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Dave Van Onselen

Dealing with Prostate Cancer
A personal account by David van Onselen

Despite the sombre subject, there are two items of good news to start with. Firstly, prostate cancer is the only cancer that can be detected by means of an antigen that occurs in the bloodstream. PSA - stands for Prostate-Specific Antigen. It is an indicator of possible cancer presence. Secondly, this cancer is curable, but only if you deal with it in time (and by that I mean before it has escaped from the gland).

The malady is predominant in aging men. So the sensible suggestion is that all men over 50 should have a PSA test at least once a year. Normality lies at or below the 4.00 level. Early detection of anything above that is important for decision making.

I was about 55 when my doctor started to comment on an elevated level. I was referred to a specialist urologist for further investigation. That’s when I started to become concerned.

Herein lays the first challenge in prostate cancer – positive detection. A competent urologist is a good start, but let me assure you, positive detection of an active cancer is far easier said than done. In my case it took 8 years!

It’s important to understand that PSA testing is not a perfect science. Factors other than cancer can cause elevated levels. In all my time dealing with the subject, never was I ever given an absolute explanation as to what those ‘other factors’ might be. But they are there and so having an elevated PSA does NOT necessarily mean you have prostate cancer. There is just this lurking possibility and if the levels show a rising trend, that possibility turns into a probability. It messes with your mind I tell you. You don’t feel sick in any way, but at the back of your mind is this haunting notion you are sitting on a time bomb that may well just kill you!!

By the way – the trend and rate of increase of your PSA levels are more important than the level itself. So this means you will probably have to undergo a succession of blood tests spread over a few years to observe the trend. If it’s a rising trend, the urologist will no doubt move to the next level of investigation – namely a biopsy.

Now let me tell you about the biopsy process. The prostate gland is the size of a large walnut and lies deep within the body, very close to the colon wall. The biopsy procedure is to insert a clever device up the rectum from which the doctor can shoot tiny hollow needles through the rectal wall and into the gland, thereby gathering core samples from the gland. Vision of what’s going on is via ultrasound scanner. It’s a dangerous game as the incisions are made from a less than pristine environment with some risk of infection, not to mention internal bleeding into the urinary tract. A plus however is that there are few nerve ends in the zone, so pain is not too much of a factor.

The idea is to gather as many samples taken from as many angles as possible – thereby covering as much of the gland as possible. You see, cancer seldom invades the whole gland at once – it occurs in isolated zones or pockets as I understand it. So even with 6 or 8 insertions, it’s still quite possible to miss the cancer spots.

That’s exactly what happened with my first 2 biopsies – they came up clear. One would imagine that to be good news hey? Well not so when you continue to have elevated PSA readings and many more uncomfortable rear-end physical examinations by the urologist confirms ‘an apparently benign enlarged gland’, but nothing more than that. Meanwhile urinating became increasingly difficult as the enlarged gland squeezed the urine duct running through the centre of it. The whole scenario tends to transform the normal man into a neurotic, hoping to be diagnosed positively as soon as possible – just so the whole horrid business can be brought to an end. I am not joking when I say this!

Around my 8th year of all this investigative stuff, I had moved mentally from neurotic to fatalist – what will –be will -be sort of thing! I could do no more.

Then came the breakthrough. On the back of an 8.9 PSA reading, my urologist suggested a third biopsy under anaesthetic. The hospital procedure was simple enough and this time 12 probes were done, of which one came up positive. At long last I had been positively diagnosed with prostate cancer. Laugh or cry – I was not sure. But I had certainty at last. Progress!

Back in the urologists rooms a new torment was placed before me, namely the spectrum of choices for treating the cancer.

The basic choice was threefold, namely:

  • Gland removal
  • Brachytherapy (radioactive bead implants to nuke the gland)
  • External beam radiation (oncology)

I had noted how popular Brachytherapy was, but I was instinctively distrustful of it. To my way of thinking, if I had cancer in the gland, I wanted it removed not treated.

When it came to gland removal, there were three options only:

  • Old style removal via abdominal surgery
  • Removal via the perineal tunnel, or
  • Non-invasive removal via robotic machine assistance.

I had heard of Prof Lance Coetzee at Pretoria Urology hospital as being an expert at removal via perineal tunnel. My urologist managed to arrange an appointment for me to see him and my data file was transferred. From the moment I met him, I knew I was in the right hands. He had performed 2000 successful removals via the perineal tunnel (an incision made between anus and scrotum), but (at that time) only a few hundred via the new robotic machine. However, his patient recovery profile was so much better with the Robotic Process, he could not in all honesty recommend the older process. What sold me was his description of how the robotic process provides a clear 3D vision at the op site (via a remote camera, adjustable in magnification, inserted through the navel) and 4 robotic arms (also with adjustable response sensitivity inserted via small ports cut in the stomach wall); all of which allowed amazingly accurate/delicate surgery technique to be performed.

Why was that so important? The Prof explained that the recovery of normal erectile and urinary function had everything to do with the meticulous prevention (or limitation) of damage to the vital nerves occurring on and around the gland that control these functions. Rather than cut them away, these nerves should be carefully paired away from the gland and placed for reattachment onto the raw tissue where the gland used to be. That gave the patient best chances of recovery; almost impossible via conventional surgical process.

A final consideration was that the process was non-invasive with a much quicker recovery time.

I returned home to my last hurdle – how to convince my medical aid to pay for what was novel surgical technique at a price tag of R150 000! Some very kind people helped me put forward a compelling motivation and in the end, I was given cover with a reasonably small cash contribution.

The operation itself was long – some 5 hours I was told, but recovery was quick and I was released 3 days later to spend a quiet week with friends in Pretoria. The urologist confirmed that the gland was large and was destined to cause me much trouble if not removed. He thought the cancer was all contained in the gland and therefore he expected a full recovery. With catheter removed, I flew back home 10 days after the op a happy man.

Urinary control returned fully within 3 weeks of the op and to my great delight, no urinary restriction remained. I could pee like a young man again!

The best news of all however was the drop in my PSA levels to zero, which is where they have stayed ever since. I truly regard myself as a very fortunate cancer survivor.

Some added points of interest

  1. Brachytherapy is more often used in South African than in other developed Western countries. I believe USA, Europe and the UK prefer surgical removal of the gland.
  2. From my experience, I would recommend gland removal via the non-invasive robotic process to be the surest way to deal with prostate cancer and urinary problems associated with an enlarged prostate.
  3. Erectile function is negatively impacted by gland removal, but this can be countered to a large extent with medicines such as Cialis. Personal attitudes of the partners can and do influence this subject.
  4. For some reason (not entirely clear to me) gland removal might well be associated with changes in mental attitude to the entire subject of intimacy. In my case, my wife and I chose quite harmoniously to live a celibate life – which is not as bad as people may think. It de-complicates a relationship; an advantage people generally don’t think about. The critical point being, in our view, to be physically well and happily celibate is much preferable to getting all steamed up via medical assistance about something that, frankly speaking, most couples would gladly put behind them in their later years. The choice is yours.
  5. I do not recommend biopsies done in the urologist’s rooms with no anaesthetic (my first two). A biopsy under anaesthetic gives the urologist more chance to manoeuvre you and the equipment physically into positions to get more insertions at better angles - without fear of hurting the patent. That (I think) gives a greater chance of a positive finding.
  6. My operation took place on 25th November 2015 and this article was written a year and a half later.
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