I am writing from a most unusual “position.” I am an urologist who has been in practice for 38 years with recently diagnosed prostate cancer. I envision a 4 part “installment” of communication related to my personal battle with this disease. These four “installments” will cover: 1) preoperative considerations and decision making (see below), 2) my experience with the surgery to remove the prostate (robotic radical prostatectomy performed early February 2019 – see below), 3) my recovery within the first few months after surgery (see below), and 4) long-term issues after initial treatment. I truly hope that my experience may help other men who are dealing with a recent diagnosis of prostate cancer.
PART 1 – I think it might be useful for others to understand my prospective on the diagnosis and future treatment options that I have been dealing with.
My father had a history of prostate cancer, so I always felt there was a strong possibility that I would develop prostate cancer as well. For this reason, I have checked my PSA annually and noted a slow rise in the PSA over the last 4 years. My current PSA is 5.5. At this level of PSA, along with my positive family history, I was fairly sure I had prostate cancer. The questions that I struggled with included:
1) Would my quality of life be better if I avoided definite diagnosis and treatment? For me the answer is no! Making a diagnosis at a potentially curable stage and getting appropriate treatment with the goal of potential cure is the best option for me. Avoiding diagnosis and treatment and potentially developing metastatic disease is a big “motivator” to deal with my situation now!
2) At age 68, is it important for me to try to maximize my life span? The answer is yes, especially when I consider seeing my grandchildren grow up!
3) What prostate cancer treatment is best for me? I can only address my own personal situation. My prostate MRI showed two highly suspicious areas on the right and left side of my prostate. There is a relatively new prostate biopsy technique called Uronav that allows the urologist to superimpose the MRI image with abnormal areas clearly marked as “targets” with the live transrectal ultrasound. With this technology, the urologist can clearly sample the target areas seen on the MRI, as well as obtain other random samples of the prostate gland. My biopsy was performed in the office with local anesthesia. Although it was uncomfortable, I was easily able to tolerate the procedure with no major problems following the biopsy. My pathology report showed 7/17 biopsy samples (from both sides of the prostate) were positive of Gleason 3+3=6 prostate cancer. I knew the biopsy would be positive, but I was surprised that the cancer was as extensive as demonstrated by the pathology report. There were multiple areas of the prostate that looked normal on both the MRI and ultrasound that were positive for cancer. To me, this is very important since there are a number of potential treatment options (like HIFU and radiation therapy), that supposedly target the prostate cancer with minimal side effects. With the extensive cancer that I have on both sides of the prostate, I am very concerned that any treatment that treats less than the entire prostate will not be successful. I am also fortunate that my Gleason grade of the cancer is “mid-range” of 3+3 (total of 6). Cancers with a higher Gleason score (greater than 6), tend to be more aggressive with a high risk for spread (metastasis). Currently, although my cancer is bilaterally extensive in the prostate gland, it appears to be localized with a favorable Gleason score. For this reason, I plan to have a robotic radical prostatectomy early in February 2019. I believe that the surgical removal of my prostate offers the best chance for cure. Also, over the last few years I have noted some decrease in the strength of my urinary stream and a feeling of not always emptying my bladder completely. These are signs of the prostate causing some blockage to the flow of urine. Removing the prostate will eliminate this problem. Other treatments, like radiation therapy, will cause the prostate to “swell” and make this problem worse. Also, with aging, the prostate may continue to grow causing increasing problems with weak stream and bladder emptying.
4) What concerns do I have regarding removal of the prostate?
- A) Being Cured of Prostate Cancer: With current robotic techniques in the hands of an experienced surgeon, the procedure usually is accomplished with few complications and good control of the cancer. Obviously, the goal is to remove all the prostate cancer from the body (which is hopefully confined within the prostate gland) and to have negative margins at the edges of the resection. When the margins of the resection show evidence of cancer, further treatment, such as radiation therapy, may be required.
- B) Urinary Control Issues after surgery: Concerns relate to the preservation of the valve muscle (i.e. external sphincter) which is adjacent to the front of the prostate. When this sphincter is damaged, stress incontinence (either temporary or rarely permanent) may result after surgery. Significant incontinence after prostate cancer surgery creates a major quality of life issue. Approximately 3% of men will have significant bladder control issues following prostate removal. The good news is that this problem is rare and it is treatable. It is my impression, that the current advanced robotic surgical techniques have dramatically decreased the risk of damage to the valve muscle (sphincter) in front of the prostate. Also, should sphincter damage occur (which is rare), the bladder control problem can usually be corrected. Personally, the goal of cure of localized prostate cancer with removal of the prostate, far outweighs the small risk of erectile dysfunction and incontinence (both of which are treatable).
