There’s a very old George Carlin comedy sketch about dogs. Dogs are always waiting for something, he says: waiting to be walked, waiting to be fed, waiting to be fussed; sometimes, just waiting to wait.

I’m naturally reticent to knock our National Health System – it is, after all, offering sometimes very expensive care to all regardless of bank accounts and/or insurance cover – but waiting to wait is exactly what my waiting to be admitted for a radical prostatectomy is beginning to feel like. Weeks elapse between each stage of the process. Here’s a rough timeline in my case:

• 27th Aug: Biopsy.
• 20th Sep: Biopsy results and presentation of treatment options. (+3½ weeks)
• 22nd Sep: Confirmed my selection of surgery. (+2 days)
• 21st Oct: Meet surgeon. (+4 weeks)
• 17th Nov: Pre-op assessment. (+3½ weeks)
• 1st Dec: Hospital admission (+2 weeks)

In stark contrast, I recently heard of a former American colleague who was in the same predicament. On Tuesday he was diagnosed; on Wednesday he elected the surgical approach; on Thursday he had the operation. I assume he had good medical insurance and that we are not comparing apples with apples but I don’t know. Another former colleague Stateside was, just yesterday, presented with brain surgery options and he is being operated on today. So, speedy action is clearly not an isolated incident on the other side of the Atlantic.

Apart from the waiting to wait syndrome, courtesy of our constant injections of gaps running to weeks rather than days, being something of a drag, it introduces a real danger. The danger is that one will not remain healthy long enough for hospital admission on one’s assigned date. The main problem is the common cold. Trying to avoid one for over a month, particularly in winter, can be a real problem. Catching one leads to missing one’s original date and adds (I’m guessing) another month or two while a second surgical slot is found.

Immediate treatment may not have been considered essential in my case but, given the inbuilt delays and potential addition of further delays should anything go wrong, I’d say it’s as well to kick things off just as soon as possible to provide some leeway.

Since retiring, I’ve been running at an average of 1 cold per year. Needing to remain cold-free for about 6 weeks results in ~10% chance of failure. For working folks travelling on germ-laden trains and working in bug-ridden offices where other inconsiderate bods insist on sharing their infection when they should stay at home, the risks are far greater. How many times have I heard someone snuffle, “I’ve only got a cold”? Far too many times. “Yes, you have, and you may be adversely affecting someone else’s critical treatment.” An attitude adjustment vis-a-vis the (all too) common cold is long overdue.

Truthfully, I’m very grateful to be waiting for my chosen treatment but it does start making we wonder about the pros and cons of alternative systems. I just want this done so I can start my recovery.

Shortly after the results of my delightful transrectal prostate biopsy confirmed that I was, in fact, developing a case of prostate cancer and having leapt at the radical prostatectomy solution [Ed: just can’t resist getting on the solution bandwagon, eh?], it made sense to begin telling friends and family so they knew what to expect of me in the coming few months.

The biggest surprise in the feedback to my announcement was just how many people know others who have been through the same mill. Our neighbours know someone in Spain who’s had a prostatectomy; good American friends know a couple of guys who’ve had theirs out; Carol even volunteers alongside a chap who surrendered his to a scalpel-wielding surgeon about 8 years ago. This is not an uncommon condition. Men are queuing up to have their prostates removed – only one each, of course. 😆

Even before I had my biopsy, whilst camping in France this year we re-established contact with another couple similarly hooked on our favourite campsite It transpired that this gentleman was receiving hormone treatment for prostate cancer. Though his case had been too advanced for surgery, it seems he’d been being treated with hormone injections for almost 10 years and declared the treatment to be very effective.

Though the numbers affected by prostate cancer might be less than wonderful, I was heartened by the amount of folks I suddenly heard of coping well in the shadow of it. The slightly odd thing, I thought, was that I’d got to know of these brothers-in-arms generally only after mentioning it myself. Clearly I wouldn’t normally be aware of anyone’s plight in a foreign country, someone with whom I wasn’t directly acquainted, but I hadn’t previously been aware of anyone suffering from the same problems.

Given the very high profile nature of the breast cancer awareness campaign and its ubiquitous pink ribbon, compared to what I perceive as a relatively low profile prostate cancer awareness campaign together with its hardly-known-at-all “real man” symbol, I can’t help wondering if a good deal of the difference is down to restricted male openness compared to female openness. Guys may not be as good at talking about these things as are gals.

