The Prostate Monologues

by Jack McCallum

  I felt comfortable about that decision, and that’s what I wrote in The Morning Call the first time. Almost immediately I received several phone calls and emails, most of a commiserating nature but others admonishing me for a wrong-headed decision. One was from a now-retired medical doctor. “You’re making a big mistake,” he said. “Get it taken care of surgically. Please.”

  (I appreciated all the messages, by the way, and they made me remember the number one benefit of writing for your local paper—an intimate connection with your readership. And I say that even though several readers wanted to string me up for a column about Penn State.)

  Anyway, even with my tentative decision, I wasn’t through researching. I made an appointment at The Johns Hopkins Hospital with a doctor who specializes in active surveillance, thoroughly convinced that he would endorse my decision.

  He did exactly the opposite.

  “You’re too young and too healthy,” he said. “Go have the surgery.” The Hopkins doctor was unequivocal and said he wouldn’t have accepted me into his active-surveillance group if I were his patient.

  It’s been quite a while since anyone told me I was too young (62) and too healthy for anything, and my wife and I did have a couple of nice seafood meals in Baltimore. So the trip wasn’t a total disaster.

  But everything changed with the doctor’s stark pronouncement. I continued to research the topic and it comes down to this: Like weekend football, prostate cancer is a game that comes with odds. They are free-floating and change as prostate research continues to trickle in, but you have to weigh those odds before making your treatment decision.

  In cases such as mine, the odds are overwhelming that the cancer won’t spread and/or kill me next year. Ten years from now? No one knows for sure, but my doctor at Penn tells me that, yes, he would bet that I would need intervention by then. Twenty years? The cancer would’ve almost certainly spread but maybe it still wouldn’t have killed me. But maybe it would’ve. And since I don’t have any other medical conditions at this time, the odds on the big board say that prostate cancer would ultimately be my cause of death.

  Further, a Mount Sinai oncologist I saw—this thing started to take on the characteristics of a United Nations fact-finding mission—would not advise me one way or the other but did make this point: The healthier you go into surgery, the better your odds of coming out of it OK. Right now I have no complicating issues except a bum left knee and a tendency to hit my mid-irons flat.

  So, I will be having surgery. I could write an entire column on why I went for robotic instead of traditional and why I chose surgery over radiation, but a little morning disease conversation goes a long way. My procedure is set for Feb. 20, and my hope is that it will be so uneventful that a third column will be unnecessary. Hey, that might be your hope, too.

  Jim Boeheim, who has been the basketball coach at Syracuse University since Moses led the Israelites across the desert, told me that he was entirely satisfied with the traditional method of prostate removal—the “open” procedure. His had been performed by one of the reigning kings of prostate cancer, Dr. William Catalona, who is adamant about the open procedure being better than its robotic alternative. I discussed it with Dr. Catalona in his Chicago office after my surgery, and he subsequently sent me his PowerPoint presentation that extols the virtues of the open surgery.

  The final slide carries this notation: “The Most Important Factor.” The image shows one surgeon bent over a console and the other standing over a patient. The message is clear. “I always tell my patients that ‘feel’ is the most important thing,” said Dr. Catalona. “You can be blind and be a great musician and you can be deaf and be a great writer, but if you’re a surgeon, you’re giving up something when you surrender sense of touch.”

  Dr. Catalona also said the virtues of robotic surgery have been oversold, that the da Vinci people and overly aggressive hospital marketers have presented the robot as a panacea, exaggerating, both expressly and obliquely, its benefits. I have no doubt that is true. There is the suggestion that the robot has been imbued with magical curative powers when, in fact, most evenhanded robotic surgeons will tell you that, in terms of surgical safety and postoperative recovery of urinary and sexual function, there are few differences between the open and robotic methods—if they are done by skilled and experienced people.

  “People like Dr. Catalona and Dr. Walsh have done so many open procedures that their performance and outcomes are consistent,” says Dr. Lee. “Their patients do really, really well because of their skill as an open surgeon.”

