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If you had the choice of only one opening to have a vasectomy or two separate openings which would you choose?

Duhhhhhh! Maybe you should ask ahead of time!

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Urology Humor

A physician should have a ready wit….dourness is unpleasant to the well and the sick alike.

“What do you call a tire made out of 365 condoms?”

A good year!

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yeah lycopene prevents prostate cancer and bla bla bla bla….

Summer is a good time to be a urologist in Georgia.  Here’s how it goes.
An older patient comes in and has a tan. I ask, ” How is your garden this year?”
The response, ” The tomatoes are just coming in.”
I say,” I’ll do half the work. You grow them and I’ll help you eat em.”
A week later the patient stops by with some homegrown tomatoes like the ones pictured above.
I need to learn how to can them. I have asked a thousand times and in fact one time bought the jars but never got around to “canning them.”
Lycopene and tomatoes are supposed  to prevent cancer. Well…I have eaten a thousand and I got prostate cancer. Go figure.
Last week I took out a prostate of a 50-year-old man whose biopsy of his prostate was very favorable one core of 12 positive at only 10% and it was Gleason 6. The psa had been about 5 or so and he had a normal rectal exam. So I encouraged him to think about surveillance.
His remark was that he did not want to be dealing with prostate cancer years from now and that he wanted to be done with it now while he was healthy enough to deal with the surgery. I made the point about “killing a fly with a hand grenade” but he had made up his mind.
The path of the prostatectomy came back bilateral disease, an area of 1.2 cm nodule of cancer and elements of Gleason 7 (3+4).
The point? I don’t think I would recommend surveillance in a 50-year-old if I had known the “true path.” So…you guys out there with a favorable path report on biopsy at least have to be aware that “what you see ain’t what you get” when it comes to the accurate appraisal of you cancer on biopsy. Think 12 hair sized specimens from a lemon. Not telling you what to do, not against surveillance, I’m just saying.
BJU Int. 2002 Nov;90(7):694-8; discussion 698-9.

Gleason score on biopsy: is it reliable for predicting the final grade on pathology?

Source

Department of Urology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Canada. fredsaad@videotron.ca

Abstract

OBJECTIVE:

To assess the correlation of the Gleason score on biopsy and the final pathology after radical prostatectomy (RP) for prostate adenocarcinoma.

PATIENTS AND METHODS:

In a retrospective analysis within a tertiary-care centre, the charts of 537 patients who had undergone radical prostatectomy from April 1989 to November 2000 were reviewed. The RPs were undertaken in one institution; 167 biopsies were taken and interpreted in the referring centres, and 355 were taken and interpreted in the authors’ institution by up to 15 pathologists. All the final pathology specimens were interpreted by the same group of pathologists. The main outcome measures were: the pathological report of the biopsy including the primary and secondary Gleason grade; the final pathological grade (primary and secondary); the margin status; and the identification of the pathologist for the biopsy and final pathology.

RESULTS:

In all, 390 patients had inclusion criteria (the Gleason grade before and after RP) available. For the individual scores 38.2% of tumours were undergraded, 32.6% overgraded and only 29.2% had identical grading in preoperative biopsies and final specimens. When grouped into more meaningful categories (Gleason 2-4, 5-6, 7 and 8-10) the correlation improved, with 48.5% of patients remaining in the same group after RP. For 39 patients the same pathologist assessed the biopsy and final specimen; in these cases individual scores were identical in 49% and group scores were identical in 64%.

CONCLUSION:

Gleason grading of the prostate biopsy remains a poor predictor of pathological outcome. Assessment by the same pathologist reduces the discrepancy but over half the patients are under- or overgraded on final pathology. Clinicians should be aware of these limitations when using the biopsy Gleason grade in decision making.

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He that wrestles with us strengthens our nerves, and sharpens our skill. Our antagonist is our helper. — Edmund Burke

About the above picture…there is no way that Penelope could not be chosen for a calendar. Is she beautiful or what?

Second opinion on a prostate biopsy to be sure that a positive finding is indeed prostate cancer? Been there done that? What I did was to ask for additional stains to prove it was prostate cancer and not something else. The result? The pathologist found another area with the stains and a higher Gleason’s score and then I got the $2000 bill for my being “clever by half.”

In my opinion the answer is no. Pathologists see so much prostate cancer that it is an easy call.  They might disagree on the Gleason’s score but it would be rare for the cancer to missed or over diagnosed. Our office uses LabCorp and each report comes back stating that it had been reviewed by a Pathology Conference and that all were in agreement.