- C) Sexual Function after surgery: The nerves that control erection are adjacent to the prostate and these nerves may be damaged at the time of prostate removal, resulting in postoperative impotence. In men that have normal erectile function before radical prostatectomy, approximately 50% will have issues with postoperative erectile dysfunction. Erection problems can be corrected with oral medications, injection therapy, or possibly a penile implant. The ability to ejaculate is permanently lost after prostate removal.
5) What about HIFU, radiation therapy or cryo-ablation of the prostate? As an urologist, I realize that the most important decision one must make is choosing the “best” first-line therapy! In my mind, that therapy should have the best chance of permanent cure. When the cancer is localized to the prostate, the best chance to remove all the prostate cancer from the body is to surgically remove the prostate. Other therapies, such as HIFU, radiation therapy, or cryo-ablation may kill cancer cells for a period of time until the PSA either becomes detectable or starts to rise! At this point, curative therapy is no longer possible. At this early stage of my disease, I have decided to choose the treatment that gives me the best chance for cure with minimal potential side effects, i.e., surgical removal of the prostate gland.
6) Can we really “localize” the exact location of the cancer within the prostate gland by using MRI or ultrasound? We know that prostate cancer is a “multifocal disease,” meaning that the cancer is usually present in multiple areas of the prostate and rarely localized to one or two “spots” within the prostate gland. It would be great if either MRI or prostate ultrasound could truly localize the cancer within the prostate and define the true extent of the disease. In my case, this is clearly not the case. Two suspicious areas were seen on my prostate MRI. Both areas were biopsied and were positive for prostate cancer. However, there were multiple other areas of the prostate that looked entirely normal on both MRI and Ultrasound that were biopsy positive Gleason 3+3 prostate cancer. These findings demonstrate to me the fallacy of selecting “localized treatment” to treat only the “cancer areas” of the prostate with HIFU or radiation therapy. When my prostate is removed and the pathologist carefully sections the prostate and examines the entire gland, I am sure the multifocal nature of the cancer will be confirmed. More information to follow after my surgery!
7) When a man chooses “non-surgical” treatment as the primary treatment for localized prostate cancer, can “salvage surgery” be performed later when the PSA starts to rise? When PSA starts to rise after radiation therapy, HIFU, or cryotherapy surgical treatment becomes much more risky. All of these therapies can cause significant scarring in and around the prostate gland that may make “salvage” surgical removal extremely difficult. Frequently, “salvage” surgery carries a high risk of damage to adjacent structures such as the rectum, sphincter or valve muscle in front of the prostate, and the nerves adjacent to the prostate that facilitate erection. When damage occurs to these adjacent critical structures, the patient may end up with a colostomy bag, in diapers with severe urinary incontinence day and night, and impotence. Also, because the disease has frequently progressed by the time surgery is considered, the chance for “cure” from the prostate cancer is significantly diminished.
Quality of life issues certainly play a major role in our treatment decision making process. These quality of life issues must be balanced with the best chance for prostate cancer cure. Personally, my main goal is being cured by cancer removal from my body. I can live with minor incontinence issues, erection issues (which can be treated), lack of ejaculation, and other hopefully minor post-operative complications. Many men look back at their initial treatment choice and comment: “If only I knew then what I know now, I would have chosen a different initial treatment.” There are no right or wrong answers that apply to everyone, but I hope that as I embark on this personal journey, that others may benefit from my experience.
PART 2 – Preparation for surgery
The most important part of the preparation for my surgery, was taking the attitude of attacking and curing my prostate cancer at a stage and time when the tumor is potentially curable by removal of the prostate. All preoperative testing (MRI, biopsy tissue analysis, etc.) indicated an excellent chance for cure.
The next most important step is to choose the best surgeon. As a urologic surgeon myself, I know this is usually based upon the trust and communication essential to an ideal patient-physician relationship. The surgeon’s experience and results are obviously very important as well as the availability of the surgeon to handle any questions or complications that may arise after surgery. I was also very concerned about preservation of the nerves that allow erection to occur as well as the sphincter (valve) muscle that allows the man to have good bladder control after the catheter (drainage tube) is removed.