Clearly, I’m something of an exception. I imagine I must be reasonably open in order to bare my soul with the sort of intimate details revealed in these blog ramblings. Many would say that in order to write any blog one has to be pretty open and unabashed. IT’s understandable that some might well find talk of restricted urine flow, erectile dysfunction, digital rectal exams (gloved finger up the backside) and transrectal biopsies embarrassing. Mustn’t talk about anything that might call one’s manhood into question, eh?

And therein lies a problem. It has been made pretty clear to me that the archetypal symptoms are much better indicators that all is not as it should be than is the PSA test. The first step to getting fixed before things have progressed too far is opening up and initiating investigations. There is nothing un-macho about prostate problems. I remember my consultant, in response to an earlier question of mine, saying:

You’re a man, you have a prostate, they cause problems.

Be aware of it and be open about it.

During my Movember series of blog posts concerning prostate cancer, a close friend mused, “I wonder what the medical folks would do themselves?”. “Excellent question”, I said, rapidly planning another Movember article, “I have some input on that topic”. The “would do” of course, related to a professional’s choice given the treatment options with which I’d been presented. To recap, my options were:

1. Watchful waiting (i.e. just keep an eye on it until it gets more serious);
2. Radiotherapy;
3. Hormone therapy;
4. Radical prostatectomy (surgical removal of the entire prostate).

I’m going for #4, surgery.

The first thing to point out is that, when acting in a professional capacity, a medical professional isn’t permitted to make a blunt recommendation. Their job is to provide sufficient information concerning what each option entails, assessments of risk, potential benefits and possible detrimental side effects, such that a patient draws their own conclusion and decides for themselves. Quite clearly, given the variety of side-effects allied to the various options, the most appropriate choice for a particular patient would be influenced by personal situation. They may, for example, still be trying to start a family.

That said, I am fortunate enough to know a couple of nurses. Knowing my personal situation and acting purely in their capacity as friends, there is nothing wrong with their letting me know their opinions. In fact, I welcomed them. One suggested:

… you are totally right in selecting option 4, as you say the rest just prolong matters.

and the other:

I’m with you on the surgery, watchful waiting would never be an option for me, and the side effects of radiotherapy and hormone treatment can, in my opinion, sometimes outweigh the benefits.

OK, a couple of thumbs up so far. [Ed: do those constitute “likes” as in facebook, these days, I wonder.]

When we were Meeting the Surgeon, I suppose because he was male and in possession of a potentially troublesome prostate himself, I was particularly interested in an aside he made while discussing things with us and jotting notes:

I’m not allowed to make recommendations but, if it were me, this is what I’d be doing.

Another “like” from the guy with the scalpel. Of course, he is a surgeon so may be inclined to favour the surgical approach. I was reminded, just a little, of another occasionally useful phrase from the management manual in the days of business bullshit:

When the only tool in your toolbox is a hammer, it is tempting to regard every problem as a nail.

Amusing such phrases may be and some certainly can be true on occasions but, in this case, I think not.

I can’t be certain what I’d be thinking if I’d encountered someone suggesting an alternative course of action but I’m not and it feels good to have these validations. I’m so comfortable with my chosen course of action that I really don’t think that any gainsayers would make me think surgery were not my best choice.

We’re getting very close to being up to date in my Movember-supporting series of prostate cancer blog posts – blogging in real-time, as it were, instead of retrospectively. As a result of our Meeting the Surgeon on 21st September, the NHS gears staggered into action and two dates/appointments duly arrived on our doormat:

1. Wed. 17th November, 2:00 PM: pre-op assessment
2. Wed. 1st December, 4:00 PM: admission for my radical prostatectomy

Poor Carol! Everything seemed to be happening on Wednesdays which is her one day a week volunteering for the Greensand Trust. At least both were afternoon appointments so she’d be able to do up to half a day and not feel too guilty. Those folks not yet retired and still concentrating will probably have noticed that 17th November was Wednesday this week. [Ed: retired folk are not expected to have any idea of the date so may be excused for not noticing.] After a mere hour’s Greensand Trusting this Wednesday, Carol dutifully returned to accompany yours truly à l’hôpital.

This was my first visit to this particular hospital, High Wycombe. All previous urology appointments had been at Stoke Mandeville in Aylesbury. It was good to see that totally inadequate parking arrangements seem to be universal to UK hospitals. We arrived early enough to  nab what I think was the last available parking space.

Good job we were early for other reasons, too. My instructions were to go to “New Building”, third floor. Is anything on the hospital’s map marked New Building? No, of course not. Nonetheless, after one error, we eventually found the required urology department. Our first task was to “run a couple of errands” – go to the Old Building for a blood test and an ECG. Rather than carry it with me, I decided to leave my urine sample with them as we trotted off again.

