well may in a 12 man ward. As I see it the doctors put in their 40 hours a week and go home. There is no incentive, except personal feelings, to go the extra mile and without other rewards, that could get old real quick. PVP apparently is by the hospital. The URO or doctor I was originally was going to did not offer PVP and I was even told by one of their doctors that it was no different that TURP. That was after I discovered this site and I then went searching. I found that doctors that used particular hospitals did PVP. Now the local hospital has purchased a green light laser and the URO group now offers PVP. However, I don't plan to use them unless I wait long enough for them to get a lot of experience. The one I switched to had done 50 PVP at the time I contacted him. He talked me into trying TUMT (he had done 500 of them) even though he said it might not help. It was not very effective but I guess a not lost on my part (except a little pain and suffering). That procedure was done almost entirely by a woman in his office (I told her in Arkansas we would be legally married). She told me that 80% of the patients said they would do it again. Only two individuals said they would never do it again. I guess in some cases it works pretty good. I cut down from getting up as often as every hour to every two hours. The last time I talked to him he had done over 100 so getting a lot of experience. >A fellow I know in London had heart problems a year or so ago. He checked >with his doctor and was told he needed an EKG. They scheduled him for one [quoted text clipped - 3 lines] >would have saved. Gives me the impression that might be one of the reasons >they can operate at lower cost. You've discovered that the dirty little secret behind the "savings" of socialized medicine is rationing. Why do I believe that the scum in congress who support socialized medicine in the US would not be standing in the same line as you or I? >> A fellow I know in London had heart problems a year or so ago. He >> checked with his doctor and was told he needed an EKG. They [quoted text clipped - 9 lines] > congress who support socialized medicine in the US would not be > standing in the same line as you or I? Ditto that one. Pete, Nicky & Rich, You're all full of B.S. about 'socialized' medicine. Get off your a.ses and come to Canada and see for yourself what its like, and *stop* regurgitating the right-wing dialogue you've ingested. You don't complain about 'socialized' *education* in the U.S.A. -- where everyone gets to go to school, so why try to paint Canada's healthcare system with the brush of communism (which in your heart is what you're implying). Canada's system was started in 1963, and has grown stronger every year. A survey across all of Canada last year showed > 95% of all Canadians want to *keep* their public health system, and do *not* want a parallel Private system for the rich. Canadians all realize that if a private system was allowed, then many doctors would get rich on the private side, and their public patients would get screwed. Most all the doctors in Canada are *private* business men ! They 'bill' their respective provincial healthcare agencies (e.g., Alberta Health & Wellness) for any service they provide, *and* they get paid quickly (2 weeks later), and with *no* paper involved and no insurance company sucking up all the premiums. Repeating of stories about (e.g., ';I heard of a case ...') is improper without complete details. In Arizona (where I live during the winter), small businesses are having a hard time surviving because they can't afford to pay for health insurance for their employees --- and any employees they *do* have keep looking for jobs with healthcare benefits. In Canada, healthcare benefits are a 'non-issue', since *everybody* is covered for *everything* for $90/month per family (free for the indigent). -Mel Smith (btw, I'm a conservatice capitalist person who owns a small business) >Pete, Nicky & Rich, > > You're all full of B.S. about 'socialized' medicine. Get off your a.ses >and come to Canada and see for yourself what its like, and *stop* >regurgitating the right-wing dialogue you've ingested. < snippage> >-Mel Smith >(btw, I'm a conservatice capitalist person who owns a small business) No thanks. BTDT. Too many Canadians like you who have been brainwashed into believing that less is more. BTW, you're killfiled for rudeness. Mel...I don't appreciate your rudeness either. If you look at all my previous messages (including our one on one conversations), I have never once said anything derogatory about your health care (and have said that ours in the U.S. had a lot to be desired), and in one of my recent messages I specifically said I was not badmouthing your system - here is my quote [["I'm not saying socialized medicine is bad, but there are certainly pros and cons for each"]]. In my last message, my ditto was applying to my belief that if the congressmen were supporting socialized