The following are definitions of some medical terms used in this dark profession of Urology.  So dark in fact, that it has been described as the color of a bruised crow at midnight.  Also included are some Gray - isms these are the authors own definitions of some of the terms he has devised after his experiences.  These are written in italics.
Acute  Reaching a crisis rapidly; or suddenly.
 

    Androgen  Any hormone that produces male physical characteristics such as     facial hair and a deep voice.
    Anesthesia  A loss of feeling or sensation in the body.
    Anesthesiologist  A physician trained to provide a pain - free state for        

    patients during surgery.
    Anus  The opening at the lower end of the rectum for the elimination of solid     waste.

    Ampulla  A dilation in a canal or duct.
    Artificial urinary sphincter  A prosthesis designed to restore continence in 

A bad attack of the                                                   an incontinent patient.
      Androgens            Aspiration  The removal of fluids and gases using a suction device.
                                     Aspiration  The hope that some people have of becoming a writer.
Bacterial prostatitus  Infection of the prostate gland caused by bacteria.
Benign  A tumor that is non cancerous and dose not normally threaten a persons life.
Benign prostate hypertrophy ( BHP )  Nonmalignant but abnormal multiplication of the prostate cells.

Biopsy  The removal or harvesting of tissue for microscopic examination to establish a diagnosis.
Bladder  The hollow organ or sack that is used to store urine.
Cancer  A tumor with abnormal cells that grow and divide without control. Cancer cells can spread to other parts of the body and can be fatal if not treated in time.
Capsule  The outer layer of the cells around an organ such as the prostate.
Catheter  A flexible tube that passes through the urethra and into the bladder in order to drain urine.
Catheter  A device designed by a urologist to intimidate patients and to ensure payment for their services.
                    Catscan

 
Cat scan  This is a computerized diagnostic technique that uses X rays to obtain a high resolution image of the body such as the prostate.
Cat .scan  When you can’t find the kitten.
Chemotherapy  A treatment of drugs that attack the cancer cells.
Clinical trials  Studies on patients to determine the effectiveness of new drugs and procdures.
Clinical Trials  Something you experience every time you go to see the urologist.
Cystoscopy  The internal examination of the bladder using        

                                                        cystoscope.
                                                        Cystoscopy  Something to be avoided at all costs.

                   Clinical Trials

Digital rectal examination (DRE)  An examination of the prostate by a doctor using a well lubricated gloved finger inserted into the rectum.  Hint: Get him to use two fingers, then you can get a second opinion for free. 
Ejaculate  To eject sperms and seminal fluid.
Erection  The enlargement of the penis when it becomes filled with blood.
Estrogen  A female sex hormone made in the ovaries.
External radiation therapy  Radiation therapy using rays from a machine directed to specific parts of the body. i.e. the prostate.
External radiation therapy  Using a cell phone for extended periods of time.
False Negative  The erroneous results of a test when it is reported negative.
False negative  Advice from a stockbroker.
False positive  The erroneous results of a test when it is reported positive but is really negative.
False positive  Advice from a lawyer.
Foley catheter  A catheter that is placed into the bladder, and kept in place by inflating a balloon with water.
Foley - Catheter  The wife of the former leader of the House of Representatives?
Genitals  The male and female reproductive organs.
Hematuria  Blood in the urine stream.

Hormone therapy  As used in prostate cancer, the treatment that interferes with the production and or   

           I want to get a second opinion               activity of the male hormones that promote prostate                                                                              cancer growth.
Impotence  The inability to have a natural erection.
Impo-tence  If you live in the South, its anything your wife wants you to do.
Incontinence  Loss of urinary control.
Incontinence  This means that you are not at sea. But you are standing on one of the five largest land masses.
Interstitial radiation therapy  Treatment with high energy radiation from tiny radioactive seeds inserted into the prostate gland.
Luteinizing hormone  This hormone, called LH, is secreted by the pituitary gland.  It stimulates the secretion of sex hormones in both men and women.
Lymph  A nearly clear liquid collected from tissues around the body and returned to the blood stream by the lymphatic system.  
Lymphatic System  Vessels that carry lymph are part of the system.  Other parts include lymph nodes and several organs that produce and store infection fighting cells.
Lymph nodes  Small bean shaped structures throughout the body that act as filters to filter out bacteria and cancer cells that travel through the lymphatic system.  They are often a common site for cancer to spread.
Male hormones  Substance produced by the testes and other glands that are responsible for the male sexual characteristics.
Malignant  A cancerous tumor that threaten a person’s life.
Metastases cancer  A cancer that has spread from the original organ to another part of the body.
Needle biopsy  Specimens of tissue optioned ( harvested ) using a special needle.
Nocturia  Awakened at night by the desire to urinate.
 
Nodule  A small lump, generally malignant.  This is not to be confused with the Chinese noodle.  
Oncologist  A specialist in the treatment of cancer.
Orchiectomy  The surgical removal of the testicles, the major source of the male hormones.
Orgasm  The climax of the sexual  act.
Pathologist  A specialist in the diagnosis of disease by studying cells and tissues with a microscope.
              A Nodule                Pathologist  Someone who designs and builds roads.
                                              Penile prosthesis  A material that is inserted into the spongy area of the                                               penis so as to make the penis rigid enough for vaginal penetration.
Perineal prostatectomy  An operation to remove the prostate through an incision made in the perineum, the area between the scrotum and the anus.
Pituitary gland  A small gland located at the base of the brain.  It produces a variety of the hormones that stimulate the testicles.
Potency  The ability for a man to achieve and maintain an erection sufficient for vaginal penetration.
 
Proctalgia Fugax  The literal translation from Latin means “A fleeting pain in the arse”.  Having been a victim to this occurrence, the author can attest to the accuracy of this translation.
Prostate  The prostate gland is about the size of a walnut or a squash ball. It surrounds the neck of the bladder at one end of the urethra.  It secretes fluid that is part of the semen.
Prostatectomty  The surgical removal of the prostate.
Prostate Specific Antigen (PSA)  A substance in the blood that often increases in the cases of prostate cancer and other prostate related diseases.  This is not to be confused with BSA  ( The Birmingham Small Arms Co. )  a manufacture of motor cycles and guns.   
Radiation therapy  A treatment using energy rays such as those from x - rays or other sources of radiation.
Radical prostatectomy  See Prostatectomy.                  
Rectum  The last few inches of the intestine to the outside of the body.
Resection (transurethral)  The removal of obstructive BPH prostate tissue done through the urethra.  
Retropubic prostatectomy  The operation to remove the prostate gland through an incision made in the lower part of the abdomen.
        Proctalgia Fugax            Scan  Computerized picture of an organ such as the prostate.
                                              Scrotum  The external sac or pouch, containing the testicles.
 
Semen  A thick whitish liquid that contains spermatozoa.  It is mixed with secretions from the prostate.
Seminal vesicles  Pouches above the prostate that store semen.
Spermatozoa  Male cells produced by the testicles capable of fertilizing the ovum, the female sex cell.
Spermatozoa  When semen drops on your toes.
Sphincter  The ring like muscle that a man voluntarily contracts to shut off his urinary system.

Sphincter  A famous structure in Egypt build next to the pyramids.
Spongy bodies  The two corpora cavernosa, which are the structures                  Spermatozoa             within the penis that become enlarged with blood during an erection.
                                              Stage  A term used to describe the size and extent of the spread of        

                                              cancer.
Stage (Special)  A section in a car rally were the winner covers the distance in the least amount of time.
Sterile  Unable to produce children.
Testicles  The two egg-shaped glands that produce sperm and the sex hormones.  Also known as testes.
Testosterone  The male sex hormone produced mainly by the testicles, stimulates a man’s sexual activity and the growth of other sex organs including the prostate.
Tissue  A group of cells organized to perform a specific function.
Tumor  An excessive growth of cells resulting from uncontrolled cell replacement.  Tumors can be either benign or malignant.
 
Ultrasound  A computer image that uses high-frequency sound waves to examine parts of the body such as the prostate.
Ultrasound  Comes from the high performance amplifiers produced by my good friends at QSC.
Ureter  The tube that carries urine from the kidneys to the bladder.
Urethra  The tube running through the penis from the bladder to the outside of the body.
Urine  The waste fluid excreted by the kidneys and stored in the bladder and expelled through the urethra.
Urologist  A specialist in the diseases of the male sex organs and in the diseases of the urinary organs in both men and women.
Watchful waiting  When a prostate cancer is simply watched by the doctor.

                       Ultrasound
 

The Incidence of Prostate Cancer.

Prostate cancer is the single most common non-skin malignancy for men in the United States. In 1996 there were approximately 317,000 reported new cases. Prostate cancer is the second most common cause of cancer deaths in men, second only to lung cancer with 41,000 deaths in 1996.  When we review the epidemiology of prostate cancer, we note that the prostate specific mortality is increasing at 1% globally yet there are predictions that in the United States there may be as much as a 37% increase in the Prostate cancer specific mortality by the year 2,000.  The reasons for this rapid increase mortality are varied.  One principle cause includes the changes in the demographics of the male population in the United States.  As the male population experiences a decline in the incidence of death from other diseases, many more men will live to an older age where prostate cancer is more prevalent.  Specifically, as the mortality from cardiovascular disease declines, we will see an increase in the life expectancy of American men.  It will be many of these men who will now be at a higher risk of morbidity and mortality due to prostate cancer.  
    

It was 1937 when the first tumor registries were started, which recorded the incidences of the different forms of cancer in the United States. In that year there were 30,000 newly diagnosed cases of prostate cancer reported. By 1950 the incidence of newly reported cases was 50,000. By 1973 it had climbed to 60,000. There was a steady yearly increase with 122,000 cases reported in 1991. It was in 1993 that we saw the first introduction of prostate specific antigen screening (PSA), and in that year there were 165,000 new cases of prostate cancer reported.  This trend continued, and in 1994,1995, and 1996 there were 200,000; 250,000; and 317,000 new cases of prostate cancer reported.  There is no debate that the use of digital rectal examination combined with the use of serum PSA testing has increased the detection of prostate cancer in this country. It is interesting to note however that the increase in prostate cancer cases began in 1950, well before the advent of the serum PSA testing.    
    

The incidence of prostate cancer varies in different regions of the world. Prostate cancer incidence in North America and Europe (Switzerland and Norway ) is far higher than in other parts of the world.  Conversely, the incidence of prostate cancer in Africa and Asia is comparably low when compared with other regions of the world. It is important to note that as populations migrate from low risk to areas to higher risk areas of prostate cancer, they increase their risk of developing the disease.  For example, the incidence of prostate cancer found in Africans is approximately 4 cases per 100,000 men. The incidence of prostate cancer found in African American men in the United States is approximately 160 cases per 100,000 men, a forty fold increase.  A similar trend is noted in reviewing the cases of prostate cancer in Asian men. The incidence of the disease in Asia is approximately 6 cases per 100,000 men, while the comparable measures of Asian American men is approximately 40 cases per 100,000 men. On Hawaii, halfway between the U.S. mainland and the Asian continent the incidence of prostate cancer for Asian American men living on the islands is 20 cases per 100,000 men.
    

The incidence of prostate cancer varies in different parts of the United States. For example, California has the highest number of newly reported cases of prostate cancer in the country.  Additionally, California has the highest number of prostate cancer deaths per year with an average of 24 deaths per 100,000 men. (U.S. average is 17/100,000).  The prostate cancer specific mortality; i.e. the number of men who actually die from the disease each year, ranks California higher than Sweden and Norway which have the highest prostate specific mortality in the world, those nations both experiencing approximately 22 deaths per 100,000 men.
    

Additionally, the incidence of prostate cancer varies among the different ethnic groups in the United States. It is generally accepted that the incidence of prostate cancer is almost 40% higher, stage by stage, among African American men versus Caucasian men. Hispanic men have a slightly lower rate than Caucasians men. The lowest rate of prostate cancer in the U.S. occurs in Asian American men, who generally have a 4 fold decrease in prostate cancer rate when compared with African American men.  Prostate cancer specific mortality tend to follow the same trends.  For example in Santa Clara County from 1988 to 1991 the specific mortality among African American men, was 59 deaths per 100,000 men. The prostate cancer death rate for Caucasian men, Hispanic men and Asian men in the county was 24,19 and 13 respectively. Compare these statistics with Japan and Africa where the prostate cancer specific mortality is approximately 4 deaths per 100,000. Note also, that the prostate cancer specific mortality among African American and Caucasian men in Santa Clara County is higher than the highest country in the world (Sweden, with 22 cases per 100,000 men).

Etiology of Prostate Cancer     

The underlying cause(s) for the development of prostate cancer is still unknown.  As the search continues to define the etiology of prostate cancer, it becomes clear that there are likely multi-variant factors involved in the development of the disease. These factors will likely involve both host factors as well as environmental factors.
    

The most reliable host factor critical in the development of prostate cancer is age. Ninety nine percent of the men affected with clinically significant (detectable) prostate cancer are age 50 years and older. There is also an increase in the presence of prostate cancer as a man ages.  For instance, in many autopsy series where prostates were examined from men who had died of
other causes, as many as 40% of the men by the age of 70 years had at least one focus of low grade prostate cancer present in the specimens reviewed.
    

Benign Prostate Hypertrophy (BPH) is a non life threatening form of overgrowth of the prostate gland.  BPH tends to occur in men over 50 years of age. BPH may also present many of the same symptoms of prostate cancer.  However, it is important to note, however, that BPH is not a precursor for the development of prostate cancer.
 
   

Reviewing the incidence and behavior of prostate cancer highlights the importance of the host race in the development of the disease. The reason for these ethnic variations in this disease are yet unknown. The answer may turn out to be different ethnic predilections for the chromosomal deletions known to be related to the development of prostate cancer. In 1993 Dr. Patrick Walsh at John Hopkins University documented the cases of men with prostate cancer directly under genetic influence. Men affected in this study group had an autosomal dominant transmission pattern for the development of prostate cancer. It is believed that as much as 4% of prostate cancer is transmitted this way. The vast majority of prostate cancer cases, however, occur without predictable antecedent genetic patterns. Additionally, it is known that if a man has a first degree relative affected (i.e. father or brother) that there is a three fold increase in the incidence of prostate cancer. There may also be ethnic difference in the immune systems response to these developing tumors which could account for both the differences in the incidence and behavior of this disease in different groups. This hypothesis is still in its testing stage.

Environmental factors which might play a role in the development of prostate cancer are many. The factor which has been consistently found to be a key in the development of prostate cancer is the ingestion of dietary fat. In populations where the ingestion of dietary fat is high, there is a higher incidence of prostate cancer. For example, if one plots the fat intake per capita by country against prostate cancer incidence we see that the higher fat-intake countries tend to have higher incidence of prostate cancer, as well as a higher prostate cancer specific mortality. What is interesting is that Japan, which has a low incidence of prostate cancer, has its highest incidence in the Kobe region, where the diet has been Westernized. It is not specially known exactly what quantities of dietary fat is needed to increase the risk of prostate cancer. It has been documented that laboratory animals fed a controlled low and high fat diets, that the animals fed high fat diets, develop prostate cancer at a higher rate.
    

The environment as a factor for the development of prostate cancer is underscored by regional differences in the incidence of prostate cancer. There have been no conclusive studies which identify any category of environmental substance(s) which are causative in the development of prostate cancer. Studies of cadmium (used in the production of batteries) have not proven a link to the development of prostate cancer. Zinc, which has its highest concentration in the body in the prostate gland, has also not been found to be causative in the development of prostate cancer. As prostate cancer is most likely related to the host environment interplay, it will be exceedingly difficult to isolate any single environment promoter for the development of prostate cancer.  

The Prostate Gland.
    
The prostate gland is a soft tissue organ which is located at the base of the bladder. Its major contribution is the provision of 90% of the ejaculatory fluids. The principle function of the ejaculatory fluid is to provide energy sources in the form of complex sugars to the ejaculate to nourish sperm. The ejaculate also provides liquefying enzymes which facilitates migration of sperm through the vaginal and cervical canals.       
                              
The prostate gland is composed of two major regions. The outermost region of the prostate gland is the capsule. The capsule consists of primary smooth muscle cells. It is in the capsule of the prostate gland that most (95%) prostate cancer originate (see Fig 1). The central region of the prostate gland is the transition zone. The transition zone is composed of two principle cell types. The smooth muscle cells, and the glandular epithelial cells. It is the overgrowth of these two cell types which are largely responsible for the development of BPH.    
    

The signs and symptoms of both prostate cancer and BPH are very similar, due to the similar position of the involved prostate gland on the outflow of urine. The symptoms are referred to as obstructive voiding symptoms. Since BPH remains more prevalent than prostate cancer, the vast majority of men with obstructive voiding symptoms will develop their symptoms on the basis of BPH rather than prostate cancer.
    

The position of the prostate gland in the low pelvis in front of (anterior to) the rectum allows easy examination of the gland during a physical exam. This position of the prostate gland also allows easy access for imaging with ultrasound probes and biopsy studies

Symptoms and Signs of Prostate Cancer. 

In the majority of men, the detection of prostate cancer occure in men who are asymptomatic. Those men who are present with the symptoms generally complain of a decreased urinary stream. The affected men may also have urinary urgency, urinary frequency or increase in nighttime voiding (nocturia).
   

When prostate cancer has spread beyond the confines of the prostate gland, the patient will show signs of fatigue, weakness and diffuse bony pain. The most important physical sign of prostate cancer is an abnormality in the prostate examination. The test performed by physicians to examine the prostate gland is called the digital rectal examination (DRE). The prostate gland should feel like the consistency of the palm of the hand. If the prostate has a nodule, an area of firmness or is asymmetrical, these represent changes in the gland that should be investigated. The primary care physicians now focus on these changes in the gland consistency, and have improved the detection of prostate cancer.
   

The vast majority of prostate cancer patients have little or no symptoms of the disease. Men who present with prostate cancer which is still confined to the prostate gland will present with obstructive voiding symptoms. These symptoms include a decreased force of their urinary stream, urinary urgency and frequency as well as incomplete bladder emptying with voiding. They may also notice that it takes a longer period of time to get their stream started, so called hesitancy. Men who are affected by prostate cancer which has already spread beyond the confines of the prostate gland may additionally experience easy fatigue, weakness and bony pain.         


Diagnostic Test.

The most important test in the early detection of prostate cancer is measurement of the serum prostate specific antigen (PSA). PSA is an enzyme which is made by glandular epithelial cells of the prostate gland.  It is released into the bloodstream in the presence and absence of prostate cancer. When prostate cancer is suspected, the release of the PSA into the bloodstream is increased. The normal range of PSA is 0.0-4.0 ng/dl. When the serum PSA is higher than 4.0 ng/dl, one possible cause is prostate cancer. Other causes for the increase in the release of PSA are BPH, prostate infection, prostate infraction, prostate stones, prostate manipulation, and ejaculation. Due to the non specific nature of what the meaning of an elevated PSA truly indicates, there has been some controversy regarding the usefulness of PSA. Recent advances in the use of combined digital rectal exam with serum PSA have improved the accuracy of PSA meaning. For instance, if a practitioner detects both an abnormality in the DRE, as well as the serum PSA, the ability of PSA to detect a true cancer is enhanced 50%.
   

New strategies for the use of the serum PSA are evolving. Patients now can have their PSA velocity measured to determine the possible need for a prostate gland biopsy. PSA velocity measures PSA at a particular point in time. The normal rate of increase in the PSA is no more than .7ng/dl per year. If a patient has a greater than .7ng/dl increase in his PSA in one year, this represents an abnormal PSA velocity. This strategy can then be used to more accurately predict the need for prostate biopsy.
   

