The Mourning of an Enlarged and Diseased Prostate

The message was clear and unambiguous, the urologist had given his unmistakable dictum: “You have prostate cancer.” “How is that possible,” replied the immediately concerned 61-year-old senior transplant surgeon, “especially when there were no signs of a tumor with digital rectal examination and the ultrasound was completely negative?” The prostate specialist reorganized his thoughts before answering and said, “I never thought you had a good chance of having a positive biopsy either. The odds were in your favor.” Without pausing, the urological surgeon added, “It is hard to understand these results, but now you need to remember these figures. Write them in some secure place. You are T1c, Gleason 6, PSA 4.1. Never forget these figures, they will give you a prognostic indicator for the future. You need to become fully aware of their meaning.” The patient did not know what the urologist meant. Even though he was a surgeon, a transplant surgeon, his knowledge of the prostate gland was primitive at best. He needed to go back to the library to learn the fundamentals of this disease [[1]], [[2]], [[3]], [[4]], [[5]], [[6]], [[7]]. It was clear that the burden of inquiry was on his side. A decision was required as to the optimal individual mode of treatment, the best that could fit his way of life and thinking, not an easy task at this early stage of diagnosis.

After uncountable visits to the library and discussions with judicious medical colleagues, it did not appear that radioactive seeds, Mayor Giuliani's choice, were appropriate for an enlarged prostate of 120 grams plus. The possibility of brachytherapy was not prudent in this case either. Three options were left: surgery, regular radiation therapy, or watchful waiting. Since the last one did not represent a truly sound possibility in this case and because radiation therapy represented a long-term approach of six weeks of daily treatments, the surgeon-patient decided to proceed with surgery. Now, what would be the best surgical procedure? This was a critical and defining question that needed ample and detailed analysis [[1]], [[2]], [[3]], [[4]], [[5]], [[6]], [[7]]. No rushing allowed under any circumstances.

After more weeks of literature review and internal searching, he favored the removal of the prostate by laparoscopic techniques [[6]], [[7]], a novel approach he considered to be less invasive than the regular approach, either retropubic or perineal. He pondered the potential advantages of less pain, smaller incisions, less blood loss, and earlier hospital discharge with the laparoscopic procedure. He embraced history as a safe and protective haven for understanding the evolution of the various procedures and important tests in the management of patients whose best option was surgery. He could not believe that even though urological procedures were old, techniques to operate on the prostate were basically in their infancy, and most of them were essentially from the twentieth century [[3]], [[4]], [[5]], [[6]], [[7]]. Goodfellow (1891), Young (1904), and Millin (1947) were the early pioneers in understanding this hidden gland [[3]]. As incredible as it might be, testing for the prostatic surface antigen (PSA) was just introduced in 1986, and the ultrasound-guided biopsy two years later [[3]]. Not until 10 years thereafter, in 1997 and 1998, did the laparoscopic prostatectomy arrive [[6]], [[7]]. As a surgeon, he realized he was dealing with the early stages of a new, very new technique. Consequently, this treatment option required the ideal place and best surgeon, as only a few surgeons were performing laparoscopic prostatectomy on a routine basis [[1]], [[2]], [[3]], [[6]], [[7]].

Further investigation led to establishing a good relationship with a noted prostate cancer surgeon in Florida who had brought the procedure to the region several years back. After speaking with former patients and clearing medical insurance issues, the operation was scheduled for January 5, 2005. There was no going back. Instructions had been given, approvals were circulated, and permissions had been reached with employers. Now the date was real and could not readily be erased. The operation was set!

The surgeon-patient needed to put his mind and emotions in order. “What would this procedure do to his intimate life?” he wondered. “What would be its effect on sphincter control and other side symptoms?” “Would he be able to tolerate anesthesia since this was the first time, at 61, that he was undergoing general anesthesia?” A great number of questions arose from his inquisitive spirit. The answer was unmistakable: “The tumor had to come out! There was no other way out,” he figured.

