Understanding and Overcoming Prostate Cancer

The most common form of cancer men experience begins in the prostate, but it's a disease that is often misunderstood. For example, many men are surprised to learn that prostate cancer can be slow to develop, and for a good number of patients, the best course of action is to monitor the progress of the disease rather than to immediately jump into surgery or radiation. For others, though, a more active approach makes sense, and today's physicians have great success delivering positive outcomes - though recovery presents its own challenges. Today's guest is Dr. Gregory Amend, a reconstructive urologist practicing on the Upper West Side of Manhattan, who shares his expertise on prostate health, prostate cancer, treatment options and recovery. 

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Music:
Rainbows Kevin MacLeod (incompetech.com)
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Transcript

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers, all available at NAFC.org. 

Welcome back to another episode of Life Without Leaks. I'm your host, Bruce Kassover, and joining us today, as always, is Steve Gregg, the Executive Director for the National Association for Continence. Welcome, Steve. 

Steve Gregg: Thanks, Bruce. This is really an exciting opportunity for us to talk a little bit about men's health, and in particular life after prostate surgery.

Bruce Kassover: Yeah, I'm really looking forward to this because men's health is something that we probably don't talk enough about in general. We're talking about a lot of incontinence care, and I think that today's guest, Dr. Gregory Amend, is going to give us some really important insights for men to understand more about their prostate, what to look for, how to manage symptoms and really how to address issues that are related to it.

So I'd like to welcome today Dr. Gregory Amend. He's a reconstructive urologist practicing in the Upper East Side of Manhattan where he offers comprehensive urology services. So welcome. Dr. Amend; it's great to have you with us. 

Dr. Amend: Thank you so much. It's a pleasure to be here. 

Bruce Kassover: Thank you. So now before we get going, can you just tell us a little bit about your background, your experience, how you got into urology and what you practice today?

Dr. Amend: Yeah, so, as you were saying, I currently practice up in the Upper East Side of Manhattan. My specialty is reconstructive urology, which is a specialized area within general urology. I got into urology just because I really enjoyed the depth of the different types of problems that we solve. I enjoy men's health and I enjoy the patient population that I get to work with.

I think what's also special about the field of reconstructive urology is that it is centered on making somebody whole. So a lot of what we'll talk about today, you know, life after prostate cancer, these sorts of things, you know, once the cancer is already dealt with and the dust is settled, there's a lot of quality of life issues.

And I got into this field by helping navigate those channels to. Help individuals who have conquered the cancer and have gone through that process to regain their loss function. 

Bruce Kassover: That's a perfect introduction to what I was hoping we could start talking about, which is about the human body, about men's bodies in particular.

I mean, we all know that as time goes on, you know, things start to fall apart. I mean, I guess the old analogy everybody thinks of is, you know, it's like a car that's been putting on miles and, you know, parts start to wear down and you have all sorts of issues. But I'm particularly wondering about the prostate because it seems to me like it's, it's especially prone to problems. Like if it were a car part, it would be recalled. I mean, is that fair to say? 

Dr. Amend: Yeah, you know, it's fair to say, and it's also funny, too, because you think about essential organs in your body, you know, the heart, the lungs, the intestines, these sorts of things. And you think about the role that the prostate actually plays in just your overall body.

It actually plays a very small role, but for something that plays such a small role, it leads to so many problems between, you know, either prostate cancer, which is the most common cancer in men, and even putting cancer aside, just a lot of the urinary symptoms that we see that's caused by prostate enlargement and growth and development over time. So, you know, for something that is not really considered a vital organ, it really certainly leads to a lot of issues over time. 

Bruce Kassover: So maybe you could tell us a little bit about what does the prostate actually do? What is it there for? 

Dr. Amend: Yeah. So the prostate is a it's an organ that's involved in the production of semen. So a man's ejaculate has the cellular components, which are the sperm that's created by the testicles and then the liquid portion of the semen. Is in part created from the prostate, though the majority of it comes from the seminal vesicles, but those 2 organs combine and create the liquid portion of the ejaculate. And so it's involved in the production of those factors, which then help the, the propagation of the sperm for reproductive capacities.

