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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.”

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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?

 

 

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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.

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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

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I’m reading a book about Edison suing Westinghouse in the late nineteenth century and the development of alternating current. The Serbian who “conquered” alternating current was a idiosyncratic man named Nikola Tesla. It is very interesting however I am in love with the nineteenth century and the men and women of history of that era. Think Twain, Edwin Booth, Henry James, Grant, Kipling, Osler, Roebling, Carnegie, Frick, etc and etc.

So about the study that follows and there are a lot like them. The advent of the MRI for the prostate and what does it mean, does it help, is it really that much better than systematic ultrasound guided biopsies considering the cost and time element.

In a time of all the talk of cost, why is there not more condemnation of the cost of the MRI and the interpretation of it by the radiologist by our “experts.”

Anyway here is the article. Keep in mind I have done thousands of prostate biopsies in my career and the expense of the procedure, the ultrasound, the materials used and what is paid to me for doing is less expensive than an MRI alone. Where is the outrage?

Poor little ole PSA. The Rodney Dangerfield of Medicine. Are the letters MRI more sexually appealing than the letters PSA. Oh by the way…why do you order a MRI in the first place? You guessed it…an elevated PSA…that dirty rascal keeps popping his knarly little ole head…don’t he?

Feel free to opine…if you are well versed in the MRI movement, the benefits, the cost, and why it should be the only study done on men suspected of prostate cancer please…comment. I truly want to be enlightened. Predict the future.

Prostate MRI in the Prebiopsy Setting

Urology – June 15, 2016 – Vol. 34 – No. 3

Prostate MRI in the prebiopsy setting may help identify Gleason 7 and higher cancers.

Article Reviewed: Prebiopsy MRI and MRI-Ultrasound Fusion-Targeted Prostate Biopsy in Men With Previous Negative Biopsies: Impact on Repeat Biopsy Strategies. Mendhiratta N, Meng X, et al: Urology; 2015;86 (December): 1192-1198.

Background: Prostate MRI has seen an explosion of use over the past 5 years. The perceived benefit of prostate MRI is in the identification of high-grade disease and thereby decreasing the overdetection of clinically insignificant prostate cancers.

Participants: Patients presenting to a single institution with elevated prostate-specific antigen (PSA) levels.

Methods: Patients underwent multiparametric prostate MRI with a 3 Tesla unit. Prostate lesions were scored on a scale of 1 to 5, with 5 being very high probability of cancer. Patients with target lesions underwent targeted biopsy with a standard 12-core template biopsy. Patients with a normal MRI were not included in the study, as targeted biopsy could not be performed.

Results: 352 patients were included in the study. Prostate cancer was identified in 207 men. Cancer detection rate was higher in the standard template group (49.2%) than in the targeted biopsy group (43.5%). However, targeted biopsies detected more Gleason 7 or greater disease (88.6%) compared to the standard template (77.3%). Higher volumes of clinically insignificant prostate cancers were detected by standard biopsies. Using suspicion level of 4 and 5, 85.9% of patients were found to have prostate cancer, with 69.1% having Gleason 7 or higher. Using suspicion level 4 and 5, sensitivity, specificity, and negative and positive predictive value were 78.0%, 81.6%, 87.6% and 69.1%, respectively, for finding Gleason 7 or greater disease.

Conclusions: For men with elevated PSA levels, multiparametric MRI is a valuable tool in the prebiopsy setting for detecting clinically significant disease.

Reviewer’s Comments: The authors present compelling data for the addition of MRI in the prebiopsy setting for patients with elevated PSA. What is not included in the study are the data for those patients with negative prostate MRI. In addition, MRI is an expensive imaging modality. Does improved detection of Gleason 7 prostate cancers justify the cost on a population level?(Reviewer–Michael Poch, MD).

 

Author: Mendhiratta N, Meng X, et al
Author Email: samir.taneja@nyumc.org

When the bladder spasms urine will go around the catheter. In the big scheme of things – urine getting out… Is a good thing.

Prostate diaries

When the prostate is removed, the bladder is separated from the urethra (the tube that runs through the penis which men void through). After the prostate is out, the doctor then sews the two areas back together. It takes about 7-10 days for this to heal. A catheter is placed through the tip of the penis in urethra, past the junction of the bladder and the urethra, which has been sewed together, and then into the bladder. A catheter (foley) stays in the bladder by a balloon at its tip. The balloon keeps the catheter from falling out and is about the size of a golf ball.

The bladder does not like the balloon in there. It perceives it as a foreign body and wants to “spit” it out. It does so by contracting as it would to make urine.  This is a bladder spasm and can result in the loss of…

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