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User
Posted 28 Sep 2019 at 09:16

I have a 3 year PSA which went up and down below 10, a 2mm tumour on mfMRI, a Gleason 3+4 with the 4 being 10% on multifocal TP biopsy within capsule and no perineural spread. I have been offered AS, HIFU and I am going for another opinion where brachytherapy and RT is their thing. What would you suggest? Im 77 and my grandfather died of PCa at 94. Father KIA. Prostate vol 70ml so will probably be offered hormones. What are they like? Im sort of OK with AS, but feel treatment now when fit might be better than waiting until Im older and less fit. Everyone lived into their 90s! Comments?

User
Posted 28 Sep 2019 at 13:39

Interesting that you have been offered HIFU. I believe it to be the mildest option for suitable candidates as you appear to be, particularly with a small tumour on one side. I walked around London in the afternoon having had the procedure in the morning. The side effects for most people are less than surgery or radiation. It can be repeated if necessary (depending on location of tumour) or RT or surgery can be done if later treatment is required. It is still one of the treatments that is regarded as experimental, only because there have been insufficient years to establish long term effects. I would look into this possibility carefully as indeed you should also for other options that are open to you. Ultimately it is your decision because each type of treatment has its pros and cons.

PS You might care to look at this interview with the widely acknowledged top man in the UK (and further afield) on Focal Therapy https://www.canceractive.com/article/professor-mark-emberton-on-high-intensity-focussed-ultrasound-or-hifu Since this interview MRI has been increasingly rolled out and advances in scan are ongoing. Also, more recently https://www.sciencedaily.com/releases/2018/07/180705114140.htm

Edited by member 28 Sep 2019 at 14:37  | Reason: Link

Barry
User
Posted 28 Sep 2019 at 14:22

Hi Doc,

I had a choice of Robotic removal but asked about Brachytherapy and was it suitable for my Gleason 4+3 =7 and PSA 2.19 and decided after reading all the pros and cons I had the Brachytherapy in September 2016 and so far three year on with my PSA down to 0.22 in January 2019 and next blood test in January 2020 I have been very lucky.

Click on my Avatar for more details and if you have any other questions please ask.

John.

User
Posted 28 Sep 2019 at 14:30
Some cancer centres offer onsite accommodation Monday-Friday for people with lengthy journeys to get there. That may perhaps be an option considering your potential 5h daily journey.

Best wishes,

Chris

User
Posted 28 Sep 2019 at 14:50
Had my HIFU at UCLH in London. as this and the Transperineal Template biopsy that preceded it, I was accommodated in their nearby 'Cotton Rooms' and a Hotel respectively overnight. Also, on a subsequent Template biopsy 3 years later I was accommodated in a ward overnight at you mustn't drive within 24 hours of the anesthetic.
Barry
User
Posted 28 Sep 2019 at 15:37
Hi doctor doolittle... Please access my profile for details of my treatment. I had to have hormone treatment prior to seed Brachytherapy

Regards Tom

User
Posted 28 Sep 2019 at 15:54

Thanks for Mark Emberton’s article. I still have the option to go back to UCLH, just thought a second opinion no bad thing. The US papers do show a significant recurrence after HIFU, but then, as you say, you can always have more, or something different! Thanks for sharing your experience. We have a good train service to Kings Cross too.

User
Posted 01 Oct 2019 at 14:25

The general view is that there is not a lot of difference between the effectiveness of various radical treatments for which men are suitable. However there are of of course major differences in the way the treatment is applied and it's potential and varying side effects. There is so much information about about surgery and various forms of radiation that I referred more to HIFU which is less well known, because I researched it and had it (following failed RT), not because I believe it is better than other treatments other than having milder side effects and being repeatable. I wouldn't be swayed by the early American results because HIFU now stands comparison with other treatments for suitable men. TULSA PRO is a similar procedure that may prove even better (I leave you to investigate it).https://community.prostatecanceruk.org/posts/t21556-TULSA-PRO-V-HIFU

UCLH provides excellent treatment but from my experience and others who have commented on here, their admin has been shown to be poor on a number of occasions - so needs patients to check everything very carefully.