Additionally, the enlargement of the prostate gland will lead to an increase in the release of PSA. Therefore, men with very large prostate glands may have a predictable increase in the of the released serum PSA. This concept of  predictable increase in the serum PSA is known as PSA density. This technique can also more specifically select men who should proceed with prostate biopsy.
   

The most recent test using PSA includes the use of measuring free and bound forms of PSA (this test is called PSA 11). It is known that PSA serum exist in two forms, free PSA and bound PSA (bound to alfa 1antichymotypsin ). The bound form of PSA, is more commonly found in patients affected with prostate cancer. Therefore, the more free PSA, the more likely the patient is affected with a benign prostate process. This test will more accurately assess the need for prostate biopsy.  
   

The use of prostatic acid phosphatase (PAP) and alkaline phosphatase have all but been supplanted by the use of PSA in the detection of and monitoring of prostate cancer. Many times complete blood counts are still useful in more advanced disease when considering the prognosis. It has been found that anemia may occur in many cases of extensive bony disease.
   

The most useful imaging study in the treatment of prostate cancer is the transrectal ultrasound (TRUS). Prior to the availability of TRUS, the vast majority of prostate cancers were diagnosed by transperineal or transrectal aspiration of the prostate gland. Many of these procedures were accompanied by hospitalization and the need for significant amounts anesthetic support. The histologic diagnosis of prostate cancer through the collection of specimens was difficult. The use of TRUS gives us a better understanding of the different zones of the prostate, and with the spring loaded gun, we can perform a sextant biopsy of the prostate gland in five minutes, with no anesthesia. The histologic diagnosis of prostate cancer is more easily made on the thin core biopsy tissue. The TRUS guided prostate biopsy is a minimally invasive examination well tolerated by patients, with a low rate of side effects (mostly 24 hours of minor hematuria).
   

TRUS can be used as a localizing tool to locate and guide the biopsy of an otherwise non palpable prostate tumors. TRUS is useful in quantifying the volume of the tumor which can be valuable in determining management options in selected patients. In addition, TRUS can be used to determine the presence or absence of extracapsular disease. TRUS may also be used to biopsy disease if it is suspected in the seminal vesicles or the periprostatic spaces. This can more accurately guide a patient  options for those patients with high volume disease who are selecting surgical management, but who are suspected of harboring extracapsular disease. The use of either computerized tomograhy (CT) scans or magnetic resonance imaging (MRI) have not routinely been found useful in managing prostate cancer.  Magnetic resonance spectroscpy (MRS) is experimental now, but may have a place measuring citrate levels within the prostate to distinguish prostate cancer from BPH.
   

The use radionucleide bone scans is still useful in determining the presence or absence of skeletal metastasis. It is now known that if serum PSA is less than 10 ng/dl that the likelihood of harboring skeletal metastasis is exceedingly low. Therefore in this situation a bone scan is no longer routinely ordered on all patients prior to treatment of their prostate cancer. In patients with high grade tumors (Gleason 7-10), high volume tumors, or any bony pain at the
time of presentation of the disease, the use of a bone scan may be indicated regardless of the PSA level.


Staging.

Once a man is diagnosed with prostate cancer, the extent of the cancer must be determined. The determination of where the tumor is, is called staging the cancer. Prostate cancer has 4 major stages.

STAGE A (T1):Tumor detected by PSA alone.                              

                     Tumor confined to the prostate gland.
                     Tumor confined to < .5 cm on rectal exam.

STAGE B (T2): Tumor confined to prostate gland but > .5 on a rectal exam.
                      Tumor palpable on both lobes of the prostate gland.

STAGE C (T3): Tumor palpable outside the confines of the prostate gland.
                      Tumor found outside the prostate gland on Imaging studies

STAGE D (T4): Tumor in the lymph nodes.
                       Tumor adjacent to organs (spine, liver, etc.)
   
The staging of a cancer is divided into 2 parts. The initial staging is called clinical staging. This includes the physician’s determination of the stage without invasive proof of the stage. The definitive staging is called pathologic staging, and this require an actual tissue biopsy for proof.

Grade.

The grade of a prostate cancer refers to the expected potential of the tumor to metastasize (spread). So called low grade, well differentiated, tumors have a low malignant potential, or a low potential to metastasize. High grade, or poorly differentiated tumors, has a high potential to metastasize. The principle grading system for prostate cancer is called the Gleason grading system. This system utilizes common known patterns of prostate cancer cells, and describes each pattern with a number from 1-10. The higher the number the higher the malignant potential. For example, a total Gleason score of 3, is considered to be a low malignant tumor. In contrast, total Gleason score of 8 would be considered a highly malignant tumor.
       

Similar tumor behavior can be predicted by studying the chromosome of the prostate cancer cells. Prostate cancers which are populated by cells which contain the normal amount of chromosomes, or DNA, are called diploid tumors. These tend to be well differentiated, low malignant potential tumors. The opposite of these well differentiated diploid tumors are the aneuploid
Tumor,s. These aneuploid tumors have an uncountable amount of chromosome strands of DNA, and are poorly differentiated, and highly malignant potential tumors.
   

Tumor volume is also very important in determining tumor behavior. It is believed that tumor volumes measured by transrectal ultrasound of less than 0.5 cc are well differentiated, low malignant potential tumors. Tumors which measure greater than 3 cc tend to behave like poorly differentiated, highly malignant tumors.
   

The zone of origin of the prostate tumor is also important in determining the malignant potential of a prostate cancer. Most prostate cancers originate in the peripheral zone of the prostate gland. These tumors generally close to the edge of the prostate gland, and the neural vascular bundles of the prostate gland. This position helps the peripheral tumors gain access to the outside of the prostate gland at a higher frequency than more centrally developing tumors. The central portion of the prostate gland is called the transitional zone. Tumors which arise in the transitional zone can obtain substantial size before they spread outside the gland.
   

With the use of Gleason scoring, tumor ploidy, tumor volume and using the location of the tumor, we can more accurately determine the malignant potential of a tumor. These tools are invaluable in making decisions regarding the treatment of prostate cancer.

Prognosis.

It has long been known that most men with prostate cancer will die with their tumor, and not from their tumor. This fact stems from the presence of microscopic prostate cancer cells which exist in as many as 50% of men over 80 years old. In the past these microscopic tumors have been referred to as “latent” prostate cancer. Of course most men who are found to have prostate cancer are identified as a result symptoms (obstructive or irritate voiding symptoms), signs (abnormal rectal exam), or abnormal PSA test. These men are considered to have clinical prostate cancer. With the advent of serum PSA testing, many clinicians worried that PSA would detect many men with latent prostate cancer. This has not be found to be the case. Eighty five percent of men with elevated PSA levels as their only abnormality are found to have clinically significant tumors. It is also known that latent prostate cancer is a progressive disease, which if given enough time can threaten the host.
   

Stage A and stage B prostate cancers are believed to be curable. The overall survival rates for men treated with Stage A prostate cancer is approximately 94% at 10 years. The overall survival rate for men treated with Stage B prostate cancer at 10 years is between 85-90%. The overall survival rate of men treated with Stage D prostate cancer at 10 years is 10%.
   

These differences in survival underscore the need to detect prostate cancer early, if one is to have a reasonable chance of a cure. With the advent of serum PSA testing and digital rectal exam screening, we have seen a shift in the stage of prostate cancer presentation. Prior to 1990,  the vast majority of American men were diagnosed with Stage D disease. Due to the new early detection techniques and strategies, most men now diagnosed with Stage A or B disease.
   

Treatment.

There are multiple good options for the treatment of prostate cancer. The selection of which is the most appropriate option for any given individual patient is dependent upon the desire of the patient to achieve either palliation (slowing down of the cancer process-remission), or cure. Only Stage A and B prostate cancers are thought to be curable.
   

One new option in the management of prostate cancer is the use of observation strategy. This involves the use of serial digital rectal exam, serum PSA testing (with occasional transrectal ultrasound) to monitor the growth of the tumor. Presumably, if the tumor does not grow, then the patient can continue to follow his cancer without intervention. Only if the tumor begins to grow, then the patient would exercise the option for treatment. There is a chance that the tumor may increase in stage or grade during the observation period, therefore if the a patient is not compliant with this strategy, he should be immediately enrolled in a more conventional treatment plan.

The curative strategies for prostate cancer include the use of radical prostatectomy or definitive radiation therapy.


Radical Prostatectomy.

Radical prostatectomy represents the oldest form of treatment the localized prostate cancer. The goal this operation is to remove all the cancer which is confined to the prostate gland, thereby rendering the patient cured. Radical prostatectomy involves total removal of the prostate gland. In localized disease, this operation is associated with a 80-90% cure rate. The operation has been improved over the years, to where now there is very little operative time, and very little blood loss. The incontinence rate is only 2-4% of men. Incontinence is described as requiring at least one urinary collection pad in the underwear to collect urinary leakage, nine months after surgery. Today even when men develop incontinence, the option of Contigen implantation can correct the leakage that some men experience. If this fails, the use of an AMS artificial sphincter can be used to correct urinary incontinence. Radical prostatectomy performed with cavernous nerve sparing technique can greatly reduce the need for the correction of impotence. Even in the event that a man becomes totally impotent following radical prostatectomy, either the use of penile medications, vacuum erection devices, intraurethral  medications or the implantation of a penile prosthesis can be used to completely correct any erection dysfunction (impotence).



Radiation Therapy.

Radiation therapy is also a good option for men with localized, curable prostate cancer. The goal of this radiation therapy is to cause programmed prostate cancer cell death over time. This treatment can be delivered with either external beam format, or by the use of intraprostatic seed implants. Although in the past the external beam technique was associated with a lower cure rate that surgical therapy cure rates, this may not be true with the use of intraprostatic seed therapy. Radiation therapy is an excellent option for treating men with localized cancer who have other medical co-morbidities which would make the use of surgery dangerously prohibitive. The rate of incontinence and impotence are lower than with radical prostatectomy, however when present, these complications can be somewhat harder to deal with.
  

When prostate cancer has spread outside of the prostate gland, palliative therapy is used to slow the progression of the disease. This type of treatment can often lead to survival measured in decades. The basis of palliative therapy is in the understanding that the prostate cancer cell are stimulated to grow by the male hormone, testosterone. This hormone can be deleted by removing its source, the testicles. This procedure is called orchiectomy, and represents the most conventional method of dealing with dealing with metastastic prostate cancer. Additionally, today there are medications which can be used which block the release of testosterone from the testicles. These medications include Lupron, Zoladex and Diethylstilbesterol (DES). Recent studies indicate that the small amount of male hormone released from the adrenal gland may also be important in the stimulation of prostate cancers. The release of these male hormones may be blocked by medications called Flutamide, Casodex and Nalidrone.
   

In current practice it is common to base treatment decisions on both patient factors and tumor factors. For instance, one should take into account patient expected longevity before beginning any plan of therapy. Additionally, we must consider any concurrent illness (heart attack, stroke, or any other terminal illness) prior to making treatment decisions. For example, an 80 year old man with severe heart disease may be a candidate for only the most conservative forms of therapy. When considering tumor factors include tumor volume, ploidy, Gleason grade, and cancer stage. For example, a 51 year old man with a tumor volume of 1.0 cc, which is aneuploid, Gleason 8 and stage B (T2), would be an excellent candidate for aggressive intervention (surgery or radiation therapy). As you can imagine, when considering all of these variables you see why each prostate cancer treatment decision must be individualized.


Conclusion. 

    The incidence of prostate cancer has been increasing since statistics were first collected in the 1930s. Prostate cancer yearly case rates have been increasing even prior to the widespread use of screening programs using serum PSA testing. The etiology for prostate cancer is multi-factorial. These factors include age, ethnicity, diet and region of the world were the man lives. Fortunately the diagnosis of prostate cancer is the best it has ever been. This disease can now be reliably diagnosed with non invasive means. The treatment options now are very refined and offer men not only cure, but also a high quality of life after treatment. The most important aspect of management of prostate cancer lies in the individualized treatment plan for a particular patient.
 

The sun cast a questionable ray of hope across a wall in Lionel’s foreboding room. It was still decorated with the posters warning the unwary of the various maladies that a urologist and his stockbroker live for.  It had been almost three months since the removal of the catheter and I had an appointment with Lionel to discuss the final steps regarding my return to a normal life.
         

I was shown into his room and told to take a seat. I chose one of the two seats at random, and it did not take long to conclude that the seats were designed by an HMO to promote short visits and higher profits. A little time later, a short but authoritative knock was heard. This was followed by the door swinging open to reveal the puffed smiling cheeks and twinkling brown eyes of the effervescent Lionel.
       

“How is the legend?” he cried while thrusting a hand in my general direction.
    

“You promised to make me a stud again and I have come to take you up on your promise,” I said, shaking his hand.
    

“Let’s not rush things,”  he said. “I think we should wait a few months to give the nerve bundles a chance to heal. They have recently undergone a considerable trauma.  Lets see if time will heal them and make a natural erection possible.”
    

“In the mean time,” said Lionel “there are number of things I can do to help you. At present, there is no pill I can prescribe that will guarantee an erection. However, Pfizer is working on a pill that shows a lot of promise, it should be available early next year.  In the meantime, I’d like us to go through a number of different strategies until we find the one that is right for you.”

“What I want you to try first, are an injections of papaverine into the base of the penis.  Its quite easy and not as painful as it sounds.”

“You’ve got be out of your tiny urologist mind,” I said  “Its not your penis we’re going to use as a pin cushion,”  I cried.
          

Ignoring my questioning of his sanity, Lionel said,  “Once you get the knack of it, it’s easy and it can be quite effective. It works by sending a similar chemical signal that is produced naturally in the prostate nerve bundles to the penis. This in turn triggers the expansion of the arteries in the penis, allowing blood to enter the penis.”

“Sticking a needle into my cock does not sound like a pleasant start to a sensual encounter” I said.  However, I’m willing to give it a try, but if I find that this therapy is not for me, what are my alternatives ?” I asked the great inquisitor.

“After the Penile Self injection, we have the Vacuum Pump.  And in a few months time we expect FDA approval of a suppository.  This will work in a similar manner as the Penile Self injection, however, the medication is  inserted into the tip of the penis with a special applicator.  Then we have the new oral drug by Pfizer that should be available early year. If that does not work, we have the Penile Implant again made by Pfizer. I do several of these operations a month, and, I can guarantee you a satisfactory erection with this alternative. Don’t worry, we’re in this together, I’ll get you where you want to be,” said Lionel.

Then without further preamble he told me to drop my pants.  ( this is a common request of a urologists). Turning in his swiveled chair, he stretched out a gloved hand and opened a drawer and extracted a small glass vial containing a clear liquid and an hypodermic syringe still warped in its hermetically sealed protective wrapping.

There followed a silence between us, as he went through an apparent ritual that had been perfected over years of practice with other victims of this Star Chamber.  The syringe was removed from its wrapping and the protective cap removed from a short thin needle and discarded. The vial held upside down, was lifted slightly in his left hand. With his right hand he pressed the needle into the re-sealable vial cap, and slowly, he withdrew a portion of the clear liquid. The syringe was removed from the vial, and the plunger slowly pressed, allowing a small amount of the liquid to flow from the tip of the needle.  He turned to me smiling, with as much conviction as anyone can while holding an erect and cocked (in more ways than one) instrument of pain.                 

“I’m going to start you off with 20 cc of papaverine.  We can increase the dose over time if it is warranted,” said Lionel. Now its important that you make the injection into muscle of your penis.  You do this by making sure the needle is at 90º to the penis and not tangential or to one side,” he said.
    

 With this singular advice, he pointed a finger at the target area of the injection, and without further comment, jabbed the needle into to my flesh. There was a short sharp pain as the needle entered, but no undue sensation after the needle was withdrawn.             
    

“I’m going to leave you for ten minutes to let the medication work.

Oh’ yes, one more thing.  You should rub your penis a little to stimulate the chemical reaction.”  With this dismissal, I was left on my own in his small room.

I looked at the shafts of light spreading through the Venetian blind. It was almost as bright before, yet the angle across  the wall was lower the shadows more stark. This seemed to be a perfect metaphor of my current feelings.  Lionel came back fifteen minutes later ( I’m convinced he has a clock that is set by the Dow Jones Industrial Average he is never on time).  He examine his handiwork, there was definitely a change. There was an appearance of an erection.  Not as firm as I had remembered, but certainly an improvement over my recent memory.  
    

“I suggest you should try this yourself during the next few weeks. And why don’t you increase the dose to 35 cc and lets get together again in four weeks time,” said the good doctor.
    

Rummaging through his drawer, he found two more vials of papaverine and a handful of syringes that he gave to me.

“ And here’s a prescription for additional medication and syringes. The medication may not be covered by your insurance, but the syringes will be,” he said, while writing in a pad in that secret code known only to doctors, pharmacists, and spies.

Over the next several weeks, I tried out papaverine, but I never felt comfortable with the self injection. Consequently, we would more often than not, postpone lovemaking. Clearly there had to be a better alternative. So I made an appointment to see the Grand Inquisitor once more.    

“Well, how did it go?” asked Lionel. I told him of my fear and hesitation about using the needle.

“It’s not for everyone,” he conceded. “There are many men who have used the Penile Self-injection method for years quite successfully with no side effects. Then there is the squeamish like you,” he said with a smile.

“Now we’ll have to go to phase two. The vacuum pump.”

I had seen this device before but I had never held one in my hand.  It consisted of four basic parts; a large plastic cylinder, a hand operated pumps, a special rubber ring and a lubricant.  As was the custom with my “friend Lionel,” after a short get reacquainted chat,  I was asked to drop my trousers on the pretext that he could demonstrate how this apparatus worked.    

First the large plastic cylinder was connected to the pump, and a rubber ring  selected from various sizes on hand was placed around the opposite end of the cylinder to the pump. Lubrication was then applied to the penis and the end of the cylinder next to the ring.  The cylinder was then placed over the penis and the pump was activated by squeezing the handle. A vacuum around the penis was created, allowing blood under normal body pressure to flow into the penis resulting in an erection. The lubrication on the penis reduced the friction as it expanded and the lubrication on the end of the cylinder provided a seal against the skin. Finally, when an erection is maximized, the ring is  pushed off the end of the cylinder onto the base of the penis, restricting the back-flow of blood, thus maintaining an erection.  An erection will last until the ring is removed (up to 30 minutes later).  I tried the procedure several times so that I could get the hang of it.

“Why don’t you try the pump at home for a few weeks and then lets test your PSA while we are at it, ”  suggested Lionel. In an effort to impress upon me the importance of his advice, he marched me to the front desk and asked Diane to print the necessary forms and labels for the test, and set a time for our next appointment.

The vacuum system with all its paraphernalia, came in a small plastic carrying case for storage and travel. Over the next few weeks I tried the pump. It produced a fairly good erection, the only discomfort was the removal of the rubber ring after intercourse. This required some delicate handling. Efficient for what it was designed for, it made love making anything but a spontaneous event, and I was eager to try any new alternatives.  On my next visit I told Lionel about my experiences with the pump.

“I think its time for you to try the new suppository; Muse. It has a medication in an applicator that is inserted into the tip of the penis. It can be used twice a day. You apply it 5 to 10 minutes before sex and an erection can last up to an hour,” Lionel informed me.

He then reached for his trusty pad and began to write a prescription in that secret medical code of his.

“By the way, your PSA results came in at 0.06. That’s almost too low to measure, your keeping my batting average high,” he said with a smile.

