Seed implantation (also call prostate brachytherapy) is typically performed as an outpatient. It can be easily managed in a hospital or even in an outpatient ambulatory surgery center. Typically the patient will go home with an indwelling catheter to drain their bladder. All of my patients remove their own catheter the morning after the procedure. There are two main techniques used and they are both successful. Each urologist or radiation oncologist will have his or her bias as to which is best. What is most important is their long term results.

Most seed implantation is done with either radioactive Iodine or Palladium. There are other isotopes used, but these two comprise the bulk of the seed implants performed in the United States. The choice between the two is dependent upon a number of factors, not the least of which is preference of the radiation oncologist.

About one week before the seed implant I meet with each patient (and often their spouse) to discuss the procedure and give them all of the prescriptions that they will need for before, during and after the procedure. The day prior to the seed implantation, my patients will undergo a bowel preparation similar to that done for a colonoscopy.

My typical seed implant takes less than an hour to complete from after induction of anesthesia to wheeling the patient to the recovery. Patients are placed in a position similar to that of a woman bearing a child. An ultrasound probe is placed in the rectum and ultrasonography of the prostate gives a very precise picture and size of the prostate. Based on these pictures the radiation oncologist determines the number and distribution of the seeds. Typically the urologist is responsible for the ultrasonography and placement of the hollow needles through which the seeds are dispensed. How many seeds each man gets is immaterial. What is important however is that a full dose of radiation is given and that it is done so in a way that spares the effect of radiation on the urethra (voiding channel) while allowing for full effect on the prostatic tissue.

After removal of the catheter my patients will take an antibiotic for a few days. Every patient is placed on a short course of steroid because they have been shown to decrease the risk of urinary retention after seed implantation. Almost all of my patients will be on a medicine such as Flomax to help with their urination after the seed implantation and this will typically be continued for about three to six months.

The most common side effects after seed implantation is discomfort with urination, slowing or the urinary stream, urinary frequency and increase in the number of times a night the patient urinates. Erectile dysfunction is more common in men that have marginal erections to begin with but in general, I have found it to be less likely than with radical prostatectomy.

In men with low risk cancer, it has been my experience that seed implantation is highly successful. Men with higher risk disease will often need adjunctive therapy such as a boost of external beam radiation or hormonal therapy, but the majority of men fall into the low risk category.

When I first started performing seed implantation, I would reserve it for the older rather than the younger men. After a couple of years of experience, I realized that seed implantation, in my hands, was as successful as surgery and this has now been borne out for the last twelve years. If you believe that radiation from seed implantation kills prostate cancer, then age really should not make a difference. What I have found that restricts seed implantation is the higher rate of complications in men who have had prior prostate surgery such as a TURP, or men who have very poor voiding function at the outset.

My youngest patient to have undergone seed implantation was 47 years old at the time of his implant. He is a black male with a family history of prostate cancer. This was very early in my “seed implant career,” and I tried very hard to talk him into a radical prostatectomy. He has just turned sixty years of age and his PSA is undetectable. Each year that he comes to see me for his exam he reminds me that I tried to talk him into surgery and how happy he was that he did not get a radical prostatectomy. As you can see, the patient often knows better than the doctor and I happily tell him that he made the right decision for him so many years ago.

Obviously you can see that I have a bias toward seed implantation. It has worked well for my patients and the side effect panel and complication rate is, in my mind, better than that of surgery. Each patient needs to pick what is right in his case, but my feeling is as follows: If we have a procedure that works well, doesn’t require a long recovery, and has a less morbid side effect panel then we should use it. It seems that many of my colleagues agree as seed implantation has become the most common radiation treatment for prostate cancer and has challenged if not surpassed radical prostatectomy as the most requested treatment for low risk disease.

Have a great week.

With radical prostatectomy (removal of the prostate gland and its associated structures such as the seminal vesicals and ampulae of the vas) there are a number of common complications that are frequently encountered. In our discussion about the procedure a few weeks ago, we specifically mentioned the big “I’s,” of impotence and incontinence. Impotence is common after radical prostatectomy. A man with excellent erectile function prior to surgery will have some degree of impotence anywhere from 30% to 70% of the time after radical prostatectomy. Much of it depends upon the technique and experience of the surgeon and exactly how you define impotence. One of the real issues with reporting potency percentages after surgery is that different studies look at different definitions and you will often end up comparing apples and oranges. Any man with marginal erections prior to surgery will very likely be impotent afterward.