Bruce Kassover: That makes sense. So what happens to the prostate as you get older that it causes problems?

Dr. Amend: Well, you know, to be honest with you, a lot of these things, we don't really fully understand, why over time we often see growth and enlargement of the prostate. Sometimes it's been speculated that it may be due to the change in the hormone chemistries of a man over time. The prostate is highly responsive to testosterone and the byproduct of testosterone, dihydrotestosterone. And these things will change over time based upon the aging cycle of a man.

But there are also other studies that have shown that urinary symptoms aren't necessarily correlated to the exact size of the prostate. We've seen, you know, a lot of men who are bothered by a lot of urinary symptoms, but not might, might not have a very large prostate, but then vice versa, we see patients with very large prostates who are relatively asymptomatic.

So part of it is a little bit beyond what we currently understand in the medical science, but what we do see in terms of population studies is that these are very common issues that having what's called lower urinary tract symptoms, which could either be obstructive, meaning you feel that you have a weak stream, you're straining, you're pushing to urinate, you get recurrent urinary tract infections, or on the flip side, what we call irritative symptoms: frequency, feeling like you need to get up in the middle of the night a number of times. These are all related and usually come into play when a man reaches late forties, fifties, and then decades further down the time in life.

Bruce Kassover: Now we're going to be talking about cancer, but cancer isn't the only prostate issue that men experience. What is the sort of universe of different types of conditions or problems that men might encounter with their prostate?

Dr. Amend: Well, you know, like we were talking about, so first off, the urinary symptoms are the big one. And the reason for that is because the urethra, which drains the bladder, runs directly through the prostate. So the prostate is kind of the gatekeeper to the exit point of the bladder. And so, right off the bat, there's a lot of issues that can occur from just the ability for the prostate to obstruct that passage of urine, leading to a lot of these bothersome issues or sometimes needing patients to have catheters because they're unable to urinate because of the obstruction is so severe.

That's one of them. What can also happen is a sequela of this. Is you could have recurrent large bladder stones that can develop and the way that I talk to patients about this, it's kind of like if you have a bucket of standing water. So, you know, if I were to fill up a bucket of water and leave it outside and come back a week later, it's growing algae and mosquitoes and all sorts of nasty stuff.

And that's really the way that it is the perfect analogy for the urinary system when there's an obstruction. So if the prostate doesn't allow the bladder to fully empty, it's like that bucket of standing water. So you have what's called “urinary stasis,” that urine is stagnant inside the bladder. And as a result of that, then that can then lead to the formation of stones because there's no forward flow. Tt could also lead to recurrent urinary tract infections. So those are some downstream events that can occur in total as a result of the urinary symptoms. Some men also suffer from chronic pain as a result of what we call chronic prostatitis or pelvic pain syndrome. But I would say far and away, the urinary symptoms are the most common. 

Bruce Kassover: If you’re somebody who's experiencing some symptoms that feel like, that seem like they are related to the prostate in some way is, is there any way for a person to sort of tell what issues they might be having or how is, how is the diagnostic process taken care of?

Dr. Amend: That's the tricky thing with prostate cancer is that oftentimes it's asymptomatic until it's wildly out of control. And that's really the importance of having moments of discussion like this to spread awareness and these critical men's health issues. Because these are things that often are can be caught early and are very treatable if caught early.

But unfortunately, if the screening tests and the proper follow up and the establishment of care isn't done, then that could lead to situations where we fail to catch it early. And then maybe dealing with a situation of where we could have cured it 5, 10 years ago, but now it's more of a containment issue.

So really, to answer your question in its early stages, prostate cancer is asymptomatic, you know, it's been correlated with the development of blood in the urine, or maybe some pain, or maybe some issues passing stool, because the prostate is directly in front of the rectum. And if it, and if the cancer tumor grows large enough, it could potentially give issues with passing feces. But for the most part, it's really just detectable on either blood tests or MRIs or a digital rectal exam. 

Bruce Kassover: I've got to say that's a little, a little frightening knowing that you could have something growing that is genuinely asymptomatic. How should men care for their prostate in general and, and how often should they have things checked out by a physician?

