Salvage radical prostatectomy

Salvage radical prostatectomy

This is Professor David Gillatt's second blog on the site. Here, he talks about the indications for salvage radical prostatectomy for prostate cancer, its indications and some of the difficulties encountered in this rarely performed surgery.

David, can you explain what salvage prostate cancer surgery is?

As we all recognise, unfortunately, in a minority of cases treated for prostate cancer the disease will recur despite that treatment. When a man has had radiation treatment for what appears to be prostate cancer confined to the prostate or its immediate surrounds, some will in time show evidence of the cancer reappearing and starting to progress. This will also happen in the less common situation of the cancer being treated with other local therapies such as cryotherapy, high intensity focussed ultrasound or brachytherapy. The disease comes back either because the treatment failed to control the cancer within the prostate or there was disease already microscopically beyond the gland which will eventually lead to spread. If the recurrent cancer is still within the prostate and detected early it may still be at a curable stage. This is the point at which we can consider salvaging the situation by surgically removing the prostate and the recurrent cancer therein.

If a patient has failed another treatment, what are the factors determining suitability for salvage surgery?

Salvage surgery is a local therapy and as such it will only remove or cure a cancer if still within the prostate. Therefore a judgement needs to be made when recurrence has occurred as to whether the disease has a high likelihood of being localised or are there features that suggest the probability of at least micrometastatic cancer.

Recurrence usually is suspected because the serum PSA begins to rise after falling to low levels after initial therapy. A variety of definitions of recurrent cancer after radiation have been used; the ASCO (American Society of Clinical Oncology) defined failure as the lowest PSA (nadir) after therapy plus 2 units of PSA is the most commonly accepted. This is applied by many to all forms of local therapy, apart from surgery, for prostate cancer.

If recurrence is suspected in my view a thorough search for obvious metastatic disease, including CT chest/abdomen/pelvis, isotope bone scan and occasionally PET scanning is mandatory. MRI and occasionally Choline PET scanning may define local recurrence. Antibody labelled isotope scanning (Prostascint for example) has been evaluated but is not in routine usage. The presence of obvious metastatic disease or locally advanced T3/4 N+ cancer will usually be a contraindication to salvage surgery.

A biopsy is again essential to define local recurrence and may be done once imaging has confirmed that the disease has not obviously spread. Confirmation of local recurrence in the absence of spread may be an indication for salvage surgery.

One further factor that must be taken into account is the behaviour of the patient’s PSA. The PSA velocity or doubling time give an indication of how much risk of progression the cancer poses to the individual over their lifetime. A rapid doubling of PSA, less than every 3 months, confers a high risk of the cancer spreading and resulting in early death. A slow doubling, more than one to two years, indicates a risk as low as perhaps 10 % of the cancer progressing over the next 10 years or more. As with many stages of prostate cancer there is a balance between needing to treat successfully those at high risk of causing damage and death and not over treating those with a very low risk of progress.

In summary a man with prostate cancer previously treated with radiation with PSA evidence of recurrence requires specialist assessment. A variety of factors including the stage of the cancer, the PSA behaviour and the life expectancy of the individual need to be considered before embarking on salvage surgery.

Obviously, this is difficult surgery. Can you outline the side effects of the operation?

This type of surgery, whether performed by the open route, laparoscopically or with robotic assistance is undoubtedly far more difficult and complex than primary radical prostatectomy. The effect of radiation, or indeed HIFU or cryotherapy, results in marked tissue reaction around the prostate. The prostate lies very close to many important organs and the effect of radiation is to make dissection of these areas more difficult and the risk of injury to other structures much more likely. Even when injury does not occur the healing of tissues is less certain following radiation. Collateral radiation effects on the distal urethral sphincter, neurovascular bundles and bladder neck may also make functional recovery slower and long term side effects more likely.

