Types of Surgical Procedures for Chronic Prostatitis

[Arnon Krongrad, MD]

A member posts the following comment: "men have been tricked into having surgeries we should not have had." Yet for some men surgery seems to be absolutely effective. For example, there are clear examples that laparoscopic radical prostatectomy (LRP) can rid some men of severe symptoms of chronic prostatitis; click here to see one example. For LRP there is a trial ongoing to help better quantify the likelihood that a man will benefit.

The member's post raises questions:

1) Which types of surgeries do men have for chronic prostatitis symptoms?
2) What is the rationale for their choice? Are there data? anecdotes?
3) In which cases have there been good outcomes?
4) Are there any data on the likelihood of good outcome with any type of surgery?

Consider the story of Merlin Gill, who had symptoms for 25 years. These drove him to have a 1) transurethral prostatectomy and 2) simple retropubic prostatectomy. Neither was effective. It was only when he had his laparoscopic radical prostatectomy that his symptoms went away.

In other words, it may be that the type of procedure really matters. And to this end, the only paper I can find on the topic is this 1982 report of transurethral prostatectomy, which leaves more questions than it answers.

If you have had a surgical procedure for prostatitis other than LRP, which type was it? What was your treatment objective? Why did you select the type of treatment that you selected? Did you meet your treatment objective?

[Nik]

An extract from http://www.pelvicpainhelp.com/:

The Inappropriate Use of Surgery and Antibiotics in Treating Pelvic Pain
Those of us who developed the Wise-Anderson Protocol for muscle related pelvic pain with no evidence of infection and no anatomical abnormality, have never seen a satisfactory surgical intervention. We have seen patients who have undergone multiple surgeries in a vain attempt to eradicate their problem. In fact, for these conditions surgery, in our experience, has often hurt the patient, complicated management of their condition, and sometimes created new pain and made it more difficult to treat the original pain and dysfunction. We strongly advise against surgery for the kind of pelvic pain we describe on this website and in our book, A Headache in the Pelvis. Furthermore, pelvic pain with no evidence of infection rarely responds to antibiotic treatment, and we have occasionally seen patients suffer increased problems from antibiotic treatment, particularly when antibiotics are given over long periods of time.

They say they have never seen a satisfactory surgical intervention. I presume they can only be talking about other surgeries such as those you mention above and not LRP, because as we all know we have seen several successful cases. I have read about guys made worse by TURP. I think any partial removal of an already damaged/infected organ has potential to worsen things, thats why LRP has worked because its complete excision of the offending organ.

Statements such as "The evidence is compelling that in these cases, the prostate is not the issue" from the above site, really wind me up because they have no evidence to back them up that the prostate is not the issue. If prostate removal has relieved this many so far, then it totally contradicts their statement with direct evidence.

I have no wish to start a treatment debate here, but I wish people from the wise-anderson protocol would back up their statements with evidence and verifiable examples. If the prostate was not the issue in 95% of cases, then I doubt we would have had any success with LRP so far with the low numbers operated on. They also say there is no evidence of infection in 95% of men. I presume they did an transperineal echo-guided biopsy on all of them into the dark areas of the prostate to verify that?

That said, I am sure they have helped many control their symptoms and that is a valuable option for many.

[Nik]

While we are on the subject of types of surgical procedures I would like to bring these prostatitis clinics to your attention Dr Krongrad, just in-case you hadn't read about them anyway:

http://www.pioa.org/prostatits.html

http://www.prostatitis2000.org/index.htm

http://www.prostatitisclinic.com/

They all involve antibiotic, analgesic & steroid injections directly into the prostate, guided by ultrasound into the dark/infected/calcified areas. A few people are cured, many have lasting relief and for some no benefit is gained from them at all. I think these treatments should be the last attempts at cure before considering LRP. I am seriously considering trying it in the near future. I think imnotcrazy on this site has had a lot of success with Dr Bahn's injections.

Thanks very much for starting this site Dr Krongrad and may it keep growing.

[Arnon Krongrad, MD]

We seem to have several things going on here. Let's explore them:

1) The Disease

Prostatitis is a very poorly understood set of symptoms. Just as with headache in the head, the "headache in the pelvis" cannot be diagnosed with an X-ray, a biopsy, or any objective measure. It is diagnosed with a questionnaire after having excluded other ailments. We call this a diagnosis of exclusion.

2) The Discussion

There is an old lawyer dictum: if you have something to say, say it, but if you have nothing to say, yell. There are very strong opinions about prostatitis, its diagnosis, and its treatments. Opinions are fine but opinions without data are not very useful. Neither is stridency, the extreme form of strong opinions.

Given how little we understand about this illness and given that no treatment has been shown to be absolutely effective in all cases, there is seemingly ample room for subtlety and nuance in our discussions. And plenty of room for us to work together to help the men who fail the treatments they have tried. So if a treatment worked in 70% of cases, then of 1,000 men treated we are left with 300 men who are miserable.. We should work together to find them an appropriate remedy, even when to do so would be to acknowledge that our favored first choice did not work.

