Making a Decision:
Odds, schmods. Statistics are aggregates of individual cases. They don’t tell you anything about the individual. They may guide you in your decision making process, but they don’t make the decision for you. My odds of getting cancer were now 100%, since I already had it. My odds of surviving cancer were pretty good, since I was relatively young. There was a chance that I could carry this cancer the rest of my natural days and die of something else, with no complications. At this point in time, I had only one point in time picture of the cancer. To determine rate of possible growth, you need more than one picture over time. I could have opted for the watchful waiting approach. Every six months for some undetermined time into the future, I would have to undergo uncomfortable biopsies. Those are accompanied by consultations with urologists who are generally eager to get on with treatment. Ultimately, I may end up having the treatment anyway. But at least this way, my life of perfect potency and continence would at least continue for some period of time.
It is here, at this time, I have to mention that singer Dan Fogelberg died on December 16, 2007 from prostate cancer. He was 56 years old. This was still very fresh in my mind. He obviously had the fast growing variety.
What to do? Not making a decision was making a decision to tempt fate. I didn’t like that either.
I did a lot of research, which is what people with medical afflictions do. And I did it on the Internet, which is usually the first and sometimes the only place where people go. Ahhh, the Internet: the bastion of instant information at your finger tips. It’s a great and convenient place to get information. Unfortunately, there’s a lot of crap on the Internet, too. My job now was to separate the good stuff from the crap. How would I know the good stuff from the bad? Fortunately, my MPH degree taught me the fundamentals of study design and evaluation, so that I could pick out the flaws (or as we so politely put it, the limitations) of studies and claims.
I was really interested in finding the best treatment method to avoid incontinence and impotence. That’s where I wanted to be. I wanted to know where to get it and who I would choose to do the work.
In the old days (ten years ago) of radical prostatectomies, the surgeon would make an eight inch vertical cut in your abdominal wall, clamp everything open, and with his naked eyes, cut the prostate out. Unfortunately, others things that are attached to the prostate come out as well. Things like part of the urethra, which runs right through the middle of the prostate. Also taking a trip outside your body are the seminal vesicles, that little gland that collects the sperm and sends it to the along with semen into the urethra when called upon to make babies. The vas deferens, or the sperm carrying tube, is cut. And the nerves that surround the prostate, which go from the brain to the penis are summarily removed with this whole mess. In the early days of prostatectomies, virtually all men were rendered permanently impotent. A good many of them were also rendered permanently incontinent. It was quick and expedient. And best of all, the cancerous prostate was gone. They hoped no cancer cells escaped to live another day during the process and come back to haunt you later.
We’ve come a long way since those earlier days. Medical folks have been honing in on how to save the nerves and increase the odds of continence and potency. The advances have been in two areas. First, they try to save the nerves. When the surgeon is in there carving away, he tries to cut around the nerves and separate them gently from the prostate gland. Imagine the trauma you case a plant when you transplant it from a small pot to a larger one. All those roots have to be fanned out and separated and place gently into new soil. While you try to minimize the damage to the roots, there is still some trauma and a delay in the growth of the plant. The same goes for the nerves surrounding the prostate. The nerves will be traumatized and unavoidable cut in the process. The rate of re-growth is something in the neighborhood of one quarter millimeter per month. That’s awfully slow. Therefore, all men who undergo radical prostatectomies will be impotent for some period of time. It is just unavoidable. The second thing that has been modernized is the use of robots. In this procedure, the surgeon cuts six holes through the abdominal wall and in those holes go the reticulating robotic appendages, lights and a magnifying thingy. It magnifies things by a factor of ten. That’s much better than the naked eye.
You probably know by now where this decision making process is going. I opted to have the prostate removed sooner than later and to have it done by the best surgeon I could find that used the robot.
