Going under the Knife
If all goes as planned, I will, in fact, be going under the knife on Monday morning. They will come for me here at the National Institutes of Health (NIH) in Bethesda, Maryland at about 7:00 a.m. By 8:00, I will be under anesthesia, and they will be positioning me – head down and feet up – on the operating table. Then, they will make seven small incisions in my abdomen, insert cameras and devices for cutting and sowing, and the fun will begin – as my surgeon, Dr. Peter Pinto, sits down at the Wurlitzer in the corner and begins the process of removing my prostate and the lymph nodes associated with it.
I am already on a clear-liquid diet, and the dread “bowel prep” looms on the horizon. I have had an EKG, an Echo Cardiogram, a chest X-ray, and a pulmonary exam, and I have spent the last couple of days cooling my heels in the hospital, working on my book on Sparta, and contemplating mortality. The odds are excellent that I will emerge from this ordeal incapable of further procreation but otherwise intact and cancer free. There can, of course, be “complications,” and none of them are pretty. Some of them you can die from. Others leave you impotent in the fullest sense of the word or permanently incontinent. It all depends on your health in all of its aspects when you go under the knife, on the effectiveness of the antibiotics, and on the skill of the surgeon. I will not tell you that I am glad that I am here. But a prostatectomy is a bit like old age. It is not so bad when you consider the alternative.
The truth is that I am lucky. One of my cousins, on my mother’s side, died of prostate cancer when he was in his early to mid-60s, as I am now. My brother had his prostate out nearly two decades ago when he was my age, and he is still going strong. If this operation goes well and Dr. Pinto removes all of the cancerous tissue, the odds are good that I, too, will still be alive and kicking in my 80s. Apart from chronic asthmatic bronchitis, for which there is now medical help, there is nothing else wrong with me.
But the real reason that I am lucky is that my condition was diagnosed early on. As longtime Ricochet regulars who read my post Prostate Cancer: New Procedures for Diagnosis – and Cure back in April, 2011 may remember, my Prostate Specific Antigen (PSA) level was quite low (ca. 1.07) but took a jump between December, 2009 and December, 2010 and was on track to double within an eighteen-month period – which can be a sign not only that one has cancer but that it is aggressive. Mindful of my family history and concerned about the welfare of my wife and our four young children, I called a distinguished urologist whom I have known since childhood and asked his advice. He consulted Dr. Pinto, who then invited me to join a study he was directing. Here is what took place in March, 2011:
On day one, the staff at the Molecular Imaging Program subjected me to trans-rectal Magnetic Resource Imaging (MRI) with Gadolinium. This involves the insertion of an endorectal coil into the rectum, the inflation of a balloon to hold it steady, and the introduction of an intravenous contrast material into one’s veins. In the course of the MRI, one is slid into a machine that produces a powerful magnetic field – where, from time to time for about an hour, one is assaulted by radio frequency pulses. With the help of sophisticated software, the technicians who operate the machine can produce a detailed picture of the prostate. And here is the kicker – if you have cancer, it shows up as a splotch in the picture, and those working with these procedures can grade any splotches they see with an eye to the likelihood that they are cancerous.
If nothing suspicious is found in the course of the MRI, that is the end of the story. If, however, there are suspicious splotches, one returns to NIH on day two to have a biopsy, which was my fate. Using sophisticated software, the technicians initially map the picture of the prostate produced by the MRI onto the picture produced by ultrasound. Then, guided by these images, a surgeon, performing the biopsy, samples the precise places where the MRI found suspicious splotches. To supplement this procedure, he then performs an ordinary biopsy, taking samples from the twelve sectors into which the ultrasound divides the prostate.
The first set of procedures is not a joy, but they are considerably less unpleasant than a colonoscopy; the second set involves some discomfort, but, at NIH, they use novocaine to deaden the prostate and reduce the pain. In my case, the MRI team identified five suspicious patches – three of them moderately likely to be cancerous, two of them worrisome but much less likely to be malignant. The biopsy revealed two minuscule patches that were cancerous. Each made up something like 2% of the biological material in the particular sample taken. In neither case was there any indication that the cancer is aggressive.
A year later – which is to say, this past March – I underwent another trans-rectal MRI. To all appearances, nothing had changed. Then, I underwent another targeted biopsy. This time, in a number of the samples, 50% of the biological material taken turned out to be cancerous. A couple of weeks after the biopsy, Dr. Pinto called to inform me of the results and to recommend intervention. Given my age (actually, he thought that I was in my early fifties) and my health, he thought that surgery was the best of the options now available, and he urged me to act soon. “Do it within six to nine months,” he said. “I would not wait a year.” I scheduled surgery with him at the first available opportunity.
There is a debate going on within the medical community concerning the PSA test. It is not an especially accurate indicator of cancer, and some think that too many biopsies are done and too many men have their prostates removed. Others, including people here at NIH, are firmly of the opposite opinion. They contend that, in the last quarter-century, there has been a dramatic drop in the number of deaths from prostate cancer. The reason appears to be that PSA testing, digital rectal testing, and biopsies – when these techniques are all in play – often enough enable physicians to detect aggressive prostate cancer early on. And, when early detection is followed by surgery or radiation, they can usually stop the cancer in its tracks.