  Dr. Catalona trained under Dr. Walsh, who perfected the nerve-sparing open technique in the early 1980s, paving the way for tens of thousands of men to have their prostates removed without permanent loss of potency or urinary control. Dr. Walsh, now 75, stopped operating in 2011—“Always leave when you’re at the top of your game,” he told me, which is roughly what legendary running back Jim Brown said after he retired despite still being near his prime—and made it clear that, as he sees it, no robot is (or ever could be) as good as he was.

  “My patients went home either the next morning or the following morning, they got their catheter out at nine days, they had a three-inch incision, they were taking no pain medication, and they were continent,” says Dr. Walsh. “The results were exactly the same as with the robotic.”

  Surgeons tend not to be the shrinking violets of the world, but I have no doubt that Dr. Walsh speaks the truth. Mention “Walsh” at a urological symposium and watch for widespread genuflection to break out. But people like Dr. Walsh and Dr. Catalona cannot be present at every procedure, and, as Dr. Walsh concedes, open surgery is more difficult to perform. This is because the larger incision it requires causes greater blood loss than the smaller ones made for laparoscopic robotic surgery, and blood in the surgical field can obscure the anatomy and make maneuvering less controllable—increasing the risk to the patient. “There is no doubt that the advantage of the robotic is that all this bleeding is reduced,” says Dr. Walsh, “and you can see better because there is less blood loss.” In OR terms, robotic surgeons generally look at a “bloodless field,” and that translates into generally no need for blood transfusions to replace what’s lost.

  Also, post-op recovery is undoubtedly quicker for robotic patients than it is for open patients. “If you see patients who just had robotic and patients who just had open,” says the University of Rochester’s Dr. Edward Messing, who is himself an open surgeon, “you don’t have to be a genius to see which is which. Sure, the hospital stay is only a day less with the robotic, but that’s because we’re pretty brutal in kicking patients out of the hospital.”

  The bottom line is: Dr. Walsh, who perfected the open procedure, has not dug a moat to drown the advancing brigade of robotic surgeons. As director of the Brady Urological Institute for 30 years, he witnessed the coming of the robot a decade ago and didn’t stand in the way. There are open surgeons and robotic surgeons on the Hopkins staff, and they don’t have daily food fights in the lunchroom. Dr. Lee is among the thousands who have visited Hopkins to observe surgical techniques.

  There is ongoing financial controversy about the robot—what isn’t there controversy about in the prostate cancer world?—and it’s safe to assume that insurers have spent many hours comparing the costs of both approaches. Some studies have already concluded that the robot costs more. Dr. Lee says that is not the case. “Both the per-case cost and the OR cost are more expensive with the robot,” he says. “But the hospital stay is shorter. We did a cost analysis and the procedures turned out to be pretty equal because the robot saved money on [length of] stay and blood transfusion.”

  Looking ahead, one does wonder if the USPSTF recommendation against PSA testing will bring down the number of cancer diagnoses, thereby bringing down the number of surgical interventions—and the likelihood of a hospital spending something around $2 million on a robot.

  On the other hand, the future surgeons being taught in medical
school right now are increasingly embracing the robot. “Once they get their hands on it, it’s hard to get them off,” says Dr. Lee. “Look, the open procedure, when it’s not done by skilled guys, can be messy.”

  But all that was background noise as far as my decision making went. Let’s be honest: Most people take the Ayn Rand route on medical decisions—self-interest above all. What’s good for me, not the health care world as a whole, is what I’m going to do. I wasn’t about to calculate the costs of my choice to the health care system. With the insurance plan I have, I was going to be out-of-pocket for a couple thousand dollars anyway.

  So from the beginning I knew I would choose the robotic method. Keith was an advocate of it even though he didn’t do it himself. He had utter faith in Dr. Lee, whom I studied up on and learned that he had performed his 3,000-plus procedures without a fatality. I wanted limited blood loss and a quick recovery. I have nothing against robots. I loved Woody Allen’s Sleeper.

