Dr. Ted Schaeffer: All Things Prostate Cancer, Urology, & Men’s Health

27:34If you have pancreatic cancer, there are specific symptoms of it. We don't, we screen for men early. Those men don't have any symptoms related to their prostate cancer on average over 95 % of the time. And so we're really just picking them up early. Then our job really, our important job as urologist is to say, you know, person A needs treatment, person B can be followed. And that strategy is definitely something that we do a lot of these days. That's a pretty strong argument for getting tested. Yeah, because you just wanna understand your individual risk and understand how closely you need to be followed.

28:10So to take it back for the audience, how do you screen for prostate cancer? It's a blood test. That's simple. The test is basically looking at this molecule called PSA or prostate specific antigen. That's something that's produced by the prostate and is normally in the semen. So that's part of the semen that keeps sperm alive and helps it impregnate or infertilize an egg. That particular fluid, that particular molecule can leak into the bloodstream. So it's supposed to be in the prostate normally and it's in the prostate in levels that are like 100 ,000 nanograms per milliliter, super high levels.

28:48it leaks a little bit into the bloodstream and we screen for very low levels. PSAs in the bloodstream are often one or two or four or eight or 10. So the relative amount that we see in the blood versus in the organ where it's supposed to be is very, very low. But we look at that low number and we basically can follow that low number over time. That's why it's good to engage with a doctor because you really wanna track trends and look at that number over time to kind of understand your risk at the time you get your first blood test and understand your risk over subsequent five or 10 or 15 years based on how that number is changing or if it's stable.

29:26Another argument to get tested early because you're getting a baseline basically. That's right. And then it's really about how are you, how are the levels varying from that baseline? Totally. It's, I always like to tell patients, it's like, I wanna take not just a single photograph. I wanna take a bunch of photographs and make a movie because then if you have a sense for what's changing over time, you can identify the bad actors from the good actors. Because even if it's low and comes off as a low risk situation, if there's a sudden extreme jump. That's right. And even if that jump is still within a reasonable range, that would be alarming.

30:01Over 70 % of people in the US when they get their blood test checked, will have a PSA below three. And that's a very safe kind of range for most men. If you're younger, when you get your first baseline PSA. So for a guy who's between 45 and 50, which is a good age to start getting a baseline PSA, as you said, your number should be below one for sure. And on average, it's below 0.6. So the median PSA for a 40 to 45 year old is around 0.5 or 0.6. A median PSA for a 50 year old is one. So for half of the male audience watching right now, that's really good news. If you're 50 and you get your PSA checked and it's below one, you don't have to worry.

30:41You should still follow it, but you should not be anxious at all or worry at all. If your PSA is over one at a young age, if it's over one at age 50, it doesn't mean you have cancer. It doesn't mean you need to do anything at the time except for closely follow it over the years. And if it ever kind of reaches an inflection point, as you mentioned, where it goes up a lot over a year's time, or if it creeps up to a number where we're not comfortable, 2.5 or four are good kind of general cutoffs, then you want to engage more with your urologist and say, hey, we've got to do some further investigation.

31:28After hosting more than 900 episodes of this podcast, I have noticed a pattern. And that pattern is that the highest performers don't buy into the latest trendy hacks. Instead, they obsess on what actually works, which is always the unassuming basics. And there is nothing more basic than hydration. But here's the kicker. Your body can't hold on to water without the right minerals. Without them, water is just like this temporary visitor. But Element has cracked the code on this, which is why I've been using it religiously for years. zero sugar, no artificial junk, just sodium, potassium, and magnesium in the ratios that actually work.

32:09And look, I'm not exactly crushing ultras right now, healing from this surgery, but in some ways I need it even more. In order to properly recover, I need to treat my body even better than ever so it can heal properly and expeditiously while also maintaining my focus and my energy levels to rock out all of these podcasts, write a book, be a husband and a dad. And I gotta say, Element keeps my brain firing in a way that water alone can't. Their new sample pack features their most popular flavors. Citrus salt, raspberry salt, watermelon salt, that's my favorite, and orange salt. Eight stick packs total, perfect for finding your favorite or sharing with a friend.

32:52Get a free eight count sample pack of Element's most popular drink mix flavors with any purchase at drinklmnt.com. slash richroll, find your favorite element flavor, or share it with a friend. When it comes to health, sleep is a big deal. And there's just so much science out there to back up the role that it plays in every facet of well-being, from heart health to mental health, recovery, cognition, and just being able to show up as your best self. Getting a quality eight hours per night is a personal, non-negotiable, that I go to great lengths to ensure. It's sort of a commitment not only to myself, but to my career and to those that I love that all begins with what I'm sleeping on.

33:36Now, I've tried many mattresses, but the one that's really won my heart is Birch, and there's many reasons for this, all of which boil down to the simple fact that Birch just does things right. In addition to being incredibly comfortable and cool, helping you regulate temperatures at night, which are essential for quality rest, Birch mattresses are also firm in all the right places, and all their materials are sustainably sourced, including organic fair trade cotton. And also, everything is hypoallergenic and toxin-free, meaning no harmful off-gassing typical of most mattresses. Birch is so confident in their product, they're offering both a 100-night risk-free trial as well as a 25-year warranty.

34:20Plus, they provide free delivery right to your door in a conveniently sized box up. And so I want to offer all of my listeners the chance to enjoy a deep and restful night's sleep with a new mattress from Birch. So right now you can get 27 % off site-wide plus two free EcoRest pillows with mattress purchase. Just go to birchliving.com slash richroll.

34:53When you talked about PSA leaking into the circulatory system and the bloodstream, this is the difference between what you would call free PSA versus bound PSA, correct? Well, so PSA will leak into the bloodstream and how the PSA appears in the bloodstream, free or bound varies if it's leaking into the bloodstream from a benign prostate cell or from a cancerous prostate cell. So there's less free PSA around in the bloodstream if the cell that's making the PSA is a cancer cell. If the cell that's making the PSA is just a benign cell, as we've talked about, the prostate gets bigger as we get older, then there's more bound PSA, there's more unbound PSA.

35:43So the percent free is high. Right, so as we age and the prostate gets larger, there's gonna be more PSA in the blood. There's more PSA in the blood, but there's also a higher percent free PSA in the blood. If you get, as you get older, if your PSA goes up, but your percent free PSA is low or goes down, that's the canary in the coal mine to tell you, you have a problem. And that problem still isn't necessarily cancer. Could it be attributed to something else? It can be other things. It just warrants further investigation. So, ballpark, I think PSA screening at age 45 is good. understand your baseline.