Dr. Amend: So the AUA guidelines have gone back and forth about what is the most appropriate protocol for men to be screened for prostate cancer. The standard would be to start at the age of 55 to go to about 70 to 75 years old with a yearly digital rectal exam and a PSA. However, there are certain situations where some men may want to start earlier than 55, for example.

Prostate cancer has been correlated very strongly to a family history. It's been found to be a very genetic disease. So individuals who have a family history with their father are twice as likely to have prostate cancer themselves. If they have a brother or a sibling, I should say, that that has prostate cancer, they're four times as likely.

And those risk factors are actually additive. So if you have a brother and a father with prostate cancer, you're eight times as likely to have that cancer yourself. So depending upon family history you, you may elect to not start at 55, but maybe start at 50 or even 45. 

There are other risk factors for exposure. So for example, we have seen a number of our veterans after Vietnam exposed to Agent Orange that have had a higher rate of prostate cancer than the normal population. So in individuals who are high risk groups, we generally recommend to start screening earlier. In terms of when to stop screening, that's really a very individualized discussion.

The tricky thing about prostate cancer is that, though it's usually asymptomatic in its early stages, prostate cancer, fortunately though, is a type of cancer that, in general, is somewhat slower growing and slower progressing than most other cancers, and so what we generally advise is that men with the projected lifespan of 10 to 15 years continue to have active screening with both the PSA as well as a yearly digital rectal exam.

So then it becomes a conversation when a man gets a little bit older in life, depending upon where his PSA is, if he's in his 80s or mid 80s or heading towards 90, the utility of detecting prostate cancer in that age group as the benefits of treatment is not clear versus the risks. 

Bruce Kassover: So active monitoring. That's interesting. If I'm not – correct me if I'm mistaken – but I hear something called the “Gleason Score” that's used to sort-of give a sense of how far along your prostate cancer is. And that's used to help sort of determine the best treatment path forward. Is that correct? 

Dr. Amend: Yeah, so Gleason Score is only one of the things that we use. So in determining what's the best treatment for a diagnosis of prostate cancer, we take into account a number of factors. So the Gleason score is a, it's a measurement of how aggressive the glands of the tumor look under the microscope. It's so it's graded in a scale from a relatively benign and slow moving to something that's a highly aggressive variant and all shades of gray in between.

So we have low risk, we have intermediate risk, we have high risk disease based upon the Gleason Score, but there are also other factors that come into play. One being your PSA. If you have a very low PSA, then that's a whole different ball game with one that's a very high PSA, despite what your Gleason score necessarily shows.

In addition to that, we look under the biopsy. Usually, we take several cores. The standard is 12 cores, and we take into consideration how many of those cores are positive. Is it one core that's positive of the 12, or is it seven cores that are positive of the 12? 

We then also look at what is the percentage of each core? Is it only 5 percent of that one 12th core or is it 100%? You know, so this is this is a multifactorial algorithm that takes into consideration not only the aggressiveness of the disease from the Gleason score, but also your PSA, what's the depth of involvement in the amount of cores and the percentage of each core.

But then also some of the other things that I alluded to, you may have an aggressive prostate cancer, but if you're diagnosing it in a 90-year-old who has a fairly low PSA, you may elect to just watch it as the risks of treatment may not be worth the benefits. So the thing to understand with prostate cancer, in a nutshell, is that it's not a black-and-white manner. There's a lot of shades of gray. And that's the reason why we really advocate screening, getting folks in to be able to have these conversations because this is a disease that takes a while to grow, develop and spread. And so, because we take a lot of factors into consideration, we don't have to rush into any treatment.

No patient should feel pressure that they need to sign up for a surgery or radiation treatment or whatnot. You have time to think about it, but that also requires the proper steps to take place so that it's caught early. 

Bruce Kassover: I find that particularly reassuring, that you don't have to make immediate decisions. That's got to be something that gives men who get this diagnosis a little bit of peace of mind, considering just how frightening the “C word” is. You know, you hear “cancer” and I think the natural tendency is to sort of not hear anything else after that because it's just so frightening. I'm wondering in general, how common is prostate cancer among men?