medicine, and if it did result in lines (like Nicky was implying), then the congressmen would not be standing in line (and I'm sure your politicians that govern and rule your country don't stand in line either). Now if you want to start cursing and insulting people, I suggest you go visit another ng. I said that this ng was way better than the prostatitis ng which is almost extinct because of trolling, porn, spamming and sicko's. The next thing to come is the four letter words, and the slam dunking, etc, which will no doubt result in us losing our good doctor who has just joined us. Thanks a lot Mel. I have never said anything to you to deserve the bullshit you just wrote. Once crap like this starts, the group will decline. I'm not going to plonk you like Nicky, but I am disappointed...Pete > Pete, Nicky & Rich, > [quoted text clipped - 38 lines] > -Mel Smith > (btw, I'm a conservatice capitalist person who owns a small business) Pete, I had a little heart problem (missing and extra heart beats) and went to see my Dr. today. He thought an EKG was in order. There was all of a one minute delay before someone entered with the machines. Not too serious but gotta watch it. Point was I did not have to wait 9 months! I wonder where they get PVP covered by their national insurance in Canada? They just got a machine somewhere about a year ago. Five years late. Even those that don't have insurance can get the treatment here, even illegals. The last time I visited an emergency room everyone was speaking Spanish. They can't be turned away. The rest of us pay for it with higher bills. I read a comment by a Canadian Doctor: 'In the US they ration health care by price, while in Canada we ration it by queue". I think the point we are making is that our medical system is not great but don't let the govenment override free enterprise. Few of those wonder drugs and marvelous medical procedures would never be developed in a socalized system. And much our public school system stinks. Those that can afford it send their children to private schools. Pete, Bigger glands need more time and more fibers. This means more cost for the patient. Patients tell me often that what I propose is more expensive than what some other surgeons do, but I tell them It is what it takes to get a good result and to do a good job. Insurance companies in Spain do not cover this procedure yet. They only cover procedures offered by the national health services, so I guess it will take a year or two before they can start covering it. I must say though that although I am very agressive with PVP in a patient who is 50 years of age, with the intention of avoiding the need for reoperations in the future, I might not be so aggressive in an 89 year old catheterised patient. If his life expectancy is short maybe there is no point in being aggressive, because long term survival is not expected. I just make sure the patient will void well without a catheter and that's it. Thanks Dr. Sancha (as always - you are a gentleman and a scholar). I guess there must be a lot of affluent people in Spain who need PVP's, since they have to pay cash price :-) . Rule of thumb in the U.S. for the indigent or non insured (I am not talking PVP's), the doc's have two sets of books IMO (which has always pissed me of). This is not advertised of course and is my opinion, but I can prove it by my own experience with a general surgeon who dropped my insurance. The old time doctor's are especially kind to their older patients, I believe. What they do is charge the insurance company one price and the ins comp pays the allowed amount which is way less than the price charged (say 25-50%), could even be less for the cheap a.s ins companies. If they go to low, then the doctors start dropping them which has happened to my blue cross federal ins. It used to be one of the best in the world and now it is one of the worst because their allowed amounts are dropping too low. But if someone doesn't have insurance at all (or if the surgeon doesn't accept the insurance), the doctor may give the person a break (call it a professional courtesy) and only hold the patient responsible for say 50% of the amount they charge for the procedure to an ins company. I'm sure you know what I'm talking about. I would expect that you only have one fee for your PVP's since they are not covered in Spain anyway, although you may give the less fortunate people a break, but I guess that could get tricky. This what I call "two sets of books" in the U.S. has always bothered me, and IMO is a game between the insurance companies and the providers. But it is nice that the providers at least will give the patient without insurance a break (i.e. they could charge him the full price if they wanted to, and a lot of doctor's will try to do that, and you have to write them a letter requesting a professional courtesy). All of what I am talking about mainly applies to surgery. In the U.S. most people who have insurance only go to what