36:21There's very few men at age 45 that have prostate cancer. So for the audience out there that's scared, don't be scared, just get it as part of your annual routine to get a PSA test and just chart it. Don't rely on your doctor to chart it, just do it yourself. Get it every single year. If your PSA rises, as you mentioned, more than half a point a year, that may be cause for concern, or if it crests over the 2.5 or four threshold, those are causes for concern. So what do you do then? Then you can get this percent free PSA. It's a free test and you can look. If your percent free PSA is high, that means that you shouldn't have to worry too much because it just means you're probably, your prostate's getting bigger as you're kind of getting older.

37:05If your PSA goes up and your percent free is low and the number you wanna think about is 16. So if it's below 16, you should be a little worried. If it's over 16, you're probably okay. Still follow it though. If you have any worrisome signs, what do we do? We don't just start poking you and doing biopsies. We do other tests. And the test that we like to deploy is an MRI. And I always explain it to patients like, you know, these days you never go anywhere without checking Google Map, right? And this is just a high resolution Google Map of your prostate. It gives us an amazing topography of the prostate and it will identify suspicious areas.

37:42If there's a suspicious area, that's when you wanna go and you can do an MRI guided biopsy of that suspicious area to figure out what's going on. And again, if you have an MRI abnormality, it's not a guarantee that you have prostate cancer and it's definitely not a death sentence. Rather, these tests allow us to identify things, rule out cancers in many guys, but pick up cancers while they're early and curable in many other men. But the MRI only comes into play once there is a PSA value that is concerning enough to inquire more deeply. In my mind, you can get MRIs and there's a lot of interest in whole body MRIs at this point, it's very much on trend.

38:23In general, I don't think a whole body MRI makes any sense or a prostate specific MRI without a baseline blood test number because that test, the PSA test is so powerful at effectively your pre-test probability of having something that unless your pre-test probability is high, I wouldn't deploy the test, which is the MRI. And in the context of the MRI, it's also important to have a qualified technician and diagnostician who knows how to take the right image and interpret that image, right? Because somebody who isn't necessarily as steeped in urology as yourself might miss something or might not have the right frame in the right place to properly interpret the result that you're trying to understand.

39:09Yeah, and it's a team based approach, right? So urologists are really the captains of the team, but we have to rely on like super talented radiologists and other folks. They're the folks that really tell us, hey, is this MRI suspicious or not? We put it into the clinical context, but they give us their initial assessment. Okay, it's an A or a B or a C. We then put that in the context and help our patients make a decision about a next step. Before the PSA though, we all have the experience with the reach around, right? So the reach around proceeds the PSA typically with your general practitioner when you go in for your annual checkup or whatever.

39:49What is that all about? It's called a DRE. What do we, is that still an effective indicator of anything or is that something we can just sidestep, just get your PSA? I mean,

40:05I do rectal exams on everybody, but almost everybody I see already has a cancer diagnosis. So for me, I'm doing it to get a sense of their extent of their disease. The benefit of doing a rectal exam in individuals who you're screening is very limited relative to the power of the PSA test. So I'm not saying that your doctor's a bad doctor for doing it, is it essential? It's not essential. And frankly, if you can get a primary care doc who will map and chart out your PSA annually over time, frankly, that's, and they're hesitant to do the exam, that's fine too. One of the things I'll have is many primary docs will just say, I'm not comfortable.

40:45I don't do enough reps to do it. Can you just see this person? And I will do it for them, but it's not essential. So if that's what guys are afraid of going to the doctor for, then go to the doctor, get the test and you're 98 % of the way there. The other ripple has to do with hair loss medication. If a patient is taking Propecia, Finasteride, that is going to artificially reduce that PSA value, correct? Yeah, so these tests, these products will, A, help with hair loss prevention, but they lower the PSA test by about two to 2.5. So if you, and it depends on the time that you start taking the medication.

41:28So if you start taking Propecia and you're a young man, then your PSA will be very, very low. It should be less than one, for sure, less than 0.5 when you start the medication, if you're taking it in your 20s or 30s, and it will remain very low over your whole lifetime. It should never, ever move. So the point is when you start the medication, your PSA will drop. It drops between one third and 50 % on average. you have to just chart that out. And that's really the patient's job to do that. You've set that new baseline and it should never go above that baseline. The new baseline PSA when you start these medications is where you are and you should never move up.

42:09If it moves up, that means that you have a four or five fold increased risk for actually having a cancer at that time. So the medication is very powerful at lowering the PSA and suppressing the PSA. If you ever have a bump up, you got an issue. And the problem I see is that there's a lot of online resources for these hair loss medications and men may not inform their family physician, their primary care doc, hey, I'm taking Propecia for hair loss. And they'll be, I see it in my practice. It's not a theoretical thing. I'll see it where a guy comes in, he's 55, his PSA went from 0.5 to one to four to six.

42:49And it's too late before the primary care doc realizes since it's not actually six, it's 12 or 14, because you have to double or 2.5 exit. So that's when the real problem happens. So a general practitioner may not know to ask that question, but any urologist is gonna know. We ask, but the question is who's doing the primary screening. So there's a really well done study done out of Southern California, where they looked at individuals in the VA and they looked at men, they said, is it safe to put people on finasteride or Propecia? And the answer was that there was a much higher risk of death from prostate cancer in people on Propecia or for an asteroid than those that were not.

43:31And the reason is because of what we just talked about, the primary doctors who are doing the screening, they're just not aware of the situation. And so the number starts rising and they missed the early detection. Another nuance to this is understanding PSA density. So if somebody has an elevated or a concerning PSA value, then you have to look at the density of that. And from what I gather, and please correct me, I could be totally wrong. This then becomes somewhat of a predictor of the aggressiveness of that cancer. Yeah, it's a difficult concept, but it's a very important concept. So as we said, the prostate, as we age, it gets bigger and more PSA leaks into the bloodstream just from a regular, just increasing size over time.

44:21And so if you think about the average size of a prostate for a man who's 50, it's around 25 grams. And if you look at a safe PSA for a man at around 50, it's less than 2.5. So if you do that calculation, 2.5 over 25, that PSA density for that individual is 0.1. and that's kind of a safe PSA density for most guys. As you get older, your prostate gets bigger. So an average prostate size for a man who's 60, maybe 40 grams. So if your PSA is four and you have a 40 gram prostate, then actually that PSA density again is fine, it's 0.1. The problem lies in if your PSA is five and your prostate's still 25 grams, that means that there's a lot more PSA being leaked into the bloodstream relative to the size of that prostate.

