But what does that mean exactly? A 75-year-old man was considered absolutely ancient by our forefathers. If you want to live to, say, 95—and at present I have no reason to think I don’t—75 isn’t all that old. According to the US Census Bureau, the average white male lives almost 8 years longer (75.9 years compared to 68) now than he did in 1970, and the average black male lives almost 11 years longer (70.9 years instead of 60).
None of those statistics recommend for or against treatment. They are merely more things to toss into the cluttered prostate cancer options bag.
As I wrote in the Prologue, prostate cancer has an increasingly high public profile. Lung cancer is far more deadly, but gets far less attention. “It’s the blame thing,” says Peter Bach, MD, a lung cancer specialist and attending physician at Memorial Sloan-Kettering Cancer Center in New York City. “Lung cancer affects people who are poor, first of all, because it lines up with smoking. And there aren’t a lot of survivors. There are a lot of survivors of prostate cancer.”
Actually, prostate cancer, according to some researchers, is much more closely linked with the environment and lifestyle than people think. Asian men hardly ever die of prostate cancer, for example, though they develop it in greater numbers when they emigrate to Western countries, possibly as a result of changes in diet and an uptick in stress.
Because a relatively small percentage of diagnosed men die of prostate cancer, there has long been a movement among those with low-risk cases not to treat it, and to instead adopt a “watch and wait” philosophy. In the February 2004 issue of The Lancet Oncology, a British medical journal, Chris Parker, MD, described prostate cancer as “the only human cancer that is curable but which commonly does not need to be cured.” Much debate is taking place—and will be covered in this book—about what qualifies as “commonly.”
The numbers are again hazy, but there will probably be more who choose not to get treated in 2013 than there were in 2012, and there likely will be more in 2014 than there were in 2013. If “active surveillance” can’t be characterized as a full-scale march, it certainly seems to be a mobilization. And as the calendar carries me further away from February 20, 2012, the date of my robotic prostatectomy, I will continue to wonder if I should have joined that active-surveillance movement. I don’t agonize about it, but I wonder.
I DON’T RECALL anything about my robotic procedure, of course, having drifted peacefully into anesthetic purgatory just as Dr. Lee and I were talking about getting together to play golf. I awakened a few hours later, having lost from my body weight 39 grams—about 1.4 ounces—the weight of my average-sized cancerous prostate.
So I am going to witness Leonard’s surgery to see what was done to me.
Kelly Monahan, Dr. Lee’s PA (physician assistant), escorts me into Operating Room 9, which is much larger than a meat locker though not a helluva lot warmer. Dead-to-the-world Leonard Collier is lying spread-eagle on a small table and three nurses and a resident are prepping him for surgery, lining the table with protective gauze, checking instrument calibrations, peppering the cool, sterile air with medical gobbledygook.
This is the moment—before surgery—that sticks with me most viscerally. Leonard Collier looks so . . . so . . . vulnerable, all the more so when the Torquemadian leg spreader is activated. I can’t help imagining what I looked like in a room that cold (let us never forget the Seinfeld episode about shrinkage), and in a position that revealing.
“When I was in here, I was all covered up, right?” I ask Kelly.
“Oh, absolutely,” she says with a smile. “We didn’t see a thing.”
Dr. Lee enters the room almost unobtrusively. He is a powerful man around Penn Presbyterian, a rainmaker who performs more than 400 robotic prostatectomies per year, but there is about him none of the stereotypical surgeon’s swagger. He is The Man without acting like The Man.
“Can we pause for a timeout?” Dr. Lee says. Everyone gets silent.
“This is Leonard Collier,” pronounces Dr. Lee. “He is here for a robot-assisted laparoscopic prostatectomy.” (That is the professional nomenclature for the robotic procedure, which goes by “RALP” in the medical journals.)
Other voices chime in with particulars: Date of birth. Allergies. The readiness of the instruments.
“It is 8:27 a.m.,” says Dr. Lee. And it’s time to begin the anatomical dig toward Leonard Collier’s prostate.
The robot is wheeled into place at the feet of the patient. The staff has named it Big Sexy for no apparent reason. They talk affectionately of the robot, almost like it’s a human being. Then again, it is doing a lot of the work.