we call preferred providers (PPO's), but the problem is that when you have surgery there are at least four (and could be more) separate bills you get (i.e. surgeons fee, facility fee, anesthesiologist's fee, and pathologist's fee as a minimum - could also add radiologist). So all the patient can do is make sure the surgeon and facility are covered, because it becomes too unwieldy to control all four or five of the charges involved. Hope I didn't bore you with our U.S. stuff. I'm sure you already know about it. Take care...Pete > Pete, > [quoted text clipped - 13 lines] > survival is not expected. I just make sure the patient will void well > without a catheter and that's it. > Thanks Dr. Sancha (as always - you are a gentleman and a scholar). I > guess there must be a lot of affluent people in Spain who need PVP's, [quoted text clipped - 20 lines] > not covered in Spain anyway, although you may give the less fortunate > people a break, but I guess that could get tricky. Sorry Dr. Sancha...I didn't want you to misunderstand what I meant here. By "one fee" I meant that would be the fee you would charge for your total surgical time plus the fibers (thus it could vary depending on the situation), versus the two different fees I was talking about above...Pete > This what I call "two sets of books" in the U.S. has always bothered > me, and IMO is a game between the insurance companies and the [quoted text clipped - 32 lines] >> survival is not expected. I just make sure the patient will void well >> without a catheter and that's it. Thank you for your comments, Dr. Sancha. With Flomax and Proscar, my situation is stable for now. But it may be better in the long run to have a PVP. This is what I am considering now. So it is good to know that the procedure is suitable for large prostates, and how to select the right surgeon. In other messages, posters have indicated that travel after a PVP should not be a problem. So when the time comes, maybe I should go to Madrid! I would feel very secure in your care. Ed >Ed, > [quoted text clipped - 20 lines] >Fernando Gómez Sancha >http://drgomezsancha.blogspot.com > Dr. Sancha, > [quoted text clipped - 21 lines] > In any case, perhaps PVP operations cannot be sold to patients > because they are run thru private healthcare providers. Mel and Ed...I am quite familiar with healthcare in the USA, but intrigued by your system of national healthcare (which is supposed to be better than ours - although I'm not convinced of that). Our ex president Clinton's wife tried to head up a major overhaul of our health system many years ago and it fell flat on its face and it still remains intact despite its many shortfalls (I guess the main one being the rich get better care). Mel, I am curious what you mean by "perhaps PVP operations cannot be sold to patients because they are run thru private healthcare providers". Do the private healthcare providers just exist for cash customers (i.e. the rich). And if so how does that make your system any better than ours. Ed says there are centers that do PVP's and should accept your province. I am confused. Also, let me ask if the poor homeless person on the street can get a PVP, or any other procedure, just as easy as one of you can, or someone who is more well to do than you are. I tend to doubt that. I don't expect a detailed answer, just a few sentences if you don't mind. Thanks in advance...Pete People in > Canada expect *all* their healthcare costs to be paid by the > provincial governments. [quoted text clipped - 3 lines] > -Mel Smith > (currently in Mesa, Arizona for the winter) Pete, What I intended to say but didn't want to get into a long involved diatribe is: Each province decides which of the 'newer' treatments it will cover at no cost to the patient. Apparently, B.C. still sees PVP as experimental, and not as a treatment that can be covered thru their provincial MediCare system. In my own province of Alberta, a practitioner has to decide if he/she will practice inside (or outside) of the MediCare system. If he decides to stay *outside*, then he cannot 'bill' the province for his patients who are 'inside' the system, but can only bill the (assumedly well-off) patient. Perhaps, at most 1% (maybe less) of Alberta's 5000-odd medical practitioners practice 'outside', but cannot have their patients stay overnite in our provincially-owned hospitals (so, have to build/run their own hospitals -- a very expensive proposition). Sooo, I gues most prostate patients would go for the free TURP rather than go out-of-province (or out-of country) and pay a lotta money for PVP. In summary, I'd guess that most business-oriented urologists would think twice rather than get in competition with the provincial healthcare systerms. btw, our healthcare system is provincially run, with the individual provinces dealing with the provincial medical associations yearly to argue over what rates to set for each of the 5000 or so medically covered procedures for