Edited by member 01 Oct 2019 at 14:34  | Reason: Not specified

Barry
User
Posted 26 Jun 2020 at 22:19
It will be really useful if you can keep updating your thread leading up to and after you have had HIFU - going into it knowing that it might need to be repeated is a risk but at 78 and with the challenges of a long round trip for normal radiotherapy, I can see why you are taking the HIFU route. Very exciting for those who will follow in the future as there is so little data to support it as a primary treatment at the minute.

Best of luck to you.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 27 Jun 2020 at 14:14

I found the Bars Statlock really useful post op. I out the 2nd on my other thigh so I could ‘load balance’ the wear and tear on my poor urethra opening. Worked well and didn’t budge. http://www.bardmedical.co.uk/STATLOCKFoleyStabilisationDevice

User
Posted 27 Jun 2020 at 16:49

Doctor D

Good advice from TechGuy about Bard statlock device, remove them after 7 days ,they can burn / irritate the skin. Not all catheters fit the statlocks you will need to check. I also use thigh straps, and leg sleeves. At night I attach the night bag to the leg bag and attach the night bag tube to a thigh strap around my ankle, you could wear PJ bottoms, but a bit hot at present.  Make sure all connections are tight even the ones the nurses do. Ask for some instilagel or hydrocaine, some trusts have stopped using it in catheter care due to adverse reactions. Oddly their protocol says do not use it unless the patient insists ??

Wear snug, but not tight underwear and perhaps a light pad in case of by passing or leaking.

Hope all goes well.

Thanks Chris

 

 

Edited by member 27 Jun 2020 at 17:55  | Reason: Not specified

User
Posted 27 Jun 2020 at 17:23
If you have HIFU at UCLH like me you will wake up with your catheter fitted and will have it removed about a week.later. It was to have been done by a nurse but my GP removed it in the morning and said if I had not passed water by that afternoon, I was to go to A&E. Fortunately, I beat the deadline time he stipulated.
Barry
User
Posted 27 Jun 2020 at 17:26

Hi there

My husband had a HIFU pre lockdown (which meant we could stay over). I documented the experience of procedure and catheter here:

https://community.prostatecanceruk.org/posts/t23095-Focal-HIFU

It was a BUPA job but Mrs Prostate all the same.

 

Good Luck

 

Clare

 

 

User
Posted 30 Jul 2020 at 14:45
Thank you for detailing your experience. You rightly say that that another man may have a different experience to you in certain respects but broadly speaking I think most men would find it similar in most respects and less taxing than they anticipated. In my case I had no leakage of blood or urine. I was uncomfortable, particularly a day or two after the procedure when the bruising became more evident for a few days. During this time I slept in an armchair with adjustable fold down back which helped. About a week after the HIFU my GP removed the catheter and I immediately felt much more comfortable. As you say, only the tumour was removed that was really thought necessary and should another develop to the extent that it should be treated, further HIFU can be delivered, assuming it can be reached with the wand and focused on and that there is not too much calcification.

A few years ago there was a risk of a fistula developing but with improvements in techniques this is now a very rare possibility. In fact the lady surgeon who did my procedure and had done hundreds of others had not had a patient of her's develop one.

So for now all seems to be promising. We should be very interested to learn how things go for you.

Barry
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User
Posted 28 Sep 2019 at 13:00
Do you have any flow issues at all? Brachytherapy makes the prostate swell up and can cause issues for older men and men with larger prostates.

I've been down the HT/RT treatment route myself and have found it relatively plain sailing with no major side-effects.

Best wishes,

Chris

User
Posted 28 Sep 2019 at 13:35

Thanks! No flow issues, but after reading research papers see its likely to require HT before treatment to shrink from 70ml. RT is a 5 hour round trip each day.....

User
Posted 28 Sep 2019 at 13:39

Interesting that you have been offered HIFU. I believe it to be the mildest option for suitable candidates as you appear to be, particularly with a small tumour on one side. I walked around London in the afternoon having had the procedure in the morning. The side effects for most people are less than surgery or radiation. It can be repeated if necessary (depending on location of tumour) or RT or surgery can be done if later treatment is required. It is still one of the treatments that is regarded as experimental, only because there have been insufficient years to establish long term effects. I would look into this possibility carefully as indeed you should also for other options that are open to you. Ultimately it is your decision because each type of treatment has its pros and cons.

