Pills for Cheap

Another hurdle is the crucial but often-dreaded first bowel movement after surgery. This is another item in the category of things men would rather not think about, but it has to happen sometime, and the sooner the better. Remember, the prostate sits on top of the rectum; when it’s removed, this part of the rectum is thin, fragile and particularly vulnerable to injury for the first three months after surgery. Therefore, it is critical that you don’t have an enema or have your temperature taken rectally any time soon. And, it’s absolutely essential that you have a bowel movement every day. For many men, this is easier said than done; pain medications, inactivity, slight dehydration (from not getting enough fluids before or after surgery)—all can add up to constipation. To help keep things moving, you’ll probably be given stool softeners or laxatives for several days. If you do become constipated, take mineral oil and milk of magnesia (but again, do not use an enema—you could perforate your rectum).

Other things you should do, or not do: Avoid lifting anything over ten pounds for six weeks from the day of surgery—and this includes grandchildren and the family pet! This is because, for the first six weeks, only sutures— stitches—are holding your incision together. After this time, the body’s own mending device, firm scar tissue, will protect the incision. Heavy lifting can cause a hernia to develop in the incision; also, lifting or other strenuous activity may hurt the anastomosis connecting your bladder and urethra—and this could lead to long-term problems with urinary control. Keep telling yourself that this isn’t forever—after six weeks, you can do anything you want.

And even during this healing time, you can eat and drink whatever you want, take long walks, and make as many trips as you’d like to up and down stairs. Also, you can drive a car five weeks after the surgery.

Expect to have some incontinence. This is normal, and it, too, is not permanent. It will go away soon—don’t be discouraged. Also, expect to have some trouble with erections.

Finally, you’ll be encouraged to sit in certain positions and to walk around almost immediately. This also is crucial—among other things, it can help reduce your risk of developing blood clots.

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The late 1970s saw important modifications in the retropubic approach. For the first time, the anatomy of the venous drainage surrounding the prostate was understood, and with this knowledge evolved new surgical methods to lessen the awful blood loss. The new techniques did two things: With less bleeding, the operation became safer; and with what surgeons call “a bloodless field,” it became possible for surgeons actually to see what they were doing—a major improvement! In the process, critical structures could be looked for and saved that previously had been unrecognized and damaged as surgeons blindly felt their way. More precise dissection and reconstruction reduced the likelihood of troublesome urinary incontinence from as high as 15 percent to 2 percent, and even those 2 percent are not incontinent all the time.

But what about impotence? It had been widely assumed that penile nerves inevitably were damaged by the radical prostatectomy. Previously, many people thought the nerves to the erectile tissue in the penis ran through the prostate and would be damaged as a necessity when the prostate was removed. It didn’t make sense, that the nerves from one organ would run through another organ, but this had always been the assumption—even in medical textbooks. One highly respected anatomy textbook, for example, reported helpfully that the nerves that enable erection were “extremely small, difficult to follow in the adult cadaver,” and that their location was known “merely through experimental studies.”

Meanwhile, something unusual was taking place: Gradually, as one urologist began using the new techniques, his patients began reporting that their potency had returned. What was happening? Insight came with the discovery that the nerves that run to the corpora cavernosa, the spongy, erectile bodies in the penis, sat outside the capsule of the prostate. Which meant that it should be possible to preserve sexual function in men undergoing this operation. Until that time, these tiny nerves had almost always been inadvertendy destroyed during surgery because doctors didn’t even know of, and therefore couldn’t appreciate, their existence. The nerves were never removed, but were damaged and left in place.

In the early 1980s at Johns Hopkins, this new knowledge—that these microscopic bundles of nerves on either side of the prostate could be preserved—was first put into action. The patient, a 52-year-old psychology professor, regained his sexual function within a year after the modified, “nerve-sparing” surgery. (Actually, this term only tells part of the story, but this description has stuck, and many people use it. The operation’s proper name is the anatomical radical retropubic prostatectomy.) Twelve years later, this patient is alive and cancer-free; his quality of life remains excellent.

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Radical prostatectomy is not helpful for men with disease that has spread widely beyond the prostate. Nor is it ideal for older patients (men who are not likely to live longer than 10 years).

