FREQUENTLY ASKED QUESTIONS

What is the best way to screen for prostate cancer?

Because the goal of screening for prostate cancer is early detection, both a digital rectal examination and a PSA serum level are essential.  Any abnormality in either or both of these may warrant further investigation to rule out prostate cancer.

PSA stands for prostate specific antigen NOT prostate cancer specific antigen.  PSA is a chemical that is produced by prostate cells and is measured by its level in the bloodstream.  Historically, if a man had a PSA level of 4 or less and a normal digital rectal exam (feeling the back surface of the prostate for cancer), a prostate biopsy to rule out cancer was not necessary.  If the level was greater than 4, it may, but not necessarily, be an indicator of the presence of prostate cancer.  More recent information has shown that the likelihood of discovering prostate cancer in younger men with a PSA between 2.5 and 4 is the same as for a PSA of greater than 4 in older men.  Therefore, today many urologists are using the value of  2.5 as the standard for performing a prostate biopsy in all age groups.

Benign enlargement of the prostate can elevate a man's PSA level in the bloodstream.  Anything that irritates or inflames the prostate, such as a urinary tract infection, prostatitis, prostate stones, and insertion or withdrawal of a catheter, can also elevate the PSA level.  Another measurement to help determine the likelihood of prostate cancer before performing a biopsy is the free:total PSA.  PSA is found in two forms in the bloodstream: one that is bound to proteins ("bound PSA") and the other that is not ("free PSA").  Each of these is measured and a ratio or percentage of the free as compared to the total PSA (free = bound) is determined.  If the free PSA is greater than 14-25%, the likelihood of prostate cancer is less.

The digital rectal examination (DRE) allows the urologist or an experienced primary care physician to feel the back of the prostate by placing a finger in the rectum.  To ensure accuracy, it is always best to have the same physician check the prostate annually in order to determine even the subtlest of changes.  One of the findings of the DRE may be a prostate nodule.  A nodule is a firm area that may feel like a knuckle and, oftentimes, prompts the urologist to suggest a prostate biopsy.  Prostate nodules may be cancerous, but they may also be caused by prostatitis or prostate stones.

What does a prostate biopsy entail?

In the department we perform prostate biopsies using transurethral ultrasound (TRUS).  Patients who are scheduled for a TRUS are asked to stop taking aspirin or non steroidal anti-inflammatory medications (i.e., Motrin or Advil) for a week prior to the biopsy.  At the time the biopsy is done, the patient will be given one dose of an antibiotic.  In order to dramatically lessen the pain and discomfort associated with performing prostate biopsies, a peri-prostatic nerve block, a xylocaine injection identical to that injected by dentists, is used.  After the nerve block is performed, a probe, about the size of the thumb, is placed in the rectum and the ultrasound, which identifies the characteristics of the prostate tissue through sound waves, is done.  The ultrasound allows the urologist to measure the size of the prostate and to locate the areas for the biopsies.  Eight to twelve biopsies are taken depending on the size of the prostate.  The biopsies are sent off for a pathologist to read and the results are sent to the urologist within 5 to 7 days. 

What other tests may be required before a final decision is made about treatment?

If a patient has a PSA of greater than 10 and a Gleason score of 7 or less, there appears to be no need for a bone scan, CAT scan or an MRI since spread of the cancer is virtually never observed.  For all other patients, the urologist will decide on the appropriate test as indicated by the PSA and Gleason score.

What is the Gleason score?

The Gleason score represents the grade of the tumor. Tumor grade means how aggressive the tumor cells appear in comparison to normal cells.  Those cells that look most different are high grade while those that closely resemble normal cells are low grade. 

Because cells may be composed of many different grades, the pathologist assigns a value to the most common grades found in the biopsies.  For example, the pathology report might read that a patient has a Gleason score of 7 (3 + 4).  Gleason scores the range from 2-4 are considered low-score cancers; high-score cancers are those with a Gleason score of 8-10.  The higher the Gleason score the more rapidly the tumor cells grow and the more aggressively they act.  It is important to remember that the Gleason score identified from the biopsy may be lower than the Gleason score the pathologist reports after surgery.  The reason for this is that following removal of the prostate, the pathologist may find other areas of cancer within the prostate not sampled at the time the biopsies were performed.

Why are the pelvic lymph nodes important in determining the stage of the prostate cancer?

Often the first place that prostate cancer cells travel outside of the prostate are the lymph nodes.  When the prostate cancer cells break away from the tumor, they enter into the body's fluids (i.e., blood or lymph).  The pelvic lymph nodes provide a system that filters bacteria and even the cancer cells out of these fluids.  In patients whose prostate cancer has spread outside the prostate (metastasis), the lymph nodes are often filled with prostate cancer cells.  The likelihood that prostate cancer spreads to the lymph nodes is closely linked to the PSA and Gleason score.  Therefore, if these are favorable, examination of the lymph nodes may be omitted. 

Will the patient need a letter from his primary care physician prior to surgery?

