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This is an excerpt of a book I am writing-101 Aphorisms, Adages and Illustrations for the Urological Resident

See what you think.

 

I remember Mr. Tomanek for many reasons but for two in particular. He loved trains. He lived in the mountains just south of Helen, Georgia and built a garage specifically for his trains and all the stuff that goes with that. I looked at pictures of the new additions at each office visit. The other thing about him was the relationship between him and his wife. When I first met them, she had just had a base of tongue resection and all of the facial and neck incisions were healing. It affected how she talked and it affected her facial expressions. I was blessed to have worked with them for over 15 years. In the beginning he was strong and she was sickly. Then they were about the same and then he had a stroke making him weak and her strong. And man was she strong. She became, over time, the dominant part of the relationship. She did right by him.
What I have described, I have witnessed many times in my 25 year plus career; the ebb and flow of a relationship and the alternating pattern of health that accompanies it over time. Mrs. Tomanek seemed to become stronger as she aged and Mr. Tomanek deteriorated equally in reverse. Mr. Tomanek had a stent that we exchanged every six months because of a ureteral stricture secondary to repeated bladder cancer resections.
In time Mr. Tomanek became home bound and on Hospice and we elected to just “leave the stent be.”
One day there is a phone call from Mrs. Tomanek, “Dr. McHugh, Frank is having a lot of blood in his urine and I was in hopes you could just remove the stent and leave it out.”
“Sure,” I say, “when do you want to come to have it done?”
“Can you come here and remove it; at our house?”
I paused. There was no question that I wouldn’t accommodate Mr. Tomanek, I was just going through my head the logistics of having all the stuff I’d need to take the stent out and if I could do it by myself with her help.
“When do you want me to be there?”
My nurse and I packed up the irrigation fluid, the graspers, the light source, betadine and the flexible light source and I was on my way. I knew the area in and about Helen but the key was to turn just before Helen at a roadside vegetable market. As I turned on to the road, I said to myself that I would be stopping there on the way back to get some tomatoes.
When I arrived, Mrs. Tomanek, who had to be almost eighty, was at the top of a twenty-foot ladder adjusting a wire that was attached to her satellite system. It was crazy seeing this; I had my camera and took a picture of her up there.
She takes me inside and in an old fashioned bedroom replete with generations of pictures, was Mr. Tomanek in his bed gazing listlessly out the window.
I set up my stuff and luckily remove the stent without an issue. I give them the stent, “look, it’s a boy” as a souvenir. Mrs. Tomanek gives me a blue wooden train engine, “He’d want you to have this,” she says.
I never saw Mr. Tomanek again. I may have seen Mrs. Tomanek once since.
Rule: One of the beauties of years of experience is perspective. You develop a feel for how things “play out” because you have witnessed the evolution of relationships just as you have various diseases. This in turn makes you a better doctor.

Urologists know the good kind of prostate cancer from the bad from the get go…the patient doesn’t and it is our job to “get that message across” and educate, advise, direct and aid in the decision process and treatment with an emphasis aligning all with the patient’s wishes.

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Everybody loves Baby Breeder!

So the doctor says to the average patient, “The government rationing board has banned the drug that would treat your prostate cancer and extend your life by several months because it is too expensive. I am sorry, but good luck.” This patient goes home to his family and relays the news and as good citizens all accept the “decision” because as we all know the government knows best.

The same doctor informs the richest man in the world the same news and then says, ” You can get this drug in the U.S.  if you are willing to pay for it and fly there to get it. I might even find a private clinic here in the U.K. that may supply you with the medicine if you will pay for it and if you receiving it is approved by the NICE rationing board. Do you know any of the members of the board? A word here or there may be of benefit to you. If I can be any help at all Mr. Buffet please let me know. With your resources I am sure that we can reach a suitable resolution to this pesky issue.”

Mr. Buffet says to his associate as he is leaving the doctor’s office, ” Call my contact in New York and set this treatment up for me ASAP.”