45:16And that is a very strong predictor that there's some kind of cancer going on in that guy's prostate versus the other guy whose PSA is five, but his prostate's 50 grams. That's just probably PSA being leaked into the bloodstream on average because their prostate's just bigger and it's just growing with time. Right, understood. So it's hard to, you don't know your PSA density unless you've gotten an MRI or had an ultrasound. So usually the algorithm is we're tracking PSA over time. We're looking for the velocity change. How much is it increasing over time or is it remaining flat? And if it's increasing or if it's increasing, we do something like the percent free PSA check and it's low and concerning, we get an MRI.

45:59I look at the MRI say, okay, number one, what's the volume of the prostate? And I calculate the PSA density. And then number two, do our radiology colleagues see something suspicious in the prostate and they'll rank order like how suspicious it looks. Those are the factors that I take with me to suggest, okay, we should do a biopsy or no, we should think about that we can just follow you. This is a pretty bulletproof case that you're making for testing early detection. But there is a very persistent second trope in your world, which is, and I've heard this many times, like, oh, don't get tested.

46:38If you get tested, they're gonna find something and you're gonna end up with an unnecessary surgical procedure because there's financial incentives for surgeons and hospitals to cut and also sort of litigation oriented incentives to make sure that you're doing everything you can. Can you speak to that controversy a little bit? I don't even know if it's a controversy, it's just a kind of - Yeah, I mean, it's certainly, so look, most people who get, most people don't have prostate cancer. And so getting a baseline PSA test will provide significant reassurance for those men. It's 90 % of men at age 50 don't have an elevated PSA, they're in the clear, there's no problem.

47:27So it's just a select group of people that have an elevated elevation in their PSA. It's not everybody, it's a very, very narrow focus of individuals who have an issue and then require additional testing and may need to have surgery. In terms of the idea that urologists are, making money doing surgery, well, the way our profession works on average is that we're paid for the work that we do. That's true for attorneys, that's true for hedge fund managers, everybody's paid in general for the work that they do. So I myself, I'm not, I'm on a flat salary, but in general, that's the way that it works.

48:05However, I would argue that urologists spend a lot of, the insurance company's money doing these sophisticated tests to really reduce the number of biopsies we do. MRIs are very expensive. They're five or$6 ,000. We deploy MRIs all the time to not lean us to do a biopsy, but actually to steer us away from doing a biopsy. So if you look backwards in the old days before MRI, everybody with an elevated PSA got a biopsy. Now with MRI testing about two thirds of men who get an MRI, actually we find out they don't need a biopsy. Then of the one third that get a biopsy, and let's just say we pick up a cancer, about 40 to 50 % of cancers that we pick up today, we don't recommend treatment for.

48:53So we're actually monitor people over time, following their cancers rather than just cutting on them and as the story goes, making a buck or two. So I think that in general, urologists are very good citizens. They're very cognizant of what they do. Why? Because unlike a lot of other surgical specialties, we follow our patients for life. So when I have a patient who has prostate cancer, they have access to my cell phone number for the rest of my life and their life. So, we follow them longitudinally. So, we're very engaged in kind of survivorship with them. And so, in that way, I feel like we have a reasonable conscience to say, hey, we want what's best for our patient because they can track us down over time if we do something to them that they don't, they have side effects from the treatment or something like that.

49:48Right. You did say something that was quite alarming though, which is no PSA number, no matter how low guarantees that you don't have cancer. So even if you go through the rigorous testing that we just spoke about, there's still a percentage chance that you nonetheless have prostate cancer. Well, I mean, cancers don't read rule books. That's why I always tell my patients when we get a great pathology report after surgery, everyone's happy. I just say, we're still gonna follow this. They don't read the rule books. So yes, there are no absolutes in medicine. Prostate cancer falls under that same general edict.

50:25there are no absolutes. And so you have to be a thoughtful, good doctor. And there are several prominent folks out there right now who are really battling publicly and they're true champions. They're prostate cancers that don't always show up with high PSAs. But on average, this approach is safe for men to engage with their physicians. And it generally speaking allows for those rare individuals who have a cancer that needs treatment to get their treatment early and be cured. And for the vast majority of men out there, they can be screened and they can feel rest assured that there's nothing going on.

51:04Hence the much lower lethality rate in comparison to diagnoses. That's right. So if you say there's 34 ,000 deaths a year, that means that there's 170 ,000 men who are surviving their cancer. And many of those men never got treatment for just monitoring them. Okay, so reach around PSA, MRI, all of these things are telling you that we need to know more. So the next step is the biopsy. And performing a biopsy on the prostate is not a small thing from what I understand. But we just finished a study where we use carefully tracked in the modern era nowadays, how people do after a prostate biopsy, how much does it bother them?

51:52And what are the results of the testing that we do? So a modern prostate biopsy at our shop is with a kind of percutaneous approach. That means that we put the needle through the skin into the prostate. We do have an ultrasound probe in your rectum and that's actually the most uncomfortable thing. The thing that guys don't like with the exam is the fact that there's a finger going in the rectum. We still put an ultrasound probe in the rectum. It looks directly up at the prostate and visualizes it. And then we can use software to kind of overlay the MRI onto the ultrasound image and then deploy a needle from the skin into the prostate just above the rectum and actually sample the suspicious areas within the prostate.

52:40What does that mean for men? It's about an eight minute procedure at Northwestern. We know on a one to 10 pain scale that they report it's about a 3.6 out of 10. So it's uncomfortable for about eight minutes. It's not painful. We deploy as much lidocaine as possible. We really max out the dose per kilogram of lidocaine and numb the area up. And with that, we can get the results of the biopsy. If you think about it, like, are we really doing this because we're incentivized to do biopsies? I would say the answer is no. About 50 to 60 % of the men we biopsy, they needed the biopsy. We pick up a cancer that is something that we wanted to know about.

53:23So we're not overly biopsying people just for fun or for money. We're doing it when the clinical indications are appropriate. The procedure is done awake in the office. It takes eight minutes. They leave the office on their own. They, the pain that they had at the time of the biopsy is gone within 10 minutes. And that's gonna definitively tell you whether a cancer is present or not. It tells us if there's a cancer that is significant enough for us to worry about on average, yeah. And so from that, what is the decision tree around surgery? The decision tree is very complicated, but it's quite simple to be honest with you.

