SurgeonPROSTATE CANCER SURGERY? Lies, lies and more damned lies.
“Choosing prostate cancer surgery was the worst decision of my life” patient

There is no creditable scientific evidence for significant curative life extension in men treated for prostate cancer through radical prostate surgery/robotics alone.

In addition, this one surgery is associated with more permanent complications than probably any other operation ever, performed on humans.
It’s an operation that is often treated as an emergency, is without merit and is
probably without equal in providing false hope. Unbelievably, this high-risk
surgical technology for prostate cancer treatment was simply given a pass by
the FDA without being rigorously and scientifically evaluated for risk or reward.
The current lack of progress towards a sincere and definitive resolution to
determining which of the few prostate cancers demand treatment, and which
treatment if necessary, is confounded by a preponderance of short term (5-15
years) clinical studies hopelessly jaundiced by treatment philosophies, egos and money. For many men, their small area of prostate cancer (which was never going to behave like a cancer we normally think of) never required treatment.
For many other men, their prostate cancer treatment with surgery/robotics was a journey to hell and back.
The absence of any real significant scientific validation for prostate cancer surgery/robotics in bringing about curative life extension or reduction in prostate cancer-specific mortality, is an indictment against prostate cancer surgeons worldwide and should stop every man in his tracks.2
Lost in all the years of so-called “data” gathering from a multitude of nonscientifically run clinical studies around the world since the radical surgery was first described by Young in 1905, has been the most basic and fundamental issue of whether prostate cancer surgery/robotics actually extends the life of a man afflicted with prostate cancer in a curative manner. That there is no evidence to support surgery for treatment of prostate cancer has not tamed the proponents of surgery from disseminating opaque prostate cancer information where sensationalism, half truths, downright lies, bias, obvious conflicts of interest, use of the word “data” to imply real results and use of marginal statistical significance to misconstrue real benefit has been spun, distilled and re-spun. Much of this socalled “scientific” prostate cancer surgery information now belongs in the category of junk science.
To date, we have no robust supporting scientific evidence from long term randomized trials using validated pathology and imaging (to diminish significant observer error) to say that radical surgery/robotics for prostate cancer results in curative life extension. In place of answering that most fundamental question of “are we doing any good at curing a man from prostate cancer with surgery?”, we have countless articles on the ignorant preoccupation with PSA testing for prostate cancer, along with endless papers on the latest imaging techniques, each desperately attempting to show how they can identify even smaller, probably meaningless areas of prostate cancer. Along with discussions on other mindless trivia, we see a nauseatingly long list of “how to” articles on surgical technique for prostate cancer removal with each egotistical surgeon trying to outdo the previous “gifted” surgeon. At the very pinnacle of these stupefying discussions however, is the apparently serious debacle questioning the relevance of positive margins (cancer left behind) in a prostate cancer operation! This is an unbelievable example of medical defensive posturing and pseudo scientific rationalization.

As you begin your journey on understanding prostate cancer, you should ask to
see internationally recognized, scientifically run, long term, independently
validated radical surgery/robotics studies resulting in significant curative life
extension for prostate cancer. See if this data exists.3
Because of the great potential for negative downstream effects of an abnormal
prostatic specific antigen (PSA) resulting in severe and possibly permanent
complications from testing and treatment for prostate cancer, full disclosure and
consent should be obtained from a man before he agrees to this PSA blood test.
Fundamentally, the PSA test is a flawed screening test for prostate cancer as it
screens more for benign prostatic disease. Its value, however, is in post prostate
cancer treatment monitoring.
At what age should you get PSA tested? Does age, family history and race matter?
New evidence suggests marginal, if any, race difference. What type of PSA testing
should one undergo? What end point should we use and how often do we repeat
the PSA to come to a consensus that it may suggest the need for a biopsy to
determine if cancer is present? How do we determine which of the few cancers
may be significant for a treatment to be considered? What is a proven treatment?
What is a rising PSA after a definitive treatment for prostate cancer? Not
surprisingly, there are almost as many “philosophies” on PSA management and
prostate cancer treatment as there are urologists. A word of caution. Never take
any action based upon just one abnormal PSA.
Once there is a reasonable concern for the possible existence of prostate cancer
and there are no compromising medical or life span issues, a definitive
determination on presence or absence of cancer can only be established through
a prostate needle biopsy.
The complications resulting from all of this testing and treatment as a
consequence of an abnormal PSA and the finding of some prostate cancer needs
to be eyed with great circumspection. Only some 7% of men die FROM their
prostate cancer and therefore, most men just live with their prostate cancer as
most prostate cancers are not lethal. Clearly, prostate cancer is NOT going to
“spread” quickly while you empower yourself on your condition.
Today, many, if not most, of the cancers detected through prostate biopsy after
PSA screening would have gone undetected and would have remained silent and 4
without impact when the PSA was unavailable. The present fervor for PSA
screening is sensationalism at best, without proven benefit, and has simply
resulted in many men undergoing prostate cancer surgery/robotics that was
neither indicated nor needed.
The word “cancer” carries a very significant emotional charge producing
considerable anxiety and leaving one quite overwhelmed. However, the
emotional charge on hearing the words “prostate cancer” is totally out of
proportion to the slow growth and indolent nature of MOST prostate cancers.
Your feelings of disappointment and “why?” and “how come?” and “is it true?”
are natural and very understandable, but your first order of business is to take a
deep breath, relax, and take charge. This “time out” is especially important for
you to assure that your anxiety cannot be manipulated by some “well meaning”
physician. There is no better patient advocate than you, yourself. You must take
charge and be in total control of the slow and methodical information gathering
and remember that treatment, if at all, is not an emergency. Also, understand
that the words “prostate cancer” includes all grades and amounts of prostate
cancer representing a huge mixed bag of prostate pathology so each mans’ cancer
is different.
The anxiety associated with this new diagnosis of prostate cancer, or even
untreated prostate cancer, is totally unwarranted. There are cancers, and there
are cancers, and the majority of prostate cancers are not deadly! Most folks are
not too concerned about a little skin cancer and you are not going to cut off your
arm for a little cancer on the hand. For most prostate cancers, a similar
understanding is warranted. In fact, it may be high time for us to coin another
term for the words “prostate cancer” as the majority of prostate cancers are slow
growing with a cell dividing time of one to two years and unlikely to impact most
men during their lifetime.
