Fighting Prostate Cancer At -90 C: My Cryo-therapy Experience At UC Health

3D image shows tumor which was subjected to  three freezing cycles, with temperatures as low as 90 degrees below zero, centigrade.


Almost five years to the day after being diagnosed with stage 1 prostate cancer I found myself Tuesday at the University  Of Colorado  Anschutz Medical  Campus  - Inpatient Bldg. to check in for focal cryotherapy surgery under Dr.  E. David Crawford.  After the requisite  initial processing of insurance  cards, ID and answering prelim questions (Would you like to see a pastor?, Do you have an advanced directive?)  I was checked in to the Urology pre-op station,  and met by a perky  RN I will call 'Greta'.   She took my vitals, then  had me change into  the standard issue gown and yellow  happy socks,  after which  my  belongings were  bagged  (taken away by Janice).  I was then connected  by Greta to an IV after some initial difficulty finding a vein.

As with my earlier experience with the 3D staging biopsy in January, I was first met by rounds of specialists, to  answer   further questions, i.e. What  is the name of the procedure you're having?, When did you last eat and drink?  Do  you have an advanced directive or living will?  Will you accept a blood transfusion if one is needed?  Do you have any allergies?  Do you suffer from sleep  apnea?  Have you had general anesthesia before?

The sole remaining formality was to sign an acknowledgement of risks form, always being told these risks (e.g. fistula) are "relatively low". But, of course, they have to disclose every possible permutation or possible outcome - much like the horrific (possible) side effects of Pharma drugs. Oh, there is also an acknowledgement that no guarantee is made that the treatment will eliminate the cancer. Well, that one's fairly straightforward and no sensible person would expect some magic cure! At least for prostate cancer.

By 7.25 a.m. Dr. Crawford and a  urological resident appeared and asked if I had any last minute questions (I had a few, e.g. 'How long does the catheter stay in?') and then I was wheeled into the OR by an anesthesiology resident. Once there I had to move myself to an adjacent table where an oxygen mask was  affixed to my face and the anesthesiologist (Dr. Erin Tracy) instructed me to breathe deeply.   Within about a minute the slight stinging sensation of fentanyl was noted and then.....lights  out.

When I came to it was nearly 10.30 a.m. in the recovery room, and the attending  nurse - Shannon - asked how  I was feeling.  As in January,  I noted the burning sensation in  the urethra - now the pain arising not only from the insertion of the indwelling (Foley) catheter. - but also  a  cystoscope to locate the bladder position as the freezing needles (cryoprobes) were inserted into the prostate.

Each cryoprobe from 1-3mm in diameter  inserted through the perineum,  used Argon for super cooling to sub-zero temperatures. The effect was to freeze the cells of the tumor creating an "iceball" with colder temperature at the center and warmer at the periphery. However, this difference is eliminated by repeated freezing and thawing cycles.  To protect the urethra a warming catheter remains in place during all the cycles.

To relieve the post -op urethral pain,  Shannon gave me two hydrocodone pills (which UCH calls  "narco)' and the pain subsided but the feeling of grogginess increased.  This was somewhat  different from the  3D biopsy when I came rather quickly out of general anesthesia with little or no hangover.  By contrast, this time I had to ask for a barf bag whereupon I did one or two dry heaves.

By 11.30  when Janice arrived, I was able to eat:  a couple of saltines with some ginger  ale. Janice told me that Dr. Crawford met with her in the main conference room and informed her the procedure went "very well" and  a total of three freezing cycles (at different temperatures) were done, including one at -90 Celsius or - 130 F.  (Cell death occurs at -40 C which is also - 40 F).  This sequence of freezing was why the procedure took longer, and hence the need for more anesthesia.

Only later, once I was dressed, did I realize another source of discomfort was a "scrotal support" that had been appended to me after the procedure. I asked the RN why this had been put on and she explained it was to prevent or inhibit "scrotal edema" - a swelling of the testicles to potential football size that sometimes accompanies insertion of the cryo-probes.  I asked how long I needed to have it on and she replied: "Maybe two to three days". Well, after 2 days I cut if off with a jack knife I brought with me to the hotel.