After a long series of presurgical tests, including an unending and primitive stress test, the word was out. “You can tolerate surgery!” said the internist. Wife, suitcases, and aspiring thoughts were packed together to travel towards recovery with serious but high hopes. The couple considered general anesthesia and its potential effects, the possible and perhaps unexpected findings of surgery, and hoped fervently that the tumor would be confined to the gland.

Promptly upon their arrival in Florida, they met surgeon, anesthesiologist, and surgical staff. The day of surgery arrived, and all doubts were erased with surgery imminent. As Versed^®, a surgical anesthetic agent, was administered, the many questions seemed unimportant and life was suddenly simpler. Exactly two hours and fifty minutes later, the prostate specialist appeared in the waiting lounge. “The prostate was monstrous in size, and all was removed. Now we need to wait for the pathology report,” he confidently reported to the worried wife.

Meanwhile, the surgeon-patient regained consciousness in the recovery room and began dealing with new questions. “Is everything done? Is the surgery finished?” he asked. Even though both were true, he felt that it could not be done that promptly and efficiently. Some abdominal pain, several surgical scars, and a well-secured Foley catheter were the main vestiges of the surgery. The well-proclaimed foe, an enlarged and diseased prostate, was by now in the hands of the knowledgeable and able pathologist.

An uneventful night passed, surgeon-patient and wife had no complaints, and at midday the distinguished urological surgeon appeared at the entrance of the room, moved toward the patient, and swiftly removed the pelvic drainage, felt the wounds, and declared the initial battle over. The patient could leave. “See me tomorrow at 10 a.m.,” he said as he stood in the doorway. There appeared to be other patients requiring his attention.

The next encounter with the reputed urologist was crucial. The pathology report was at the forefront. Nervousness permeated the room, as thick as a heavy fog. The specialist suddenly appeared in regular street clothes, no starched shirts or accompanying ties, and said, “Didn't I give you the pathology report?” “Not really,” said the surprised and extremely anxious surgeon-patient. “Very well. You did good. The surgical margins were negative. You are now T2c, Gleason 7, negative margins, prostate of 135 grams. These are your new statistics,” exclaimed the pleased prostate surgeon. And then he added, “You have a good chance of living another thirty years.” No good photographer or gifted artist could have depicted the aura of happiness on the faces of the surgeon-patient and wife. Even though he did not know exactly what T2c meant, he figured that Gleason 7 went up a notch from the initial Gleason 6, and T2c, he deduced after reading the literature [[1]], [[2]], meant that the tumor was present in two lobes of the prostate without extracapsular involvement. “The surgical margins were free and that was what mattered most,” he mused to himself, almost incredulous.

Being a religiously committed individual, the surgeon-patient acknowledged the helpful hand of God in these events. He personally thanked God for enough strength to face this opportunity and for the initial positive result. The rest, Foley catheter still in place for ten days, unknown length of urinary incontinence, and important matters of intimate discourse were secondary after hearing the pathological report. Everything else seemed so miniscule at this point!

Exactly three days after surgery, when the surgeon-patient and wife were flying back from Florida, hundreds of thoughts inundated their minds, but the most fundamental of all was, “The tumor is confined to the surgical margins. They are free.” This sentence clearly summarized his experience and reverberated throughout his mind. Nothing else needed to be said. As the plane took off, husband and wife said their prayers and thanked God for this incredibly positive experience.

Two important questions remain: Why is this writing so special for the surgeon-scientist? How can this experience have an effect in the professional life or human endeavor of the practicing surgeon? Undoubtedly, the personal experience of a fellow surgeon enhances our perspective of the profession and, equally important, increases our experience as human beings. Recognizing how others handled a significant personal event, such as the one described here, can give us a better understanding of the important human side inherent in the surgeon's private life. It also allows us to contemplate how unpredictable events might improve our lives within the context of this experience. And, finally, the positive assimilation of experiences—our own and others'—permits us to be better individuals and, in the end, better professionals.