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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So…this is a classic convoluted story told in the fashion of your’s truly…”Dad quit skipping around and finish the story.”

My wife and I were married thirty-seven years ago in Augusta, Georgia. She had it in her head that we should recite the vows by memory. I was in medical school at the time and did not quite get around to memorizing my part. By the way there is a reason why the preacher breaks up the vows for the “bride and groom” to repeat because the long phrasing lends itself to errors. Well, I stayed out until about 4 a.m. doing the bachelor’s party stuff with my old college frat brothers and my new med school friends and witnessed my best friend climbing to the top of a confederate statue in downtown Augusta. “I climb to the top of statues all the time,” he tells me.  In the aftermath of this, I am left to memorizing my lines the morning of the wedding and this was, let us say, not ideal. I get up at about 7 a.m. and drive to car wash parking lot and set about to memorize the damn lines. I had to go there because I was at the time living out of a dining room of a classmate and needed the privacy.

During the wedding I recited my part to perfection and my wife to be forgot a line or two and needed the help of the preacher to get through it. (Served her right-hint…don’t add the stress of memorizing something to an ready stress laden affair.)

When we get in my 1978 Toyota Corolla to begin our honey moon, my best friend from high school, Weasel-a DNR officer, has put skunk oil in all of the air vents and has put some type of deceased animal grease on all of the door handles and window levers. He had broken into the car during the wedding reception.

We drive to Savannah for the evening on our way to the final destination of Ft. Lauderdale. We stay in a motel on Tybee Island and the next morning we stop by a C and S bank to get some money from an ATM. The suitcase is in the back seat and when I put my hand in it to get my wallet something crawls over my hand. I jump out of the car and throw the suit case onto the parking lot and out of it slithers away a large black and orange snake. All I can think is that, “I’ll  get that “f..ing” Weasel back! You went to far this time as…..hole!” This meant that the snake had been in an opened suit case in the motel room all night the night before.

So…this morning I am pondering the 37 years of marriage and all the phases. The dating process at North Georgia College, and as a medical student in Augusta. The marriage event itself, the children, the trip to California and back in the 1.2 liter Toyota Corolla with a four month old child breast feeding, and pulling a pop up camper. We spent the night in an Oklahoma state park restroom with the ranger during a tornado and in Oakland were in a Motel 6 next door to a domestic violence episode. I went to tell the manager, who was behind a prison bar like office, and when I returned my wife, holding our 4 year old in her arms, was out side the door of the perpetrator with ear up against the door. After asking my wife, “What in earth are you doing?” we pack an leave. She told me later that she was only trying to help-I guess using our newborn as a  weapon?

Then the three children, my wife teaching art, med school, residency, and then moving to Gainesville, Ga to start our career with a golden retriever Meg, the three children-the youngest two months old. My wife is a petite person but after the pregnancy and childbirth her breast enlarged and they did not fit her body, so none of her clothes fit properly. About a week after arriving in Gainesville she got her hair cut by a new stylist and they cut her hair way too short. When I come home from a very paltry and sparse day of seeing a smattering of patients, she is crying in the kitchen and holding the two month old. The kitchen had 60’s era wall paper and appliances and the linoleum floor was orange. I remember the wall paper was green with streaks of gold thread.

There she is, red faced, tears everywhere, big breasted with a shirt way too small, a really screwed up hair cut shorter than I had ever seen and to top it off holding  the crying baby.

“This house, these clothes, my breast, this hair cut…It’s not me!”

Then the children grow up, the schools and teachers, the sports, ballet, soccer, AUA basketball, baseball, vacations, trips out west, issues with most everything we participated in, then each to college and so on and so on.

Thirty years later the children are out of sight but not out of mind. All the children are in their thirties but no one is or has been married. I’m ok with it.

I’ve been treated for prostate cancer, have been in four law suits, and my wife broke her hip last Christmas almost to the day, actually on Pearl Harbor’s anniversary. She was born on D-Day. Not sure what to think about military holidays and my wife.

So…I do these microscopic vasectomy reversals-I do as many as anyone in Georgia. I also enjoy social media and have several blogs and connections  on Linkedin. One such connection, a urological professor in Italy Fabrizio Dal Moro, several times a week posts urological pictures he has drawn. They are very good. I commented on one that I do vasectomy reversals and would it be possible to draw “a sperm navigating the vas deferens to get to the promised land.” The next day I see the picture below and the comment “To my friend John McHugh M.D.”