The rectum lies close to the posterior prostate and will often be quite stuck after radiation. Surgical dissection needs to be very careful in this region as injury to the rectum increases the risk of infection, fistula (a connection between the bowel and bladder resulting in urine leaking into the rectum) and the need for a colostomy. While this complication is still uncommon it is more so than after radical prostatectomy with no prior radiation. Incontinence is common in the short term after radical prostatectomy, resolving relatively rapidly in most. After salvage radical prostatectomy, the risk of incontinence is much higher, the time to recovery longer and long-term problems more common. At least 30-40% of men may experience long-term continence issues, some requiring correction, after salvage prostatectomy.

Sexual dysfunction, mainly erectile problems, are very common after salvage prostatectomy as the bundles may well have been compromised by the radiation before embarking upon a difficult salvage procedure. Because of fibrosis (scarring) around the bladder neck subsequent contractures requiring dilatation are common and in some will further increase the chance of long-term continence problems.

Can the operation be performed by laparoscopic or robotic methods?

The answer is yes; salvage prostatectomy can be performed by any of the recognised methods of radical prostatectomy. Is there evidence in favour of one procedure over another? – There is no evidence as there have been no trials comparing the techniques in this situation. As with many difficult procedures the likelihood of a successful outcome will in large part depend upon the experience of the surgical team dealing with the operation.

You are a high volume prostate cancer surgeon, but this is quite a rare operation. How many of these salvage prostatectomy operations do you perform per year?

Salvage prostatectomy is an uncommon operation even in very large busy prostate cancer centres. Even in US centres where 3-6,000 or more robotic prostatectomies have been performed the number of salvage cases is often far less than 100. The Bristol experience has been around 2000 open radical prostatectomies of which around 65 were salvage and over 1000 robotic cases, in 21 cases these were salvage cases. Our outcomes including functional recovery have been very good. However as these numbers suggest, most specialist units are very selective about to whom they offer salvage radical prostatectomy.

One interesting question is should we be considering more men for salvage RP? Undoubtedly the answer is yes. The perceived morbidity of all salvage treatments and the uncertainty as to which men most benefit from this approach has led many oncologists to take an observational approach. It is the urological cancer surgeons’ role to convince our Medical and Radiation oncological colleagues that appropriate salvage surgery can deliver a high chance of cure to men with locally recurrent prostate cancer at risk of progression in their lifetime with acceptable functional outcomes. It is my belief that minimally invasive surgery, in particular robotically assisted LP, offers the opportunity for the experienced prostate cancer surgeon to deliver salvage surgery safely, effectively and with rapid recovery times.

Categories: Other


The Role of the Clinical Psychologist in Prostate Cancer

The Role of the Clinical Psychologist in Prostate Cancer

This week’s Guest Post is by Dr Addie Wootten, a Clinical Psychologist with Australian Prostate Cancer Research and The Department of Urology, Royal Melbourne Hospital. She talks about the psychological impact of prostate cancer on men, and what can be done to help.

The Psychological impact of prostate cancer

A prostate cancer diagnosis, like all diagnoses of cancer, can have a significant impact on psychological and emotional wellbeing. Many men speak about the shock, fear, uncertainty and anxiety they experienced when told they had prostate cancer. Many men also speak about the diagnosis as feeling like it ‘came out of the blue’ as many men are diagnosed with localised prostate cancer without any symptoms of warning. Unfortunately many men experience periods of depression or anxiety following a diagnosis of prostate cancer and emerging data indicates that men with prostate cancer have a higher risk of suicide than other men their age. This indicates the significant emotional impact that prostate cancer can have on some men.

Prostate cancer can have a very personal impact

While the initial shock of a cancer diagnosis can take its toll it is often the side-effects of prostate cancer treatment that men find the most challenging. Unfortunately all treatment options come with their share of side effects, but different treatments will have different side-effects. All treatments will have an impact on sexual and erectile functioning including changes or loss of ejaculation, changes in orgasm sensation, loss of penile length and changes to penile sensitivity but at different levels and rates depending on the treatment type. These side effects can have a significant personal impact for many men as well as a direct impact on their intimate relationships.

For many men the loss of sexual functioning can be even more difficult because of remaining normal sexual desire and this can compound the significant loss and associated impact on masculinity and self-esteem. Urinary incontinence can also have a very personal impact in terms of self-esteem, ability to maintain social connections and the experience of anxiety. Self-esteem, masculine identity and self-confidence can be significantly impacted on by the experience of prostate cancer and treatment side effects.