PS You might care to look at this interview with the widely acknowledged top man in the UK (and further afield) on Focal Therapy https://www.canceractive.com/article/professor-mark-emberton-on-high-intensity-focussed-ultrasound-or-hifu Since this interview MRI has been increasingly rolled out and advances in scan are ongoing. Also, more recently https://www.sciencedaily.com/releases/2018/07/180705114140.htm

Edited by member 28 Sep 2019 at 14:37  | Reason: Link

Barry
User
Posted 28 Sep 2019 at 14:22

Hi Doc,

I had a choice of Robotic removal but asked about Brachytherapy and was it suitable for my Gleason 4+3 =7 and PSA 2.19 and decided after reading all the pros and cons I had the Brachytherapy in September 2016 and so far three year on with my PSA down to 0.22 in January 2019 and next blood test in January 2020 I have been very lucky.

Click on my Avatar for more details and if you have any other questions please ask.

John.

User
Posted 28 Sep 2019 at 14:30
Some cancer centres offer onsite accommodation Monday-Friday for people with lengthy journeys to get there. That may perhaps be an option considering your potential 5h daily journey.

Best wishes,

Chris

User
Posted 28 Sep 2019 at 14:50
Had my HIFU at UCLH in London. as this and the Transperineal Template biopsy that preceded it, I was accommodated in their nearby 'Cotton Rooms' and a Hotel respectively overnight. Also, on a subsequent Template biopsy 3 years later I was accommodated in a ward overnight at you mustn't drive within 24 hours of the anesthetic.
Barry
User
Posted 28 Sep 2019 at 15:37
Hi doctor doolittle... Please access my profile for details of my treatment. I had to have hormone treatment prior to seed Brachytherapy

Regards Tom

User
Posted 28 Sep 2019 at 15:54

Thanks for Mark Emberton’s article. I still have the option to go back to UCLH, just thought a second opinion no bad thing. The US papers do show a significant recurrence after HIFU, but then, as you say, you can always have more, or something different! Thanks for sharing your experience. We have a good train service to Kings Cross too.

User
Posted 28 Sep 2019 at 16:05

Thanks for your bio tp, sounds like plenty of side effects from brachytherapy. And recurrence in your case. Making decisions on uncontrolled trials of one person probably not helpful!

User
Posted 01 Oct 2019 at 11:18

Thank you to the nurse who talked with me for nearly an hour. Extremely knowledgable, particularly about which centre do what and side effects of different treatments. Really helpful and reassuring, and phone answered at once! What a great service.

User
Posted 01 Oct 2019 at 14:25

The general view is that there is not a lot of difference between the effectiveness of various radical treatments for which men are suitable. However there are of of course major differences in the way the treatment is applied and it's potential and varying side effects. There is so much information about about surgery and various forms of radiation that I referred more to HIFU which is less well known, because I researched it and had it (following failed RT), not because I believe it is better than other treatments other than having milder side effects and being repeatable. I wouldn't be swayed by the early American results because HIFU now stands comparison with other treatments for suitable men. TULSA PRO is a similar procedure that may prove even better (I leave you to investigate it).https://community.prostatecanceruk.org/posts/t21556-TULSA-PRO-V-HIFU

UCLH provides excellent treatment but from my experience and others who have commented on here, their admin has been shown to be poor on a number of occasions - so needs patients to check everything very carefully.

Edited by member 01 Oct 2019 at 14:34  | Reason: Not specified

Barry
User
Posted 26 Jun 2020 at 22:07

PSA risen in 4 stages to 15.9 
1.5 year fMRI shows no change at all. Nevertheless going for HIFU even though 4 mm from urethral sphincter and to get a margin ‘quite challenging’. Mrs Prostate says 1:4 chance that more HIFU needed after 5 years. Seems good odds to me, and RT still available. Noone will do a robotic removal because of incontinence issue at 78. I am NOT 78! really

Edited by member 27 Jun 2020 at 07:54  | Reason: Not specified

User
Posted 26 Jun 2020 at 22:19
It will be really useful if you can keep updating your thread leading up to and after you have had HIFU - going into it knowing that it might need to be repeated is a risk but at 78 and with the challenges of a long round trip for normal radiotherapy, I can see why you are taking the HIFU route. Very exciting for those who will follow in the future as there is so little data to support it as a primary treatment at the minute.