If your treatment decision hinges on the Gleason’s score or the volume of disease and it is important to you then by all means get a second opinion on the path. Easy to do. Just say you want it done and the slides are sent to institutions that commonly do this. In our area most are sent to Johns Hopkins. I personally have never seen a change in the diagnosis but it does happen I am sure.

I think  in some patients a confirmatory reading is comforting and in that case it is fine to do.

Now on a second opinion regarding treatment options? Hell yea! And I’d recommend a radiation therapist not another urologist…that is of course unless it is me.

Why me you ask?  Cause  ” I ain’t got no dog in this fight.” (Bias…that’s right I am a urologist and have no bias  in the decision that the patient makes and strongly encourage speaking to “another kind of doctor” about this.

How about a medical oncologist? I wouldn’t. These doctors are excellent but don’t as a rule see people who are newly diagnosed and trying to decide what to do. Great doctors and informed…yes. They just don’t see people at the time of diagnosis. Usually after the original treatment has failed and now the patient is hormone refractory. They will be helpful but I’d get the second opinion with someone who treats the “virgin” disease.

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“A diplomat is a man who always remembers a woman’s birthday but never remembers her age.” – Robert Frost

Of the top ten questions I have gotten over the years about misconceptions/misunderstandings of the various treatment of prostate cancer-the concept of the delayed effect of radiation on one’s body is one of the more common.

The typical situation will be the guy who has either had seeds or external radiation. He may have had a little bit of a bumpy go of it early on in the radiation, maybe some urinary symptoms of frequency or urgency or mild self-limited diarrhea, but then did well. That is until about 2-5 years later when he notes blood in his urine or exacerbation of the urinary symptoms again.

In the case of blood that is now visible in the urine and often times associated with clots, I’ll mention to the patient and  the wife that his is probably an effect of the radiation and the expected come back is, “But he had radiation five years ago.”

I’ll come back to my thoughts on that but first a note about clots because this is another thing that patients have trouble grasping and something I hear very frequently. Patients will spend an inordinate amount of time explaining clots, the color, how it felt to come out, what it looked like and so forth. This is because they feel that a clot makes the bleeding more significant. The truth of the mater is that a clot is simply blood that settled in the posterior aspect of the bladder then formed a clot. When the clot is voiding out it is compressed into “worm form” as it goes through the prostate and urethra. If you can void at all i.e. no obstructive problem because of the clot then it has no real clinical significance.

“I noticed blood at the tip of my penis after I pee’d red blood. And then a maroon looking gelatin thing came out shaped like a worm, a bunch of them, then there was more blood at the tip of my penis. Ever since then the color of my urine has been blood-red.”

  • You rarely lose enough blood in the urine to affect the blood count (it won’t make you anemic.)
  • Clots are the result of blood doing what it does, clot, and are molded like my old Mattel worm maker when I was young.
  • Think of a clot as a bouillon cube swishing around in the bladder discoloring the urine until it is gone. This is why a patient will say they had blood in the urine, passed a clot and then the urine cleared. The bleeding from the prostate or bladder as a result of the radiation probably stopped hours or days ago. So no active bleeding just the bouillon effect of the clot coloring the urine by dissolving slowly.
  • People on blood thinners, including low dose aspirin, are more at risk of bleeding secondary to the effect of radiation.

Radiation cystitis and for that matter radiation urethritis of the prostatic urethra is a given consequence of radiation. It is not a given however if a particular patient will have any symptoms related to it. The symptoms and clinical issues:

  • With seeds the vessels along the course of the inner channel of the prostate (the prostatic urethra) become very engorged and the vascularity of blood vessels increase. Visually they look like dilated vessels on a person’s nose if they have that disorder that Jimmy Durante had. In turn they become friable and easy to bleed.
  • Radiation cystitis is a term for the same process of the bladder mucosa. The normal vascularity of the inner lining of the bladder becomes more reddened, the vessels more prominent. In some cases the vessels in one spot change and in other patients the whole bladder is involved.
  • It usually progresses with time and is more common a year or two out rather than immediately.
  • This is why in my book I say “Do you want to pay me now…the immediate issues related to a prostatectomy” or ” Do you want to pay me later-the delayed side effects of radiation.”

What are some of the treatments or management of blood in the face of a past history of prostate cancer and radiation?