As we discussed before, incontinence while less common than impotence is for many men much more socially bothersome. Incontinence can be classified as stress (cough, laugh, strain and leak), urgency (oh my gosh if I don’t get to the bathroom I’m going to urinate on myself), and mixed (components of stress and urge.) While this is not a complete list it does cover the large majority of continence problems.

Other complications of radical prostatectomy include heavy bleeding (requiring transfusions), deep venous thrombosis of the legs and its potential life threatening cousin the pulmonary embolus, penile shortening, and scarification of the bladder neck where the anastomosis of the bladder and urethra is made. All of these potential complications while unusual do occur and for the man that gets the complication it can be life altering. For example, the man that develops scarring of the bladder neck will often need to go back to surgery (done through a cystoscope) multiple times and it significantly increases his rate of profound incontinence by having to cut up the neck of the bladder that has scarred down.

As with surgery, radiation has a series of well documented complications or side effects. Incontinence is much less frequent, but frequency of urination and urinary urgency is much more common than with surgery. Impotence is another complication of radiation although most sources will quote a lower likelihood than with surgery. With seed implantation, slowing of the urinary stream is common and then need to take a medicine like Flomax for a few months after the implantation to assist with urination is pretty much standard practice. Some men can develop urinary retention after radiation. This is rather uncommon and is typically found in men that have enlarged prostates (separate from their cancer) and significant voiding issues prior to the prostate cancer treatment. Radiation to the prostate can affect the bowels as well as the bladder. Rectal urgency, loose stools, and occasional blood from the rectum is not uncommon after radiation to treat prostate cancer but typically subsides within a few weeks to months after completion of the treatment course.

The bottom line is that any definitive treatment option for prostate cancer has a number of side effects and complications that can run the gamut from minimally annoying to profoundly troubling. Unfortunately, there is no free lunch. You as the patient are obligated to research these issues and ask your urologist about them if you have questions. All decisions for treatment involve what we call a risk benefit ratio. What are you as the patient willing to put up with in order to “cure” your cancer? Are there other methods of treatment that offer similar “cure” rates with a side effect/complication profile that is more acceptable to you? As I have said before, when you see six or seven different methods to treat the same problem you have to realize that none of them are perfect. If one was heads and tails better than the others, everybody would be doing one thing. But obviously that is not the case.

At the risk of getting flamed again for dragging politics into this discussion, your treatment options will undoubtedly be affected if this Congress passes the health care legislation that is currently proposed. One of the main tenants that is not being discussed is the creation of government panels to determine the most cost effective treatment for specific disease processes. There is no assurance that these panels will be staffed by physicians, let alone physicians in the specialty involved in the disease process.  A lot of big words are being tossed around, but lets tell it like it is. In order for this proposal to work, there will without doubt be rationing of care. Right now you have the choice of having a DaVinci Robotic prostatectomy. It is an incredibly expensive tool to do what can be done as an open procedure but it is highly sought after as a treatment modality in the public. Do you want your government telling you the following…. “Mr Jones, you are 67 years old. Your life expectancy is 9.8 years by insurance actuarial tables. Because of this you are not eligible to have a radical prostatectomy or radiation therapy. You are only eligible for watchful waiting. Have a nice day.”

I have been a practicing physician for over 20 years. My decisions are based on the best practice of medicine as determined by peer reviewed studies in conjunction with patient preference, expectations and medical history. In my view, it will be a sad and dangerous day when we allow our government to intrude into the doctor patient relationship to the point that real medical decision making is taken out of the hands of the people who are most directly affected by the decision.

Finally, I would be remiss if I did not mention that that Ravens have a huge game this Sunday against the Broncos. At the beginning of the season this was penciled in the win column as most people saw the Broncos as a rebuilding football team. Well, six games later, we are treading water and the Broncos are on a roll. Our secondary needs to step up to the task. Dawan Landry needs to remember where he is in space and recreate the thumper that we saw in his rookie year. Most importantly, our defensive coordinator needs to shed the vanilla schemes he has been tossing out on the field all year and design plays for our front seven to get to the quarterback. If we can’t pressure Kyle Orton, he will pick us apart with Brandon Marshall and his other receivers. We can score with anyone in the NFL. The question is can we stop anyone?