Best of luck to you.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 27 Jun 2020 at 07:52

Yes, 6 hour round trip by car for HIFU, plus 2 hour GA means driver (family volunteer) has a 15 hour day confined to car as I clearly cant drive home. Overnight facilities presently closed. Covid rules, mean total isolation for 2 weeks before and an additional trip to London 2 days before for Covid test etc. Threats that local preop testing results do not materialise (quite possible) and proceedure cancelled. Both of us have isolated for 4 months and probably had Covid in Feb returning from France. Covid testing is obvious to protect isolated urological unit of UCLH which is Covid free, but also anaesthetic risks with Covid patients significantly increased. Other options were further Active Surveillance (until what? Only option then is RT with 4 hour round trip for 4-6 weeks). HIFU for me now is a single though somewhat exhausting day plus a catheter for a week, which can be repeated if necessary. Any advice about catheters? Turning in bed etc! My least looked forward-to element. The thought that a blog of my intimate experience might be of help to someone else has cheered me up!

User
Posted 27 Jun 2020 at 13:17
They pay particular care about pre op testing before HIFU or even Template Biopsy at UCLH. as it involves general anesthetic .Last time I had the latter they found a level slightly low and deferred procedure. I put this down to my breathing shallowly during the test. So I got the test repeated by my GP who clipped a small device on my finger. Somebody else had given me a tip to take some deep breaths before the test and not to breath shallowly during it. I did this and there was no problem. I think the test was to establish the oxygen percentage if I remember correctly.

The catheter is more uncomfortable than difficult to manage but I found if so much more comfortable after it had been removed. As I said in a thread about my HIFU experience, try not to sit upright for a few days after HIFU to help avoid placing extra pressure where not wanted.

Keep us posted!

Barry
User
Posted 27 Jun 2020 at 13:25
Yup testing oxygen saturation in the blood. We have a pulse oxymeter at home (about £20 from amazon) in case of Covid. I’m 99% at rest so should be OK! Thanks for info. Hope they dont cancel, it’s a 6 hour round trip at best.
User
Posted 27 Jun 2020 at 14:14

I found the Bars Statlock really useful post op. I out the 2nd on my other thigh so I could ‘load balance’ the wear and tear on my poor urethra opening. Worked well and didn’t budge. http://www.bardmedical.co.uk/STATLOCKFoleyStabilisationDevice

User
Posted 27 Jun 2020 at 16:49

Doctor D

Good advice from TechGuy about Bard statlock device, remove them after 7 days ,they can burn / irritate the skin. Not all catheters fit the statlocks you will need to check. I also use thigh straps, and leg sleeves. At night I attach the night bag to the leg bag and attach the night bag tube to a thigh strap around my ankle, you could wear PJ bottoms, but a bit hot at present.  Make sure all connections are tight even the ones the nurses do. Ask for some instilagel or hydrocaine, some trusts have stopped using it in catheter care due to adverse reactions. Oddly their protocol says do not use it unless the patient insists ??

Wear snug, but not tight underwear and perhaps a light pad in case of by passing or leaking.

Hope all goes well.

Thanks Chris

 

 

Edited by member 27 Jun 2020 at 17:55  | Reason: Not specified

User
Posted 27 Jun 2020 at 17:23
If you have HIFU at UCLH like me you will wake up with your catheter fitted and will have it removed about a week.later. It was to have been done by a nurse but my GP removed it in the morning and said if I had not passed water by that afternoon, I was to go to A&E. Fortunately, I beat the deadline time he stipulated.
Barry
User
Posted 27 Jun 2020 at 17:26

Hi there

My husband had a HIFU pre lockdown (which meant we could stay over). I documented the experience of procedure and catheter here:

https://community.prostatecanceruk.org/posts/t23095-Focal-HIFU

It was a BUPA job but Mrs Prostate all the same.

