Since my prostate specific antigen (PSA) went from 1.5 ng/ml to 2.8 ng/ml in one year and a half, I had a biopsy in February 2001. Cancer was found in 3 of the 10 biopsy cores. The right mid lateral portion showed 80% involvement by tumor, the right middle 60%, and the left mid lateral 10%. All were moderately differentiated adenocarcinoma, resulting in a Gleason score of 3+3=6.
I was diagnosed at age 49, and had heard that prostate cancer in "younger" men can be very aggressive. I didn't find anything in the medical literature, however, to support that. In fact, in an article in July 2003, urologists reported that men diagnosed with prostate cancer who are younger than 50 years of age and are candidates for surgery tend to have a greater probability of organ-confined disease than older men. They also found that younger men demonstrate greater long-term cancer control rates than older men.
Treatment Decisions:
Although I considered radiation, I ruled that out for the following reasons. I already had a "hyperactive gut", as a result of being treated (several decades ago) with a drug called carbarsone for amebic dysentery (picked up in Puerto Rico). The "active" part of the drug is arsenic, which can be pretty toxic and is no longer used as a treatment. In addition, I had a sensation of incomplete bladder emptying (which seems to have been unrelated to the cancer). Since radiation could have resulted in even more gut hyperactivity or urinary symptom flare, it didn't seem like a good option. So I had to get "comfortable" with the idea of surgery.
Some investigators have found that simply the number of biopsy cores with cancer can predict cancer-free survival after radical prostatectomy (with a 10-core biopsy, "3 or less" being "pretty good", but "more than 3" being "not so good"). In this case, I looked in pretty good shape. In more recent studies, however (mostly after my surgery), the "greatest percent core" (GPC) (i.e., the highest percentage of cancer observed in any core from a given patient) had a better correlation with such survival. Looks like "10% or less," "11-59%," and "60% or greater" could kind of be classified as "low," "medium," and "high" risk, respectively. Since I rated 80%, with that analysis (if I had known it at the time), things initially may not have looked so great. HOWEVER, upon further examination of the data, one finds that my low PSA would tend to negate any extra risk predicted by a high GPC.
The fact that I had bilateral positive biopsy cores in the middle portion of the prostate put me at higher risk for a subsequent positive surgical margin. Having them on both sides of either the base or mid-gland appear to be worse than in the apex of the prostate.
Even though my surgeon helped pioneer the return of the original perineal ("rear-end") approach, my prostate was "riding high up", which wouldn't allow for an easy task that way. I also considered a laparoscopic approach, but it was a fairly new technique (lately, however, more and more have been done). And a smaller prostate makes dissection as difficult as in conventional surgery. That left the retropubic approach as the best option for me.
Radical Retropubic Prostatectomy:
Had my radical retropubic prostatectomy in mid-May 2001. Three and a half hours after starting, the surgeon emerged from the operating room and gave my wife a thumbs-up. It would have gone a lot faster (normally does for this excellent surgical team), but MY prostate was more tightly attached to the rectum than usual, and they really had to work at it. (I've heard of one patient whose surgeon said the attachment was so extensive that they couldn't proceed; they just closed him up! I think this is very rare.) During surgery, I had several "vaso-vagal episodes" (these usually refer to "fainting" when one is conscious, NOT under general anesthesia). I was told that, despite these events, the surgery itself was "pristine." They were able to spare the nerves on both sides, and to spare the bladder neck. I lost a good amount of blood, but I never needed to have any transfusions, so as far as I was concerned things went great!
The First Days of Recovery:
I was probably in worse shape than most patients the first few days (but I bounced back fast; see below). My discomfort seemed to be not so much at the surface site of the incision, but rather "deep down" low in the abdomen (I think this is quite a bit different from most patients). Until the 3rd day after (when I got out of the hospital), they decreased the limit on my "patient-controlled analgesia" (i.e., "self-administrated morphine") to every 8 minutes. They also gave me ketorolac (trade name "Toradol"; a non-opioid anti-inflammatory agent) i.v. several times. (Again, this apparently is not what most patients experience.)
The First Weeks of Recovery:
A small percentage (~20%) have bladder contractions due to the Foley catheter (the second week I was one of them). Once I got the catheter out, life was good again! Was back to work half-time 2 weeks after surgery, full-time after a month. I never really seemed tired at all.
My surgical pathology still showed a Gleason 3+3, so I was glad not to be "upstaged." And the margins were clean. There was cancer in quite a number of areas (if you divide the prostate into 12 sections [right & left and anterior & posterior of base, mid, and apex], it was in 5 [3 in base and 2 in mid]).
Four years post-surgery:
The "bottom line" is this: I had surgery, which was successful in the three categories considered to be the important things: (in order of importance:
[1] getting rid of the cancer,
[2] maintaining continence, and
[3] maintaining potency.
Some of us are lucky (or have good surgeons).
Thanks:
My thanks go to Dr. Ian M. Thompson, Chief of Urology, and Dr. Aldo A. Ghobriel (3rd-year Resident in 2001) at the University of Texas Health Science Center at San Antonio; and all of the staff at University Hospital.
Latest PSA (four years post-surgery) was less than 0.10 ng/ml.
I've developed another site for those who have decided to schedule radical prostatectomy: "THE RADICAL PROSTATECTOMY PAGE".
Jim's latest PSA (five years post-surgery) was unchanged - still less than 0.10 ng/ml.
I guess my updates are pretty "boring": simply "still doing good" !
At seven years past surgery, urologist has said no more PSA follow-ups needed.
Some day when I retire, I will have time to update my home page with all the new research results that have come out in the last few years.
At eight years post-RP, went ahead and had another PSA level done (just "out of curiosity"!? :-) ) Still undetectable at less than 0.1. No problem.
Diagnosed 10 years ago this month. No problem.
Surgery was 11 years ago next month. No problem.
Twelve years after surgery; no problems.
In the recent medical literature, on the basis of some studies, a "true" (i.e., verified from post-surgery pathology) Gleason 6 is "not really cancer," as it does not metastasize. Wonder if that will be shown to be "true"?
Hit the "lucky 13-"year mark since surgery. "No prob."
Thriteen years after surgery, things still fine.
15 years after surgery, A-OK.
Sixteen years after surgey, no problems.
Seventeen years after surgery, no problem.
A coincidental finding on an elective CT scan was numerous enlarged lymph nodes. One possibility discussed was a "type of transformed prostate cancer that doesn't secrete PSA" (since my PSA was less than 0.1). Turned out I have advanced-stage non-Hodgkin follicular lymphoma. On "wait & watch" for that. (It's interesting how different cancers have different nomenclature for "not being treated." With prostate cancer, we're all familiar with "watchful waiting" instead.)
Still no evidence of prostate cancer after 21 years.
History of prostate cancer makes all clinicians suspicious of return of adenocarcinoma, even after 22 years. Currently have advanced-stage follicular non-Hodgkin lymphoma. Probably needing treatment soon for that, but no symptoms.
No recurrence of prostate cancer after 23 years post-surgery. Treated for non-Hodgkin lymphoma in 2024.
Jim's e-mail address is: forensicllc AT gmail.com (replace "AT" with "@")