Robotic removal of the prostate is a very technical procedure that requires not only an excellent surgeon, but also significant support from the hospital to run a successful robotic surgery program. Specially trained staff, expensive equipment (i.e. the robot), ongoing maintenance, etc. are essential to a good surgical outcome. I was confident that my choice to have my surgery at Cedars-Sinai was the best option for me. Fortunately, the surgery was completed without complication with preservation of both the erection nerves and the sphincter muscle.
As a practicing surgeon for 39 years, I rarely get to see things from the patient’s perspective. Although I always realized how important the nursing staff is to postoperative patient care on the Urology Floor at the hospital, having a first-hand experience really opened my eyes! The nurses taking care of me after my surgery were amazing. They always responded in a timely fashion, they provided excellent care and never acted in anyway like I was “bothering” them. Again, choosing the right hospital is very important.
The combination of excellent preoperative preparation, good surgical technique, and wonderful postoperative care allowed me to be discharged home at 8am the morning after my surgery. I am fortunate that I live only 10 minutes from the hospital, so I felt very comfortable going home with my drainage catheter in place for the next 6 days. I am also very fortunate to have an excellent caregiver at home who was extremely helpful at each stage of my recovery.
PART 3 – Postoperative Recovery
Although there was some postoperative abdominal pain, it was not severe. Most of the pain was managed with Tylenol and ibuprofen. I was very concerned that wearing a catheter (tube) to drain the bladder for 6 days following the surgery would be very uncomfortable. To my surprise, the catheter did not bother me at all and was only a minor inconvenience. Each day I would walk more and had less pain.
Six days after my surgery I had a CT cystogram. The is an X-ray study to check the healing at the prostate removal site before the catheter is removed. The bladder is filled with a special dye and a CT scan is performed to make sure that no dye is “leaking” at the site where the urethra is sewn to the opening of the bladder. Fortunately, my CT scan looked good and the catheter was removed. Now I got to urinate and check my bladder control.
After prostate removal for cancer, it usually takes 4-6 weeks to regain full bladder control. Rarely (less than 3%), men may have major bladder control issues that require further treatment. This was my biggest fear! Thankfully, my bladder control has been excellent, without the need for diapers or protective pads. Since the “blockage” from the prostate has been removed, I noticed that my urination stream is much stronger, and I empty my bladder better. It is still too early to know if preservation of my nerves will allow return of my sexual function. Some have suggested that taking a daily Cialis pill and using a vacuum erection device may facilitate successful return of the erection. Since I am only one week after surgery, I will consider these options (if needed) in the near future.
Pathology Results: pT2
After the prostate is removed, the pathologist does a very careful sectioning and examination of the gland under the microscope. The surrounding tissues which are also removed are examined as well. Based on the microscopic pattern of the prostate cancer, a final “Gleason Score” is determined by the pathologist at this time.
The pathologist reported that my cancer had not spread outside the prostate, but cancer cells were close to the margin of the prostate capsule. All lymph nodes and surrounding tissues showed no sign of spread. At least 10% of the cancer cells showed a Gleason pattern of 3+4=7 (which is of more concern than the pre-surgical biopsy which showed only 3+3=6). It is very common that the final examination of the prostate after removal shows a greater volume of higher grade cancer. Thus, being lulled into a sense of security based only on the biopsy results may be a big mistake. Also, many areas of the prostate that contained cancer looked totally normal on my preoperative prostate MRI study.
Given my pathology results, my PSA should go to zero in the next few months. Going forward, I will check my PSA every 3-6 months on an ongoing basis. No other treatment is planned at this point. Should the PSA become detectable at a later date, further treatment, such as radiation therapy, may be required.
Since I am doing very well with regard to my bladder control, fortunately, this is not an issue for me. Should urinary leakage be a major ongoing problem for some men, effective treatment is available.
It is still too early to know about my sexual function (my surgery was one week ago). I will continue Cialis 5 mg daily (or the generic equivalent) and consider the use of a VED (Vacuum Erection Device) or penile injection therapy later if required. I have also had a frank discussion with my two sons urging them to get a PSA and digital rectal examination annually starting at age 40. They have a strong family history of prostate cancer (both their father and grandfather), so they should have close monitoring at an earlier age.
The most important message that I want to convey to other men is that if your PSA and/or prostate examination is abnormal, do not delay further evaluation and treatment. For every man with prostate cancer, there is a “window of opportunity” for cure that exists for a finite period of time. Getting treatment (with the goal of cure) within this window is extremely important. Like my four year old grandson told me: “Grandpa had a monster growing in his prostate, and now the monster is gone!” I know I have done (and will do everything in my power) to get the best chance for cure from prostate cancer and I encourage you to do the same!