54:01It's what's the age and the health of the patient and how aggressive and how bulky is the cancer. It's those two things that really kind of way we put into the equation as to whether or not the person needs treatment for their cancer. And if they need treatment, what's the best treatment for them. So about 40 % of the cancers we pick up today are low grade and they're small and we monitor those. And historically those individuals would have had surgery. When I was training, those men automatically had surgery. We've now learned that those cancers are indolent. They're not aggressive. They don't grow very quickly and they can be followed safely for five to 10 years sometimes before an intervention is necessary.

54:45So those men we follow, we call that active surveillance. And is indolent the opposite of metastatic? Indolent is the opposite of like fast growing and aggressive. I see. So it just kind of sits around. It may change slowly. Indolent, low grade cancers at five years, about 40 % of them flip and they start growing. at 10 years around 60 % kind of have flipped and start growing. And you'd say, well, that's not very good odds. And I would argue, well, if 10 years after diagnosis of cancer, that 40 % of men don't need anything, I'd say that's a huge win. When historically everybody who had that got treatment.

55:25So that's 40 % of guys who we do biopsies on have a cancer that we can follow and they don't need any treatment. What does that mean for the guy? It means that they can live their regular healthy life and not have to worry about it, except for once a year when they come in for their biopsy. So there's no pharma intervention or any other kind of treatment protocol. Yeah, I mean - Other than just consistent screening. A hard healthy lifestyle is the best thing for those guys. Of the men who have a cancer that needs to be treated, those men can choose to have surgery or they can choose to have radiation based approaches.

56:02Again, in the whole spectrum, from only about four or 5 % of men that we diagnose have metastatic prostate cancer, prostate cancer that's spread to other parts of the body. So if you're getting a biopsy 40 % of the time, it's something that can be followed. What's the math? 55 % of the time, it's something that we should probably treat and treatment will prolong your life. And 5 % of the time you get treatment, but it's intensified other kinds of treatment, not surgery and not radiation to really extend those individual's life spans. But radiation would be the preferred treatment protocol for a metastatic version that has spread to other areas of the body, obviously, because surgery is not going to.

56:44Yeah, so when it's metastatic, we use two things. We use systemic therapy by medications that will aggressively block your testosterone levels to zero, testosterone is the fuel for prostate cancer to grow, so you can suppress and really halt its growth significantly. And in many cases in those scenarios, we will also use radiation to kind of spot weld any little areas that we see the cancer in. That's very effective for men with metastatic. For men with clinically localized cancer that needs treatment, then they can either have surgery or they can have radiation. In general, both are effective treatments.

57:20We usually will direct young individuals, individuals with a 15 to 20 plus year life expectancy towards a surgical approach versus a primary radiation-based approach because surgery in general is more durable. It lasts longer than a radiation-based approach. So for young guys, we will usually deploy surgery. In general, for older guys, we will usually deploy radiation, but there's a lot of nuance and it's a very individualized decision process that we usually will work through with our patients to allow them to make the best decision for themselves. And is that because surgical intervention in an older person becomes a higher risk scenario?

58:04So you're really kind of measuring and trying to gauge and balance out the life expectancy of the patient and then the efficacy of the treatment. So in general, radiation is not as, doesn't have as many profound or potential profound side effects as does surgery, particularly in older men. So the main side effects with treatment are impacts on urinary function and impacts on sexual function. The impacts and then cancer control. So in an older individual who maybe has less robust muscle mass and less resiliency in their tissue, surgery may result in higher rates of urinary incontinence, for example, with surgery.

58:46Whereas with radiation, there are really effectively minimal or no rates of urinary incontinence. And if the radiation can effectively control the cancer or for what we anticipate is the patient's life expectancy, then we'll go with radiation. There are a lot of nuances to it and variations in terms of what we select for individual patients. And so, I will often really encourage patients to go see a radiation oncologist and learn more about the disease from their perspective before we make a decision about what's best for them. Understood. So, for the patient who is a good candidate for surgical intervention, the surgery is called robotic prostatectomy.

59:28Yes. And I'm envisioning, I don't know what this looks like. You mentioned the DaVinci machine, but I'm imagining a large computer-based sort of thing where you have a high precision joystick and somehow you're operating an arm or there's a program that goes in that can do the cutting and the incisions in a very specific and targeted way. Is that a fair? You claim you're a lay person, but you're a budding neurologist, you need to know it. Yeah, so that's basically the best way to think about the robot from the, the utilizers perspective is like, it's like playing an organ in many ways. You have foot controls.

1:00:11So when I operate, I use my two feet and my two hands. So you control things, individual hand movements with each hand and then you have foot pedals to also augment your ability to move things. The actual, the technology that really was the edge for intuitive in terms of doing this was two things. One, their technology allows for something like the size of your pen. That's the size of the instrument that we put inside the human body. It's fully wristed and allows for seven degrees of motion. So exactly what my arm can do. the instrument that I put inside the body can do. it's just totally miniaturized.

1:00:51That was a huge, huge advance that Intuitive developed and came up with and patented. The other was that they came up with this idea that you could create a laparoscope. That's how we see things on the inside of the human body that had two eyes. So previously, all the laparoscopes had a single lens or a single eye, and all you would be able to do is see two dimensionally. Their technology allows for processing of images from a right eye and a left eye. They're adjacent to each other. They're very close, but they can actually triangulate an image and they provide three-dimensional views. So basically - You can understand depth.

1:01:28When you put your head into their console, which is like basically the size of this table, when you enter that space, you are entering the inside of the human body in three dimensions. I mean, it is just like spectacular, spectacular stuff. So with that, you can see things that you could just never see with open surgery. When you're doing open surgery, it's your regular eyes. Even if you wear magnifying glasses, you can't see things. There's much less bleeding when you do it with the laparoscopic robotic approach. So there's no kind of blood hiding the surgical field. So the view and the ability to do things, you just cannot do them with traditional instrumentation.

1:02:10And that is part of the skill of what makes a great prostate surgeon. And then the other one is just understanding the nuances of the human body and how the anatomy varies. And it's just like, it's that old 10 ,000 hour adage, right? If you do a lots of, because you can't, there's no automated program to just take a prostate out because your prostate's different than my prostate and everyone else's out there. So that idea of understanding the anatomy, I learned that from Pat Walsh. And that guy saw stuff that I only saw when I started doing robotic. I mean, he just had, he just understood the anatomy spectacularly.

1:02:44So it's the robot and that as a very sophisticated, very expensive set of tools, and then understanding the disease and really understanding the disease in the sense of skating where the puck's going to go and really anticipating what you're going to see in that particular case that really make for, I think, a great prostate surgeon. How long did it take for you to master this machine? You know, there's ways to kind of gauge that performance. And so how you do in your first 50, 100, 200, 250 cases. So when we looked, I was good out of the box. But you get better every time. Those surgeon hands.

