It was the five words I dreaded hearing in sequential order for many years: “You’re going to need surgery.”

The message was delivered last month by my Cedars-Sinai urologist, and a second opinion wasn’t necessary. I’d been warned years ago that my urine retention, or post void residual (PVR), was dangerously high and that I’d eventually need a transurethral resection of the prostate, better known as a TURP. A PVR of 50 to 100 mL is considered healthy with someone in my age group. Mine exceeded 300. I was at great risk of one day not being able to urinate and over time damaging my bladder and kidneys.

My Cedars urologist, who I began seeing about five years ago when I moved to L.A., allowed me to live on borrowed time. As is the case with about 50 percent of men over 55, I developed an enlarged prostate, known medically as benign prostatic hyperplasia (BPH), which in itself isn’t cause for alarm. Although some men fear that an enlarged prostate increases the likelihood of cancer, a study by Michigan’s Beaumont Health published last year indicated the reverse is possibly true: Men with enlarged prostates in the sample study had a lower incidence of prostate cancer.

An enlarged prostate becomes an issue when it wreaks havoc with one’s urinary plumbing. My enlarged prostate was partially blocking my urethra and limiting my urine flow, making it impossible to adequately empty my bladder when I went to the bathroom. An enlarged prostate can cause a host of other problems, including frequent urination, the inability to delay urination, a weak or interrupted urine stream, urinary incontinence, and painful urination.

My PVR exceeded 100 mL for years, but my Cedars urologist said if the need to urinate more often wasn’t a quality-of-life issue, there was no immediate need for surgery. That my Cedars urologist wasn’t pushing surgery like other urologists I’d seen, made me trust him.

I perceived my Cedars urologist as exceptionally competent, possibly the Michelangelo of prostate chiselers.  He said the risk of complications from a TURP was less than one percent because of how he does the procedure, offering up a technical explanation I didn’t quite understand. I felt rushed and disrespected because of an insensitive comment he made. He also glossed over one permanent change that would result even if his TURP was textbook successful: Retrograde ejaculation. Had I not asked about risks and complications, I’m not sure he would have mentioned it.

At Cedars, patients are required to spend one night in the hospital after the surgery and wear a catheter for four days. It takes four to eight weeks for a TURP patient to fully recover and resume normal activities.

The Dangers of a TURP

Put simply, a TURP is a roto-rootering of the prostate, with the point of entry being the penis.  The urologist inserts a thin metal tube called a resectoscope outfitted with a light, camera, and loop of wire that passes through the urethra until it reaches the prostate. The resectoscope is heated with an electric current and the urologist cuts away the problem section of the prostate. A cut even fractionally too deep and it’s possibly a lifetime of diapers for the patient.

When the urologist is finished his handiwork (most TURP surgeons are men), a catheter is then inserted into the urethra to pump fluid into the bladder and flush away the pieces of prostate that have been excised.

A TURP has many risks, my urologist’s one percent claim notwithstanding. The procedure was first performed in 1926 in the UK, and while the equipment used to perform it has significantly improved over the decades (death is no longer listed as a significant risk), one needs to be aware of the potential complications.

Among them are temporary and sometimes persistent incontinence, erectile dysfunction, ongoing difficulties voiding, and urinary tract infections. Risk of infection is also material, particularly at Cedars-Sinai, whose latest safety rating from the Leapfrog hospital watchdog group is a “D.” The hospital was cited for its high incidence of urinary tract infections and sepsis infections after surgery. Leapfrog’s ratings are based on stats predating the pandemic, and hospital infections have since soared nationwide because safety precautions among medical staff have declined.

Another risk that’s not commonly understood is the possibility of contracting covid in a hospital. According to an analysis by Kaiser Health News, more than 10,000 patients in 2020 were diagnosed with covid in a U.S. hospital after being admitted for another ailment. More than 20 percent of these patients died.

My experiences with Cedars-Sinai and its affiliated doctors have been universally disappointing, including the colonoscopy I underwent a year ago. I’d liken the attitude and professionalism of Cedars’ support staff to California’s DMV. I once saw a Cedars doctor whose front desk person took down all my relevant information without ever once making eye contact.

The thought of spending even one night at Cedars was horrific.