Obamacare, NHS, Rationing boards, NICE…Fineberg Iceberg its all the same to me.

I recently read a historical account of the relationship of England and Ireland and how back in the day the Irish were harshly treated and many of their rights were abridged by the English. A rule of having to give up your house or a horse by an Irishman if an Englishman wanted it comes to mind. I found the sentence at the end of this piece odd, that the drug alluded to was “banned” in Scotland. Banned? Really? Why Scotland?

Mr. Cass enlighten me. The U.K. is England, Wales, Scotland, and Ireland. Why is Ireland not mentioned?

Prostate drug ban lifted as NICE U-turn gives cancer sufferers chance of longer life

By Jenny Hope

PUBLISHED: 19:46 EST, 13 May 2012 | UPDATED: 20:15 EST, 13 May 2012

The NHS rationing body is poised to reverse a proposed ban on a drug that will give precious months of extra life to men with advanced prostate cancer.

The U-turn is a victory for the Daily Mail, which has fought for years for better care for prostate cancer sufferers, and follows a campaign by the Prostate Cancer Charity and a rare intervention by the Department of Health.

Abiraterone – which costs £3,000 for a month’s treatment – was judged too expensive by the National Institute for Health and Clinical Excellence.

Vital medicine.Armoury: Drugs like abiraterone and cabazitaxel, which cost around £3,000 for a month’s treatment, have been proven to add months to terminally-ill patients’ lives

But now the drug will be the first specific treatment for the disease approved for use on the NHS for more than a decade.

Experts say it is stark evidence of the neglect of those who suffer from a disease that strikes 40,000 British men each year.

Abiraterone is one of two new drugs proved to prolong survival when other treatments have failed. The other, cabazitaxel, was banned for NHS use last week.

Trials show that men taking abiraterone and a steroid survived for nearly 15 months, while those given steroid treatment and a ‘dummy’ pill lived for 11 months on average.

But some patients live far longer than expected, including Britons who have survived on the drug for almost five years with advanced disease. Abiraterone is widely believed to have kept Lockerbie bomber Abdelbaset Al Megrahi alive.

The pill, taken four times a day, also eases pain and improves quality of life.

The plan to ban the drug was adopted by NICE despite protests that it failed to use the correct criteria to assess it.

Cancer specialists said it should have been assessed under the end-of-life system in which NICE is supposed to give weight to the value of a few extra months for terminally ill patients.

The outcry was led by the Prostate Cancer Charity, while Department of Health officials asked NICE to ‘carefully’ reconsider its proposal.

The rationing body is expected to announce this week that it will approve the drug using end-of-life criteria.

Abdel Basset Al-Megrahi.Effective: Abiraterone is widely credited with keeping Abdelbaset al-Megrahi alive for much longer than doctors first predicted

It also looked at data from the Cancer Drugs Fund, which gives patients in England access to treatments that are hard to obtain on the NHS, suggesting it is the second most popular drug, after Avastin for bowel cancer.

Around 3,300 British men with advanced prostate cancer that has become resistant to standard hormone treatments could benefit each year from abiraterone.

The drug, manufactured by Janssen, was developed by UK scientists at the Institute of Cancer Research and trials were partly funded by British charities.

Owen Sharp of the Prostate Cancer Charity said its campaign had been supported by patients and MPs appalled at the prospect of a drug available in other EU countries being banned here.

He said: ‘It was the wrong decision. This breakthrough drug will make a real difference to men with prostate cancer at the end of life who have no alternative – this is the only hope they have.

‘It gives them significant extra months of life. It also gives a huge reduction in pain. Disagreement over cost was not a reason to deny it to patients.’

Professor Jonathan Waxman, a prostate cancer specialist at Imperial College London, said the proposal to ban abiraterone was based on false cost estimates and had ignored end-of-life criteria meant to apply to such drugs.