1:03:26I'm not sure what it is, but I did okay out of the box, but we have this very sophisticated software that allows us to actually, we record every single case we do. So I look at my cases and I look at how patients do and I can actually help just like professional sports teams do. And my mentor did the same thing. He used VHS tapes. We have everything digitized. And by the end of the day, my cases are downloaded to my virtual inbox and my surgeries and I can pull those cases and look at them, which is pretty awesome. Like game tape. Game tape. Takes a lot of time, but it's pretty amazing when you go back and look and you kind of analyze and say, where could I have done better in this case?

1:04:06Or what was it about this case that was a challenge? and that's kind of the fun part of doing it, right? You can just kind of continually try to perfect your technique. I think some of Pat Walsh's procedures are on YouTube. He has them. You can actually watch it. Yeah, that was one of his gifts back was to say, like he really was the master and he owned the space, but he really shared that space. And so we have a YouTube channel at Northwestern. I put up many, many of my techniques and I'm always developing new techniques that I think will result in better outcomes. And I put them out there so that other surgeons can, you know, all of our trainees, they're ultra talented.

1:04:46I train our residents, physicians, how to do my techniques, teach them the tools to learn them and to deploy them in their own practice. And I put my videos out there so people can see them. It's not proprietary. It's so that everybody can be better. Right.

1:05:10I own a bunch of spectacles, and I made the grave error the other day of donning a normal non-Roka pair on my indoor trainer when I was riding my bike indoors. And I got to tell you, it was a disaster. Every three to five seconds, I had to take my hands off the handlebars and push my glasses back up my nose until I got so frustrated, I just tossed them aside. This is the dilemma of every active but optically impaired person I know. And as someone who has relied upon eyewear every single day since I was five years old, it is also the source of endless aggravation. Thankfully, now eradicated thanks to Broca, the stylish performance eyewear company founded by two former Stanford swimming teammates of mine who have gifted everyone like me and, quite frankly, the world with their fashionable line of super lightweight prescription glasses and sunglasses with patented no-slip nose and temple pads that are just impervious to sweat.

1:06:14And no matter what you do, remain locked on your mug, no matter how intense your workout. Without the dork factor, these things go everywhere with me from the trail to the dinner party. Put them on, feel the difference and wear without limits. Unlock 20 % off your order with the code RITCHROLL at ROKA.com. That's R-O-K-A.com.

1:06:44How many of these DaVinci machines exist? Nowadays, it's hard to say. I think we have at our hospital 10 and then deployed, we have a 11 hospital system out throughout Chicago. we probably have 25 different machines. They were the market share leader. They had the patents on everything up until just this past year. So they really had the ability to kind of be very proactive and develop really nice tools for us to kind of use for our patients. But is it the case that every major hospital has one of these machines in their urology department? Well, they're used now for almost all kinds of surgery.

1:07:23you can use the robot to kind of advance things. It was originally developed for cardiac surgeons because that's very precise suturing and you need magnification and it just wasn't adopted in cardiac surgery. Urology is a specialty that's very kind of innovative. We're always kind of progressive and trying to do things better with new tools and new technologic advances. And so we saw this tool, deployed it in our space. We just started doing it on prostatectomy And now for almost every major surgical procedure we do, it's done with the laparoscopic robotic approach. Every surgery requires an intense level of precision.

1:08:05But from what I understand, the prostate is particularly sensitive because of the density of the kind of vascular system there. Is that what creates the complications and the risks? It's the size of a golf ball. Everything surrounding it is like high price real estate. So you have to be very precise about dissecting the prostate off all the structures around it. And there's something that those structures exist to do. There's no redundancy when it comes to where the prostate's located. So you have to be very precise about separating it off of something on all the different sides that it's kind of abutting.

1:08:49And then you have to reconstruct it. So you're disassembling things, you're putting them back together. And so, yes, the robot enables more surgeons to remove prostates, but you also have to be skilled in how you remove it and put the pieces back together effectively. And that's where, that's a big differentiator from a good surgeon to like an exceptional surgeon. And does prostate cancer show up as a singular mass, like a lump, or is it something that's sort of diffused across the prostate? Like when you go on to take it out, is it removing one thing or lots of little things and trying to find where it's hiding?

1:09:29Yeah, it's a great question. And I like to explain to patients, it's a weed with roots and those roots can kind of disseminate and infiltrate throughout the prostate. So even if you can see a spot, an MRI, that may be the weed above the surface, the depth and the extent that the roots disseminate throughout the prostate is variable. And so you can't just go carve out and pull out the spot that you see on the MRI because the roots of that spot kind of do disseminate not everywhere in the prostate, but they may go from the right side across to the left side or more in fact grow outside of the prostate.

1:10:06And when you have roots of the weed growing outside of the prostate, that's where, you know, that's where part of the surgery becomes technically more difficult because there's no, everything around the prostate is really important. So you have to kind of gauge, okay, is the tumor have roots outside? If the prostate cancer has roots outside, am I clearing all those roots out when I'm doing the operation, et cetera? And so that's where it becomes technically very difficult and you're kind of processing this. The procedure takes around three hours. So you're in this machine, you can take a break and give your eyes a rest, but you are hyper-focused for three hours where you're really just focused on and doing this one particular craft.

1:10:47if you do that several times a day, it becomes like training, it becomes hardcore training to be able to do it for 10 or 12 hours in a day. In terms of risk factors, you mentioned sexual dysfunction, urinary tract dysfunction, are there other risk factors and what is the incidence level of these risks showing up? Yeah, so those are the main ones. So it's really, we focus on cancer control and how often are you removing the cancer at the time of surgery? Theoretically, it should be 100 % of the time. A really excellent surgeon is removing the cancer, you know, 95 % of the time when it's contained within the prostate.

1:11:25And that's kind of how I track my numbers and we're able to track your performance. And then rates of urinary leakage should be very low. And it's hard for me to say what other folks are doing. For me, you know, 95 % of my patients are dry by three months after surgery. about 55 % are that way immediately after surgery, like no leakage at all. And about 2 % of guys, there's something else wrong in terms of their urinary function that requires them to have a small secondary procedure to be totally dry and comfortable. So overall, with an experienced surgeon, you should be looking at rates that are in the one, two, 5 % range.