If you Google on “davinci robotics”, you’ll come with a variety of hits. The da Vinci robot is used for various procedures, including prostatectomies, cervical cancer removal, bariatric procedures, and many others. Find this one: http://www.davinciprostatectomy.com/index.aspx. There is a surgeon locator button. Click on that and enter your zip code. As of this writing there were more than 75 physicians within a three hour drive from me that were licensed to use the machines for prostatectomies. Many of them were at well respected institutions in our major cities. But who was the best?
My friend Nancy from my high school days in Huber Heights recently lost her husband to cancer. I was commiserating with her about cancer and how she dealt with it. I understood that the Cleveland Clinic, with its reputation as a world-class medical center, was a place that I was considering. Indebir Gill was a surgeon there who had a nice video on the Clinic’s web site. Nancy said that she new Indebir Gill. He treated her husband and he was the best, most caring surgeon in the world. She pleaded with me to choose him.
However, in my search, I also went to the OSU Hospital and Medical School. There I discovered a young surgeon (at least on the Internet) by the name of Ronney Abaza. While he was very young, he came with a pretty lengthy list of accomplishments. Besides, it was half the distance to Columbus as it was to Cleveland. Not only do you have to report for surgery, but there are preoperative visits and postoperative visits that could go on for years. I might as well make an appointment and check this guy out for myself. If he didn’t make the grade or impress me, then I could always go to Cleveland. After all, it’s only my life.
Another reason that I chose Ohio State was that they had a well documented complete program. They were into fixing the ills that normally follow the surgery, particularly the impotence. They have and erectile dysfunction clinic available as a matter of course for all patients. It’s a new treatment modality that is more theoretical and experimental than based on actual proven results. But it was all that was available. Better to have some hope than none at all. More about this in the post-operative phase.
The urologist that I had been seeing in Troy for the biopsy also did prostatectomies. He did the old-fashioned kind that I referenced earlier. He pooh-poohed the robotic surgery as no big deal, that my fears of impotence were overblown. “You just take some Viagra and you’ll be fine.” He had undoubtedly done hundreds of the open-cut surgery and was probably very good at it. He said that his surgery would result in a two day hospital stay and recovery would be about six weeks. He recommended that I have the surgery as soon as possible. I decided then and there that he wasn’t going to do my operation. It had to be someone else.
I decided to make an appointment with Dr. Abaza at the Ohio State Medical Center. I did this on April 23rd. I brought all my charts and cancer slides. He looked at them and made the same conclusion: I definitely had prostate cancer. It wasn’t very much and it was very early, but it was still cancer. With only this one snapshot of a single biopsy, he stated that the first urologist could have been either very lucky to hit it on one needle sample or could have been just as unlucky not to hit more. We could always take more samples over time, but it was till cancer. It may grow, it may not; no one really can predict at this point. He also suggested removal.
I also spoke about my odds of having permanent impotence. After all, I was a 56-year old active and healthy male. 20%, he said. No better than the posted odds on the Internet. “It only gets worse as you get older” he said. For that reason he said that it would be best to do it sooner rather than later.
He also explained the benefits of using the robot. Six small incisions, one day in the hospital, one week on a catheter, three to four weeks to being back to normal. This was roughly half the time of the old style cut-em-up-the-middle surgery. Also, there is much less blood loss, rarely calling for blood transfusions. If I was going have the procedure done, this is where it was going to be. I didn’t want to travel all the way to Cleveland.
I have to mention here that there was one thing about Dr. Abaza that had me a little on edge. He was very young. He couldn’t be much over 30 years old. He did his residency with the da Vinci machine at the University of Toledo Hospital. He had only been at OSU for a relatively short period of time, maybe a year or two. But this is all he did. He does three surgeries twice a week. He probably has about a thousand chances under his belt by this time. I guessed that was enough practice on other people. I decided to go with him. I made the appointment for Monday, June 16th.
In the intervening two months I went in for more preoperative tests and they loaded me up with a booklet of information about what to expect along the way. And let’s not forget those instructions about how you have to clean out your insides and starve yourself for three days prior to surgery.
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