This one is a little more off topic for hiking – however if you have BPH and considering surgery it’s worth a read. This post covers a little history and then the aquablation surgery and recovery. I’ll keep updating it as the recovery continues. I have read online other people’s experience but wanted to share mine in detail. Of course everyone’s experience is different, and as they say, your mileage may vary. At the time of this surgery I was 58 and about 135lb. I hike a lot and that’s the main way I stay fit.
Preamble
About 10 years ago I had noticed symptoms associated with LUTS and went to see a Urologist at OHSU. However I didn’t follow through after the first visit – and at the time the symptoms were pretty manageable. Roll on ten years and they had got quite severe and impacting my quality of life. On the IPSS score was somewhere around a 26. Even thou the human body is pretty fantastic at adapting to change – I decided that it was time to revisit this and schedule another visit with a urologist – about a decade after the first one.
This second round of investigations began in October 8th 2024 and OHSU Urology at Adventist Health Portland. This was just a new patient introduction as apparently after ten years you nob longer count as an existing patient. Not much happened at this meeting except to schedule a follow on meeting to have a cystoscopy on Dec 8th. You can see from the link that this is something to look forward too! In addition to making you feel like an old man – urology issues make you very comfortable discussing what you might consider embarrassing issues with your doctor.
Cystoscopy – December 8th, 2024
Looking back on the entire process – this was probably the worst of everything. A cystoscopy is basically a flexible camera that is inserted up your urethra to give the doctor a visual inspection of your urethra and bladder. This was combined with a TRUS to ultrasound my prostrate for its size and shape. So within a 30 minute visit you have a tube up your penis and one up your rectum. Welcome to the world of old man problems!
The good news is the doctor only saw an enlarge prostrate that measured at 68g. Whereas maybe its should be 30g ish for a man of my age. There were no signs of prostrate cancer. My prostate was constricting the urethra and also bulging into my bladder. And we had a discussion about Aquablation as a treatment. At this point I really had no idea of the treat option available and so would have to some research. He also ordered a blood test to major my PSA.
After the procedure I got a UTI, which although cleared up quickly with antibiotics, was by far the most painful part of the entire process.
Virtual Visit – December 20th
I went off for a couple of weeks and reviews the various options available and formulated a list of questions. I scheduled a video visit with the doctor on Dec 20th where we discussed the procedure again, some alternatives and went through the potential risks and side effects. I also shared with him at this point my PSA – which was 8.6 for which he scheduled an MRI. To some extent PSA is related to the size of the prostate so an elevated PSA, although a potential sign of prostate cancer, can also be a result of an enlarged prostate.
We discussed what would be a positive outcome (increase flow, retention, decrease in frequency) and what would be an bad outcome (any kind of incontinence) and what I didn’t really care about (change in semen volume). Overall, given all the criteria and the fact that my prostrate is not that large – Aquablation seemed like a good fit.
It was at this point that we decided to go ahead with the surgery.
A few days later the surgical scheduler called and scheduled the pre-op visit for March 13th, surgery for March 27th, and the post-op visit for April 23rd.
MRI – February 5th, 2025
Had the scheduled MRI – 9.30 at night. To be clear the MRI was scheduled as “MRI PROSTATE W ENDORECTAL COIL WWO CONT MULTIPARAMET PROST” another opportunity to lie on a table with some device inserted into your rectum! This is the first MRI I have ever had and, outside lasting for over an hour, the results where quite fascinating. The images are fantastic in that you can see all the muscle structures, organs, etc in extreme clarity and effectively sliced through your body. You can see the femur change at the ball of the hip, tail bones of the spine (Shoutout to Siemens Healthineers who were the manufacturer of the MRI machine – and part of the company I work for).
I picked out just a couple of images – not a doctor so I can’t be sure that what I am writing is accurate in any way at all.
More good news from the radiologist “No convincing tumor foci are identified.” which I guessed meant no indication of cancer but they could use some more encouraging language in other parts of their reports!