Phlebotomy (I just love that word, I’ll say it again, phlebotomy) had an intriguing system in operation. Patients were to take a numbered ticket, exactly as in French supermarket cheese and deli counters, and wait until their customer number appeared on a neon display to be served. Eventually, my “64” sprung onto the display so I ordered un demi Reblochon, 250gms pâté forestiere and had 15ml blood taken by the chatty phlebotomist. (Once more – phlebotomist.)

Off to the echocardiography (sounds like ECG) department where my unexpected arrival caused eyebrows to be raised. We backtracked to a different set of stairs leading to the correct ECG department where, rather than give a false reading, we sat for five minutes while my heart rate recovered from climbing two sets of eight flights of stairs in rapid succession.

It seems that little has changed in NHS hospitals since 23rd June, 1961. Here we are, almost 50 years further on and it’s all very familiar. “What is significant about 23rd June, 1961?”, I hear you ask, quizzically. I’m very glad you asked. Look left at the picture I snapped on my pathetic mobile phone camera. For those carrying sufficient age, does this notice ring any bells? It certainly should do. 23rd June, 1961, was an historic date. On this day, the late and incredibly great Tony Hancock first performed his seminal sketch, The Blood Donor, on British TV. As I looked at the notice in disbelief, his unforgettable rendition of “Coughs and sneezes spread diseases, catch the germs in your handkerchief”, sung to the tune of the German national anthem, instantly rang in my head through the mists of time. Go on, click “The Blood Donor” link – it’s just the relevant middle 10 minutes – and watch a true comic genius in action. I did. Utterly fabulous!

Eventually, a very pleasant young lady called me in and demanded that I bare my torso. Regrettably, she only stuck a few monitoring terminals onto me. I thanked her and toted my ECG readout back to the urology department where I met another very pleasant young lady. This delightful lady demanded that I drop my trousers. I like this hospital. Unfortunately again, she just wanted me to swab my groin for an MRSA test. My luck just has to change soon, otherwise I won’t have a prostate with which to benefit. 🙂

Seriously, the people at the hospital were universally terrific and very approachable. If nothing untoward is found in any of my test results and if I can avoid cold-germ laden shoppers snuffling their way around Tesco when they should be at home rather than infecting other punters, I’ll be admitted to High Wycombe hospital on the afternoon of 1st December, ready to be dissected starting at 08:30 hrs on 2nd December.

Quite a few ifs but exciting stuff. I hope I can stay healthy enough to clear this obstacle first time.

Following my prostate biopsy in late August, ‘t was results time in mid-September. The truth came as no real surprise to me, my prostate was misbehaving and had developed a touch of cancer. 14 samples had been taken. One sample showed 10% cancer cells, another showed 1% cancer cells, the remaining 12 were clear. The malignant samples were said to be “average” in terms of aggression. The aggression rating rejoices under the name of a Gleason score, mine being 7 (3+4, I think). If I understand this correctly, the score designates the aggressiveness, from 1 to 5, of the most common cancer cells seen followed by a similar 1 to 5 rating for the second most common cancer cells seen. The two scores are added together to form a total, so 2 (1+1) would be the lowest (least aggressive) and 10 (5+5) the highest (most aggressive).

The good news (I hoped) was that, since I’d been having PSA checks for 5 years, the consultant was very hopeful that we’d caught it early enough for there to be several treatment options open to me. I guess it must’ve been early ‘cos one option, not offered to too many, was the first one below. [Ed: in this day and age, we should probably be referring to these options as prostate cancer solutions.]

Watchful Waiting

(Or some such medical mumbo-jumbo.) Basically that means it ain’t urgent so do nothing but continue to monitor PSA levels, ultimately having another biopsy – another set of 14 holes being punched through your rectum wall – in 18 months time to see how things have developed.

Radiotherapy

Computer-targeted X-ray beams sauté the offending organ and serve it over a fresh green salad with a little dressing of your choice. “And for your main course, sir?”

Hormone therapy

This is kicked off by a dose of Radiotherapy, in this area, apparently. Prostate cancer cells feed on testosterone and injections of female hormones put the brakes on their feeding – and probably enable one to get further insights as to how the other half lives.

Radical Prostatectomy.

Surgery – rip the troublesome gland out. Why “radical”, I wonder? I mean, I guess ripping out someone’s prostate is pretty radical but why highlight that in the name of the procedure?

I had arrived at a crossroads on a journey that I’d rather not have embarked upon in the first place but, hey, that’s life, and at least things sounded reasonably hopeful.