Have a great Shabbos. Looking forward to a wonderful Hannukah.

There are multiple methods of dispensing radiation into the prostate gland and while I do not plan to go in-depth with each method, I will take at least a couple of the treatment options and discuss them specifically. This may not be a fully inclusive list but at the present the following are currently the most utilized methods of dispensing radiation to the prostate:

Prostate Brachytherapy - also call prostate seed implantation. Radioactive seeds about the size of a grain of rice are implanted directly into the prostate typically using ultrasonic guidance. This is also referred to as interstitial therapy as the radiation is placed directly into the prostate gland rather than being directed from an outside source.
IMRT (Intensity modulated radiation therapy) A mode of high-precision radiotherapy that utilizes computer-controlled linear accelerators to deliver radiation doses to a the prostate. This is an external radiotherapy treatment.
IGRT (Image guided radiation therapy) The process of frequent two and three-dimensional imaging, during a course of radiation treatment, used to direct radiation therapy utilizing the imaging coordinates of the actual radiation treatment plan. Again, this is an external radiotherapy process.
Proton Beam Therapy - like IMRT and IGRT in that the source is directed externally the difference is that the radiation source is protons rather than photons. There are only a handful of centers in the United States currently offering Proton Beam Therapy.
Cyberknife Sterotactic Radiosurgery - this is the newest treatment that has Medicare approval. While conventional radiation therapy (radiotherapy) administers a broad beam of radiation from one or two directions through normal tissues and requires between over 40 treatments to complete the course, stereotactic radiosurgery delivers highly focused beams from many directions so that the normal tissues experience less radiation and the treatment can be completed in only five sessions.

While it may be a simplistic way of looking at the options, I believe that a helpful way of thinking about the treatment is in the number of treatments needed to complete your course of therapy. Seed implantation in the majority of cases is completed in one treatment. Cyberknife is completed in five treatments typically over the course of one week. The other treatment options all require typically over forty sessions over the course of anywhere from six to eight weeks.

Each of the above mentioned treatments has their proponents and naysayers. All will claim results as good as surgery with less complications. Because of the expense of the external radiation therapy units, typically one center will only perform one type of treatment and there have been cases of financial conflict of interest that are currently being evaluated by CMS (Center for Medicare and Medicaid Services) for privately owned units.

There is no argument that radiation has the ability to eradicate prostate cancer. Like the older version of the radical prostatectomy, the old version of external beam radiotherapy was fraught with serious complications. Modern day radiation treatment has become much more focused and like surgery the goal has become to decrease the morbidity of the treatment while maintaining its efficacy. Over the next few blogs, I will discuss the complications and side effects that are most common to radiation therapy as well as the two versions of radiation therapy that I have used extensively. And while I will not specifically discuss the other radiation treatment options, there is a tremendous amount of information available on the web for those interested in more than I can offer in this forum. Remember however, that many of the sites you will come to are dedicated to their treatment option as the best available to treat prostate cancer. So you will need to look at the information they present and realize that there is very likely some bias in their presentation. I do not mean to imply that they are not being truthful, but there is no oversight of what is presented on the web, so be careful and if you have questions write them down and ask your urologist.

Ravens aside - as a football fanatic, I listen to a lot of sports talk radio. The talk of the week is how the Ravens lost the New England game because of officiating. Personally, I think that’s a copout. And while I will agree that the officiating of the game was poor, if you are going to beat a team like the Patriots and do so in their home you have to play a perfect or near perfect game. Unfortunately, the Ravens did not fill that prescription. Fumbling the opening kickoff, throwing a pick as you are driving to score before the half, and dropping a perfectly thrown pass at the end of the game on a 4th down just doesn’t get it. The fact that we were in position to win the game with 45 seconds left tells us that we have the ability to play with and beat the elite teams in the NFL. We just can’t afford to leave that much on the table and expect to win against the upper echelon of the NFL. That may fly when we are playing the Browns, but to beat the Pats, the Colts, and the Steelers in their home we have got to bring our best. Unfortunately, we came eight yards short last week. Now let’s go take out our anger on the Bengals.  Go Ravens!!!!!!