VESSELS: Unremarkable.
BONES AND SOFT TISSUES: Unremarkable.
Let’s take a quick detour – Health Insurance
Just about at this time, OHSU and United Healthcare sent out letters to patients saying that OHSU would no longer be under contract come the 1st of April. This resulted in more stress than any medical issue and I spent more time calling billing and insurance to find out what would be covered and what would happen if insurance contract ended a few days after the surgery? Would my post-up be covered? I went as far to find another provider who would be in network for the whole procedure and got another referral. For about two months there was no reliable information from OHSU or UHC on anything. I went as far as calling OHSU to cancel the surgery and was then assured that the surgery and everything up to 90 days after would be covered. Was told this by both the hospital and the insurance company – but could get neither to provide this in writing.
There was absolutely nothing in this process that was patient centric, of a medical benefit and merely created a significant amount of stress.
Pre-op visit – March 13th 2025
Being just about confident enough that the procedures were going to be covered – I proceed with a very uneventful pre-op visit. Not being on any medications and being relatively healthy there were no conditions that gave any concern. A urine test showed a very small amount of bacteria, for which the doctor prescribed some antibiotics to start before the surgery.
Aquablation Surgery – March 27th 2025
I can’t say I was looking forward to the surgery – but I was definitely not nervous and was very hopeful for a positive outcome. The surgery was scheduled for 11.15am, with an arrival time of 9.15am. No food after midnight the night prior and only clear liquids up until 7.15am.
We arrived at the hospital at around 9am and checked-in – the initial part of the process was mainly financial – to be honest discussing finances just before surgery was probably not what I wanted to do – maybe that’s why they do it then. Indeed I have failed to get a complete estimate for the cost of procedure and again this is a very non-centric patient part of the process.
After that the real part of the day got underway – surgery, or any medical procedure, is a very personal experience for the patient, but for the staff it’s just part of their daily routine. It’s overall swift and efficient. We checked in to a room on the second floor – it has the schedule for the day on the a whiteboard:
Transport: 10.45am
Surgery: 11.15am
Post Op: 12.45pm
Short Term: 1.15pm
I changed into the surgical gown and put all my personal items in a couple of bags. Given that I was to spend the night in hospital, I had bought a few things with me – but kept it to a bare minimum. I had to sign one consent form and actually had plenty of time to read it and answer a bunch of questions. There was a little bit of hanging around and waiting at this point in the process. My wife had brought me to the hospital and she now left. We agreed that the doctor would call her after the surgery, just to let her know how it had gone. They fitted me with some massage equipment for my calfs so that post surgery they would automatically massage them to prevent blood clots.
At about 10.30 they moved me to pre-op – little ahead of schedule.
Pre-op
I was skillfully navigated down to the first floor on the gurney and parked in pre-op. Things start to move a little quicker. A nurse checks that I know who I am and why I am here (have to answer that question a lot). She sets the IV – this hurts quite a lot – in terms of pain – this might be the most pain I experienced the day – and it lasts about 3 seconds. They give me a Tylenol.
I meet the anesthesiologist – she asks me who I am and why I am here – asks another bunch of medical questions. But this lasts just a couple of minutes. One of the OR nurses stops by to say high as well. They are about to move me into the OR but have to wait for the doctor to come around. He does, asks if I have any questions, which I don’t and they are wheeling me the 20 yards from pre-op into the OR.
Surgery itself
I remember being rolled into the OR – but my memory literally stops at about moving through the doors. I have no recollection of any conversation I had in there – if anyone spoke to me – to when the general anesthetic was actually administered. The next thing I remember is waking up in the recovery. So everything here is summarized from the doctor’s notes, which I have shortened some.
Procedure in Detail:
The patient was met in the preoperative holding area. His identity was confirmed by name and date of birth by the preoperative staff. All questions were answered to his satisfaction and informed consent was then obtained. The patient was then brought back to the operating room and placed supine on the operating room table. Following an uneventful induction of general anesthesia, the patient was placed in a relaxed dorsal lithotomy position with careful attention being paid to pad all pressure points and to ensure that no joint was flexed beyond 90 degrees.