Once prostate cancer escapes the wall of the prostate to the point where it widely invades the seminal vesicles, pelvic lymph nodes or bone, it can no longer be cured. Surgery in these men, with its side effects, including the risk of incontinence and impotence, not only fails to cure, it is an unnecessary ordeal. The principal goal here is to control the tumor locally; this can be done with radiation, hormone therapy, or a combination of both. Ultimately, these men need palliative care—treatment that will lengthen their lives and ease their pain. With late-stage cancer, the goal is simply to do everything possible to fight the cancer and buy more time. The focus changes to ensuring good quality of life, rather than a cancer-free life. The main line of treatment for late-stage prostate cancer is hormone therapy and, later, chemotherapy and spot radiation to treat painful metastases.

Why is age a factor? Several reasons. One is that men in their seventies often have more advanced cancer than the clinical findings might lead a doctor to suspect. As men age, the prostate enlarges from BPH—so by the time a doctor can feel a cancerous lump in these men with their larger prostates, it’s probably bigger than the cancer that can be felt in a younger man with a smaller prostate. Studies have shown that for men with Tab (B1) disease, the likelihood that the cancer is confined to the prostate is less for men in their seventies than for men in their fifties.

Also, older men are more likely to suffer side effects from surgery; they don’t do as well as younger men in recovering continence and sexual function. And finally, because men over age 70 aren’t likely to live as long as men twenty years younger, it’s difficult to show that radical prostatectomy actually does more than radiation therapy to lengthen life in these men.

Radiation Is a Better Option For . . .

The ideal candidates for radiation treatment are patients who are older, or who are less likely to be cured by surgery.

Men who undergo radiation treatment are said to be “negatively selected” —that is, they get radiation therapy because radical prostatectomy has been ruled out as the best option for them. They are generally older men; men in poor health who aren’t considered strong enough for surgery; or men who have disease that has extended beyond the prostate to the point where it can’t be removed surgically (stage T3 or T4, or C).

However, others who opt for radiation treatment are men with organ-confined disease who just don’t want to have surgery.

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One of the first lessons a doctor learns in medical school is that, “There are always two things you never say—always and never.” The truth is probably somewhere in the middle.

For many years at Johns Hopkins, the approach was that if a man had cancer found at a TUR but not a tumor large enough to be felt in a digital rectal exam (men with stage Ti or A cancer), then his cancer was the incidental kind, with “low malignant potential” and not much clinical significance—the kind of cancer men die “with,” not “of.” And so they weren’t treated.

In 1976, Johns Hopkins investigators embarked on a pioneering study using tumor volume to predict cancer patients’ prognosis. They analyzed the medical histories of more than 100 of these men who were not treated, and they followed their progress for an average of seven years. Their findings: One group of these men did reasonably well; their cancer rarely progressed. But another group did not fare so well; their cancer continued to grow.

What was the difference between these two groups? The clue, investigators found, was in the percentage of cancer found in tissue removed during the TUR. (This work provided the now-standard classifications for stage Ti disease.)

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Another technique is called PSA velocity—its rate of change from year to year. PSA velocity is a fluid continuum, not a cut-and-dried, one-shot reading. It’s like having a prostate barometer—your doctor doesn’t have to wait for PSA to reach the magic number of’4- What matters instead is an average, consistent increase of greater than 0.75 nanograms per milliliter per year, over the course of three readings spaced no closer than 12 to 18 months apart. (Say a man’s PSA level went up from 1.2 to 2.3 to 3.6 over 24 months—clearly, something’s happening here, and it needs to be investigated.)

Finally, some investigators use age-specific ranges for PSA. The theory here is that, as a man ages, his prostate gets bigger. Therefore, why should the PSA cutoff point be the same for a 40-year-old man as for an 80-year-old man—who probably has a higher PSA anyway, due to BPH? Advocates of this approach recommend a cutoff of 2.5 for men in their forties, of 3.5 for men in their fifties, of 4.5 for men in their sixties, and of 6.5 for men in their seventies. Using this system, doctors hope to detect more cancers in younger men, and to prevent unnecessary biopsies in older men.

Further study should determine which of these techniques is most useful. Once a diagnosis of prostate cancer has been made, the next step is to determine the cancer’s stage—in other words, how far has it spread?

What tests do you need? For most men, the only imaging study that’s really necessary is a bone scan. Under some circumstances, further tests—an MRI or CT scan, or lymph node evaluation—may be advised. However, for most patients with a negative bone scan (which indicates that the cancer has not spread to the bone), information from the physical examination, the grade of the tumor (using a system called the Gleason score, which is discussed in this chapter), and the PSA findings can enable physicians to estimate the extent of cancer—and therefore, a man’s likelihood of cure. And then this crucial determination helps a man select which form of treatment is best for him.

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