My fluctuating PVR

My excessive bladder retention was first diagnosed around 2015 by a Stanford Health urologist in Silicon Valley. I was living in San Francisco at the time and began experiencing sudden and debilitating pelvic attacks so severe that a neighbor once found me in my condo hallway curled up in a fetal position. The pain was so excruciating that if I had owned a gun, I might have killed myself.

The Stanford urologist wasn’t concerned about my pelvic attacks. While examining me, he discovered my excessive urine retention and focused on that. He wanted to book me for a cystoscopy, a painful exploratory TURP-like procedure, sans the roto-rootering. I didn’t like or trust the urologist, particularly since he was indifferent to my pelvic attacks. I sensed he had a quota of cystoscopies to meet, and that he perceived me as a hapless putz who would blindly follow his directives.

Fortunately, a family friend who previously headed another Stanford department found me an alternative urologist. This one had far better credentials, having been trained in the UK in both traditional and laser surgeries. He nixed the need for a cystoscopy, and upon learning that I was drinking more than two 1.5-liter bottles of water daily plus coffee and tea, suggested cutting back on my fluid intake.

As for my pelvic pain, the urologist diagnosed it as an ailment dubbed, “A Headache in the Pelvis.” What causes and triggers the condition is medically unknown, except invariably only Type A people get it. I’m a Type A++ person, so I fit the profile. You can read more about the condition here.

I briefly took Flomax, a commonly used drug to treat BPH conditions, but I didn’t like the side effects, and I rejected Finasteride, a drug used to shrink the prostate, because I didn’t like the risk profile, including increased risk of dementia and the possibility of triggering an aggressive form of prostate cancer.  

Eventually I was referred to an independent urologist in San Jose who trained at Cleveland Clinic, which is renowned for the specialty. After seeing her for a couple of years, she said I needed a TURP. She didn’t perform the procedure, but her urologist husband did.  

What I learned seeing all my urologists was that my PVR fluctuated considerably based on certain conditions, including being tested after an extended drive and whether I was stretching and doing yoga regularly. Without exception, my urologists said none of this mattered.

My PAE Discovery

Returning home after seeing my Cedars urologist I immediately began researching risks associated with TURP and whether there might be a less invasive alternative. Among the first things to show up was this August 26, 2019 article in the New York Times by legendary health columnist Jane Brody.

NYTimes, August 26, 2019

Unfortunately, Brody characterized the TURP as the “gold standard.” I was familiar with most of the information in her column except the UroLift System and Rezum Water Vapor Therapy. Brody cautioned that most of the information touting the benefits of these procedures came from their manufacturers. I’d never undergo a medical procedure based solely on the recommendations and studies of a medical device manufacturer. The industry isn’t dominated by choir boys.

Scrolling through the comments on Brody’s story most recommended by readers, I came across this one posted by someone named Harold in Sarasota, FL.

I recently had a Prostate Artery Embolization procedure. An interventional radiologist blocks the arteries supplying the prostate and the blockage causes the prostate to shrink. Out patient, no catheterization, and quick results.

Under Harold’s comment was this one from C. Hammer in Kosovo.

I did a prostate artery embolization in Vienna. It cost me $11k. One night in private hospital. Immediate results. A mere three weeks later and the prostate has shrunk from a whopping 106 cc to 70. No side effects. All blockage gone. Sleep though the night. Fully empty bladder.

Aetna, my insurer considers it “experimental.” So, I had to fight tooth and nail to get it approved, even though TURP in the USA would have cost twice as much. Exasperating! The medical establishment rejects PAE because they make their money off the other treatments. In this case they are 5 years behind Europeans.

Thomas Burns of Portland, OR, posted this:

For urologists, TURP is both the gold standard procedure and the goose laying golden eggs. In Great Britain their National Health Service recommends the PAE procedure (over TURP) which was developed by a specialty outside urology – radiology. I had mine – in the US, covered by Medicare – three months ago and I am over the moon with its success, no thanks to my urologist who never mentioned it to me (thanks, Google).

More PAE reader testimonials followed. One included a reader shoutout for the radiologist who performed his procedure, Dr. Justin McWilliams.

Justin McWilliams’ Must See Video

Dr. McWilliams, it turned out, is an interventional radiologist at UCLA Health and a professor at the David Geffen School of Medicine, respectively among the top hospitals and medical schools in the country. The hospital and medical school are an easy 15-minute drive from my home.