Managing these challenges

We know from the research literature that one of the biggest predictors of psychological distress post prostate cancer treatment is unrealistic expectations pre-treatment. That is, men who are not fully informed and counseled, pre-treatment, about the impact of treatment on their physical functioning (particularly the sexual impact) will experience much higher levels of distress post-treatment. While this isn’t rocket science the delivery of adequate information and support prior to treatment in preparation for these side-effects surprisingly doesn’t occur all the time. Many men report feeling ill-informed, and unsupported, in navigating life with these side effects.

So what role does a psychologist play in prostate cancer?

As a clinical psychologist I have the privilege of hearing the very personal experiences of men affected by prostate cancer and their partner or spouse. My role in working with these men and couples is to explore the personal impact of their experience and help them weave a new way of living, whether that be a new way of being intimate, a new outlook on life or a new level of emotional awareness.

A large part of my role is to help men and their partners explore what it might mean to experience the side effects of treatment before they have treatment. I try and speak with both members of the couple before treatment to help them plan and prepare for life after treatment and to ensure they fully understand how this might impact on them personally and as a couple. These issues are also the focus of much of my work after treatment.

A clinical psychologist will also be looking out for symptoms of anxiety and depression and other mental health concerns and will provide psychological counseling that focuses on reducing these symptoms and improving emotional wellbeing.

How to access a psychologist

Seeing a psychologist is not routine in most practices but there are many psychologists available in Australia. Ask your specialist or nurse for a referral. If they don’t know of anyone in your local area, check with your GP. If you still can’t find the right person there is an excellent listing of psychologists on the Australian Psychological Society website

To get a rebate back through Medicare you will need a referral from your GP with a mental health care plan. This care plan entitles you to up to 10 rebateable sessions per year.

New online support

I have been working to develop easily accessible psychological support for men following treatment for prostate cancer and I am currently running a study evaluating the benefits of an online support program called My Road Ahead. I am currently looking for men who have had treatment for localised prostate cancer to participate. To learn more go to myroadahead

Another new online program I have been working on is called PROSTMATE. This is an online prostate cancer portal that provides tailored information, a place to record treatments, appointments and track progress and also offers web-based consultations with prostate cancer nurses and psychologists. Follow this link to learn more about PROSTMATE


I would like to acknowledge the men and their partners who I have worked with over the years who have helped me understand the personal loss and the impact of prostate cancer; I would particularly like to acknowledge James Waller in sharing his insights.

You can follow Addie Wootten @addiewootten on Twitter.

Categories: Other


Percutaneous Stone Surgery in the Supine Position

Percutaneous Stone Surgery in the Supine Position

This week’s Guest Post is by Denby Steele, an Adelaide Urologist, an expert in the management of complex kidney stone disease and pioneer of supine PCNL in Australia

"Marberger, Clayman and Whickam, in different parts of the world, were instrumental with the development of percutaneous stone surgery in the late 1970’s and early 1980’s, and for many years this has been performed in the prone position. Extracorporeal shock lithotripsy in the early 1990’s and flexible ureteroscopic laser lithotripsy in the later 1990’s have provided less invasive alternatives for upper tract stone surgery but percutaneous surgery still offers an excellent minimally invasive option, particularly for larger stones.

"Traditionally, percutaneous stone surgery has been performed in the prone position but since the first description of this in the supine position by Valdivia et al in the Journal of Urology in 1998, there have been pockets of interest and increasing expertise in surgery in this position.

"My series of 322 cases published in the Journal of Endourology in 2007 is still the second largest published series, but there are increasing reports from around the world and numerous reviewers and commentators have highlighted the advantages of surgery in this position. Randomised trials have proven the safety, efficacy and time saving.

The supine position for Percutaneous Stone Surgery (PCNL) by urologist Denby Steel

"The supine position was presumably neglected because of fear of colonic injury, but it has been shown radiologically that the colon floats further away from the kidney in the supine position, exposing a greater area for safe percutaneous puncture. With the patient tilted over a 3 litre bag under the flank it is possible to puncture even more posteriorly than some prior prone punctures. There have been no reports of colonic perforation in the supine position in the literature.