Watchful waiting seemed to be prevaricating or burying my head in the sand, even though this seemed to be the medical team’s favoured option. (I’m a cynic and think they were trying to save the NHS money.) Their thinking officially was that the cancer may not continue developing and that treatment may not become necessary. Right! That’s not my belief. My PSA stayed fairly even for a couple of years but over the last two years had risen steadily (3.5 – 4.1 – 5.1). I saw no reason to suspect that it would miraculously decide to stop rising. The alligator that was already biting me in the arse would still be in the swamp.

I didn’t fancy radiotherapy for a couple of reasons. Firstly, this option comes complete with warnings of potential collateral damage, American military style, to bladder lining and rectum. Not appealing. The main factor, though, was that radiotherapy generally negates the surgical option at a later date. (I don’t know why, unless the effect of radio beams on tissue makes a surgical repair resemble trying to sew together a roast chicken. Anyway …) Too many bridges burnt.

Hormone therapy seemed a reasonable candidate and I now know a man who is being successfully treated that way. I’m already enough of a girlie, though. The last thing I need is even larger man-boobs. Besides, hormone therapy remains an option if other attempts don’t work as well as hoped. Reassuringly, if any prostate cancer cells escape to other parts of my body, hormone therapy still treats them effectively, I was told.

I’ve elected for surgery, the so-called radical prostatectomy. My personal belief is that any suggested cancer clear-up rates that are touted are largely made up of the type of cancer that can be excised. Why keep an unnecessary prostate? It’s the sort of organ that can get one into bags of trouble even when it’s healthy, for Darwin’s sake. Now it has the potential to do some serious harm. If we’ve truly caught it early enough and the cancer cells are completely localized, let’s maximize the benefit of that fortune and remove it entirely. This is the only prostate cancer solution that speaks about the possibility of a cure as opposed to containment.

I informed the medical team of our decision and would be receiving an appointment with the wielder of scalpels.

Such a wonderfully descriptive phrase, transrectal biopsy. In my five year journey to my current PSA-out-of-bounds stage, I have learned some interesting things about transrectal biopsies of the prostate gland.

My consultant and specialist nurse discussed the possibility of a biopsy with me in the early stages when my PSA level was bouncing around in the 2’s (2 – 3 ng/ml), still within specification but higher than they’d have liked for a man of my tender years. [Ed: yeah, right!] They explained the procedure. One assumes the same position as is required for a DRE (Digital Rectal Exam) – bare your backside, lie side down on the physician’s couch and draw your knees up to your chest. Very elegant! Your backside thus correctly presented, instead of the now familiar gloved finger of the physician, a rather more impersonal ultrasound probe is then inserted through your anus into your rectum. The ultrasound probe enables the doctor to “see” your prostate on a monitor and to position the probe accurately for the taking of tissue samples using the same probe. It’s obvious when you think about it but worthy of note that the probe is inside one’s rectum but the prostate is hiding sneakily on the other side of the rectum wall. So, once correctly positioned, the probe’s needle must be fired through the rectum wall into the prostate to snag the required samples. All this rectum wall puncturing leads to the slim possibility of infection so prophylactic antibiotics are prescribed.

In my original discussions, eight tissue samples would have been taken, four on either side of the central line of the prostate. The procedure could probably best be described as uncomfortable, naturally enough. What I was very surprised to learn was that the medical folks actually expected to get about 30% false negatives; that is a third of the biopsy results finding no cancer would actually have missed cancer cells that were, in fact, present. This little gem was instrumental in my deciding against a biopsy during those early stages; there seemed little point going through that level of relative discomfort only to be left wondering if I was the 1 in 3. Monitoring my PSA level would be fine until readings dictated otherwise.

In April this year, that pesky PSA level had hit 5.1 ng/ml. As expected, the consultant suggested biopsy time had now arrived. I agreed. He shovelled me off to the specialist nurse to make the arrangements and explain the procedure once again. A couple of significant details had changed while we’d dallied for a couple of years on blood tests.

1. 14 samples would now be taken. It seems most European countries had been taking 16 samples so maybe peer pressure upgraded the UK procedure. Quite why we’ve now settled on 14 instead of 16, I know not but it’s an attempt to reduce the instances false negatives.
2. Local anaesthetic would now be administered before the needle was fired thru’ the rectum wall into the prostate. Patients had apparently reported that things were more comfortable with a local anaesthetic. Surprise, surprise! For this revelation, we need seven years of medical school?

Both sounded like excellent modifications to me.

