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Urology Times Opines on the Subject

Northeast Georgia Urological Associates

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This is a real scenario and shows the complexity of managing certain situations about the prostate. Part of the problem is the common misconceptions about the prostate and prostate  cancer. As well all the things you read in the paper or hear on TV about new studies showing that the PSA is unreliable and is used too often by Urologists and in turn resulting in too many men being biopsied and then subsequently being treated…and subsequently as a result negatively affecting their lives with incontinence and impotence.

So imagine you are in the exam room with your doctor in the above situation and your urologist is walking you through the fine line of doing just the right amount of tests or procedures to determine if you have prostate cancer. The bottom line is that if you have cancer and this is found out a year after your office visit…you’d be…

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The Real...Prostate Cancer Second Opinion

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Since all of the treatments for Prostate Cancer have similar cure rates at 15 yrs many patients base their choice of treatment on the potential for side effects.

For instance:

  • If you absolutely could not tolerate total incontinence don’t choose surgery as this has the biggest risk for that complication.
  • If you are worried that you could be totally impotent as a possibility don’t choose surgery. I am not saying it will occur you just have a higher chance of total loss of erectile function with surgery as opposed to radiation.
  • Radiation negatively affects erections but not quickly or dramatically. It has a negative effect over time.
  • Radiation patients don’t have total incontinence but do get urgency and frequency.

You get the drift…my advice?

Choose the treatment that you feel gives you the best chance of cure with the least side effects that matter most to you i.e. a patient…

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If you have had a MRI would you comment for me on how much it cost…both the procedure and the radiologist reading it. Don’t get me wrong. I think the MRI will be very helpful for all…but weren’t we just talking about costs of psa, biopsies, treatment, etc and etc. Where is the outrage? USPSTF where are you? Issue a statement and recommendations regarding the use and payment of the MRI. You picked on Mr. Psa but is Mr. MRI too big a boy for you? You talked about the “risk” of having a Psa drawn…now let’s hear about the “risk” of having an MRI…you know…the expense and inconvenience of the MRI, the finding of a “spot” but the spot when biopsied, oh yes that terrible biopsy, but the spot has no cancer because the spot was a false positive, and oh yes the patient became septic because of the biopsy and had to be admitted to the hospital and etc and etc. Someone please…speak out about the risks of an MRI. As they say, “the silence is…deafening.”

Ps…I’ll find out the cost of a prostate MRI and the cost of reading it and I’ll compare that to the cost of a Psa, urologist office visit, prostate biopsy, and the reading of it by a pathologist-all combined and I’ll wager that the latter is much cheaper than the former. Have you read anything about the costs of an MRI? HmmmmmmmInvestigative report by pepe the prostate

Do you have a “naive” prostate?

 

Pts Who Are Biopsy Naive Can Benefit From Prostate MRI

Urology – May 30, 2016 – Vol. 34 – No. 2

Prostate MRI improved the detection of significant prostate cancer in patients undergoing initial prostate biopsy.

Article Reviewed: Presence of MRI Suspicious Lesion Predicts Gleason 7 or Greater Prostate Cancer in Biopsy Naïve Patients. Weaver JK, Kim EH, et al: Urology; 2016;88 (February): 119-124.

Background: The use of MRI has become more common in patients considering prostate biopsy after a prior negative biopsy. However, for patients who are biopsy naïve, the role of MRI has not been established.

Objective: To conduct a study of patients undergoing prostate MRI prior to prostate biopsy.

Design: Single-institution retrospective study of the records of 100 patients undergoing prostate biopsy after MRI at Washington University, St. Louis, Missouri, between 2012 and 2014.

Methods: The study evaluated prostate MRI and other factors to identify predictors of Gleason ≥7 prostate cancer (G7+) on prostate biopsy. Patients with MRI-suspicious regions (MSRs) underwent cognitively targeted biopsy. Those without MSRs underwent a 48-core template biopsy.

Results: On multivariate analysis of biopsy-naïve patients, presence of MSR was the only significant predictor of G7+. However, for patients with prior negative biopsy, MSR was not a predictor. PSA density >0.15 was predictive of G7+.

Conclusions: Patients who are biopsy naïve can benefit from prostate MRI if a MSR is identified that can be used to guide prostate biopsy.

Reviewer’s Comments: The use of MRI and guided biopsy has become increasingly common. Several studies have shown an increased detection rate of significant cancer in these patients. However, the use of prostate MRI in biopsy naïve patients is less well studied. This was a retrospective study evaluating prostate MRI in men undergoing prostate biopsy at Washington University in St. Louis, Missouri. All patients underwent an extended template biopsy (48 cores), but patients with an MSR underwent cognitive fusion biopsy with 4 to 6 directed cores. Multivariate analysis was conducted to identify factors associated with G7+. Patients were evaluated as biopsy naïve or prior negative biopsy. For patients who were biopsy naïve, presence of MSR was the only significant predictor of G7+ on biopsy. However, for patients with a prior negative biopsy, only PSA density was predictive of G7+. Prostate MRI and fusion biopsy have become increasingly utilized in patients with a prior history of negative biopsy and those undergoing active surveillance. However, use of prostate MRI in patients who are biopsy naïve is less well known. The potential cost implications could be prohibitive. However, improved detection may ultimately benefit patients. In this study, prostate MRI improved G7+ detection in biopsy-naïve patients but not patients with a prior negative biopsy.(Reviewer–Kelly L. Stratton, MD).

 

Author: Weaver JK, Kim EH, et al
Author Email:  uropro2012@gmail.com

If you have trouble voiding and have been diagnosed with prostate cancer remember you can correct the obstructive symptoms with the GreenLight Laser before radiation but you can’t safely do any surgery on the prostate after radiation.

Prostate diaries

What makes my book special ( I think ) is the attention that only a urologist who has been through the prostate cancer process and treatment could make of the voiding issues. That’s what urologists do…we are human plumbers. We understand how men void, the difference between obstructive (slow stream) and irritative (frequency, urgency, getting up at night) and the medicines and surgeries used for each. It is confusing. In my book there is a very large chart showing the differences in each and how all the treatments affect each.

I once wrote on a prescription pad the symptoms and the meds for each for another doctor. A year later, he pulled it out of his wallet to use to treat a patient in my presence and said, ” John, you just would not believe how many times I have used your little cheat sheet!”

Back to the question. Obstructive…i.e. an …

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One of my favorite pastimes as a urologist is to have my picture taken with WWII vets-truly, to me, the greatest generation. I have pictures of patients who served in Germany, landed on D-Day, fought in all of the significant islands in the pacific, Pearl Harbor and on and on. You can easily recognize WWII vets because most all of them enjoy wearing the hat representing when and where they served. In this instance you see a sophisticated older gentleman, like one you might pass in a grocery store and think nothing of it other than he is older and maybe moving slower than you’d prefer if you were behind him in line. But oh…. yes but oh… he’s a hero, he’s tough as nails and fought for you and put his life on the line.
The best part of this interview done in my office during an office visit unscripted was when he said, “Other than people shooting at me, it was the prettiest Christmas day I have ever seen.” Breathtaking!

Prostate diaries

The Battle of the Bulge- The bloodiest battle of WWII.

If you listen carefully you have the Mr. Cornelssen  carrying his machine gun and a 53lb tripod and two other soldiers carrying the ammunition. Walked from Normandy Beaches to Luxembourg, wounded in the Battle of the Bulge, operated on in a field hospital that was attacked (buzzed) and then flown to England across the channel and then to the hospital in Michigan. Are you kidding me? His career, prostate cancer..

Man o man they don’t make em like they used to!

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