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….

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.

Depending upon your risk stratification, your evaluation after your diagnosis of prostate cancer may be minimal to quite involved. For the average man who is low risk (PSA < 10, Gleason’s sum 6 or less) very often no further evaluation is necessary.

Dr. Alan Partin of John’s Hopkins University Department of Urology has simplified what used to be rather tedious decision making. Based upon his research looking at thousands of patients, we can now give our patients their percentage risk for probability of having lymph node involvement or cancer outside of the confines of the prostate. This has obviated much of the testing that was traditionally done for patients diagnosed with prostate cancer.

Still, there are patients that will need further evaluation prior to making specific treatment decisions. If the PSA is high or the Gleason’s sum is over 6, many urologists will recommend obtaining a baseline whole body nuclear bone scan. Because one of the common landing sites for metastatic prostate cancer in the skeleton, a whole body nuclear bone scan will often help identify this aspect of disease before it ever becomes symptomatic. Again, for patients with high risk disease, some urologists will obtain abdomen and pelvic CT scans looking for obvious enlargement of the lymph nodes that “live” near the prostate gland. It needs to be understood that a CT scan is only good for finding gross enlargement of these lymph nodes and has no ability to pick up microscopic disease. The Prostatscint scan which is another test similar to the whole body nuclear bone scan which is more sensitive than either a bone scan or a CT scan but is not even close to being a “perfect” test for determining if the prostate cancer has spread past the confines of the prostate gland.

In most cases which are low risk, it is common to proceed directly to definitive management of the disease. All treatments of prostate cancer impact urinary function. Some treatment options which we will discuss in future blogs have more impact on voiding function than others. Because of this many urologists will recommend a urinary flow test and check of post void residual urine to get a better idea of the functional capacity of the lower urinary tract. Should this test be abnormal, cystoscopy, or endoscopic evaluation of the urethra, prostate and bladder would be the next logical step. A flow test is a non-invasive study that requires the patient to urinate in a machine which measure the peak an caliber of the urinary stream. While cystoscopy involves instrumentation of the urinary tract and is somewhat uncomfortable, for the majority of patients the test takes only a few minutes and can be done with local anesthesia rather than sedation or general anesthesia.

Our next discussion will outline all of the various options for treating prostate cancer. After that, we will go further in-depth into each of the ways that prostate cancer can be attacked.

Until then, enjoy your summer, tend your garden, cheer for the Orioles and keep your fingers crossed that the Ravens get Terrell Suggs signed before the July 15 deadline to the contract extension that he so richly deserves. (And rich he will be after signing it.)

For millennia, it has been said that the Jews kept the Shabbos. Actually, the reverse is true. It is Shabbos that kept the Jews. All one has to do is look at assimilation rates amongst people who are Shabbos observant versus non-observant and you will see the truth. And while I would never tell someone how to practice religion, I do feel that as a community it would be a bad precedent to have our own Jewish Community Center open on Shabbos in violation of the fourth of the ten commandments. It is not some minor law. It is part of ten major laws given to our people by our Creator. Again, I would never tell anyone how they should practice, Lord knows I have enough to work on myself to keep me busy for the rest of my life and then some. But the rest of the world looks to us. And when they see us make a statement which approves of violating our own commandments, they take notice, and not in a good way. Anyway, I’ll get off the soapbox and back to urology.

“Come on in Mr. Cohenthalstein and have a seat. We need to discuss your biopsy. Unfortunately today, I have both bad and good news. The bad news is that your biopsy was positive. The good news is that with today’s techniques of treatment and your risk profile, which we are about to discuss, I really believe that you have a great chance of being cured of your prostate cancer.”

This is the way the discussion begins in my office. The first thing I do is let the patient know the diagnosis. As I have said before, I much prefer doing this in person. My father was told he had cancer over the phone many years ago and I thought it was a terrible way to break someone that kind of news.

Today we are going to discuss risk stratification. The first thing we need to do is look at the patient’s PSA. In general, if the PSA is under ten, that puts the patient at low risk. Under four is even better, however, the most common presentation is for a PSA to be between six and ten.

