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Drains, exiting the abdomen (or perineum, in the radical perineal approach), will be left in place for about three to five days, and the Foley catheter, inserted in the penis and anchored by a tiny balloon in the bladder during surgery, will remain in place for two or three weeks. The main reason for the catheter is that it allows the anastomosis, the reconstructed urinary tract, a chance to heal. The drains are there to evacuate any urine that might leak from the anastomosis as it’s healing; they stay in place until nothing more flows through them. It is critical that the Foley catheter stay in place. If it is inadvertently pulled out or removed too soon after surgery, this can be disastrous, and may lead to permanent incontinence. Your catheter should be securely taped to your thigh, and you should examine its mooring often. The catheter may take some getting used to, but remember—it’s only temporary, and its presence is helping the body heal. While you’re at home, keep the catheter connected to a large drainage bag most of the time, and use the leg bag only if you plan to go out of the house. The reason many doctors suggest this is that the leg bag doesn’t hold as much urine, and if the bag becomes full and the patient doesn’t realize what’s happening, the urine can “back up” into him because it has no place else to go.

You’ll be dealing with the catheter mostly at home; the economic trend these days is for patients to leave the hospital as soon as possible after any procedure, and prostate surgery is no exception. Fortunately, radical prostatectomy patients are actually able to go home and generally be more active sooner than ever before, and this is due largely to a new pain medication called ketorolac. As it turns out, one factor that kept men in the hospital was their inability to eat or to keep down oral painkillers after surgery. We always blamed this on the operation, but now we know what really happened—it was the pain medications they received after surgery that made them nauseated. Ketorolac belongs to a group of drugs called nonsteroidal anti-inflammatory agents (NSAIDs; these drugs include the over-the-counter painkillers Motrin or Nuprin). Patients on ketorolac usually are able to eat on the day after surgery— and for many men, this often is the first hurdle back toward normal life, even if it is bland hospital food!

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The operation to remove the prostate as a treatment for cancer was first performed in 1904, at the Johns Hopkins Hospital by a urologist named Hugh Hampton Young. Young’s procedure, called a radical perineal prostatectomy, was a success: Six and a half years later, when the patient died of other causes, an autopsy showed that his prostate cancer had been cured.

In the late 1940s, another approach, called the radical retropubic prostatectomy, was developed, and like Young’s operation (which still is used today, although not as often as the retropubic approach), it proved extremely effective in stopping prostate cancer in its tracks—if, that is, the cancer was confined to the prostate.

Both the radical perineal and retropubic operations had a definite down side—in the form of two devastating side effects, incontinence and impotence. Worse, radical retropubic prostatectomy also became known among urologists for the extreme bleeding that went along with it. Every surgeon who performed it would probably admit that this operation used to be performed in a sea of blood.

So, understandably, when radiation treatment for prostate cancer was introduced and popularized (see Chapter 6), doctors as well as patients welcomed this alternative therapy. (In men who receive radiation treatment, an average of 60 percent remain potent, and incontinence is not a problem.)

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The ideal candidates for radical prostatectomy are the men most likely to benefit from it. Therefore, radical prostatectomy should only be considered in men who have cancer that appears to be confined to the prostate and therefore is potentially curable. Also, it should only be considered in men who are young enough and healthy enough to live long enough to benefit from being cured.

Good candidates for surgery, then, are men in their fifties or sixties, in otherwise good health, with localized prostate cancer. This includes men with stage T1b (A2), T2a (B1N), T2b (B1), and T2C (B2) cancer. It also includes some men with stage T1a (A1) cancer, and most patients with stage T1c disease.

Also, radical prostatectomy can cure cancer that has penetrated through the prostate wall IF the cancer is well- to moderately well-differentiated (a Gleason score of 7 or less) and if it’s possible for doctors to get what’s called a “clear surgical margin” so they can cut out all the tumor.

Men with stage T3 (C) disease generally are not considered candidates for radical prostatectomy. However, sometimes the interpretation of the digital rectal examination can be wrong. Sometimes, doctors overestimate the tumor’s actual extent—when indeed it may not have spread beyond the prostate. Twenty-five percent of these men who undergo surgery turn out to have organ-confined cancer. (Again, tallying the results of the PSA test, Gleason score and clinical stage may help doctors avoid such overestimation).

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The benefits of watchful waiting aren’t that clear for younger men with localized disease—men who probably could be cured if they act in time. The biggest disadvantage here is that what one doctor calls the “window of curability” may silently close forever while the patient is being watched.