The words “prostate cancer”, unlike some other cancers, rarely, if ever, demand
an emergency solution to “do something before it spreads”. Naturally, after 5
hearing the words “you have prostate cancer”, one would think that a quick
surgical removal, especially with a state-of-the-art sounding technique like robotic
surgery is going to solve all of your problems. This belief is both false and
potentially very harmful.
During the normal and mind-numbing disbelief you feel after hearing the words
“prostate cancer”, you may hear many enticing words and terms during your cat
and mouse interaction with your surgeon under the guise of counseling.
First, the dialogue will be filled with a liberal sprinkling of very hopeful terms
designed to lend credence to the wishful concept of curative surgery. You will
hear such terms and words as: “may benefit”, “may reduce complications”, “may
cure”, “curable”, “curative intent”, “curative treatment options”, “curative
intervention”, “definitive treatment”, “survival” (does not mean cure), “survival
benefit”, “survivorship”, “excellent results” (this does not necessarily mean
treatment was appropriate), “may reduce”, “superior outcomes” and “probability
of progression free”. All of these terms sound very hopeful but are very
misleading and just a play upon words. Surgery has never been proven to cure
prostate cancer but continues to be implied or intuitively thought to be
reasonable. Despite ongoing wishful attempts at surgical cure, in many men,
metastatic disease can and often does present some 20-30 years later.
Second, you will hear terms flattering surgery and which seem plausible, but are
absolutely unsubstantiated and simply self promotion. The term “gold standard”
is a very unfortunate, self-anointed, self-serving term, which implies scientifically
established and proven benefits for radical surgery/robotics when the truth is far
from it. Surgery is simply the oldest treatment modality for prostate cancer and,
because of this history, it was deemed “appropriate” by surgeons to anoint their
treatment as the “gold standard” for prostate cancer treatment. However, the
appropriateness of this label for surgery has never been proven with randomized,
long-term scientific studies and, in addition, there were no other prostate cancer
treatment modalities available for many years to challenge the use of this
unworthy moniker. Similarly, the bold-faced claim of surgery being the “first 6
choice” of treatment for younger men, or men who have aggressive prostate
cancer, also belongs in the fairy-tale bin.
Third, you will hear many misleading marketing terms used to glorify the robotic
technology for radical prostatectomy by spinning this robotic surgery as some
unbelievable miracle. These terms include, “state-of-the-art”, “advanced” (high
tech, robotics, minimized operative trauma, enhanced precision, decreased post
operative pain, faster recovery time, nerve sparing, tremor control, optical
magnification) and “minimally invasive” (but still requires hospitalization) as well
as liberal use of the over-reaching superlative, “superior outcomes”. It should be
appreciated that these impressive words and self-serving statements for robotic
surgery have not resulted in any reduction of cancer-specific mortality for
prostate cancer. What the surgeons don’t tell you is that prostate cancer surgery
is solely responsible for the worldwide increase in urinary incontinence and
impotence. Surgery is no panacea for prostate cancer and, rather than providing
curative life extension, for most men it will leave them with one or more lifelong
complications to remind them permanently of their foray with the surgical
treatment. Often, this is for a cancer that did not even need treatment.
Unfortunately, this unforgiving surgery is final and you cannot have your prostate
back should you change your mind. All Prostate Cancer Awareness campaigns
should underscore these concerns about the absence of benefits and the
propensity for after effects and negative quality of life issues from radical
The absence of long-term curative life extension may also exist for the other
definitive treatment modalities like the radiation options, hifu or cryoablation for
localized prostate cancer after thorough review. But because the radical surgical
treatment option for prostate cancer has been with us the longest, and it is
unjustly glorified more than any other prostate cancer treatment modality and
plagued more often by significant and permanent complications, that particular
focus on this option is warranted. Currently, there is a total lack of evidence to
support one treatment modality for localized prostate cancer over another.
Therefore, men should focus on treatment options that result in less
complications and better quality of life.7
There are several moves you can undertake to become informed and empowered
as well as to lessen the complications and negative issues associated with
prostate cancer treatment. First off, you need to send your biopsy slides out to a
nationally recognized reference laboratory so your diagnosis, benign or
malignant, can be validated. Unfortunately, there is some discordance amongst
pathologists at coming to the same diagnosis on the same specimens so you
should only consider further actions on your prostate cancer diagnosis based
upon a consensus of reliable pathology results.
You should always obtain copies of all of your test results and pay particular
attention to the biopsy report, and to where and how much prostate cancer was
diagnosed. If your biopsy report indicates cancer at the base or apex of the
prostate, you should consider having further biopsy evaluation of these areas as
significant tumor volume in these areas may suggest that there is tumor at the
margins of your prostate and that your cancer is no longer organ-confined or
localized to the prostate. The importance of determining the location and volume
of tumor in your prostate is important especially for those men who are still sold
on radical surgery/robotics as it is associated with about a 20-40% positive margin
rate (particularly at the apex), meaning cancer left behind after the prostate has
been removed. In some scenarios, when you add this percentage of positive
margins to the 10% or so of men who develop spread of their cancer after surgery
and who did not have positive margins, you can have a 50% chance of having
recurrent cancer after this complication-ridden surgery. This high rate of
inadequate cancer control is a very important concern and should be researched
before considering the invasive, irreversible, high-risk robotic surgical
No imaging study, such as an MRI, can diagnose conclusively the presence or
absence of prostate cancer. These imaging studies MAY suggest that there are
areas of possible involvement or even that it is clear. However, ALL imaging
studies are affected by observer error and associated with too many false
positives and false negatives. Never, ever consider treatment based upon a 8
supposed cancer from an MRI study of the prostate without pathology
confirmation through a combination of random and targeted (if suspicious areas
are seen) prostate biopsies.
While you are in this stage of coming to grips with the words “prostate cancer”
and attempting to understand your particular disease state, you can safely take
a period of time for a course of active surveillance (AS). This is a great first step
to adopt while empowering yourself with knowledge on localized prostate cancer.
This process of AS is a course of periodic monitoring and examinations every few
months with PSAs and additional prostate biopsies (usually annually or so) to
monitor any possible prostate cancer progression. AS is a common course for men
to follow who have a normal prostate exam, a PSA less than 10ng/ml, a small
number of positive biopsy cores and a Gleason score 6 or less. This initial course
(which may become permanent and lifelong) of close observation can be safely
adopted by many men with a new diagnosis of prostate cancer. One micro focus
of prostate cancer (less than 5% of a Gleason 6 in one core) should never be
treated but simply monitored as not uncommonly, this cancer can not be
confirmed on a future biopsy.