The second factor I look at is called the Gleason sum. This is to be differentiated from the Gleason score. Basically, the pathologist looks under the microscope and finds the most prevalent pattern of cancer glands. He gives this a score of one to five. He then finds the second most prevalent pattern of glands and again gives this a score of one to five. He adds the two together and you get a Gleason sum which obviously can range from two to ten. I have never seen a two, three, or four. In my career, I have seen a small handful of fives. About 80% of men fall in at six. Ten percent are a seven and then the last ten percent are eight through ten. The higher the score the higher the risk. You want to be a six and if you are that makes you low risk. High risk would be an eight through ten, and seven is controversial.

The third factor I review is volume of disease. If I told you that of the ten biopsies we performed, every one was positive and in each core biopsy there was a lot of cancer it would lead you to the conclusion that you had high volume disease. If you had only one small piece of one core which was positive, it would be considered to be low volume disease. In general, low volume disease is lower risk and high volume disease is higher risk. Remember please that these are generalities.

So in conclusion, we have a few ways to determine what is your risk stratification. Your PSA, Gleason’s sum, and disease volume are all factors in helping to determine if your prostate cancer is considered low risk, moderate risk, or high risk. In our next discussion we will talk about further evaluation needed to help determine the best course of action for your prostate cancer. Remember, the bad news is that you have the disease. The good news is that if you are low risk, as most people are, you stand a great chance of beating the most common cancer in men and the leading cause of cancer deaths in men. Until next time…. Go O’s.

First lets cover the Ravens draft.  While I was hoping for a receiver to show up on draft day, I was very satisfied with the work done by The Wizard of Oz, Eric DeCosta and the rest of the gang at 1 Winning Drive. We needed a long term solution at right tackle and got it in Michael Oher who not only can play, but is a great human interest story. Paul Kruger, our second round pick, reminds me of a young Michael McCrary. Hopefully he will do so on the field. The rest of the draft filled needs with Ravens type ball players. Once again, Ozzie has proven why he is one of the top GM’s in the business. Hopefully the NFL will fail to notice DeCosta for a long time, because I think he is a large part of the process.

Now onto the results of the biopsy.

Today is going to be easy. Your biopsy that caused so much heartache when we discussed it oh so many weeks ago has come out benign. That means not cancerous. Typically, I have a patient come in to discuss biopsy results. I really hate giving bad news over the phone. I think it is very impersonal and I would not want to receive a cancer diagnosis that way. So everyone benign and malignant comes in for the news.

Often the biopsy is purely benign. In other words, there are no other findings. In this case, I will tell the patient that he should come back in six months for another PSA and rectal exam. After a benign biopsy, I will see a patient every 6 months for about 18 months to get some more PSA data points for each patient’s PSA graph. That way we will know if, “the trend is your friend.” If the PSA remains steady very often I will just follow the PSA. If the trend is upwards, I will often recommend a repeat biopsy. There was a study done at University of Michigan that showed that the likelihood of missing a significant prostate cancer with one set of random biopsies is 20 - 25%. This drops to about 4 - 5% with a second set of biopsies. Hence my willingness to recommend repeat biopsies.

Often the biopsy will show evidence of acute or chronic inflammation or both. This in and of itself, is enough to raise PSA. For this person, I will often recommend an extended course of antibiotics. This will often run 4 - 6 weeks and afterward a PSA will be obtained. I would like to see the PSA be driven down by antibiotic treatment. It makes me feel a whole lot better about the histologic findings of inflammation being the cause of the PSA elevation.

Occasionally, the results will show atypia or something call PIN which stands for Prostatic Intraepithelial Neoplasia. Neither of these are cancer but both can be harbingers of cancer. Typically recommended is repeat biopsy or close followup of the PSA.

Finally, for the avant-garde guy who wants to be proactive about his prostate health, I will often recommend dietary changes or nutritional supplements to promote the growth of healthy prostate tissues. Soy isoflavins, tomato lycopene, selenium, Vitamin D and E, Fish Oil are all compounds that have been purported to aid in prostate health. My feeling is that they can’t hurt you (as long as done in moderation) and that they may well help you. I consider these type of treatments investments in your health. You benefit by doing it, but I don’t think you are hurting yourself if you defer.