He added: ‘The ban should be reversed because it would limit what we as clinicians can do for our patients and their families.’

NICE’s decision will affect patients in England and Wales. The drug is banned for use on the NHS in Scotland, but the decision will be reviewed.

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where there is a will...i want to be in it- a paraprosdokian

So who do you believe-the folks that say the PSA doesn’t save lives or the ones that say it does. You want to know the answer-simply view it as if you or someone you love has been diagnosed late and has disease too late to cure and you didn’t do the screen stuff because you saw on t.v. that it was not helpful and so you did not get tested. Now how do you feel? Which statistics mean the most to you now? Are you the “vast majority” or are you the one that goes unmentioned, the “very small percentage that it helps.”

If the odds are one in a hundred and you are that one then it’s 100%

I’d love to agree with you but we’d both be wrong…

I love these things….paraprostdokians

Etymology

“Paraprosdokian” comes from Greek “παρά“, meaning “against” and “προσδοκία“, meaning “expectation”. Canadian linguist and etymology author William Gordon Casselman argues that, while the word is now in wide circulation, “paraprosdokian” (or “paraprosdokia”) is not a term of classical (or medieval) Greek or Latin rhetoric, but a late 20th century neologism.[2][3] However, it occurs—with the same meaning—in Greek rhetorical writers of the 1st century BCE and the 1st and 2nd centuries CE.[4][5][6][7]

Examples

  • “If I am reading this graph correctly — I’d be very surprised.” —Stephen Colbert[8]
  • “You can always count on the Americans to do the right thing—after they have tried everything else.” —Winston Churchill[8]
  • “I’ve had a perfectly wonderful evening, but this wasn’t it.” —Groucho Marx[10]
  • “A modest man, who has much to be modest about.” —supposedly Winston Churchill, about Clement Attlee[10]
  • “She looks as though she’s been poured into her clothes, and forgot to say ‘when’.” —P. G. Wodehouse[10]
  • “I like going to the park and watching the children run around because they don’t know I’m using blanks.” —Emo Philips[10]
  • “If I could just say a few words… I’d be a better public speaker.” —Homer Simpson[11]
  • “I haven’t slept for ten days, because that would be too long.” —Mitch Hedberg[3]
  • “I sleep eight hours a day and at least ten at night.” —Bill Hicks[3]

So I bet at least five people from patients to a guy in the operating room show me the article from a magazine like American Scientific saying that the PSA was not helpful in the diagnosis of prostate cancer and resulted in too many this and that…and bla bla bla.

“Whada ya think about this article doc,” the orderly asked as my patient was being put to sleep in the operating room.

On the cover it said something like this…”In most cases prostate cancer is slow-growing and in the vast majority of patients death will be the result of something other than prostate cancer.”

I say to the well-meaning orderly, ” let’s say this is your father we are talking about and you are there and I am there and he has just been diagnosed with prostate cancer and you show me this article.”

“I’ll ask you if it matters to you and your dad that the articles says that “most” are slow-growing and that the “vast majority” of patients will die of something other than prostate cancer. What will you want for your dad. If  “most” or “vast majority” is good enough for you then don’t have your prostate cancer treated. If it ain’t enough then I’d have your prostate cancer treated.”

I then asked, ” who would you be in this scenario.”

The twenty something orderly with no knowledge of prostate cancer replied, ” I’d want my father to be treated.”

“Well then that is the right answer…for you.”

Now this from Australia….80% of men never tested? What the hell?

Oh the statistics and the paraprosdokians….just thought it sounded good. I was going to link the two together in a clever fashion but now I am bored with this….so down to the cove with the four dogs above and see if I can catch just one for more pictures on my iphone.

Study: Prostate Blood Test Reduces Cancer Deaths

By: Daryl Nelson  |  Yesterday  |  TheCheckup.com

Thinkstock

A new study suggests men screened for cancer using the prostate specific antigen (PSA) blood test reduces the number of prostate cancer deaths.

