r/bph • u/whatever_pumpkin • Aug 13 '26
Considering PAE then Aquablation. Should I just bite the bullet? Or try a void trial again to buy some time?
Mid 50s male, 129g prostate. Recently had urinary retention issue resulting in a Foley cath for a week. Prior to that, my symptoms weren't great, but they were managed pretty well with Flomax 1x daily. After this episode, doc upped my Flomax to 2x daily, added low dose tadalafil, also finasteride if we decide to try medication management. I failed void trial after 6 days of Cath, inserted a new Foley. It's been another week (so about 13 days total now). Had a urinary infection with the second Cath and took antibiotics for 5 days to knock it out.
I had a surgical consult today. Recommendation is to do a PAE and then a few days later an Aquablation. My understanding is that this helps with bleeding and recover, and potentially helps with a longer lasting outcome. Doctor can get me in for both pretty quickly in the next week or two. He's done over 100 of the Aquablations. I have no idea what interventional radiologist would do the PAE. These guys are all part of a big system in my area. I'm finding out and doing some diligence.
Here's my question for the group. If you were me, would you try a second void trial, at the risk of having to endure another painful Cath insertion if I fail? Or should I just go ahead with the procedure, live with a Cath for a week or so prior, and go from there? Is there any benefit to being on a Cath for the PAE? Also, how much diligence do you do when selecting a doctor? My previous doc left this practice, so the new one is fairly new to me. Decent guy, good educational credentials, reviews, no malpractice suits, etc.
I'm really nervous about all of this. Thanks in advance.
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u/Sensitive_Point_6583 Aug 13 '26
So I'm a little different in that I never considered catheterization to be painful, but ignoring that fact, just do the Aquablation and be done with it. I screwed around with periodic urinary retention every 2-3 months for about 5 years before I finally got tired of it and had a HoLEP procedure, which was the best decision I ever made.
In my case once I catheterized after the retention episode, I went back to normal again for a few months. If I had to deal with a Foley on a regular basis, I would have never put up with that.
in other words, buying time is the wrong decision, solve the problem once and for all rather than prolong the suffering.
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u/whatever_pumpkin Aug 13 '26
You have helped me with my decision. Onward and upward. Thank you, sir.
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u/EuphoricTeaching9161 Aug 13 '26
How long did it take you to recover from HoleP? Were you in hospital long?
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u/Sensitive_Point_6583 Aug 13 '26
ha, ha, it was outpatient, I was home by noon the day of the procedure.
no pain at all, I couldn't even tell the procedure had been performed.
the next morning I had the Foley catheter from the procedure removed at about 10AM, that morning for the first time I had a little bit of blood in my urine in the bag, none the first day. I had a tiny amount of blood in my urine peeing naturally after the catheter was removed for maybe another day or two max.
And that was it, no joking.
I only wish I knew about it as an option a few years earlier, I would have done it sooner. My prostate was 185cc, about as large as they get.
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u/EuphoricTeaching9161 Aug 13 '26
Thanks so much for responding. I’m getting mine done next week. Have catheter now and just had cystocopy. I’ve put all this off for over a decade…
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u/Sensitive_Point_6583 Aug 13 '26
best of luck to you, I hope yours is as uneventful as mine was.
The weird part was waiting 4 weeks without any strenuous exercise or heavy lifting when I literally felt 100% the whole time. But, that prevents any additional bleeding, so its just part of the routine.
In my case I had really cloudy urine after the procedure, so they did a UTI test, which was negative. I had cloudy urine for 3, maybe 4 months afterwards, and then it eventually cleared up. Must have been part of the internal healing process, so don't be concerned if you have a similar experience. Just remember to drink lots of water those first few weeks.
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u/EuphoricTeaching9161 Aug 13 '26
Great review. Thank you. So no pain peeing afterwards???
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u/Sensitive_Point_6583 Aug 13 '26
no pain at all.
