Posted 12/28/2014 11:21 PM (GMT -6)
Muchisimos apologies in advance for this super-long post.
To Fence-Sitters and Associated Lurkers:
My advice is to get the GG procedure...providing that you can easily afford it. The downside is limited: Nothing as far as I've heard. If worst comes to worst, you would be out $25K or whatever, but otherwise be whole and undamaged.
Here's my take on the GG-decision calculus:
If you have some type of varicose-vein situation going on in your abdomen, then the GG procedure may totally fail. There might be collateral bypasses that cannot be sealed, foiling the procedure. Or, another bypass could arise later on, causing failure down the road. Either way, there will be pressure and backflow to the veins that drain the prostate and other organs, and there will be no benefits from the procedure.
What are the odds? I know that this has already happened to one member of this board, so the odds have to be greater than zero. I suppose that there's a 10 or 20 percent of either initial failure or subsequent failure. That's just my guess; I have no data to support that.
Say the chance of outright failure is 20%. That still leaves 80% who will benefit from the procedure to one degree or another. Naturally, that includes benefits to the prostate and LUTS-type symptoms. But it also includes possible benefits to other organs which share the same venous drainage, including the bladder and testes. I believe that I personally have seen helpful benefits in both these areas from my May 2011 GG procedure.
There is also a theoretical benefit of lowered risk of prostate cancer (PCa). I myself viewed this as a "fail-safe benefit" when deciding to get the procedure. Having already experienced benefits to my LUTS syndromes and an objective shrinkage in my prostate, I also hope to be at lower risk of PCa as I age. A trifecta of prostate-related benefits. Guys might also enjoy increased fertility from GG, but I doubt this would be an issue to many guys reading this board.
If 80 out of 100 GG patients eventually reap a benefit, it's still a fact that not all 80 will have a great resolution of prostate issues. Thanks to Martin's posts, forum readers now know that an enlarged median lobe is one condition that might foretell a less-than-satisfactory outcome. I suspect that guys with really humongous prostates or who had symptoms for decades may also not have fully satisfactory results. (I have no data to support that last statement; I'm merely doing armchair speculating. And bear in mind that I'm a patient not a doctor.) So out of those 80 guys who might theoretically benefit from GG, perhaps 30 to 70 might have really good symptom resolution. So is it closer to 30 or closer to 70? Beats me.
As Bob so sagely observed (I'm liberally paraphrasing): If a particular treatment happens to work for you, then you think that particular treatment has a 100% success rate. And should it fail, then the treatment has a 100% failure rate. (Subjunctive aficionados: We call your attention to the use of "should fail" above.)
Even if the GG procedure fails, you have still kept all your options open. And if GG has halted the slow, annual growth of your prostate, isn't that a good thing? It means that your follow-up laser or TURP or Urolift or whatever procedure will last that much longer without needing to be repeated or replaced.
"You pays your money and takes your chances." It's your body, your money and ultimately your decision. In health as in life.
I've said it before and I'll say it again: I most regret not having this procedure done 20 or 30 years earlier. In the future, I think that GG might come into its own as an early-intervention, quasi-preventative procedure to be undertaken soon after symptoms first emerge. But that's the future, it's not where we're at now. Instead, the current treatment paradigm is to wait until the prostate/BPH/etc problems become so unbearable that guys have no choice but to do *something*. And then they start looking at their "alternatives": the lasers, TURPS, etc, etc, etc. To me this is positively medieval. I hope and I trust that in 50 years medicine will have a completely different mindset in treating male "age-related" "prostate" "problems".
In the meantime, I recommend GG for guys who can afford to place a calculated bet on an experimental procedure.
Now, my take on the how GG works to restore circulation to the prostate, bladder and testes. This was hashed out at length in the Fall of 2013. (Those posts are still available for the reader's edification and/or amusement.) I'm fairly burnt out on this discussion, and I'd wager that Thunder and Martin are similarly disinclined to revisit this territory. But here's my recollection of our conclusions, amended and simplified by my rapidly deteriorating senior-citizen (age: 57) memory.
The Intra-Spermatic Veins (ISVs) span from near the scrotum to the renal vein (as Thunder reminds us). There are two of them, one on the right and one on the left. Their job is to drain the prostate circulation by returning the oxygen-depleted blood back to the heart and lungs.
Unfortunately, there is insufficient blood pressure there to optimally force the venous blood through the ISVs simply from the action of the heart. To lift the venous blood from the prostate-level to the kidney level, nature has devised a series of one-way valves. These are the notorious "valves" we've been talking about. The ISV valves have a dual-function: (1) When mechanically sound, they help return venous blood to the heart. (2) When busted, they help support the lifestyles of various medical specialists. Let's look at (1) in more detail.
When you bend your torso while moving, the ISVs are squeezed. Now consider what would happen without any valves: This squeezing would force the venous blood in the each ISV down and up at the same time. When you unbend your torso, the blood would rush back in, leaving things much as they were before. No net movement of blood would occur. Now imagine the same system with working one-way valves, which permit flow going up (toward the heart), but block flow going down (toward the prostate). The squeezing of each ISV still forces the same amount of blood out of the ISV, but the working valves channel all this blood up and out of the ISV on its way to the heart. When the squeezing stops, the ejected blood is blocked from re-entering the ISV by the topmost valve, which also impeded Dr. Goren in my procedure. The partial vacuum allows new blood to enter the ISV from below, and the cycle repeats the next time you move. This the normal function of the ISV when the valves are working to block backflow ("reflux").
