Today’s discussion regarding prostate cancer will address surgical removal of the prostate. Other treatment options will be addressed at a later date. Radical prostatectomy implies removal of the prostate and seminal vesicles with reattachment of the bladder to the urethra. It can be performed in multiple fashions including open retropubic (abdominal incision), perineal (subscrotal incision), laparoscopic and robotic fashion.

The procedure in one form or another has been present in urology for decades. It would be unfitting to speak of radical prostatectomy without mentioning Dr. Patrick Walsh of Johns Hopkins Medical Center who was one of the pioneers in the advancement of the procedure. He, along with some other notable urologists, turned the procedure from what was a bloody surgery with a very high complication rate into a technically sound procedure with good to excellent results in terms of complications and efficacy.

The last five to ten years has seen the introduction and incorporation of laparoscopy and robotic prostatectomy into the surgical options to treat the disease of prostate cancer. There have been a number of studies performed which show that there is no real difference between the methods of surgical extirpation in terms of complication rate and results. There is no question that laparoscopic or robotic prostatectomy has a longer “learning cure” for the surgeon and in general takes much longer to perform.

A detailed review comparing the robotic procedure to the open procedure was recently performed by Dr. Herber Lepor who trained under Dr. Walsh at JHU and is the current Chairman of Urology at New York University. I have met Dr. Lepor and have had the opportunity to watch him perform radical prostatectomy. As a surgeon who has performed the procedure many times it was a real treat watching Dr. Lepor operate. He is technically outstanding and truly an “artist” as a surgeon. He makes the argument that as a minimally invasive procedure, his version of the radical prostatectomy is in truth less invasive than the robotic procedure and to be honest his arguments are sound. The important point to remember is that you want a surgeon who has done a large number of radical prostatectomies and it is not inappropriate to ask your prospective surgeon how many he or she has done in total or on a yearly basis.

The procedure is performed as an inpatient in the hospital. Most men are discharged from the hospital before the third postoperative day. Significant blood loss is common and many men “bank” their own blood in case of the need for a transfusion. It is uncommon with today’s procedure to need to get transfusions from other donors. After discharge from the hospital most if not all men will need to wear an indwelling foley catheter to drain the urine from the bladder while the anastomosis (the connection of the urethra to the bladder) heals. Catheterization times are dependent upon the surgeon and typically average 10 - 14 days. Most men return to work a few weeks after surgery.

The big worry of most patients regarding radical prostatectomy is what I call the big “I’s” of impotence and incontinence. Most sources report that even after a prostatectomy designed to spare the nerves responsible for erection a large number of men will have difficulty with erection. The percentages reported are dependent upon who is asking the question and how it is phrased. It is fair to assume that if you have excellent erectile function, are less than 60 years of age, and get a nerve sparing procedure by a skilled surgeon you will have a very good likelihood of maintaining your ability to get an erection sufficient for completion of penetrative intercourse. If you have marginal erections, are over 60, have medical issues like hypertension, hypercholesterolemia or diabetes it is fair to assume that radical prostatectomy will make things worse to the point that you will need either oral medications or penile injection therapy to augment and sustain your erectile function.

Incontinence is much less common than erectile issues after radical prostatectomy, but for most men it is much more troublesome. It is hard to predict who will have major continence issues after surgery and for most men the worst of it is an occasional loss of urine with sneezing or swinging a golf club. But for some men (less than 10% in most studies) profound incontinence is a serious potential complication of radical prostatectomy. It is cited by most of my patients who have no interest in surgery as their main concern and while profound incontinence that truly limits lifestyle is uncommon, for the guy that gets it after his surgery it can really cause problems. The good news is that there are good secondary surgical procedures available to treat the problem, but the problem itself is enough to put many men off of extirpative surgery to treat prostate cancer.

