Are you in shape for surgery? Your doctor will want to check you out thoroughly beforehand. Surgery may be delayed if you’ve recently had other prostate surgery for BPH (see below), and it’s generally scheduled for six to eight weeks after a needle biopsy of the prostate. These delays give the body a chance to recover from the earlier procedures. Also, imagine a surgeon’s difficulty in trying to operate on inflamed, irritated tissue, where a needle has penetrated the rectal wall six times, and it hasn’t yet healed properly! A few weeks’ wait, though it may seem agonizing to a man who’s anxious to have the cancer removed as soon as possible, can be critical in helping the surgeon preserve the delicate neurovascular bundles and avoid injury to the patient’s rectum during the procedure.
Before surgery, when you give the doctor your medical history, be sure to say so if you’ve had any unusual problems with bleeding in the past (from dental work, for example). Also, aspirin can cause excessive bleeding; if you are taking aspirin regularly, make sure you stop at least ten days before the operation. Another point to discuss with your doctor: Many men who undergo radical prostatectomy need a blood transfusion during the procedure. The best blood for you to get, obviously, is your own; if your hospital allows this, it’s a good idea to donate several units of your blood ahead of time. This is another good reason for the six-to-eight-week delay; it gives you plenty of time to make up your own blood bank. The night before surgery, you’ll be given an enema and perhaps some laxatives, as well. Or, if you’re scheduled to be admitted the day of your surgery, you may be asked to give yourself an enema or take laxatives the night before. You’ll probably be told not to eat anything the night before surgery, as well.
This is how some men find out they have prostate cancer—when the prostate tissue removed in a TUR procedure or open prostatectomy is evaluated by a pathologist. It’s more difficult for surgeons to perform a radical prostatectomy after an open prostatectomy, but that doesn’t mean it can’t be done. It often is, and with greater success. You may be told to wait, however, about twelve weeks after a TUR procedure, until the inflammation from this operation has gone down.
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First, educate yourself. Learn everything important there is to know about your own cancer—your clinical stage, PSA level and Gleason score. Explore all your options—we’ve done our best to cover them all in this chapter, and specific forms of treatment are covered in greater detail in the next chapters. Get a second opinion, and a third if you need it, and talk to patients. If you can’t get some names from your doctor, call a prostate cancer support group (see “Where to Get Help,” at the back of this book) or another organization that specializes in prostate cancer. Be your own advocate, and take heart—there is much you can do to make sure you get the best treatment possible.
Say a man has a palpable tumor involving one entire lobe of the prostate (stage T2b, or Bi disease), a Gleason score of 7, and a PSA between 10 and 20. The likelihood that his tumor is confined to the prostate is 19 percent; the probability that his cancer has penetrated beyond the prostate wall is 81 percent. He has a 33 percent chance of having cancer in the seminal vesicles, and a 24 percent chance of lymph node involvement. What should this man do? Here, age plays a major role. Say this man is in his early fifties. Even though cure is not certain, it’s clear that if he does nothing he will probably die of his disease. Because the side effects of surgery are much milder in men this age, surgery is certainly a reasonable option, and it does offer the possibility of cure.
On the other hand, say he’s in his seventies. The question here is whether a man who may not live long enough to die of prostate cancer should be put through an operation with an uncertain likelihood of cure. Surgery has more side effects on people in their seventies. So, for this man, radiation therapy is a better, more reasonable option.
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Some men who opt for watchful waiting take solace in the fact that their cancer cells are well-differentiated. But unfortunately, just because you have well-differentiated cancer cells today does not mean they’ll stay that way forever. There are two concepts here; one is genetic drift. As a cancer progresses—as its cells double again and again—the DNA becomes less stable. The cancer develops new mutations; it becomes more aggressive. As the tumor progresses, well-differentiated cells deteriorate into poorly differentiated cells. The other concept is heterogeneity, or clonal selection. By the time a prostate cancer is large enough to be diagnosed clinically, its cell population is mixed—a diverse group of cells, all jockeying for position in one location. In this varied group are both well and poorly differentiated cells, cells driven by hormones and cells untouched by hormones. And although an initial biopsy may find well-differentiated cancer cells, almost certainly some poorly differentiated ones have mingled in there as well. With time and further growth, these poorly differentiated cells grow at a faster rate than do their more sedate, better-differentiated counterparts. Eventually, they will outpace the stately progression of the well-differentiated cells and dominate the tumor. So a well-differentiated cancer, one that’s localized to the prostate, may be only a temporary condition. And unfortunately, we can’t tell which well-differentiated cancers are going to stay that way.
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Watchful waiting is certainly not a new approach. It’s been a mainstay of prostate cancer treatment for years; and today, one third of men with prostate cancer are treated with watchful waiting.
Some doctors who argue for watchful waiting refer to studies that suggest the mortality rate for men who don’t get treatment is low—about the same as for men who don’t have prostate cancer.
But results can be seriously misleading. One prominent Swedish study, for example, citing a “high ten-year survival rate in patients with early, untreated prostatic cancer” has been widely criticized because it’s based on a group of older men, average age 72, with small, slow-growing tumors. (Only 4 percent of these men had aggressive, poorly differentiated tumors—unlike the 10 percent to 20 percent of men with localized cancer in this country who undergo therapy. So basically, this was not a typical group—many of these patients would have been followed with watchful waiting in the United States, as well.)
After ten years, 13 percent of these men had died from the cancer. And the disease had progressed in another so percent of the men. Most of these men eventually did need treatment (castration or hormonal therapy) to treat urinary obstruction, bleeding or pain.
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Most men experience temporary urgency and stress incontinence after the catheter is removed—in fact, it would be remarkable if they didn’t. Think about it: The urethra has been stretched and possibly irritated for three weeks by the catheter; it’s probably going to take hours to days for it to recover from this insult.
Urinary control generally returns in three phases . Phase One—you’re dry when lying down at night. Phase Two—you’re dry when walking around. And Phase Three—you’re dry when you stand up after sitting. Persistent stress incontinence (leaking urine when you stand up or exercise) is rare, and total incontinence is even more rare.
There’s also something you can do to control stress incontinence—special exercises, called Kegel exercises, that strengthen the external sphincter. To help speed up your recovery, practice starting and stopping your urinary stream every time you go to the bathroom. The best way to do this is when standing to urinate: Try to shut off your urinary stream by contracting the muscles in your buttocks tightly. (There are other methods of performing these exercises, but by doing them this way you can be sure you’re exercising the right muscles.) Only perform these exercises when you urinate—don’t do them at other times, because you will tire out the sphincter muscle.
Until your urinary control returns completely, wear a pad, such as a Serenity pad, or disposable diaper, such as Depends. You can get these at the pharmacy or grocery store. Some men prefer using a special kind of padded underwear called Confidens Brief; your doctor should have good suggestions and perhaps even some samples for you to try. Whatever you do, do not wear an incontinence device with an attached bag, a condom catheter or clamp! If you use these devices, you won’t develop the muscle control you need to be continent. Also, until your urinary control has returned, avoid drinking excessive amounts of fluids, and limit alcohol and caffeine—both can make the problem worse. Again, remember: You will get through this.
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