This morning, barely two hours ago, Janice used a saline syringe given to us by the UC staff to change the pressure inside the catheter to release the bulb and the connection. "Liberation" arrived with immense relief but also lots of blood and clots, much of which was probably associated with the dead cancer tissue that had morphed into the "ice ball".  After drinking quarts of water the urine has gradually begun to return to the usual (straw)  color. The pain has also subsided enough to sit down and write this post - to bring interested readers up to date-  also indicate why no posts appeared the past three days.

Anyway, the takeaway is that now I will have to get PSA tests done at 6 month intervals, and then hopefully, see it dive down to negligible levels in about 12-18 months. Otherwise, another biopsy may be needed. But in any case, I've made it clear no further treatments after this.

The prognosis, however, is very good and by all accounts from Dr. Crawford the tumor ought to be literally terminated as an ice ball that subsequently turns to dead cell slush.

Fortunately, I've not had to pay for any of the treatments, tests, biopsies I've had over the past five years. Ok, I take that back, I had to cough up about $1200 for the HDR Brachytherapy treatment I had at UCSF in 2012. But the total I would have had to pay for all cancer treatments, had I not had Medicare, is estimated to be around $115,000 when the cryo-ablation is factored in. In fact, without Medicare, we'd likely have had to declare bankruptcy.

That brings up the question as to what millions of Americans will now do that this misnamed Senate health care bill ("Better Care Reconciliation Act Of 2017") is ready to pass.   And by the way, let's also cut the crap this is a health care bill. It  is not. It is a revival of the zombie tax cut paradigm that the GOP has turned into an abiding fetish. This despite the fact that NO evidence exists that cutting taxes for the rich or corporations increases economic growth..  That canard was last exposed during the Gee Dumbya Bush reign, but now has been revived by Paul Ryan and Co. Never mind, the Repukes are salivating to cut the critical medical access for tens  of millions to give the richest more gold-lined tubs, yachts, 20,000 sq. ft. vacay homes and blood diamonds that they don't need.

So this vile tax cut bill  - in the words of one commentator - "takes a meat axe to their health care.". That is, to Medicaid, through which $800b would be cut, lowering the bottom on 75 million Americans. What if the males  in that population get a cancer like I have, what can they do? Well, the Repuke bill will ramp up their deductibles, increase co-pays (by an average of 20%)  and limit access, while offering only measly tax credits - if they pass an income test. End result? Most would either have to go bankrupt accessing the treatments needed, or allow the cancer to progress.

For people with disabilities, Medicaid is the primary benefit that allows them to stay in their own homes.  Without it they will be homeless on the streets, hence the reason for their plaintive cries yesterday (in front of Bitch McConnell's office)  to "Save our liberties!"

For lower income folks, the bill amounts to the most massive transfer of resources in history from them to the wealthy for $600b in tax cuts. The low income people will be left with virtually nothing by 2025, or be at the mercy of private insurers. Here in Colorado, Medicaid access will revert back to what it was before the ACA arrived, with draconian qualification measures applied - given the extirpation of Medicaid expansion will leave us with a $750 m. plus deficit. That means a low income mother of 2 kids in 2025 will have to earn no more than $300/ month to qualify to receive Medicaid benefits after this god -awful plan allows only limited block grants to the states. The worst hit will be the underclass disabled and seniors barely making ends meet living in high premium states. Seniors alone will have to cough up 5 times more in premiums thanks to this misbegotten atrocity.

And for a take on the for profit health insurance industry we have these words from  William Rivers Pitt - who wrote in a recent Blog post (on 'smirkingchimp.com')- on how they compare to a Mob protection racket:

"The health insurance industry, for the most part, is the Mob painted over with a veneer of legitimacy. They're a protection racket. The Mob got people to pay by offering "protection" for your restaurant or store, and would burn it down if you didn't pay up. With the insurance industry, your body is the store, and as all flesh is inevitably weak, your store will eventually burn down, taking your financial stability with it unless you pay the insurance middleman in full. Nice health you got there, be a shame if something happened to it. That's only if they don't turn down your claim because of a typo on your claim form, which is hardly rare. I had ICU nurses telling me insurance horror stories that made one wistful for the ringing sound of guillotines in the town square.

The problem is the fact that health care in the United States is a for-profit industry, like petroleum speculation or automobile manufacture. It's a few people making a lot of money off of sick people, and after so many years of this being the status quo, they have the political system wired to keep it that way."