"There has been debate about which position is best, but this will depend on the sex of the patient, body habitus, whether concomitant rigid lower tract instrumentation is required, stone burden and position of the colon relative to the kidney. I recommend a 3 litre (1 litre in small patients) saline bag under the ipsilateral flank, a pillow under the ipsilateral leg for males, and lithotomy position for females or males requiring a rigid cystoscopy or ureteroscopy. The ipsilateral arm is always brought across the chest. The flank and perineum are prepared and draped together for a single stage procedure starting with flexible cystoscopy and ureteric catheterisation over a glide wire. The image intensifier is angled back 5 – 10 degrees to allow for the patient tilt. Kidney puncture, tract dilatation and stone surgery are then performed in the standard fashion. I tend to leave a ureteric stent afterwards and drain the bladder but do not leave a nephrostomy tube.

"The supine position is very attractive to nursing staff, anaesthetists and surgeons, and offers the following advantages:

  • Reduced manual handling with no position change
  • No dangerous prone position
  • No patient shoulder strain
  • Single set up and draping
  • Easy concomitant rigid cystoscopy and ureteroscopy
  • Comfortable surgery in the sitting position
  • Reduced radiation to the surgeon as hands not under the image intensifier
  • Increased safety as it is easy to pass a wire through the puncture and out the urethra
  • Stone fragments will spontaneously exit the obliquely placed sheath
  • Reduced operating theatre time
Urologist Denby Steel performing Percutaneous Stone Surgery (PCNL) using the supine position.

"I have performed percutaneous surgery in the supine position in all 680 cases since 1999 and regularly lecture and run workshops in Australia and overseas to promote and teach this simple and improved technique."

Denby Steele is a Urologist in private practice in North Adelaide South Australia, a Senior Visiting Urologist at the Royal Adelaide Hospital, the inaugural Chairman of the Endourology Special Advisory Group of the Urological Society of Australian and New Zealand, the immediate past Chairman of the SA & NT branch of the Urological Society of Australian and New Zealand and an examiner in Urology for the Royal Australian College of Surgeons.

Categories: Other


Cytoreductive Nephrectomy In Clinical Practice

Cytoreductive Nephrectomy In Clinical Practice

David Nicol is a Consultant Urological Surgeon at the Royal Marsden Hospital in London where he is also Chief of Surgery. His clinical work deals with complex kidney and testis cancer including surgery in patients with advanced and metastatic disease. Here, he explains the use of cytoreductive nephrectomy in metastatic kidney cancer.

David, can you explain what is meant by cytoreductive nephrectomy?

Cytoreductive nephrectomy refers to the removal of the primary kidney tumour in patients who have metastatic disease. Historically it had been noted that occasional patients experienced spontaneous regression of metastatic disease when this was performed. This however only occurred in a very small number of cases and general opinion was that cytoreductive nephrectomy as the overwhelming majority died within 12-18 months from metastatic disease. In the late 1980’s and early 1990’s, drugs which stimulated the immune system(immunotherapy) had an effect on metastatic kidney cancer.

Small trials with 2 agents interferon-alpha (IFN-a) and interleukin-2 (IL-2) showed response rates better than what had been observed with conventional cytotoxic chemotherapy. Analysis of these studies suggested that patients who had a nephrectomy performed prior to treatment resulted in a better response to both INF-a and IL-2. The basis for this was uncertain with possibilities including a selection bias with only fitter patients, who would otherwise expect to live longer, having nephrectomy. Alternatively it was also proposed that cytoreductive nephrectomy may exert some biological effect improving the effectiveness of immunotherapy and thus overall survival.

Which patients with metastatic kidney cancer are suitable for cytoreductive nephrectomy?