This period of AS is also the time when men should review all the possible
complications associated with the various treatment modalities and especially
those which may be permanent and negatively impact you and your wife’s quality
of life (QoL). Those men who are uncomfortable with a “watch and wait” policy
may decide to abandon the process of AS and seek an alternative definitive
treatment from the ala carte menu of treatment modalities. Men would do well
to consider minimally invasive outpatient treatment options that offer fewer
complications than surgery/robotics but with similar survival benefits.
It is absolutely the patient’s prerogative as to what treatment modality he
chooses, if at all, to treat his prostate cancer. After any diagnosis and especially a
“cancer” label, it is imperative for the patient to empower himself and seek
several opinions. Most of the information given by physicians will be skewed with
bias, but often one is still able to work around this issue as well as the egos of
those in the medical profession offering advice. Second and third or more 9
opinions can be important, however most surgeons offer surgery and most
radiation specialists offer radiation. Do lots of research and reading as well as
seeking the counsel of physicians who will give you time to digest the information.
Finally, not all prostate cancers are the same and you should be very wary of
following the treatment adopted by a friend who may not have been treated
accordingly or has a Gleason score, tumor location and tumor volume different
from yours. It should also be very clearly understood that most men will die
WITH their prostate cancer and not FROM it.
Men given the prostate cancer label need to find the support of a very dedicated,
sincere, empathetic physician who is experienced in the arena of prostate cancer.
Choose one who has an understanding and ability to review your results with you
in a slow, calm deliberate fashion, as well as work through your questions and
The initial approach to dealing with a man who has been given the cancer label is
one of absolute support, sincere empathy and understanding, and to emphasize
that time is on his side. All findings, doubts and concerns need to be addressed
and discussed openly and with opportunity for questions from both patient and
spouse. The patient should undergo an initial risk stratification based on his tPSA
level, Gleason score, tumor volume and estimated stage of disease. Basically,
three risk categories are recognized, Low, Intermediate and High. The
Intermediate category has the following criteria, tPSA of 10-20 ng/ml, Gleason 7
with risk adjustment depending upon number of positive biopsies. The Low and
High risk categories fall on either side of this Intermediate risk category with
respect to tPSA and Gleason scores. However, these criteria are not absolute in
predicting which of the few prostate cancers really need treatment and which
prostate cancers do not need treatment.
The size of the prostate or prostate volume also needs to be reckoned with as
treatment success can be compromised in large prostates and the prostate may
need downsizing before considering a definitive treatment. There should be no 10
rush to “judgment” by the physician. Treatment is not an emergency and a man
should never feel coerced towards a certain treatment modality.
Being able to discuss the various treatment modalities used in localized prostate
cancer and with an ability to address fairly the many potential complications
relative to the perceived benefits of treatment is a very uncommon quality for
most prostate cancer specialists.
Men and their spouses should be given literature on prostate cancer treatment
modalities (realizing that most if not all is biased towards the modality being
featured) and given an opportunity to empower themselves regarding their
disease state and return for follow up with their questions. In the interim, the
specialist should have the patient’s prostate biopsy slides sent to a nationally
recognized reference laboratory for pathology validation so that when the couple
returns with questions, there is a consensus with respect to the diagnosis, tumor
grade and Gleason score and tumor volume. Because many men will fall into the
favorable risk category, the subject of AS can be discussed. In those men who
have a less favorable risk category, particular attention should be paid to volume
of tumor in the apex and base of the prostate. Apical areas of involvement, as
previously discussed, demand particular attention.
Unfortunately, some prostate cancer specialists are not above the deceitful
practice of psychological manipulation of men diagnosed with prostate cancer by
fear mongering and playing the “cancer card”. By misleading them with
inaccurate information (see above, “What your surgeon will say”) some doctors
may steer men to adopt a treatment regimen that is more for the benefit of the
physician than to the patient. The manipulation and exploitation of someone in a
vulnerable emotional state because of the “cancer” label is reprehensible.
Every man expects total curative life extension after treatment of his prostate
cancer, no complications and a full return to normal daily activities and the QoL
he had before the surgery. This happens rarely, if ever, after radical surgery/11
robotics for localized prostate cancer, but it is a naive dream still pursued by
many surgeons.
The prostate cancer arena is a world of inaccuracies and probability estimates.
When a man has been given the prostate cancer label, it is absolutely imperative
that while he empowers himself about his disease, he fully understands that
virtually nothing in the world of prostate cancer is written in stone, and, like the
very questionable merits of prostate cancer surgery/robotics itself, prostate
cancer information is a world bounded by treatment philosophies, misleading
information, rampant self-serving speculation and inaccuracies caused by
pervasive subjectivity. There is a preponderance of marginal and uninformative
information misconstrued as data spiced with vague guidelines and hypothetical
outcomes under the guise of scientific outcome.
Many men considering the surgical/robotic option are never cautioned on the fact
that much of the information in the prostate cancer arena, and especially that on
“surgical success” and “complications” is hopelessly clouded by bias and opinions
(theirs and their colleagues) where doctors are really advancing their own
treatment beliefs rather than management supported by strong scientific trial
data which unfortunately, does not exist. There have never been long term
scientifically run randomized studies comparing treatment in men with equal
amounts of prostate cancer and Gleason score.
Because of this preponderance for “shaky” prostate cancer surgical information, it
is absolutely naive to expect a man or even his internist/ family practitioner for
that matter, to come to an understanding on all of the double-speak of “success”,
“complications” and “survivorship” for so-called “curative intent” radical prostate
surgery/robotics. It must also be realized that the pre-surgical ritual known as
“informed consent” is really nothing more than an exercise in futility leaving
most, if not all men, hopelessly confused, more anxious or downright scared.
Finally, it is even more naive to think that all doctors in the field of prostate 12
cancer have the patient’s best interests in mind. For some physicians this could
represent an oxymoron.
The prostate exam or digital rectal exam (DRE) is extremely subjective (observer
dependent) in terms of feeling an irregularity, lump or nodule. Generally the
accuracy is about that of a coin toss, 50%. Some physicians however, can feel
nodules in nearly every prostate they examine and employ the “cancer” or fear
card to induce men to follow up with the next step, a prostate biopsy. This can
then be a chance to treat an insignificant prostate cancer (“don’t want to let it get
The total prostatic specific antigen (tPSA and PSA are the same) is NOT prostate
cancer specific and generally, INACCURATE as a blood marker for EARLY prostate
cancer. The tPSA can be normal and you can have cancer, and the tPSA can be
high and you can have no cancer. Furthermore, there is no evidence to support
the use of courses of antibiotics to try to “normalize” abnormal levels of tPSA.