In almost all cases, a letter from the primary care physician indicating that the patient is an acceptable risk for this surgery will be requested.  Every patient who chooses to have surgical treatment is required to get medical clearance.  This is frequently obtained by the patient's primary care physician.  I request that all men over the age of 65 have a cardiac evaluation prior to anticipated surgery.  This usually includes a stress test.  I ask that the patient discuss this with his primary care physician or cardiologist.  If the stress test is satisfactory and the patient has medical clearance, it would be extremely unusual for there to be an untoward event at the time of surgery.

What are statistics regarding potency following a nerve sparing radical prostatectomy?

First it is critical to decide who is best suited for a nerve sparing procedure. The decision as to whether or not to preserve the nerves adjacent to the prostate depends on the patient's age, potency prior to surgery, the location and extent of the tumor based upon the biopsy information, and the Gleason score.  If these factors suggest that the cancer is confined to the prostate and the patient is potent, then a nerve sparing procedure is attempted.  It is usually successful.  If the nerves are not preserved the chance of retaining erections is small.  If both nerves are preserved, the chance of maintaining erections with or without the use of Viagra is approximately 50%, depending on the patient's age.  Men under 50 are much more likely to recover erections than those over 65.

What is the chance of loss of urinary control or urinary incontinence following surgery?

Fortunately with the technical improvements in performing the radical prostatectomy, the chance of significant urinary incontinence is less than 1%.  Very few patients have required surgery for urinary incontinence. Approximately 20% of men will wear a small pad in case a few drops of urine leak with physical stress, i.e. heavy exercise or sports.  Approximately 50% of men have excellent urinary control when the catheter is removed 10 days following surgery.  The remainder gain control over the next several weeks.

One of the potential problems that can occur following surgery is the development of scar tissue at the region where the bladder is attached to the urethra (termed the "anastomosis"). One to two percent of men will develop narrowing at this junction and this usually presents as a distinct slowing of the urinary stream.  If slowing of the stream occurs, it can easily be determined if scar tissue has formed by the use of a flexible cystoscope.  If narrowing occurs, a simple procedure performed in the hospital as an outpatient will correct the problem.

What are the chances that the patient will require a blood transfusion?

Although it is not required, all patients can donate one unit of their own blood.  With the occasional use of a technique during surgery called the cell saver, it is rare for a patient to require blood other than that which he donated.

What is the type of anesthesia preferred?

The discussion of the type of anesthesia is left up to the patient and the anesthesiologist.  Some doctors use the epidural form of anesthesia for radical prostatectomies.  With the use of an epidural, some of our physicians found there may be a higher incidence of delayed bowel activity.  Therefore, a general or a spinal anesthetic is preferred.  There are advantages to each.  Both are well tolerated and there is usually little discomfort following surgery with either.

How long does the operation take?

The operation ranges from two to three hours.

How long will the patient stay in the Recovery Room?

The two hospitals where the surgery can be performed, OSF St. Joseph and BroMenn Regional Medical Center have superb staff in the recovery room.  The recovery areas are close to the operating room and to the anesthesia team.  The patient is usually in the recovery room for approximately two hours before being transferred to a hospital room.

What is used for pain control following surgery?

If a patient has had a general anesthetic, a patient-controlled anesthesia device is used so the patient can control his pain independently.  This intravenous analgesia or pain medication can be supplemented by oral agents, such as Percocet or Tylenol with or without codeine.  This usually controls the pain.  For patients who have a spinal anesthetic, a long duration spinal is usually used which often eliminates pain for the first 24 hours.

What type of tubes will I have after surgery and how long will they be in place?

In addition to the intravenous, a catheter will be placed in the urinary bladder.  This will remain for approximately ten days to two weeks.  There may be a drain exiting from the lower part of the abdomen.  This will be removed on the second post-operative day prior to discharge from the hospital.

Is the incision closed with staples or internal sutures?

Currently, we will perform what is termed a "subcuticular closure" with absorbable sutures that disappear over a few weeks.  We believe this gives a better cosmetic result and eliminates the discomfort of staple removal and having to come to the office prior to the time the catheter is removed.  The incision is a small transverse incision located just above the pubic bone in the lower abdomen.  It is similar to that used for a C-section in women.

When will the patient get out of bed?

We encourage every patient to sit in a chair the day following surgery and can begin ambulating that afternoon.  The more one uses his legs, the less likelihood of blood clots.  Ambulation also encourages the bowel tract to start working again.

When will the patient hear about his pathology report and thus the extent of the cancer?

The pathology report is usually available 5-7 days following surgery.  As soon as the doctor receives the report, he will write a letter regarding the particulars of the pathology report so the patient will have documentation of the results.  The doctor will also go over this information in the office when the catheter is removed and answer any questions the patient may have at that time.

When is the patient usually discharged from the hospital?

Patients are discharged between twenty-four to forty-eight hours following surgery.

How long will it take the incision to heal?

If takes the incision approximately six weeks to completely heal.

Is there any limitation once I leave the hospital on walking or going up stairs?

No.  There should be no limitation in either of the above.

When do patients usually go back to work?

Many activities can be initiated within one to three weeks following surgery.  It is difficult to know when you can resume driving.  I think this should be individualized.  The main point is not to drive when you will be a danger to yourself or others.

Going back to work will depend on the type of work the patient does.  If the patient's employment requires heavy activity, he may have to wait six or more weeks.  If he works at a desk, he may be able to return soon after the catheter is removed.