1:12:06Erectile dysfunction is not quite as good. And that depends on a lot of factors. So why is it that men have erectile dysfunction after prostate surgery? So when you wanna have an erection, you get a signal from your brain, it goes all the way down your spinal cord. It goes through the nervous system into the penis and those nerves run right adjacent to the prostate. These nerves are microscopic. You cannot visualize them. We know where they are, but you can't actually see them. And we have to kind of peel them off of the prostate. In doing that, they often will be damaged. and so they have to kind of recover from that damage.

1:12:44And that the recovery rate is variable. It depends on, well, what's the function of the patient before the surgery? What's the age of the patient? So the younger you are, the more resilient your nerve tissue is. And then what's the extent of their cancer? Because one of the first places that cancers grow is just adjacent to the prostate. And that happens to be where the nerve tissue is. So there's lots of variables that affect your ability to recover our erectile function after surgery. So it's hard to kind of just say, okay, if you have surgery with Schaefer at 95 % should be dry at three months.

1:13:17It's hard to give that equal number for recovering erectile function. And that's where really we are much more kind of individualized and kind of giving that patient's probability of recovering. Urology and what you do is somewhat unique in the world of oncology because cancer doctors are constantly contending with death and they're combating a disease that eludes our ability to figure out how to cure at least so far. And so there's a lot of sort of tragedy around it, but you're in this situation where you're performing this lifesaving procedure that is taking lethality off the table. So you have this rare opportunity and experience of treating patients and being with patients on the other side of this surgery, like literally saving their lives, preventing this lethal cancer from robbing them of their lives too soon.

1:14:18I'm curious around what that experience is like for you when you go and visit the patient after the procedure, or you have the opportunity to look them in the eye and spend time with them afterwards. Yeah, it's a good question. They have this new lease on life. They have this opportunity all of a sudden. Yeah, I think that being an oncologist or a cancer doctor has a lot of high highs and a lot of low lows. For me, it's a gift that I was given, this is my talent. So I feel grateful and I have a tremendous amount of gratitude that I can help with my gift to help other people. And I'm always, I try to be as empathetic as possible, these are people who, as we talked about earlier, they have no symptoms.

1:15:06They're living their regular normal life and then they get this diagnosis and it's not in their 2024 agenda. And so, although we can cure them, it's still a process for them to think about and to kind of work through. And last week I took care of a 44 year old man who has a four year old kid. So, although I know that he's gonna survive, it's still, if you just pause and think about that stuff, you have a family, it's remarkable and it's scary and very powerful. So I feel honored that I can participate in these individual patients journeys with them. I feel that there's a lot of, I do have, you have a burden that you really have to be a cheerleader for them.

1:15:52You have to be a psychiatrist for them. You have to really try to be, you know, in this one moment in time, a lot of things for them. And so for me, that heavy burden is fed forward and I get a payback from my patients and several of my patients and the relationships that I've developed with them over time is really, it gives me kind of the energy that I need individually to kind of get back to the next 10 men who we help in their journey in life. Yeah, I mean, one patient that I know of yours, said basically like suddenly you think your life is getting stripped away, your life is returned to you.

1:16:34And this question comes up of, well, what are you gonna do with this? And I would imagine having done this for as long as you have and performed as many of these procedures that you've seen people take stock in inventory of their lives and make changes as a result. like to not to say that this is like a gift, but there is an opportunity in there. And I'm curious around like what you've seen people do with that opportunity. Yeah, you're absolutely right. And it's the silver lining of the diagnosis is when you can see an individual really take that, accounting of their life and perhaps how they've given back in whatever capacity they have and really being making what they perceive as a negative into a positive.

1:17:32I know for me personally, I've done that. I've taken stock of my own, the gifts and accounted for what I've done. And it's made me, I think a much better person, a much better husband and a much better dad. So that when I do spend time with my kids, I think about, okay, this is really this, in this moment in time, how can we make it better? And so it's helped me, but it's also really nice to see patients. They've done just many, many things. It doesn't have to be that they start fundraisers for prostate cancer. I don't want a million people doing that. I want people to kind of, again, re-engage with their talents and deploy those talents to make the world a better place.

1:18:13It sounds super cheesy, but it's actually people do that. And it's very, very powerful. Another trope that you see in movies and television is the surgeon with the terrible bedside manner, right? That's just all about like the cutting and getting on with it. The emotionally stunted, kind of overly materialistic character. You're certainly not that, you strike me as a deeply empathetic person who's very aware of the role that you're playing. But within that, how do you manage, like from a psychological perspective, the toll and the heaviness of it all? Like, do you have to have certain kind of psychological boundaries?

1:18:58So you're not like this porous membrane where all of this angst and fear and pain is seeping in? Like, how do you comport yourself over the longterm so you can continue to do this and take care of yourself? Well, one, I bike ride a lot. So that helps me personally, just in terms of if I can get my blood, my heart rate over 150, that helps me a lot. Peter got you on a program. Do you have the indoor bike? You're not riding in Chicago in the winter, are you? I rode in February this year. Did you? Because it was 70, right? But in general, I'm indoors in the winter and I try to get out and bike commute in the summer best I can.

1:19:39but I would say that it's definitely something I've thought about it. And to be honest, I will tell the patients to their face how I'm feeling and I will try to be as empathetic and say, listen, I know this is hard for you and I feel for you and I'll just tell them to give me a hug. And that idea of having fewer barriers at that moment with the patient, I've actually found helps me a lot and actually helps those patients tremendously. And it's tough. I mean, after doing surgery for 12 hours in a day and I probably lose five or six pounds in water weight just because the OR doesn't have humidified air and it's just an intense process.

1:20:23It's hard sometimes to go and see these people, but you have to think about, I just try to think about how they're scared and how I do this thing every day. They do this once in their life. And so I try to remind myself of that. And then I have my wife to remind me of that too. So she keeps track of me and make sure that I'm good to my patients. Yeah. Have you ever had any moments where you felt like you needed to step back because it was all too much or you're able to navigate it and kind of find a way to balance all of that? I think, it would be too much, it'd be too macho to say you don't have those.

1:20:59And you have them when you have, you're doing the surgery and you have a side effect, you have a complication and it's super duper hard to process and develop a game plan when you do have a complication and the greatest surgeons in the world have complications. And then that's when you need to rely on your friends, your colleagues who are usually I think in your specialty, in your line of work to just decompress. So I try not to decompress professionally with my family because I just don't wanna be that guy, which is why I'll spend time on the phone on my drive home with colleagues and just say, I had a tough case or I had a hard day and it was, or I had a patient who they're young or they're this or that.