Sterile wrap remains around all of Big Sexy except for its six protruding arms. I have relative freedom to roam around the operating room, but have been cautioned to stay away from both the robot (“Don’t even let your hair touch it,” Dr. Lee admonishes me) and the instruments (“Jack, you get close to my instruments,” says nurse Felicia Wrice in a faux menacing tone, “I’m going to put you to work”).
Before Dr. Lee begins the robotic procedure, Leonard’s abdomen is basically turned into a pincushion by Kelly and Shailen Sehgal, MD, a resident. They make six small incisions for four robot ports and two laparoscopic instrument ports that will be handled by Kelly. Leonard’s abdominal wall must be lifted to allow the insertion of a Veress needle, through which carbon dioxide is pumped into the abdominal cavity, “blowing it up like a balloon,” as Dr. Lee describes it, to make more room to operate within.
I ask if this would be harder to do on a younger man with a muscular stomach.
“Absolutely,” says Kelly, probably fighting off the temptation to add: “Though it was pretty easy when we did yours.”
Kelly and Dr. Sehgal are on either side of Leonard, but when Dr. Lee sits down at the console he is a good seven feet away from the patient. He peers at his screen and begins to work the robot hands. He is seeing a picture of Leonard’s abdomen that is magnified 10 times. One of the advantages of robotic surgery is that the surgeon’s “physiological tremor” is not a factor in the patient outcome.
The robot’s console is equipped with video simulation, but Dr. Lee doesn’t find it all that helpful. “Airplane simulators are amazingly close to reality, but it is hard to replicate the body of a living organism,” says Dr. Lee. “You need to see blood and tissue deformation.” Dr. Lee learned his robotic technique primarily by operating on pigs.
The surgeon eats, plays golf, and stitches with his right hand, but writes and plays tennis with his left. “Being ambidextrous is very beneficial for a surgeon,” he says.
As he moves his hands, his right foot also works two pedals. He looks like a cross between a kid playing a video game and an adult playing a church organ. The right pedal is in charge of power, the left is responsible for the motions of the robot. “I only have two hands and there are four robotic instruments,” he says, “so I need the pedals.”
I ask Dr. Lee, who is in his mid-40s, if he was good at video games. “I have to admit I was,” he says. “It seemed to come to me easily. I was right there at the beginning with the Atari system. I remember Space Invaders. And all through medical school it was Tetris.”
I am able to watch what Dr. Lee is doing at another console. The picture is 3-D and is so clear and clinical looking that it’s not really gross. There is relatively little blood.
There is talk, not constant but steady. “A little more suction, please,” Dr. Lee might say. Or “Great, Kelly,” after she uses a clip to stanch blood flow. “When you’ve done as many cases as Dr. Lee and I have done,” says Kelly, “there’s not a lot of back and forth. Better for us, better for the patient. Less time in the OR, fewer complications.”
In the silent spaces I can hear the sonar-sounding beeps of the operating room machinery—Leonard’s blood pressure (about 112/70) is being monitored by a nurse sitting behind him—and the snip, snip, snipping of the robot claws. It’s a little eerie. From time to time the lens that is peering into Leonard’s abdo
men gets dirty and has to be pulled out for a rinse. The nurses spray it with water kept at about 120°F. They don’t want it to cool and then fog up when it’s returned to the warm body cavity.
The surgeon continues his deliberate advance upon Leonard’s prostate, scraping away the fascia that lies on top of the gland, cutting the bladder away from the prostate and dissecting the seminal vesicles. The scene brings to mind the old Raquel Welch movie Fantastic Voyage and the similar Innerspace. I had been fascinated by the journey through the human body because normally we don’t think about what’s inside of us.
At one point Kelly says matter-of-factly, “The fat’s in the Mayo.” What, we’re ordering sandwiches now? Actually “the fat” is the layer of fat on the front side of the prostate that Dr. Lee removes, and “the Mayo” is a stand with a tray used to either hold sterilized instruments or collect surgical trash. Dr. Lee had “handed” the fat to Kelly, who removed it from Leonard’s abdomen and left it for the scrub nurse. The fat will be sent, along with the prostate and the seminal vesicles—which will be coming out with the gland—to the pathology lab for testing.
