EXECUTIVE SUMMARY
Surgery took a bit over four hours. I left the hospital 24 hours later, catheter in place. I was able to walk immediately, and today went 2.15 miles in 50 minutes. Nine days after surgery, I remain functional, but more tired than usual. My abdomen has five inch-long incisions on it (8mm), with associated bruising and swelling. There is more swelling south of there, tender but slowly resolving. The catheter came out three days ago, and my bladder function is slightly better than I expected. I spoke with the surgeon yesterday about the pathology report, which in general is about as expected. Next major steps: in about 2 weeks, begin sildenafil-aided training of affected vasculature. And in about 4 weeks, obtain the first of what will become life-long monitoring of prostate specific antigen levels. Details follow for the morbidly curious.
POST-OPERATIVE COURSE
I did not like how my lower abdomen felt when I woke up. Multiple sharp, stabbing pains, which I grade @ 7-8/10. Several doses of fentanyl brought that down to 6-7, then dilaudid helped a bit more. But I was not having any fun when they sent me to the floor after an hour in recovery. The surgeon, Dr. Winters, stopped by in the midst of my narcotic fog. He said something about “stickiness” in one spot of the specimen, which provided me with no insight. The next 24 hours featured the usual parade of nurses, blood pressure, temperature, and pulse checks. Toradol helped with the pain, and gave me several episodes of 1-2 hours of sleep. I walked twice, for 10 minutes with a nurse the evening of the surgery, and for 20 minutes by myself the next morning. The most pleasant part: getting my calves rhythmically massaged by the leg compression device. Soft, comforting. Cody (with Abby) and Shaine each visited me for a half hour or so. I am so lucky to have adult children who live nearby, and care about me. Makes me feel I did a few things right as a father.
After lunch, Cheryl drove me home, and I began 5 days of dealing with an indwelling catheter. Irritating, but manageable. I had gained 5 pounds of water weight during the surgery, and started mobilizing and excreting it, at the rate of about 2 liters a day. The swelling has been most evident in (graphic detail follows) the obvious dependent locations: ankles and calves; medial thigh and groin; penile shaft; scrotum; base of the abdomen with floppy sacs like a bilateral hernia at the level of the pubic bone; and in the lower abdomen in the area of the incisions. Bruising was evident to a greater or lesser degree in all those areas. While I took some Tylenol and Alleve on a regular bases for the first five post-op days, I am back to my standard 650 mg of extended release Tylenol every morning, and no issues with pain, at my current movement level.
Over the course of the past nine days, my sleep cycle has returned to normal, with the exception that my naps can be longer, like a hour or more. I began structured walking immediately, trying to add 5 minutes each day. The distance and pace has increased as well, but I am not trying to “go fast”, just walk without discomfort.
BLADDER
More graphic detail… With the prostate gone, my bladder function is, well, different. A bit of anatomy here. Urine exits the bladder through its “neck”, which is shaped like a funnel. That neck, along with the prostate below it, is removed during the surgery. Those two anatomic features provide males with significantly more control than women have over the flow of urine from the bladder. With them gone, it is a lot easier for urine to simply drain from the bladder with the slightest amount of pressure from above. Now, instead of trying to force urine to “break the seal” at the bladder neck, and then squeeze through the ever enlarging prostate, when I want to go it flows right out. Without those barriers restricting flow, urine also comes out unbidden, a drop at a time. Not a flood, or even a flow, but enough to result in wet garments if I don’t use a pad to absorb it. At night, though, the bladder behaves itself. I am awakened by very subtle signals of fullness, and can make it to the toilet easily in time. In medical speak, I have mild stress urinary incontinence, but no urge incontinence. Everything I’ve read and heard says this is normal post-operative, and may start to improve within 3 months, continuing to get better for a year or two. However, about 10% of the time, further help might be needed. For now this is manageable. About 5-10% of the urine I make during the day seems to leak out a drop at a time, primarily when I move around. I’m trying to learn not to notice.
CORPUS CAVERNOSA
Even more graphic detail follows…Penile erection occurs though the engorgement of blood vessels in the shaft called the corpus cavernosum (there are two, one on each side). The trigger(s) of that engorgement are multiple and complex, involving hormones, emotional state, tactile feedback loops, and parasympathetic nerve stimulation. Prostatic fluid and semen storage may also play a role. Much of this is disrupted by a radical prostatectomy. Small nerves are cut, blood vessels are harmed, swelling and bruising squeezes the tissues involved. It’s a major trauma, from the point of view of sexual function. In the past two decades, surgical techniques have improved to allow “nerve salvage” in favorable cases. Dr. Winters, my surgeon, elected to dissect free and “save” both nerves.
He and his staff are eager to find out how much erectile function I have left. According to them, I should try to stimulate the area, digitally, not through intercourse, to help the blood vessels regain their engorging capacity. This will be aided by the drug sildenafil (generic Viagra). Cheryl and I are going to wait on this until all the swelling and bruising has gone, another two weeks or so I suspect. It will be a new stop on our mutual intimacy journey now extending 48 years.
As a side note, ejaculation and erection are two different functions. In simple terms, it is the sympathetic nervous system which mediates ejaculation. That, as well as orgasm, can happen even in the absence of erection. Although without the prostate gland, it results in a “dry ejaculate” (oxymoronic, in my opinion as a wannabe English major).
PATHOLOGY
Less graphic, but maybe more gruesome. This is the real story, as opposed to the after-and side-effects above.
Top level diagnosis: Stage pT3b N0 prostate adeno carcinoma.
Details: Good news – there is no extra-prostatic extension. There is no bladder neck involvement. All Lymph nodes removed were free of cancer. Estimated percentage of prostate involved with tumor is 15%. No intraductal carcinoma identified.
Histologic grade: Grade Group 3 (out of 5), Gleason Score 4+3=7. [Grade 2/score 6 would be the best prognosis, 5/10 would be the worst.] A little worrisome, but treatable and curable in the large majority (85-98%) of cases.
Not so good news: there is cancer in the seminal vesicles. That’s the “b” in the cancer stage. My surgeon did not expect this finding; all the rest was consistent with what he anticipated based on my biopsy and other studies.
Additionally, I had a genetic DNA study done which shows no known mutations which make me more prone to aggressive forms of this disease.
WHAT’S NEXT?
I have done some research about the likely course of my disease based on what we know now, but it is premature to go down that rabbit hole. The goal of the surgery was to remove all of the cancer. My surgeon is guardedly optimistic he has done that. But even with a “perfect” path report, prostate cancer patients receive on-going follow up. Luckily for us, the prostate makes a protein, known colloquially as PSA, which is found nowhere else in the body. Cancer cells make more of this protein than normal prostate cells, hence the use of PSA as a screening tool It is even more valuable to follow the course of the disease and guide further treatment. Ideally, if all cancer cells are gone, the PSA should fall within 3-6 months (the earlier, the better) to “undetectable” levels. If it doesn’t, or if it begins to rise, then additional treatment might be required, involving radiation and/or hormone suppression. Prostate cancer cells grow better when “fertilized” by male hormones; suppressing the hormone production starves those cancer cells.
Dr. Winters wants to get a PSA level in about 4-5 weeks. I’ll work on keeping my mind off that as best I can.