Dr. Amend: Well, it's the most common cancer that's, you know, that’s of male origin, you know, so we, we see prostate cancer very, very commonly. And then as a result of that, we have a lot of survivors of prostate cancer because it is a disease that's very treatable if caught early. And I know we'll be talking about some of the survivorship issues in just a moment.

Bruce Kassover: Dr. Amend, you talked about screening, and you talked about having things like a digital rectal exam. This is not something that anybody looks forward to. I certainly don't want to go do that right now myself, and I can imagine that most people listening don't either. It feels, you know, embarrassing and awkward and all those other things. So can you help put my mind at ease and the minds of our listeners at ease that this is not as terrible a procedure as we might imagine it beforehand? 

Dr. Amend: Absolutely. You know, I think with a lot of the things that we do in urology in general, you know, they're very sensitive, you know, areas of the body to examine.

In my personal experience, I think that the mental anxiety is worse than what the actual patient experience undergoes. You know, I think the way to look at it is that it may be unpleasant but it's brief. And it's something that's very important for your health. So, like I had said earlier, the more proactive that you are, the easier that things will be.

So, being comfortable with your body and being in a position where you can detect and catch things early will portend better outcomes for you. But in my personal experience, I usually actually see a sigh of relief on most individuals’ faces after we conclude one of these procedures because they had this horrible mindset that it was going to be very medieval and barbaric and actually shocked at how brief and painless it really was.

Bruce Kassover: That is reassuring. You know, one of the things that we say at the National Association for Continence is that there's no shame in being human, because that's really what it's all about, you know, our bodies are natural things and everybody has one, but getting over that anxiety, that mental hump, is a challenge for so many people and that's what we're working to do is sort of remove that stigma and make it easier for people to seek out the help that can make a real difference in their health, their longevity, their wellbeing, and their happiness. But what sort of treatment options are men generally presented with once it's realized that they have to do something about their condition?

Dr. Amend: So we tailor the aggressiveness of the therapy to the aggressiveness of the disease. So there are some variants of prostate cancer when looked at under the microscope when considering the PSA.

There are some variants that are maybe slow growing and we put patients on what's called an active surveillance protocol, meaning that we don't necessarily treat it up front. We watch the tumor to make sure that it's not growing or acting in a harmful or an aggressive way that requires certain metrics to be fulfilled in order to, you know, recommend a surveillance strategy. What we find in the literature is that roughly 20 percent of men who start out on surveillance will eventually end up to go on to need some sort of definitive treatment. And so that's why we watch these individuals closely with PSA monitoring and somewhat frequent MRIs or biopsies in order to see what the tumor is doing over time.

So option number one is surveillance, if appropriate. If there is going to be treatment for the prostate cancer, treatment comes into a variety of two forms, although lately there's a third coming into play, which I'll touch base on briefly. 

The main stem treatments are surgical removal of the prostate with prostatectomy. That removes the entire prostate gland, and perhaps depending upon the aggressiveness of the disease, the lymph nodes surrounding the prostate are also removed too. The other option for treatment is that of radiation therapy, which may involve the use of what we call androgen deprivation therapy. 

I alluded to the fact that previously that the, that the prostate is very responsive to testosterone and dihydrotestosterone. So when, when the influence of testosterone is blocked on the prostate, and in addition to that, radiation used to try to eliminate the tumor in a less invasive way than surgery, those two treatments in combination can be used. There are many forms of radiation therapy. There's external beam. There's brachytherapy. There's all diff-, there's proton beam. There's a lot of different forms of radiation therapy. And so guidance from a radiation oncologist can help to determine what's the most appropriate for you. Should you choose radiation therapy? 

What's coming into play recently are newer strategies, what we call focal therapy, so rather than necessarily delivering radiation to the entire prostate gland or surgically removing the entire prostate gland, we've been starting to develop different treatment strategies to just focally intervene on just the tumor, leaving the rest of the prostate intact. This is very new, within the last couple of years, and so it's going to be exciting to see where that kind of leads us.

Bruce Kassover: Yeah, so now tell me if you if you do wind up having to get the prostate removal surgery, what is that surgery like? It doesn't sound like it's a simple procedure.