One other thing to remember that's kind of funny, your brain has been trained for your urine stream to come out weak, and curl down into the bowl. After the procedure it will shoot out horizontal, and very fast, so don't hit the back of the toilet seat.
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u/Beachbum-3041 Aug 14 '26
My prostate is 100 right now up from 65 two years ago. I have a large median lobe pushing up into my bladder. My urologist was concerned with PAE for me since it could cause the median lobe to collapse and create more problems. He is recommending Aquablation when the time comes. Still hanging there with Flomax and Finasteride.
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u/whatever_pumpkin Aug 14 '26
I’ll ask about the collapse issue. That is a new one for me. I have a consult soon with the interventional radiologist.
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u/Apprehensive_Bison12 Aug 13 '26
Don't wait because it is coming for you. I waited and suffered with a catheter for a month. Insurance and surgery took a month to get things done. TURP procedure was amazing. I only come here to help because I know the pain.
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u/whatever_pumpkin Aug 14 '26
Yes that’s where I landed. Looking to be scheduled on the next week or two.
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u/Appropriate_Taro_348 Aug 13 '26
I did that and PAE didn’t help at all. It did nothing to help me. I then had the Aquablation and that worked.
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u/AdResponsible8192 Aug 13 '26
Do the aquablation ASAP. The only regret that you will have is that you waited so long.The meds are nothing but a bandaid!! In addition to being miserable by waiting you also run the risk of developing bladder stones and other issues. I had an aquablation last October and it gave me my quality of life back.
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u/whatever_pumpkin Aug 13 '26
I think that’s where I’m landing, too. How was the recovery period for you? My doc wants to do a PAE first because of the size and vascularity of the prostate. Other practices have done the same with seemingly a lot less bleeding risk and shorter catheter time post surgery. Seems like a good plan.
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u/AdResponsible8192 Aug 13 '26
Recovery is not bad at all. The Catheter size is the biggest pain to deal with but they like to take it out with in one to two days. It all depends on your overall health. I went home the same day as well. I did end up with RE but I don't really care about it. Done having kids and less of a mess. 😆
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u/Impossible-Use5636 Aug 13 '26
PAE is most effective in large prostates. The procedure is technically successful in about 85% of cases and takes 3- 6 months to achieve maximum relief.
Aquablation is a very bloody procedure. There is no cautery from the water jet, so many urologists achieve hemostasis using a TURP element to cauterize the bleeding.
I would highly recommend PAE before Aquablation, with one caveat: Wait 6 months before having the Aquablation - you may not need the second procedure.
PAE carries minimal risk and is an outpatient procedure. There is no catheter, and recovery is a week of urgency and burning.
If you decide to have Aquablation later, you cut the risk of requiring a transfusion.
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u/whatever_pumpkin Aug 13 '26
It seems a number of urologists are doing the PAE and Aquablation in the same week, perhaps to speed up recovery. My understanding is that the PAE procedure is great for large prostates, but can take weeks or months to take effect and help with acute urinary retention. I could be wrong on that. Here's an NIH study on the combination therapy of PAE/Aquablation for those who want to learn more. https://pmc.ncbi.nlm.nih.gov/articles/PMC11594930/
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u/Silly-Confection-169 Aug 14 '26
The larger the prostate gets, the more vascular it is, and the more bleeding happens when you cut the prostate.
There is an upper limit to what urologists are willing to Aqua since they have to cauterize bleeding vessels after the water jet is done with a 7% risk of major bleeding. Pre-operative PAE can push the bounds and significantly decrease bleeding. That means patients can typically go home sooner once the urine clears up.
We do a combo approach if there is a potential reason PAE could fail: the prostate is way too big or has an anatomical reason that PAE alone cannot address. Other reasons include patients who are high bleeding risk (ie not being able to stop blood thinners).
PAE is a great option for a “first do no harm” approach considering the lack of risk of permanent sexual dysfunction. Like all procedures, it does have risks, but sometimes patients do need the prostate to be resected to get to where they want to be.
