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Patients speak about prostate cancer and laparoscopic radical prostatectomy

Robert Schettig, Key West, FL

On the 3rd of July, 2007, I was diagnosed with prostate cancer in Milan, Italy.

Each year before returning to our summer home in Europe, my wife and I undergo complete physical exams. This spring I learned my PSA level had gone from 2.5 to 5.8 ng/ml in one year. My doctor suggested that we take a conservative approach and prescribed antibiotics for a 30 day period and another prostate PSA test two weeks after finishing the antibiotics. This was done in Italy, where I found that my PSA had gone from 5.8 to 7.8 in less than three months! At this point I scheduled a prostate biopsy and 13 samples were taken, of which 5 turned out to be malignant.

My wife and I drove straight from Milan to a 4th of July party given by American friends. When I announced the results of the biopsy to an English acquaintance he offered to lend his “Prostate Manual”, a 400 page book which explained more than anyone really needs to know about the disease unless he is a doctor. I read it cover to cover.

I quickly eliminated radiation treatments because some traces of radioactivity remain in your body for the rest of your life; but more importantly I learned that if one has radiation treatment and it does not get all the cancer, it is almost impossible to have surgery afterward. On the other hand, if you have first prostate cancer surgery and it doesn't get all the cancer you can always have radiation afterward. This is an important piece of information, and it had a lot to do with my decision to opt for surgery.

My brother-in-law had radiation therapy last year because his doctor refused to operate due to his age (he was 75, and his doctor’s cut-off is 70), even though he was in good health. One year later the cancer has recurred and now the doctor is suggesting cryotherapy (freezing the gland to destroy abnormal cells). His choices are limited and none sound very promising to me. I also read about the other prostate cancer treatments available. Most seemed a bit risky and I quickly discarded them.

I discussed my situation frequently with my Italian urologist, a smart 40-something doctor who works in one of the best clinics in Milan. He told me not to panic as the cancer was contained within the prostate, and since it is a slow growing cancer if detected early as mine was he
felt there was no urgency to have the operation right away. The doctor suggested taking the time to study all the options and then deal with it within 6-8 months after the diagnosis. He favored radical prostatectomy in my case (the traditional open surgery to removal the prostate). I agreed that having surgery seemed better than radiation and asked him about a relatively new process which is minimally invasive and robotically assisted, called laparoscopic radical prostatectomy (LRP). The Italian doctor knew of this process and said that I could be a good candidate for it, but told me that honestly he couldn't recommend anyone in Italy, and in fact the only person he knew of with a lot of experience in this process was a surgeon in Paris.

Within a month after the biopsy I had decided that LRP was the best solution for me and the next step was what turned out to be the most important decision regarding my cancer – choosing the right doctor.

I admit to being a nerd. Before buying a new computer, an electronic gizmo, or even a new TV, I thoroughly research everything available, study all the technical aspects, and seldom regret my final decision. It was therefore natural to take the same approach in my choice of a doctor. After having spent countless hours on the Internet, asked for recommendations from all of my doctor friends and everyone I knew who was well connected in the medical community. I finally narrowed my choice down to two doctors. One was a well-known urologist of Latin-American origin who was recommended to me by three physicians, two of whom were friends of mine. He was described as being “world class”, and one surgeon said that if he were going to have the procedure himself this is the doctor he would choose. The other was Dr. Krongrad, who was recommended to me by a lawyer friend who seems to know everybody in Miami.

I would like to describe my first impression of these doctors, because it taught me a lot about how differently two physicians can analyze the same situation and why it is so important to learn enough about prostate cancer to be able to select the right one:

Doctor #1

-His office was completely disorganized (I waited 1½ hours before he saw me).

-The doctor never bothered to check my prostate, although his assistant did check my weight, temperature and blood pressure, which seemed to me to be irrelevant information for a prostate exam.

-He informed me that he no longer did robotic prostate surgery because there wasn't much demand for it (which was the opposite of everything I've read) and also because the learning curve was so long. I translated this as meaning that he never really perfected it, and I do know that it takes a minimum of 100 operations before a surgeon becomes competent in this procedure. He then tried to talk me into traditional open radical prostatectomy, saying that he only had to make a "bikini" cut, and the recovery time was only about a week longer than with laparoscopic surgery, which I knew was not true. My Prostate Manual says that complete recovery averages 2 to 3 months for a traditional radical prostatectomy and a friend of mine was out of work for six months after having open prostate surgery.