The accuracy of the tPSA blood test generally, is about 50%, or like a coin toss.
Whereas only some 30% of biopsies done for tPSAs between 4-10ng/ml (some
labs have different limits) show areas of cancer, some 15-20% or so of men with a
“normal” tPSA under 4ng/ml, have areas of prostate cancer. Many of the small
areas of prostate cancer detected from tPSA screening however, are simply due
to serendipity and from the inherent fluctuations of the tPSA normally and NOT
secondary to the small area of cancer that was detected.
The accuracy of the %free PSA, tPSA velocity, tPSA density, and tPSA doubling
time as well as the PCa3 test, are somewhat more reliable for suggesting early
prostate cancer. Sometimes, downward manipulation of the tPSA is tested with a
3 month course of proscar and if the tPSA drops by about 50%, it is thought that
chances of a prostate cancer being present are diminished. 13
Also, there are many medicines and scenarios including laboratory error that can
influence the tPSA level. Men with an abnormal result should ensure they remove
or resolve those factors or issues that can affect the tPSA result, up or down, and
track several tPSAs and %free PSAs before considering the merits of a prostate
biopsy. In fact, it can be very challenging for both patient and doctor as to when a
prostate needle biopsy to rule out cancer should be considered.
Sometimes tPSAs do not reflect accurately what is going on in the prostate as
some of the rare aggressive prostate cancers do not produce much PSA resulting
in a low PSA, or minimally elevated PSA, giving the patient and physician a false
sense of security. This also happens on occasion after a definitive prostate cancer
treatment and the residual or recurrent prostate cancer has upgraded into a more
aggressive form of prostate cancer producing little or no PSA and misleading
patients and doctors into believing their cancer is still under control when it is
not. Aside from these few uncommon scenarios, post-operative PSA monitoring is
a reasonably accurate method of determining treatment status.
The claim for generalized screening, detection and treatment of prostate cancer
(unlike for cervical cancer) earlier rather than later with the tPSA has never been
substantiated and, up until now, is considered another inaccuracy and misleading
claim in the world of prostate cancer. The perceived benefits of prostate cancer
screening and subsequent treatment with radical surgery/robotics are far
outweighed by its lack of curative life extension, propensity for complications
and a negative impact on QoL. Screening for prostate cancer often represents
pure exploitation of men troubled by the undeserved fear associated with the
words “prostate cancer”. Having men tested and retested provides them with no
apparent health benefits.
ALL imaging tests such as MRIs, x-rays, ultrasounds, CAT scans, bone scans, and
Prostascint scans are UNRELIABLE in determining the EXISTENCE of prostate
cancer. No imaging study to date (not even the MRI) can conclusively diagnose a
prostate cancer. These studies may SUGGEST an area or areas of cancer however.14
The interpretation of all types of imaging studies (like the interpretation of all
prostate biopsy pathology) are affected by “subjectivity” and “observer error”
and/or bias, with different physicians “seeing” different things. Not only does
physician observer error lead to inaccuracies in staging, but all of the imaging
studies are prone to “false positives” (suggesting cancer where there is none) and
“false negatives” (suggesting absence of cancer when it is actually present).
At times, one may be advised to biopsy only the areas of the prostate that appear
to be problematic on an imaging study such as an MRI. Of course, this is naive
because of the propensity for false positives and negatives associated with these
imaging studies. Therefore, if one did have an imaging study suggesting possible
areas of prostate cancer, evaluation should be through targeted biopsies in
addition to performing random biopsies of the rest of the prostate to rule out
cancers that “did not show up” on the imaging study. Sometimes, the “problem”
areas on an imaging test show no cancer and a “normal” area does show cancer.
Other common imaging studies such as CAT scans and bone scans are absolutely
valueless in detecting possible spread of cancer until the tPSA reaches about 15-
20 ng/ml.
The standard 12 core biopsy performed under local in the office or under
outpatient sedation has about a 70% accuracy for identifying cancer (depending
upon the pathologist) compared to step sectioning the whole prostate (when
removed surgically). Biopsying the prostate is the only way one can determine the
existence of prostate cancer. There is NO EVIDENCE for the conjecture that the
needle biopsy of the prostate spreads cancer, especially for early disease.
For men considering minimally invasive options, their prostate margins should be
biopsied to ensure that the cancer is indeed localized to the prostate or organ
confined. For those men considering focal treatment of their prostate cancer, a 24
core biopsy under outpatient sedation should be considered to ensure that the
prostate cancer is indeed focal or unilateral. The 24 core biopsy has a higher
accuracy than the 12 core and because of this increased accuracy, a 24 core 15
biopsy is recommended for men who wish to follow a course of AS. Which of
these areas of cancer are truly significant though, is another story and although a
24 core biopsy may diagnose more insignificant cancers, the 24 core is suggested
for those men adopting the AS course in order to lessen the chances of underestimating his prostate cancer. As the needle core only samples about 0.015 ccs
of prostate, increased sampling numbers may be reasonable for bigger prostates
also, in order to minimize cancer underestimation.
Inaccuracies or mistakes in the taking of your prostate biopsy can come about
through inappropriate prostate measurements, failure to identify prostate
landmarks, failure to recognize possible pathology, improper random sextant
sampling of the prostate usually through inexperienced trans-rectal ultrasound
technique, inadequate prostate needle core length samples, core contamination,
incorrect recording and labeling as well as transport errors. This long list of
concerns is why some men insist on having their buccal DNA swab accompany
their biopsies to confirm that the prostate biopsy belongs to him and no one else.
The diagnosis of cancer from your prostate biopsy is absolutely affected by
“subjectivity” and dependent on which pathologist is looking down the
microscope. The diagnosis of prostate cancer is NOT straightforward, and quite
observer dependant. It is quite possible that you may even be given a diagnosis of
cancer when no cancer exists or vice versa!
Not only is diagnosing the presence or absence of prostate cancer not
straightforward, neither is interpreting the Gleason score, tumor volume and
presence of precancerous lesions in the needle core. If the diagnosis of prostate
cancer was straightforward, we would not find such a discordance between
different pathologists reading the same slides. In fact, the difference in opinions
between pathologists on the same biopsy slides is uncomfortably high.