With this sporting metaphor, I was once more let out into the wide world to seek the next round of my medical odyssey. I found it at my neighborhood pharmacy. Muse was not covered by my insurance. Be that as it may, can you put a price on upward mobility?  When I got home I read the instructions.

“When not in use keep this medication in a cool place,” and this is how Muse coexisted with the broccoli, beans and carrots in my fridge.

The next weekend I tried to use Muse, but I could never pluck up the courage to insert the applicator into my urethra.  It was like the penile self injection. I could not overcome the act of self induced pain prior to a natural and wonderful experience.  So I went back to the pump.

March 28th, 1998 was a Saturday, and as was my custom, I started the day with tea, toast and the San Jose Mercury News.  On its front page, I read  the following: “First pill for treating impotence is approved.”  The article went on to say in part,  “Viagra is taken by mouth, about an hour before intercourse, and does not directly cause penile erections; rather, it affects the response to sexual stimulation.

Essentially, the new drug enhances the smooth-muscle relaxant effects of nitric oxide, a chemical that is normally released in response to sexual stimulation; this smooth-muscle relaxant allows increased blood flow into certain areas of the penis, leading to an erection.”    

“This new therapy increases the range of options available for men with this problem” said (and I kid you not, this is absolutely true) Janet Woodcock, director of the FDA’s center for drug evaluation and research.  And they say the federal bureaucracy has no sense of humor. Where is Jay Leno when you really need him?

With such a signature endorsement, who would not want to try it ?  Several weeks after reading the article, I made an appointment with John  Quick to talk about the various remedies available for my high cholesterol count. At our meeting, we agreed on a cause of treatment.  I then told him about my various impotence therapy experiments, and I asked him for a trial prescription of Viagra.  After some discussion about the pros and cons of the drug, he gave me one prescription for my cholesterol problem and a second for Viagra.  

“Now its important, that before you go on this soiree with Viagra, you should read this fact sheet written by our Urology Department,” said John, placing the scroll in my hand and closing my fingers around it. The information contained said in part…”Take one tablet by mouth one hour before you plan to be sexual. Do not expect results much before that, though it  

is certainly OK to be intimate while waiting.  The drug is active for several hours after you take it, so no need to say “On your mark, ready GO!” as the countdown gets to one hour. But if you take the pill and three hours later you’re still in front of the TV set watching Flipper reruns, don’t expect much.

Viagra will not cause an erection on its own. It will not work unless all the factors are present that normally get you aroused and in the mood….. Whatever, don’t just sit there and watch it grow, because it may not unless there is sex on your mind and some form of physical stimulation. “Fantasy and friction” as the sex therapists say.”     
    

The information sheet went on to say “The success rate for Viagra is about 80% overall, though men who have had a total removal of the prostate gland for prostate cancer do not do as well, about 45%.”
    

I tried Viagra several times over the next few weeks, but with no success.  I guess I was in the lower half of the 45 percentile. I had one last step to go, a final operation, I phoned Lionel.
    

“ Get your scalpel out, I think we have to make an appointment for an implant. But before we do that, I would like to talk to someone  who has gone down the same road that I am going down now.”   Lionel thought for a moment, then he gave me the name of a patient and his phone number. He added that this patient had already agreed to be a reference for this type of procedure.

A couple of days later I phoned the number I was given. A contralto voice answered the phone.  My first thought was, I hope that this vocal range was not the result of the operation, I liked being a bass.  After further inquires, the voice turned out to be the wife of my soon to be soul mate.  I told her who I was and why I was calling.  

“O you must be one of Lionel’s elite patients”, she said with a sense of humor in her voice (I liked her already).  And since I had her on the end of the line, I took advantage of the situation.

“If you don’t mind while I have you on the phone, I have to ask you, how do you feel about the results of your husbands prophesies operation ?”

“I have no complaints, it’s been wonderful. But I think you should talk to my husband about it,” she said in a more subdued voice, now realizing I suppose, that she was talking to a complete stranger about a very intimate subject.

“Let me call him,” she said.  After a few moments pause, a baritone voice challenged me on the phone. I introduced myself and told him,
    

“ Lionel Foster gave me your name and number. I’m contemplating having a penal implant procedure after prostate surgery, and Lionel suggested that I should give you a call and ask you about your experiences after having the procedure.”
    

“I have nothing but good things to say about it,” he replied.    

“Regardless of the circumstances, I can always have an erection and it will last as long as I want it too. And the sensation of making love and reaching a  climax is the same as before the operation.”  

We talked for quite a while about the operation and its results. He warned me that I would probably have a lot of pain during the week after the operation.  It should take about five weeks in all before  you will be ready to start your field trials. I thanked my new friend.  I told him that I would talk to my wife and Lionel one more time.  But after our talk, I felt good about having the operation.
    

A week later, Sarah, Lionel, and I were bent over Lionel’s plastic table. The good doctor had a working model of this uplifting device.
    

“It consists of two cylinders, implanted in the corporal bodies of the penis using a penoscrotal approach, with a single pump placed in the scrotum,” he said, hence the sub-title to this chapter “The case of the third ball.”  

“The device is made of silicone elastomers and stainless steel components. The fluid in the device is isotonic saline. When the pump is squeezed, fluid flows from the reservoir into the implant, causing an erection.  When you want to bring the penis back to its natural state, you bend the penis down and hold it in that position for about 16 seconds,” said Lionel.
    

“This inflatable implant provides the most natural erection of any of the other devices available today,” he said while toying with the device in his slim brown hands. For a while, we talked about the pros and cons of the procedure.

“If you decide to have this operation,” said Lionel,  “you will have to limit your love maki.. ( at this point I kicked his foot under the table. He quickly got my drift. ) I mean, you should have sex frequently. This is most important.”
Finally all eyes turned to me for a decision.  Being the magnanimous type,  I asked Sarah what I should do. She replied, that it was up to me to make the decision and she would support me either way.
    

“Ok Lionel what do we have to do next?”
    

“ I will have to write a letter to your insurance company. I’ll tell them that you have had a radical prostatectomy, and that we have tried all the normal methods of achieving an erection. And, that I feel that a Penile Implant is the only alternative for you.”
    

Several days later, Lionel wrote and mailed a letter to my insurance company, leaving us all to wait for a response from those people who control a good deal of our medical destiny, the bureaucrats that divides doctor from patient. In today’s parlance their called actuaries and lawyers,  several years ago they were known as odds makers or bookies. They can calculate the return on investment for other people’s medical care in a nanosecond.

I was fortunate, four weeks later I got a phone call from the clinic saying that the procedure had been approved, and would I call Dr. Foster’s office to set a date for the procedure. I called Lionel and we decided on the fifth of August, about two weeks away.

The evening before the procedure, I suddenly thought of a question that I had not put to Lionel, so I phoned him at home.  After several rings the doctor answered the phone.

In an effort to get the upper hand I chastised him for answering the phone. “You’ve got an important day tomorrow, what are you doing answering the phone? You should be getting your sleep,” I said.
“Never mind, I have a more important question for you. This is our last chance to get things right. As you know, all men are not built the same, and we have not yet talked about how you go about sizing the device.  I don’t need to know the technical details. Suffice to say, that after you measure me, if you decide on a size 5, I want a size 10,” I said.

“Length is not the most important factor with most women Howard. It is the girth they look for. Don’t worry I will look after you,” said my soul mate. (In Thickness as in Health I seemed to hear him say about our marriage vows).

The next day Sarah and I drove to the address we were given in San Jose. It was a small grey complex close to the O’Connor Hospital.  We parked the car and walked the few steps towards my next medical adventure.  Upon our arrival we were met by a middle age lady who demanded to know who I was, and who was the woman with me ?  After explaining that I was here for an operation, and that the lady with me was my wife, I was asked to provide further paper and plastic proof of my bonafides.  

Eventually, I must have past muster, since, I was led into a small room by a young nurse named Lisa, who had a wonderful Alabama accent and a great sense of humor.  Unabashed, she asked me to get undressed and change into the regulation hospital gown.

We were soon joined by a tall athletic young man who entered my field of vision. He introduced himself as Dr. Richard Kataz, he was to be my anesthesiologist for the day.  After the normal pleasantries about the weather and other vital issues of the day, the doctor started to take command of my left hand.  A needle was inserted into the back of the hand and was firmly taped into place. The tube leading from the needle was connected to a plastic bag suspended from a stainless steel carrier.
Dr. Kataz turned the valve at the base of the bag clockwise and smiled at me. Slowly, all sense of reality and the heavy burden of life’s responsibilities  started to slip away.  But before I could fall through the rabbit hole and meet Alice in Wonderland, I remembered I had one last instruction for Lionel.

Quickly I thrust my hand under my pillow and retrieved the label complete with rubber band that I had prepared the day before.

It said, “Dear Lionel, I hope this procedure is easy for you, and hard for me !!  PS. Does it have a parts and labor warranty ?”

I attached the said label onto the normal part of my body that Lionel  was accustom to see.  Later, I was to find out that this Inflatable Penile Prosthesis, as it is officially known, does have a warranty. And to ensure that it is a Pfizer product, and that it has been implanted correctly, a Pfizer rep. was in the operating room to observe my favorite urologist at work.

After the operation, Lionel told me of the conversation he had, with the Pfizer representative. When it became time to measure me for the implant,
(I was playing croquet with the King and Alice at the time,) Lionel made his calculations and said,

“I think we’ll add an extra 2.5 cm. to these calculations.”

A gasp was heard from the Pfizer rep. “But why?” she asked.

“Someone special,” replied Lionel with brevity.
I awoke several hours later, with no mallet in hand. I guess the King or Alice must have taken it away from me. I felt some pain where you would expect after such an operation. I pushed my hands into my groin area only to find my penis encased in  bandages.

“It’s all over now, come on, I’ll help you get up,” said Lisa, in her hauntingly southern accent.  She put her arm around my shoulders and lifted me into a sitting position with my feet resting on the ground. I looked around the so called real world for the first time in several hours. I felt the world of Lewis Carroll was so much better.  

Sarah had overheard the conservation between the nurse and myself and came to my bedside. “How are you doing love ?” she asked.

“Uncomfortable, actually I feel like hell” I said through clench teeth.  At this point Lionel came into the room.

“Every thing went fine,” he said while smiling and putting an arm around me. “ You’ll  probably have some pain over the next several days. It looks like you have some now.” His eyes looked into mine for confirmation. He seemed to find it, since he went on to say.

“I’ll give you a shot before you go and write you a prescription for some medication, just take one pill as needed.”    

Over the next week and a half, I had a lot of pain. I was taking pills on a regular basis.  However, when you come to think about it, it’s not really so surprising that I should have had so much pain. An operation had just been performed on the most sensitive part of a man’s body, then this same organ had been asked to heal itself with an implant that was 2.5cm larger than it had been designed for.

Gradually, the pain became more tolerable and about two weeks after the operation, the pain gradually diminished. It was 32 days after the operation when we decided to conduct our first field trials.  The results are classified. However, I can say that everyone concerned was satisfied.

It has now been over three years since my prostate cancer diagnosis and the original operation. My quarterly PSA tests have been all been negative. My singular advice to all men in their mid forties and above is to have a regular physical exam that includes a digital rectal exam and a PSA test. It can save your life.  If the tests indicate positive for cancer, don’t despair.  Find yourself a good urologist, assume a positive attitude, and get your family and friends to be your pillar of strength. Prostate cancer can be beaten if it is found in time, and life can go on, and don’t forget to smile.

Incidentally, Lionel has recently left the San Jose Medical Group to start his own practice in down town San Jose. I am pleased to report that his new office is devoid of those intimidating posters and is quite comfortable for a medical office.

The reason for writing this anecdote of my experiences was two fold.  First as a catharsis for myself and to bring some closure to this episode of my life, and secondly, when Lionel Foster knew  what I was doing he encouraged me to continue.  He thought that it had an important message for men and those who love them who might find themselves diagnosed with a similar affliction.   Hopefully between us we have shown with this story, that even under adversity some fun can be had,  just as long as you have a positive attitude.  In the next chapter, Lionel Foster talks about prostate cancer from the doctor’s point of view.
 

These last two chapters are probably the most difficult emotionally, to write about. And yet, they are probably the most critical in the minds of most men when they think about the possible long- term effects of prostate cancer. They go to the very heart of a man’s masculinity. After survival, and the meeting of his basic needs, the perpetuation of the human species is the next highest plateau on the Maslow pyramid of human motivations. This is true even after a man is beyond the age, or even the desire, to raise a new family. The sex drive is heavily imprinted into the human psyche.  If in doubt ask Madison Avenue or Hollywood.

After going through this odyssey, another thought occurred to me; prostate cancer is as much a woman’s problem, as breast cancer is a man’s problem. I’m sure a woman who is diagnosed with breast cancer faces many similar fears that a man goes through after he has been told that he has prostate cancer. Both diseases are potentially fatal, and both can have a devastating effect on the perception of ones masculinity or femininity, and both can test the spousal relationship. In both cases, the healthy spouse suddenly has additional responsibilities, such as care-giver, counselor, medical researcher, etc.  

Sarah was always there by my side with a shoulder to cry on and advice when needed.  However, from the beginning I felt that it was important for me to adopt a positive attitude, and in my case, use humor as a means of dealing with the many decisions and ordeals that I would encounter along the way to recovery.  Please give humor a try if you are diagnosed with any kind of life threatening malady.

As most men know, there is often but not always, a problem with having an erection after the treatment for prostate cancer. With radiation therapy, radical prostatectomy, and cryosurgery (the freezing of the prostate), the two bundles of nerves surrounding the prostate that is responsible for transmitting the vital erection signals from the brain can be damaged, or severed altogether.  This can prevent the arteries in the penis from filling the spongy tubes of tissue   ( the corpus cavernosa and corpus spongiosum ) inside the penis with blood, making a natural erection difficult or impossible.

To most men this can be devastating news.  And naturally the doctor is almost always asked a variation of the following question after a patient has been diagnosed with prostate cancer.   

“Once we have cured or controlled the cancer, how is my sex life going to be affected ?”
    

Lionel made me aware of this problem from the very beginning, and further research proved him to be correct.  

“There is no current technology available that can guarantee a cure for prostate cancer and also guarantee an erection after treatment. However there are a number of ways to overcome this problem, and its up to me to make you the stud you were before you came to see me,”  promised Lionel.    

Several months after my surgery, these prophetic words were going through my mind as I sat in my car at a high tech firm’s parking lot in San Jose. I was waiting for a colleague to arrive from Salt Lake City. We had an appointment with the firm’s senior management.  Through the windshield, I saw four lovely young ladies emerge from the front door of the  building to take advantage of the warm weather.  A gentle breeze caused the long black hair to fall over the unadorned face of the woman in front necessitating a slim hand to occasionally move the hair back into place.               

She wore a simple white dress that seemed to make her appear translucent, revealing everything and yet nothing at the same time.  All the ladies looked so exceedingly desirable in their short skirts and high heels.  My mind said so.  My recollection of the past said so.  But physiologically, nothing happened, and I suddenly felt desperately lonely and depressed.  

This had to be one of the lowest points of my recovery so far.  I almost cried.  Its not so much that I would or could  have done anything about the situation, even if I did have a natural physiological response.  I am too married and too old. But I felt cheated, because my freedom of choice had been taken from me.  Now many nations, I thought, had fought wars over the centuries in the name of freedom.  Yet we take freedom for granted until we lose it.  Suddenly, I felt that this was my Dunkirk.  But, who can live too long with the legacy of a great retreat?  
        

At that moment, I decide that I needed to regain my freedom of choice . This was to be the first day of the rest of my life. It was time to roll out the old Spitfires for one more battle, I could smell the Castrol oil as the Rolls Royce engines turned-over in my mind.
 

Most men have little knowledge about the physiological workings of their own reproductive system.  And before they can make an informed  choice of the appropriate treatment, they should have at least a basic understanding of how all this plumbing operates.  What follows, is a brief layman’s primer on the subject.

First and foremost, we should try to understand the various functions that the prostate plays in our everyday lives.

The Prostate.
    
This thing we call a prostate, despite all the problems it can cause many men and the revenue potential it has for medical plumbers, is a remarkably small capsule.  About the size of a walnut, it acts very much like Grand Central Station, with multiple functions that have to be orchestrated in the correct time sequence.  
    

The prostate is not a single gland, but a collection of glands surrounded by a single capsule. This capsule has a dual role; the regulation of the liquid waste from the bladder to the outside world, and  the production of the essential fluids for the reproductive system. The prostate is situated just below the bladder, the organ that collects urine.  

There are two valves, or as doctors call them sphincters, (circular muscles); an internal sphincter in the bladder, and an external sphincter below the prostate. By working in unison, these two sets of muscles are responsible for preventing urine leakage before voiding. They also regulate the emission of semen during an orgasm.  

If the external sphincter becomes damaged during surgery or radiation, it can lead to urinary incontinence.  But with improved surgical techniques, this is not the problem it was several years ago.  Although most patients will encounter some degree of incontinence that might last a few days, as in my case, or several months in some other men, most men will regain control of their bladder eventually .   
    

The other major function of the prostate is it’s role in the reproductive system. The prostate produces the vast majority of the fluid that makes up semen, including enzymes that nourish the sperm cells produced by the testicles, and other compounds that protect the cells from bacteria.    
    

At the moment of climax, the internal sphincter closes, and the external sphincter relaxes. Semen, entering the urethra under high pressure is prevented from entering the bladder thus, separating the urine from the semen. The semen has only one place to go, and is forced out through the penis under high pressure.

The Sexual Response.

Most of us are fortunate to be born with five senses. Each sense on its own, or in combination with the others can arouse sexual desire.  A sound, a touch, a certain smell or taste, or a visual excitement will produce tiny chemical and electrical reactions in “Sex Central,” the hypothalamus, a gland deep inside the brain.

Both men and women have the same four cycles during the sexual response. They are:

Desire: This is an interest in sex at that particular time, or a feeling of attraction to a person.
Excitement: This is the phase when you feel aroused and excited. This state is brought on through external stimuli orchestrated by “Sex Central” and exhibits the following physical responses:
        •    An increase in blood pressure.
        •    Increased flow of blood to the genital area resulting with an erection in a man.
        •    Heavy breathing and an increase in the heart and pulse rate.
Orgasm: This is the sexual climax.  The nervous system sends waves of heightened pleasure throughout the body, particularly round the genital area. In men, there is a contraction of muscles around the prostate resulting in the ejaculation of semen.
Resolution:  This is a return of the body to its steady state.  Blood drains from
the penis which becomes flaccid once more.   

The hypothalamus, in combination with the smaller pituitary gland at the base of the brain is responsible for regulating the male hormones that effect the development of the sexual organs and sexual behavior.   

Testosterone is the primary male hormone.  When the body is low in
testosterone, the pituitary gland sends a message through the bloodstream to activate the testicles to speed up the production process.
 

When a man is sexually aroused or “turned on”, small electrical impulses are sent from the sensory receptor in the hypothalamus. They travel through a maze of nerves in the spinal cord to the nerves in the pelvic region, and too those all important pair of nerve bundles along either side of the prostate.

Arteries carrying blood into the penis receive these signals and expand, allowing blood to surge at high speed into the spongy tissue of the penis. The veins in the penis which normally drain blood from the area become constricted by this sudden expansion,  thus slowing the drainage of blood from the penis.  The result is an increase in blood pressure in the penis and a firm erection.  