  I made an appointment with Dr. Lee’s office. It was January 12, 2012, by this time. So here is my prostate cancer time line:

  • Rising PSA detected in July 2011

  • Biopsy on September 7

  • Fairly firm intention to choose active surveillance until November 2, the date of my appointment with Dr. Carter at Johns Hopkins

  • Choice switched to surgery after my appointment with Dr. Waxman on November 29

  • Pre-op appointment with Dr. Lee’s office on January 12

  • Surgery set for February 20, 2012

  A seven-month arc in all.

  During that January appointment, one of Dr. Lee’s staff members went over the preliminaries. Arrive at the hospital in the morning. Procedure would take between two and three hours. An hour or so in recovery. Wake up in my hospital room and stay only one night as long as there are no complications. Leave with a catheter and a supply of pain medication, etc. She also gave me an instruction sheet detailing how to do Kegel exercises, the pelvic squeezing movements that are designed to improve post-op continence.

  “I have every reason to believe you’ll come through this fine,” Dr. Lee said when he arrived for a brief conference.

  Easy for him to say. But his confidence was comforting.

  ONE HAS TO BE CAREFUL not to enter the I’m Special Because I Have Cancer Club. I didn’t have symptoms. My life was not disrupted. There was nothing heroic or tragic about my having cancer. My story was different from that of a five-year-old battling brain cancer who heads off to kindergarten bald, a woman going to bed with her partner for the first time after a mastectomy, a man with a colostomy bag standing up and checking his trousers before stepping to the podium to make a speech.

  My story was different from that of my friend Dale Briggs, who lived with pancreatic cancer for two years, never complaining, never talking about it, kayaking, hiking, and enjoying life as if nothing was the matter. Pancreatic cancer continues to defy researchers because, in the words of cancer researcher Dr. Chu, “There are no early pancreatic patients.” The disease arrives stealthily, presents with relatively unremarkable symptoms (“I have a little backache”), and kills quickly and efficiently.

  So there was no reason to obsess about the operation, and most people around me forgot I had a procedure scheduled. But why not play the cancer card when it can be helpful, right? At the time, I was finishing up a book on the 1992 Olympic Dream Team and still had not secured an interview with one key player—Boston Celtics legend Larry Bird, then the president of the NBA’s Indiana Pacers. He had rebuffed my attempts on several occasions, and 10 days before my operation I made one last call to his assistant, Susy Fischer.

  “Tell Larry I’m having cancer surgery,” I said, “and if I die on the table my last thought will be that he blew me off.”

  I said it in a semijocular manner but with enough seriousness to (hopefully) push the guilt button. Bird called me back. I made an appointment, flew to Indianapolis two days later, and did the interview. With the tape recorder off, Bird and I spent a few minutes discussing the prostate, erections, peeing, and the general horrors of two men growing old.

  THERE ARE FEW THINGS MORE DEPRESSING than the predawn slog to the hospital for surgery. The sleepy-eyed receptionist taking your information like you’re the least interesting person on earth. The low, drowsy hum of hospital machinery coming to life. The strange isolation of the prep room with that open-in-the-back robe whose fabric has been graced by a thousand foreign buttocks. The wary glances of other patients waiting to be cut open, all of us wondering, Are you in worse shape than I am? And worst of all, the donning of those pressure stockings, designed to prevent blood clots, that make me think of Richard Nixon and his soul-killing phlebitis.

  All in all, you feel like this just might be the Last Roundup.

  An orderly came to get me. “I see you’re having surgery with Dr. Lee,” he told me. “The man has magic hands.”

  I didn’t know whether that was part of the Penn Presbyterian rap, but I appreciated it.

  “You’ll have to leave him here,” he said to my wife. There were traces of wetness in the corners of her eyes.

  “Next time you see me I’ll have a catheter in me,” I said.

  “Yes, but you won’t have any cancer in you,” she said, her lips brushing mine.

  I don’t want to make this overly dramatic because I wasn’t going in for brain surgery or anything like that. But a line from The Virgin Suicides came to mind, the part where the author, Jeffrey Eugenides, paraphrased T. S. Eliot: “She was the still point in a turning world.” So I wanted to make Donna the last thing I saw if she was, for whatever reason, the last thing I saw.

