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Acute and chronic prostatitis discussion. Arnon Krongrad, MD, moderator.

Can prostate removal for prostatitis really offer a cure for suffering men?

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I have no idea how to interpret ultrasound findings vis a vis the question of the likelihood of relieving symptoms with prostatectomy. The association of radiologist reports with clinical outcome has not been studied.

Bob said:
Dr. Krongrad;

My doppler TRUS shows infection in both lobes and the seminal vessels. I guess it is safe to assume that all the gentiourinary nerves and tubes are infected as well. By removing the prostate, do the infected gentiofemoral nerves, spermatic cord, epididymis and all other associated nerves heal as well? I hope this makes sense. Sorry, for any misspelled words.
Surgery is contrainidated for this condition
I originally wrote in this forum that total prostatectomy does more harm than good in Prostatitis.

Someone responded that a damaged organ causing chronic pain is better removed than living a life of pain.

I later posed a question about the pros and cons of total prostatectomy relative to Prostatitis.

It would be interesting to know the complications that would affect an existing Prostatitis condition after a total prostatectomy is done. Eradicating a disease entity by completely removing the gland may give way to another equally troublesome condition without any means of relief is not exactly a solution. And perhaps, it would be much worse than the disease itself. Complications associated with TP are sepsis, bleeding, incontinence, impotence and sometimes death, to name a few.

Choosing between TP that is permanent and irreversible vs the prevailing treatments for Prostatitis that is lacking but could change tomorrow (hypothetically speaking) is equal to a patient without a gland and sadly encounters more problems along the way but is now helpless even in the light of remedial measures and cure promised in the future.

It is recommended to focus on the discussion about TP in Prostatitis that is presumably under NIH Category IIIa (Inflammatory Non-Bacterial) and IIIb (Non-Bacterial or Prostatodynia under the old Stamey classification), and set aside the issues on the NIH Categories I , II and IV temporarily for the sake of uniformity.




2nd point, On all 4 NIH categories we have no issue on Category 1 and IV so we could put that aside for the moment. Category II (CBP) we could put also temporarily put that aside, so for the sake of uniformity in this forum we probably have to define Prostatitis.

At the moment since our discussion is on total prostatectomy in Prostatitis I can presume that we are referring to Category IIIa Non bacterial Prostatitis (NBP) and Category III b non-inflammatory Prostatitis or prostatodynia in the old Stamey classification?

Okay, Category IIIa and IIIb are often misdiagnosis because no work up is ever done on prostate specific specimen i.e. expressed prostatic fluid (EPS ) At most, diagnosis would be based on Pre and post massage urinalysis this will miss an accurate diagnosis in more than 80% of cases therefore these cases might end up to surgery that is not needed.
The literature offers basically nothing scientific on this question. The best I can find -- please let me know if you have other references -- is a paper dating to 1982 about "radical TURP" that showed some improvement in some patients..
I don't have the original paper and don't know how improvement was characterized, measured, and followed.

On this issue of “radical TURP” as Physicians we all know that the procedure does not take the peripheral zone and since Prostatitis is on the peripheral zone, TURP will never work.


Other than this, we have anecdotal reports. I am aware of several places where radical prostatectomy was reported to have eliminated symptoms of prostatitis. I am not party to the clinical cases and cannot provide you detail.

Anecdotal reports are not acceptable in the age of evidence based medicine.

My personal experience is as I have written here. Mr. Radford was sent to me by a surgeon at the Cleveland Clinic. He had had eight years of misery and failed treatments. His situation was completely remedied by a laparoscopic radical prostatectomy. Eighteen months out he is pain free, continent, and reporting normal erections.


I believe based upon this case that some men will find relief with prostatectomy. I cannot quantify the likelihood. I would stress again, as I did above, that for any man who is considering such a move it is absolutely imperative that he go with a surgeon whose focus is radical prostatectomy and who has a lot of experience.

This data is not complete because we do not have the pre and post op diagnosis of this case. What is good for this case may be not be true for the majority.

If we initiated a clinical trial of laparoscopic radical prostatectomy for chronic prostatitis, would you collaborate?

Yes that is for sure.
Would you work with me to design the study?
Yes.

Would you refer patients to it?

If it is evidence based why not

Regards,
AEF
Dr. Feliciano

I am learning a lot by reading what you write. As you probably know, I am a life-long prostate cancer expert. My interest in prostatitis was sparked by Mr. Radford, for whom the benefits of LRP were dramatic.