The Aquablation treatment zones were planned utilizing real-time TRUS to visualize the contour of the prostate and the depth and radial angles of resection were defined in the transverse view. In the sagittal view, the AQUABEAM nozzle was identified and position registered with the software. The treatment contours were then adjusted to conform to the intended resection margins. The bladder neck and verumontanum were marked and confirmed in the treatment contour.
The Aquablation Treatment was then started following the resection contour confirmed under ultrasound guidance.
TOTAL AQUABLATION RESECTION TIME: 7min
Once Aquablation resection was complete, cystoscopy and tissue/clot evacuation was performed using a 26 Fr resectoscope until light pink. Focal bladder neck cautery was performed and minimal obstructive tissue at the bladder neck was resected. This was sent for pathology. Hemostasis was excellent at the end of the case.
A 20Fr 3-way foley catheter was inserted under ultrasound guidance. Balloon was inflated to 30 cc. Balloon positioning was confirmed and CBI started.
Ultrasound probe was then removed.
The catheter was placed on moderate tension and continuous bladder irrigation was started in the operating room.
The patient was then taken out of relaxed dorsal lithotomy position and awoken uneventfully from general anesthesia. The catheter was secured on gentle tension. The patient was transferred to the postanesthesia care unit in good and stable condition.
DISPOSITION:
The patient will be admitted to the urology service overnight for monitoring.
Luckily I remember none of this. However I am very thankful to the surgical team for their skillful work.
Post-op
I have had general anesthetics just a few time and I find waking up from them quite odd. Not only is there no perception of how long I was unconscious for – the first few minutes are just a vague recollection of pieces that don’t fit well together. I remember asking the nurse multiple times the same question – what time was it. I think it was here that they removed what I assume were the EKG pads – but I don’t recall them ever putting them on. But other than that memories are disjoint and vague. From what I can figure out I went into surgery at about 11am, 15 minutes early – it ended about 11.40 and I was in the post-op recovery until just after 12. At this point no real sensation of pain – but also not really back in the work of reality.
Short-term recovery
I am going to guess at around 12 they wheel me out of Post-op and into the short term, post operative room where I’ll spend the night. This is on the 5th floor so again some skillful navigation of the gurney. Reality is now getting a but more concrete. I meet Brian, the nurse who will be looking after me for most of the day. At this point I notice that in addition to the IV drip there are two bags of saline at the end of the bed and probably about now I feel the discomfort from the catheter. It’s not a pain but it is definitely a discomfort. It’s secured to the side of my leg but anything that pulls it in a different direction increases the discomfort exponentially.
You can see from the doctor’s notes that this flush was started in the OR when they set the catheter. I was aware of this part of the procedure from all the reading I had done. This was to continue until 3am. At the moment the liquid going in was clear and the liquid coming out was cranberry juice colored.
They connected the massage boots to a machine that gave a very nice leg massage!
During the course of the afternoon – Brian would come in and check my vitals – all ok. Ask about pain – again none really. My throat was just a little bit sore – I assume from the tube for breathing and outside of that just the general discomfort from the catheter. As far as I can remember the only pain medication I had for the entire procedure was the Tylenol earlier in the day.
At around 2pm I had a light lunch – soup and a cheese plate – pretty good and no problems eating it. Drank some cranberry juice. Feeling pretty good. At around 3pm, with the help of Brian I went for a gentle walk around the wing – no real problems either, nice to get out of bed. Great chat with Brian who is a snowboarder and hiker.