If you have curable disease and opt for watchful waiting, you will have to live with uncertainty about the future. At present, there is no reliable way to tell when the disease is just beginning to progress, even if it hasn’t yet escaped the prostate. In about 25 percent of men with growing prostate cancer, there is never a significant, telltale rise in PSA.

So if you’re a man under age 70 with localized, curable prostate cancer who decides to watch and wait, think hard about this risk. You should return to your doctor at regular intervals—every six or twelve months at least—for repeat digital rectal examinations, PSA tests and, probably, yearly prostate biopsies to help doctors find out if the cancer that’s in your prostate is staying put or if it’s on the move. You also need to understand the risks you could be facing down the road if cancer spreads—the long-term symptoms, and the side effects and costs of treatment for advanced disease.

When Watchful Waiting May Be a Safe Gamble

You’re young and healthy enough to have surgery, and your disease is certainly considered curable—in fact, it’s microscopic, probably incidental prostate cancer. Why seek treatment now?

There used to be two polarized schools of thought about this: One was that all of these men needed treatment as soon as possible. “We can definitely cure it now. Time’s wasting—let’s get going!” some doctors said. They urged patients to have their cancer “nipped in the bud,” treated when the chances of curing it were at their peak. The other group was not nearly so optimistic; these doctors believed that treatment didn’t really prolong life by that many years anyway, so what was the point?

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Should every man have a PSA test? No. The goal of PSA testing is to identify curable cancers in men who are probably going to live long enough to need to be cured. Therefore, there is no reason for most men over age 75, or is man with a life expectancy of less than ten years, to have a PSA test. Creating anxiety about what to do—what treatment decisions to make—is not helpful, humane or necessary for these men.

If something abnormal is found in the digital rectal exam, regardless of your PSA level, you should have a prostate biopsy. (This is done with the help of transrectal ultrasound; biopsies ).It ‘the rectal exam is normal and your PSA is greater than 4, you should also have a biopsy.

The number 4 comes up often in discussions of PSA and prostate cancer. That’s because it has become something of a “magic number.” Many doctors believe that a PSA level greater than 4 is abnormal, and a PSA less than 4 means everything’s fine. But more and more doctors are realizing that having a strict cutoff number probably isn’t the best way to use PSA, and they’re beginning to use other definitions for early diagnosis of prostate cancer.

One of these is called PSA density, in which the PSA number is divided by the prostate size, which is estimated by transrectal ultrasound. The reason size is important is that having BPH (benign enlargement of the prostate) can make PSA higher anyway—so it’s tougher for doctors to distinguish between BPH and cancer. Basically, if you have benign enlargement, your PSA should not be more than 15 percent of the weight of your prostate. If it’s greater than that, advocates of PSA density believe, vou should have a biopsy.

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French-kissing, which some people call tongue-kissing, means that one or both people put their tongues in the other person’s mouth while kissing. Some people like French-kissing; others don’t and choose not to try it. There is no right or wrong way to French-kiss. Some people just put the tip of their tongue into the other person’s mouth. Others put more of their tongue in; still others manage to get their tongues in each other’s mouth at the same time. There aren’t any specific rules about this.

What is necking? What is petting?

Necking – or snogging, as some people call it – means having prolonged kissing sessions. Different people define petting differently. Some people use the phrase ‘petting above the waist’ or ‘light petting’ to describe a situation in which a male feels or fondles a female’s breasts. ‘Petting below the waist’, or ‘heavy petting’ means touching or rubbing the other person’s genital organs. Some people further divide petting into petting outside or over your clothes and petting inside or under your clothes.

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There are basically two answers to these questions: you can do it on your own or you can have a friend do it for you.

If you decide to have a friend do it, be sure to pick someone you can really trust or the next thing you know it will be all over school! It’s often easier to let someone else do the talking for you. But keep in mind that if you do this, you don’t have very much control over what’s being said. Suppose, for example, you want your friend only to bring up your name in a roundabout way to see how this other person reacts. Your friend may not do it exactly the way you’d like; instead, your friend might tell this other person that you’re madly in love with him or her!

For these reasons many people prefer doing it on their own. You can let someone know you like him or her by being friendly, starting conversations, going out of your way to be round that person, asking the person to go out with you, showing the person how you feel by the general way you act or simply telling the person how you feel. You can find out if a person likes you by watching to see if that person does any of these sorts of things to you.

Regardless of whether you tell the person yourself or have a friend do it for you, make sure it’s done in private and not in front of the other kids. Otherwise the person may be so embarrassed that he or she may say they don’t like you even if they really do. The other person may even stop liking you if you embarrass him or her in this way, so it’s best to do it in private.