Dr. Amend: Well, you know, you know, there's no such thing as a simple surgery, you know, every single thing that we do in life has its risks and benefits, and there's certainly risks and benefits of not doing surgery, you know, but prostate cancer surgery is a very common surgery.

And so when done in the right hands is very safe. What we do currently is we use the Da Vinci robotic console. This allows us to do a minimally invasive surgery with about 5 or 6 incisions that are about a centimeter or 2 on the belly. And through those small incisions, we use laparoscopic instruments guided by the robotic console in order to remove the prostate.

The way that that is done is that the prostate is removed in the area right below the bladder. So what happens is it puts the urinary tract into discontinuity because the urethra that drains the bladder runs through the prostate. So that segment of the urethra is removed with the prostate.

And so the final part of the procedure, once the prostate is removed, is to what we call to “reanastomose” or to recreate the channel and to plug the stump of the urethra back into the bladder so that there's continuity of urine flow.

Bruce Kassover: And after you have the surgery, what is the recovery like?

Dr. Amend: Well, so, you know, from where that, from where that area is reconnected, all men will have a catheter in place usually between 1 to 2 weeks at the discretion of the surgical provider.

Also, depending upon how the surgery went, the surgery usually is a one-night stay in the hospital, although everybody heals at their own rate. So patients will go home the next day after surgery with a catheter that will be removed in the office in a couple of weeks. What we find in our experience using the robotic surgery is because it's, it's minimally invasive, individuals are able to get up, walk around. There's, there's less pain, better mobility and just a better surgical tolerance in the post operative period for folks. 

Full healing usually takes place in a course of 6 to 8 weeks. We ask that you avoid heavy, strenuous activity because we don't want any hernias over those little areas that we made incisions on the belly to put the instruments through, but most of the recovery will happen after the catheter is taken out.

Bruce Kassover: If I'm not mistaken, isn't incontinence a real issue for almost everybody who goes through this procedure for at least a few months afterwards? 

Dr. Amend: Yeah, so incontinence and sexual issues are almost normal unexpected side effects of prostate cancer treatments. The reason for this is that there is a muscular sphincteric valve that's embedded with inside the prostate and that valve closes subconsciously when your bladder is full to hold the urine  inside the bladder. So when the prostate is removed, there isn't a way to feasibly spare that muscular unit; it's removed with the prostate. And so as a result, it is, it is 100 percent expected that when the catheter is taken out a couple weeks after surgery that there will be some leakage of urine.

However, our bodies do have a backup mechanism. So you have what's called the external urinary sphincter, which is the partner unit, which you can strength train to compensate for the lack of the muscle that was removed with the prostate. So we often will send our patients to pelvic floor physical therapy.

It is very much akin to when female patients are taught to do Kegels and what you're doing is you're clenching your pelvic muscles to try to strength train that external urinary sphincter so that it could compensate for the loss of its partner unit. 

What we find is that, as with anything, rehabilitation is slow. Usually by the time a patient gets to around 6 to 9 or 12 months after surgery, we expect them to have improved continence. If that fails to occur, then we have other treatment options that I'm sure we'll get into in just a moment. 

Bruce Kassover: Maybe give us an idea of what those treatment options might be, because I'm sure that men may be concerned about what the future looks like if they have to go through this procedure.

Dr. Amend: Of course. So, like I was explaining, the origin of the problem is the loss of this muscular unit. So you physically have an anatomic defect. So, it's for that reason that treatments for this, there isn't a pill that could be given. It's not a biochemical deficiency that can be treated with a medication. It's an anatomic deficiency that is treated with a surgery. And the reason why I bring that up is because I think most patients are surprised and then are also daunted by the fact that they've just gone through a surgery to treat the cancer. And now we're facing an additional surgery to deal with the quality of life concern that comes as a result of beating the cancer.

However, devices have been created that are on the market that simulate the action of that lost sphincteric unit. Boston Scientific, which is the parent company of American Medical Systems, has developed what's called the artificial urinary sphincter. So what this is, is it is an implanted device that acts as an internalized clamp around the urethra.