Furthermore, the same pathologist reading the same slides at a later date is
highly likely to change his diagnosis.16
Most prostates affected by cancer have several areas of involvement. About 75%
of prostate cancers are multi focal, usually with about 4 distinct areas of
involvement but often with one, possibly significant index lesion and several
possibly insignificant satellite lesions.
In order to determine the existence of early prostate cancer, pathologists are
using more and more special stains to aid in the diagnosis. These stains are
diagnosing more and more insignificant prostate cancers and leading more and
more men into unnecessary evaluations, treatments and, potentially, lifelong
complications. Therefore, it is vital for men to seek validation of their prostate
pathology from a nationally recognized reference laboratory to get a consensus
on what’s really going on before considering any further steps towards evaluation
or even considering a definitive treatment.
Finally, if a small area of prostate cancer is verified, most men should simply
consider a course of AS while they take charge and empower themselves. Most
low risk, low volume prostate cancers will never impact your life. Furthermore,
we have yet to discover the ability to reliably identify those few prostate
cancers that could benefit from treatment from the majority of prostate cancers
that do not need treatment.
There is absolutely no consensus on definitions of the various complications
arising from radical surgery/robotics, and your risk from one or more
complications associated with this radical surgery is very high. Trying to obtain
real data on complications is virtually impossible owing to the fact that there is no
standardization and that nearly all, if not all, results on complications are
clouded by self-serving spin to reduce the true incidence.
a) death
The most severe complication in this most unkindest cut of all, is death. The
reason for this is the fact that this surgery, until the early 80s was a primeval
blood-letting exercise and many men died from blood loss. If we use a 30-day
post operative period, the death rate (despite death certificates being unreliable), 17
as has been estimated by Dr. Anthony Horan in his book, “The Big Scare”,
becomes quite significant.
b) recto-urethral fistula
Another severe complication which mercifully occurs infrequently but more
commonly after surgery than any other treatment modality for prostate cancer,
and requires reconstructive surgery for repair, is the recto-urethral fistula where a
hole was made into the rectum inadvertently during surgery. When you
understand that many men with small volume, low grade prostate cancers did
not need this heavy-handed robotic surgical treatment, any death or
complication becomes very significant, and especially when the surgery does
not provide for curative life extension.
c) cancer left behind
Another very significant and frequent complication associated with the radical
surgical removal of a cancerous prostate is that of “residual cancer”. This
complication occurs in some 20-40% of men undergoing radical surgery. The
prostate cancer therefore, was never totally removed. This is a complication so
unbelievably common and contrary to the principles of cancer surgery that this
fact alone should question the validity of radical robotic surgery for the treatment
of prostate cancer. This amazing fact, however, is trumped by the even more
outrageous issue of some surgeons encouraging robotic removal of a prostate
cancer that they know is not localized but locally advanced, and that they know
will leave cancer behind. This travesty goes under the guise of a “debulking”
procedure, and like the “salvage” prostatectomy, is fraudulent as not only does
the prostate cancer surgery alone not provide for extension of life, but a
debulking or salvage procedure certainly does not extend life and only increases
the odds for a host of permanent miserable complications.
d) limp and leaking
An area particularly beset with doublespeak and lies are the various
interpretations of the words “incontinence” and “impotence”. These are words
that used to be self explanatory but are now hopelessly subject to self serving 18
physician interpretations and non-standard definitions, simply to keep these
horrible after effects out of the usual and common complication column
associated with radical prostate cancer surgery/robotics.
These two words, incontinence and impotence, are very troubling issues to deal
with both for surgeons and patients. The surgeons want to pretend that these
problems hardly ever occur after “their” surgery, while men, who now live with
the problems as well as deflated feelings of manhood, simply want to forget
about their disappointments. Men affected by the surgery in this way just don’t
feel complete anymore. This scenario is like a win-win situation for surgeons
allowing them to exaggerate their “good results” and affected men, too
embarrassed to admit to their disappointments and too dejected to challenge the
so-called “good” results.
i) diapers and clamps
Urinary incontinence is a complication no matter how it is defined. Of course,
surgeons have adopted less stringent definitions again to exaggerate their “good”
results. The urinary leakage or urinary incontinence complication is
extraordinarily common (but less common depending upon how you define
incontinence) and varies in degree. The big problem is in understanding the
difference between what the surgeon believes to be incontinence compared to
the normal understanding of incontinence meaning even the spillage of one drop.
Unfortunately, many surgeons have forgotten this usual and customary definition
and have made up their own so that in their terms you can still spill, leak, use a
clamp or use more than a pad or diaper per day and still be dry!
The fundamental reason why the prostate cancer surgery necessarily results in
urinary leakage of some form is simply because of the two cuts required for
removal of the prostate. The cuts, one close to the urethral sphincter level and
one at the bladder neck level totally divides the smooth muscles at these levels.
Some contiguity of these muscles is required for normal urinary continence. If
either one of these areas is maintained, urinary control may be preserved
normally but, as the whole prostate is removed in radical surgery, normal function
and control is never possible. Irrespective of the surgical technique (conventional 19
or robotic) for prostate cancer removal, it is the fundamental act of cutting and
disrupting these smooth muscle fibers that involve the bladder neck prostate and
external sphincter that leads to urinary leakage. These smooth or slow twitch
muscle fibers cannot repair or regenerate themselves to resume the normal
urinary function and urinary control they had before radical surgery/robotic
After removal of the prostate, the urethra is joined to the area where the bladder
neck existed, and a controlled scar or stricture is created. A scar never functions
like muscle. This area or join, gives some men a semblance of control but it is not
a normal return of smooth muscle sphincteric function as many men will leak on
straining or sneezing, as well as leaking urine during an orgasm if lucky enough to
have some return of erectile ability. Commonly, there will be incontinence post
operatively but as the area of the join closes down an improvement in urinary
control is often noted. However, if the scarring continues even further, urination
can become difficult and urinary tract infections, bladder stones and even urinary
retention because of bladder neck contracture, may occur. In order to treat this
complication, this contracture or scar will need to be opened. After this, urinary
leaking usually resumes. In a few men, urinary control may be better than
anticipated because the surgeon has purposefully left the apex of the prostate
(and probably some cancer) attached to the urethral sphincter to minimize the
disruption of the muscle fibers.