I quickly found a video McWilliams prepared explaining Prostate Artery Embolization (PAE). It’s well done, but here’s a brief explanation of the procedure.

A PAE blocks the arteries supplying blood flow to the prostate, causing the prostate to shrink over a period of months because its source of sustenance has been curtailed. Because it’s impossible to block the blood flow to the prostate entirely, it doesn’t die. There are typically two arteries feeding the prostate, one on either side. However, there can be more.

Typically, once the prostate shrinks, the urinary problems caused by the enlarged prostate are alleviated or disappear entirely.

A PAE is a technically demanding procedure requiring considerable skill, precision, and patience. It also requires costly state-of-the-art imaging equipment. The interventional radiologist makes a pin-prick sized puncture in the groin or forearm, inserts a microcatheter, and snakes it toward an artery supplying the prostate. Once properly positioned, the radiologist releases thousands of tiny beads that embolizes, or blocks, the blood flow. An experienced and highly skilled radiologist can reach and embolize all the arteries feeding the prostate with a single puncture. The procedure takes two to three hours, depending on the size of the prostatic arteries. The patient is mildly sedated but conscious throughout the procedure.

The PAE procedure was developed independently more than a decade ago by Dr. Francisco Carnevale, a Brazilian interventional radiologist, and João Martins Pisco, a Portuguese interventional radiologist who died in 2019 while attending the meeting of the Society of Interventional Radiology (SIR) in Austin, Texas. Dr. McWilliams was trained by Dr. Carnevale and introduced the PAE procedure at UCLA in 2012. Although he is too modest to make this claim, my research indicates that Dr. McWilliams was among the first, if not the first, to perform a PAE in the U.S.

Dr. Carnevale

There have been several medical studies confirming that a PAE can be an effective alternative to a TURP. Here’s a portion of a study abstract published last October by the NIH:

Prostate artery embolization (PAE) has emerged as a novel treatment option for this common problem with clinical efficacy comparable to the current surgical gold standard, transurethral resection of the prostate (TURP). PAE offers fewer complications and side effects without a need for general anesthesia or hospitalization. 

Indeed, the only critical study I found on PAE was conducted by a urologist and published in 2018 by the BMJ, a prominent medical journal. The study’s conclusion was that PAE wasn’t a proven alternative to a TURP, particularly long term, and should be considered an “experimental treatment modality.” An interventional radiologist I spoke with who asked not to be identified (it wasn’t Dr. McWilliams) told me that the BMJ sample study involved PAE patients whose prostates weren’t sufficiently enlarged to warrant a PAE procedure.

Regardless, Medicare doesn’t cover experimental treatments, but it will pay for a PAE. Many insurance companies won’t, which I consider a disgrace.

An Unexpected Call from Dr. McWilliams

Dr. McWilliams’ video included his email address and I promptly reached out to him, explaining that I was told I needed a TURP but was anxious to learn about the PAE procedure ASAP. Although it was the holiday season, to my surprise McWilliams promptly replied to my email. After a few days of correspondence, he called me out of the blue late on a Friday to manage my expectations.

While studies show that PAE can diminish urine retention, Dr. McWilliams said that a TURP is still a better alternative for those with excessively high PVR levels. He said that he wouldn’t typically do a PAE on someone with a PVR higher than 200-300 mL because there might not be sufficient improvement to prevent long-term bladder damage. Dr. McWilliams also said that he prefers performing PAE for large prostates over 50 cc, as larger prostates tend to have larger prostatic arteries and better clinical results after PAE.

Dr. McWilliams asked if I knew my PVR and prostate size. I recalled my Cedars urologist referring to a 300 number, but as I didn’t know for sure if it referred to my PVR, I didn’t share the information. I didn’t know my prostate size, but I was confident it would meet Dr. McWilliams’ minimum threshold.

Dr. McWilliams put me in touch with a nice woman named Gretel, who managed to schedule me for Jan. 3 back-to-back ultrasound and imaging tests, followed by an immediate appointment with Dr. McWilliams. Thanks to Gretel, I’d know the results of my tests shortly after undergoing them.

Knowing I was doomed to a TURP if my PVR was too high, I began stretching on a near daily basis. I also gave up alcohol, which supposedly can exacerbate urine retention. I wanted every possible edge I could get.