The report from the Prostate Cancer Foundation of Australia found men who were given the PSA test showed a 21 percent drop in prostate cancer deaths after being re-examined 11 years later. The study involved more than 162,000 in eight European countries.

“Importantly the prostate cancer mortality difference between men who  were screened and men who weren’t became wider the longer they were  followed up after screening began,” a statement from the foundation  said.

Researchers at the foundation found that 80 percent of Australian men between the ages of 45 to 74 did not get a PSA test and 3,300 died annually from prostate cancer. With the PSA test about 700 lives would be saved, the foundation president said.

In conflicting results, U.S. researchers found no decline in prostate cancer deaths among men who were regularly screened, however, Dr. Lowe believes the seven year U.S. study wasn’t long enough to draw a complete conclusions.

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being a leader is a lot like being a lady....if you have to say you are then you arent...m thatcher

Guitar Capo-Or as my mother used to say, ” Necessity is the mother of invention.”

When I was a urology resident I had to do a research paper on Fournier’s gangrene. I got somehow the original article on the subject by Mr. Fournier himself. It was in French and much to the chagrin of the chairman of the Dept. of Urology, it cost something like 500 dollars to translate it. Fournier’s is an interesting and devastating disease process. Two things are remarkable about it: one it can start as a small scratch on the scrotum and in hours infection can devour tissue from the scrotum and then up onto the abdominal tissue and skin (an infection that gallops) and despite all the destruction, the testicles themselves are spared. Why? The skin of the scrotum and that of the testicles are different so the testicles are unaffected. Think of a forest fire and one species of tree is left alone. The only treatment is wide and radical debridement of dead tissue, often times just leaving the testicles hanging there alive but with no covering. I saw about five cases of this in my time as a resident and hence the paper.

Now about the scrotum, I had a saying as a resident, “The scrotum is your friend, the urethra your enemy.” The scrotum is very forgiving usually, ” John, you only need a postage stamp of scrotal skin alive to cover testicles. An amazing organ indeed,” Dr. Witherington used to say. The least amount of trauma to the urethra and you’ve got issues forever.

As men age small little clusters of blood vessels develop on the scrotum. The are asymptomatic and really don’t mean anything or amount to anything…usually. Scrotal petechia or specifically Angiokeratoma of Fordyce– little things that look like a blood vessel pimple.

Anyway, on Thursday of this past week I was on my way out the door to work and my wife asks, “John did you cut something. There is blood in the bathroom and it leads into the living room.” We go back to look  and sure enough there is fresh blood from the bathroom to the living room hard wood floor and then it mysteriously stopped. Nothing anywhere else.

“It must be Penelope or Chloe,” I say. But after checking the two of them and their sleeping area (our bed) no blood there. Since the blood was in front of my sink, I became the suspect. I check my nose, hair, ears and arms and stuff. No blood. I check other places…nothing. “I don’t know Karen, I don’t think its me. Maybe I cut something opening the orange juice this morning. (The orange juice has a serrated top that you have to pull off to open.)

I go to work and no other issues are noted by me, our dogs or Karen. “I was never at your sink John. It can’t be me.”

So the next morning, I turn the shower on to let the water get warm, and as I step in, I see blood swirling around down the drain. (I reminded me of the Alfred Hitchcock movie where the lady is stabbed in the shower, Psycho I believe. We saw a reanactment of that at Disney World.  That scene ha been rated on of the best ever in movie making annals.) I start to look around on my body to see where it is coming from and you guessed it…my friend the scrotum. I put pressure on the area and notice that I have the little blood vessel bumps in other surrounding areas that I’ve told my patients about over the years. I figure I must have popped one of them and now it was bleeding.

Over the years patients have come in to my office with bloody pants where blood had soaked through their underwear and pants because on of these things rupturing. “Doc, I think I am bleeding to death. Where is this coming from? Why won’t it stop?”