So it's a multi-component system where the clamp is surgically placed around the urethra and it provides 360 degree compression of the urethra, in essence, to shut it off and to regain continence to stop the leakage. Now, that's going to result in the bladder filling. So in order to open the clamp to allow for voiding, there's a small control pump that's placed underneath the skin of the scrotum.

It's about the size of like your pinky. And there's a button on that where you would press the button to open the valve, allow for adequate urination, and the system will automatically reclose itself down in about 60 to 90 seconds to then regain the confidence. There's another device, it's called the urethral sling.

That's works a little bit different than the artificial urinary sphincter. It supports the urethra and puts a kink in the system to then, with that restriction of flow, makes urine leakage less likely. Generally, what we do is, in terms of figuring out what is the best procedure for the patient, again, it's a multifactorial decision, but it's heavily weighted on the amount of incontinence. There's different levels of incontinence between mild, moderate, and severe, and that's usually dependent upon how many pads or pull ups or diapers or underwear changes that the patient has and how it's affecting their life.

But generally speaking, for mild-to-moderate incontinence, patients are usually offered a sling versus moderate-to-severe is usually the artificial urinary sphincter. But of course, that's just a general guideline. Those things could change depending upon patient factors. 

Bruce Kassover: How common is the need for one of these follow up procedures after prostate surgery initially?

Dr. Amend: Statistically speaking, roughly 10%. So historically, what's been offered is that we will usually advise a patient that if they get to about 12 months after their prostate cancer surgery and they still have bothersome urinary leakage, despite conservative measures like the pelvic floor physical therapy and the strength training that I discussed earlier, that's when we usually start to talk about one of these devices. However, in my particular experience, we've been doing some studies on this really show that you could start to offer these, these interventions to patients as early as six months after the initial prostate cancer surgery.

Bruce Kassover: Oh, very good. Now you mentioned that in addition to the incontinence side effects, there are also potential sexual side effects as well. Can you tell us a little bit about those? 

Dr. Amend: Sure. So, again, these are these are almost expected. The reason for that is the major blood vessels and nerves that govern erections, they course right along the sides of the prostate. And so often what happens is, is that in the case of the surgery, those blood vessels and nerves are tried to be carefully peeled off the prostate very much akin to, you know, you're trying to peel different layers of an onion off. 

Now, ultimately speaking, some degree of neurovascular damage will occur and that's really no fault of the surgeon per se. It's just a matter of, you know, of the nature of the surgery and the nature of the disease. And so as a result of that neurovascular damage, there could be some issues with erections. 

Bruce Kassover: Okay, that that, of course, is something that I'm sure men will be very interested in hearing about as they consider their treatment options. But I suppose dealing with that is better than dealing with the consequences of untreated cancer. 

Dr. Amend: Absolutely. You know, like I said, there's a, there's trade offs to everything, you know, so there's, there's trade offs to, you know, to having procedures performed, there's tradeoffs to the surgery, there's tradeoffs to radiation therapy, and there's tradeoffs to doing nothing.

And so that's what really the guidance of an experienced urologist, particularly someone who is experienced with prostate cancer therapies, can help to guide that discussion, whether treatment is right for you. And in that case, what form of treatment is right for you. 

Bruce Kassover: Now this is a really good overview of a lot of the issues related to prostate cancer, prostate care. If I'm not mistaken, you recently did a really detailed webinar in cooperation with Boston Scientific, which is the medical device manufacturer you were just talking about. And we actually have that webinar available for people who'd like to learn a little bit more up on the NAFC website.

We're going to add a link in the show notes so anybody can take a look at that and see your more detailed discussion of it. But I'm wondering, is there anything from that webinar that you think we haven't addressed today that really ought to be, that we ought to speak to now?

Dr. Amend: Yeah, you know, I think that one of the things that we could certainly talk about a little bit is you know, not only the effect that the surgery has, but also some of the effects of the radiation, too. You know, I think it's important to distinguish the different types of incontinence because they have different treatments associated with them.

So, like I was saying that, you know, after the surgery, the muscular unit is removed, and so therefore it's the lack of an anatomic unit. Men who have radiation therapy, they suffer from a different type of incontinence. This is what we call urge incontinence, or it's often from bladder overactivity.