  The anesthesiologist performed his magic and soon I was in dreamland, that strange interruption of the time–space continuum. You somehow hope that you’ll come back a little younger or a little smarter, or at the very least find that something significant happened, movement on the Palestinian situation or the announcement that Breaking Bad had been renewed for nine seasons.

  Nothing like that happened, though, and by 11:00 a.m. I was awake in my room, Donna seated on a chair beside my bed reading a magazine. I was feeling sore in the abdominal area as a hideous cocktail of blood, urine, and God knows what else drip-drip-dripped into a bag from the goddamn catheter that now defined my existence. I had gas pains. I wasn’t hungry at all, which is a good indication that something had happened.

  But I was alive and didn’t feel that bad, all things considered.

  Everybody assured me that the operation had gone smoothly, and one of the nurses who checked my stitches said, “Dr. Lee, right? I’d recognize his work anywhere.” Did they hand out cue cards at employee indoctrination? Or was the guy just that good?

  The day passed slowly. I got out of bed a half-dozen times, walking better and better but with some abdominal pain and utterly conscious of my catheter, afraid it would suddenly slip out and start spraying urine like an anarchic garden hose. But the night passed without incident. Most of the rooms at Penn Presbyterian are private, and that is a major blessing. During hospital stays, I would hand over my life savings for privacy.

  The next morning Dr. Lee came in and announced that everything was fine. “Your prostate was normal-sized and the procedure only took 90 minutes,” he said. “That is good. I spared as many nerves as I could. You should have a good outcome. You’re scheduled to come back and see me in a week.”

  “Thanks, Doc,” I said. “But, look, why don’t we save ourselves some time. Yank this catheter out right now and we’ll call it a day.”

  He laughed. He had probably heard that one before.

  “You need it,” he said. “It takes time for everything to repair down there. But I’ll see you soon.”

  “You want to take a look at the stitches before you leave?” I asked.

  “No need to,” he said.

  Okay, that was badass. The man was so confident he didn’t even have to look at his work. Patients tend to think of their procedures as speci
al and precious things, models to be studied by doctors and nurses. They’re not. Dr. Lee was happy that things had gone well, obviously, but here’s what my post-op day was for him: Tuesday.

  Before my wife and I left, a nurse gave us detailed instructions about the Foley catheter. The patient will usually refer to it simply as a “catheter” or “that f—ing thing strapped to my leg,” but hospital folks respectfully include the adjective “Foley” and sometimes just call it a “Foley.” I wonder if its inventor, Frederic Foley, a Boston surgeon in the 1930s, was proud of it, or, more to the point, if his family was: “Yeah, my dad came up with the thingie that goes into men’s penises so they can carry around their own urine.” All in all, not conversation for the high school cafeteria.

  (An early flexible catheter, by the way, was developed by Ben Franklin—what didn’t that guy stick his nose in?—who used it to ease his brother’s pain from kidney stones and also to play childish pranks on serious-minded Alexander Hamilton during the Constitutional Convention. Okay, I made one of those up.)

  I’m not a systems guy. I don’t like straps, buckles, and tubes—particularly when they’re going into my penis, through my urethra, and into my bladder—and asked my wife to please pay close attention to the catheter instructions.

  You leave the hospital with the big bag, the one you carry like an obscene oversized purse, as if fulfilling some medieval punishment imposed by the church. The little bag is the one you wear in public. It straps easily to the side of your knee. The nurse told me that showering, blessedly, would not be a problem as long as I didn’t scrub at the incision sites. You simply disconnect the tube from the bag and clip it off, and you don’t even need to use the clip if you don’t mind urine running down the drain. I did not, though my wife might’ve had another opinion. It was freedom. It also sounds like a plot device for an episode of Curb Your Enthusiasm.

  Needless to say, the catheter consumes your every thought. You’re kind of amazed, first of all, at the thickness of the thing. Shouldn’t it be thinner if it’s going to fit in there? Jeff Jarvis, the writer, refers to the act of removing a catheter as a “hosectomy.”