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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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