And the reason why that's different is because what happens in radiation is that the radiation cloud is delivered to the bladder because of the proximity for the prostate being beneath it. And so while the prostate is not removed and therefore that muscular valve is still there, what can happen is that the radiation changes that impact, the bladder can lead to issues with bladder overactivity, constantly feeling like, you know, the patient has to go to the bathroom and also leading to, importantly, diminished bladder capacity.

So as a result, the usual individual may, usually will feel the need to urinate when the bladder gets to be about half a liter full. But in situations where an individual has had radiation, the bladder might not be able to hold half a liter anymore. It might be a quarter a liter or 300 cc's. And so as a result, you know, we have patients who suffer from what's called urge incontinence that is the result that the bladder physically can't hold any more urine and then automatically triggers a strong urgency, which then leads an individual to have to rush to the bathroom and maybe can make it on time.

So, while radiation therapy and surgery will cause incontinence, the nature of that incontinence is different, and so, therefore, the therapy for that incontinence is different. 

Bruce Kassover: So, if you're somebody who is potentially concerned that you may be having issues with your prostate, what do you recommend is their first or their next move? What should they be doing?

Dr. Amend: Well, really what they should be doing is they should be at least visiting with their primary care doctor for a screening PSA and rectal exam on a yearly basis. If there's any abnormality seen in the PSA or on the exam, or if they have a lot of bothersome urinary symptoms, the next step would really be to meet with the urologist for a more thorough, in-depth consultation.

Steve Gregg: Dr. Amend, as you were talking about post surgery and seeing a physical therapist, a pelvic floor physical therapist, is there anything a patient could or should be doing prior to going into surgery? 

Dr. Amend: Yeah, Steve, I think you, you bring up a great point there. Studies have actually shown that in individuals who start the pelvic floor physical therapy and the Kegels before surgery portends greater outcomes.

And I, I'm not sure if that's necessarily because you have more time to strength train the prostate and the pelvic floor, or if it's because you already have some experience on the, under your belt in terms of how to do the exercises correctly. And so therefore you really hit the ground running versus, you know, undergoing the, the learning curve after surgery.

But certainly the data is very clear that doing those things in advance are helpful. It, you know, I get a lot of questions from patients about what sort of things they can be doing, you know, to help prepare themselves for these types of procedures. And really the way to look at it is that, anything that's good for your general health and wellness, proper diet, proper exercise, proper sleep, stress reduction, any of those things will ultimately help you in your journey after these therapies.

One thing that I didn't touch on is actually the importance of the obesity epidemic with these incontinence issues. Because of the nature of what we call stress urinary incontinence, the type of incontinence where you're physically missing that muscular valve that's removed with the prostate. So what happens is, is that because that valve is not there to contract when you cough, laugh, sneeze, bend over, pick up a grandchild, that can cause some leakage because you're just putting more pressure on the bladder.

So therefore, the heavier that a patient is, the more pressure that's on the bladder just on a daily basis. So we find that individuals who are thinner, more physically fit, and are carrying less abdominal fat, do better in terms of their amount of leakage after going through one of these surgeries.

Steve Gregg: That's really great to know. We hear something similar to women prior to giving birth that if they actually do pelvic floor exercises, their recovery goes often smoother or easier, however, you want to define that, and their likelihood to leak or transitionally leak seems to be somewhat reduced. So it's good to hear that men can do something very similar if they actually just do them and do them correctly.

Dr. Amend: Absolutely. And that's where I think is the importance of the physical therapy. Because I have a lot of patients who just kind of feel like they can do it on their own. And while that may be true to a certain extent, I think the advantage of the physical therapist is that they put certain monitors and systems onto your, your specific pelvic floor muscular groups.

And so they could actually measure the contractions of a particular muscle unit to make sure that you're not only targeting the right muscles, but you're also applying the right amount of force to have a productive session. So I strongly recommend a formal pelvic floor physical therapy for any patient undergoing prostate cancer treatments.

