Read Part One here.
At 8:15 a.m. on Dec. 17, I walked into Kaiser Santa Clara for my surgery appointment. I had been diagnosed with cancer and surgery seemed my best option. I left 13 hours later without my prostate gland, and my new scars were a sign my journey to wellness had begun.
The preparations for my surgery started weeks before, with pre-op appointments, tests and instructions. I had also researched the procedure and the staff who would be carrying it out. The surgery would be done using a Da Vinci machine, an advanced robotic system made by Intuitive Surgical. My surgeon, Dr. Michael Jae Hyok Choi, started the robotic surgery program at the Kaiser in Santa Clara and told me he has used Da Vinci machines “in various iterations” for 13 years.
The Da Vinci machine has large robotic arms ending in an array of interchangeable surgical tools, all controlled remotely by the surgeon using 3-D monitors connected to the tips. Large movements of the surgeon’s hands are scaled down by the machine to become more delicate and precise. One popular video demonstrates the machine removing the peel from a grape.
Rather than the traditional long incision traversing the lower abdomen, robotic surgery, in my case, involved five incisions each roughly an inch long. The operation took three hours and had a dual objective: to remove the prostate and to look for any localized spread of cancer.
“When they get in there,” said Dr. Laura Stampleman, a medical oncology specialist, “they will explore around a little. They will be looking at the lymph nodes and if they see any that are abnormal they will take them out to test them.”
Not knowing what would be found in the course of surgery was on my mind that morning as I was prepped for surgery. Dr. Choi and the anesthesiologist both came by to reassure me as best they could before a nurse gave a blood-thinning injection in my abdomen and a suppository that would relax my pelvic muscles. As I felt my body relaxing, I found it impossible not to drift off.
I woke up in a post-op room, groggy and disoriented, with a nurse attending me. I had no information as to the success of the operation.
They had predicted one hour of recovery time in the hospital before I was released, but I spent seven hours there, propped up in a chair and attached to an oxygen feed, as I struggled to revive myself. I sensed a profound impatience from the staff, like I was taking up space and their time when there were better uses for both—perhaps a reflection of the hospital overload caused by COVID-19.
I was driven home around 9:30 p.m. I was strong enough to climb a flight of stairs, with a bit of a wobble and a friend behind me to catch me if I fell. I was weak and exhausted. And that night, with a walker to steady me, I was able to get around on my own.
Remarkably, there was little pain from the operation. A couple of Tylenol in the mornings and the evenings were sufficient to keep it at bay. The greatest irritants were the catheter and a sore throat from the anesthesia.
‘Here’s your interview’
Prior to my operation, Dr. Choi told me he would give me a note getting me off work for a month. I told him, as a reporter, I would be able to just lay on the couch, watch TV, and work on my stories. He told me, “Of those three, the one you probably will be able to do is lay on the couch.”
He was right. For the first week, I could not work and I could not focus on anything. I slept a lot. I had so little appetite or strength that an omelet with potatoes could last me for the whole day.
Every time I needed to lift myself off the couch, however, I was reminded that I had just had major surgery. Sharp pains would hit me throughout my abdomen. The fluid in my catheter tube would turn pink from blood and clots would pass as well.
Ten days after my surgery, I went back to Kaiser to have the catheter removed and to meet with Dr. Choi. He asked how I felt. “Kinda like my insides are Swiss cheese,” I responded. “That’s because your insides are like Swiss cheese,” he said.
It takes a lot of cutting to get to the prostate gland.
After he checked on the swelling of my abdomen and my stitches, I asked if I could interview him for this article. He said, “Here’s your interview right here—your pathology report.”
My prostate had been cut into 12 slices and seven lymph nodes had been removed as “possible” or “probable” for cancer. The areas around my prostate were found to be “uninvolved by invasive carcinoma,” indicating no signs of spread. The lymph nodes all came back negative for cancer.
My prostate itself was a different story. Previously, the biopsy had come back with a Gleason score of seven, an indication of the amount of cancer, with three parts of aggressive cancer to four parts of less aggressive cancer.
This put me in a moderate risk group, suggesting I could have taken a more passive approach where the possible spread of cancer would be monitored in lieu of surgery.