Cytoreductive nephrectomy is really only an appropriate option for patients who are otherwise well. Patients whose performance status is impaired are at high risk of complications from major surgery and also generally have poor survival that is not improved with cytoreductive nephrectomy. Therefore patients who have noted significant weight loss, are anemic or who feel tired and generally unwell are not considered candidates for cytoreductive nephrectomy. Some patients may present with significant symptoms including pain and bleeding for which nephrectomy is recommended. This is regarded as a palliative intervention to control symptoms rather than a cytoreductive nephrectomy which is performed with the expectation that it may improve survival.

Can you outline the evidence that cytoreductive nephrectomy can be beneficial in some patients?

There are 2 trials – one performed in Europe and another in the United States that have demonstrated a survival benefit with cytoreductive nephrectomy in patients who are subsequently treated with IFN-a. These were both randomised controlled trials - in which patients, who all received IFN-a were randomly allocated to either cytoreductive nephrectomy or no surgery. Comparing the 2 groups which were of equal size revealed that patients undergoing cytoreductive nephrectomy had a median survival of 14 months compared to 8 months without. These studies also reinforced the lack of benefit in patients with poor performance status.

This is obviously difficult surgery. Are complication rates much higher compared to other forms of kidney cancer surgery?

Patients with metastatic kidney cancer usually have quite large primary tumours with a rich blood supply being a common feature. Both of these factors can make surgery very difficult and associated with a higher risk of complications, particularly major bleeding, compared to other forms of kidney cancer surgery. Most patients with kidney cancer have relatively small tumours and are able to have surgery performed either laparoscopically or robotically with low risk of complications. In contrast cytoreductive nephrectomy, in almost all cases, requires major open surgery as minimally invasive procedures are usually neither feasible nor safe. Patients with metastatic cancer are also generally at higher risk of complications with major surgery. Deep venous thrombosis and pulmonary embolism are 2 specific examples of this.

A relatively new treatment for metastatic kidney cancer is a class of drugs called tyrosine kinase inhibitors (TKIs). Is there any evidence that cytoreductive nephrectomy followed with TKIs is beneficial for patient outcomes and survival?

The treatment of metastatic kidney cancer has rapidly changed and now IFN-a and IL-2 are rarely used. Both agents have been largely replaced by a new group of drugs – termed targeted therapies due to their effect as tyrosine kinase inhibitors (TKIs). These drugs have a completely different mechanism of action – rather than stimulating the immune system they target tumour blood vessels. Essentially they reduce the blood flow to tumours.

At this point in time it is unknown whether or not cytoreductive nephrectomy improves the outcome in patients treated with TKI’s. It is important to note that the previous studies on cytoreductive nephrectomy only addressed the question as to whether or not this improved survival when patients were treated with IFN-2. Accepting the lack of clear evidence at this time it can still be considered in some patients. For example a patient who is otherwise well presenting with a kidney cancer and small volume metastatic disease I would suggest a cytoreductive nephrectomy as their initial management. The patient would then be observed, avoiding drug treatment until they show clear evidence of substantial progression of their metastatic disease. The rationale behind this is that TKI’s can have significant toxicity and also that resistance to treatment inevitably develops. By removing the kidney and delaying drug therapy the patient avoids toxicity of treatment and also emergence of resistance at a time when their metastatic disease may be stable or only slowly progressing(ie reserving it for maximum effect when it is really needed).

A different approach to cytoreductive nephrectomy would be considered in the patient with high volume or symptomatic metastatic disease. In this scenario I would not recommend cytoreductive nephrectomy as an initial step. Rather the patient should consider commencing a TKI from the outset. Surgery could delay therapy during which time his disease may progress with an overall deterioration in his condition such that he is never suitable for a TKI (as again these drugs only appear of benefit in patients with good performance status).

Categories: Other


Aerospace Medicine and Urology

Aerospace Medicine and Urology

This week’s Guest Post is by Dr. Gordon Cable, a specialist in Aerospace Medicine, based in Adelaide. He discusses what this specialty involves and its relevance to Urology. He also talks about some of the big names at NASA he has met.

Gordon, can you explain what Aerospace Medicine involves?

Aerospace medicine is a specialty area of medicine that deals with the determination and maintenance of the health, safety and performance of all those who fly in the atmosphere or in space. It is an important specialty because those environments are so hostile to the anatomy, physiology and psychology of humans adapted to an earth-bound existence.