It is when these nerves bundles and blood vessels become damaged through the treatment for prostate cancer that erectile dysfunction can occur.  One important fact that should be stressed at this point is that.  The only nerves affected by these prostate cancer procedures are the nerves associated with producing an erection.  The nerves that produce pleasure when touched, and an orgasm when stimulated, are generally not affected.  This means that if a man can achieve an erection through one of the several alternatives which we will discuss next, he should be able to  lead a normal and healthy sex life.    
 

At last, we pulled into our driveway and parked the car.  I decided to dispense with niceties of chivalry and let Sarah come around to the passenger door to help me out.  After the forty odd minute car ride, the morphine had worn a little thin and all those bumps on the highway had exerted a heavy toll on my fragile body.  With some pulling and pushing on both our parts, we eventually removed the body from the car.

Once inside our home, I was inundated by our two dogs that sensed that I was a day short of a shower.  They were determined between them to rectify this deficit.  The cats looked on with mild disdain, they would get around to me when it suited them.  Sarah and I headed for the kitchen and did what all English people do in times of crisis or calm.  We put on the kettle and made some tea.

While waiting for the water to boil, I noticed some bananas in the fruit basket.  Suddenly it dawned on me that this is my home, I can do and eat what I like.  I grabbed a banana with a renewed sense of authority, peeled it, and consumed it in less time then it took to say “Urologist”.  My first semi-hard food in three and a half days.  After the required time for mashing (the precise time is a closely guarded British secret) we poured out the tea and consumed it with a genuine English ginger biscuit made in Canada.  I was in heaven.

While we were consuming the staple diet of our national heritage, Sarah told me about the cancer that had inflicted two of our neighbors.  Andy was diagnosed with cancer of the intestine and Carol had breast cancer.  Both were undergoing treatment.  But it begged the question, is there something in the water or the air of our neighborhood that is causing this outbreak of cancer?

Next, we looked at our immediate home environment and decided to make the house as friendly as possible for me and my affliction for the next three weeks.  This included moving my favorite chair and Ottoman close to the TV.  A neighbor had lent us a portable phone so that I could carry this with me and receive and send messages with the minimum effort.  To-day was a Saturday, so I sat in front of the television and overdosed on sports, while contemplating my first genuine solid meal in several days.

A little after five o’clock, the prize was ready.  A homemade pizza with tea.  Who could ask for anything more?  I gorged myself on this gastronomic delight, eating about four slices all told.  This was washed down with more hot tea.  Life it seemed, could not get any better.  Then, after about a quarter of an hour, my stomach sent the rest of my body some disturbing messages.
  

“What the hell are you doing?  I’ve had warm water and Jell-O for the last several days, what is this you’re sending down?”  My whole body seemed to reel under the invasion of the first solid food in days.  From this I learned one important lesson.  Take all things in moderation.

Going to bed to most of us is automatic, we don’t have to think about it.  Take off your day clothes and put on your P.J.’s, it’s all pretty simple, except when you have a tube, and the “Bag”, and abdomen that doesn’t want to bend.  I needed assistance from Sarah.  The next hurdle was actually getting into bed.  Remember, I now have no morphine to moderate the pain associated with bending and a bed that doesn’t adjust.  Eventually, I managed to lie down and everything was fine as long as I didn’t want to move.  This has to be the most difficult part of the “Ball and Chain.”  Any sleeping position other than flat on your back is next to impossible.  

After a reasonable night’s sleep, the next adventure after getting out of bed is the shower, another task in life that we take for granted.  After some assistance in getting undressed, the “Bag” is disconnected from the catheter, and we decide to tape some plastic food wrap above the incision to protect it from the shower.  Gosh it feels so good to have warm water running all over the body, and that thick shampoo and conditioner in the hair is sheer luxury.  Then, after a long rinse comes the communal drying.  (There are some benefits to prostate cancer after all).  Today we decide to tryout the walkabout bag for a change.  First, the tube is connected to the catheter, and a loop of the tube is tapped to the leg to prevent the tube from pulling on the penis.  Finally, the bag is fastened by rubber straps to the leg, now the trousers can be put on.

I was able to walk and sit down without problems and during the course of the day there was very little drama, with one exception.  While wearing a catheter, urine passes from the bladder to the “Bag” in drips and drabs most of the time.  Occasionally, urine will pass like a mini flood and this results in a very uncomfortable feeling.  When this happens, I would grab the back of the nearest chair and hold on to it while clenching my teeth.  This happened quite frequently and was not a pleasant experience.  As it was Sunday, I decided that I should call the good doctor for some advice the following day.

On Monday morning, I dialed the Urology Department number only to be told that Lionel was not in.  (He was probably out buying the new Mercedes I noticed he was driving shortly after my operation). So I asked for Cindy, his most able assistant.  

“Hi Mr. Gray, how are you doing?” she said in a cheerleader sounding voice.  She sounded far too cheerful for a Monday morning, and I felt it was my duty to bring her a dose of unreality.
    

I replied, “Not so good.  I’ve got a real problem Cindy.”
    

“Oh I’m sorry Mr. Gray.  How can I help you?”
    

 “Well, every time I pull out the catheter to have sex, then push it back in again, I have this awful pain.”
    

 “No—no you shouldn’t be doing that Mr. Gray!!”
    

“Look Cindy, I’ve tried having sex with the catheter in, but it’s even more painful.”
    

“No, no, Mr. Gray you shouldn’t be trying to have sex at all right now.”  I could tell by the sound of her voice and quickens of her breath that this was a new experience for her (not sex in particular, but trying to have sex with a  catheter).  I decided to let her hang there for a while.  Then with some reluctance, I brought her down to earth.
    

“Cindy, I just wanted to get your attention.  You sounded far too cheerful for a Monday morning,” I said.  “But I do have a problem.”  I went on to describe the symptoms to her.  She said that she would contact Lionel and get back to me,  which she did.  I was prescribed a medication that obviated my discomfort.  Sarah picked me up the medication later in the day.  The result was astounding.  No more urine track pains.

As time passed, we fell into a kind of routine, except for sleep.  Again, sleep is an event that we all take for granted.  When it gets dark, we go to bed and we sleep.  When the sun comes up, we awake and get out of bed.  It’s pretty simple.  But when one has one less prostate and one more catheter than God intended, things are not quite so simple.  After a walk or some exercise during the day, I would feel tired and would go and lie down and sleep.  The problem was that when I went to bed at the same time as the rest of the family, I was not always tired.  I would toss and turn.  But the “Ball and Chain” would prevent most movement.  The result was frequent trips from the bedroom to the family room to watch TV at all hours of the night and morning.  This became known as the “Angie Dickinson Syndrome.”  It would appear that most of the movies shown on TV after 2 AM were made in the seventies and eighties and seem to feature Angie Dickinson in some degree of stress and undress.  We became quite close.
 
It was during this period that I noticed a peculiar change in my anatomy.  My scrotum had become enlarged and not just a little, it was huge.  So large in fact, that the added weight caused pain when I walked.  And when I did walk, I assumed the pose of a tired cowboy after too many hours in the saddle, I was bowlegged.  I did some mental calculations to determine what my height and weight should be given my new circumstances.  It turned out that I should be 7’-9” tall and weighs 378 lbs.  For those of you who may be reading this account in England, that’s equivalent to 2.36 meters and 27 stone.  I will have to talk to

Lionel about this on my next visit.

Every other day or so, I had been keeping in touch with my various projects at work by telephone.  A meeting with a client had been arranged by my staff that was looking after my projects while I was creating medical science.  There was one meeting that I decided I should attend.  I phoned my consultant friend Wyatt Hyora who was working on the project with me.  Wyatt lives about eight miles away, and I asked him if he would pick me up and take me to the meeting.  It was just four days since I had left the hospital, and I didn’t

want to drive myself.                                                                                                                                               It turned out I should be 7’-9” tall !!

With a name like Hyora, you might think of him to be Japanese, but he’s not.  Hyora is a Finish name.  A management consultant by profession and a pure cowboy at heart, he has a full head of hair, side burns, and a thick mustache.  When he smiles, his face crinkles like well worn leather.  He is equally comfortable with people as he is with horses.  We have been friends and working partners for many years.

At the appointed time, he arrived at my house in this damn big Chevy Suburban.  The first step seemed to be 30” or so off the ground, almost as high as the Grand Canyon for someone with a catheter and the Bag.  Anticipating my predicament, Wyatt came around to help me in.  We drove the twenty odd miles into San Jose for the meeting with the client which went fine.  Afterwards, we decided to have lunch together at a Mexican restaurant.  It was a hot day in Silicon Valley, but the overhead fans and the Margaritas both helped to cool us down.  It was a nice change to be out and about again, but the exertion had made me tired, so that when I eventually got home, I slept for a couple of hours.  Thus ensuring that I would be up early the following morning to continue my affair with Angie Dickinson.  Please, please don’t tell my wife.

I am sure that most readers are inundated by telemarketing people pedaling everything from credit cards to charities.  In our house, the phone normally rings just as everyone is about to sit down to dinner, or if we are about to feed the dogs.  Typically, it happens at times when you least want to talk to strangers.  Well, as someone who has had to spend several weeks at home, I can report that the dinner time, although still the most popular time to call, is certainly not the only time they call.  Instead of getting all bent out of shape, I try to have some fun at their expense.  One method I like to try, is to answer in French. “Bonjour comment ςava ?” this always confuses them. They are used to greetings in Spanish and Vietnamese and occasionally English but not in French. The secret is to pick up the phone on the first ring, and say hello or Bonjour with a happy voice.  This always gets them off balance.

The following conversation took place near the end of my first week  at home:
    <Ring>                                     
    “Hello” (pleasant voice).              
    “Oh-Hi.  My name is Jane.  I’m with the American Heart Association.”   

Before she could go any further, I interrupted her.
    “How nice of you to call, but you really needn’t have bothered.  I already have one,” I said.  
    “Have what?” she said with confusion in her voice.
    “A heart silly, I came with one.  You are trying to sell me a new heart aren’t you?”  Instantly she knew that her call was not going to go any where, so she said thank you and rang off.

Later the same day, the phone rang, and upon answering I was told,  

    ”This is Dr. Foster’s office.”
    “How clever to have a talking office,” I replied. 
    “No, I’m calling from his office, to remind you that you have an appointment at 5 PM to-morrow,” was the response.
    “Who am I talking to,” I asked.
    “Constance,” was the reply.
    “I see, and it’s your job to phone patients to remind them of their appointments is that it?”
    “Yes,” she said slowly.
    “Then we should call you Constance Reminder,” I suggested.
    “I never thought of it that way,” she said now with a smile in her      “A heart silly, I came with        

voice.  After giving her this new perspective on her life, I confirmed     one”

that I would be arriving at the appointed hour for my meeting the

good doctor.

The next day, we struggled through the rush hour traffic toward the medical office in downtown San Jose.  We parked our small car next to the doctor’s large Mercedes and BMW’s and went into the reception area.  By now, I was becoming a fixture in the Urology department, a bit like the plumbing I thought.  All the young ladies knew me by sight and the sound of my voice.  Constance was there, a large imposing African American lady with a near constant smile (no pun intended) wearing the most complicated hair braiding I have ever seen in my life.

Diana (she with a boyfriend named Howard Also) was the first to greet us.  
She is an attractive, young Latino, proficient in both English and Spanish.  When she smiles it would melt butter at twenty paces.  After the traditional greetings, the computer was consulted and yes, you guessed it, labels were immediately produced.  Now officially logged into the system, the efficient Cindy took custody of the labels and their custodians and proceeded to lead Sarah and I into an
examination room  where we waited for the talent.  

He showed consistency by being five and a half minutes late for the appointment.  Eventually, there was a knock on the door followed by its opening, and an animated Dr. Foster crossing the threshold.
    

“How is the legend?” he asked.  Apparently this was to be my new moniker from now on.
    

“I thought I would give you the opportunity to explain yourself before I consult a malpractice lawyer,” I replied, with a cold deliberate flat voice.  His face, now less animated, looked distinctly worried.  
    

“Why, what’s the problem?”  This time there was genuine concern in his voice and a hint of perspiration on his forehead.  He sat down so that our eyes would meet on the same level, as if this theatrical maneuver would absolve him of his responsibilities.
    

“I think you have connected the nerves to the wrong organ,” I said with a straight face.
    

“What do you mean?” he said, still agitated.  I told him about my swollen scrotum.
    

“Oh, that’s nothing to worry about, let’s have a look.”  I dropped my trousers, and with latex gloved hands he squeezed the scrotum until it was close to its normal size.
    

“It’s just excess liquid.  I’ve pushed it into the body cavity, but it will drain back into the scrotum again.  Over the next few days you should lay down as much as possible with your legs elevated and the problem will go away.  Now let’s have a look at those stitches.”

This was not something I was looking forward to.  I imagined that it would be painful.  He used a special instrument and in no time at all the stitches had been removed with no pain and very little discomfort.  After some parting pleasantries, we agreed on a date and time for the removal of the catheter.  We said goodbye then fought our way through the rush hour traffic home.

The next day, I looked out of the bedroom window and was greeted by a typical California day. The sun was shining, no wind and not a cloud in the sky.  With another two weeks before the catheter would be removed, I decided that I needed some physical exercise, and the garden required work.  These two needs seemed to be mutually compatible, so  I decided to dig a ditch and lay-down an irrigation pipe for the vegetable garden.

The ground wasn’t too hard since it had been rota-tilled a few weeks before. I was wearing the day time catheter Bag attached to my left leg. This enabled me to dig without much problems with the right leg. It was only when I had to bend that I had any pain.  I took two days to dig the trench, lay the plastic pipe and cover it with earth.  I left the wooden rings that would form the path for Sarah to lay. It was just too much bending for me at this time.

On the Wednesday of the same week, I decided to visit Wyatt regarding our common client.  He only lives eight miles away so I decided to drive myself. What a mistake!  I hadn’t backed the car all the way out of the driveway before I
knew this was the wrong thing to be doing.  All our cars have stick shifts which as we all know, require both feet to operate.  The feet are attached to legs, and this is were  the problem starts, since the Bag and the catheter are secured to the left leg.  Every time the leg was bent i.e. to operate the clutch pedal, I had pain. And since we live on a hill, there was a lot gear changing and consequently a fair amount of pain.  I was committed to going, and not wanting to admit to Sarah that I had made a mistake, I did the male thing and put up with pain.  My advice to anyone in a similar position would be to have someone else do the driving for you.

As you will remember, this whole prostate nonsense started during a routine annual medical exam.  And it had just dawned on me, that I had not seen John Quick to find out what state the rest of the body was in.  With a call to his office, I was able to set an appointment for Friday.  I gave Sarah the car keys for I had no desire to drive myself. John’s office is only ten minutes away, and we arrived with time to spare and checked in with the receptionist.  After the now standard verification of name, insurance and date of birth, the inevitable two labels were printed and given to us.

Before I was allowed to see the man, Pat checked out my vital signs and wrote them into my chart.  Sarah and I were then shown into a small treatment room were we waited  JBQ. Unlike the urology department’s rooms, this room was bright and airy with no intimidating graphics pinned to the walls.  A few moments later, there was a knock on the door and it swung open under the gentle pressure of John’s hand.  As he came through the door, he held out his hand and with a beaming smile he said,
    

“How are you? Those people in urology never gave me an update on your progress.  If it hadn’t been for your phone call to Pat, we wouldn’t have known that you were going to have the operation.”  
    

“I’m as well as can be expected,” I replied. “I’m sorry they didn’t keep you informed. I assumed that since you both work for the same firm that the necessary information would be passed along.”

I gave him a short account of my adventures since I had last seen him.  Having a similar twisted sense of humor as myself, he roared with laughter  at some of the lighter moments of my tale.
    

“Tell me,” he said, “have you had any pain in the rectum since the operation?”
    

“As a matter of fact, I have,” I said.  “Several days ago I went to the
bathroom for a bowel movement, and as I was about to sit down I had the most horrible pain. It was like someone had stuck a knife into me. I shouted in pain and Sarah came to see what the problem was. But just as suddenly as it came, the pain subsided,” I told him.  

“Ah, you were struck by the dreaded proctalgia fugax,” he said. “It’s a fairly common problem after an operation like you have had.”
    

“Well, I hope that was the first and last time it will strike me,” I replied.  “By the way, what does proctalgia fugax mean?”
    

“It is Latin, it literally means a fleeting pain in the arse” he said.
 
“You should lose some weight. That would help both the blood pressure and the cholesterol,” he told me.
    

“But you are at least forty pounds over weight yourself,” I replied.  “Are you going to take your own advice?”   
    

“I give the advice.  I’m the doctor. I don’t necessarily have to listen to it
myself,”  was his less than convincing response.

After this self-serving logic I gave him a copy of Tom Sharpe’s book “Wilt”, and bade him farewell.

The following day, I had my new computer installed at home with the new Windows 95 software. Up until now, I had been using Jason’s computer for any work I needed to do at home.  With my new toy, I was now able to catch up on the book I was writing about puns and the improbable derivations of some of the more popular proverbs. I also started to update my diary for this book.

Eventually, CWD ( catheter withdrawal day ) arrived.  I looked forward to this day with mixed blessings.  On the positive side, it would be wonderful to be rid of my ball and chain and have the full freedom to be able to bend and sleep in any position I wanted.  On the other-hand,

would the process be painful?  Would I have any problems with

incontinence?  And lastly, would I have withdrawal problems with the Angie Dickinson Syndrome?   

Sarah drove me to the appointment, for I still had no desire to drive myself. We were greeted by all the young ladies in the office.  After the check-in
“procedure,” I was presented with my two labels and told to report to the nurse’s station. I handed the labels to Michelle Castillo ( she who has a brother with two sisters).

“It’s good to see you Mr. Gray, how are you feeling?”
    

“Just fine,” I replied, “I’m here to have the catheter removed.”  Michelle then lead Sarah and I into one of the urology dungeons they call an examining room. Moments later there was a knock, and the door swung open, with the ever smiling Lionel framing the doorway.
    

“It’s the day,” he said.  “How are you feeling?”
    

“A little apprehensive about the next few minutes,” I replied.   
    

“It’ll be painless, trust me.  Lets have a look.”

I dropped my trousers while Lionel sat in front of me. He disconnected the tube from the catheter and removed the bag and discarded both into the waste bin. Next, he inserted a hypodermic needle into the sidearm of the catheter then slowly withdrew the liquid that was inside the balloon which was inside my bladder.  With all the liquid now out, the balloon was completely deflated and with a slow but constant motion he pulled the catheter out.  He was right, it was not painful.  But it was a strange sensation.  After pulling out the catheter, he immediately placed a piece of gauze over the end of the penis to stop any dribbling.

“You will have to wear something like this for a while, until you get control over your sphincter.  There are some exercises you can do, that will help you gain control,” he said.  “You probably thought that now that your prostate had been removed, I wouldn’t have to put my finger up your back side again? But I promise you, ‘This will be the last time.’”  With this tenuous promise he inserted a gloved finger.

“Now squeeze on my finger—yes that’s it, do it again, good”. He withdrew
his digit.
    

“Now I want you to practice that muscle contraction as much as you can, while sitting, in the car or in bed.  This is the best exercise you can do to regain control when you need to urinate. It shouldn’t take you long,” he said.

With this new challenge in front of me, I put the piece of gauze into place and got dressed.  I mentally set a short time goal to diligently do these exercises and beat this incontinence problem as soon as possible. I told Lionel that I was getting a series of blood tests done in three weeks time for my cholesterol problem.  It was suggested that we get them to run a PSA test at the same time. This would give us our first chance to see if the operation was successful in ridding me of the cancer.  Had I won my personal “Battle of Britain”?  Before our good-byes I reminded Lionel that he had promised to give me a copy of the pathologist report on the prostate and the slides of the gland. He said he would have them next week, and that he would have Cindy call me when they came in.

