This is a common question in my office and I am sure one for some of you. I hope it is helpful.- JM

TRT Requires Close Long-Term Follow-Up

Urology – May 1, 2007 – Vol. 22 – No. 11

Patients with low serum testosterone levels and symptomatic hypogonadism who have undergone treatment for early, localized prostate cancer may be treated with testosterone replacement therapy as long as they are followed closely and remain in remission.

Article Reviewed: Testosterone Replacement for Hypogonadism After Treatment of Early Prostate Cancer With Brachytherapy. Sarosdy MF: Cancer; 2007; 109 (February 1): 536-541.

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Johns Hopkins Surveillance Program-A Must Read Source if you are newly diagnosed prostate cancer patient.

“A word to the wise is sufficient.”

From Urological Wit and Wisdom-

Johns Hopkins University was founded in 1876 and the money given to establish it was by Johns Hopkins. Hopkins made his money in the railroad business and retired at the age of fifty-two. His first name was the last name of his paternal great grandmother Margaret Johns. The first president of Johns Hopkins was Daniel Coit Gilman. In time a very talented team of physicians was assembled for the Johns Hopkins University School of Medicine, which was established in 1893. Four of the physicians became known as the “Big Four,” pathologist William Welch, surgeon William Halsted, internist William Osler, and gynecologist Howard Kelly. Each of the doctors, in his own way, had a profound and lasting influence on American medical education and research.

Hugh Hampton Young was given a surgical resident spot in 1986 by virtue of another resident leaving. He had no particular interest in urology and in fact was troubled that he was unnoticed by the head of surgery Halsted. Just as he had gotten into the residency program fortuitously, so too, did he begin his illustrious career in urology at Johns Hopkins.

“One day in October, 1897, I was walking rapidly down the long corridor of the hospital. As I turned the corner, I ran into Dr. Halsted with great force and almost knocked him down. I caught him just before he hit the floor and began to apologize profusely. Dr. Halsted, still out of breath, said: ‘Don’t apologize, Young. I was looking for you, to tell you we want you to take charge of the Department of Genito-Urinary Surgery.’ I thanked him and said: ‘This is a great surprise. I know nothing about genitourinary surgery. Whereupon Dr. Halsted replied, ‘Welch and I said you didn’t know anything about it, but we believe you could learn.”- Hugh Hampton Young


Young performed the first perineal prostatectomy in 1904, was the innovator of many the procedures we use today, and is considered, “The father of modern urology.”


Considering how Young got his appointment from Halsted, he may have been the first practical example of, “See one, do one, teach one.”



Free Psa low…damn it!!!

Your PSA, rectal exam and biopsy report – Understanding the specifics of your disease is key to making the right decision.

I had been checking my PSA for years and had watched it slowly creep up to just above normal. I decided to obtain a Free and Total PSA to see if it would offer any guidance regarding pursuing a biopsy. (In your blood, a portion of PSA is free (unbound), and a portion is bound by blood components. A low Free PSA indicates a higher possibility of a positive biopsy.) The day after my blood was drawn, my nurse Tina approached me with the lab report indicating a very low Free PSA.

She had drawn a frowny face next to the lab value. I was crestfallen. “Tina, did you really have to put the little unsmiley face on it?” I decided at that moment that the time had come for me to have a prostate biopsy. I asked my partner to do it at lunch that very day, and the pathologist had the tissue samples in his hands by 1:30 p.m.