At around 5pm I had dinner – I moved to a chair to have dinner. After dinner, while still seated in the chair i felt the pressure start to build in my bladder – this resulted in some blood, saline and urine – leaking around the catheter. Called Brian who took a look and thought it was still draining ok into the catheter bag. Five minutes later had to call Brian again – definitely not ok – more leaking and quite a lot of discomfort. Brian moved me back to the bed and proceeds to back flush the catheter (for those of you who are hikers, think of cleaning a Sawyer filter). With a syringe he injected maybe another 100ml of saline into what is already a full bladder and then pulls it out and along with it a relatively small blood clot. After that he reconnects the catheter bag and instantly everything begins to feel much better.
This was the only time anything happened remotely concerning.
The emptying of the catheter bag is a regular part of the day. At 7PM the nurses switch shifts, Brian leaves and Giovanna will be looking after me for the night. She is happy with the color of the liquid – says it’s progressing very well and getting lighter. All looks good for a discharge the next day.
At around 10pm I go for another walk around the wing – no issues there either.
Recovery Day 1 – March 28th, 2025
Overall I got very little sleep – it was not so much the discomfort as it was all the odd machine sounds and lights from them. Every two hours they would come in and check vitals etc and at 3am they closed off the saline flush. I was still drinking plenty of fluids. I guess I managed to catch about three hours of napping – but also read quite a lot. It got pretty uncomfortable lying on my back in the same position – but moving would just stress the catheter a little.
At 7am the next morning Brian comes back and Giovanna leaves. Again happy with the progress of the liquid in the catheter bag. Should be good for a morning discharge. Have breakfast and some coffee.
McKenzie comes around, the doctor’s PA and goes over how I am feeling, checks all my vitals, says the procedure went well. Goes over the discharge stuff and what to expect. We have a conversation about recovery and when I should engage in certain activities and the general gist is when there is no more blood in the urine you can start to go back to normal activities.
Brian retunes to remove the catheter. One of the preconditions for discharge is that you can void without the catheter and without problems. He fills my bladder with about 300ml of liquid from the saline flush and then removes the catheter. This is definitely a moment I had not been looking forward too. I had imagines it to be quite awful but he says take a deep breath and pulls it out in one, fairly quick motion. It’s not too painful and I feel instantly much better than when it was in. He then removes the patch that was holding to my leg – and of course that hurts more as it rips some hair out as well.
I quickly go and urinate as my bladder was pretty full. Brian had given me a plastic urinal bottle. I urinate into it and it is 1000% better than I have urinated in the last 10 years. The improvement is instant and incredible. Holy Shit.
The last thing to come out is the IV – nothing notable except more hair comes off with all the tape. At this point I am really feeling pretty good. There is no pain. The discomfort from the catheter is gone. I am no longer tied to all the tubes. We go through the discharge papers, which I sign and then wait for my wife to arrive. I urinate twice more while waiting – and in both cases pass blood clots – they are not large – and Brian is not too concerned about them. When I urinate there is pain from the tip of my penis but nothing like the UTI I had several moths ago.
At around noon my wife arrives and we leave. I had been in hospital for just over 24 hours. A huge thanks to Brian, Giovanna and the entire care team. The food was pretty good too!
We were home by 1PM – at this point everything feels very good. I am ecstatic at the results of the surgery. The rest of the day passes uneventfully. I bought the urinal bottle back from the hospital so that I can easily check for clots – however there is just very small amount of debris. The color is still tinged with blood – but it is quite light and only present at the start of urination.
I go to bed at about 10pm, not having had much sleep the night before. I get up at about 2.30 to pee, which has been pretty normal, except now it only takes a few seconds. And then sleep though until 6, which is when I normally get up any way.
Recovery Day 2 – 29th March
So I am feeling pretty good at this point. Just a little pain when I urinate, but nothing where medication is needed. When I urinate it just has a tinge of red in it but already you can see it a little more urine colored. I feel great and am super happy with the surgery so far. Flow has dramatically increased retention has dropped a lot, there is no hesitancy to starting, no leaking or incontinence. There are still some things I need to work on – the biggest is volume – I have to retrain my bladder a little for that and it is a well known effect from having BPH. The urgency is still there as well. But I would say at the moment my IPSS score dropped from 26 to around 8 almost instantly.