What sort of Urological problems do you encounter, and how do these affect pilots?

Pilots can of course develop any urological problem, just like any other member of the community, but the problem is how those conditions interact with the hostile aviation environment, and most importantly, how they affect a pilot’s performance and safety. Another important consideration is how any treatments for urological conditions might affect pilot performance, whether they be surgical or medications. The aerospace industry is still very heavily gender biased towards males, so mens’ health issues such as testicular cancer in younger males, prostatic hypertrophy and cancer in older males are common problems. Asymptomatic haematuria is a common finding at routine aviation medicals, which must be investigated thoroughly because the biggest showstopper of them all is the potential for renal calculus disease.

Kidney stones are a particular concern. Can you explain how the management of kidney stones in pilots differs from those in the general population?

The primary concern with renal calculi in pilots is the risk of sudden acute incapacitation due to renal colic. The presence of any calculi in the renal tract is bad news for pilots. Generally unrestricted medical certification is not possible, even if there is parenchymal calcification. When stones are present, even if asymptomatic, definitive treatment and proof of stone clearance is required before a pilot will be allowed to fly unrestricted. After an episode of renal colic, the risk of recurrence is also quite concerning, so careful management of stone-forming risk factors is particularly important, as is regular follow-up. Low-dose CT scanning is the preferred method of screening over ultrasound. Dehydration is common in many types of aviation operations, and some pilots are even known to intentionally dehydrate prior to flight so they don’t get caught short in the aircraft! This does not bode well for renal calculus risk.

What are the key areas of research in Aerospace Medicine?

Current hot topics and areas of ongoing work include fatigue management, especially as long haul flying now becomes commonplace with extended range aircraft. Aviation has always been a 24-hour a day industry, and combating the effects of shift work, long hours of “vigilant boredom”, and circadian dysrhythmia across multiple time zones are critical in maintaining pilot performance. The “ageing pilot” is an area of increasing interest with more and more pilots flying into their senior years beyond 60 years of age.

Cardiovascular risk, and determining the subtle effects of altered cognition are important areas of inquiry. Looking beyond earth, commercial space tourism is coming to a Spaceport near you – will you be fit to become an astronaut? This is a big question facing our specialty, and medically risk-managing a large cohort of the general public venturing into the near-vacuum microgravity conditions of suborbital flight is a topic we need to grapple with. Finally, maintaining the health of astronauts for long duration space flight will be essential if we ever intend to land humans on Mars, or travel beyond that on exploration class deep space missions to asteroids and beyond. Here radiation protection and the psychological aspects of isolation are important concerns.

You must have met some interesting people in your work. Who are the standouts?

Gordon Cable with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.
Gordon with Navy CAPT (Ret) Jim Lovell, Mission Commander of the famous but ill-fated Apollo 13.

Attending international conferences in the field always affords the opportunity to meet some really interesting people, even some boyhood heros! I think the highlights have to be the NASA astronauts and flight surgeons I have met over the years. Last year I had the privilege to meet Jim Lovell, commander of the Apollo 13 mission, and Dr Charles “Chuck” Berry, NASA flight surgeon for the same mission. Previously I have met CAPT (Dr) Joe Kerwin, former USN Flight Surgeon and first US physician to fly in space as science-pilot aboard Skylab 2. Dr Story Musgrave, who flew on 6 Space Shuttle missions, attended one of our Australian conferences some years ago and in many ways was the most impressive individual I have ever met – physician, scientist, military and civilian pilot, astronaut – not sure how one can achieve so much in one lifetime!