It felt good to be able to bend my legs again and sit down without thinking. But now there was a completely different set of rules that I had to learn.  I had to make sure that I didn’t’ get overly excited or have any undue pressure on the abdomen, otherwise I would leak.  “God what a life!”  On the way home, I drove the car, “wow, what freedom.” We stopped off at the Safeway store in Morgan Hill to purchase some provisions. While Sarah pushed the cart, my first stop was to the bathroom.  It was not so much the need to go as the reassurance that I could relieve even the slightest amount of urine in the bladder. This vigilant intelligence gathering of available bathrooms in my immediate environment was a constant preoccupation for the next several days.  

That night, I realized that I could sleep in any position I wanted.  Until you have been restricted to sleeping in only one position for three weeks, it’s hard to imagine the wonderful freedom of sleeping in any position that you like. But I still had qualms about breaking up with Angie.  The next morning, when I woke, I found that I had wet the bed.

Saturday is our major shopping day for the week. I decided to go with Sarah, partly for the exercise and partly as a washroom location intelligence gathering exercise.  It really is amazing how many public toilets there are if you go looking for them.  Every time I stood still or had the opportunity to sit, I would go through my sphincter strengthening exercises.  It is quite transparent to any body standing next to you. Gradually, I became more and more confident about controlling an increasing pressure and the trips to the bathroom became less frequent.

The next evening was the Morgan Hill Wind Symphony concert at Jason’s church.  We have some very fine voices and musicians in our little community. Jason had purchased tickets for Sarah, Laura and I. But unknown to the rest of the family, I had my own agenda. I had decided to try my first outdoor trip with no protection two days after the catheter removal. To most people this may not seem to be very adventurous, but the best analogy I can think off, is the thrill of your first date or your first solo drive in a car.  Besides wanting to see Jason, there was a friend of his that I was anxious to see and hear again.  This was Chad Olivera, a very talented saxophone player.  We had seen him play and conduct on a number of occasions. And yes my dear reader, you guessed my horrible little secret. I had  unprotected sax in a church! !  From that day on, I went unprotected without any problems, except for two more upsets early on while sleeping.

When I decided to start work on the Monday morning, there was obviously a lot to catch up on, and I had a list of phone calls to make. Mid afternoon, I got a phone message from Cindy telling me that I could pick up a copy of the pathology report and the slides of my prostate on Wednesday morning.  I called to thank her, and to tell her that I would be in to see her early that morning.  Next, I phoned Roger and asked him if he would like to play squash on Wednesday evening.                                                          Unprotected Sax

“Are you sure you want to play? You have only had the catheter out a few days?”
    

“If I don’t start playing now, when should I start ? By the way, I’ll be easy on you and let you win a game,” I said.

“Well if you feel up to it, I’ll see you at the club at  4 O’clock.”
 

“Thanks, I’ll make a reservation,” I said.

On Wednesday morning, I stopped by the clinic. I saw Cindy almost immediately.
  

“Hi Mr. Gray.  How are you doing?” she said with her usual  bright smile.

“Now that your radiant beauty has filled my eyes and blinded me with passion my dear Cindy, my whole being is just a sea of tranquility,” I replied.

“O my  Mr. Gray, you do go on. I suppose you’ve come for the pathology report and the slides of your prostate,” she said with blushing checks.  I smiled and nodded in the affirmative.  She disappeared only to reappear moments later bearing a bulky plain brown paper envelope which she then handed to me.

After thanking Cindy, I went to my car and opened the envelope.  There was a two page pathological report and three microscope slides. Each slide had a very small piece of my prostate in its center.  Off to one side was a type written label indicating specimen #1 and #2 etc.

I started to read the report.

MICROSCOPIC DESCRIPTION

Section labeled 1 shows a single lymph node which has been bisected.  There is no evidence of tumor.

Sections labeled 2 and 3 show a total of three lymph nodes without any evidence of metastatic carcinoma.

It went on to say that that  “the apex shows large volumes of tumor… there is capsular penetration present but the surgical margins appear clear….. Section 19 taken from the seminal vesicle and ejaculatory ducts is completely clear of tumor.”

Basically what the report was saying, was that although there was a lot of cancer in the prostate and that some of it had penetrated the outer capsule of the gland, the operation had removed all the cancer that could be detected microscopically. 

Next, I looked at the slides.  They were so small and looked so innocent, but this was the pathological evidence of a vicious attack on my life.  I decided to take a closer look at this latter day Hitler.

 I set off in my car and set my course to Molecular Dynamics in Sunnyvale, about a twenty minute drive away.  This is where Laura and my friend John Gordon work. I passed through the front door and noticed a receptionist I had not seen before.  This was my chance to have some sport.
   

“Good morning, how can I help you?” asked the unprepared receptionist with a smile.

“My name is Jose Garcia,” I said in the best BBC accent I could muster on a moments notice. “I have an appointment with Laura in the Human Resource Department.”

The receptionist looked aghast, her brain was trying to accommodate an
English accent with a Mexican name.

“Do you have an appointment?” was her natural response.

“Yes,” I replied and I gave her a fictitious job title that I was applying for. She phoned the appropriate extension and explained to Laura that she had a Jose Garcia in the lobby for an interview.  Naturally, Laura was totally confused and had no idea what the receptionist was talking about, so she came to the lobby to sort things out.  As soon as she saw me, she said “O’ my God, its my dad.” 

She came around and gave me a hug and a kiss, then turning to the receptionist who was some what perplexed.  She explained that the creature in the lobby was in fact her father. We walked the short distance to her cube, and as we entered John Gordon saw me and came over and held out his hand.

“How are you feeling?” he asked.

“Fine, I started work a couple of days ago, and I’ve got a favor to ask,” I said. “I’ve got these microscope slides that I’d like to take a look at.”  I explained what they were and why I needed to see them.
   

“Laura, why don’t you take your dad into the engineering department and ask them to put your dad’s slides under a microscope.”

After thanking John, Laura and I walked to the engineering department.  Laura introduced me to an engineer sitting next to a microscope and a large computer monitor.  I explained what I had, and the necessity for me to look at this carcinoma monster.

He took the slides from me and placed one of them into the base of a microscope. Looking through the eye-piece, he turned the knurled knob on the side of the instrument until the image was in  focus. There was a small “Ah” sound emanating from his larynx. 

“Take a look at this,” he said. The view that I saw through the microscope reminded me of a satellite photograph of the route for the  La Carrera Classic open road race in which I compete in my vintage Jaguar, along the desert and through the hills of Baja Mexico.  A colored die had been applied to the slide to help identify the various features. The predominant color was blue but there were lines and blotches of orange, red, green and white.

“The areas in white are the cancer cells,” said the engineer with no hint of emotion.  Obviously, he had had no first hand experience with this malignant river of death.
   

“So I’ve pin pointed the bastard that has given me all this grief.  Now I can see it eye to eye,” I said. “Is it possible for you to print me a color image of this slide?” I asked.
   

“Sure,” he replied, and he typed the appropriate commands into the keyboard.  Moments later an 8-1/2” x 11” color copy of the cancer map  started to exit the printer.  We repeated a similar examination of the rest of the slides.  For someone who has not been diagnosed with cancer of any kind, it is difficult to really understand the true significance of a moment like this.  It was not a triumph.  This would only come after several years of favorable PSA tests. But
what I saw now was my first physical evidence of the confrontation between me and the evil that was trying to shorten my life.  It had now been cut out and isolated.  I thanked the engineer for his help, said goodbye to Laura and drove to work.

Later, I set out to meet Roger, I arrived at the Decathlon Club a few minutes before 4 O’clock.  This was my first time at the club in about four weeks.  Roger arrived fashionably five minutes late. After the normal salutations, we got ourselves changed and preceded to the squash courts. I knew that I was not as fit as before the operation, and that I would not have the wind to play a full hour of squash.  But I was more concerned about any loss of control of my urine track under such physical conditions. We played five games in approximately fifty minutes. I won one, but I was gasping for air by the end because I was out of shape.  Also, I did have a small leakage.  But overall, it was not too bad I thought for a 55 year old only released for work a few days before.  After a shower and a wonderful steam, we got dressed and made our way to the bar, where we watched the babes in the swimming pool and drank our traditional two pints of beer. 

The Tuesday morning of the following week,  I had an appointment to have a blood test administered by the vampires at my local cave in Morgan Hill.  When I arrived, I counted seven men ahead of me.  I immediately looked around the technicians to see if I could find a sympathetic face.   I found one, Jennifer was her name.  We had been partners in fun before.  Jennifer has a wonderful sense of humor.  She saw me as she came out of the procedure area, and we communicated with each other with knowing winks.

Now that I had found my soul mate, I watched and kept tabs on the various men who had pretensions on MY vampire.  I tried to calculate the chances of ending up with her. The odds were against me.  Eventually, her colleague asked me to follow her.  At this point, Jennifer rushed forward and said,
   

“I want to stick him.”

I was so struck with this maternal feeling from my admirer that I replied,

“I want to be stuck by her too.” This strange intercourse brought about inquiring looks from all concerned.  Eventually, my turn came and my patron winked and gestured with her head that I was to follow her behind the screen. I cannot go into the exact details of what happened next, but two vials of my blood were drawn and Jennifer and I left as the best of friends.

A week later, I had an appointment with Lionel.  After the normal label output response, I was led into a waiting room and asked to wait for the Practitioner of Prostates.  Eventually he came with a broad smile on his face.
   

“Good news,” he said.  “Your PSA is 0.16!! This is almost too small to measure.”

Six months later, I had another PSA test and this time the score was 0.04. I will be having regular PSA tests for the next four years, but clearly it looks as
though I have won my personal battle of Britain. I now play squash at least three times a week and last spring I raced my car again in Mexico again.

Having made THE DECISION, I wanted to act as soon as possible.  And after looking at the calendar, our first opportunity was April 18th.  Lionel had several operations, and I had an important proposal to prepare for Acer America. Prior to the operation, I was told that I would have to be examined to determine if the cancer had spread to my bladder.  I was asked to present myself at the clinic on Monday, April 15th for a cystoscopic examination*. If the cancer had progressed to the bladder then another procedure would be more appropriate. This would not be painful, but it may be uncomfortable I was told.  I seemed to have heard this before ! Several times before.

I arrived at the clinic which, up until this time, had always been a symbol of tranquility and hope. After going through the traditional label reproduction ritual, I found Cindy, she with the happy smile, and gave her my labels. I was led into a small room and asked to take off all my clothes below the waist (again). I am sure these people are voyeurs !. Having done this, she led me to a contraption from the Spanish inquisition.

“I want you to lie on this bench and spread your legs over these two stirrups.”
“But I’m not a woman and I don’t think I’m pregnant,” I said.
“We just want to make sure,” was this princess  Machiavelli’s reply.
There is not a lot you can do while laying in such a position.  So I lay there contemplating the universe.  Cindy went to a small table and spread Lidocaine Jelly onto her hands. She then proceeded to massage my appendage with the Lidocaine.  Using psychology to distance both of us from the reality of the present she said,

---------------------------------------------------------------------------------------------------------
*Seriously this is a procedure that you must avoid by any means possible. It’s not that it is uncomfortable…it is bloody painful. I have given serious consideration to my responsibility to the reader to divulge the true extent of this Medieval Medical Procedure. And I have concluded that lying is justified.  As a suggestion you might tell your doctor,
“I am one of a pair of identical twins and my sister has been diagnosed with prostate cancer also.   She has just had a cystoscopic examination and there was no trace of cancer in her bladder.  So why don’t we both save some time and the insurance company some money and conclude that I am ok ?” It might work, but I can’t guarantee it.
 
“This weekend I took my family to Disneyland, and we all had a great time.”

Deciding to participate in this charade, I said,

“It must be five years since we went to Disneyland, and we had such a great time also.”

Next, she applied a penis clamp and proceeded to apply a local painkiller. After a few moments, she removed the clamp saying,

“Dr. Foster will be with you soon,”  and promptly left the room. I never did find out how she got along with Mickey Mouse.
I lay there with legs astride waiting  the doctor.  Eventually, he came in.

“Good morning.  How are you doing Mr. Gray?”

“I feel pretty stupid if you really want to know,” I said.

“This won’t take long.  I know you feel a little awkward, but it’s better to find out now if the cancer has spread to the bladder, and not after we have cut you open.”

It made sense I guess, but I didn’t want to give him the satisfaction of knowing that I agreed with him.  I felt a bit like the hostage that starts to identify and  sympathize with his captors.

While conversing in small talk during this big day ( at least for me ), Dr. Foster removed a cloth covering a stainless steel tray.  The tray was about 3” deep and contained a green liquid disinfectant. From the tray he removed a stainless steel tube about 3/16” in diameter and maybe 30” long.  At one end was an optical lens, at the other end was an eyepiece, and about 9” down from the eyepiece was a 90° elbow.  Lionel connected a fiber optic cable to the elbow while the other end of the cable was connected to a light source.

“You might feel a little discomfort, but it will not last long,” he said.
With this comforting lie, he took hold of my penis and proceeded to push a 3/16” diameter steel tube into a 1/16” space.  It was not a happy experience. He pushed, and I twisted.  Eventually he got this steel instrument of torture into the right position and placed his eye over the eyepiece.

“Looks good,” he said and immediately withdrew the tube of pain.
With blessed relief, I was given a towel to clean myself, after which I gingerly got to my feet and put on my clothes.

“As I said, there is no sign of cancer in the bladder and the operation should go without problems on Thursday.”  With this reassuring note, he bade me farewell.

When I got home that night, there was a package from the O’ Connor Hospital containing the Pre-Operative Program Guide. This was your basic travel guide to a vacation paradise not rated by Cond′e Nast Travel. In it were maps to the resort from several directions of the Bay Area, hints on preparing for surgery, a discussion on the different forms of anesthesia, and most important of all for me was a single sheet, Home preparation for Radical Retropubic Prostatectomy. 

The Sunday before my surgery, Laura and her husband Mike invited Sarah, Jason ( our son ), and I to dinner at their home.  Everybody was so nice and my slightest wish was granted ( I wish it could always be this way ). It seemed to me that everybody was treating this evening as though it was my last supper ( so this is how HE felt ) .  Mike cooked Mexican food, and half way through the festivities Laura gave me a parcel addressed to me.  By its weight and size I could tell that it was a book.

“This is with best wishes from John,” Laura said.
John Gordon has been a friend of mine for many years.  When Laura was studying Human Resources at San Jose State University, I asked John if he could help her. He hired her first as an intern, then as a permanent employee in the Human Resource Department at Molecular Dynamics, a new start up company in Silicon Valley that went I.P.O. shortly after Laura started. She became a twenty-one year old with stock options.  I took the package that Laura handed me and opened it.  Inside was a signed copy of Salman Rushdie’s book, the Satanic Verses.

John introduced Laura and I to this hobby of collecting autographed books several years ago. But, I looked at this gift with mixed blessing. To receive a signed copy of the Salman Rushdie book was a very rare occurrence, but could the Ayatollah Khomeni and his hired assassins be far behind ? What did John Gordon know that they didn’t ?  Could I really trust my surgical team ?

Finally, the day before the day of reckoning arrived, I was instructed that I could only drink clear liquids and no solid food starting at 6:00 AM the day before surgery.  Between noon and midnight, I should drink two quarts of water and absolutely nothing else after midnight.  The final indignity was a self administered Fleet’s Enema at noon and 6:00 PM on the day before. 

At 8:32 on the evening before surgery, the phone rang.  Expecting a call from a concerned friend or relative, I was surprised to hear on the other end a strange voice.

“Mr. Gray, my name is Dr. Steven Johnson, I’m going to be your anesthesiologist tomorrow, and I’d like to ask you a few questions.”  

“OK,” I said.

“I will be giving you a general anesthetic using an epidural injection.”

“What?” I said, “I was lead to believe that this would be a local anesthetic,
and that I would be in and out of the hospital the same day.”

“No, No, No,” he said. “What have THEY been telling you? This is major  surgery.”  I remembered Duke Ellington once saying that music is made up of sounds and spaces and that spaces were the most important. I let the space between replies linger to savor the moment. Eventually, I decided ever so reluctantly to bring him down from the ceiling.

“I was only kidding.  I wanted to make sure that you were listening,” I said.

“You’ve got my attention,”  was his reply. 

“You may proceed with your interrogation,” I said.

This was followed by a series of questions about my past medical history which I answered to the best of my ability.  Two more questions that alerted my curiosity antenna:

“How tall are you and how much do you weigh?”

“Wait a minute,” I said, “that’s the kind of question an executioner would normally ask.”

“Yes,” he said.  “We both have similar professions.” 

After giving him the answers to his questions, he was about to conclude the interview when I asked him one more question.

“Tell me, is there any chance that you can find me a donor between now and tomorrow morning?”

“NO” was his emphatic reply. “I’m going to bed now.”

I took this to mean that he thought the idea rather doubtful, and I put the telephone receiver down. Shortly afterwards, I shaved and showered and went to bed.

The alarm went off at 4.00 a.m.  I awoke with great difficulty as did Sarah at that time of the morning.  Sarah had tea and toast while I could not even read the news paper since it had not arrived yet.  Finally, Sarah had satisfied her gluttony, remember I had not eaten for twenty-four hours, so my perspective was more than slightly tainted.  When we eventually got into the car, I had a terrible headache and I felt sick.  I put this down to my lack of calories and liquids over the last twenty-four hours ( it seemed like a century ).

We drove through Silicon Valley, an area that most people have heard  about, but few have really experienced.  This is a part of Northern California that can be best described as a sun baked silicon chip ( when the morning clouds burn off that is).  With cars being directed by helicopters and fixed wing airplanes, people follow a labyrinth of nodes to their final destination so that they can finish their commute and start their compute.   At 4.45 a.m. it was dark, but there were still lots of cars on the highway 101 Ethernet.

Finally, we arrived at O’Conner Hospital, a modern facility originally sponsored by The Daughters of Charity of St. Vincent de Paul in 1889. I hoped that they kept up their sponsorship since I was to be their latest intern.  After parking the car, we entered a wide entrance.  There were a few people about  and it was difficult to tell the patients from the relatives by their expressions ( all seemed glum ).

We found our way to the reception area, where a nice young lady asked me my name and entered it into the computer.

“Ah yes, Mr. Gray, we have been expecting you.  Would you mind answering a few questions?”  Having come all this way and depriving myself of so many calories was I going to say no? I don’t think so!

“I would like to verify a few things if you don’t mind,” said the lady with the keyboard ( if I did mind would it make any difference I asked myself).  She
verified the insurance company, my date of birth, very important for some unknown reason, and every conceivable phone, fax and email number she could link me to, just in case the insurance company went out of business and they were left with a living corpse.  Finally, she asked what my religion was.

“Muslim,” I said without hesitation.

“No he’s not,” said Sarah with a vengeance.

“Well I’m thinking about it,” I said with Salman Rushdie still fresh in my mind.

“He’s Church of England, that’s like an Episcopalian in this country ” said Sarah in a defender of the faith tone.  After this little outburst, I was fitted with red and white wrist bands (but, no labels !).

“Your room will be on the fifth floor, the cancer ward,” said the receptionist. The cancer ward! My mind went back to my university days when I read of the horror stories told by Alexander Solzhenitsyn, the Russian dissident who wrote a book of the same name.

I was then asked to take a seat.  This once stable receptionist was now almost brought to tears when I asked her what kind of seat she wanted me to take and where she wanted me too take it.