Steve Gregg: Dr. Amend, you mentioned patients that have gone through a prostate surgery are often very apprehensive about a second surgery. And that's pretty common sense, one would think. Can you talk a little bit about their thought process of how they reconcile what the second surgery would be like, and then any thoughts you have about levels of satisfaction based on patient outcomes? “So I was really worried about having a second surgery. How do I make the decision? And then after I've had the surgery, How do I feel about it?”

Dr. Amend: Absolutely. So these devices have been around for a long time. There has been several iterations to these products. So, as a result, we have a lot of really good outcomes-based data in terms of patient satisfaction scores.

Not only does the literature show well over 90 percent satisfaction with these devices, but my own personal experience is that patients who were initially apprehensive will often say that they wish they had done this sooner because these are really significant quality of life issues that, though it does seem daunting to undergo another surgery, usually some of these procedures is quicker. These are same day procedures. They're procedures that take less than half the time, if not a quarter of the time, of the initial prostate cancer surgery. And there are, though, and these procedures are associated with quicker recoveries. So all those in combined, my personal experience that patients are very happy with them.

And I do find that it's very helpful to be able to talk to other prostate cancer survivors with their experience with these things. So, for example, in my practice, I have patient advocates who have gone through the process and are willing to share their experience going through these procedures and the recovery with prospective patients.

And I think that that helps to ease everybody's, you know, frame of reference and to, you know, certainly make the transition to having one of these procedures a little bit easier knowing what other people have gone through in the future. 

Steve Gregg: Well that’s really terrific. Is there anything that you can think that NAFC could do to help support those efforts, either, helping them understand going into surgery or helping them understand the process coming out of surgery? Is there anything that you think we should be more focused on than what we're currently doing today? 

Dr. Amend: Absolutely. I think really awareness is the biggie, right? So the issue that I currently run into in patients that I see as new consultations for either erectile dysfunction or incontinence after prostate cancer therapies is a couple of things: Number one is that a lot of these patients are surprised that these outcomes have occurred despite how common these side effects are, so I think patient counseling and patient awareness of up front, knowing that these are expected side effects, is extremely important, so that folks are not caught off guard when these common things are occurring.

And in addition to that, number two is knowing that there are good treatment options available. I can't tell you the number of folks who struggle with these issues for 5, 10, 15, even 20 years, not knowing that there are good treatments available for these issues. So I think that that takes a concerted effort amongst providers who may not be reconstructive urologists, but at least have a good initial understanding of what these more sophisticated treatments are, and all of it should be aimed towards improving the patient experience through awareness.

So I think that if individuals understand fully the ins and outs of what they're getting involved into as a result of undergoing one of these treatments, that then they could already be in a mindset and empowered with the knowledge of what the different options are, should they experience one of these complications.

Steve Gregg: That's really good advice. Thank you very much. We'll make a concerted effort to make sure we help raise awareness of this. 

Bruce Kassover: Excellent. So, Dr. Amend, as you know, the name of the podcast is “Life Without Leaks.” And oftentimes when we end the podcast, we like to ask the experts that we're speaking with to share with us their one best hint or tip for patients to help them live a life without leaks. And I'm wondering if maybe you can share your thoughts from a perspective of male health and prostate health, what your single best piece of advice might be. 

Dr. Amend: My single best piece of advice to any patient is to screen early and be aggressive and proactive about your health. Don't wait for it to be a problem because, like we talked about, prostate issues are generally things that are slowly progressing and give you time to figure out what the best course of treatments are.

If you are proactive about making sure that you're doing the proper screening procedures and that you're checking in with your primary care doctor so that if something is caught, it's caught early, the earlier you catch something, the easier the procedure will be, the easier the recovery will be, and the more likely the opportunity will be that you'll be in that 90 percent of individuals who have good continence 6 months to 12 months out after the prostate cancer has been treated.

But if you're in a position where the tumor is more aggressive, there's a larger tumor bulk, and there's more surgical manipulation that has to be done, the more procedural support that's needed to remove the tumor, the more side effects that will naturally come from it. So, as with anything, prevention is really the key to this.

Bruce Kassover: Outstanding advice indeed. We appreciate it and thank you for joining us today.

Dr. Amend: It's been a pleasure.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin MacLeod. More information about NAFC is available online at NAFC.org.