The holiday season couldn’t pass soon enough. I was excited but fearful about my upcoming appointment with Dr. McWilliams.

Rendezvous With Dr. McWilliams

Although I was confident that I could improve my PVR, I didn’t think I could get it down to Dr. McWilliams’ threshold. For weeks I’d been rehearsing a plea in my head explaining to Dr. McWilliams that I understood a PAE wouldn’t be as effective as a TURP, but I was prepared to accept the risk. My anxiety level was such that I began delivering my plea before Dr. McWilliams presented my test findings.

I should have waited. My ultrasound scan revealed my PVR was 160 mL. I was more confident in UCLA’s scan because the tech spent more than 20 minutes scanning me, while my Cedars-Sinai urologist spent less than two minutes doing his ultrasound test.

My prostate size was 88 cc, so I qualified for a PAE. Dr. McWilliams said my artery architecture posed some navigation challenges, but he was confident that he could overcome them.

With a 160 mL PVR, there was no emergency need for me to undergo a PAE or a TURP. But I didn’t want to risk finding myself in a more critical situation a year or two down the road where I might not qualify for a PAE. As I had already talked and corresponded with Dr. McWilliams at length prior to meeting him, I explained my rationale for wanting to go ahead with a PAE. He confirmed my rationale was sound. Dr. McWilliams was incredibly patient with me, answering all my questions and addressing my concerns. I didn’t feel rushed or pressured.

Dr. McWilliams cleared up one discrepancy in the information he previously gave me and everything I had read about PAEs. All the studies and promotional materials I found pegged PAE’s success rate at either 80 percent or 90 percent. Dr. McWilliams cautioned me that in cases where the PVR is very high, that the clinical success rate may be lower, perhaps as low as 50 percent in patients with severely distended bladders.

“I like to under promise and over deliver,” Dr. McWilliams explained.

Lady Luck was looking out for me. Gretel was able to schedule my procedure for the following Tuesday, January 11 at 11 a.m., which required me to show up at the Ronald Reagan UCLA Medical Center at 9. My birthday was the following week. I declared Gretel my BFF and told her she had given me the best birthday present I could ask for.

Processing and Preparation

I was doubtful that it would take two hours to process me and prepare me for my procedure, but I was mistaken. UCLA’s admissions team is competent and well-staffed, and I was immediately taken aside to meet with a young woman who processed my paperwork and prepared my hospital tags. Over the next several hours, I’d be asked to confirm my birth date about a dozen times.

UCLA’s Ronald Reagan Medical Center

After the paperwork was completed, I was instructed to go to the second floor where I was directed to go into a cramped waiting room and sit in an assigned chair, presumably for social distancing purposes. A tech pulled me out to take my blood pressure and other vital signs, and then led me to a curtained area where I was told to change into a gown. A pleasant nurse named Azeb poked and prodded me further, including marking various parts of my body where she found a pulse. The elegance of Azeb’s body markings suggested she has some artistic talents. I appreciated that Azeb laughed at my jokes, perhaps only as a courtesy. 

Looking at my chart, Azeb remarked, “You’re a patient of Dr. McWilliams. You are in really good hands.” I didn’t need the assurances, but I appreciated them, nonetheless.

Dr. McWilliams came by and introduced me to his resident, Dr. Zachary Haber. A medical student who looked a tad shellshocked also was with him. Dr. McWilliams didn’t have to explain the procedure or what to expect, as we had already talked at length. He volunteered he was under no time constraint, a comment that meant a lot to me. I learned from my research that a successful PAE requires laser focus and 100 percent accuracy. It can’t be rushed.

Soon after, the interventional radiology nurse came to fetch me. Her name was Medy. Wheeling me out of my curtained section, Medy cheerfully said, “C’mon. We are going to have a party.”

UCLA’s operating room corridors are long and extensive, and I imagined one could easily get lost. It was clear from Medy’s aplomb this wasn’t her first rodeo.

Undergoing the PAE Procedure

Thanks to my confidence and trust in Dr. McWilliams and his willingness to prepare me for what to expect, I never once feared the procedure except for the initial moment when Medy wheeled me into the procedure room. The spacious, well-lit room had expansive machinery, including as I recall a mechanical-like arm spanning the width of the suite. There were multiple monitors and a covered table, which I soon learned contained all the medical utensils Dr. McWilliams and his team would use on me. There also was a glassed-in viewing area, which I imagine is used for teaching purposes.