Question: If the health insurance lot are analogous to the Mob in a protection racket, what does that make Bitch McConnell, Paul Ryan and the GOP?

Answers?  Inquiring minds want to know.

See also:


http://www.edavidcrawford.com/targeted-prostate-cancer-treatment

And:

https://www.youtube.com/watch?v=Hoi0872F3Cg

Is Proton Beam Therapy Worth It?

Comparing degrees of localization of proton beam therapy with other treatment  modalities, in terms of dose v,  tissue depth. 'SOBP' denotes 'spread out Bragg peak' - or the collation of several such peaks via different beams, for different depths. Red line denotes depth dose plot of x-ray beam..


The Wall Street Journal article 'Making A Case for Proton-Beam Therapy', to treat cancer - actually posed an interesting conundrum. On the one hand "six new proton beam centers are set to start delivering state of the art radiation to cancer patients around the country by y ear's end" - with no fewer than ten additional centers expected by 2018 bringing the total to 30.

On the other hand, these centers are "entering an uncertain market" since the therapy still "lacks evidence that it is better than traditional radiation despite costing significantly more".   Indeed, as the WSJ piece notes, Aetna and United Health Group, Inc. have stopped covering it for prostate cancer, "once seen as a main source of patients".

I also (briefly) considered getting proton beam therapy when my prostate cancer was diagnosed back in July, 2012.  However, my wife (a former radiotherapy software specialist) convinced me that high dose rate brachytherapy - which her company specialized in - was the better option.  Plus,  she knew the best center in the nation to get it: the Helen Diller Cancer Center at University of California - San Francisco and had worked with the world-famous oncologists there .  She was  also  skeptical proton beam centers existed that could give 100 percent assurance and confidence that through all the 30 or so days of treatment one would not see a "geographical miss". That is, the proton beam hitting a critical region like the bladder or lower bowel instead of the cancer, putting an  unwanted micro-hole in either..

For those not aware,  proton beam treatment is a form of external beam therapy in which positively charged particles (protons) are accelerated to 60 percent of the speed of light, or 180,000 kilometers per second. They are constrained to form a powerful beam that can be programmed to deposit most of its energy directly into a target tumor - say in the prostate gland - minimizing radiation exposure to surrounding healthy tissues (say bladder and lower bowel in the case of prostate tumors)

While the therapy - according to existing evidence - isn't necessarily "better" than traditional radiation treatments, the proponents (which include now the top ten cancer treatment centers)  insist it can reduce many harmful side effects, especially for localized cancers.  As the WSJ noted:

"The benefits are undisputed for rare pediatric brain cancers, adult eye tumors and cancers at the base of the skull."

But for prostate cancer the jury is still out, and certainly the benefits of the radiation treatment I received have to be considered at least as good and much more cost effective. (I was in the treatment center for one day, and received one high dose of 1930 cGy via Iridium 192 needles introduced in situ, see e.g.

http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html

While the advocates for  proton beam therapy brag of its accuracy - assuming it's done in the right hands- my own therapy relied on a specialized inverse planning, or "IPSA" software, see e.g.

http://radonc.ucsf.edu/research_group/jpouliot/pages/ipsa/ipsa_hdr.htm

For which testing of the algorithm at multiple sites disclosed  automatic protection for critical organs  achieved by generating contour solutions that cleared a 3D "tunnel" around the urethra and rectum (for example)  to spare them from the maximum delivered dose.
 
The worst side effects for me were in the immediate three or four month aftermath and included frequent urge to urinate and some burning upon urination. Also burning accompanying sexual activity. (Only a bit later I learned I could control the burning effects by taking one cranberry sofgel a day)

Medicare covered almost 95% of the total treatment costs, which - if I'd  had Paul Ryan's stingy "premium support" (voucher)  plan - would have likely bankrupted us - given it would only cover $10k or so a year.

It should also be known, as the WSJ notes, that Medicare also covers proton beam therapy  "at about $1,100 per treatment session" . Nonetheless,

"several major insurers stopped after a 2012 study found it has no long term added benefit. "

Originally, as the WSJ notes,  men with prostate cancer had made up 70 percent of patients at some proton centers, and that is now 50 percent.  