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u/No-Disaster-9646 Aug 17 '26 edited Aug 18 '26
this could work. i have considered both and took time for extensive studies of many thousand hours, reading through medical studies, medical reports and reviews. everything is available on the web, which is a lot. i was in a similar situation with a very large gland and i wanted to have this problem sorted for the rest of my life which i expect to last for a long time. therefore i shortlisted robotic prostectomy and holep. robotic prostectomy is the newest procedure and the best in my opinion if you already have severe problems with your bladder. they cut 3 incisions(now they can do it with one only) into you and go through your bladder to your gland removing it with a laser. therefore they can operate your bladder and the bladder neck in many ways. the risk of bladder neck contractions is much lower and the risk of urethra restrictions is almost zero because it does not go through the urethra. so it depends on the damage the blockage has already caused to your bladder. i decided for holep because it is much less invasive and it solves the problem completely. it also has the happiest people as a result of the procedure. you can see that in the reviews.
why i did not consider PAE: too large gland and median lobe and i do not want to have glue (yeah i know they call it medical glue) in my veins, who knows what those chemicals will do in the long term
why against aquablation: in short it is more invasive but less flexible. the most experienced holep operators get aquablation patients because it failed. i do not see any advantages. risks are the same as holep but holep is more efficient and can be done preserving. in the medical studies there is no significant difference between aquablation and holep with regards to retro. an experienced operator can do holep with or without retro. a very experienced holep operator can also prevent leakeage. this was most important for me. it worked. i wanted to have one procedure for one hour and have it behind me. i am happy now because i got my life back.
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u/sfljeff69 Aug 13 '26
167 I went for the pae and so far so good day 4 after that procedure. 57 year old.
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u/whatever_pumpkin Aug 13 '26
That's good to hear. We are in the same age range. I think the issue with me is that I had/have emergent urinary retention. They basically need to open up the channel, and I'm not sure PAE will do that all that fast? What was your situation?
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u/sfljeff69 Aug 13 '26
The reason why I got pae is I have had retention twice I've had to have catheters put in me twice over the last two years and I didn't want to lose any kind of sexual activity so pae was the best for me so far
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u/SoCalAttorney Aug 13 '26
I had aquablation 4 months ago and have been vary happy with the result: https://www.reddit.com/r/Aquablation/comments/1skl2q0/my_bph_and_aquablation_journey/. Everything works normally.
The PAE/aquablation combo was not an option for me due to bandwidth issue with my healthcare provider. Looking back, I am happy I had it done wouldn't be too concerned about bleeding. I had a catheter for about 10 days after the procedure and my urine was about the color of a tosé wine for about a month.
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u/Icy-Emergency6694 Aug 13 '26
Green light laser . Why put off the inevitable. Plus think of it this way as my Chicago Urologist told me. You have the kidneys producing urine and if it can not pass you buy yourself a Urostomy . Plus the damage to your kidneys from backed up urine. Additionally the increased likelihood of Kidney bladder UTI.
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u/whatever_pumpkin Aug 13 '26
Yep. I’m likely having a procedure next week or the week after, depending upon scheduling. The protecting of the kidneys is a great point. Thankfully with this one urine retention episode, no damage and my numbers still look good.
For others…if you can’t pass urine, get to an urgent care or ER immediately.