-The doctor also said that due to my age, 67, I should seriously consider radiation treatment as an alternative, as it is a procedure they recommend for older persons. By this point radiation was an option I would not even consider.

This, apparently, is "world class" to some people in the medical community.

Doctor #2 (Arnon Krongrad):

- Dr. Krongrad was born in Israel, and while not having the carefree Latino personality of the other doctor, I found him completely focused and supremely confident. He immediately got down to business. I was in the waiting room for approximately 2 minutes before his assistant Hope introduced herself and led me to his office. This was quite surprising as I had arrived 10 minutes early, so the doctor actually saw me before my scheduled time.

-He asked me to drop my pants and did a rectal exam to verify the size and shape of the prostate before even speaking to me. After checking my records and the pathologist's report Dr. Krongrad said that I was a good candidate for LRP, because I was in good health and that health was the determining factor for surgery – not age. Dr. Krongrad told me there were no real "robots" involved in performing the surgery – they only assisted the doctor - and that the most important factor for success was in the hands of the surgeon (at which point he extended his hands and gave them a very admiring look). He never mentioned radiation and nixed all the other new techniques such as high frequency sonar, cryotherapy, etc. as being too experimental.

-Dr. Krongrad said that with LRP I would only have to spend one night in the hospital and the typical recovery time was 5 days, but most of his patients are up and functioning fairly normally (i.e; being able to go out to restaurants, etc.) within 2 days. According to him the worst part of operation for most of his patients is the catheter, which he recommends leaving in for 10 days.

-Dr. Krongrad is the only doctor I was able to identify who does nothing but laparoscopic prostate surgery. Although I don't know how many he has done, I do know that he had more than 200 under his belt when he operated on Pat Robertson, the leader of the Christian Coalition, in February 2003, and that the week before seeing me he had performed 8 LRPs. Even assuming that he takes a month's vacation each year, I figure he is getting pretty close to 2,000 of these operations by now. In a field where the technique is so important, this fact alone made him the ideal candidate in my mind.

My final decision was easy to make, and I have never regretted it for one minute.

All of the pre-op arrangements (cardiac exam, stress test, blood analysis, hospital arrangements, etc.) were taken care of by Hope, who seemed genuinely happy to help me – all I had to do was show up on time.

Part Two (after the operation)

Tuesday, 20 November (operation day) - In the prep room they gave me a "happy shot" to relax me before giving me the general anesthesia. I drifted off a bit and watched some fuzzy
figures walking back and forth. Eventually the anesthesiologist went by and I asked him when they were going to start the operation. He said "Oh, it's been over for some time now". They wheeled me up to my room where my wife was waiting (they set up an extra bed so she could spend the night), put me in bed and I kept touching myself trying to feel the pain from the surgery - there was none! A bit of soreness, but no pain. In fact the only pain medication I took after the surgery was at 3AM, when I asked for a Tylenol because my back was sore from not being able to move around in bed (I had the catheter bag on one side and a little suction bottle attached to a drain tube on the other side so I became stiff after a while).

I was discharged the following day around noon, came home, had a nice lunch and then took a long nap. Still no pain! If it hadn't been for the catheter bag attached to my leg I would not have known I had surgery at all.

It was incredible that 30 hours after having major surgery I was home, feeling fine and in no pain. I am so glad I had sufficient time to research this procedure enough to feel completely relaxed with my decision as to the best procedure and the best surgeon for my situation. I feel sure that LRP was the best option for me and am convinced that Dr. Krongrad is one of the top surgeons in the world performing robotic laparoscopic surgery.

Two days after surgery was Thanksgiving Day. After sitting at the table for three hours with no discomfort except for having eaten too much, I made a toast and gave special thanks to my lucky stars for having guided me to Dr. Krongrad.

PS – The picture above was taken three days after surgery. I felt so good that I decided to celebrate by buying a new Vespa scooter and taking my wife on a tour around Miami Beach.

PPS – Dr. Krongrad was not happy when he found out about the scooter, but I reminded him it wasn’t on his list of things not to do after surgery.

Milan England Miami robotic laparoscopic prostate cancer surgery