the following year. The Federal Government has very little to do except to punish provinces financially if the provinces try to 'de-list' what the Feds think should be covered by Medicare. A complex issue -- but more than 95% of Canadians want to retain this system. -Mel Smith Thanks Mel...that's kind of how I figured how it worked (based on a rough description). Now let me rephrase my last question. Can the poor homeless person on the street get a TURP (I said PVP before), or any other procedure, just as easy as you can, or someone who is more well to do than you are. I still tend to doubt it. What I am really asking is - is your medical system truly equal and fair for *everyone* (i.e. the poor homeless person gets just as good care as the better off person, even though he may not have a place to live). I am not talking about the super rich who can pay anyone (private or otherwise) for special procedures, etc. Pete > Pete, > [quoted text clipped - 36 lines] > > -Mel Smith Pete said: > description). Now let me rephrase my last question. Can the poor homeless > person on the street get a TURP (I said PVP before), or any other procedure, > just as easy as you can, or someone who is more well to do than you are. I > still tend to doubt it. Pete, The short answer is : Yes ! The slightly longer answer is: The poor (i.e., indigent, homeless or with a home) pays nothing for his healthcare. (but all families that *can* -- pay approx $90/month (single adults pay about $46/month) All the indigent person has to do (in fact what *all* people do) is: go to a doctor of your choice, have him examine you, have him refer you to a specialist( i.e., urologist), and have the urologist schedule an operation if needed. The urologist has no (economic) advantage in scheduling a rich person first, because the province pays the same to the doctor whoever the heck is operated on. When one goes to the doctor, there are no insurance forms to fill out, you just have to be a regular patient of the doctor (or a referral from another doctor) *or* show the medical receptionist your Alberta HealthCare Card (with your healthcare number on it). The practitioner forwards his claims electronically (i.e., FTP'ing via computer) to the Alberta Health Care agency weekly , and two weeks later the payment is deposited into his private bank account. No forms to be filled in *any* of this sequence. Interesting and automated stuff !! btw, the base rate paid to a urologist for a TURP is $472.30 (Cdn) -Mel Smith Mel...thanks for the info. I like the theory and I am sure it works, but I'm sure it has some shortfalls. But it probably is better than ours (we are said to be the richest most advanced country in the world with one of the worst healthcare systems -lol). Hell, I have insurance and I can't get any help with my profound problems. I am a retired federal employee and have Blue Cross Federal, which used to be one of the best insurance's in the world and now it is one of the worst (except for one big advantage), because the cheap bastards don't pay enough for their allowed amounts and the doctors are dropping them, and all the doctors band together in groups these days so when you live in a smaller city you're screwed (i.e. all the uro's, ent's, pulmo's, etc are in one group). Oh well, medicine is a big business these days, with not much personal care to the patient. I see one big problem with your health system, even though I will have to admit it seems much better than our archaic system (which benefits the people that have health insurance or can afford health insurance). I believe approx. 40% of the people in my country (the USA) are without health insurance (I'm sure that includes the people on welfare, as well as all the people who are not, but just can not afford health insurance for whatever reason, work related or otherwise). That is a staggering number. Since everyone in Canada is covered (so to speak), you must have one hell of a problem with waiting lists to see the doctors and schedule procedures (i.e. you have just added the 40% of the people who are not covered in my country - if you follow me). So theoretically that would mean you need more doctors and facilities. We have a way of treating the truly indigent people (its called welfare and Medicaid, and it has its problems indeed), but I can guarantee you they don't necessarily get as good treatment as the more well to do patients with health insurance. I am sure you have similar situations with at least some of your indigents, although you indicate not. Anyway, am I right about the waiting list in Canada, which I assume a large percentage of the patients are poor or indigent (in other words the rich have to stand in line with the poor to see the doctor or have a procedure). Pete > Pete said: > [quoted text clipped - 37 lines] > > -Mel Smith Pete said: > Anyway, am I right about the waiting list in Canada, which I assume a large > percentage of the patients are poor or indigent (in