  • If the patient is on coumadin or aspirin and okay with the cardiologist it is best to stop those.
  • The hope is that it is one vessel and that stopping the meds and increased hydration that it stops on its own. This is a common scenario.
  • If the patient continues to have blood in the urine with or without clots, for the short-term as long as voiding is possible and no problems with being unable to empty the bladder, it is best in this case as well to pee patient, I mean be patient-ha. You can wait up to 7- 10 days if necessary. Again it usually have very little effect on the hemoglobin.
  • Bleeding, with clots and difficulty voiding is a bad case scenario because now the urologist has to do something to get the clots out, place a catheter and get things flowing again. He may or may not have to be fulgurated or treat a bleeding vessel which is the culprit.
  • Here’s how it plays out. The patient had seeds three years ago. He notices some blood in the urine. He calls his urologist-note he calls the urologist not the radiation oncologist and is advised to stop any blood thinners, increase water intake and be seen that day or the next. The patient begins passing clots and then in time he can’t void at all “clot urinary retention.” This occurs right after the doctor’s office closes. He calls the operator at the hospital who contacts the urologist and is advised to go to the emergency room.
  • By the time the patient gets to the ER he is in near excruciating pain because of the inability to urinate. The clots have clotted off the opening from the bladder to the prostate and as a result urine cannot flow.
  • There is a wait to get into a room at the ER however once in the room an IV is started and an attempt probably by one of the ER nursing staff who is good at putting catheters in.
  • If the patient has had a prostatectomy and then the radiation, there may be a narrowing at the bladder neck area, the area of the anastomosis, and this will not let the catheter get by and hence after several attempts and meeting no success, the patient may be given pain meds and the urologist is called and told ” We can’t get a catheter in. You need to come.”
  • If the nurse is able to get a catheter in then the clots are attempted to be irrigated free so that urine can flow into the catheter and in turn relieve the patient.  What normally happens is the irrigation of clots and release of urine and hence relief for the patient is piecemeal. By that I mean that a little urine will come out and then the clot obstructs the foley catheter. The nurse then irrigates the catheter in hopes to retrieve more clot and re-establish urine flow. This may or may not happen as  you can’t irrigate as well through a pliable tube such as a catheter as it collapses on itself and thwarts the process. Over time with the suction of clots, irrigation of the clots and often times having to take out a catheter filled with clot that won’t irrigate and reinserting another one hopes to achieve a free-flowing catheter with clots.
  • At this point if not already having done so, a three-way catheter is placed so there can be continuous irrigation of fluid to prevent the catheter from getting obstructed and prevent the formation of more clots hence restarting the whole process.
  • If a catheter can’t be passed or if catheter keeps being obstructed by clots then the patient often times is taken to the operating room by the urologist and under anesthesia places a rigid cystoscope that is of larger diameter than the catheter and doesn’t collapse on itself, to irrigate out all the clots, stop the bleeding point and then placing the largest three-way catheter as possible.
  • All the while this is a very painful drawn out process that can be associated with bladder spasms which have been alluded to many times on this site.
  • In time if the clots are all out, the bleeding stopped, the catheter can be removed after a few days and things then go back to normal. The patient still has radiation cystitis, is still at risk for bleeding in the future and if lucky the degree of cystitis stabilizes. It will not go away, but it may quieted down a bit and not progress.
  • Now there are things the surgeon did not mention if you had a robotic prostatectomy for sure…but I can see now the brochure and the ads on the internet of the radiation guy playing golf “a few days after the procedure.”
  • As I say in the book, “There ain’t no free ride.”

More on this later ….think hyperbaric O2 treatments.

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“John, these stories you write about me are not really true!”

I asked some female nurses who I work with in my amubulatory surgery center what exactly the term “my wife keeps me grounded” means? One lady said that when her husband started talking about all the things he was going to do or get she has to remind him that, ” honey, we need to pay the house payment first don’t you think.”

It reminds me of the story that Lou Holtz, a coach that took Notre Dame to the national championsip, tells about the time he was invited to be an assistant coach at South Carolina and then when he got there with his family the coach that hired him was fired. This in turn meant that his job was gone as well.

As Holtz tells it he then made a list of all the the things that he planned to accomplish in his life. Things like meet the President, skydive, and of course win a national football championship.

“Honey, I have here a list of 100 things I plan to accomplish before I die,” he said proudly to his loving wife.

“Maybe you should add 101…get a job.”

If you are ever drifting off in church or thinking about something good to read get out a bible and turn to Proverbs in the Old Testament. Find the section of wives. Very illuminating and so true today.

“Read about wives in Proverbs like I said….You hear.”

From “The Decision.”