The whole scene is one of such calm that I keep forgetting about the danger, the delicacy of the whole thing. Dr. Lee will come close to the obturator nerve at the very top of the inner thigh, and he has to be careful that he doesn’t put a hole in Leonard’s rectum. Still, he says he considers prostate surgery infinitely less dangerous than, say, kidney surgery, during which he must cut across the renal nerve, which lies atop the aorta.
After about an hour Dr. Lee is ready to cut away the prostate, which he does near the urethra—“the downstream side,” as he puts it.
“Big prostate,” says Dr. Lee.
“Big prostate,” everyone agrees.
That just makes the morning a little more taxing, as it had been when Dr. Lee once had to remove a prostate that weighed 280 grams—about 9.9 ounces—well over a half pound.
“The farther you go down to the tip of the prostate, the tighter and narrower is the space,” explains Dr. Lee. “It’s like a cone. So when you have guys with really big prostates, there is no room to go from side to side to be able to dissect the tissue away from the prostate.” Also, bigger prostates tend to have a more vigorous blood supply, and blood is the enemy of the surgeon.
I feel a surge of relief that my prostate had been so medium-sized and so easily lifted out of the body cavity.
When Dr. Lee finally frees the prostate and the seminal vesicles, they are placed in a plastic bag that had been inserted through one of the ports. The bag is used both because it makes extraction easier and also because it keeps the cancerous prostate from “seeding” cells in other tissues on its way out of the body.
Roughly half of the operation is devoted to getting to the prostate and the other half to stitching. Meanwhile, the bagged prostate remains inside the patient’s abdominal cavity, rather like a flounder lying on a dock before being collected and sent to market. The prostate is left there because a slightly larger incision above the navel will have to be made to get it out, and Dr. Lee doesn’t want to do that too early lest “we start getting a gas leak.”
The stitching continues at a deliberate pace. “What I’m doing now,” says Dr. Lee, head buried in the console, “is the Rocco stitch.”
“Don’t tell me it’s named for an Italian surgeon,” I said. Not to mention about 173 pizza joints.
“Exactly,” he answers. “Now I’m doing a running stitch, going outside-in on the bladder and inside-out on the urethra. Then I run this all the way around to 12 o’clock on the left side and 12 o’clock on the right side.” The man loves to stitch, lives to stitch. When he is finished, he will have used 13 stitches to make a watertight connection between Leonard’s bladder and urethra. After the prostate is gone, the anatomy in that area is essentially like two pipes with a missing joint: There is a hole in the bladder and a hole in the urethra, and they must be united to restore normal urinary flow.
Finally, Dr. Sehgal wriggles the prostate bag out of Leonard and places it on the Mayo. I stare at it for several seconds.
“I don’t care what anybody says,” I inform the OR. “Leonard Collier’s prostate is a helluva lot bigger than a walnut.”
CHAPTER 2
... In which we learn why your prostate is kind of like Liechtenstein
UNTIL A MAN GETS CANCER, his prostate is basically a punch line, a setup prop for a comment about urination, or a comic mispronunciation waiting to happen. NYPD Blue, one of TV’s great one-hour dramas, got a season’s worth of humor out of detective Andy Sipowicz fretting over his “prostrate.” This is an understandable mistake, if only because hearing that someone is about to reach inside your rectum and finger-jag your prostate is liable to make a man go prostrate. Throughout the writing of this manuscript, my spell-check software resolutely changed “prostate” to “prostrate” every time, and I sincerely hope that the editors and myself have caught all of them.
Even if you never learn the correct way to say it or spell it, there is one fact about the prostate that will be drummed into your head—its size relative to a salad and sundae staple. For whatever reason, almost every medical professional feels compelled to say, by way of introduction to the gland, some version of the following: “The first thing to know is, your prostate is about the size of a walnut.” Back in 1967, J. I. Rodale (the founder of the company that published this book) used the walnut comparison to size up the gland in his book titled, quite logically, The Prostate. At least it’s easy on the memory—your prostate has much to do with your nuts, so you identify it by association with a nut.