 

Good Luck

 

Clare

 

 

User
Posted 30 Jul 2020 at 10:55

Well, I finally opted for HIFU at UCLH and since I have found all your comments so incredibly helpful I felt it was up to me to give an account of my experiences! Covid has certainly made it slightly more complicated particularly with a seven hour round trip to London but my wonderful younger son became the uncomplaining driver. It clearly wasn’t possible to use public transport, indeed this was not allowed. Last Friday was a trip up for all the pre-Op assessment which had to be done in London because of the difficulty of collecting local results. Last Monday was the journey which began at 3 o’clock in the morning to get there for 7 am.I have to say that what was the National Heart Hospital, and now is the Institute of Urology was not designed for patients with urological problems! I Was met by ............. who performed the procedure and took the usual details. He was very reassuring, and showed me the MRI and the target he was aiming for. The procedure is painless, but you have to be incredibly still during it in order to ensure accuracy of the ultrasound beam and the fact that it takes about an hour to do the whole procedure presumably because they are making sure that not all of the energy is passing through the same area of the rectum.One of the rare side-effects is a fistula caused by the energy of the beam, and it was reassuring to know that ........... who is perhaps the most experienced with HIFU In the country, has never had this complication. Next up was my lovely lady anaesthetist who was kind enough to let me know what she was going to use, having spent my whole life working with anaesthetists having been a surgeon. It turned out to be a question of deep sedation rather than traditional anaesthetics with which I was familiar 20 years ago! Anyway recovery was almost instantaneous without any side-effects whatever. Postop ............. was very confident that he had dealt with the small area of malignancy which showed up on the MRI  although there is another area of lower malignancy elsewhere in the prostate which doesn’t show up so it cannot be targeted yet and doesnt need anything but watching. Follow-up will be with three monthly PSAs and yearly MRI.
As the catheter is inserted during the anaesthetic with local anaesthetic applied to it which remains active for about six hours the 4 hours car journey home was fine. Despite the long journey it was nice to get back into my own bed rather than stay overnight which was offered. 
I have a few suggestions to make which are in no way criticisms, and may reflect the fact that because I was once a surgeon at the hospital, everyone presumes that I know everything. However the amount of information about catheters etc. that an ENT surgeon retains dates back about 50 years to general surgical training when I was never able to see anything down a rigid cystoscope.

There was therefore a certain amount of trial and error joining the various tubes together and deciding on the best strategy for stopping the leg bag from falling off. As far as the taps are concerned I was more familiar with the concept that a tap that is in line with the pipe is flowing and one that it is at 90° is off. So the next morning as I was sitting reading the paper after breakfast our lovely young black Labrador Millie was paying me a great deal of attention. She was indeed trying to inform me that there was a fairly large pool of urine on the tiled kitchen floor and that it was not hers.

Another recommendation is to request or order from Amazon some padded incontinence pants as in my case there was a significant bloody discharge down the side of the catheter which can make a somewhat alarming stain on your trousers. It also helps to steady the end of your penis which reduces the amount of discomfort from movement of the catheter. I noticed from other comments on this site that people were supplied with an antiseptic lignocaine preparation to apply to the tip, but no one I spoke to at the hospital or the practice nurse seem to have heard of this.

Before going any further I cannot praise too highly our local general practice which has been so incredibly supportive and was all prepared for me coming home with a catheter and doing the TWOC next Monday. Life is not easy for them or anyone in the medical profession at the moment with Covid going on.
I have had virtually no problems at all during the day and it is very easy to empty the leg bag by propping your foot on the edge of the loo and opening the bottom tap. The main problem comes at night where I found it very difficult to sleep without night sedation and a lot of painkillers as every time you move your wake up! I haven’t taken any sleeping tablets for about five months but fortunately had some leftover and eventually needed a double dose.

Taking an overview of the whole procedure so far it is really very trivial and if it means it reduces your chance of needing radiotherapy later on it must be worth it, if you are considered a suitable case. If you are reading this please be aware that this is an uncontrolled trial of one, and is almost certainly not going to be the same as your experience although it may be similar. As I said earlier I found it very helpful to read what other people had written and that’s the reason that I am doing this, and also the fact that my wife (also a retired doctor) keeps telling me I should learn when to stop talking. So I am.