I was totally incontinent for about three months. I initially thought that diapers would manage the problem, but even the most absorbent brand would last only 45 minutes without getting heavy and beginning to sag down between my legs. I went back to work with a full patient load 11 days after my surgery. It quickly became apparent that a diaper alone would not work. Going back and forth to the restroom in between every four or five patients got old very quickly. I then tried the technique of adding an absorbent liner inside the diaper and only changing that, but the liner was cumbersome as well, and still I had to dispose of and replace it several times a morning. I soon found that the only thing that would let me have freedom from all the paraphernalia related to diapers was a condom catheter. We used to joke as urology residents, saying, “I’m going to go empty my leg bag,” instead of saying we were going to go to the restroom. There were residents who would take condom catheters from the urology clinic and put them on at baseball games so they could drink beer without the inconvenience of going to the stadium restroom. I ordered several types to try out (I won’t tell which size I ultimately used) and actually got along quite well with them. The ones I used were like a condom with sticky glue on the inner surface. As you roll it on, it sticks to the skin and forms a water-tight seal; the end of it has a spout that connects to a tube and a bag that attaches to a leg, hence the term “leg bag.” I could wear this under my scrubs and no one knew I had it on. I worked in the office, operated, and even taught youth Sunday school with this set-up undetected. This system malfunctioned and popped open only once. This soaked the pant leg of the scrubs I was wearing, but no one saw it and I was able to correct that quickly with a new pair of scrub bottoms. There was an ever-present fear that it might leak at an inopportune time, but that never happened. I had told very few people who I had had my prostate removed, so hardly anyone knew that I had a “leakage” issue and was wearing a leg bag. I would be speaking to a patient about what they should do for their prostate and answering questions about incontinence, all the while wearing my leg bag. It was an odd time; I elected not to tell patients about my situation. I bet in those three months of wearing protection that I must have treated hundreds of patients with prostate issues. “What would you do if it were you?” they would ask as I could feel my leg bag filling up. The bag holds about a pint, so I could feel it getting heavy and bulging the scrubs at the calf level of my leg. If you let the bag get too full, then it begins to pull down on the tubing, which in turns pulls down on the condom, which pulls down on the… You get the picture. With time, as I am sure it is with most inconveniences that patients endure, all of the issues associated with the condom catheter became second nature, just part of my life.

 

I would take off the condom before my shower and then jump around to see if the leaking had improved, and each morning for those three months, I was disappointed. Following the shower, I would dry the area to perfection and then carefully roll on my condom catheter and begin the process of hooking everything up. I had a routine that took about 15 minutes. On one particular morning, some of the skin of my “you know what” was very irritated and little blisters were all over the skin, particularly where urine would contact inside the condom. The condom catheter’s glue made taking off the condom a very unpleasant experience, as it would pull at the irritated areas of skin and open the blisters as well. It was very painful to take off the old and miserable to then put on the new. I remember being quite depressed by my situation that morning, more so than usual. As if it were not bad enough to be leaking all the time, now my system for dealing with it was also problematic. The thought of wearing this contraption all day, considering all the movement and discomfort that this entailed, also added to my despondency. The other issue was that if the skin kept getting irritated, I would not be able to use the condom catheter and would have to go back to diapers. I was pondering my plight and was just about “situated” when my wife entered our master bath. I was stooped over in order to connect the rubber straps of the bag to my calf and looked up at her. She looked at me oddly and with what I perceived as a look of concern. I thought that maybe she had detected my frustration and slight depression. I remember being disappointed that my true feelings might have been revealed, as I had been trying to down-play to my family the pathetic “urinary” situation that had become my life. By the way she peered down at me I was sure she was going to ask, “Is everything O.K?” She then said,” John, I think I see a black hair on the tip of your nose.” Somewhat relieved, as I connected the last leg strap, I said, “Thank you dear.”

 

 

 

                        

 

 

 

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Never give a sucker an even break….

From the  “Decision”

Part Two – “Who are you?” and why it matters

 

“Dr. McHugh, what would you advise me to do if I were your father?”

 

I am asked this question very often after telling a family that a biopsy shows prostate cancer. I almost anticipate it and have to be careful not to smile after hearing it; certainly a smile after delivering bad news would come across as inappropriate. The irony of the question is that I am not a big fan of my father. He left my mother and her five boys when I was in the seventh grade and moved to Alaska. (That he went to Alaska reminds me of Jonah rejecting God’s command to go to Nineveh. Jonah instead went to Tarshish; a location that was not only in the opposite direction but a “far and distant land.” I have often thought that Alaska was my father’s Tarshish.) I saw him only one time after that, when he showed up at my part-time job during the Christmas break of my freshman year in college. He quizzed me briefly about my grades, told me that his had been better at Auburn University, and then left. I never saw him again. After the divorce, my mother, brothers, and I moved to LaGrange, Georgia to live with my grandmother Bess Davis who was 73 at the time. Looking back on it, this was one of the best things that could have happened to me. LaGrange was a great place to grow up, I adored my mother and grandmother, and I feel that not having a father to depend on made me a stronger person. So, when the inevitable question comes up, I fight back the smile and answer the question as if it were a good one, in the context of a normal father-son relationship. Rarely, however, after failing to withhold the smile, I’ve said, “That really is not the best question to ask me in light of my past relationship with my father. Considering the part of the male anatomy urologists work on, you might not like what I would recommend.”