ii) shorter, softer and less of a man
Another significant complication bragged about in clinical studies as “rarely”
occurring is that of impotence, loss of erections, loss of sexual activity and loss of
manhood. This definition too has undergone much self serving revision and the
standard understanding amongst all men (except maybe prostate cancer
surgeons) of getting a “hard on”, being able to get it “in” and “come” now has a
variety of meanings clearly designed to have the surgeons’ results with so called
“nerve sparing” and “preservation of function” appear more favorable than
actually occurs.20
For a normal, healthy, pleasurable sex life, genital/sexual anatomy needs to be
intact. Clearly, the act of cutting out the prostate cancer through the radical
surgery/robotics will not leave your anatomy intact and will impact your sex life,
resulting in one or more of the following: lack of libido and spontaneous sex,
penile pain or absence of penile sensation, loss of penile girth, loss of penile
length, a decrease or loss of penile rigidity, lack of seminal fluid on ejaculation,
sterility, altered orgasm or the discharge of urine during orgasm if by a stroke of
good luck some erectile function is maintained. Surely, it is not surprising to
discover that after their radical prostate cancer surgery, many feel less of a man.
The cutting and removal of the prostate is responsible for the loss of semen
production as well as responsible for ejaculatory issues. The disruption of the
adjacent nerves and blood vessels invariably impacts the quality of erections
resulting in either incomplete or total loss of erections and impotence. This nerve
damage resulting in loss of erections often occurs despite the laudable concept of
“nerve sparing”, an approach which is more academic and philosophical than
real. In some men, however, there may be a resumption of erectile ability, not by
surgical design or dexterity but because the nerves for erection took an atypical
route and were therefore undamaged from the surgery. Invariably, however,
most men will be left with a penis requiring medicines or devices to achieve some
fullness of the penis post operatively and “stuffability” after radical
surgery/robotics. This is certainly not the normal sexual function you had before
the surgery.
An additional insult associated with the radical surgical procedure is the
shortening of the penis by 1-2 cm. This is another complication that is said not to
happen but it is obvious to all men (except prostate cancer surgeons) that when
you remove a prostate of at least 2cm and attach the urethra to the bladder, you
may lose some 2 cm of length.
e) what QoL?
This destruction of manhood and effective emasculation by the radical robotic
prostatectomy under the guise of a cancer surgery is, not surprisingly, associated 21
with a basket of psychological issues that also affect the spouse, their partnership
and QoL.
Clearly men will appreciate that you cannot possibly be “whole and normal” after
surgical removal of an organ that was necessarily important in the first place for
normal urinary and sexual function and why most will feel a loss of manhood after
radical prostate surgery. The preponderance of papers discussing the fairy tale
post operative management of “bladder and penile rehabilitation” leading men to
believe that they will return to “normal” is quite astounding. Now, remarkably,
surgeons have instituted preoperative counseling of men to prepare them for
their disappointment postoperatively. Admittedly, there are some men who have,
through a tincture of time, apparently “normalized” their urinary and sexual
dysfunction after radical prostatectomy. However, this occurrence is often more
from good luck than any great technical robotic expertise. Just like some can slip
out of a hangman’s noose and live to tell the tale, some men have reasonable
erections and urinary control. This occurrence, along with a prostate cancer
removed with clear margins, has allowed some surgeons to crow that they (the
surgeon) have achieved the trifecta. This occurs rarely as the wife’s interpretation
of normal erectile and sexual function is often at variance with that of her
husband after surgery. Radical prostate surgery/robotics is not the panacea
surgeons would have you believe it is.
After receiving your tentative diagnosis of prostate cancer and while awaiting the
validation of your pathology, you may well be subjected to the charming “spin” of
your most capable and incredibly skilled and gifted surgeon. You will be led to
believe that the clinical studies they quote to endorse their approach will have
you “cured” and back to “normal” in a very short order. Like the previous
paragraphs outlining the various inaccuracies and liberal use of self-serving
definitions to minimize the true impact of all of the severe complications
associated with the radical surgery on the prostate, we have a multitude of
clinical studies full of self-serving definitions on surgical “complications” and
“treatment success” and generally, pure fabrication. 22
Empower yourself and consider your next move while you follow the AS course.
You should also realize that all of the definitive treatment modalities for localized
prostate cancer have similar survival benefits generally, but any reading on how
“good” and how “safe” they are, is generally unsubstantiated scientifically.
For example, what is “success”, “treatment success”, “cure”, “cancer specific”,
“progression-free”, which means you can have cancer but it’s not identified,
“biochemical recurrence”, which means you do have a recurrence but we have
yet to identify it, “cancer specific mortality”, “survivorship” and “survivor rate”?
Trying to understand each interpretation of these terms from the prostate cancer
literature is an impossible exercise and again, hopelessly clouded by bias and
inaccuracies. Furthermore, each word or term can have a different interpretation
in a different paper with a different surgeon. Robotic technology marketing
literature is what it is and just cannot be believed regarding rates of complications
or the mythical “superior outcomes” for prostate cancer treatment.
Indeed, you rarely, if ever, see the term “cure rate” as most physicians in the
prostate cancer arena finally realize this is a wishful and nebulous term for
success in prostate cancer treatment. That is mainly because reliable results
require 20-30 years of study and residual or recurrent prostate cancer, although
common before this time, can take these longer time frames to present.
Not only can we not be 100% sure on how much and what Gleason score prostate
cancer you have (because of observer error), but when it comes to staging, we are
not sure exactly what stage you have. Again, all imaging studies, including MRIs,
are subject to observer error and so-called misreads or over-reads and underreads as well as the studies being associated with false positives and false
negatives. Combining all the observer errors in pathology reading, along with
errors in imaging reading, it is abundantly clear that the addition of all of these
inaccuracies must lead to inaccurate staging of prostate cancer. For example, the
T1c stage of prostate cancer, which comprises the majority of prostate cancers
these days and is diagnosed on the basis of an abnormal PSA, is a large
conglomeration of various prostate cancers differing in amounts and Gleason
score. Because of limitless subjectivity and observer issues and lack of validation, 23
as well as the pooling of different amounts of cancer as well as grade in the same
stage, it is clear we have no real handle on what we are treating. Basing prostate
cancer treatment results and success on this much inaccurate information is
Even more farcical are surgeons quoting 98% 10 year “survivorship” data after
radical surgery. Note that the word “survivor” is NOT the same as “cure”. A 10
year “survivorship” of 98% simply means that 98% of men are still ALIVE after
radical prostate surgery AND, would likely be alive without having had surgery.