The final pathology indicated the cancer was much more aggressive, with it still being a seven on the Gleason scale, but the numbers flipped. It was determined to be four parts aggressive cancer instead. Cancer had consumed over 70% of my prostate. Dr. Choi told me had I held off on surgery, the cancer most likely would have started to spread to my bones or lymph system.
Certainly, one of my concerns about the surgery was how much the area surrounding the prostate would be impacted. It’s one of the unknowns of the surgery—exactly how things spread—which could lead to nerves and muscles being damaged.
“They will be very careful about sparing the nerve structures in there if they can, to try to preserve your urinary and sexual function,” said Dr. Stampleman. “But they will be more focused on signs of cancer spread.”
Should the surgeon reach the prostate and discover the cancer has clearly spread outside the gland, the incision would be closed with no further surgery and the patient would face hormone and/or radiation therapy instead.
In my case, the pathology was good and the negative impact of the surgery was much better than average. Dr. Choi told me he had been able to spare the nerves that control erectile function and there had not been a need for more radical surgery. However, he said, the trauma of the surgery would take time to repair.
“The first thing is that you are going to have to be potty trained again,” he said. “And your system is asleep so we have to wake it up.”
To that end, I was instructed to drink a lot of fluids to be sure blood clots passed easily. My bowel functions would be erratic for a while, requiring laxatives. And I was given a prescription for Viagra, one-fifth of a normal dose, to increase blood flow to the penis.
After the catheter removal, and regardless of the success of the surgery, a certain degree of temporary incontinence is expected.
The prostate is joined to the bladder at the lower end, where the urethra begins. The section of the urethra that passes through the prostate is removed when the prostate is taken out. There are three sphincters controlling urine flow, with two of them in proximity to the prostate, to be removed during surgery. The ability to control urination depends on the strength of the one remaining sphincter.
There is no way of knowing what kind of incontinence might occur or how long it will last.
Most men will suffer from the mildest form: stress incontinence. When the bladder contains a good amount of urine, simple triggers like laughing, coughing, sneezing, or running squeeze the bladder resulting in urine leaking out. In my case, I quickly found out the triggers are certain postures while laying down and as I am standing up.
The second form is urge incontinence, where the need to urinate comes on too fast to get to the restroom. The sphincter is too weak to hold back the flow.
The majority of men overcome these problems within three months. And actively working to strengthen muscles by doing Kegel exercises can resolve the issue even faster.
The worst case is total or complete incontinence, where there is no control of urinary function at all. This can be treated by self-catheterizing, medication, and the use of incontinence underwear. Should the problem persist beyond a year, there are surgical solutions that will assist in keeping the urethra closed including implanting an artificial urinary sphincter.
During surgery, the surgeon tries to spare the nerves that control erectile function, as my doctor did. Recovery of sexual function involves the use of drugs like Viagra, injectable medication, or implants. Recovery is slow, but within a year 40% to 50% of men will have restored function, with the figure going up to 75% within two years with treatment.
The next step for me, besides recovering from surgery, is to have another prostate-specific antigen test in one month. With my prostate gone, the prostate cancer should be gone as well. The test should come back “zero,” though I would still need to come back for PSA tests on a regular basis.
Cancer cells can escape the prostate, infiltrating the body, and creating areas of new prostate cancer. Should that happen, further therapy would be needed.
“The standard therapy for prostate cancer that has spread is hormone blockers,” Dr. Stampleman said. “They block the testosterone that feeds prostate cancers. If that does not stop the cancer, then chemotherapy may be needed. And there is new research into immune therapies as well. But nobody can say at this point that cancer that has spread is cured, with ‘cured’ meaning it will never ever come back.”
Between the biopsies, bone scans, lymph scans, and pathology reports, Dr. Choi placed the odds of my having any cancer spread at 95% in my favor.
Twenty to one odds. I like that.
Prostate cancer is the No. 2 cause of cancer deaths in men. I was lucky in having my cancer caught before it could spread. I encourage any man over the age of 40 to discuss getting regular prostate checks with their doctor and getting PSA tests when appropriate.
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