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Friday, 24 October 2014

Prostate postmortem

University Hospital Leipzig
So that's it done. Prostate out and on my feet again. Wait and see what happens next and whether the cancer cells have been banished or simply set sail for pastures new.

For once I'll keep this post fairly serious because some of you will face the same choices I have and maybe find it just as difficult to get the information you need. Without steady pushing for the past few months I'd have had the wrong kind of surgery.

If the tumour is confined to the prostate, as mine was, there are a bunch of treatment options, including surgery, radiation therapy and cryogenics. I was offered the first two and recommended surgery - "the gold standard", they said - because of two factors, my Gleason score and my PSA level.

Gleason score is a measure of how aggressive the cancer cells are, when examined after biopsy. Mine were 4+3 which is intermediate but tending towards get-it-out-sharpish before it spreads beyond the prostate, at which point surgery is no longer an option. My PSA level was 12.8, which is fairly high and a further trigger for action.

Once surgery is selected there are three options - open, laparoscopic or robot-assisted laparoscopic. Finding out which is best took me a while, because I was referred initially to a surgeon who, while highly regarded, practises only open surgery and had his own reasons for not briefing me fully. He was in the process of trying to persuade the Scottish Government to buy him a robot. At one point, when I was questioning him, he said he felt like Alex Salmond during the first televised debate.

At my request, he did refer me to a robot practitioner in England, Professor Prokar Dasgupta, but insisted that if I went robotic I would have to fund it fully myself. The inaccuracy of this statement only emerged after much more digging. He also referred me to just one, rather than the choice of several consultants that I'd asked for.

The Harley Street consultations went well and involved meetings with the surgeon, the anaesthetist, a continence nurse and a sexual function specialist, all of which cost me £750 before a scalpel was lifted. Total cost of this option would be around £27000, they told me, only £9500 of which went to the surgical team, the remainder being the cost of private hospital care for three days and nights in the world's most expensive city centre.

The specialist consultations were very helpful because two inevitable side-effects of prostatectomy are incontinence and impotence, either or both of which might not be temporary. During surgery, part of the sphincter muscle that controls the flow from the bladder is excised along with the prostate, so what remains needs to be retrained to do the job. This can take months and might not fully happen.

Impotence arises when two sets of nerves passing through the prostate to the penis are removed. So nowadays nerve-sparing may be attempted, provided the stage of the cancer allows and the surgeon has the necessary skills. This is where the robot comes into its own. A surgeon-operated robot is more precise than a surgeon alone, provides better vision of the site, more degrees of freedom than a human hand and no tremor.

A further improvement in recent years is "frozen sections" or intraoperative consultations. This means that excised tissue is sent to the lab for analysis during surgery to see if the cancer has been fully removed or more tissue needs to be cut. Without this technique the surgeon must err on the side of caution, which means less chance of nerve-sparing.

Hard scientific evidence for the superiority of the robot-assisted prostatectomy over laparoscopy is scarce, as large-scale randomised control trials have not, and will not now, be done - both for ethical reasons and because isolating the one variable of the robot is impossible. Softer evidence is mounting however and the surgeons who use the robots are convinced that they provide better outcomes in the trifecta of cancer removal, continence and potency. The superiority over open surgery, in the hands of an experienced surgeon, is well established.

But here is the problem for viewers in Scotland. Not only can you not get robot-assisted prostatectomy in our country but you can't get frozen sections anywhere in the UK. So after lots of research and talking to doctors, and with my robot-assisted, friends-and-family-funded surgery in Harley Street just five days away, I was offered two further options - laparoscopy in Edinburgh or robot-assisted laparoscopy with frozen sections, and the best chance of nerve-sparing by Professor Jens-Uwe Stolzenburg, in the University Hospital, Leipzig.

This option had been briefly mentioned very early by Forth Valley Health Service, but had sounded too far out to me, so I dismissed it. But in that final week two experienced NHS prostate surgeons, Alan McNeill in Edinburgh, on my request for an NHS second opinion, and Hasan Qasi in Glasgow, on his own initiative, having studied my notes and priorities, persuaded me independently that this was my best option.

I had less than a week to prepare for ten days away from home, work and internet, to organise travel and accommodation and to buy a German phrase-book. Which I left behind.

On the morning after our arrival in Leipzig I got a phone call from the director of Forth Valley Health Service asking how I wanted to be reimbursed for the £10,000 cost of the surgery and hospital care under Article 56, the EU directive on cross-border healthcare. On the day after the operation the surgeon told me he had spared both nerves. 

So far so good is the most you can say with any cancer. But at the moment I can say that. My Killearn GPs were fantastic as was Forth Valley Health Board. The surgery and aftercare at Leipzig were outstanding. My experiences of Gartnavel Hospital, to which I was initially referred, ranged from unhelpful through obstructive to incompetent.

This is the short version. There is more. If you'd like to ask me anything, please email, replacing at with @ in the usual way.

And for regular readers whom prostates fail to fascinate, a few observations on hospital stays, in Leipzig or elsewhere. 

Rules of survival
1.  The only sane answer to Have your bowels moved today? is Yes. See 2.

2. You may be tempted to flirt with the most attractive nurse, but she is invariably the one that wields the enema. She will not see your best side.

3. Just because the mad bastard who bangs on the wall and sings Deutschland Uber Alles in the middle of the night is ill doesn't mean he's not a homicidal maniac. Do not complain. 

4. The sound that resembles a body being dragged along the corridor at three in the morning could well be. Go back to sleep.

5. When your hand accidentally brushes the ample bottom of the big nurse bent over shaving your belly, don't let it linger there. She has a sharp blade one inch from your genitals. Do the math.

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