Your notes of caution are music to my ears. Obviously LRP is not the first treatment. As with Radford, it is a last treatment. The questions revolve around who will benefit, how much he will benefit, and what will he risk.

With this in mind and with your kind offer, I am very serious about designing a trial to test this specific hypothesis: radical prostatectomy cures chronic prostatitis. As a corrolary I would like to use the accumulated experience to identify patient factors that will mark the likelihood of success and failure.

What is the best way to send you drafts? If you like, please write to me at ak@laprp.com

AK
I truly believe, That when it comes tp prostatitis, there are two different diseases getting lumped into the prostatitis mold.

There are the people with chronic pelvic pain, Pain which seems to originate from the pelvis, Tests all normal prostate small in size. Current research points to pelvic floor stress as the cause for this type...

Second is the group of patients with prostatitis. True prostatitis. Ultrasound reveals a inflamed slightly enlarged prostate. The pain seems to come from the prostate. The golf ball feeling and frequent urination and dribble can be felt coming from the prostate. Prostate stimulation increases symptoms. I feel people in this group will all see cures from prostate removal


doctor so are you putting together a clinical trial using surgery for prostatitis as a cure?
Doctor so are you putting together a clinical trial using surgery for prostatitis as a cure?

Yes. And I have invited Dr. Feliciano and will invite others with experience to help me think through the design. Your input is welcome always. I will keep you posted as things develop.
This is Great news....
My thoughts exactly.

mike said:
I truly believe, That when it comes tp prostatitis, there are two different diseases getting lumped into the prostatitis mold.

There are the people with chronic pelvic pain, Pain which seems to originate from the pelvis, Tests all normal prostate small in size. Current research points to pelvic floor stress as the cause for this type...

Second is the group of patients with prostatitis. True prostatitis. Ultrasound reveals a inflamed slightly enlarged prostate. The pain seems to come from the prostate. The golf ball feeling and frequent urination and dribble can be felt coming from the prostate. Prostate stimulation increases symptoms. I feel people in this group will all see cures from prostate removal


doctor so are you putting together a clinical trial using surgery for prostatitis as a cure?
Arnon Krongrad, MD said:
Doctor so are you putting together a clinical trial using surgery for prostatitis as a cure?

Yes. And I have invited Dr. Feliciano and will invite others with experience to help me think through the design. Your input is welcome always. I will keep you posted as things develop.

I have e-mailed Christopher Eden in the UK in the hope that he may also add his input to the trial as he has done 3 LRP's if Im not mistaken on CPPS patients with success. (I am not sure of exact details) He is the most experienced LRP surgeon in the UK with well over a thousand operations under his belt.
Eden is a good man. I'd be interested in what you cite and will look to his response. Thank you.

The design is in progress. Involving a biostatistician from the Johns Hopkins School of Public Health and aim to do this to the highest scientific level. It won't come quickly but when it's done we'll know what we've observed. Details to follow as this evolves. Thanks for the support, Nik.
Your welcome Arnon, I hope Christopher can find the time to get involved. This trial is seriously good news. I am hoping if Chris Eden could also get involved, we could get the numbers up quicker..?? Fingers crossed! The ball is in his court now as I emailed him this weekend with a link to this forum.

Arnon Krongrad, MD said:
Eden is a good man. I'd be interested in what you cite and will look to his response. Thank you.

The design is in progress. Involving a biostatistician from the Johns Hopkins School of Public Health and aim to do this to the highest scientific level. It won't come quickly but when it's done we'll know what we've observed. Details to follow as this evolves. Thanks for the support, Nik.
I have done 5 radical prostatectomies for 'chronic prostatitis' to date, all of which have cured their patients of intractable perineal pain. Four patients had immediate relief and one patient waited 6 months before his symptoms disappeared. Interestingly, four out of the five men had prostate cancer present on their final histology, which was undiagnosed prior to surgery and all currently have unrecordable PSA levels.
Although it is anecdotal evidence, I think that what has been written in this discussion is important as the overwhelming majority of men with chronic pain are unaware of surgery as an option and would welcome the opportunity to at least discuss it. But caveat emptor - for it to be reasonable to treat a benign condition by radical prostatectomy patient morbidity (complications) would have to be minimal so the surgery should only be done by experienced surgeons. I would be delighted to collaborate in a study to look at the efficacy of radical prostatectomy in treating chronic prostatitis.

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