What surgeons don’t tell you is that many of these men in this “survivorship”
group have residual or recurrent cancer as well as surgical complications and
diminished QoL. Furthermore, prostate cancer recurrences can take 20-30 years
to present. Survivorship is a common but deceitful play upon words.
Every man assumes a “survivor” is one who is cured totally and without residual
or recurrent cancer. However, this is NOT so and if you are still convinced that you
want to try and remove your prostate cancer through surgery/robotics, you need
to appreciate how hollow the terms “cure rates”, “survivorship”, “treatment
success”, “complications” and “superior outcomes” are in the prostate cancer
business. No man needs a daily dose of misery to be reminded of his misguided
choice for surgery. Furthermore, no man expects the after effects of radical
prostate cancer surgery/robotics to be worse than the disease he started with.
For over 100 years, the conceited and self-absorbed proponents of this primitive
assault called radical prostate surgery have obstinately remained entrenched in
their irrational support of an operation where curative life extension fails to
occur. This surgery was the first treatment modality offered for prostate cancer
and has its origins in antiquity and in the same Baltimore halls of academia where
the grossly mutilating radical breast surgery had its origins, and under the same
misguided principles.
From the early 1900s and still performed up into the 70s, this primeval, mutilating
and unscientific blood-letting catastrophe (under the guise of real cancer surgery) 24
called radical prostatectomy was still being practiced like there was no tomorrow.
Astoundingly, this example of unadulterated human experimentation is still being
given serious consideration despite this operation never having proven curative
life extension. Recently, however, the nagging concern amongst many urologists
regarding the preponderance of complications associated with the radical
prostatectomy, more than the absence of curative life extension, brought about a
painfully slow, virtual disappearance of this surgery in the 70s and 80s. But, like
the Phoenix rising from its ashes, the development of every new surgical
technology from laparoscopy to the current robotic technique was seen as a
license to resurrect the radical prostate cancer surgical concept and continue this
outright human experimentation. Apart from less blood loss, at times, than in
conventional prostate cancer surgery, the incidence of all the other complications
associated with the robotic technique remains about the same. These
complications remained the same simply because, irrespective of the approach to
total radical prostate removal, this organ cannot be removed without the cutting
of the intimately connected and associated muscle fibers and nerves about the
prostate. It is this basic fact that necessarily leads to many of the complications
associated with radical prostate removal for cancer. What seems to be correct
intuitively, that cutting something out quickly, is necessarily beneficial is not
always correct. Furthermore, the natural instinct to assume that everything hightech has to be an advance over a conventional treatment does not necessarily
follow. Robotics has been a great advance for many things in surgery but not so
for prostate cancer treatment.
This fact that surgical cutting is required to remove the prostate cannot be
circumvented, no matter how advanced the technology, places continued
experimentation with any technique for radical prostate surgery in a very
questionable light. Despite these undeniable concerns, this shameless ongoing
human experimentation with prostate cancer surgery is afforded in part by an
indifferent urology hierarchy and exploited by the bio-tech industry. The situation
was indirectly endorsed by the FDA when it gave the robotic technology for use in
prostate cancer surgery a simple “pass” without this technology for prostate
cancer treatment being validated by rigorous scientific scrutiny and long term 25
studies. The question “what are we doing?” when it comes to radical
surgery/robotics and prostate cancer treatment remains in force.
CONFLICTS OF INTEREST (egos, treatment philosophies and money)
The prostate cancer arena is full of conflicts of interest from testing to treatment
and, commonly, the money trail fosters these conflicts of interest. Today, the
prostate cancer business is a multi-billion dollar industry with many moneymaking opportunities and all possible treatment options vying for a piece of the
prostate cancer business pie. This addiction to the dollar in the prostate cancer
business has led to a lot of misleading information, unnecessary testing and overtreatment as well as over-reaching claims of superior outcomes for robotic
prostate surgery that just cannot be substantiated. Unfortunately, this prostate
cancer business requires the involvement of physicians in addition to the
technology companies: physicians working for financial incentives and biomedical and bio-technology industries working for stock holders. The “follow the
money” trail begins with the misguided concept of prostate cancer screening
and early diagnosis and ends with the fairy tale of amazing “curative intent”
and “superior outcomes” robotic prostate cancer surgery.
Repetitive testing is quite insincere and capitalizes again on the undeserved fear
associated with the words “prostate cancer”. However, since the testing is
rewarded financially, like Pavlov’s dog, we see more and more testing, more and
more evaluation and more treatment. Many physicians have even lowered the
tPSA threshold from 4 ng/ml to 2.6 ng/ml before suggesting a prostate biopsy.
This means even more tPSA monitoring and more prostate biopsies using a blood
marker that is not even prostate cancer specific.
More testing has resulted in more doctors offices purchasing tPSA testing
equipment, more office ultrasound machines for more in-office prostate biopsies,
more biopsies per prostate as laboratories are paid per core sample, more use of
expensive specialized stains by pathologists to identify more and more
insignificant prostate cancers. In addition, there exists more costly sophisticated
imagery to detect equally more insignificant cancers. All of these abnormal areas
found on imaging also require biopsy for diagnosis placing a man at risk of sepsis. 26
This complication can result in possible hospitalization, adding to overall costs in
addition to downtime from work and loss of income. Couple this financial
incentive for testing along with many physicians having financial interests in
various equipment options and treatment centers as well as the hospitals wanting
a return on investment in their expensive robots (cost, supplies and maintenance)
and we have unabashed and shameless, very profitable ongoing surgical human
experimentation for prostate cancer treatment.
Incomprehensibly, many organizations such as various urology academic groups,
the Veterans Administration, insurance payers, hospital ethics committees,
prostate cancer support groups and even the FDA have failed in their role of
stewardship to challenge the alleged benefits of this heavy-handed, high-risk,
non-beneficial radical robotic prostate cancer operation with its inherent, long list
of usually permanent complications. The opportunities to review and challenge
the merits of this operation have presented themselves many times over many
years. However, each opportunity was “tabled” because of the egos of the
believers in surgery and the convenient occurrence of new “advances” in
technology such as when the radical prostatectomy surgery morphed from
conventional, to nerve-sparing, to laparoscopic and then to robotic approaches.