There are two reasons why this little known issue of the male scrotum is not easy to stop. For starters, patients won’t hold pressure for the time it takes to achieve clotting. They want to peek every two to three minutes, see it bleed and then repeat that process. They never do the full 7-10 minutes. The other is that is not like a scratch, this is an issue where the top of a blood vessel is scraped off. There is a larger area to coap and then stop bleeding…like a whole in a small blood vessel that can’t close.

Well I am in the shower and am pinching the area to keep it from bleeding and switching hands in order to “scrub both sides of my body” and with each switch the bleeding continues. This process continued through the time I dried off, shaved and dressed. It wasn’t until I got my socks on that I could “practice what I preached about holding pressure without looking.”

It was then about 8:55 a.m. and I already had a text from my nurse that, “three waiting.” What to do?

As I am holding the area  between  my fingers I ask, ” Do I hold this all the way  to work? What if it’s still bleeding when I get there?” I had already tried putting a bunch of toilet paper and pulled up my underwear real tight…not enough pressure. The degree of bleeding, just as my patients had told me, was impressive.

Then I had an idea, “Karen, do we have any of those clips we use to keep potato chips fresh?”

“John are you kidding? Ouch!”

“I think it will work,” I say and she begins looking through drawers. She finds one but it was about 8 inches long. I found one that was about 3 inches and wadded toilet paper up over the area and put on the clip. The problem was that the pressure exerted was too broad so the area just  kept on bleeding. “This won’t work,” I say dejectedly.

“Here’s a guitar tuner. Will this work?” I look up and she has a guitar capo. A glorified clothes pin I think. Later my wife said she offered up the capo as a joke, but it looked like to me that it just might do the trick.  “Perfect,” I say. “Pin point pressure right to the area I need and “it’s hand free.”

I fold up toilet paper again in tight bundle, pinch out scrotal skin away from the testicle, and put the capo on. It stayed in place, and it stopped the bleeding. Except for the intense pinching sensation, I thought it would be fine for me to drive to work and once I get there see if it did the trick. The drive satisfies the requisite 15 minutes of holding pressure. “John, you are crazy,” I heard my wife say as I went off to work.

At work I go into the bathroom to take the capo off and see if the bleeding had stopped. When I go to take off the capo, the back side of it (which some family musician had put tape on-see picture) had impressed and attached itself to the scrotal skin. So when I went to take it off it got stuck on the back side, very painful, and the effort to get that off disturbed the front side and it started bleeding again. I get a bunch of paper towels and press that up against the scrotum and pull the underwear again, but to no help. I decide to try the capo again. This time I folded a paper towel so that it protected the skin on the front and back and put the capo back on. “Dr. McHugh, Line One,” I hear as I am flushing bloody paper towels down the toilet and washing my “hands free of blood.”

Lab jackets are very forgiving. They cover wrinkled shirts, an ever-increasing waist line and the rigid silhouette of a capo in one’s britches to stop scrotal bleeding. I see about five patients over about the next 25 minutes and then make my way to the bathroom again. I carefully remove the capo…and no bleeding. It was done.

In scouts…starting a fire for a scout is not usually a big deal. But if you tell a scout, “start a fire…and you have three matches and two minutes,” well that is a different story. In this case the bleeding alone was not that big a deal but add the other stresses…well I was concerned. I knew I’d be alright and that there would be a “story in it.”

All day I carried the capo in my lab pocket. I told the story (yes I did) about ten times to certain fun-loving patients and to my all female  staff. “This is the thing right here,” as every time everyone cringed. It was a great Friday afternoon pick-me-up of sorts.

Everyone thought it must have been very painful to wear a capo,(especially when I used the capo to pick up a book of about 100 pages to show how strong the pressure was) but they did not know what I knew and that was that, ” One’s scrotum is one’s friend.”