That’s it for today. I am working on the later discussions which will be all about your diagnosis if your biopsy is G-d forbid positive for prostate cancer. Until then, enjoy the spring, plant your tomatoes to get your tomato lycopene, and wait for Ravens Camp to start.

Actually with modern ultrasound and advances in the use of local anesthesia, a prostate biopsy should not be as horrific as you would expect. Lets talk a little about the indications and the procedure.

If your PSA is elevated for your age and/or if you have an abnormal digital rectal examination of the prostate, you need a prostate biopsy. That is assuming that there are no other reasons for the abnormality such as an active urinary infection or recent ejaculation within 48 hours of the blood test.

You will likely be given a couple of doses of antibiotics to take before and after the procedure. Some urologists will have you use a Fleet enema a few hours prior to the procedure. You will be told to stop any blood thinners such as aspirin for one week prior to the procedure.

Prostate biopsy is performed in the large majority of cases under local anesthesia. Ask you urologist if he does a needle block with lidocaine. If not, he is using “OK anesthesia”. That’s where he continually says, “ Don’t worry, your gonna be OK…” If that is the case, find another urologist. This procedure is much better tolerated with local anesthesia or sedation. The majority of patients are perfectly fine with a local anesthetic.

An ultrasound probe is placed into the rectum. It is bigger than an examining finger and slightly smaller than an elephant tusk. (Just kidding…..)  For most men the most difficult part is the placement of the probe. Once placed, the procedure is quick and with a lidocaine block, painless.

The urologist will measure the size of the prostate with the ultrasound. He will look for abnormal areas to specifically biopsy. Next, he will administer the lidocaine block and within a minute or so the prostate will be fully numbed. Typically, anywhere between six and twelve biopsies will be taken from the prostate.

After the procedure, it is common to see blood in the urine and some blood in your bowels. This will typically last for a day or two, but can extend out to a week or so. It is also very common to see blood in your semen. This can last from a couple of weeks to a couple of months depending upon your frequency of ejaculation.

The pathology typically takes about one week to return. Many urologists will call a patient with there results, but I think it is more typical to plan to come in and discuss the results with your urologist. I never like to give “bad” news over the phone. I find it very impersonal.

Next week we’ll discuss biopsy results and their meaning. For now, this has been the next step in the pathway to learning about the organ known as the prostate. Feel free to comment or ask questions. Talk to you next week.

PSA stands for Prostate Specific Antigen. It is a protein that is responsible for the liquefaction of semen. More importantly, it has become one of the most sensitive markers for cancer we have in medicine.

PSA is made in both health and disease states. There is a range of normal values and depending upon the lab and your age, your PSA may be anywhere from almost zero to upwards of 6.5 ng/ml.

PSA can be elevated because of prostate infection or enlargement. It can be elevated by ejaculation within 24 - 48 hours of having your blood drawn. It can be elevated by chronic inflammation. It can also be elevated because you may be outside of the range of normal yet still be totally normal. But we are most concerned about an elevated PSA because it is often an indicator of prostate cancer. And while infection and inflammation can be a problem, prostate cancer can be a terminal problem.

Most urologists recommend getting your PSA checked on a yearly basis once you are above age 50. If you have a family history of prostate cancer or are of African-American descent, we recommend that you be screened starting at age 40. The good news is that it only requires a blood draw. The bad news it, you need a rectal exam at the same time. And while it may be uncomfortable, it should be fast and like taxes it should only be once a year.

If your primary care doctor tells you that your PSA is elevated, he or she will most likely recommend that you see a urologist. As I said before in my opening remarks, urologist are doctors who specialize in disease of the urinary tract and are often considered the “Mens Health Doctor.” 

When you go to the urologist, make sure that you know your PSA number. Better yet, ask your primary care doctor for a copy of your labs and bring it to the urologist along with a list of your medications and any other pertinent medical facts about you.

Having an elevated PSA does not mean that you have prostate cancer. But having an elevated PSA means you need to make sure you don’t have prostate cancer. On the whole most urologists are good guys with off-beat senses of humor. In other words, the kind of person that would be fun at a dinner party. Do the right thing and get your elevated PSA checked out. It may be the best step you make in preserving your health.