Update Day 5

while the proceedure was a piece of cake, the catheter management afterwards was more like rocky road. Firstly I had quite profuse discharge and fresh blood (warned) around the catheter which presumably comes from the seminal vesicles and cant get into the bladder to be washed away with the urine. In my case this created strong irritation of the urethra and especially pain at the tip of the penis where there was no device to stop it moving especially at night. Every turn in bed produced a lot of pain, and awake for 2 hours until I gave in and took more valium (20 mgs most nights). I took 75mgs volterol SR night and morning, 4 hourly panadol and gave up on the codeine as it makes you constipated. NB volterol not provided on NHS, but in my medicine bag. Anyhow no amount of analgesic made the slightest difference to urethritis. On day 4 emailed GP who immediately provided lignocaine gel 5% which when eased up urethra pain stopped in 1 minute and had first night’s sleep. I noted the following comment from the prostate cancer website

‘Ask for some instilagel or hydrocaine, some trusts have stopped using it in catheter care due to adverse reactions. Oddly their protocol says do not use it unless the patient insists ??‘

I did, noone had heard of it, tho it appears the norm for private patients.

Another aid to reduce catheter pain is a sticky pad for the thigh to reduce movement at the tip. Again that would have been a help, and recommended by the prostate cancer site. A bandana at the top of the thigh was the next best thing. Next instalment after TWOC in 2 days time. Cant wait!

Day 7

Well, last 2 nights were hell. Only survived the rwisting catheter at night with 100mgs of Tramadol . Why have I got class A drugs in the house? Well they were 10 years old (so probably less potent) and part of my cruising medicine box allowed as a ships captain and a paid up member of the GMC and college of surgeons. Thank God for expired medicines. 
2pm Monday my TWOC. Trial without catheter. For me WOC. There was never going to be a trial of this monster. Removal simple and the minimal pain worth the anticipation of freedom. 

What follows
Suddenly you feel euphoria, but its not all over. You have a penis that is not a lovely smooth hosepipe but something like an exhaustpipe from a car wreck. Firstly, lots of congealed exudate from, and still stuck to, the prostate, some bleeding and DO NOT pee standing up. You will spray the entire room. So as I do at sea when there is a swell, do it sitting down, like the ladies. To begin with you may have lost sensation in the urethra so you can only tell whether something has happened by looking in the bowl and return of bladder comfort. 
Looking forward to escaping on the boat out to sea. As normal 3 monthly PSAs and another scan next year. Remeber I could have chosen to do nothing!

 

Edited by member 04 Aug 2020 at 19:28  | Reason: Surgeon's name documented

User
Posted 30 Jul 2020 at 14:45
Thank you for detailing your experience. You rightly say that that another man may have a different experience to you in certain respects but broadly speaking I think most men would find it similar in most respects and less taxing than they anticipated. In my case I had no leakage of blood or urine. I was uncomfortable, particularly a day or two after the procedure when the bruising became more evident for a few days. During this time I slept in an armchair with adjustable fold down back which helped. About a week after the HIFU my GP removed the catheter and I immediately felt much more comfortable. As you say, only the tumour was removed that was really thought necessary and should another develop to the extent that it should be treated, further HIFU can be delivered, assuming it can be reached with the wand and focused on and that there is not too much calcification.

A few years ago there was a risk of a fistula developing but with improvements in techniques this is now a very rare possibility. In fact the lady surgeon who did my procedure and had done hundreds of others had not had a patient of her's develop one.

So for now all seems to be promising. We should be very interested to learn how things go for you.

Barry
User
Posted 01 Aug 2020 at 09:07

Thanks Chris

your instiagel local anaesthetic comment was spot on. Asked for it, told not necessary, not provided . No sleep until 5th night because of intense pain in urethra. Pain killers useless, although 20mg valium finally did it. GP provided 5% lignocaine gel (for piles) no applicator but massaged it up penis and total relief in 1 minute and first night’s uninterrupted sleep.
Its not rocket science that blood and exudate from HIFU of prostate passing down the side of catheter can cause a urethritis. It cant get into the urine stream and be washed away as after your perineal biopsy. 

Edited by member 01 Aug 2020 at 09:28  | Reason: Not specified

User
Posted 01 Aug 2020 at 14:14

I must of been one of the lucky ones as no evidence of blood until after catheter was removed, then very small amount of blood ejected initially with urine and completely cleared almost immediately before much urine expelled.

Edited by member 01 Aug 2020 at 14:15  | Reason: Not specified

Barry
User
Posted 01 Aug 2020 at 23:57

Really interested to hear your experienced following my husbands HIFU in February

He was private and he did get instagel for the catheter days. So sorry to hear you had to cope without. Re ‘unless the patient insists’ .. what a strange protocol! 

Good luck with the TWOC

 

Clare

 
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