Meanwhile, the manufacturers themselves are designing more compact machines as opposed to the Hitachi machine - nearly the length of two thirds of a football field. But smaller is no guarantee of success and as the Journal piece pointed out, ProTom International Inc.  - maker of compact systems- already had to file for bankruptcy protection.

My advice to anyone considering this option is to look into it carefully, also consider that a simpler, less complex system might actually be better for your cancer treatment needs!

Rising PSA After Radiation Therapy ? Don't Be Rushed Into "Salvage" Therapy!

After another increase in PSA, now to 2.8 (from 2.5) after only 3 months, yes I have begun to panic. In the ideal world it would have been going down, down, down and the 2.5 reading would have just been a "flare" as my radiation oncologist at UCSF put it.  But am I about to hit the 'chicken switch' and run for a urologist, or for 'salvage therapy'? HELL NO!  Not after pouring through dozens of technical papers  (mainly in the Journal of Radiation Oncology) since the test result came back.

To sum it all up: radiation, namely HDR brachytherapy, e.g. see my description of the treatment at UCSF in 2012 here: http://brane-space.blogspot.com/2012/09/thge-longest-dayand-then-some.html

takes much longer than surgery before a true PSA nadir is hit. Generally from 36-40 months, and in one article noted in the Oncology Times, a time of 5 years was assessed as proper before one could compare "apples to apples", i.e. with a typical prostatectomy nadir of 0.1 ng/ml. Five years is a long damned time!

Now enter a voice of reason in Kent Wallner, M.D., Associate Professor in the Radiation Oncology Dept, at the University of Washington Medical Center, who as early as 2001 reported three confirmed cases of men who had "temporary, self-limited PSA rises as well as post-implant biopsies showing "histological evidence of persistent  cancer" . All 3 declined to have salvage therapy (i.e. anti-androgen therapy, salvage prostatectomy or salvage radiation treatment). The hum dinger?Despite refusing further treatment all saw their PSAs fall.

In a subsequent interview, Wallner observed he was "met with skepticism" when describing the cases.  He said this was because:

"it defies common sense to have a rising PSA and a positive biopsy and not have cancer".

True, but again, mayhap the Medical Industrial complex doesn't know everything after all, and despite all their proclaimed 'insider' knowledge of what ought to happen after a radiation treatment, they are still on the short end of the learning curve.

As an aside, all of this pretty well confirms Medical author Shannon Brownlee's take, in her book 'Untreated: Why Too Much Medicine is Making Us Sicker and Poorer' (2007, p. 202):

"The evidence suggests that PSA testing is not saving any lives, and even it is the large numbers of men who are treated unnecessarily are paying a terrible price. They're the equivalent of civilian casualties in our war on cancer.".

Again, I reiterate, yes I did have treatment - under pressure from my wife, my urologist, my primary doc and others. BUT......as a fellow Intertel member emailed me (soon after I wrote about the experience in the Intertel Regional Newsletter 'Port of Call') I might also have lived with only minor problems (the cancer stage was T1c) and croaked eventually  of something else. This is because 97% of prostate cancers are slow growing. (Incredibly, 99% of males autopsied who are 79 years of age or older are found to have prostate cancer .....and most never knew about it!)

So now AFTER treatment (and many of the still lingering side effects like burning urination) I am to go back for more? Uh unh! Don't think so!

And I am validated by Dr. Wallner's research. Wallner has noted that since up to one third of men will have rising PSAs sometime after brachytherapy (possibly for a number of reasons including inflammation or enlargement because of the radiation effects - thus imitating BPH) " a fairly large percentage of them might have unnecessary biopsies and unnecessary surgeries."  (Oncology Times, Vol. 23, No. 10, 27-30)

Wallner acknowledges that his study lacks a denominator, because "not every man has a biopsy following brachytherapy" (with good reason, as the cells are in a 'mess' from the radiation, and the gland is still affected, so the histological skills to discern cancer are much much greater than for an ordinary biopsy). Most of the literature I've seen argues it would be foolish to even think of a biopsy before about 3 years AFTER treatment. There is simply too much room or error, and getting false positive or false negatives.

Wallner (ibid.) documents his following 6 men (beyond the original three) who had PSA bumps and also positive biopsies but "whose PSA levels have since fallen and are consistent with long term cancer control".