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This kind of problem is not at all unusual among boys. It’s called retrograde ejaculation, and it happens when the semen is prevented from spurting out through the opening in the glans during ejaculation. In older men there are certain medical problems that cause retrograde ejaculation, but in boys, it usually happens when the boy is masturbating and he covers the opening in the penis as he’s about to ejaculate, as the boy who asked this question did.

‘Retrograde’ means ‘going backwards’. In retrograde ejaculation the semen can’t come out of the end of the penis, so it travels backwards down the urethra. It may be forced up the tube that leads to the bladder, which can cause the urine to be cloudy for some time afterwards. The semen may also be forced into the prostate gland. In either case there may be pain and discharge from the penis. .

In some instances the symptoms will clear up by themselves, but often a doctor’s care is needed. Although it may be embarrassing for a boy to tell the doctor that he’s been masturbating and to explain how the retrograde ejaculation happened, it’s important to see the doctor if you have pain, a milky discharge or milky urine. If the semen is forced up into the prostate gland, the tissues of the gland could become irritated and susceptible to infection. The doctor can treat such infections with antibiotics and, if necessary, with pain-killers. From this, you can see that it is not a good idea to prevent your ejaculate from coming out of the end of your penis.

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This is another increasingly common STD. The chief symptom is warts in, on, or around the sex organs. A person can have warts without knowing it. The warts may go undetected because of their location, their small size or the fact that they can disappear on their own. However, if undetected and untreated, they tend to recur. Untreated genital warts are a serious problem because they may lead to pre-cancer or cancer of the cervix. Treatment is by means of a special solution that is painted on the warts, causing them to fall off. In stubborn cases cryosurgery (freezing) or electrocautery (destroying by means of an electric current) may be necessary.

Syphilis-This is a rare disease in Britain nowadays. The symptoms appear in stages, beginning with a painless sore at the exact place where the germs entered the body. The person may not notice the sore, which will eventually disappear, but the germs remain in the body and eventually produce second stage symptoms such as a red rash, mouth sores and an ill-all-over feeling. Most cases are treated by this stage, but if untreated, the disease may progress to a third stage, which can cause serious and permanent damage to the brain, spinal cord and other organs. Treatment is by means of antibiotics, usually given by injection.

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Effectiveness Chart 1 gives you an idea of how many pregnancies occur because the method has simply failed to do its job (there are no statistics yet for the female condom).

Effectiveness Chart 1-In a group of 100 women using the method for a year, and using it absolutely correctly, exactly according to instructions, we would expect:

• none or, at most, 1 out of 100 injectable contraceptive users to become pregnant;

• 1 or, at most, 2 out of 100 combined-pill users to become pregnant;

• about 2 out of 100 mini-pill users to become pregnant;

• about 2 out of 100 diaphragm or cap users to become pregnant;

• about 2 out of 100 condom users to become pregnant;

• about 2-4 out of 100 IUD users to become pregnant;

• about 3-4 out of 100 contraceptive foam users to become pregnant;

• about 7 out of 100 Natural Family Planning users to become pregnant.

Of course, people make mistakes. Very few people use their methods absolutely correctly and properly all the time. So in a typical group of 100 women, there would undoubtedly be more pregnancies than the figures in Chart 1 would indicate. With the IUD and injectable contraceptive, we wouldn’t see more pregnancies than indicated in the chart because the IUD is inserted and removed by a doctor and the shots are also given by a doctor. The woman doesn’t have to do anything. So there’s little chance of her using the method improperly and, therefore, little chance of a pregnancy occurring due to an error on the user’s part with these methods.

But with methods like NFP, the condom, cap, diaphragm and spermicides, people can and do make mistakes. For instance, people make mistakes in their NFP charts and have sex during the fertile time; they forget to put enough spermicide in the cap; they insert the diaphragm improperly or remove it too soon; they neglect to use a condom each and every time they have sex; they allow too much time to pass between insertion of the spermicide and intercourse; and so on. Since people can and do make these sorts of mistakes, we could expect a greater number of pregnancies in a typical group of 100 women than indicated in Chart 1.

With the pill, there’d also be a greater number of pregnancies than indicated in Chart 1 because women can and do forget to take all their pills on schedule. However, women who choose the pill as their method are usually the types who are good at remembering to take pills, and they make pill-taking part of their daily routine. Besides, with the pill people needn’t interrupt their love-making to deal with contraception and they don’t have to refrain from intercourse for a certain number of days each month as NFP users must. Moreover, all a woman has to do with the pill is to swallow it, whereas, some of the other methods, especially NFP, are more involved and therefore more open to error. So you can see that pill-users are generally less likely to have unplanned pregnancies due to errors on the user’s part than people who use the diaphragm, cap, condom, foam, or NFP.

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