1:21:47So I try to do that with my colleagues and I try to proactively reach out to them because I know that they go through that same thing. It's very much in the forefront of medicine, this idea of physician burnout and processing all these different outside stressors in your individual life and then your professional life and just working to kind of balance them. And it's definitely something that's a work in progress for me, but I think outlet through friends and then outlet through family and then outlet through high heart rate. Yeah, I mean, the conventional idea that you would have would be, you're modeling something different.

1:22:23Like there's this idea like, listen, I'm performing thousands of these procedures. Like, do you want me to do a good job? If you want me to do a good job, like I got to mute out all the emotional stuff because all that does is take up mind share that should be deployed in the process of performing the best surgery that I can. So let me just do that, right? To instead say, I'm gonna give this guy a hug and I'm gonna understand that they're in pain and there's a lot of fear here. And to have that gentler approach and to have that work for you is interesting. I'm sure it's powerful for the younger doctors that are working underneath you.

1:23:05And knowing some of your patients, like it's appreciated. Like these people are, well, I just can't say enough amazing things about you. I try, I can always do better, but I always try to be the best guy I can be for that. And it's easy when you put yourself in these people's shoes, it's like not, it's not hard to understand what somebody needs in their particular situation when they're confronted with a health event in their life. speaking of cycling, every time I get on my bike and I'm out for a couple hours, I'm thinking, what is this doing to my prostate? And nothing, don't worry about it.

1:23:42Good, we cleared that up. Yeah, no issues. Cycling good, not, yeah, like, cause there's a lot of, sometimes like if my fit isn't right, I get a little numbness down there. Yep, I mean, as you know, fitment is key. Speed comes from a good fitting bike, right? So yeah, there are special seats. There are nerves that it's not the prostate, but there are nerves around the prostate that actually you can get a compression injury to and have numbness. So there are different seats that can kind of relieve that pressure in the area where the prostate lives. And they can be significant game changers for those some of those folks.

1:24:21Yeah, I found that the saddles that have the cutout in the middle and kind of an elevated rear that's like right on the sit bones. Yeah, way more anatomic, 100%. The saddles have gotten a lot better. They have and the tri bikes are often like the worst because the old tri bike, you're just really, you're really in it, you're right on. Yeah, exactly. You're not on the sit bones at all. Exactly, so those ones where that's where the seat is the biggest kind of factor. Cause if you're on a tri bike for a long, long time, which I imagine you've been, your prostate is not an issue, but you can actually have problems with the urethra, the tube that you pee through because you can just compress it and cause issues with the blood vessels to it.

1:25:02So fitment is key. What is the relationship between prostate health, prostate cancer and TRT, like testosterone therapy? Yeah, I actually think there's no increased risk for developing prostate cancer and testosterone replacement therapy. So that's a very broad and maybe provocative statement, but there's a lot of good recent studies that have shown that that's not a major player. Peter and I are gonna do a very deep dive on that coming up. So we'll have a really nice, super nuanced and detailed podcast about a big picture. A couple of recent trials came out. They gave men testosterone replacement.

1:25:42These were men had low T, they brought them on replacement to like just below low T, so not very good replacement. So the quality of life for those guys wasn't super great, but with mild testosterone replacement, there was no increased risk for developing prostate cancer. And in general, I think testosterone replacement to relatively reasonable levels is not gonna induce any cancer issues. It can cause your prostate to grow and cause more urinary symptoms over the long haul, but over a shorter term period of time, it's probably not a problem either. Does it have any impact on PSA results? Is it something that the neurologist needs to know about?

1:26:21Good question. It can bump the PSA, but in general, it's in the tenths of a point. So not major changes in PSA with testosterone supplementation. Again, normal ranges for testosterone, a low is considered below 300 and high ranges are eight to 900. So if you're low and you go on replacement, you may have a subtle bump, maybe half a point, 0.4 of a PSA value rise, and then it should be stable. If you go in the thousands, you may have more of a rise initially, but then beyond that, actually, it shouldn't go up substantially. If on TRT, your PSA is rising, just like in every other space, if your PSA is rising, that's when you need to get an investigation with the urologist and get the workup we talked about earlier.

1:27:13Are there any other kind of pharma that would have an impact on PSA values or be something that's contributing or creating a greater risk for prostate cancer? So there is some correlation with some of these very strong immune modulators that people take for autoimmune disease. So Crohn's disease and ulcerative colitis, which can be very catastrophic diseases of the colon. there are some very effective medications that can make those symptoms go away. And remember Crohn's and ulcerative colitis are really profoundly catastrophic if untreated in individuals. The medications that you use to suppress those can raise your risk of developing prostate cancer.

1:28:02So again, if you have Crohn's or ulcerative colitis on any TNF alpha blocking medication, so those of your audience that are on it, they'll know what I'm talking about. Just follow your PSA very carefully. Again, screening the way we do it in America is pretty aggressive. And so it works if you deploy it, it will work for most everybody to pick up something early. I would definitely not advocate for not taking those medications because you're taking them for a real disease. Just have to be careful in terms of following. So those medications for autoimmune disease can do it. Testosterone, Clomid, which raises testosterone can do it.

1:28:36And then the Finasteride, Dutasteride, Propecia that protect your hair loss in general or your prostate from growing in older men, it can alter your numbers. And so you have to be cognizant of that too. What is happening in terms of new and developing science in terms of better understanding prostate cancer? And where are we in terms of the possibility around a cure? Yeah, good question. So a lot of the cancers that we diagnose, we diagnose them and we gauge how aggressive they are based on how they look under a microscope. and in the last decade, there's been a huge shift in terms of looking at the genomics, what drives those individual cells to look the way they do under the microscope and when you start looking at genomics, you can understand the fundamental kind of recipe for an aggressive or a non-aggressive cancer and if you understand the recipe for an aggressive or non-aggressive cancer on a genomic level, you can then deploy more customized, more precise therapies for those individuals.

1:29:41So how has that impacted individuals who have a localized cancer? We're now learning that you can use genomics and probably will be able to kind of help titrate and tailor some of the types of radiation treatment you get. There's trials that are ongoing that will answer that. In terms of more advanced prostate cancers for those men that are unfortunate enough to have an advanced prostate cancer, genomics has really transformed how we treat the disease. So we've identified vulnerabilities, developed into deployed medications to attack those vulnerabilities. So we're getting there. And there's been tremendous progress over the last 15 or 20 years to like do newer, more customized, more precise and powerful medications.

1:30:23So less overall side effects, more toxicity to the cancer cells. They're not creating cures yet, but we're getting closer kind of every year, to be honest with you. From a lay person's perspective, why is cancer just cancer generally such a challenge in terms of trying to figure out a cure? So many brilliant minds devoted their lives to trying to solve this and getting closer and closer and closer, but there's something missing that's preventing. Yeah, it's a good question. I think about it like, We know the best example of medicine about where we probably would wanna be with cancer is how we treat HIV.

