Posts Tagged ‘prostate cancer book’


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

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wit and wisdom picture

No. 123
Doctors, Pigs, and Incrementalism

incrementalism (noun): A policy or advocacy of a policy of political or social change by degrees: gradualism.
I was thinking about all of the intrusions into the lives and the profession of physicians by the government, insurance companies and hospitals and this joke came to mind. Most everything reminds me of a joke.
An insurance salesman is approaching a house that he intends to call on and notices in the side yard a three legged pig.
He knocks on the door, introduces himself and after talking about insurance for a while, asks the man of the house about the pig.
“So, tell me about that pig you have in your yard. Why does it only have three legs?”
“Oh that pig is very special. Our house caught on fire one night about a year ago and we were all asleep when it happened. That pig realized it and ran through the house oinking real loud to wake everybody up and get them out of the house. He saved the lives of my entire family. That’s one smart pig he is,” says man.
“So, he has only three legs. Did he lose one in the fire saving y’all?” the salesman asks.
“Nooooo,” the man says, “a pig that special you don’t eat all at one time.”

Rule: Yeah, us doctors are real special too. They ain’t gonna eat us either. At least, not all at one time.

Will Rogers said one time: “Be glad you ain’t getting all the government you pay for.”
If he were alive today he’s say: “Be glad you ain’t getting all the government health care you pay for.”

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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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You Don’t Cure Strictures…You Manage Them

All strictures are "almost" created equal regardless of the etiology.

All strictures are “almost” created equal regardless of the etiology.

I have always enjoyed pretending to talk about something completely ridiculous, but in a serious tone, in front of strangers. In fact, on my first trip in an airplane to Washington D.C. for a Key Club convention, the friend I went with told me, “John, if don’t start acting normal, I am not going to be seen with you.” As a resident I had this “skit” I’d do with the chief resident when we found ourselves in a crowded elevator of patients, residents and employees at Talmadge. I had a three year old son at the time and the skit involved speaking of him to the chief resident as if my son had gonococcal urethral stricture disease.
“Doug, I want to thank you for seeing my son in the clinic today. His stream had gotten down to a dribble and that watering pot perineum of his is making him have to wear diapers again.”
“No problem John. Man oh man does he have one bad ass stricture. He’s a trooper though; he tolerated an internal urethrotomy in the clinic today like a champ. Y’all can take the catheter out when he stops bleeding. Is he still self-dilating at home with Van Buren sounds?”
“Yes he is, well that is until the 10 French won’t go, then his mother uses the filiforms and followers to get him back up to a 16 French. That Blandy you did on him, although I appreciate your efforts, was a lot to go through and then still have to keep up the dilations.”
“I understand John but your son should have thought about all this before he went about catting around. His stricture is pan urethral and very tight. He may end up with s perineal urethrostomy with the stricture he’s got.”
“Doug, what makes this so hard for his mother and me is that he is only three.”
“Well John, as my mother bed used to say, “You make your bed.”
Rule: Gonococcal urethral strictures-The gift that keeps on giving.

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Penelope decided to take matters into her own hands. She got the stick, scooted it up the dock gang plank, put it in the water herself and then completed the task by taking it to shore. She’s in complete control.

At the end of the day what you decide to do about your prostate cancer is your decision. To elect a particular therapy and then retrospectively criticize the doctor or the treatment modality is…well waiting for someone else to throw your stick.

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Search this site for ” Robert Frost- The road less traveled.”

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I did everything he did but backwards and in high heels.    Ginger Rogers

You are welcome!!

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