OK,
QF WP.
I had my prostate removed on Tuesday afternoon and came home yesterday morning.
The story started seven years ago when a moderately elevated PSA score (BTW, a VERY unreliable indicator of prostate cancer - a rise merely suggests further investigation is prudent) had my GP refer me to a urologist. He, in turn, felt that the level/age combination warranted a biopsy and a single, small, localised, low-grade (Gleason Score 3+3) focus of cancer was detected, with no indication of extra-prostatic extension.
OK, first up: it's not an emergency. So what to do? First: STOP (ie. don't panic), THINK and RESEARCH (and I don't mean Dr Google (although, carefully handled, useful material is there) - although as a scientist I do have the advantage of being able to source original literature not available to people outside research institutions or academia).
Prostatectomy is potentially fraught with many adverse consequences that are not to be taken lightly or without good physical and mental preparation, if rapid intervention is not required.
So as an AFFer, what's the first thing to do after some broad reading? Why, jump on a plane of course and go to French Polynesia for a couple of weeks to have a bit of a think about things over a few wines on Bora Bora etc.
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First up on return was to ask the diagnosing urologist about what was then the quite new robot-assisted laparoscopic prostatectomy technique. He was an older open-surgery specialist but was happy to refer me to his younger colleague in the same practice who was a RALP specialist (at that time with 160 operations under his belt - by the time he got to me this week it was around the 900-mark).
The first thing is that, in the hands of a skilled and experienced surgeon, there is no statistical difference in outcomes between open and RALP prostate surgery. And it's really experience - the number of times they've done the operation - that explains most of the variability. However, as someone experienced in using microscopes for fine dissection (anyone like to know how to dissect the ovaries of a fly?
) the idea of doing the operation essentially under microscopy appealed, as did the minimally-invasive nature of the procedure, so I put myself under the RALP guy. But it is a procedure that comes with very significant out-of-pocket costs.
Around that time, mounting world-wide concerns about severe over-treatment of prostate cancer had reached a peak, leading to the concept of ‘Active Surveillance’ for non-urgent low-grade and small internally-definable cancers. While it was always close to inevitable that I would eventually have to have the organ removed, there are the significant urinary continence and erectile function quality-of-life issues that at risk with prostatectomy. So there's a trade-off between being shot of the cancer immediately against the significant risk of adverse side effects.
It is known that some men emotionally can't handle the idea of the big-C being in their body and just want done with it, so Active Surveillance is not for everyone.
Essentially, AS means monitoring by roughly annual biopsies, although in the time I was on AS, improvements in the power of MRI devices meant that the non-invasive MRI could be put into the mix - as more of a check than a definitive measure. The downside with repeated biopsies is they can leading to scar tissue and adhesion of the sheath that surrounds the prostate and which contains, particularly, the nerves that control erectile function. This can make the 'nerve-sparing' ideal of modern prostatectomy surgery a little more difficult (the analogy sometimes used is peeling an individual grape).
In the end, I had 5 biopsies (3 trans-rectal and 2 trans-perineal, as each on its own tends to have a mutually-exclusive 'shadow' area, and 2 MRIs).
My clearly-defined trigger point for surgical intervention was if the grade in any part of the bad bit went to 4 in the two-part Gleason Score. That happened to a small extent at last biopsy in late November last year (GS 3+4). It was clearly indicative that after all those years something was changing for the adverse - so the booking for surgery was made the day I discussed the biopsy results with my urologist.
It has been a calm, rational, evidence-based, well-planned process totally consistent with modern thinking on the issue for someone in the non-urgent category.
That’s one reason I’m happy to air my experience freely - and to interact directly with any guys out there who may be facing decisions on the issue.
An interesting thought came to my mind while under the shower this morning: I've spent 10% of my life to date on Active Surveillance for prostate cancer
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Of course, it’s all different for someone suddenly diagnosed with extensive, high-grade cancer where immediate action is clearly required.
My catheter comes out next Tuesday. I reckon I was as well-prepared as I possibly could be, but that will begin the real test of my physical and pelvic-floor muscle exercise preparation...
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