He added:

"This is a real problem because common sense would tell us we've got to operate on these people. But because there's no clear answer we should think long and hard before recommending a salvage prostatectomy ."

Indeed. And while we're at it, let us bear in mind that often in science the failure of a simple common sense signifies massive ignorance in an area. In physics, for example, it is "common sense" that a dart fired at a board with two apertures or holes can only transit one or the other, not both. Yet at the quantum level the electron violates this script all the time in the classic two-slit diffraction experiment. Hence, the danger in using common sense as a guide, including in the medical arena.

Dr. Wallner hypothesizes that a repeat biopsy might be positive because of residual tumor in the prostate.  As he describes it (ibid.):

"We know it takes a couple of years to clear cancer after high dose radiation, so for the first two years or so you can see residual cancer in the prostate.  But you don't know if it is viable or not."

This again makes eminent sense, because the effects of radiation occur over time, not all at once as in the case of radical surgery. Hence, the medical industrial complex ought to be sensible enough to realize that and hold back - but that's not in their nature. Like gunslingers of the old West they want to 'kill' any sign of the 'bandit' - even though he's basically moribund and on his last legs.

Wallner is backed up by Bradley R. Prestidge, M.D.,  a radiation oncologist at the Cancer Therapy and Research Center in San Antonio. He points out (ibid.):

"The older literature is fraught with misreadings of biopsies done too soon. within 12 to 18 months post radiation treatment. Cancer cells take a while to die off and even though some may look like cancer architecturally, they are not dividing."

Dr. Prestidge went on to point out that especially after brachytherapy, y prostate cells labeled 'indeterminate' on biopsy "may look cancerous because of background radiation effect."

His recommendation: Patients, urologists and oncologists "should not rush into this".

Indeed.

Dr. Wallner's main take away: he would personally wait three years for the PSA to decline after brachytherapy.

He concedes this is a "tough option" because "some men will indeed have recurrent cancer".

But he adds:

"If I had done a salvage prostatectomy on these men (in his original study) I would have done them a great disservice."


Footnote:

In a study of 779 men following Dr. Wallner's , Frank Critz, MD, and colleagues, found that the median PSA rise was 0.4 ng/ml above the median pre-bump PSA of 0.7 ng/ml. For 10 to 20 percent of these men, the rise was 2.0 ng/ml during the bump. In one case the PSA level reached 15.8 ng/ml before dropping.

The median time to the rise was 18 months from the time of implant, and in 92 percent of men it was observed within 36 months.

Dr. Critz defined a bump (which he called a “bounce” in his report) as a PSA rise above 0.5 ng/ml with a subsequent fall to less than 0.5 ng/ml, for men who had a post-treatment PSA nadir of 0.5 ng/ml or less. For men with a pre-bump PSA of greater than 0.5 ng/ml, a bump was a rise of 0.1 ng/dl or more with a subsequent fall below the pre-bump PSA level. He noted, however, that one percent of men have a bump with the very first PSA assay taken after treatment.

The mechanism of PSA bounce after radiotherapy and its relevance to long-term survival were unknown, Dr. Critz said, in an interview for the OT. But he noted that curative surgery for prostate cancer differs from curative radiotherapy, in that time must be allowed after successful irradiation for malignant and benign prostate epithelium to disintegrate.

It may be this process that causes a clinical or sub-clinical prostatitis and leads to the temporary PSA rise.

Perhaps it's time  (before making generalizations about treatments) the medical community do much more study and research on the effects of radiation - at different doses - on living tissues, including cancerous tissues!

Addendum: 1/ 26:

An email received this morning from my radiation oncologist, Dr. Hsu, acknowledged my research and that he agrees what we're seeing is a PSA "bounce".  He also said that the original PSA reading of 2.0 ng/ml was not the nadir. So, this may well be a 2-3 year wait!

Is There Sex After Prostate Cancer Treatment? Good Question!

Perhaps the more apt question, given we KNOW the sex has to be different, is: What is the quality of sex after prostate cancer treatment? And to answer this question presumes not only knowing which treatment modality we are talking about, but the manner in which delivered. For example, if radical prostatectomy, then was it delivered via “robot” as in the da Vinci procedure, or via the hands of a skilled surgeon. (Typical books, and medical sites like Hopkins suggest the robotic surgeon ought to have at least 1,000 under his belt for a decent outcome).