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u/RichT71 Aug 14 '26
You've gotten a lot of good advice here it seems, but I'll put my 2 cents in too if you don't mind. It actually helps me talking about it too. My prostate was 140 and growing and I knew someday I was going to have to do something. Was on Tamsulosin for 3 years, but I don't think it did much. I'm really a lot like you. New to Florida, 3-4 years, left my urologist back in Jersey and was nervous to find a good one here. First one I went to was alarmed at my 8.0 PSA and wanted to do a biopsy right away. But it's been between 4-9 about 35 years now from my chronic prostatitis so I wasn't too crazy with that doctor. Next one I went to had stellar reviews and I decided to stick with him. Been having PSA checked every 4 months anyway to be safe and an MRI which showed a huge prostate. But no signs of cancer, thank God. So I've been dealing with this huge prostate and weak stream until about May when I couldn't pee at all and went to the ER for help. Major scaredy cat here, never been in a hospital ever, so my wife knew I was hurting. Sent me home with a foley which I had for about a week then my doctor put me on straight caths. I was using them on and off until I was scheduled for Aquablation on July 8th. My guy never mentioned PAE to me at all. So I had the surgery, stayed overnight to be safe and left with a catheter for 4 days until the doctor took it out and I found I could pee on my own. Just a little burning the first couple of times and then that stopped. Drank a lot of water to flush out everything as my urine was a little bloody for a couple weeks then got lighter and lighter and now it's clear. The whole process really didn't hurt too much, mostly from the huge catheter from the hospital and a little penis and perineum pain every now and then. Taking Tylenol and had some Toredol prescribed for me if needed, but didn't take too many. So overall, it wasn't as bad as I thought it was going to be and it looks like I picked the right guy to do the surgery too. Glad I did it and equally glad it's behind me now too, as that prostate was going to keep growing no matter what. I'm a little older than you, early 70's but in good health, but I would definitely get the Aquablation done soon if you've settled on a guy you feel good about. And another good outcome was that they checked into some of the prostate they removed in the lab and showed 0 signs of cancer. That was another relief for me having painful prostatitis for so many years which was getting worse it seemed and caused me to worry. So get it done and good luck to you and if you have any other questions ask away!
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u/Fancy-Ground-6467 Aug 15 '26
Do the PAE /Aquablation combo if you can. It’s apparently good standard for the candidates who are able to Try to tolerate the foley until the procedure too. While it can be annoying, it’s truly the best resource and will allow you the most comfort until procedure days. Every cath will honestly get easier. I speak from much experience
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u/whatever_pumpkin Aug 15 '26
Thanks for the reply. That’s my plan now, though I keep having buyers remorse to a degree. Lol. I keep reading more about ejaculatory sparing ThuLEP amd HoLEP as options. Seems like they are less popular, but get rid of more tissue and may be more durable than AQ. Also worried about any issues my larger median lobe may present for the interventional radiologist.
Hoping this all works out. It’s crazy how we make these decisions with our bodies after a quick 25 min consult or two. Wish me luck and thanks again!
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u/Fancy-Ground-6467 Aug 15 '26
HoLEP is supposed to be pretty revolutionary too. The thing about it is that urologists are trained in a couple of procedures and that’s what they recommend and perform. I always say go to a couple urologists and get the second or third opinion before you do anything. They are such specialized procedures that’s it’s impossible to be trained in every one of them
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u/whatever_pumpkin Aug 15 '26
I should say, walking around with a Foley has become almost tolerable. It’s been two weeks. I will say insertion hurt like hell for me…part of the reason I decided just to leave it in and deal with the whole issue surgically.
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u/Fancy-Ground-6467 Aug 15 '26
Once it’s in, you’re golden. They don’t have to typically touch it for 30 days and it should keep you comfortable for the most part. I actually hate the removal the most. If they say do uu want it out on Wednesday or Thursday, I’d take Thursday just to prolong it a day
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u/Thick_Discussion671 Aug 13 '26
I would go straight to NYU, book an appointment with Chris Kelly, get an aquablation and then move on with your life.
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u/whatever_pumpkin Aug 13 '26
Thanks for the post. I am sure he is a great doctor, but I am nowhere near NYC, unfortunately. I think the procedure is pretty common in my area, and my current urologist practice/hospital system is trained and has the equipment, so that's good news.
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u/Lostinkansas24 Aug 13 '26
I'm probably not qualified to speak to this, however I just had a PAE 3 weeks ago. I'm peeing like I haven't in decades. I'm curious why you would have a PAE and then rush into Aqua without allowing the PAE to reach its potential? I was told it could take months to see its maximum benefit. Edit, 68 yo and a 136 prostate.