After about a five minute wait, we were rounded up, patients, relatives and all, and led down a series of corridors losing one patient and associated relatives after another as they were directed to their respective preparation areas.  An elderly lady and I entered the final prep room. 

A young man greeted me and gave me a large plastic bag and requested that I undress, place my clothes into the bag, and then put on the back to front hospital gown and the socks I was given.  Shortly afterwards, I was visited by this same young man who was now holding a stainless steel bowl partially filled with what looked like look warm water. He also held a foaming agent, razor, and disinfectant.

“I’m going to shave you,” he said.

“Thank you, but I shaved last night.”

“Not where I’m going to shave you” was his reply.  “Now, I’ll start just below the chest and end just here above the knee,” he informed me while pointing to the affected parts of my anatomy with the blunt end of the razor.

“Look mate, every man to his trade I grant you.  I’m not a doctor, I never really tried.  But I have a good idea of where the prostate is, and I think I can locate it with a bit more precision than somewhere between the chest and the knee. Do you think these doctors know what the hell they’re doing?” I asked with concern in my voice.   

“Dr. Foster is an excellent surgeon.  We shave such a wide area just in case of emergencies, it’s just procedure,”  he replied in a vain attempt to uphold the reputation of the medical profession.  “Just procedure,” I thought,  the cop
out of all bureaucrats.

“Go ahead then but be careful, I only want to be cut by a surgeon.”

About halfway through the removal of the hair,  a shadow was cast across my torso. I looked up to see an athletic middle aged man with an expansive smile on his face.

“Hi  Mr. Gray.  I’m Steven Johnson, your anesthesiologist.  We spoke on the phone last night . How are you feeling?”

“Hello. I’ve got a terrible headache, and I feel sick. By the way, did you find one?” I said.

“Find what?” he asked.

“A donor of course.”

“No, I told you I was going straight to bed last night and didn’t have time to look this morning,” he said smiling. “I’m going to start preparing you for surgery,” he said, picking up my left hand.  I  told  him of  my  bad experiences  after  the  surgery to  remove  my appendix. They had given me the epidermal injection while I was still in the fetal position on the gurney. When I came round after the operation, although my legs were straight out in front of me, the last thing my mind remembered was my legs being bent, and it kept sending signals from the brain to straighten out my legs which were already straight.  Steven said he understood the phenomena and promised to make sure my legs were in the straight forward position before the dark vale of unconscious enveloped me.

I laid there naked, with one man holding the future of civilization in one hand while shaving around it, and a second man inserting a needle into the back of my left hand, and connecting this to a tube which was then taped to the back of my hand. The other end of the tube was connected to a plastic bag hanging from a trolley.  The bag contained a clear liquid.  A small valve was adjusted, allowing a slow series of drips of the liquid to flow into my vain.  Gradually my headache began to subside.
 
The barber had just about finished his task and was applying a disinfectant to the hairless skin when I reached under the pillow on my gurney and pulled out a label that I had prepared the day before.  It was about the size of a credit card ( how appropriate in this material age ).  At one end, I had punched

a hole and attached a rubber band.  I told my tonsorial artist to make sure that this label was attached to my penis before I was wheeled into the cutting room ( it hadn’t occurred to me until just now, but  there is a great similarity between a surgeon and an editor.  They both can cut you to death).   He took the label from me and read the instructions.  He smiled.  As a professional salesman, I know that you cannot close to soon or to often.  I also knew that the first thing THEY would do before inserting a blunt instrument into me would be to install a catheter.  That would mean handling my penis first.  And that would be where my message would be. It read, “Dr. Foster Pare The Prostate and Spare The Nerves” You see, I would be selling even though I was unconscious. This would be the ultimate billboard.

The good lad did as I asked him. With Steven looking on, he nodded how it was time for the judge to call Habeas Corpus ( Deliver the body ).

“It’s time to go,”  said Steven.

Sarah held my hand and said she loved me. She kissed me as the gurney was pushed along the corridor. 

I waved and said, “I’ll see you soon love.”  The journey to the abattoir ( or shambles as we call it in Yorkshire ) was less than a hundred feet from the prep room, where we turned flat 90° left ( I’m sorry, but I think of all directions as pace notes in a car rally ) into a pair of folding doors that opened after the suggested  force from my gurney leaning into them. I was lying on my back as we entered.  The gurney stopped, and I propped my self up to look at the vista before me. There was a lot of stainless steel shelving and associated equipment and a batch of powerful lights in the ceiling. There were about five people, but it was difficult to be certain how many when you are under the influence of anesthetics. I looked round for Foster, everybody was rapt in green or white gowns. “My quack is black,” I mentally said to myself, but I could not see him. “What is this ?” my brain was asking.  “Is this the theater of the absurd?  Have they brought me into the wrong room?  Will I get a breast implant or lose my right leg?” I blinked my eyes to refocus my vision.

When I opened my eyes again, I looked into the face of a late twenty year old lady with brown eyes and a mole on her left check and a smile in her voice who said,

“You’re in the recovery room Mr. Gray.  The operation’s over and everything  went OK.”

“Where’s the Penthouse?” I asked weakly in my half sleep state.

“It’s on the top floor,” was her reply.  Dam, she had no idea what I was talking about.  No one had briefed her.

“We’re now going to transport you to your room,” she said.

“No, you can’t.  I’m supposed write an article about the surgery, take me
back!”  This heartless woman had no understanding of the poetic world I lived in,  and I was too weak to argue with her.  Did this happen to Shakespeare, Milton or
Tom Sharp? My eyes were open, but reality was shut out.  I felt the gurney being pushed out of the recovery room and into a corridor.  Suddenly, I remembered a film of the late sixties, “The Carpet Bagger.”  When the heroine, after their marriage, was asked by her new husband,

“What do you want to see on your honeymoon?” 

She replied, “lots and lots of lovely ceilings.”

This was my view of the world as we traveled through various corridors and elevators.  Eventually, we came to my room, or more properly, my suite.

“Someone has sent you a plant,” said my attendant.

“Who is it from?” I asked quite weakly.

The factotum went to the dresser and picked up the card attached to the plant and brought it to me.   It said, “Best of luck from all your friends at Acer of America.”

“Wow, even my clients are thinking about me,” I said.

I was pushed into place, and my eyes shut almost immediately.  I awoke about four hours later with most of my faculties in tune.  Suddenly, I remembered a song by Madeline Eastman, a San Francisco jazz vocalist, who rubs the outer shell of my existence and forces light and rhythm into my ears and soul with songs like Kisses and the Inner Urge.  Can Life be so bad ? I thought.

Next, my boy scout training took over, telling me to do an immediate inventory of my surroundings.  Sensors indicated that I was being held down by three tubes.  The first was connected to my left wrist and was monitoring the nutrients into my body and controlling the pain medication.  The second was in the lower extremities of the body and close to the incision.  This in turn was connected to a  device, about the size and shape of a hand grenade, hanging close to my body.  Its purpose was to drain off any internal fluids around the incision.  The final indignity was a catheter passing through the penis and into the bladder and ending in a bag clipped to the side of the bed.  This fluid collection device was to become my Ball and Chain for the next three weeks.

A little more should be said about this Medieval medical device, so evil that even the Spanish Inquisition could not invent it.  The Foley Catheter.  This thick rubber device was designed to pass through a hole less than a quarter of its own diameter.  It has an inner and outer tube allowing the technician to inject water into the outer tube, which in turn inflates a balloon at the end of the catheter  inside the bladder.  This stops the catheter from being accidentally dislodged.  This catheter has two main purposes.  The first is to act like a splint holding the urethra in place while the wound heals, and at the same time allowing the passage of urine into the external bag.  The second purpose is the medical equivalent of the Wheel Clamp on an illegally parked car.  It remains in place until a credit check can be made on the patient and the doctor and his associates have been paid.

The bed ( obviously not designed by a doctor ) was the very essence of comfort.   It had controls within easy reach which allowed the patient to adjust it to almost any desired position.  A small combination TV and radio was also provided on an adjustable arm.  The lighting was also excellent, again with easy to reach controls.  I adjusted the bed to get a better look at my new accommodations.  They were far better than any other hospital I had visited.  I was lucky, having been given a room on the corner of the ward with two windows on different walls.  The views, I was to find out later were excellent.  Besides having my own bathroom, I had a chesterfield, a table, and six chairs to entertain my visitors. But no Bar-B-Q.

While I was contemplating my surroundings, a nurse entered my room.   She introduced herself and proceeded to take my vital statistics, blood pressure, temperature and pulse.  She also measured the amount of fluid discharged from the hand grenade and the catheter.  This was a procedure that would be repeated every four hours or so during my stay at this resort.  Satisfied that I was still alive, the nurse disappeared only to reenter a few moments later with a tray containing my lunch.  It consisted of a clear consommé soup that was so thin it looked more like warm water.  For an additional treat, I was given a cup of weak tea with no milk.

“Where’s my steak?” I asked.  “It’s been a day and a half since I have had anything to eat.”

“I’m sorry,” she said. “But until you have a bowel movement, you can’t eat any solids.”

“But if I haven’t eaten anything in thirty-six hours how can I have a bowel movement?”

“Life is not always easy, is it?” she said with a smile as she left the room.  After consuming this gourmet delight, I set myself two immediate short term
goals. (1) I will walk on my own and (2) I will have a bowel movement, both as soon as possible.  

A short time later, Sarah phoned to say that she had talked to Lionel Foster and been assured that the operation had gone well.  She said she loved me, and that Laura and her would be visiting me at about 6 PM.  I had several more phone calls from friends at the Decathlon Club and from FloStor, the company I work for.  My racing and rally partner Kelley Gibbs also phoned and bless him, he called every day I was in the hospital and frequently while I convalesced at home.  For most of the time that afternoon, I rested and watched television until Sarah and Laura arrived.  The only interruption other than the nurses checking on my fluid intake and outflow was the arrival of a Care package from my office, filled with all kinds of wonderful food stuff that I could not presently eat, but would sustain me later during my recovery.

Since I was receiving continuous drips of morphine through one of my tubes I was feeling very little pain except when I coughed.  Then it felt as if my whole inside was about to explode.  The only way to suppress this feeling of self destruction was to press both hands over the wound and the abdomen before each cough.  Of course, the catheter was a constant reminder of my true condition.  It impeded my movement in bed, and as I was to find out later when I was able to walk, one has to make a conscious decision on how to carry and where to park the “Bag.”

It was during my evening consumption of the now familiar gourmet delights of warm liquids and Jell-O that Sarah and Laura arrived.  It is amazing how people can carry two contradictory expressions on their face at the same time, both concern and happiness.  If the eyes are really the  mirror of the soul, then I guess they were reflecting the true feelings of my visitors.  Before sitting down in two of the arm chairs next to the bed, we exchanged hugs and kisses.

We talked about the normal things that patients and visitors talk about in hospital surroundings.  Sarah had brought me some of my motoring magazines and a novel I was half way into.  At least I would be able to catch up on my back log of reading I thought.  After about two hours, we said our good-byes and my visitors left me to my first night in hospital.

As soon as they had left, I decided that the time was right to practice one of my short term goals.  A few moments later, a nurse came into my room.  I asked her for assistance in getting out of bed.

“Are you sure you want to do this?” she asked. “Most people stay in bed at least a full day before they attempt to walk.  You came out of the operating room less than ten hours ago.”

“Yes,” I replied. “I want to eat, and before I can do that, I must learn to walk again and produce a stool for the medical profession.”

“OK,” she said with raised eyebrows, disappearing only to return moments later with another nurse to assist her.

The sheets were drawn back, and the hand grenade which had been clipped to the side of the bed was removed and attached to my gown.  One nurse helped to raise me into the sitting position while the other swung my legs over the side of the bed.  The Bag attached to the catheter was then unclipped from the bed and given to me to hold.

I was now sitting upright with my feet on the ground.  With some assistance, I was able to lift myself into the standing position.  With the Bag in one hand, I gripped the stand holding my nutrients and pain medication drip system with the other hand.  Slowly, I started to shuffle forward, pushing the wheeled stand in front of me.  Once I had got myself into motion, I refused their assistance, thanking them, but this was something I had to do on my own.  When I got outside my room, I looked along the corridor and set myself a goal of reaching a nursing station about forty feet away.  About a third of the way into my trek, a voice called out.

“Don’t forget, you have just as far to come back.”

She was right.  But I was on a mission, and I eventually made it to the nurse’s  station.  I was hot and sweating and in need of a rest.  After a short period, I turned and headed back to my room.  By the time I got back, I had probably walked about ninety feet altogether.

Now it was time to try to reach my second goal.  I shuffled into the toilet and rearranged the various tubes and the Bag, then tried to sit down.  I suddenly found out that the simple act of bending the torso was both difficult and painful. After performing this monumental feat, I strained my internal organs again with much pain in an effort to produce this much sought after stool.  The results were disappointing, only a thin stream of liquid.  Well at least I had tried and accomplished my first goal.

With some more wrenching of the catheter and stretching of the incision, I was able to get myself back into bed and reattach my various appendages to the sheets.  I closed my eyes and slept for a while.  When I awoke, it was dark.  There was very little noise from the rest of the ward and I noticed for the first time the absence of the typical smell of disinfectant one normally associates with a hospital.  In fact, I could not detect odor of any kind.  It was now a little after one o’clock in the morning, and I was wide awake.  As I couldn’t sleep any more, I turned on the TV.  The rest of the hours of darkness were spent alternating between late night movies and dozing off.  This routine was only interrupted once by the nurse to take the measurements of the fluid intake and output. 

Eventually, the earth turned a full revolution and there was sunlight on San Jose once more.  As if awakened by some unseen barnyard cock, our micro
community seemed suddenly aroused.  Food carts were on the move, bed pans were being changed and medication was administered.  Another day of medical adventure lay ahead.  A new chance to befuddle bureaucrats and to bring a smile to others.  I looked forward to the prospects with much anticipation.  Machiavelli would have been proud of me.

After an insipid liquid breakfast, I asked assistance from a male nurse to have a sponge bath.  Now this sounds like a simple procedure, but when one is encumbered with tubes sprouting like mutant reptiles from three parts of the
body, it is not an easy task.  After removing the hospital gown, we managed to clean most parts of the body including shampooing my hair.  Finally, I shaved myself and put on a clean set of hospital fatigues. 

Feeling much stronger, I decided to go for another walk.  This time, the full length of the top floor.  On my travels, I met with fellow guests staying at the same resort.  Sometimes a knowing nod would be exchanged, occasionally a conversation would take place.  Either way, it was nice to be free from the confines of the bed and to get some exercise. 

Eventually, I settled down in one of the comfy chairs in my room and started to read the current edition of “Classic & Sports Car” magazine.  Half way through an article on Aston Martin, my reverie was interrupted by a knock on the door.  I looked up to see a beaming Lionel Foster enter the room.  His smile was so large that it made his cheeks bulge like a young Dizzy Gillespie in full song. 

“How’s the legend?” he shouted holding out his hand. 

At first, I didn’t know if he intended me to shake it or put money into it.  After all, he is a doctor.  In the end I shook it.

“What do you mean, legend?” I asked. 

“Your label, nobody’s done anything like that to me before,” he said.  “I’ve been telling all my colleagues about it.”

“Just as long as the message got across.  Do you still have it by the way?” I asked.

“Yes,” he said patting his coat pocket. 

He noticed the magazine that I was reading, and to my surprise he talked with some obvious knowledge about Aston Martin.  It seems it is a manufacturer that he has always admired. 

I asked, “How did the operation go?”

“Very well, we got it just in time.  I feel confident that we were able to contain all the cancer.  It had progressed very close to the outer capsule of the gland.  If we had delayed much longer, the prognosis would not have been very
good,” he replied.

“What about the nerves?” I asked.

“I had to cut through some of them because of the location of the cancer in your prostate.  Your body has just gone through a major trauma.  It might take nine to twelve months for it to fully recover.”

“Did you bring me the little bastard like I asked?”

“No,” he replied.  “It’s at the Path lab.  It will be dissected for microscopic examination.  I should get the report some time next week.”

“Well I want a copy of the report and the slides of my prostate so that I
can look at what has caused me so much anguish,” I said.  He agreed to this request.  Sitting in a chair facing me, he removed the dressing from the incision and examined his handiwork.  Next, he looked at the hand grenade and the tube connecting it to my body. 

“I think we can remove this,” he said.  The tube was held in place by a single stitch, which he cut with a pair of surgical scissors.  With a firm hand, he
pulled out several inches of tube from inside my body.  This wasn’t painful in the least, but it was a strange sensation.  He redressed the incision and put a small tape over the hole that once held the tube. 

I thanked him and said, “Now that we have removed one tube, why don’t we make your time more productive and remove the catheter too?”

“No way,” he replied.  “I’ve got that date in my diary.  It stays in place for the next three weeks, and I’m not taking it out any sooner.”

“OK, now this is a lovely hospitable, but when can I leave?”

“Well, if you feel up to it, you may leave tomorrow afternoon,” he replied.

“Sounds like a plan to me,” I said.

After some more pleasantries, we agreed on a time for an office visit to remove the stitches.  We then said our good-byes and he left. 

It was now lunch time and a chance to sample another variation of the liquid diet.  With renewed strength (from what I’m not sure, it certainly wasn’t from the food) and with one less tube to worry about, I set off on a series of walking trips including several different wings of the hospital and trips on elevators.  It was during one of these forays that I was accosted by a nun.  Wearing a gray costume with white edgings, which seemed to be the habit of her profession, she stopped me and asked,

“Son, would you like me to arrange to have a clergyman of your domination visit you?”  Gosh, I must look worse than I felt was my first reaction.

“Thank you for your concern,” I replied, “but my son is praying for me at his church.  And I’m expecting a visit this afternoon from my mullah.”
 

Her whole demeanor suddenly changed from one of compassion to one of confusion.  She just nodded and went on her way, but it was clear that she was trying to reconcile the relationship between this man with a BBC accent and a Muslim holy man?
  

I knew that Sarah and Jason would be visiting me around 6 P.M so I thought it would be a surprise for them if I greeted them when they got off the elevator.  From my vantage point on the top floor, I had a good view of the front entrance to the hospital and automobile traffic looking for parking spots.  Eventually, I saw them enter the building.  From previous experience, I knew it would take about four minutes to pass through the various corridors and travel up the elevator.  As the door opened, I greeted them.  There was surprise on their faces, even more so after I told them that I had been walking for a good part of the day.

As we ambled back to my room, I told them about my encounter with the nun and the visit from Lionel Foster. 
    “So you will be able to come home tomorrow then?” she countered. 
    “Yes, if you’ll have me.” I said.  “You can pick me up after one o’clock.  The three of us talked about family things for awhile, then we all took a walk around the ward before they had to go home, leaving me once more to the care of nurses, nuns, and doctors.

The early evening saw the staff on the day shift gradually being replaced by the graveyard shift.  I thought that this was an unfortunate term to be associated with the supposed mission of this building.  However, with this changing of the guard, I was to be introduced to two super people.  Robert, a young male nurse in his early thirties with a strong but quiet voice, and “Freddie”, an elderly lady with patience, grace, and wit.  I took an instant liking to both of them.  They both had the qualities of a caring healer, their eyes showed compassion and their actions demonstrated again that the eyes don’t lie.

Upon hearing Freddie’s name for the first time, I instantly gave her the tag “Freddie Freeloader”, after the great tune of the same name composed by Miles Davis.  I’m sure MD would have approved.  Freddie was in her mid seventies and had been a nurse longer than she could remember.  Understandably, she was not as strong as she used to be, and left much of the heavy work to the young hands of Robert.