Time to take the dog out for a walk! 1.5 miles. The rest of the day was very normal – some shopping. Out and about as normal. At the end of the second day there is nothing that is worse than before surgery and the majority of urinary symptoms are much better. I decided to start a bladder diary – I would like to increase the urinary volume and decrease the frequency a little. This might take a some time.
Recovery Day 3 – 30th March
Uneventful night – got up once to urinate and then at around 6.30am as I normally do. My smart watch says I am very rested! There is almost no blood tinge to the urine this morning at all.
I’m still cautious with my activities and want to make sure I don’t overdo any exercise early in the recovery. But I do feel comfortable taking Hunter for a 3 mile walk, just a little bit slower than pre-surgery.
I did urinate some tissue today – I did not feel this and it was definitely not a blood clot – but looked like a small, white, fibrous piece of fluff. I told my wife who looked at me quizzically and asked how a piece of tissue could have gotten into my bladder and whether the surgeon had left it there. Hilarious.
Recovery Day 4-8 – 31st March – 4th April
Back to work week. To be honest at this point there is not much difference from day to day. Everything is feeling great. There is possibly only a hint of blood in my urine but then again maybe not. Very occasionally there have been some very small blood clots, but they are very small. There is no pain at all. I feel comfortable enough to organize some travel for the week of the 14th April.
I moved from caffeinated coffee to decaf with the understanding that caffein can be a bladder irritant. Too early to tell if this will make a difference – but it was a very easy transition – I think I just need a hot drink the morning. On Friday I did overdo the decaf a little and that led to a feeling of urgency and frequency I hadn’t had earlier.
I know the doctor said not to do anything intensive – it’s always difficult to know what intensive means – if it’s about lifting weights I have pretty much avoided doing that for the last 58 years! Friday was beautiful night so I decided to spend it backpacking on Mount Hood – a 2 miles hike in – spent the night camped out next to Mirror Lake. No issues with the backpack or the entire trip – and it was great to be able to take leak outside and not have to worry about urine hitting your feet!
Recovery Week 2 – April 5th – April 12th
Week one was fantastic. Maybe too good. Week two turned into a little bit of a disappointment. Whether this is just part of the recovery process or it’s just a step back – I’ll have to wait and see. At the start of the week there was definitely an increase in the amount of blood in my urine – not a lot, and just at the start and the end of urination, but definitely more than in most of the previous week. It was certainly not enough to get worried about but seemed like a step back. Towards the end of the week, this seemed to have dropped off again.
Perhaps a little more disappointing is that the flow rate seems to have dropped off quite a lot. It now feels somewhere in the middle of before surgery and last week. It’s definitely an improvement but feels definitely like a step back. This seemed it have happened fairly quickly somewhere either at the end of last week or the beginning of this week and has also now stabilized.
I have read some about the potential formation of scar tissue that has to be removed later or sometimes just part of the recovery process and it recovers after a few more weeks. I’ll have to wait and see. I have the post op appointment in 2 weeks.
There still has been no pain in the recovery process.
Recovery Week 3 – April 13th – April 19th
Everything was pretty stable this week. I travelled for work for most of the week and it was pretty uneventful. Blood as disappeared completely. Everything seems to have stabilized. The flow rate has stayed the same. Better than before surgery but not as good as week one.
My biggest concerns remain the frequency and urgency.
Recovery Week 4 – April 20th – April 6th
Two major highlights from this week. The good news is now retrograde ejaculation. So all of that seems to be good. This week was all the week of my post op follow-up. I met with Dr. Koprowski – overall it was a brief meeting as everything seems to be going fine. I brought up the weakening of the stream and the urgency – he seemed to think that everything is progressing well and it may take up to three months for the bladder to readjust. At this point he recommends continuing the recover for the next couple of months and then get back in touch if there are any concerns.
