This will be an intensely personal post. There is no delicate way to describe what took place during the prostate biopsy. If you came to this blog expecting something else, you might want to take a break from reading this now, head over to the archives, and wait until the more characteristic posts make a comeback.
A Bit More Waiting
You can read a lot about the procedure that is technically known as transrectal ultrasound-guided prostate biopsy on WebMD and the many good sites that have written about men’s health and prostate cancer. Most of them will say that it “doesn’t hurt much,” that it’s “not so bad.” But, “doesn’t hurt much” and “not so bad” only seemed to mock me. Despite the vast amount of information I had accumulated over the previous ten days, I am wading deep into the unknown, nearly drowning in a mix of fear and anxiety. As I drove the thirty minutes to the office I’m thinking about the needles. Upon checking in I am shown into a standard exam room by an efficient but very kind nurse who checks my vital signs and goes over a list of questions about my medical history. Then she explains everything that is going to happen from that point forward. Her calm, deliberate, two-minute speech drains away some of the fear that has been washing over me in waves. The nurse leaves, and following her directions I get naked. I put on a hospital gown so it opens in the back and have a seat on the exam table as I wait for the doctor. I’ve been told it will be about ten minutes. This exam room has two carts set up with monitors and keyboards. The nurse has one powered up and sitting next to the exam table. I recognize the image on the screen as the pie-wedge that will display an ultrasound image. But it is the wand clipped in readiness on the side of of the cart that gets my attention. The business end is about eight inches long and about the diameter of a roll of nickles. The doctor is obviously an advocate of safe sex as the wand is sheathed in a form-fitting condom. From my reading, and the nurses’ explanation, the wand will be used to get an ultrasound image of my prostate gland and map where the doctor will take his biopsy. That’s okay. What sets off alarms is the very slim metal tube that runs down the length of the wand. I start to go into meltdown as my forced-calm exterior gives way to the anxiety within. The metal tube indicates the ultrasound wand’s second use: to guide the placement of the biopsy needles. One at a time, a dozen needles will be shot down that metal tube by a spring-loaded biopsy gun, through the wall of my rectum to snatch and bits of tissue I wasn’t all so sure I wanted to surrender. “Good afternoon, Mr. Kinnaman,” says Dr. de la Paz as he offers me his ungloved hand. “How are you feeling?” Summoning a weak smile: “A little nervous, but not too bad, I guess.” He sees right through my bluff and gives me a pat on the shoulder as he makes his way around the table. The nurse takes over. She gets me into position on my left side and has me draw my knees up toward my chest in a loose fetal position. She positions pillows for me, the last one between my knees. All the action is set to go on behind me, and the strategically placed opening in the hospital gown now exposes to the doctor what I would really rather lock-down and hide.
“Okay, now relax.”
The doctor begins by performing a digital exam of the prostate. This is a good bit more aggressive than the standard annual exam. If feels like he’s trying to get to the front side of the gland as well as the back. “Okay, Mr. Kinnaman, now I need you to relax.” As I try my best to follow his direction, he inserts the ultrasound probe. So far so good. The tip of the ultrasound wand assaults my prostrate and, it feels like, a whole lot more. If I didn’t have a clue where my prostate was, I certainly do now. While not painful, it was decidedly uncomfortable “Mr, Kinnaman, you doing okay?” I evidently mumbled, because he asked again a little more urgently. I realized that not only was my butt going to act as host for the doctor’s ministrations, I was going to need to further participate by responding to de la Paz during the procedure. “Mr. Kinnaman, your going to feel a little pinch.” And with that comes several shots of Novocaine, or some such numbing agent, right into the prostate. De la Paz’ assessment of a “little pinch” from each injection is pretty accurate and I felt four little pinches before things became comfortably numb. I find my anxiety growing instead of fading. De la Paz uses the ultrasound wand to take several measurements and pictures. The wand is moved left and right, up and down. I didn’t know my anus can move in so many different directions. The doctor informs me that my prostate weighs 25 grams, about 5 grams more than he would like to see “for a man your age.” Then there is a break in the action. The doctor and nurse are consulting. The moment draws near when the biopsy needles will do their work, all pretense of relaxing “back there” is shot; I take a few deep breathes and try to ignore the technical exchanges between the doctor and nurse. “Ok, Mr. Kinnaman,” he says, “you’re going to feel another little pinch.” Every move he makes is accompanied by grip and release, grip and release. I am nearly out of control with fear. “Shathunk.” I manage to avoid screaming-out in surprise and anxiety. The spring-loaded needle gun sounds like a staple gun being fired behind me. There is definitely pressure from the needle as it pierces the rectum wall, the prostate and then makes it’s hasty exit, but there is no pain. Oh, thank you, God, for creating Novocaine! As the second, third, and fourth, and the rest are announced I begin to breathe easier. “Shathunk,” now means we are getting closer to being done. “Shathunks” eight through twelve, feel decidedly different. When announcing these Doctor de la Paz said they were at the apex of the prostate. By the time he is done, 12 specimens have been collected. When it’s over, the doctor comes around to the front of the table and shows me couple of pictures of my prostate and says that I should hear from him within a week. If it is positive, he’ll see me in two weeks, if it is negative, I have an appointment in three months. From the time he came in to the time he departed it has been 18 minutes. The nurse has me get up slowly and watches me to make sure I don’t roll off the back of the table. Left to myself, I wash antiseptic and lubricant gel from the work zone and change back into my own clothes. From what I read on the post-op paperwork I was handed, this won’t be the only blood I see back there over the next couple of days. By the time I step off the elevator in the lobby, I am breathing normally. Other posts in the Prostate Cancer Journal can be found under Categories in the sidebar of this blog.
I have come across some other interesting post on the subject of the transrectal ultrasound-guided prostate biopsy. While my procedure was decidedly uncomfortable, it was not painful. My anxiety and fear of the unknown was greatly worse than what I experienced in the hands of my doctor. And this is a point that I have learned along the way (now five weeks after the biopsy), there is NO substitute for doctors with skill and experience. Seek them out, and then as your own journey progresses, ask these trusted men and women who they would want to see for the “whatever” that is the next procedure . If all else fails, or your anxiety will keep you from doing what is necessary, Henry Morgenstein’s post, Prostate Biopsy, might give you some options. This post gives a fairly unvarnished blow-by-blow. I like his line, “Fear Factor is a 10, actual procedure is a 2.” That is pretty much it. Herb Greenberg’s blog post brings up another good point. There is no better advocate for your medical treatment than an informed patient. While this post from Ron Kaufman is about his whole prostate cancer journey, his experience of the biopsy is very much what I have heard others say. What I think is very useful are these two paragraphs about early detection:
Friday, April 19 was another milestone day. The results of the pathology came back. Was I to be listed as cured, or did the cancer get away from the prostate, and was I looking at radiation, chemo, or more surgery. It was close. Everything came back perfect. The cancer had come within 1 millimeter of breaking out of the prostate, but in fact had been caught in time. Time. If there is any message that can spell the difference between success and anything else in the detection of this cancer, it is being tested early and annually, and acting quickly once cancer has been found. One millimeter, a few human hairs of tissue thick, was all that remained between me being cured, and a survivor, and my ongoing war with cancer.