The take home message is straightforward. Radical prostatectomy done through any number of avenues is a valid and successful treatment for prostate cancer. If you are the type of guy who says, “Doc, get it out of me!!!” then radical prostatectomy is for you. Understand that as a major surgical procedure there are a number of significant risks and potential complications. Ask your surgeon how many he or she has done and it is totally appropriate to ask them about their complication rates and success rates. The most important factor is to be sure that no matter what treatment you have selected, you are comfortable with the person performing the procedure and the type of procedure performed. I tell every patient that this is their cancer and not mine. So they better be darned sure that they have researched their options and have selected the treatment that makes the most sense in their particular case.

Football aside. What a relief to have a quarterback in Baltimore that can win a game. The win against the Chargers was huge for the Ravens. To go across to the left coast and beat a team that many had pegged for the Superbowl and to do so in their home opener says a lot about our team. While there are questions on the defense, it’s great to watch our team go 2 - 0. Now the Browns come to town and we need to take care of business. It wasn’t so long ago that we would play down to the level of our competition. Somehow, I don’t think Coach Harbaugh will let that happen. Go Ravens!!! Beat the Browns! 3 - 0. Ho… Ho… Ho….

Thanks to all the wonderful comments on the last blog. We obviously disagree on the Presidents version of good medicine. Looks like the majority of America disagrees with the President as well. As far as access is concerned the 44 million number bandied about by the left includes millions of illegal immigrants, those who refuse to buy healthcare, and those already eligible for medical assistance but for one reason or another are not assigned. I like how M. Hyman opines on the proper role for government. Where by the way does the Constitution create an entitlement for healthcare?  That is debatable to say the least, and if Canada is such a wonderful provider of healthcare, why are they now re-instituting some level of private insurance and why do the wealthy of Canada come to the United States for they “elective” surgical procedures such as hip replacement, radical prostatectomy, and hernia repair. Just some questions to ponder as you get prepare to flame me again. Bring it on.

Treatment for prostate cancer is broadly divided into extirpative surgery, radiation therapy, cryosurgery, and watchful waiting. There are some other fringe treatments such as HIFU which are only being performed in very specific settings. Within each subsection there are a number of options. For example extirpative surgery implies the total removal of the prostate with reattachment of the bladder to the urethra. This can be done as an open procedure through the abdomen, as an open procedure underneath the scrotum, via laparoscopy and finally via the DaVinci Robot. All of these accomplish the same goal and all are valid, acceptable and successful methods of treating prostate cancer.

Radiation is another broad category which has a number of sub-treatments. External beam radiotherapy, prostate seed implantation, IMRT/IGRT, proton beam therapy, and finally Cyberknife Stereotactic Radiosurgery are the balance of the radiation options available to treat prostate cancer. Watchful waiting is often employed for those with a life expectancy of less than ten years. In Europe, watchful waiting is much more prevalent because of their medical systems.

Finally, cryosurgery or freezing of the prostate has a number of proponents as well. The morbid joke in urology is the butcher, the baker and the ice cube maker. The bottom line is that all of these treatment options are valid and have a similar degree of success. There likely will never be head to head studies, so all we can do is our best to compare apples to apples. For someone with low risk disease the chance of long term success is very good irrespective of type of treatment. For someone with high risk disease the probability of success is less and that statement holds true irrespective of treatment chosen. The real bottom line is for the patient to chose the surgeon with whom they are comfortable and the treatment with which they are comfortable. Don’t be afraid to get a second or third opinion and make sure that you are happy with your choice. I tell each of my patients that there are many ways to skin the same cat, just make sure that you choose what feels right for you.

Finally (really finally) to J.M. Reynolds whose response to my blog was rude and frankly inappropriate. What I write in this blog is my personal opinion. I am entitled to it. The Jewish Times does not censor me. They have allowed me to make sports, political, and medical commentary if that is what I want to do. If you don’t like what I have to say then you have a great option. Don’t read it. If you want to respond, feel free. But personal attack, semi-rude language and your obvious anger issues are as you say “sophomoric.”  As I am sure your mommy told you many, many times, it doesn’t hurt you to say it nicely. And by the way - Go Ravens!!!!! Beat the Chargers!!!

Wishing everyone reading the JT a K’sivah Vchasima tova. All of K’lal Yisroel should be inscribed for a year of sweetness, health and prosperity.