However, there are variations. I read the account of one doctor (presumably from the tropics) who described the prostate as “about the size of a kiwi.” Johns Hopkins urologist Patrick Walsh, MD, one of the most important figures in the history of prostate cancer detection and treatment, has been known to compare it to a large strawberry. But in his celebrated book Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer, Dr. Walsh also uses “walnut,” and “walnut” remains the default description. As if to reinforce that, Paulie Gualtieri, one of Tony’s associates on The Sopranos, required a prostate biopsy in an episode in the show’s sixth season. His nickname? Paulie Walnuts.
Humble size notwithstanding, the prostate is strategically located. Its etymology is (of course) Latin, from the Greek prostates, which means “one who stands before,” a “protector” or “guardian.” There is a theory that the prostate evolved to protect the bladder from infection, but in truth, it is as much guarded as guardian. It lies southeast of the bladder and southwest of the rectum. It is wedged between the seminal vesicles and, in a complicated bit of spatial geography, envelops the urethra. So it is most properly described as a walnut being strangled by a garden snake, an ideal symbol, it would seem, for a frightening fundamentalist religion.
“What you have to remember about the prostate,” Ballentine Carter, MD, one of Dr. Walsh’s preeminent colleagues at Johns Hopkins, told me, “is that it lies in the middle of a lot of valuable real estate.” Indeed it does. If there were really such a thing as intelligent design, the prostate would not be so intricately landlocked. Or, alternatively, there would be a little door located at that part of the body, complete with an EJECT button, so the prostate could be easily removed, like an unwatched DVD of Gigli.
When a surgeon has to get at the prostate, see, it takes some doing. “All of the anatomy around the prostate is concealed,” says Dr. Walsh. And in this hidden location the prostate is rather like doubly landlocked Liechtenstein, a country that nobody talks about or actually visits but is nevertheless somewhat significant because it is bordered by Switzerland and Austria. (Liechtenstein, by the way, is also about the size of a walnut.)
Rather unlike Liechtenstein, however, the prostate actually does something, has a function, doesn’t just lie there acting all walnutlike. It is a part of the reproductive system, secreting a slightly acidic fluid through small pores that lie
between it and the prostatic urethra. That fluid nourishes and carries sperm as it passes through the urethra on its voyage to wherever the sperm might be headed at the time.
But how much the prostate does is open to debate. Dr. Walsh estimates that it provides only about one-third of the fluid that makes up semen, and, if it stopped producing that entirely, a man might still be able to produce sperm sufficient for fatherhood. Plus, as Leonard Collier and I now know, you don’t need the prostate to get or maintain an erection.
Males can achieve orgasm through stimulation of the prostate, though that fact does not come from firsthand observation. An orgasm is the last thing on my mind at that moment when a doctor gives me a digital rectal exam. Technically, I suppose, such a response really isn’t an orgasm since—and I haven’t completely worked this out yet—orgasm is at least partly a mental act, whereas ejaculation is purely physical. Some men who have trouble ejaculating but want to be fathers choose an operating room procedure in which an electrical probe is passed through their rectum to innervate the prostate, forcing an ejaculation. They are asleep at the time, which is not the normal ejaculatory state, unless you’re a 13-year-old experiencing a nocturnal emission.
Testosterone, which is produced in the testicles—better-known prostate neighbors—causes the prostate to grow, which is why stopping testosterone production is often part of the battle against advanced prostate cancer. The simplest way to stop or slow testosterone production is with castration by one of two methods. An early prostate pioneer, Charles B. Huggins, MD, who shared the 1966 Nobel Prize in Physiology or Medicine, is credited with delaying many deaths with hormonal treatments or surgical castration. “The cornerstone treatment for metastatic prostate cancer is still medicinal castration,” says Edward Messing, MD, a noted urologist at the University of Rochester Medical Center. But keep in mind that castration is only for these advanced cases, in which the cancer has spread beyond the gland; if you get a diagnosis of localized prostate cancer and a doctor suggests castration, you are in the wrong medical facility and should run immediately for the door marked EXIT.
The Prostate Monologues Page 2