 

My father a Navy Pilot during War World II, to my knowledge did not serve in active combat, the one on the front row second from the left. He has almost a Cherokee Indian look with dark complexion and very angular cheeks. These two traits, along with prominent teeth from my mother’s side, explains the look of myself and my four brothers.

I am from LaGrange, Georgia and I think my father is from Birmingham, Alabama and that later in life his father “Big Mac” owned The West Point Motel which at the time was on the river ( I remember there were boat sheds and boats with small outboard motors on jonboats that could be rented.) Across the river from West Point, Ga or so is Langdale, Alabama. That is where I was born so I assume that the hospital in Langdale was closer than the one in LaGrange and that my parents lived near my father’s parents at the time I was born. I wish I was born in LaGrange though, I love LaGrange and identify with my mother’s family much more so than my father’s family who I hardly knew after my 5th year or so. I think we moved to Columbus, Georgia about then and I have no memories of my father’s family.

I visited my grandmother every year in the summer in Lagrange. I was born in 1955, my grandfather on my mother’s side died around 1958 at a time near my birthday. He left me a couple of silver dollars and regrettably I don’t have those today. More on Robert Cooper Davis later. So when I visited my grandmother it was to visit her as her husband had passed away before I was old enough to visit for a week in the summer. I remember quite well all the trips to LaGrange from Columbus. We would pass a Boy Scout Camp which I recall was named Fort McKinsie. We dropped off one of my brothers there and I was fascinated by the rope bridge. (I was in charge of building one when I was a scout leader for my son Sam, an Eagle Scout, and the completion of it was a very proud moment for me and the group of scouts that did it. I to this day am fascinated by rope bridges and the knots and stuff.) We passed a small elementary school near Pine Mountain, Georgia. I remember this spot well. It was the half way point between Columbus and LaGrange and where unfortunately my Aunt Betsy and grandmother would meet my father to “collect” my mother for the sobering up process to be done in LaGrange and then to return her at the meet up spot when she was over her binge. ( Okay , it sounds bad and it was tough on all of us. But I adored and adore the memory of my mother to this day. As she said often of others and now I say of her, ” She could do no wrong in my eyes.”) I mention it only because I can to this day can see the school’s playground and the dirt parking lot where we’d meet for the “drop off.”

My father was an attractive and smart athletic man. He I feel was however a very flawed individual. He went to Auburn and graduated, I was told with honors, and then joined the Navy. After marrying my mother I believe was, a my grandmother would say often of others, a “near do well.” His stichk was selling things. He was a seller. Ultimately in Columbus he rose to the level of a Vice President of a large real estate company there. Our first house was on Norris Circle, a dirt road, and then when I was in fifth grade we moved to a ranch house on Flint drive in a new subdivision that his company was developing. Three bedroom, two baths, a one car garage that abutted a small room where the freezer and the washer and dryer were. No central air. Going in from the garage you entered a small kitchen with a huge window air conditioning unit that would freeze any one in the kitchen and particularly the person at the sink. From there the den with the T.V and then down a hall with a room off to the left (Rushton’s) and then a bath to the right, a bedroom on the right (Cooper’s), another room to the right (mine and Bob’s) and then across from that my parent’s room. As I sit here writing I cannot for the life of me remember where Jeff slept. He would have been young, maybe he slept in a crib in my parent’s room. Then across from the den, like so many other ranch houses of that time was a dining room and living room. The living room had a stand up stereo and it was on that I first heard “Meet the Beatles” while we played Risk. I have no clue about Jeff during this time. Nothing. All I remember, other than the horrible transgressions of my father perpetrated upon his family, are my other brothers, playing football in the front and back yard, Cooper’s chest of drawers with a lock on it and everything a person could ever want in it, not the least of which was a skate key, and being subservient labor for my brother Bob’s treehouse across the street on an empty lot.

I lived in that house when JFK was shot. I was in third grade and in the bathroom of Clubview Elementary School. The announcement came over the intercom. My mother was very upset about it. I remember telling a friend that it would not surprise me if she drove to Washington D.C. to see the funeral.

To be continued….

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