That evening my wife and I met at a little cabin we have on Lake Sidney Lanier, which is not uncommon on my half-day off on Thursdays. I had not told her that there was an issue with my PSA or that I had had a biopsy that day at lunch. I debated mentioning anything to her before I knew the biopsy results, but I chose to have her involved in the drama of waiting for the results and all the possibilities that entailed. “Karen, I had Bill do a biopsy on my prostate today. My PSA is slightly elevated, and I want to be sure that it doesn’t mean I have a problem.” (Remember, you don’t start with the C word. You tell a patient and his wife, “There may be a problem with,” ” They found something,” or “They have some concerns about…”) We were sitting on the cabin’s porch at the lake, and I had a panoramic view of the little piece of property where I spend a good portion of my weekends cutting grass, fishing, and working on the little vegetable garden we have there. My weekend ritual has become for our dog Chloe and me to pack up the trash in the back of my 1985 Toyota truck (my first car with air conditioning), take it to the county compactor, and then go to the lake. For years I have spent my weekends out there, always making a point to be home, as my mother would say, “by the time the street lights come on.” As we were sitting there, out of nowhere, I said, “I don’t really love this place Karen. I enjoy coming out here, but I don’t really love it. I mean I wouldn’t really miss it.” She looked at me with disbelief. “What are you talking about John? You know you and Chloe love this place; are you thinking you are going to die or something? That’s crazy.” My wife (like most patients who have their prostates biopsied) didn’t understand the possibility of having the “bad” kind of prostate cancer, the Frank Zappa kind. Frank Zappa died shortly after being diagnosed with inoperable prostate cancer, at the height of his musical career, in his 50s. That was my fear, and I will tell you it was real. As I pondered the possibilities of my pathology results, I gravitated to an acceptance that having the “slow-growing kind” of prostate cancer would be okay, but I prayed, “Please don’t let me have the bad kind.” If you have favorable parameters, you may die of prostate cancer, but it will take many years. If the biopsy has unfavorable parameters, the prognosis is unpredictable, with a higher likelihood of the cancer progressing quickly. I had seen this played out in patients of mine; I knew this, but my wife and family did not. I elected not to elucidate my concerns about the dual nature of prostate cancer to my wife; I had awakened her enough.  This time period of “waiting on the results” really gets you thinking, and I was becoming very philosophical about my mortality, with a mentality of “what will be, will be” starting to set in.

A word to the wise is sufficient…

Prostate diaries

  • No symptoms…does it matter?
  • Low PSA…does it mean no cancer?
  • Big prostate…means cancer?
  • Small prostate means no cancer?
  • Surgery better than radiation?
  • Proton better than regular “ole” radiation?
  • Age over 75-is surgery best?
  • Do you have a higher incidence of impotence with cryosurgery?
  • Why do they only do Proton on the well-mod prostate cancer in terms of the “favorability” of prostate cancer?
  • High PSA means prostate cancer?
  • You have a biopsy of your prostate cancer because of a high PSA…and it is negative…was the biopsy unnecessary?
  • Can you die of prostate cancer?
  • Can you have it before the age of 50?
  • Are all urologists the same?
  • Are all surgeons the same?
  • Will surgeons only recommend surgery?
  • What is the Gleason’s score?
  • If the guy at your church had seeds for his cancer is that the best treatment for you?
  • Are all prostate biopsies that have cancer the same?
  • Are all…

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GreenLight Laser Surgery to Beethoven’s 9th Symphony?
The “Joy” of a laser compared to the standard TURP.

Prostate diaries

green light before and after

When I began my urological practice in Gainesville, Georgia 27 years ago the standard surgical procedure for the prostate was a T.U.R.P. (Some patients refer to the procedure as having a “roto rooter.”)  This procedure at that time took about an hour, and most patients were admitted to the hospital for 2-3 days. It was often times a bloody procedure and as a result patient’s were advised after the procedure to not do any strenuous activity for about a month because of risk of bleeding.

The GreenLight Laser usually takes about half the time of a T.U.R.P. because there is very little bleeding and there are no chips (shaving of the prostate tissue which a T.U.R.P. results in) to irrigate out of the bladder and there is very little bleeding for which the surgeon to contend. In addition this can be done as an out patient, and the catheter remains usually for only one day. The limitations regarding post…

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The Real Prostate Cancer Second Opinion-That’s Right…I don’t have a dog in your fight!