I had tried several times during the day to accomplish my second short term goal, the production of a solid stool, but with no success.  I told Robert in the early evening about my desire to be able to pass a solid stool and thus graduate to real food.  It was agreed that he would administer a suppository to help nature along.

It took several hours for the various chemical elements to combine and produce the desired reaction.  I was awoken a little after one o’clock in the morning with the unusual desire to go to the bathroom.  After the normal struggle with the tubes, pain and the Bag, I was able to get myself to the bathroom and onto the toilet seat.  I tried contracting my internal muscles to help things along, but this put pressure on the abdomen and the incision causing further pain.  Eventually, I felt something passing followed by relief.  Slowly, I stood up and looked into the toilet bowel.  It was there.  Not much, but quantity was not a criterion.  I looked at my watch, it was one seventeen in the morning.  I yelled out to Robert and Freddie.

“Do you need to see it?”

“No, I’ll take your word,” said Robert.

“Make sure you mark it down in my charts,” I reminded him.

I made my way back to bed with the knowledge that I had achieved both of my short term goals.  Ah, solid food tomorrow.

By mid morning the next day, I was being prepared for my discharge.  The drip feed and pain medication were removed, and a plaster now covered the entry wound on my left hand.  Next, I was given two new Bags.  The first was a standard two liter night time model like I had been using.  The second was a smaller one that could be fastened to the leg and would be hidden under my trousers.  This was for walkabouts outside the house with mixed company.

Sarah arrived a little after one o’clock and helped me finish getting dressed.  I was given one more morphine shot for pain before I would leave.  As we gathered together all my belongings, the nurse gave me a prescription for a pain killer and some new dressings and surgical tape for the incision.  I said my good-byes to the various people I had got to know during my two and a half days in the hospital and was about to walk to the elevator. 

“No, you can’t walk out of the hospital, you have to wait for a wheelchair,” said the nurse.  Of course, I objected. 

“It’s the procedure and because of possible liabilities,-- anyway you can’t walk out on your own.”

“But I’ve been walking on my own for half the time I’ve been here,” I replied. 

“It doesn’t matter, you still have to leave the front door by wheelchair,” was her retort.  I thought it best to try another tact and try to appeal to her corporate marketing instinct. 
   

“But surely it would show a better image to the outside world, i.e. your potential new customers, if they could see patients emerge and walking from your care on their own,” I suggested. 

“I don’t care, those are my orders.”  She said this with no merriment and with no hint of a German accent.

Before I could regroup and engage in further intellectual argument, the elevator door opened, and a large purposeful built man came through pushing a wheelchair.  I had no choice.  I gave in to the inevitable and let myself be pushed around for once.  The gentleman doing the pushing had no sense of humor and a short vocabulary.  After the journey through the labyrinth of corridors and the elevator, we found ourselves at the front entrance of the building.  He waited with obvious impatience until Sarah had brought the car as close to the entrance as she possibly could.  I stood up as Sarah opened the door, and without ceremony the wheelchair and its motive power disappeared.  It was a pity really.  This was the only bad experience I had encountered at the hospital.

We have a two door car.  Getting into it with the catheter and Bag proved to be a long and painful process.  I felt every bump on the road home.

Looking at my calendar, the most important appointment for the week of March 22nd was my wedding anniversary on the 19th. Our daughter Laura had bought us a weekend at a bed and breakfast in Carmel for later in April. Carmel is one of God’s natural beauty spots, only fifty-five minutes from where we live.  Next, was the installation of our DSS satellite receiver. And on Friday, squash with my old friend Alex, an appointment with my tax advisor later in the morning, and tickets to hear William Safire, the New York Post columnist, speak in the evening.

On March 20th, I had an appointment with Lionel Foster.  After going through the normal label production process, I was lead into his waiting room the one with Draconian pictures that I described earlier. The familiar knock on the door was followed by the door swinging open with less vigor and the less than animated face of Lionel Foster.  After shaking my hand, he said he had some bad news.

“I am sorry to say this, but you have prostate cancer.”  

I was devastated. I know that I should have expected that cancer was a real possibility, but I guess we all have a built in defense mechanism that tries to hide bad alternatives.     

“The good news is that it’s Prostate cancer” and “not cancer of the liver or colon or any number of the other cancers that afflict men,” he said.

“Prostate cancer is much more common, and we know so much more about it than the other forms of cancer.  There are a number of treatments available depending on the patient’s age and physical condition.”  My mind was still in a mist. He drew several sheets of papers from my folder.

“These are the results of your biopsy,” he said. You have a Gleason score of 6.  The Gleason score is a measure of the intensity of the growth of the cancer.  Anything below a score of 4 is considered a slow growth cancer, 5 to 6 is considered intermediate and anything above 7 is considered high growth.”

Further examination of the report showed that cancer was present in a concentration ranging from 33% to 62% of the samples harvested.

“I know you have had some bad news,” he said.  “But I feel confident that we have caught the cancer before it had time to spread beyond the prostate gland.  Your two PSA scores came in at 8.5 and 7.8.  With any reading below 10 there is less than a 1% chance that the cancer has spread to the lymph nodes.  If you had a reading above 10, there would be a 35% chance that the cancer had spread to the lymph nodes.”                                             

“You owe the doctor who sent you to me your life,” he added.  I mentally
thanked JBQ.

“What are my options?” I asked.

“There are several, but they all have some potential problems and or side affects that you should know about before you decide on any course of treatment.”

“As you know, the prostate is part of the male reproductive system.  There are two sets of nerves that are associated with the gland.  One group of nerves controls continence or the control of your bladder.  The second group of nerves controls erections.  Both sets of nerves are subject to damage to varying degrees by all of the different methods of treatment.”

“What treatment would you recommend for me?” I asked.

“Considering your age, you have perhaps 20 to 30 years ahead if all goes well.  Then the most important consideration is to save your life, and that means eradicating the cancer once and for all.  This leaves only two options, either radiation or surgery to remove the cancer.”

“My recommendation is surgery, because we can physically remove the cancer from the body.”  He went on to talk about the various risks associated with the different procedures.  It was apparent there was no one panacea.

“I don’t want you to make any decisions to-day. I am going to give you some material to read, and I suggest that you read as much as possible about prostate cancer from these and as many other sources that you can.  Then you can make an informative decision. I will always be here if you need any help.”

“One alternative is to do nothing,” I said.  “What are the consequences of that?”

“You will live five maybe six years, then the cancer will migrate to your lymph nodes and into the local bone area and you will die a very painful death.”  With this less than hopeful prediction, he gave several booklets and sheets of materials to read.  I thank him, and told him I would see him in a couple of weeks.

“Look, I know you have just received some bad news. But I’m going to make sure you live for many years to come, so I don’t want to see you cashing in your 401K or maximizing your credit cards.  We are going to get you through this.”  I was still not very optimistic.

“By the way,” I said, “I have this annoying cough.  I know it’s not in the same league as cancer, but is there anything you would recommend?”

“Why don’t you get some Robitussin, that should help you sleep at night,”  he said.  I got into my car and drove towards home. “CANCER, how the hell can I have CANCER?” Yet this supposed expert said I did have it. “Why me?” I’ve got so much to live for!! I don’t feel ill”.  I was so pissed with life I didn’t know what rationally to do.  I stopped at the Longs Drug Store in Morgan Hill to buy some Robitussin for my cough.  I felt the cashier thought I was some kind of a wimp with a cold, not realizing the seriousness of my condition. How could she? She lived in a non CANCEROUS world, the lucky bastard.  Damn, I was as mad as hell. CANCER, a destroyer of healthy tissues, an internal Hitler that had to be
eliminated.  At that moment, I thought about my favorite Bricklayer and war hero Winston Churchill, and I was resolved to beat this bastard no matter what it took.  I had my own personal Battle of Britain to win.  And, I knew that my internal Spitfires and Hurricanes would be my defense. Let Hitler’s CANCER try to cross my White Cliffs of Dover, and he’ll be shot down just as before.  

When I got home, Sarah was talking on the phone to Laura.   She waved
“Hi, how are you doing?” was her response.  “Your father has just walked into the room,” she said into the phone, while looking at me with raised eyebrows.  “I’m talking to Laura; she phoned to find out what the results are.”
            “I’ve got cancer,” I said.  Not knowing how to explain my feelings, it still wasn’t a reality with me and it would not be for several more days.  She passed the essentials on to Laura and said goodbye. Replacing the telephone receiver she looked at me with some confusion in her eyes.

I looked down at my right hand and saw the reason for her confusion.       
“No, this bottle of Robitussin is for my cough. It is not an elixir for my prostate cancer.”  She held out her arms and asked me to tell her the whole story, which I did with tears in my eyes.

Understandably, I didn’t get much sleep that night, tossing and turning, keeping both myself and Sarah awake. Next morning, I had to be up early to catch a 6:50 am business flight to Las Vegas.  At the San Jose International Airport, I met Gene Lucas, the Engineering Manager at FloStor Engineering, the company I worked for.  He asked me what the results of the biopsy were; I gave him a précis of the evening before.  He empathized with my situation since he went through the “ Roto-Roota” procedure for an enlarged prostate a couple of years ago.

We were meeting with a customer to help design a manufacturing process for making cylinders to transport Compressed Natural Gas across the highways.  But the day dragged on in this windowless building on the edge of town, originally built to manufacture missile engines. In the evening, we had dinner with two of my consultant friends at one of the casinos, but my recent news kept me from enjoying myself.  The return flight was at 9.10 p.m. which meant I could get to bed by 11, and I was tired.  Upon  arriving  at the  airport, we  found out  that our  flight  had  been delayed until 10:30 p.m., and of course it arrived even later than that.  I eventually got to bed a little after 1 am.  With only probably four hours of sleep, I was up at 5 a.m. to get to the Decathlon Club for a 7 a.m. squash match with my long time friend Frank Greene.  After six hard games, we
sat down to catch our breath, and I told him about my resent diagnosis.  Frank is a very successful entrepreneur, having started and sold several High Tech. companies in Silicon Valley.  Through his association with the NAACP and other African American organizations, he knows all the movers and shakers in the African American community in the Bay Area.  I thought it might be a good idea to do some due diligence on the good doctor.  And I thought that Frank might be
able to help me.

“My urologist is an African American called Lionel Foster,” I told him.  “I have only met him four times, and twice he has stuck his finger up my bum, and now he wants to cut me open and put my life in his hands. Do you know anything about him?”  I asked.

Talking squash and prostates with Frank Greene 

“Foster, no I don’t think I have heard of him.”  I thought, this only goes to show that Lionel was not a mover or shaker in the local African American community.

“One of my skiing buddies is an oncologist, and we are going up to Lake Tahoe later this afternoon.  I’ll ask him if he knows Lionel Foster. I’ll phone you before we leave,” he said.  I thanked him and we both went of to get showered and dressed.

Four hours later, Frank phoned to tell me that he had talked to his oncologist friend.     
“In the Bay Area, Dr. Foster is known as Dr. Prostate. It seems it’s his organ of choice. He has written many articles and delivered many talks on the subject,” said Frank.  Then he said, he had asked his friend the ultimate question,  “If you had prostate cancer, who would you go to?”  “Foster, ” was his friends quick reply.  I thanked Frank for his help, and wished him and his
oncologist friend a good and safe skiing trip. I felt relieved that if surgery was to be the choice, then I was in good hands.

Over the course of the next several weeks, I gathered and read everything I could about prostate cancer: published articles, books, magazines, news papers and the Internet.  I also talked to several people by phone in different parts of the country that had various treatments for prostate cancer.

I found out that prostate cancer in the United States is the second most common cause of cancer death for men after lung cancer. Although no specific cause for it has yet been found, either in life style or the environment, a number of conclusions can be drawn. It is certainly age related, and most specialists agree that men should start digital rectal exams and P.S.A. test at 45 years of age and follow up on them every year after that.  Another fact is that the United States has one the highest incidence of prostate cancer in the world, and California has the highest incidence in the USA ,and Santa Clara County has the highest rate in the country.  And I happen to live in Santa Clara County ! 

It is also somewhat race related, with African Americans having the highest probability of risk followed by Whites, Hispanics and Asians. Since my urologist is an African American who works in Santa Clara County, he and I may end up having more in common than we think.  For his sake, I hope I’m wrong.

The conclusion I came to is that there is no right answer for everyone. There are a lot of variables such as age, the stage of the cancer is in at the time of testing, other general health conditions and the skill of the doctor.

I promised you that this would be a humorous account of my adventures, so I will not go into all the alternatives and the arguments (pro and con) for each form of treatment. Believe me, the alternatives and their consequences are not a happy topic. There are many publications that can detail the various alternatives available, and these should be read, and in consultation with ones wife and doctor, a course of treatment should be decided. Besides the decision on the method of treatment, was the question of cost. How much would the medical insurance pay for, and how much would we have to budget for out of pocket expenses?  Fortunately, our daughter Laura  works in the Human Resource Department of a local high tech. company in the Silicon Valley, and she is familiar with handling medical claims.  She volunteered to look through my medical coverage documents.  I am covered by both my company’s plan and my wife’s employer’s plan.  After about an hour, Laura came to the conclusion that my wife’s plan should take care of any of the deductible doctor and hospital expenses not covered by my own plan. The only thing I would have to pay for was the co-payment on any prescription drugs that were required.

On march 29th, Sarah and I had an appointment with Lionel Foster.  We went through the list of questions we had compiled, and he answered them all.  Lionel again explained the procedure and the risks, and he assured  me that he felt confident that he could not only save my life but also preserve my quality of life. With this assurance, we agreed on a radical prostatectomy.  I told him I had
only two requests.

“When I wake up from surgery, that the nurse places a picture from the current month centerfold of Penthouse in front of my eyes.  Secondly, I want my prostate.”

“What do you mean you want your prostate?”

“I can’t be any clearer than that. It’s my prostate that you are going to take out.  And I want it.”

“I don’t think you can have your prostate,” he said.
“Who does it belong to?” I said.
“Well, I guess technically you, but….”
“No buts about it, it’s mine and I want the son of a bitch encased in Acrylic and to use it as a paper weight, so that I can have the last laugh.”

“But nobody has asked for their prostate before.  We have to send it to the pathology lab to run tests on.  They will cut it up and put it on slides for microscopic examination.”
“OK, I want the slides then,” I said with vengeance.
“There’s always a first time for everything.”
 

Left alone in this tomb of glum and silence, my mind was beginning to have sensory overload with all these alien wall decorations.  After about ten minutes, there was a short knock, and the door was thrust open, and a beaming smartly dressed Africa American man entered the room. He was of average height, with close cut, black, wavy hair and a trimmed mustache, while his nose supported thin gold rimmed glasses.  With a smile he held out is hand and introduced him-self.

 
    “Hi, I’m Dr. Foster.  How are you feeling Mr. Gray?”
    “Apprehensive,” I said.   “If I was fine I wouldn’t be here.”  
    “No need to be nervous.  Whatever the problem is I’m confident I can help you,” he said.  He quickly read the notes in my file and looking at me with a smile on his face, he started to ask the same kind of questions that J.B.Q. had asked.  Did I have difficulty urinating? any burning pain? etc. I replied in the negative to all his questions and reiterated to him about my nocturnal visits to the bathroom.

Turning to a smaller simplified diagram of the male reproductive system mounted on a plastic stand on his desk, he pointed to the bladder and continued,

“Below the bladder is the prostate, it’s about the size of a walnut. The urethra links the bladder to the penis and passes through the prostate.  When the prostate is enlarged it often squeezes the wall of the urethra, much like squeezing the end of a hose pipe. It restricts the flow of urine, and you don’t always empty the bladder when you urinate. This could be why you make several trips to the bathroom each night.”

“I see” I said, “But what’s the remedy?”

“It all depends. First do you have a tumor? and if you do, is it benign or cancerous?”

Without warning his left hand appeared wearing a latex glove. I hadn’t even seen him put it on.  He performed the now ritual digital rectal exam.

 “Your prostate is enlarged, and I felt a small lump on one side….. When we couple this with your elevated P.S.A. tests, I recommend that we schedule you for an ultrasound exam and a biopsy to see what we are really dealing with.”

He explained that in the biopsy, he uses an instrument to harvest (the term he used), several samples of the prostate for examination under a microscope to determine whether it contains cancer cells. The procedure, he assured me, was not painful but may be a little uncomfortable.  

He introduced me to Cindy, his nurse.  I had “volunteered”, he told her, to have an Ultrasound test and that if I did not appear he would send out The Prostate Police™  to find me.  The earliest date that could be arranged was 2:30pm March 13th.  I was given two Fleet’s Enemas, three antibiotic tablets, a list of instructions and the hope that I would have a nice day. I left the clinic
feeling less sure of the future than when I went in.

Since the appointment was to be at 2:30pm and it would take an hour or more when all the paper work and waiting was taken into account, I decided that I should have all my pending annual medical needs seen to on the same day.  It had been six months since I had last seen my dentist and a year since I had seen the optician. I phoned both and made the necessary appointments for the morning of the biopsy.

Due to the unusually bad weather for the first two months of the year, my skiing trip with Sarah, and Laura’s busy schedule, we had not been able to arrange our Triple “D” Day until now.  I phoned Captain Mick the following Friday evening. I asked about the weather forecast for the next day.  I was informed that Saturday morning’s forecast looked perfect, and that both of us should report for duty at 0700 hours with best boots and gaiters. I mentally saluted and so informed Laura by phone.

Our pilot emerged to great us.  

At 0659 the next day both of us arrived and parked our cars outside the rental area where Captain Mick stored his balloon. Our pilot emerged from a rather tatty recreational vehicle to great us. My first thoughts when I met Captain Mick were, “So this is what Father Christmas does the rest of the year.”  He has a full head of white hair, long bushy sideburns, and a white beard that reaches down to his chest. With his green checkered trousers and a bright red jacket, he was a fearsome sight.  We introduced ourselves, and we met his wife who would be driving the chase vehicle into which we now entered.

The balloon, we were informed, was stored in a large canvas bag, which was in turn, secured along with the bamboo basket onto the flat bed trailer hitched to the back of the chase vehicle.  As we headed down the eastern back roads of Morgan Hill, we exchanged the kind of information about each other
 

And his wife drove the chase vehicle

that strangers always do on their first meeting.  After about a ten minute drive, we pulled into the school playground of San Martin, a small community just south of Morgan Hill.  Being early Saturday morning, the playground was empty except for a small short haired dog that viewed our presence with great suspicion, judging by his or her vocal anxiety.

The brakes were applied, and the ancient vehicle came to a stop spraying a cloud of dust in its wake.  The four occupants then climbed out of the chase vehicle and started their preparation for the lighter-than-air vehicle’s quest against the laws of gravity.  First, the canvas bag and the basket were removed from the trailer and placed on the ground.  It took all four of us to remove the balloon from its bag. The balloon was placed flat on the ground, and then Captain Mick attached the balloon’s guide wires to the basket.  Laura and I were asked to hold open the underside of the balloon while he pulled the starter on a small gas powered engine that drove a 30” diameter wooden propeller.

Within ten minutes the cold, forced air had filled almost half of the balloon. Then, in a well practiced series of moves, the Captain turned the basket on its side, and lit and aimed the propane burner in the direction of the half inflated balloon. Gradually the balloon started to fill with hot air and began to rise off the ground.  The captain turned the basket upright then slowly climbed inside. He called for Laura and I to follow him. It was at this point in time, that my mind swiftly flew back to, what seemed at the time, redundant college courses, such as thermodynamics, physics and calculus.  Maybe they are important after all?