If radiation, then what form: external beam or HDR (high dose rate) brachytherapy – where the source is directed inside the gland (such as I had done – see my blog on it “The Longest Day and Then Some”). If HDR Brachy, then where was it done, at which site?Do they specialize in it (like UCSF's Helen Diller Cancer Center) or is it one of many modalities they offer but for which prostate cancer treatment is no more focused on than say, breast cancer. All these matter. But given the lack of specifics let’s employ a more overarching addressing of the question.


Let’s understand first that testosterone presence is critical for prostate cell growth and function.Thus, these cells and their function are sensitive to the presence or absence of testosterone. Since prostate cancer cells are derived from the prostate gland it ought to come as no surprise that they’re also dependent on testosterone for survival. Cancer cells proliferate when testosterone is present and shrivel up and die in a mass cellular suicide called apoptosis when absent. Removing the whole gland can effect this, and also dosing it with high levels of radiation ….or having the cancer patient take large amounts of female hormones. (TIP treatment)


Cut the gland out and you also cut out the basis for testosterone production associated with semen production. Dose it with radiation and you ‘fry’ the prostate cells and cancer cells and reach basically the same result. Ingest enough female hormones and ditto.  The issue for most guys who choose a treatment then, is twofold: 1) get rid of the unwanted cancer cells or growth, and 2) Preserve some semblance of sexual function. Obviously if the whole gland is removed and ancillary erectile tissue – say in a radical prostatectomy, then achieving (2)  will be more difficult. It’s also one reason many guys on radical prostatectomy and de Vinci procedure net forums often complain about not having been fully informed of the loss of sexual function and the extreme lengths they must go to in order to recover it. As one guy put it on one forum after reading how another member complained about priapism after taking too large a dose of Viagra to stay hard ….”Well, there are some guys who can’t even dredge up enough desire to even want sex if we have to go to those lengths.”


The concerns are less for radiation therapy such as the HDR brachytherapy (single treatment)  I had, since the basic organs, gland and tissues remain in situ. The entire pelvic floor isn’t re-adjusted as it is for radical prostate surgery or da Vinci surgery. Still, treatment modes vary and so does the competence of those who deliver them. As my wife put it, even putting the prostate template in place – suturing it to the perineum- can vary significantly from one treatment site to the next. One small error in the template placement means the indexers will not deliver the dose to the correct locations. That can be catastrophic. The dose delivered is also critical – too much and you can't preserve function, too little and you do but the cancer comes back. You need the maximal optimal dose for the grade and stage of the cancer!


As for surgery, another risk which isn’t much mentioned (but ought to be according to the men on the surgery forums, some of whom have threatened “legal action” against their urologists for not giving them the full lowdown) is penile shrinkage. Dr. John Mulhall, in his book, Sexual Function in the Prostate Cancer Patient, notes an average of ½” shrinkage after radical prostatectomy - no matter how done. Overcoming this often demands an aggressive regimen including: Viagra, vacuum pumps and injected prostaglandins. But as Dr. Mulhall notes, to be effective the therapy needs to be started almost right after the operation. Trouble is most men are in no mood after having to have Foley catheters inserted in their urethras for days or weeks, not to mention a good deal of post-op pain and possible complications (i.e. need for a pelvic drain in case of abdominal infection after da Vinci robotic surgery)

In terms of HDR monotherapy (brachytherapy) effects, the St. Joseph Prostate Cancer Center notes (in terms of HDR brachytherapy – such as I had):

“Erectile dysfunction (ED) is often difficult to quantify; however, men who do not have ED prior to HDRB most often maintain sexual function after HDRB. Men with ED prior to HDRB will likely continue to have ED after the treatment as HDRB is not a treatment for ED”


Other than this it’s hard to gain a handle. The UCSF Patient Guide for Sexual Rehabilitation – in terms of post HDR monotherapy sexual indicators- notes that the initial ejaculations will be either bloody (laced with black blood, or old blood), “thick” and off color, or non-existent. Up to now I’ve no idea but suspect likely bloody ejaculate if there was anything. Just a guess. Obviously, from my point of view, any remote consideration of even attempting ejaculation is out of the question so long as urinating delivers a burning sensation! (So try to imagine what forcible expulsion of prostate contents would do!)