We should also acknowledge limitations in what we know and share this with patients, who have a right to know what we know. This network invites insights and input from any interested party, be it about surgery, massage, cayenne pepper, Cymbalta ... whatever. This is an open forum.

3) Anecdote

Anecdotes serve an instructive purpose. They raise hypotheses about what might work and they warn us about possible risk. However, they do not have the ability to test hypotheses. As a very simple example, a single man's experience is insufficient to tell the next man about his probability of faring the same.

The case of David Radford, who summarily ended 8 years of misery with 2 hours of surgery (of the LRP type) and 2 Tylenols and who has been pain free and fully functional for 3 years hence, is not evidence that John Doe will fare the same. The case of David Radford did raise that hypothesis that for some men surgery with LRP will be associated with fewer symptoms some of the time. This is a testable hypothesis. To test this hypothesis will move us from anecdote to far more useful data.

4) Data

There are some terrific data about prostatitis. There are, for example, high quality data to show that alpha blockers are not very effective; we are pleased to have such data because they can tell us what will probably not work.

There are some early data to show that for some men for short periods trigger point release can be useful. These data are not of the quality of the alpha blocker data -- smaller numbers, not randomized, not multicenter -- but they suggest a useful path for some men.

There are treatments about which there are only the most preliminary data. In some cases, as with surgery, we have only collected case reports. So with LRP-type surgery, we have such cases as those of Ike, who publicly shares that his CPSI dropped from 38 preop to 2 post op, who adds personal narrative to give more color to his experience, and who makes himself publicly available for elaboration and discussion. With LRP-type surgery, we also have reports of effectively treated cases by more than one surgeon: Dr Eden and I have publicly shared cases treated effectively with LRP and I am aware of other such cases effectively treated by at least 5 more surgeons.

We also have rumors freed of any specificity -- clinical situation, type of procedure, when was surgery done, who did the surgery, what were the coexisting illnesses, how old were the men -- and/or public and/or direct report. Contrasted with the case of Ike, the rumors are basically impossible to place into useful context.

We start with anecdote, generate hypothesis, test hypothesis, and, with prolonged focus and effort, progressively increase the quality of the data with which to support or reject the hypothesis. This is a path on which we have embarked for LRP-type surgery for chronic prostatitis. The first step is a trial to prospectively collect standardized data about men having LRP-type surgery for chronic prostatitis. It's not the last word, but it's more than an anecdote. We may not have good data today, but we want to have it tomorrow.

5) Surgery

There are many types of surgery. And surgery depends upon the surgeon. So to lump all surgery into one class of treatment would be like lumping medication into one class of treatment. Is aspirin the same as penicillin? No.

To simplify and/or blind us to details of surgery and which type was done is useless. We need detail. As the case of Merlin illustrates, transurethral prostatectomy and simple retropubic prostatectomy were useless, but laparoscopic radical solved a problem of 25 years.

When someone says "surgery," ask: "Which type?"

[Arnon Krongrad, MD]

As with prostate cancer and a thousand other diseases, it's not "one size fits all." It's good that you posted those clinic links. Others may find benefit.

[Nik]

I will post my experience with the injections when I do them.

[Jon]

I'm interested to know what the success rate was for removal of the prostate for chronic prostatitis pre-LRP. I understand surgery for this condition was abandoned, although I don't know when or why. Did some men experience total relief of symptoms? If so, what proportion?
Dr Krongrad's study is important so that we can get this information for LRP. It's great if some men benefit from this procedure, but the essential point is what percentage benefit. Of course, I'm hoping the figure will be extremely high, but only the hard data can tell us its efficacy.

[Arnon Krongrad, MD]

Do you understand that we don't really have a standardized working definition of "effective" in this context?

Ike, for example, has posted that his symptom index dropped from 38 preop to 2 postop. This is not a "total relief of symptoms." If we set "total relief" as the standard of success, very few patients, if any, will find "effective" treatment. So we are left with the burden of defining what we want when we speak of "effective." And the burden of precisely conveying what studies have shown as we help the next patient to make informed decisions.

To be clear, the study relies upon a standard measure of symptoms known as the Chronic Prostatitis Symptom Index, a numerical scale ranging from 0 to 43. The study will quantify changes in CPSI scores over time. This is not the same as assigning a cut-point to represent "effective." So we will not so much say "__ percent had effective treatment" so much as say "CPSI scores dropped by ____ points over ___ months after LRP."

In parallel, we will encourage patients to publicly share their narratives such that facets of their experience not measured by CPSI will be available. While Ike's numerical reports are interesting, I find the color in his narration fascinating and equally useful.

PS: It's hard to say that surgery (which type?) was abandoned because we have no data about how embraced it had been. In all these years, I do not remember hearing even whispers that surgery (which type?) had been done in great volume. As to its abandonment, I have heard stories dating back as early as 1986 of men who got "complete relief" of chronic prostatitis with surgery (which type?). Unfortunately, details remain sketchy and our modern measure, the CPSI, was not applied. So we split time into BR (Before Radford) and now. We are only just beginning to quantify the effect of surgery (which type?) on the symptoms of chronic prostatitis.

[Jon]

Many thanks for the speedy response.