other words the rich > have to stand in line with the poor to see the doctor or have a procedure). Pete, There are always 'waiting lists' (even in the good ol USA) !! Nobody stands in line --- one just waits for the call. If you are dying of a bad heart, you get bumped to the top of the line for a transplant in alberta. Those lesser affected get 'pushed down' a noth, However, in my own immediate and extended family and close friends we have had a multitude (5) of knees replaced, hips replace (3 as of a month ago) with only modest waiting times. With world class hospitals, and a provincial surplus of 8 *billion* dollars this year, we can afford to get people moving thru the system properly. With all that, the Federal Government has, (a couple of weeks ago) announced waiting list guidelines. If a Province *fails* to schedule a patient for a procedure within these just-announced guidelines, then the Province *must* ship the patient to another province for the procedure *and* pay all expenses for the province and patient. So, we're making progress btw, my golfing buddy lady friend who just had her hip replaced had to wait three months for the operation (but she's been grumbling for years anyway :))) (so, I won't get to golf with her and gamble against her until Jan 14th) (if we continue with this discussion, we should start at new thread) -Mel Smith Thanks Mel...Pete Mel, PVP can have poor results if it is poorly performed. In some centers, doctors buy the equipment, read the instructions and some published papers, watch a video and jump to operate without interaction with experienced doctors, or formal training. PVP needs to be done with care not to coagulate prostatic tissue, and if the laser fibre is not handled efficiently, one can cause deep coagulation of tissue and this causes edema, inflammation and painful urination postoperatively. Also, one needs to be aggressive removing prostatic tissue, otherwise the flow results are not very good. It is possible they tried the technique and were discouraged to use it after a bad experience with initial patients.... PVP seems easy to perform, specially for an expert TURP surgeon, but it is not so easy if one has to learn on his own. In my initial experience, patients complained of disuria after the operation more often than now. It can happen, but it is quite rare now, whereas it was relatively frequent in my first 50 cases. Once you master the technique, the tolerance and the clinical results are excellent. My recomendation is to look for a surgeon with an experience of more than 100 cases, specially if your prostate is bigger than 60 grams. Bests, Fernando Gómez Sancha http://drgomezsancha2.blogspot.com Dr. Sancha, Thank you for explaining why 'poor results' may occur after PVP. (I also apologize for mixing up healthcare issues with prostate problems. If I reply to 'costs' or 'insurance issues' again, I'll start a new thread.) Now I have to start 'shopping' for some urologist in Canada that provides good PVP in Canada -- inside or outside of our public system. -Mel Smith (currently in Mesa, Arizona) > Mel, > [quoted text clipped - 11 lines] > PVP seems easy to perform, specially for an expert TURP surgeon, but > it is not so easy if one has to learn on his own. Dr. Sancha (and others)...Hell, the uro who did my TURP didn't even know what a PVP was, when I asked him if they did it (and he and all of his partners are in one gigantic office - they have a support staff of about 35 - pretty big business and the only uro's where I live). They also do the indigo laser. It find it disturbing that I know what a PVP (which has been around since 1996 or 97 I believe) is, and my damn uro doesn't. Hell doesn't he read his own journals, and you doctors have to have some kind of yearly participation in seminars or something I believe - I don't know the regs - and I'm sure it varies by state/province, etc. Dr. Sancha, do you have any comments (pro and con) about the indigo laser procedure and its comparison to TURP, PVP and other BPH procedures, pertaining to effectiveness, problems, etc. Thanks...Pete In my initial > experience, patients complained of disuria after the operation more > often than now. It can happen, but it is quite rare now, whereas it [quoted text clipped - 7 lines] > Fernando Gómez Sancha > http://drgomezsancha2.blogspot.com Pete, Many doctors apply the rule "don't be the first to adopt new technology or medical treatment, but don't be the last". The problem is that even if you browse medical journals, there is so much information available that sometimes it is difficult to retain or to distinguish among new surgical techniques, specially if they involve new technology. PVP catches your attention at congresses, or when you see a video of the procedure. I was lucky to be advised by an English colleage to embrace PVP, he had been doing it for 6 months, and he told me "this is like no other previous alternative to TURP, this is really it". "It is amazing