My biopsy date duly arrived and I returned to the scene of my earlier ultrasound scans, the x-ray and radiology department. My biopsy doctor turned out to be a rather attractive lady. I assumed the position. Under more normal circumstances I would have been delighted by this lady’s taking an intimate interest in my prostate. Regrettably, I was not in a particularly good position fully to appreciate her attention. I was however, in a good position for her to stick the ultrasound probe up my backside.

I had originally, sadly incorrectly, thought that the probe might be armed with as many intercontinental ballistic needles, multiple warheads as it were, as were required to take all the samples in one fell swoop. Not so; the probe has but one warhead and takes 14 samples individually. Oh joy! The taking of each sample made quite a loud click and, despite any local anaesthetic, I felt a shockwave very slightly. Given the situation, I figured it wasn’t a good idea to flinch. Part way through the harvesting of my samples, Mr. Senior Radiologist, disturbingly called Dr. Savage (I kid you not), appeared before me and began chatting as though nothing were happening. Clearly this was a classic distraction tactic. I trust that you have painted an appropriately colourful mental picture. There is something decidedly surreal about nattering with another guy while an attractive young lady continues rummaging around inside your rectum playing with your prostate gland. Weird!

Eventually we were finished with tissue harvesting. Not only is there a very slight risk of infection, hence the antibiotics, but, with more new holes in your rectum wall than there are in a colander, there is a distinct chance of some bleeding. I was presented with something akin to a large sanitary towel to wear on my way home. So this is how the other half lives.

Time to await my biopsy results.

[Ed: It’s necessary to suspend any smutty schoolboy humour for this one.]

A couple of weeks ago, an appointment with the specialist nurse at my hospital’s urology clinic turned up. D-Day was Thursday and H-hour was 1:00 PM. Though the purpose of the meeting had not been made clear, the original message did included the immortal phrase, “bring the missus along”, so off we both went.

The prostate is surrounded by nerves. One of the functions of the nerves is – how shall I put this delicately? – to control one’s erectile function. The surgeon performing a radical prostatectomy will attempt to preserve those nerves intact [Ed: that’s very considerate of him.] but, even if successful, the nerves tend to get bruised during the operation. Hardly surprising, really. This bruising is detrimental to one’s aforementioned erectile function. Actually, even prior to getting anywhere near a surgeon, just having an enlarged prostate can put pressure on those nerves and the erectile function can already be detrimentally affected. This, it transpired, was the subject of our meeting.

Hopefully, eventually things return to normal but, fear not, medical assistance is available. The medical assistance comes in two guises: as drugs (the most well-known variety being Viagra) and/or as a mechanical device. [Ed: WHAT!?] The device in question is a vacuum pump. After the specialist nurse (he’s male, BTW) had given us a swift intro to the drugs available, he led us off to another chap who had turned up to give us “a demonstration of the vacuum pump”. Scary spiders!

OK, so the idea is that one introduces one’s, er, penis/old man/dick/todger into the vacuum pump and begins manually pumping, preferably quite gently. The vacuum so induced takes over where the temporarily interrupted Mother Nature left off and replaces the normal erectile function. Got the idea?

“So, let’s try it – stand up and drop your trousers”, said my new acquaintance, from the relative comfort of a hospital chair.

Gulp! “Er, OK”, I replied with forced bravado as I stood before him debagged, as it were. 😳

After a little lubrication, I was engaged and the pump was in operation. I should point out that, though it was my anatomy in the pump, it was my new acquaintance, rapidly becoming intimate friend, actually doing the pumping. It was a weird and, I have to say, somewhat uncomfortable sensation; I felt like a balloon about to burst. My experienced pump operator assured me that this sensation would die down – I’d get used to it.

While digesting this latest of the day’s reassuring messages, I began to feel a little strange so I sat down.

“You’re fine, still a decent colour …”

The next thing I was aware of was a loud whistling in my ears. I couldn’t see anything but, slowly, some sensation of light began to return though not accompanied initially by any recognisable shapes. Where was I and what had been happening last time I knew about anything? The whistling began to abate and a few vague shapes began to form. More light. A man’s face appeared before me. Ah, the hospital – my new intimate friend. I was on my side in the recovery position.

[Ed: OK, you can slip back into juvenile humour mode, now.]

There’s a very old schoolboy joke that concerns a well-endowed chap who passes out every time he gets an erection because there isn’t enough blood for both of them. Boom, boom, Mr. Roy!

Even though I was still recovering from fainting myself, I just couldn’t resist reminding my personal pump operator of that joke. He looked a little quizzical. I can’t think why. No sense of humour, some people.

Never in a million years did I imagine that the joke was based on reality. 😆