Well it is a long journey from a vasectomy, to a reversal, to achieving pregnancy. The artist then states, “In the spirit of Louis Armstrong.” Well I know a lot of Armstrong stuff and I love jazz. So I look up Long Long  Journey and find the song and that’s the youtube at the top of this post.

So…this morning I get up first and make the coffee and turn on the fireplace (that’s right turn on..it is gas logs and it is wonderful (having made hundreds of fires in my lifetime) and begin searching around for different version of the song and best youtube to represent it. My wife comes in and says,”Happy Anniversary.”

I say, “Happy Anniversary.” We hug and she gets coffee, I play the song and tell the story about the picture that the urologist from Italy (Padova) drew for me and that he labeled it Long Long Journey.

And then my wife says, “Well it has been a long long journey John, hasn’t it?”

And then the song waffles about in the background and I hear this verse…….

It’s a long, long journey
And I can’t make it on my own

There’s seven million people
Living right here in this town
There’s seven million people
Living right here in this town

I don’t need but one person
So, baby, why won’t you, please, stay around?


So,Karen…Won’t you please stay around?





The following is a comment to a previous post- Who regrets prostate treatment worse…

I did my due diligence after diagnosis at age 54 and decided on surgery first, salvage radiation in case of recurrence. Because I was well informed, my oncologist/surgeon was extremely honest and blunt. With my high PSA (40.98) and short doubling time he would be performing a non-nerve sparing Laparoscopic radical prostatectomy. This would result in no possibility of spontaneous erections following surgery. He would do his best to preserve continence. And if he couldn’t get a good ‘feel’ through the Laparoscopic tools, he would cut me open and ‘gut me like a fish’ to ensure the best possible outcome… life. Surgery was performed in November of 2008.
It took 3 months to get continence back. There have been no erections, even using trimix.
In June of 2011 my PSA started to rise, and in June of 2012 I underwent 40 radiation treatments. Both my primary oncologist and radiation oncologist explained the probable loss of continence and probable chronic colitis following radiation. The only adverse reaction is chronic colitis, but I am still in remission.
I do not regret having surgery, radiation, or the 6 months of hormone therapy post surgery. Based on the aggressiveness of my cancer I would probably be dead without all of the therapies. It’s important knowing all possible outcomes (death, complications from infection and scarring, incontinence, and erectile dysfunction) to make a decision that is right for you.
I have an acquaintance who is dying from aggressive prostate cancer. He was diagnosed with late stage cancer at 64, after not seeing a doctor for 15 years. For anyone in remission, no matter what symptoms we have as a result of treatment, those symptoms are a cakewalk compared to what my acquaintance is going through.

Something to think about.


From Urological Wit and Wisdom

Chapter 56

If I Am Going to Be Impotent Then I Am Going to Look Impotent


Okay, there is a classic urology joke that every urologist should have in his armamentarium and never fails to get a good laugh.

A man walks into a vasectomy clinic for his vasectomy all dressed up to the hilt. He has on a tuxedo, top hat and has a walking stick laden with diamonds. He was quite the dandy.

He begins the sign in process with the check-in nurse. She notices his unusual attire.

“Sir, why are you so dressed up for a vasectomy,” she says.

He replies, “If I am going to be impotent I want to look impotent.”


Rule: Impotency relates to the inability of having an erection. Libido relates to sex drive and is dependent on testosterone which is produced by the testicles and released into the bloodstream. Fertility is having the presence of sperm in the ejaculate. A vasectomy causes sterility and does not affect testosterone. To neuter one would be cutting off the testicles which do affect testosterone. Once a male goes through puberty and the voice deepens, doing an orchiectomy (or vasectomy for that matter) will not make his voice high, i.e. talk like a girl. Most of the ejaculate is produced by the prostate and not the testicles. An orgasm is caused by the violent contraction of the external sphincter.  You could explain all this to the patient so that he can defend himself from his coworkers when they find out he is having a vasectomy…or you could just tell him the joke and move on. Despite all of this and that the punch line has no medical basis and works only because of the male’s lack of understanding of their genitourinary system, the joke is still universally funny and should be employed on a regular basis.

“Eunuchs do not take the gout, nor become bald.”-Hippocrates