This unadulterated human experimentation under the guise of real surgery was
able to continue, because some academic “leaders” in urology had an unwavering
but misguided belief in their ability for complication-free surgical removal and
curative benefit, despite existing information to the contrary. However, these
anticipated improvements and benefits have never materialized and robotic
surgical “cure” remains unreachable as a treatment for prostate cancer.
There have been a few brave hearts like Dr. Anthony Horan who have had the
testicular fortitude to challenge the so-called conventional wisdom of prostate
cancer surgery and provide supportive evidence and references for its meritless
place in the prostate cancer treatment arena. 27
Much more time and energy has been spent by surgeons comfortable with the
confused status quo of prostate cancer surgery in discrediting the challenges to
this misguided operation rather than working to develop the truthful long-term
scientific data from which men can become truly informed. Even some university
physicians, conveniently cloaked by the gown of academia to imply authority,
but an authority which can be hollow and not always tempered with real
experience, honesty or ethics, have failed to rise and challenge the alleged
benefits of prostate cancer surgery and its very questionable “gold standard”
status with randomized long term scientific trials. In fact, most surgeon believers
of radical prostate cancer surgery/robotics have gone out of their way to
intentionally cloud the pool of information on the known absence of long-term
curative benefits as well as its propensity for lifelong complications.
The charade on the “benefits” for prostate cancer surgery continues and we really
need nonmedical committees to audit and oversee the medical committees
overseeing doctors. Many physicians appear to be both unable and/or ineffective
at monitoring and auditing treatment test results without bias and these
physicians do not deserve our trust. In fact, to underscore the circus phenomena
in the world of prostate cancer, we have physicians who endorse the robotics
procedure knowing that the procedure is associated with a multitude of
complications and without life extension but dare to criticize and judge
alternative prostate cancer treatment modalities that they do not “believe” in.
These actions expose their flagrant bias and surgical treatment “philosophy”
when true physicians should be unbiased, impartial and scientific in their review.
That prostate cancer surgical treatment is so controversial is hardly surprising
when one understands it is mostly based on opinions, philosophies and
consensus. What is a mystery is that, after all of these years, surgeons are still
trying to establish a case for the place of surgery in prostate cancer treatment.
Surprisingly, there may be a flicker of realization by some prostate cancer
surgeons these days that there are real clues that their “gold standard” surgery
may not be the panacea that they would have you believe. First, many urologists 28
now require a written consent from a man before having him tested for his PSA
because of the potential for very significant negative downstream effects from
testing and surgical/robotic treatment for prostate cancer. Second, there is some
realization and acceptance now by some of these surgeons for significant, real
and permanent surgical complications from treatment and along with an absence
of curative benefit. Therefore, many men are now steered towards AS with
monitoring and postponement of treatment of their prostate cancer. Third, there
is a recognition by some robotic surgeons for significant disappointment in men
post operatively because of the complications resulting from their prostate cancer
surgery that these urologists have instituted a program of preoperative
psychological counseling so patients can deal with their postoperative
disappointment more effectively.
Yesterday’s untenable dishonesty has become today’s accepted standard practice
of confusion and something far from the truth. Truth, honesty and integrity, even
in medicine, appear to be fading. This clouding of physician trust and advocacy
makes it even more imperative that each man given the diagnosis of prostate
cancer take charge and take the time to become informed and ask many, many
questions. Prostate cancer information generally, but especially for radical
surgery/robotics, is a very thick soup of inaccuracies and fabrications but mostly,
an epidemic of lies.
Finally, the obligation of physicians to endorse only those cancer practices that
have been proven to benefit man is paramount and pivotal studies for prostate
cancer curative treatment are wanting. Lies, opinions, philosophies, egos and
hopeful-sounding rhetoric now trump information based upon proven facts and
truth. This appalling lack of established, real and reliable curative data for
prostate cancer surgery/robotics, as well as a pervasive lack of sincere patient
advocacy in the prostate cancer arena, is unconscionable, requires urgent
remedy and makes a mockery of urology “best practice” guidelines.
“physician, heal thyself”29
Required reading for all men diagnosed with prostate cancer as well as all urology
residents (especially those sections on radical prostatectomy). These books will
serve as an antidote to the omnipresent misinformation about the alleged value
of prostate cancer surgery/robotics.
1.The Big Scare-the business of prostate cancer, Anthony Horan, MD (this book
contains over 500 supporting scientific references)
2. Surviving Prostate Cancer without Surgery, Bradley Hennenfent, MD (this book
contains over 200 supporting scientific references)
3. The Male Lumpectomy, Gary Onik, MD
4. I Want my Prostate Back, L. Stains. Men’s Health, March, 2010
5. Life After Prostate Surgery Worse than Expected, Fox News, July 1, 2011
6. Why Should the After Effects of Some Prostate Cancer Treatments be Worse
Than the Disease Itself? Bert Vorstman MD,, August, 2011
7. Prostate Surgery is Booming, but at What Cost?. Sun Sentinel newspaper,
September 11, 2011
Other books, journal articles, newspaper articles, TV articles and web articles
about the misery surrounding prostate cancer treatment, as well as articles
detailing individual patient experiences are also available by searching the web.
About Bert Vorstman MD, MS, FAAP, FRACS, FACS
Dr. Vorstman is a Board Certified urological surgeon with some 30 years of
experience. He is Fellowship trained in Pediatric and Adult Reconstructive
Urology, a former NIH surgeon researcher and a former Urology Faculty Member
at the University of Miami, Florida. He also earned the honor of a Masters of
Surgery Diploma through Otago University, Dunedin, New Zealand for pioneering 30
research on urinary bladder reinnervation using nerve cross over techniques.
These techniques could have possible application in patients with neurogenic
Dr. Vorstman is well published and has lectured nationally and internationally. He
belongs to a number of organizations including the prestigious Societe
Internationale d’Urologie.
Dr. Vorstman’s passion and dedication is to help men and their partners fully
understand the treatment options available to them as well as their possible
complications when facing a diagnosis of prostate cancer.
He works to promote the acceptance and use of minimally invasive treatment
options such as hifu and cryoablation for localized prostate cancer in
appropriately selected men. In that regard he has developed a Center for
Minimally Invasive Treatment Options for localized prostate cancer.
In addition, Dr. Vorstman has developed a leading urology practice, Florida
Urological Associates, pa, was instrumental in developing the Coral Springs
Surgical Center and developed websites highlighting prostate cancer issues