The new techniques, being pioneered by Dr. Pinto and his team here at NIH, promise to identify the tissue that is suspect and to enable those conducting biopsies to hone in on the suspect tissue. When these techniques are sanctioned for general use, they should make early diagnosis easy, and they should then even more dramatically reduce the number of deaths resulting from prostate cancer.
Tomorrow, if I do not die under the knife, the odds are good that Dr. Pinto will remove everything that is cancerous and that I will get a new lease on life. I owe the fact that the odds are on my side to vigilance on the part of physicians and on my part. If the powers that be succeed in striking the directive that causes physicians to administer the PSA test on men over the age of fifty as a matter of routine and you are such a man, you should exert yourself and insist on having the test done, and – if there is any indication of danger – you should have a biopsy. In my case, the indications were not strongly indicative. At the time of my first biopsy, my PSA had actually dropped from its mildly but suddenly elevated level. And last December, though it had gone up a little, there was no dramatic change. If I am alive in five years, it will be because I was alarmed when I got the news in December, 2010.
One further word of warning. Genes may not be destiny, but, in these matters, they come pretty close to having that status. Know your family history, and take precautions. My father died of pancreatic cancer at the age of seventy-eight. Perhaps by the time I reach that age, there will be a regimen of treatment for that. If I get past this crisis, I will be alert.
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Comments:
Re: Going under the Knife
michael kelley: My father once told me that if you make a list of the ten most significant people in your life, you will be surprised at how many of the ten were teachers.
As a not very noteworthy student, I had the great fortune to take several of your courses in Lancaster, PA. and you are quite high on that very short list. A true teacher.
May God bless you and your family. · 4 minutes ago
Wonderful to hear from you, and thanks.
Jul '10
Re: Going under the Knife
Thoughts and prayers from the back of the Class Here in TEXAS.
Godspeed, Professor.
Dec '10
Re: Going under the Knife
Best wishes for a speedy and complete recovery. It sounds as if you are in the best of hands. And than you for your candor in relating your experience, and the caution about genetic predispositions in your last paragraph. I know this to be true from my own family experience, and I am sure your forthrightness about this subject will help many others come to terms with it.
Oct '10
Re: Going under the Knife
I liked Tabula Rasa's prediction, and he is rarely wrong. I'm not the most accomplished prayer but will definitely be praying for you.
Mar '11
Re: Going under the Knife
You do us all a favor in sharing this with us Professor Rahe. To be reminded of our own mortality and that of those who we respect and consider friends is a blessing. Godspeed sir, be not afraid and know others whom you have not even met and know nothing of are wishing you well.
I look forward and expect to see your next posting as soon as you are able.
Roberto
Jun '10
Re: Going under the Knife
I think this is exactly right. My doctor said that the issue isn't so much what one test says (although a very high one indicates cancer), but where several tests are in relation to others over time. In my case, the PSA was never sky high, but it went up consistently over a three year period. They did the biopsy, and I had cancer--they removed the prostate and it appears I'm as good as new.
So don't just get one test.
Jul '10
Re: Going under the Knife
My prayers are with you.
A very dear friend recently underwent this (robotic) surgery, and he is just fine now - as we all know you will be.
Mar '11
Re: Going under the Knife
May I add my best wishes, also?
With any luck, Monday may also be the day that Obamacare is surgically removed from us all. Or this coming week, anyway.
Dec '10
Re: Going under the Knife
God speed and good luck! I'll say a prayer for you.
Mar '11
Re: Going under the Knife
My prayers go up for you and your surgical team, Professor Rahe.
Oct '11
Re: Going under the Knife
Good luck and God Bless Dr. Rahe.
May '10
Re: Going under the Knife
What a lovely community we have here at Ricochet! The S family adds its prayers and best wishes from Connecticut. And for us girl-persons: get your mammograms and regular poke-and-prods. I just turned 50 so I get to have a colonoscopy this year. Un-yay, but I'll do it anyway.
Sep '10
Re: Going under the Knife
I went in several years ago for work on my prostate. A chat with St. Christopher before they put me under helped.And a couple of things to look forward to. In only a few days, you'll be p---ing like a teenager. And sleeping better too.Godspeed.
Feb '12
Re: Going under the Knife
Dr. Rahe,
My prayers have also been submitted.
I also like the prayer of Mel Foil at no. 20!
Re: Going under the Knife
I had not thought of that last bit. No more getting up in the night.
Sep '11
Re: Going under the Knife
Good grief! I stay away from Ricochet for a day and look what happens! Prayers and best wishes, Dr. Rahe.
Apr '11
Re: Going under the Knife
Sincere wishes for an uneventful, speedy, and full recovery.
Re: Going under the Knife
Dr. Paul: You are in my prayers and I wish you a successful surgery and very speedy recovery.
Apr '11
Re: Going under the Knife
May the Lord bless you and keep you.
Dec '10
Re: Going under the Knife
Paul: thanks for sharing this news with us. May God comfort you and your dear family. May He guide the surgeon & his team in the surgery and after-care. May you just lie still. Know that your family here at Ricochet cares for you tremendously! You are an important voice in these stressful days!