Under Dr. Gat's hypotheses, these valves eventually fail in many/most men, and the ISVs no longer drain the prostate. The action of the ISVs with failed valves will be like ISVs with no valves above, as described above. Here's a visual image that came out of last year's discussions. Imagine two pencil-thick tubes filled with blood sitting atop the prostate. These represent the ISVs with failed valves. The blood there just bounces up and down, but doesn't actually flow, blocking the drainage of the prostate area.
The GG procedure seals up ("sclerotizes", from the latin word for "harden") the ISVs. Often there will be collateral bypasses that run in parallel to the ISVs along some of their length. Naturally, these collaterals lack any one-way valves. They represent some type of "varicose" process going on. As I'm not a doctor, I don't understand exactly how they arise. Some men have them, and some men don't. I did not have them; the difficulty in my procedure arose only from the difficulty in guiding the catheter tip and in obtaining access to the ISVs which were blocked by the topmost valve, which happened to be working. Dr. Goren said that it's not uncommon for the topmost valve to work even after the lower valves have already failed. The other thing I know about collaterals is that they might grow in some men *after* the GG procedure, but no one really knows exactly how often this might happen or when. In either case, untreated collaterals are bad news and will block the benefits of the GG procedure.
(It's very possible that the GG procedure sclerotizes other minor veins, too, as Golfosca has reported. I am content to leave the mastery of its subtleties to Dr. Goren and his colleagues. It would not surprise me--in fact, I would expect it--that the procedure is done slightly differently for different cases. After all, most medical procedures need to be customized to the patient for best effect.)
Now for the $64,000 question: How does sealing up the ISVs help restore the normal circulation of the lower abdomen? After all, the ISV is the main return path of venous return to the heart. So it's counterintuitive, to say the least, that by blocking the main return path, the flow can be improved. It's sort of like saying that North-South traffic in the Los Angeles area could be improved by permanently closing the 5, 100 and 405 freeways. This is where things get squirrelly and complicated. At one time, while deciding whether or not to go forward with the procedure, I was very interested in this question. Not only did I read all of Dr. Gat's paper where he tried to explain it, but I also read the emails from Dr. Gat which explained how it all worked with a lot of math equations. Alas! Though I may have known at one time, now I don't.
As I recall through the dim mists of memory, there is indeed an alternate return path for venous blood from the prostate to return to the heart (as Martin confirmed). This alternate route has different diameters of veins and according to some strange laws of hydrodynamics--which govern the movement of the blood through the circulation--the particular combination of the small diameter veins with the larger diameter veins they connect with, allow the miracle of increased circulation. (I said above that the pressure in the ISVs was not enough to optimally return venous blood to the heart. Maybe I misremembered: Maybe it was enough, but that the normal ISVs acted as a turbo-charged system for venous return. It's complicated, guys, so be warned.)
Go back to the image: Imagine the pencil-thick ISVs bouncing up and down as the body twists, sucking up venous blood from the prostate area and splashing it back and forth, interfering with the flow in the alternate return path. Now imagine those ISVs totally sealed off, and the venous blood placidly flowing through the alternate path back to the heart. Now imagine that the improved drainage brings a lot more fresh blood to the prostate/bladder/testes region and that this new fresh blood improves the function of those organs. Better function=fewer problems.
Granted, this is an exercise in visualization rather than a scientific demonstration of how GG improves the circulation. But at least it helps one keep in mind what the issues are.
As I said, before my procedure, these theoretical issues were a major concern for me. Now, three years later with good results, I don't care. Maybe Dr. Goren told me the truth about blocking the ISVs as I watched the monitor in the hospital. Or maybe the monitor was merely a clever Potemkin-style ruse to hide the fact that he was injecting smart nanobots into my groin to rebuild the prostate and bladder. Or possibly elves or medical fairies were somehow involved. I used to care about all these details, now I'm pretty blase.
So that's my fuzzily remembered take on the GG procedure. Before I let you go I want to call your attention Dr. Gat's findings about increased testosterone (T) concentrations in the prostate circulation. This has been discussed previously on this forum, most recently by Golfosca. Dr. Gat measured the T concentration at a point in the circulation in hydrostatic connection with the prostate circulation. I think this measurement was done on just one patient, but it's probably a very tricky measurement. The T concentration was like 130 times (more than 10,000 percent!) higher than elsewhere in the patient. Back to the imagination exercises: Imagine bathing your prostate and bladder in a T concentration 100 times larger than usual, and with oxygen-depleted blood to boot. Do you think your prostate and bladder would appreciate this? Now imagine asking your personal physician for a prescription of T to raise your overall T level 100 times. Do you think he'd give you such a script, given that MDs agonize over prescribing doses of T to raise the T concentration to 2 or 3 times pre-treatment levels? Granted, this measurement was performed on just a single patient, but it's pretty disturbing if it's representative of the situation in guys with busted ISV valves, which is many guys eventually.
Guys: If you want to edit or modify one of your earlier posts, just click one of the icons at the upper-right of the post in question. If you don't see the icons, then you probably have to sign-in again to the forum.
Martin: I agree that the etiology of BPH is probably multifactorial (where "multifactorial" is construed in its technical sense of "heck if I know").
Seasons Greetings To One and All!