One site run by an RN who also offers massage therapy and other post-op aids, notes serious difficulties following just about any kind of prostate cancer treatment and observes even healthy males post-op will likely have much difficulty gaining and sustaining erection. She actually recommends males in this predicament just agree to use “mutual masturbation” with their wives (assuming they're willing) as a solution though she acknowledges some patients – out of religious inhibitions or proscriptions- might have problems with that.

The UCSF Guide includes a section on “solutions” to any sexual dysfunction, which range from using a “penile implant” (i.e. an inflatable device surgically implanted into the penis) to the use of a suction device or “penis pump”. Neither of these will likely be very appealing to most guys, so they also include use of Levitra or Cialis but at higher doses than what would ordinarily take - say for ordinary ED. (This may be why the guy cited earlier on the radical prostate surgery forum complained of priapism, which is a painful erection lasting 4 or more hours.)


Another aspect not much discussed is that of “dry orgasm” or retrograde ejaculation. This is normally associated with a prostatectomy but can also occur after radiation therapy. In the former case tissues associated with the muscle that normally blocks off the entrance to the bladder have been removed. In the normal case prior to the surgery, contracting muscles always force the semen unidirectionally through the penis outwards.


After the surgery, with the loss of muscle tension and control, this is no longer possible, plus the bladder neck is frequently enlarged after surgery so that it cannot close completely. Hence when the muscles associated with the urethra contract the semen is ejaculated backward through the open internal sphincter and into the bladder. This is later flushed out in the urine.


IN the case of radiation treatment, the dry orgasm is of different physiological origin since the sphincter muscles are not affected. In this case, since the whole volume of the prostate has been irradiated. My wife actually corrected me on that, as I’d earlier believed it to be a more directional treatment. Her point was that the IPSA software contour solutions provide a 3D "tunnel" around the urethra and rectum to protect them from the maximum delivered doses.  The point is that  the cells that produce prostatic fluid (the milky stuff that mixes with sperm to produce semen) are basically killed off with the affected prostate cells. Since the seminal vesicles also receive a dose of radiation (perhaps up to 10 Gray in my case or 1000 cGy) any sperm cells produced are also killed off.

In other words, after the last 'old blood' is ejaculated there’s really nothing left: all or most of the sperm cells are “cooked away” as well as the cells that generate prostatic fluid (this of course is also why one expects PSA to fall). Given there’s basically nothing left “in the tank” then there’s nothing to ejaculate. You get the sensation (at least part of it) of doing so, but nothing is being expelled.

No, I’ve not experienced any of this yet because I haven’t attempted anything! However, it falls within the bounds of what a former Nucletron Corp. radiotherapy consultant told me before I received my own treatment (he also went to UCSF for early HDR brachy), but at that time they were still delivering the dose in two treatments. Only in the last 5-6 months have they adopted the one time HDR treatment based on a study done by Dr. Alvaro Martinez at William Beaumont Hospital-Center which showed that the results for a single treatment were good, with low toxicity. (See, e.g. http://dr.beaumontphysician.com/news/pages/single-dose-brachytherapy-treatment.aspx )

So UCSF changed over to that regime.


Here’s the skinny: While many may insist that men make too big a deal out of post-treatment sex activity and add ‘You ought to be glad you’re just alive!” the truth is more complex, and the self-identity of most of us is bound up with our ability to sexually perform. Erase that, and you erase a lot of self-worth, though true …not all and not necessarily the most crucial aspects. But from reading many of the prostate cancer blogs and forums, and the degree of depression and anger in many men (especially a LOT of younger guys in mid to late 30s and early 40s, whose wives left them because of their difficulties in performing post-treatment) it is still no small deal. And little wonder 90% of these depressed guys had the radical prostatectomy and were neither informed fully of the side effects in terms of prolonged incontinence or concerning the loss of erectile ability and sexual function in 75% of cases. This may be one reason most weren’t merely depressed but bloody angry to the extent of threatening legal action against urologists.

It seems that not only do we have lots of work to do in getting information – full information – to men facing prostate cancer and treatment options – but we also need the urologists, oncologists to deliver the flat out truth instead of wishful thinking fantasies – as per their patients' expected post-op sex lives!