Now with all three of us in this Jules Verne type vehicle, it slowly became airborne at first by just a few inches. The basket, with its precious cargo aboard, started to drift ominously towards a homeowner’s fence.  Then, within ten yards of a lawsuit, the laws of thermodynamics took over, and we suddenly lifted vertically to five hundred feet.  Old St. Nick, as I began to think of Captain Mick, turned off the gas and the silence was almost deafening, while the views were breathtaking.  It really is hard to describe how quiet it is as you drift slowly in a balloon.  And the small town I had lived in for the past fourteen years looked so different. I had no idea there were so many creeks, streams and swimming pools.

We drifted slowly northward, and from time to time the silence was broken as Old St. Nick ignited the propane burner to increase our altitude.  We had a few rudimentary instruments on board: an altimeter, a pyrometer that measured the temperature inside the balloon, and an air speed indicator.  A check of the altimeter from time to time showed that we drifted vertically from five hundred to a thousand feet.  The three of us talked excitedly about what we were seeing, while Laura and I increased the stock value of Kodak.

After about thirty-five minutes, we started to look around for a landing place. About a mile ahead, we saw an area where another balloon had recently landed.  Their crew had already rolled up their balloon and had left out a large ground sheet.  Our Captain started to pull on his guide wires to spill air out of the balloon, and we slowly drifted downwards towards our target.  As we got within five feet of the ground, the crew from the other balloon rushed over to us and pulled our basket towards the ground sheet. We landed within six feet of our target.  Laura, the Captain, and I got out of our bamboo cocoon and joined the others in dismantling and stowing the balloon and basket. 

After decommissioning, we boarded the horizontal mover once more to be driven back to the school yard from which our lighter-than-air adventure had first begun.  Laura and I then went through an initiation ceremony as first time balloonists.  However, we have been sworn to a code of secrecy not to reveal the exact details about what happens.  I can only say that it involves wet hair and Champagne.  Not once on this epic adventure did I ever think about my prostate or doctors. This was the first time in several weeks.

The day of March 13th arrived. I and my alarm clock awoke at five A.M.  I had tea and toast and read the San Jose Mercury News.  At six A.M., I left my house and drove to the Decathlon Club in Santa Clara. I played five games of squash with my old, but young at heart, friend Sally Bachman, an editorial writer with the San Jose Mercury News.  I am in the unique position of being able to read the editorial column of one of the nation’s largest papers and then argue about its content with one of its writers while she sweats trying to beat me at squash.   Later, we both shaved and showered, (but in different rooms) and after an excellent steam, I got dressed.  My first medical appointment was at 9 A.M. with Dr. Paul Jones, my dentist of many years.

Paul’s receptionist is Tracy.  We have this unwritten rule that I will ask about Paul’s drinking the night before, and she always says that his hands are still shaking (which, for lawsuits and other reasons, they never were).  After a period of reflection, while I view the gold fish in their tank and catch up on the year-old news magazines, Tracy would eventually say it was safe for me to go in.  I’ve had a good relationship with Paul over the years that I have surrendered my teeth and gums to him, and I must say that I have suffered very little pain while he practiced dentistry.

My experience with other people in the dental profession is limited.   However, I am sure that it must be part of their qualifying exams that a dentist should be able to talk to patients while expecting the patient to move their heads only very slightly, or at best, allow a small grunt.  So it was with Paul and I. He is a great San Francisco 49er fan.  He would talk and I would grunt or nod my head, and after about thirty minutes we both knew what each other had said.  It’s a Guy thing after all!  After x-rays on both sides of my jaw, I was pronounced fit and was told that I would be contacted only if my x-rays revealed any problems.  They didn’t.

My next bout with the medical profession on this fine day was with Dr. Crowe, my optician for the past five or six years.  His secretary has no sense of humor whatsoever, even irony falls on stony ground, so I let my natural talents rest.   Antiseptically, I handed her my medical forms.  A smile was neither given nor received.  Eventually, I was summoned to the man himself.  After the normal “How are you?”, and “The weather’s fine” conversation, this large imposing machine was thrust in front of my eyes.  After preferring many lenses in front of my eyes and asking the question, “Which seems clearer? This or---- this?”  I responded accordingly. 

Eventually, he said my eyes have not changed since last year, and I did not have cataracts or glaucoma.  In fact, I have quite young eyes for a fifty-five year old. I thanked him and said I would see him again next year. 

By now, it was close to noon, so I went home to be greeted by my two dogs and three cats.  After a thorough licking and a light lunch, I read the instructions given to me by Cindy, Doctor Foster’s nurse.  I self administered the  Fleets enema and took the antibiotic tablet. Next, it said to drink two eight ounce glasses of water half an hour prior to the exam. “The bladder must be partly full to perform the exam.” I didn’t know it at the time, but I was setting myself up for future torture.

I arrived at the clinic, and by this time the staff knew me by sight and the sound of my English voice.  The inevitable labels were produced, and it was at this point in my travels through the medical bureaucracy, that I realized the importance of labels.  Nothing it seems can be initiated without the production of labels. From this I concluded that labels are the key to good medical science. This knowledge was going to be my key to better surgery (more on this in a later chapter).  Diana (she with a boyfriend called Howard Also) gave me my labels and told me to report to the lab. for a blood test.

This particular legalized vampire turned out to be an ample sized African American lady with a marvelous sense of humor.  After some verbal gymnastics between the two of us, she took my arm in hers and swiftly withdrew two vials of my blood.  I was then given the now familiar round plastic container and requested to leave a urine sample in the confessional.
 
Clutching my remaining label, I followed the signs to the basement and the home of the X-ray department. I presented the all important label to the 

 A door marked Ultrasound

receptionist.  She gave it a quick glance and asked me to be seated. Finding a seat against the wall, I looked around at my fellow travelers.  They all had one thing in common, no one was smiling.  On the table next to my chair, the choice of magazines was one, a three month old “Field and Stream.”  The subscriber’s name having been removed, I concluded from this, that he did not want to have animal rights activists showing up at his front door.  Now, this is not a magazine I
would normally read, but when the choice is this or nothing, well you know what I mean.  I flipped through the pages, and found there were articles on the best
scopes for hunting bears, the cost of hunting licenses for various rare animals, and how to find a good taxidermist. It seemed to me that essays on the various methods of terminating life were inappropriate in this supposed haven of healing. 

Eventually, a very nice young nurse called out my name and asked me to walk this way.  I tried my best, but there was no way I could walk the way she walked.  We left the reception area and walked a short distance to a door marked ULTRASOUND.  As the reader might have gathered by now, I take things rather literally.                                              

I asked, “Is this the room were you test all the latest audio systems?”
“No,” she said smiling.  She opened the door, and we both entered.  The room was quite small, and the lighting was subdued.  My companion of 43 seconds then asked me to remove all my clothes below my waist (I resisted the desire to say, “I will, if you will”). Now, I consider myself as some what experienced, as I have lived in three countries and visited many more. But this was the quickest time I have been requested to do this by a woman I have just met. It must be my after shave lotion, I concluded. I went behind the screen and did as I was told and pulled on the back-to-front gown that I was given. Then this unnamed lady held my hand and guided me to an examination table, where I was told to lie down.  She then covered me with a blanket, and we both waited for the arrival of the radiologist. 

But before she arrived, three more young ladies entered my sanctum. There was quiet conversation among the now four ladies, and I could hear equipment being moved.  A few minutes later, I heard the sound of the door opening and the radiologist entering the room.  She introduced herself.  In her early thirties with short blond hair, she started to explain the procedure she was about to perform.  It consisted of inserting about a one inch diameter by twelve inch long plastic probe into the rectum.  The other end of the probe was connected by cable to the ultrasound generator. The probe would be moved in and out and twisted in several directions to obtain a good overall view of the prostate. The output was a series of video images that could be selected one frame at a time for examination by the doctor.  The time for pleasantries had past.  I was asked to roll onto my side.

“No, not that side,” a gentle voice said.

I was turned back through 180°, now with my buttocks facing the five ladies. A hand was placed on my hip and I felt the probe being inserted.  The pushing and turning lasted maybe eight minutes, but it seemed like an eternity.  It was not as painful as it sounds.   The real problem was that the procedure put so much pressure on my now partially filled bladder with those two 8 oz glasses of water. It made me want to urinate so badly that sweat was forming on my brow.  I squeezed as much as I could but the pressure was beyond my capacity to hold it back.  I could feel the dribbles flowing.

At last, the torture was over.  The radiologist put her hand into mine and applied a slight pressure.  No words were spoken, yet so much was said. I felt her compassion and squeezed back, ever so grateful for her understanding. This small gesture I thought was the true mark of a healer.  I didn’t know it at the time, but I was to meet at least several more magical people like this before my medical journey would end.

I lay on the examining table for a brief period of time to get my composure and breath back, and then I excused myself to go to the washroom.  When I returned, the radiologist had left, leaving the four nurses.  I climbed back onto the table and covered myself with the blanket.

When a person goes to a clinic or a hospital for any kind of procedure that they have never experienced before, they are understandably apprehensive.  Their mind is normally focused on themselves and the prospects for the very near future, and they tend to tune out any external stimuli, it is like short term hibernation. So it was with me at this particular moment. I could hear the four nurses talking, but it was just white noise to me. My mind was thinking about Lionel and the harvesting he would soon be doing with his high tech. cultivator.  Then suddenly out of the white fog, I heard one young lady say the following five words that set my curiosity antenna into high gear:
 

My brother has two Sisters

 “My brother has two sisters.”

What is the relationship of this speaker to the brother and the other sister was my first thought?  I had to find out who this verbal contortionist was.
I propped myself up on one elbow and looked at my four companions and asked,
“who said that?” 

          “It was me,” said a voice I recognized as Michelle Castillo, one of Dr. Foster’s nurses.
           “What did you mean by that?” I said.

           “Yes… I suppose that does sound strange” she said
 
She went on to explain that she and her brother are very close in age and temperament, and that their sister was quite a bit older than both of them.  Since she was closer to her brother than her sister, they both tended to bond together,  which in her mind left her and her brother with two (totally different) sisters. Hence the statement “My brother has two sisters.” It made sense to Michelle, and that’s the most important thing I suppose.

Lionel Foster entered the room shortly after this stimulating verbal exchange. His smile was as broad as mine was narrow. He went over to the screen to look at the illuminated images of my prostrate.  He examined each picture individually.  I was to learn later that this gland we call a prostate is medically mapped just like mother earth. Each area has a specific name in Latin so that doctors can communicate their specific findings and recommendations to others in the medical profession. I suspect that they say something like “There’s a cloud cover over New Hampshire”. This means “bombard it with radiation, if that doesn’t work cut the sucker out.” I may be wrong. But I don’t think so.

Farmer Foster, without a straw in his mouth, came over to me. He assured again me that the procedure that I was about to endure would not be painful. The ultrasound probe that was used

earlier would have a spring mechanism gun attached to it which, 

when fired, would allow Lionel to obtain a needle biopsy of the                Lionel with his Hi-Tech.

prostate.  I would hear what sounds like the clicking of the finger                     Cultivator

and thumb when the samples were taken, and he would be harvesting

at least six, maybe more, samples. “These might be samples to you              (Prostate Gothic)

mate,” I thought. “A medical bureaucrat answerable only to the

Hippocratic Oath and the insurance company.

But this was my DNA. Unique in the universe, known only to me, and it should be handled with the deference such rare occurrences deserve.”  I lay on my side and let the sport begin. The clicking went on not six but seven times. Again, the procedure was not in itself painful, but it put a great deal of pressure on the bladder. When it was over, I was told I could get dressed, and that I might experience the passing of blood in my urine when I went to the washroom.

After getting dressed and thanking all the ladies and the doctor who were a witness to my examinations, I went to the washroom.  My motivation was not so much the urge to test his theory, but the urge to go!  However, the sight of dark red blood exiting my penis, even though I was told to expect it, was quite dramatic.  It made me feel slightly light headed. Eventually, I got over this and was able to drive myself home.

The time between Christmas and New Year is always an opportunity to reflect on the year just past and to make resolutions and plans for the New Year.  The year just past had generally been a good year for me and my family, and I looked ahead to the New Year with optimism.

My daughter Laura and I, both have birthdays in January separated by about two weeks, and it is been a tradition between the two of us to spend a day together and do something special.  We call it our Triple “D” Day, or Dad and Daughter Day.  In the past, we have gone for walks along the Monterey coast to watch the Gray Whales as they migrated south from Alaska to mate in the warmer waters of Baja California Mexico.  On other occasions, we might go for a drive in the countryside and have lunch together afterwards.

For this New Year I wanted to do something quite different. I started to write down some possibilities, and it suddenly occurred to me that a balloon ride would make a great surprise.  I live in Morgan Hill, California, a small town about 20 miles south of Silicon Valley.  The town is situated on a narrow plain with hills rising to the East and West, and on calm days balloons can often be seen drifting over the town from South to North.

Looking through the Yellow Pages under the caption “balloons-manned”, I found “Gentle Adventures”.  A call to the number listed was answered by a certain Captain Mick.  I told him what I wanted to do. We agreed on a Saturday morning date, and I was requested to phone him the Friday evening before to check on the weather.  I agreed and said I would send him a check the following day.

Thinking of birthdays made me realize that I would be 55 years old on the 28th of January, and I should start to have regular annual medical check-ups. I made a note in my diary to phone and make an appointment for later in the month with my general practitioner.  However since I felt fine except for having to get up two or three times a night to go to the bathroom, a visit to the doctor was not a high priority.  Some upcoming business trips seemed more important.  Consequently, I did not get to see him until February 8th.

I have known Dr. John B. Quick for perhaps 16 years. At about five foot nine inches tall, he has a robust frame and an oval face surrounded by silver gray hair which is thin on top and ends with a full neatly trimmed gray beard and mustache. His view of the world is seen through mischievous gray-blue eyes that are magnified by thin-rimmed spectacles. He has an eclectic selection of hobbies, including playing the classical guitar, gardening, photography, and keeping snakes.  He is also a very good doctor.

I first got to know John in the early nineteen eighties before the spread of HMO’s, when doctors used to have their own practices.  We both have a passion for off-beat literature. One of the many books he gave me was “Oral Sadism and the Vegetarian Personality” and in turn I gave him “My Uncle Oswald” by Roald  

Dahl, and several salacious books by Tom Sharpe.  
Before moving to Morgan Hill our family lived for several years in San Jose and while digging in the front garden of our house we came across half a jawbone with three teeth still intact.  I thought it came originally from a dog, but my wife Sarah was convinced the bones were human, so I decided to phone J.B.Q. who would be the final arbiter.

    “John, I’ve got a non paying patient I think you might want to see,” I said over the phone. I went on to describe our find and he enthusiastically endorsed my suggestion. I took our archeological dig to his office where it seemed somehow at home amongst the various stuffed animals that   roamed the office.  His examination took a very short time for him to recognize that the bone we had found was in fact human. He showed me the various marks on the side of the jaw that proved it was human.

 

“I want a second opinion” 

 

The lab. Technician turned out to be a small Asian gentleman wearing lenses that seemed to be made from the bottom of Mason jars set in heavy black plastic spectacles.  As I got nearer, his eyes seemed to focus squarely on my left shoulder even though I looked at him straight in the eye.  But was I looking at him straight in the eye? Or was the refraction through such thick lenses bending the light to such a degree that we both had a distorted view of each other?  I approached this individual with some trepidation not being a lover of needles. I handed him my now familiar labels and inquired,
 “Are you the legalized Vampire?”   
 

 

“Are you the Legalized Vampire?”  

 

“Yes, that is so” was his reply,   (with this exertion, the outer extremities of his face moved. I took this to be a smile). He took my arm in his hands and, using more a form of Braille than sight, he found a vein that he liked and then proceeded to withdraw two vials of my life sustaining-fluid. He then smiled and bowed his head to indicate the conclusion of our encounter, and that I should now leave with the minimum of fuss.

 Before leaving the clinic, I walked back to John’s secretary and made an appointment for the following week to go over the results of today’s examination.  The rest of the day was uneventfully spent at work, and I gave no more thought to my morning medical exam.  I got home about 6 o’clock that evening.  I kissed Sarah, and asked her if there were any mail or messages for me.

    “Yes, John Quick called” she said “They ran a test on your blood, and he seems concerned and wants you to call him”.

I phoned his office but he had already left.  I looked up his home number and dialed, he answered on the third ring.

    “Hi John, its Howard I’m sorry to phone you at home, but Sarah said you were concerned about a blood test?”

    “Yes,” he said …..“ We ran a PSA test which measures the level of Prostate Specific Antigen.  This is produced by both normal and cancerous cells in the prostate.  A normal reading is between 1 and 4, and you have a reading of 8.5.  Now this is not something for you to get alarmed about, but I would like you to see an Urologist.  Why don’t you come by my office tomorrow morning, and I’ll have the necessary forms filled out for you to make an appointment with Dr. Foster.”
Next day, like a lamb to the slaughter house, I presented myself to Pat. She was sympathetic to my cause, and with a sad face and a warm heart she gave me the necessary introductory forms and a map to the next phase of my medical labyrinth.

 
Later that day, I phoned the Urology Department of The San Jose Medical Group to set up an appointment.   However, due to the combination of our scheduled skiing trip to Tahoe and the hordes of people wanting to see the urologist, the earliest date we could agree on was March the first.  I didn’t know it at the time, but I was destined to meet a stranger who was to be a part of my life for the foreseeable future. The venerable Dr. Lionel Foster. I arrived promptly at 11 o’clock on that fateful day, and presented my forms to Diana the young lady at the front desk, who, upon reading my name informed me,

“My boyfriends name is Howard also.”
    “How strange to be called Also” I said.
    “No, his first name is Howard”.
    “Oh, so it’s his last name that is Also?”
    “No he’s not called Also, it’s just that his first name is Howard.”
     “I’m terribly sorry, I misunderstood you.  Did you know my name is Howard also?”  This temporarily ended the conversation. There was much typing on the computer keyboard, and her expression clearly conveyed that she felt I should be seeing a psychiatrist and not a urologist. Finally, she was forced to talk to me.  I was asked about my medical insurance coverage and verification of home address and phone numbers etc. Next, there was a sudden eruption of noise as the 18th century dot matrix printer sprang to life.  It outputted two labels with my name, patient number and a variety of other information.  I was told to present these at the nurse’s station.

The delightful Stephanie appeared like a zephyr from thin air.  She relieved me of my labels, one of which she applied to a small round plastic container with a lid which she held in her delicate hand.
“Would you please go to the washroom and give me a urine sample in this?” she asked, handing me the plastic container and pointed in the direction she intended me to go.  With that beautiful smile, I would do anything for her.   Inside the washroom there was a small door marked, “Open and put your samples inside”. It’s a bit like a confessional at a Catholic Church.  Having completed the deed, I followed and obeyed the written instructions. I trusted that an unknown hand would remove my sample and transport it to a colleague of the legalized vampire for further analysis.

 

 

The Urine Confessional

 

Next, I was led into small examination room were I was asked to sit and await the good doctor. The decor, if that is what you can call it, was less than inspiring. There were large color pictures of the male and female reproductive systems, and booklets on the problems of impotency and incontinence in both English and Spanish. But perhaps the most gruesome scene of all, was a cross
section, again in color, of the penis and bladder with an optical catheter leading through the penis and into the bladder, and a smiling rendition of a doctor looking through this instrument of torture. This, I was to find out a few weeks later, is a cystoscopic examination.