One other thing…I anticipated one day one of my son’s sitting down to strum the guitar and beginning to use the now famous medicinal capo and me saying quickly, ” I don’t think I’d use that one my friend.”

Finally, why the capo story. It intensely reminded me of my prostate cancer journey during the time I worked with a condom catheter on daily for three months. Each day in that recovery to continence and potency was an uncomfortable adventure…ahh… the  memories….

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a friend in the court is better than a penny in the purse

Is this not one beautiful and happy dog or what? We love our Chloe.

The above question is good one.  Reviewing the search items that get folks to my site are revealing and offer an opportunity to address issues that concern prostate cancer patients.

When the urologist does a prostate ultrasound, it usually is used as a guide to systematically sampling the prostate. For me, it allows for 12 biopsies that are equally spaced out and geographically sampled throughout the gland.

When the prostate ultrasound and biopsy first came out, we were told that prostate cancer could be seen as a hypo echogenic area in the prostate gland. Later we learned that not all prostate cancers made a nodule that could be seen as hypo echogenic. Many prostate cancers are infiltrative and as such may not be seen on an ultrasound.

So…the dirty little secret is that the prostate ultrasound is not used so much as a diagnostic tool in and of itself, its primary use is to allow for the appropriate spacing of the biopsies  to adequately sample the gland.

The answer to the question is yes and no. The ultrasound does not necessarily identify the prostate cancer, but it does aid in the diagnosis by allowing for a systematic method of obtaining specimens which in turn facilitates the diagnosis.

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pride is the only poison you can swallow that won't kill you....

A question I saw on a prostate cancer forum:

My urologist has prescribed me cipro to take for a month and then get re tested for a rising psa score. it is currently 5.8 and i had a radical in 2003. my psa has been steadily rising over the past 7 years. i apparently have rogue cancer cells in my prostate bed. has anyone on the panel been prescribed cipro for a rising psa level?

This question is a variation of a theme. What do  you think the right answer is?

Before the diagnosis of prostate cancer is known to be present or not…prescribing Cipro ( an antibiotic that is “good for what ails the prostate” ) is a reasonable thing to do for a high PSA. The thinking is that often times the PSA can go up in the face of prostatic inflammation. Cipro helps with that so often times the PSA  will decrease and the doctor will not act on the elevated PSA if it reverts to normal. If not, the doctor proceeds to biopsy. This is about a rising PSA when the diagnosis is not made. Lots of things can cause the PSA to go up other than cancer and the Cipro is helping ferret that out.

Now…if you’ve had the prostate removed, then all the things that falsely cause the PSA to go up go away. If the PSA is up, and you have had your prostate removed , then there is only one reason for that and that is the presence of prostate cancer. I did not say the “return” of prostate cancer. Probably small amounts of undectected prostate cancer, other than in the prostate, was present at the time of the surgery. Read and understand the Partin tables. (See informative links on this site.)

So, will giving Cipro to a patient with a PSA of 5 who has had a prostatectomy for prostate cancer help?  No. I am suspicious that it is not a urologist that advised this, or that the information we are given is incorrect. In any case, this patient needs a metastatic work up and a radiotherapist evaluation.

This is an example of a urologic caveat…Yes Cipro helps pre diagnosis and increased PSA-No it does not if the prostate has been treated for prostate cancer.

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Penelope "multitasking"

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 urine around the catheter alone, or associated with excruciating pain. This leakage around the catheter with or without pain is relatively common and is of no real medical consequence.

Blood that seeps around the catheter and appears at the tip of the penis is common as well and is nothing to worry about.

As a urologist, what we worry about is when clots form in the bladder and block of the foley and prevents the free flow of urine. Now that is an issue. Urine or blood around the catheter is just part of the deal when you have to wear a catheter for a period of time for any reason.

If you don’t have spasms or leakage, just consider yourself lucky. I had a bladder spasm to high heaven and I have never had pain like that before. It was something else…my friend.

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