to see how patients recover so quickly and how we can get this wonderful results". I decided to buy a KTP laser based on a trustworthy friend's recomendation, rather than on published results (there were few papers out then). There have been more than 50 alternatives to BPH. They have always caused initial enthusiasm in the urological community, the first papers always stressed the advantages of these new BPH treatments, and then were unable to show benefits in comparison with TURP. The advent of these techniques was motivated by the fact that TURP is very efficacious, but its morbidity is HIGH (it can cause incontinence, impotence, severe bleeding, etc...). Several lasers were tried, as the Nd-YAG laser in the VLAP (visual laser ablation of the prostate) procedure, Holmium laser procedures (HOLAP relatively inefficient for vaporization, HOLEP very difficult to learn and to perform enucleation), ILC- interstitial laser coagulation of the prostate used a diode laser, and indigo laser falls into this category of failed procedures. Those who bought one of this very expensive lasers, were forced to stop using it, and maybe they keep it for very special cases of very frail patients where TURP is not possible, or when asked about lasers they say "we have an indigo laser". This past history has caused escepticism in urologists about lasers, so maybe when they read a paper on a new laser for BPH, their first reaction is to turn the page and focus on something else. In my mind, PVP is equivalent to TURP in terms of efficacy, but morbidity and risks are much lower. There are other techniques in the market, microwave, termotherapy, TUNA, and so on, but these are minimal risk minimal efficacy techniques, they produce only moderate improvement in patients. I guess holmium laser enucleation of the prostate is an option for patients with huge prostates, but you need to go to New Zealand to visit Dr. Gilling. He can do the procedure safely, but it has proven very difficult to learn by other urologists, even the manufacturer has started promoting the vaporization with Holmium, and does not promote the enucleation procedure any longer. And the KTP laser used for PVP vaporizes much better than Holmium. Holmium lasers are very useful for stone treatments... So I would stick to PVP if I had to have a BPH operation myself, but performed by an experienced and aggressive surgeon. Fernando http://drgomezsancha2.blogspot.com I would imagine that Gordon Muir at Kings College, London was your PVP Guru. If you Google this NG you will find some of his satisfied patients have posted.. As far as I am aware we still only have about six UK hospitals doing PVP. My Scottish urologist was rather reluctant on my request to be referred to the Freeman Hospital in Newcastle for a PVP. I had refused the TURP his predecessor had said that I needed as a matter of urgency in 1995. He said that I was taking a "A rather starry eyed approach and that PVP is just a TURP by another name" The three Freeman urologists are excellent and and enthusiastic about the procedure, I had no qualms on being one of the early patients. Derek. > Pete, > [quoted text clipped - 55 lines] > Fernando > http://drgomezsancha2.blogspot.com Derek, Mr. Gordon Muir is a consultant urologist in London, and good friend of mine, I invited him and he came over to Madrid to teach me how to perform PVP. He had done about 60 cases at that time. He is probably one of the best PVP surgeons in the world. He teaches regularly and he is certainly aggressive. So I guess he would be the man to perform my own PVP if I happened to need one. All the best, Fernando http://drgomezsancha.blogspot.com Dr. Sancha...Once again, I thank you very much for your complete and detailed response. I have saved this to my hard drive, as well as all your other responses...Pete > Pete, > [quoted text clipped - 55 lines] > Fernando > http://drgomezsancha2.blogspot.com Dr. Sancha, I have had two PVP's in the last ten months. It is only been four days since the second one with no complications whatsoever. My urine flow was very strong the first and second day after the surgery but since it is basically as it was before the surgery with decreased flow. When I take Flomax the channel opens up well but if I quit the flow decreases. Do you have any idea what is going on? I certainly don't want to stay on Flomax the rest of my life. Dr. Lin did my second PVP and I know he knows what he is doing. Maybe it is not my prostate causing the problem and something else? Dr. Lin told me in addition to not enough tissue being removed from the prostate the first time that I had two places in the bladder that needed repairing. Any suggestions you have would be greatly appreciated. Thanks. Buford >There is no theoretical limitation to the number of PVPs one could have >in his life. [quoted text clipped - 50 lines] >Fernando Gómez Sancha >http://drgomezsancha2.blogspot.com |
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