Dr. McWilliams had previously briefed me that the sedation was intended to keep me calm, but I told Medy when she came to get me that I preferred to forgo the sedation, mistakenly thinking it would allow me an earlier discharge. Dr. Haber, the resident, suggested I undergo sedation before he inserted the catheter into my groin, which Medy convinced me to do after promising to administer only half the sedative dose that’s normally given. In less than 30 minutes, Medy had already garnered my trust. I found her presence very comforting.

Drs. McWilliams (r) and Haber

Surprisingly, I felt little discomfort when Dr. Haber made his insertion on my right groin. During the following 150 minutes I experienced no pain, except for two brief moments when some diagnostic imaging was performed. Dr. McWilliams explained everything he was doing, which I could observe on the full-sized television monitor to the right of me. It was like watching the Discovery channel, except my prostate and arteries were the stars of the show. My name appeared on top of the screen, so I was even given a credit.

Dr. McWilliams had previously told me that he suspected I might have a third artery feeding my prostate, and his hunch proved correct. He zapped that one as well. I was awed by Dr. McWilliams’ patience, grateful for his obvious attention to detail, and his commitment to excellence.

Some 90 minutes into the procedure I experienced a very Zen awareness. I took in all the state-of-the-art equipment, Dr. McWilliams, and the half dozen other people in the room assisting him. I appreciated I was experiencing the best and latest medical care available in the world for my condition. At that moment, there was no place I’d rather be.

My PAE Recovery

When Dr. McWilliams finished the procedure, I was instructed that I had to keep my right leg ramrod straight for several hours to allow the puncture wound bandage to set. A nurse and an orderly lifted me onto a gurney and Medy wheeled me to recovery. I was delighted that I was again assigned to Azeb to handle my discharge. After about two hours, Azeb called for a wheelchair and an attendant took me to the hospital pharmacy to pick up the drugs Dr. McWilliams prescribed. UCLA’s pharmacy, unlike CVS, is well staffed and I was in and out within minutes.

My cousins pulled up at the front entrance just as I was wheeled outside. As I hadn’t eaten or had any water since the night before, I was hungry and thirsty. We picked up a couple of pizzas and went back to my place for dinner.

A few hours after my discharge, I felt the onslaught of the severe pelvic pain I experienced years ago. I took the pain medication Dr. McWilliams prescribed and I was fine. I took the pain medication again in the morning but stopped after that. Five days later, I was allowed to resume light exercise. Two days more, and I could resume my normal daily activities, including rigorous weight training.

One doesn’t typically experience noticeable improvements from PAE procedures for at least two weeks, but I’ve already noticed some benefits. I’ll spare you the details, except to say I feel like a teenager again.

A Shoutout for UCLA Hospital

Having only once experienced UCLA’s care, I’d be mistaken to make a blanket statement that the extraordinary treatment I received is pervasive throughout the hospital. I’m comfortable saying that Dr. McWilliams is unrivaled with regards to his skills, compassion, and empathy and is the benchmark against which UCLA should judge all its physicians. It’s surprising how down-to-earth Dr. McWilliams is given his credentials and awards.

The cash price for a PAE at UCLA is $19,000. If the procedure is done at UCLA’s ambulatory center in Calabasas, it’s $12,500. Dr. McWilliams only works at the flagship hospital. As an FYI: Calabasas is where the Kardashians live.

I estimate that I interacted with at least 24 medical persons undergoing all my procedures and tests. They all were very professional and engaged. As I have an interest in hospital HR, I asked every person who treated me whether they liked their jobs. While I didn’t expect them to confide if they hated their jobs, without exception everyone said UCLA was a great place to work.

Throughout my time at UCLA, I felt I was in a world-class medical center. U.S. News & World Report ranks the hospital the best in California and third best in the nation. Everyone in L.A. knows this because all the city’s buses are seemingly outfitted with posters trumpeting these details.

UCLA’s medical staff are well served by the hospital’s marketing folks.

Spread the Word

Typically, I wouldn’t share details of my medical history and treatment. But I’m grateful to the New York Times readers who took the time to share their PAE experiences, and I want to make it a tradition. If this post spares just one man from a TURP, it will be well worth the effort.

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