“Morning, Surgeon. What’s the news?” I am trying to remain chipper and upbeat. At today’s appointment, I am to find out about the biopsy results.
“Your results came back positive for cancer of the prostate, Mr. New. However, let me re-emphasize, at fifty-nine years, you are still a young man. You are in excellent health otherwise. The BCG treatments appear to have the cancer tumors–that have been growing from the interior bladder surface–under control, although, as you know, that rating could change with the next cystoscopic examination.
“Now, I need to explain some things, Mr. New,” continued Surgeon. “When I say that your results were positive, here’s what I mean. Before I performed the biopsy, I did a DRG, which means Digital Rectal Exam. I placed my gloved finger into your rectum and pressed it against the front wall of your rectum. I was feeling for a bulge on the backside surface of your prostate, which is right next door, so to peak. I felt nothing, meaning if there is a tumor, it is not big enough to feel. This is a good thing.
“Remember, we took twelve pickings of the prostate tissue?”
“Yes.” I nod my head.
“Okay. The tissue rating came back as a T1c. T1 means the DRG test was negative. I could not feel any tumor growth. A T1a or T1b result is usually found by accident, during surgery for relief of BPH, which stands for benign prostatic hyperplasia, an overgrowth of normal prostate tissue. Over time, this problem blocks the urethra from discharging urine from the bladder and you, Mr. New, do not have that problem. However, your PSA level, the prostate specific antigen level, has been trending high for the last two years.”
Surgeon held up a hand, as if to ward off my interruption.
“Yes, I know that you and your GP have been monitoring the PSA for some time now. And, yes, all of the manipulation of the prostate from the BCG catheterizations could be causing the PSA increase. At this point, because your PSA is running on the high side of normal, you are rated at a T1c, the most commonly diagnosed stage for early prostate cancer. With me so far?”
“Yes. No tumor felt via the DRG, yet the PSA is running high. T1c or early prostate cancer.”
Surgeon nodded. “Correct. Now, about the twelve tissue samples—”
“Yes, the biopsy samples.” I nod in turn.
“The samples are run through a preservation procedure, then sliced and diced into small fragments so thin that light can pass through them with ease. Placed on a microscopic slide, a pathologist examines them. She can detect whether cells look normal or not. She will ‘grade’ the cells on how abnormal they appear. If they are barely abnormal, they get a grade of two (2). If they are the most abnormal possible, they get a grade of ten (10). Based on how abnormal they appear, they could also get grades of three (3) through nine (9). These are called Gleason grades, for the pathologist that developed the system. Yours, Mr. New, came back as grades three and four. These are added together for a total of seven, or, a Gleason seven, which is classed as a medium-aggressive case of prostate cancer.”
“Okay. So, what can we do about it?”
“Based on your young age of fifty-nine, a T1c for early prostate cancer, and a Gleason Score of seven, I can recommend two procedures. The first is prostate brachytherapy, where radioactive seeds get implanted directly into the prostate. This low-dose radioactivity kills the cancer in place. This may or may not be permanent, as a cancer cell far enough away from the seeds may survive and start growing again, some years down the road.
“The second option is surgery to remove the prostate entirely. I am a surgeon and I think this is best all around.”
“Get it out and gone before it has a chance to spread.”
“Exactly. With it removed from your body, a better slicing and dicing can be done to determine precisely how close to the prostate boundaries the cancer had grown. That way, by knowing accurately how far it had gone, we can give you a more concrete understanding of what you did have. In addition, of course, ‘out-and-gone’ means, it is no longer a problem for you.”
“What is involved, actually?”
“For the radioactive seeds, a little discomfort at the time of insertion. Nevertheless, it may return. For the surgery, I do a procedure called Robotic Assisted Laparoscopic Radical Prostatectomy, where I control the cutting and cauterizing via a robotic system. This uses minimally invasive surgery and computer technology. Several one to two-inch incisions are made in your lower front abdomen. Sterile robotic surgical instruments—at least one gripper and one blade (both can cauterize as they work, reducing blood loss)—and a laparoscopic camera, are inserted into the sterile operating field. With these tools, I can tease away connective tissue from around the prostate (which produces a lubricating fluid for sperm), tease free the seminal vesicles (which produce additional lubricating fluid), and cut the Vas deferens (the tube the sperm travel through from the testicles to where it joins the urethra inside the prostate. This officially makes you sterile). The urethra runs through the middle of the prostate. This is cut just above and below the prostate, and the prostate and attached seminal vesicles are removed for pathological testing. Any nearby lymph nodes are removed at the same time. Then I sew the ends of the urethra back together. You will spend at least one night—maybe two—in the hospital and go home with a Foley catheter and attached urine bag. This is similar to what you went home with after the first bladder tumor was removed.”
“Yeah,” I say. “I remember it well.”
“After you get home from the hospital, I recommend four weeks rest for proper recovery. No lifting, exercising, mower riding, or anything really, for the first two weeks. Believe me, you won’t feel like doing anything, anyway. By the third week, you will feel more mobile. This is okay, but still, no heavy anything. I’ll see you sometime around the fourth week to release you back to normal activities.
“The two minor problems you will have for a temporary time are erectile dysfunction and urinary incontinence. The degree of erectile dysfunction depends on your age and overall health, sexual function before surgery, the stage of the cancer, and my abilities to save the erection control nerves. Younger men—those under sixty, like yourself, Mr. New—are less likely to have problems with their erections than are older men. If it does occur, erections usually return to normal over time, say one to two years. These days, there are medications to help with that, if needed.
“Short-term incontinence is a common side effect. Many men require a protective pad for several weeks to months after surgery. Most men do recover urinary control. Besides, there are exercises that can help build up the urinary bladder control muscle.
“That is pretty much it, Mr. New.”
“All right, then.” I’m busy processing all of this information. Surgeon has given me a handout that explains in black ink on white paper everything he’s said. “Guess I need to discuss this with my wife, Carle, and get her take on it. I know she had something similar done with her thyroid some years ago. She didn’t like the idea of having a dead anything left within her from radioactive seeds, so she opted for surgical removal. And to be honest, I’m kind of leaning that way already.”
“Well, think it over, Mr. New. Call my cancer-scheduling assistant when you decide which route to take. Here is her number.”
Final Results: Radioactive seeds or complete prostate removal via surgery? Personally (and it is personal), I like the complete removal idea. Out-and-gone!