Gordon Cable: Biography

A graduate of the University of Sydney, Gordon is a specialist in aerospace medicine, and a designated aviation medical examiner for CASA and CAD Hong Kong. His professional affiliations include:

  • Fellow of the Australasian College of Aerospace Medicine
  • Clinical Senior Lecturer, Discipline of Public Health, University of Adelaide
  • Past President/Honorary Member of the Australasian Society of Aerospace Medicine
  • Member of the International Academy of Aviation and Space Medicine
  • Fellow of the Aerospace Medical Association
  • Fellow of the Royal Aeronautical Society

Gordon is a Senior Aviation Medical Officer for the ADF, and has been a consultant to the RAAF Institute of Aviation Medicine since 1996. He has worked part time as a medical officer for CASA's aviation medicine section in aeromedical certification and complex case management. He holds a Postgraduate Diploma in Aviation Medicine from the University of Otago (NZ), and a Graduate Diploma of Occupational Health and Safety Management from the University of Adelaide. The author of many scientific publications, his professional interests include:

  • Altitude physiology of hypoxia and hypobaric decompression illness
  • Hypoxia awareness training of military and civilian aircrew
  • Postgraduate education in aerospace medicine for medical professionals

In his civilian clinical practice Gordon takes a particular interest in the management and certification of complex aeromedical cases, and education of aircrew in health, safety and performance issues.

Categories: Other


Movember ­- Casting a Line for Men's Health

Movember ­- Casting a Line for Men's Health

A Fishing Story

Time flies, and the month of Movember is already halfway over. As my mustache begins to grow, so does my understanding of why it is important for physicians to participate in this global men's health campaign. But before all of that, a quick fish story...

The Woolly Bugger

The Woolly Bugger

One of the many great things about living in Western Michigan, USA, is the fishing. Our lakes and streams are loaded with a wide variety of freshwater fish including salmon and trout. So a few years ago, I decided to learn how to fly fish.

I quickly found fly fishing to be a beautiful and elegant sport. A "fly" is simply a hand-tied imitation of a fish's natural food source. One of the first ties that I was introduced to was the woolly bugger. Depending upon how it is fished, this fly can be used to resemble or imitate a nymph, drowning insect, baitfish, crayfish, shrimp or crab.

Woolly bugger in, and fly rod in hand, it's then a matter of casting, retrieving, and waiting for a fish to show interest and strike.

Fish On!

What happens next is difficult to explain. When the hook is set, the fisherman and the fish become engaged in a conversation by way of the fly line. The fish typically first runs downstream. Then jumps, turns, and tries to find cover, all the while attempting to break the line. Meanwhile, the fisherman keeps steady pressure on the line, either letting it out or reeling it in line, depending upon the actions of the fish.

Sometimes the fisherman is able to land the fish. Other times, the fish escapes. Either way, the experience is not soon forgotten by either the fish or the fisherman.

Fishing to Improve Men's Health

This Movember, I have come to realize, I am fishing for men to take better care of themselves. Toward that end, this ridiculous mustache has become my bait and hook. When patients see my mustache, it breaks the ice.

Suddenly, it's not about me being a doctor, it's about the mustache. The mustache initiates a conversation that might include a Movember specific topic, such as prostate cancer, testicular cancer, and men's mental health. Alternatively, the conversation might center around threats to a patient's long term health, such as untreated obesity, hypertension, diabetes, or sleep apnea.

Sometimes, I am able to reel patients in with these conversations, and they choose to make a positive lifestyle change, or seek additional medical treatment. Other times, patients "get away." Either way, I believe these conversations leave a lasting impression with the patient.

Fishing with Friends

Male urological system

Fly fishing and Movember have one more thing in common. They are more fun when you participate with others. That's why this year I've gone "North of the Border" and joined my friend, Dr. Rajiv Singel's International Toronto East General Hospital Movember Team. If you haven't yet signed up for Movember, or joined a team already, you are welcome to join us.

Signing up is easy. However, if you join our team you will need the post code for Toronto, Canada, which is M4C 5T2.

Mo season runs thru the end of November. However, the conversations it helps facilitate, and the changes it can make in a man's health, can continue throughout the year.

Dr. Brian Stork

Guest post by Dr. Brian Stork. Dr. Stork is a urologist from the U.S. in private practice at West Shore Urology, in Muskegon, Michigan. Dr. Stork has a passion for patient education, healthcare technology and healthcare social media. You can read more from Dr. Stork on his blog, and follow him at @storkbrian on Twitter and Google+ .

Categories: Prostate Cancer


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