1:31:10So we don't have a cure for HIV, but we have a very powerful cocktail of medications that can suppress the growth of HIV virus and allow a person to live out a full healthy life and die with, not from their HIV. In prostate cancer, we have a portfolio of super powerful medications. And our goal is to enable people short-term to not die from, but die with their prostate cancer. And so I would argue that, yeah, it is very, very difficult to find that cure. And there are cancers we can cure, testis cancer in men, for example, is curable. Other cancers are just way more elusive because they're always changing over time.

1:31:50So we find something to attack them and then they evolve and they develop resistance and they change. But I think if we get enough of those different new medications that we can kind of continually suppress and think about deploying them in cocktail formats like we do for HIV, you could actually suppress the disease and enable them to live out a full healthy life. So for example, if a man's diagnosed with metastatic prostate cancer today, he can live on average eight to 10 years, median survival eight to 10 years. That means that some people are living 15 or 20 years with metastatic prostate cancer.

1:32:25And there are some side effects from the meds, but in general, they're able to live out a nice full healthy life. So we're not there yet in terms of cure, but we're there, we're getting closer. And in the meantime, we can live, people can live substantially longer with limited kind of side effects. What kind of advances can you reasonably anticipate in your lifetime? I think further ways to target like testosterone is the main kind of driver for prostate cancer progression. So further more sophisticated methods to suppress testosterone in individual cancer cells will be key. And then further deploying like immune-based therapy.

1:33:07So immunotherapy has really changed a lot of other cancers, melanoma, kidney cancer, bladder cancer, and enabling people to live longer. And I think we haven't yet cracked the nut as to how to kind of deploy immunotherapy within the prostate cancer space. So that's, I think, super exciting. and on the horizon. And then in the localized space for most guys, just refining, hey, who really needs aggressive treatment? And if you need aggressive treatment, should it be surgery? Should it be radiation? How do we fine tune and tailor that? Those are the kind of exciting things in the next five to 10 years that we'll have.

1:33:41Yeah. As groundbreaking as the PSA test is and as revolutionary as this DaVinci machine is, we're seeing such rapid technological advancement right now in robotics and diagnostics and screen, like screening and with the advent of AI, like applying like, you know, hyper intelligence to massive data sets. It feels again, from a very lay person's perspective that we're on the precipice of being able to make some pretty astronomical breakthroughs in medicine. Yeah, they're happening, you know, so AI is deployed in medicine already. We just don't, for example, if you get a CAT scan, you lie on that machine.

1:34:27I don't know if you've ever had a CAT scan, you lie on the machine and it weighs you and it figures out, it's just deploying very basic AI machine learning, how much radiation you should get based on your weight and your body composition. Now we have AI that can read X-rays for people that come through the ER so that the doctor who's reading them is not overtired and it's for reading them and screening them and identifying things that are much more precision than a regular physician. They're doing that in mammography. So for breast cancer screening. So we have a project looking at AI to read MRIs better perhaps and try to find the needle in the haystacks that maybe we were missing before.

1:35:11So again, lots of deployment in that space. And then also in terms of that kind of physician life balance, once we talked about like, how can we use AI to actually give physicians a break to allow them to not feel like the weight of the world is always there on their shoulders because they have their patients are accessing them all the time with information. So using AI to actually improve wellness and decrease burnout, that stuff is very much what I think we would benefit from tremendously. So not just better medicine, but actually better care of the physicians who are delivering that better medicine.

1:35:48I'm gonna get practical here. So look, it's pretty common as you get older that sleep becomes a little more elusive and you might have to get up in the middle of the night to take a pee, generally happens to me sometime between two and 3 a.m. Pretty regularly, not multiple times, but generally one time during the night. A, should I be alarmed? And B, what can I do to ameliorate this or make it less likely that I have to get up and go to the bathroom in the middle of the night? Yeah, so you shouldn't be alarmed. Most people get up, most people over 50 get up, men and women get up one time at night to go to the bathroom.

1:36:34Usually that's not too disruptive for an individual person's sleep. When you get on to two to three times, that it becomes incredibly disruptive and it's not effective in terms of your overall sleep habits and so forth. How can you mitigate it? You can do basic things like time, when you stop drinking fluids. And so for you, that's like, are you working out later in the day and then having to rehydrate and excess fluid is coming off overnight, et cetera. And for the general listener, it would be the warning signs that you wanna think about if you have nighttime urinary issues are, what other things besides your prostate could this be a sign of?

1:37:16The key thing is actually sleep apnea. It affects one third to 50 % of individuals, not just men. Sleep apnea is when you stop breathing at night. I mean, you just stop breathing and you go apneic. That's like, it's scary to think about. And sleep apnea has a profound effect on so many different organs in our body. But one of the things that is a blessing is that it can actually cause you to urinate more at nighttime. And so if you're getting up a lot at night to urinate, you have a, you know, even if you're, you know, it's typical, the way to think about sleep apnea is like, oh, you have a thick neck, you have a floppy neck.

1:37:54Risk factors for sleep apnea are male sex and men over 50. So it doesn't mean if you're thin and you're fit that you may not actually have sleep apnea as a problem. So sleep apnea is a key thing to just think about and be screened for if you start having increased nighttime urinary frequency. There's other cardiovascular things that you can have. You don't have, you individually don't have them, but a listener would want to think about. And so, yes, more than once at night, it's good to bring up with not just your urologist, but your primary care doc, because there may be other factors that precipitate that nighttime frequency.

1:38:28What is the relationship though between sleep apnea and the urge to pee? Well, sleep apnea increases your urine production at nighttime. So some people have increased urine production at nighttime and therefore they have to get up to go pee. Other individuals just have an urgency to go to the bathroom at nighttime, but it's actually not related to a tremendously increased amount of urine. It's just something that they're awoken and they get up and they'll do small volume urination. So that's something that is more in the urology space. But if you're urinating 20 or 30 % of your total 24 hour urine volume at night, then there's a couple of factors that you may wanna look in.

1:39:07You can look into to see not just prostate specific, but hormonal and or sleep apnea and or heart related. What about compression socks? I heard that if you have this issue, wearing compression socks might be helpful. Not that I really wanna put on compression socks. I have mine on right now. Once a cyclist, always a cyclist. I mean, once you just adapt to them, yes. It keeps the - Sleep in your Normatec boots. It keeps the interstitial fluid, it just diminishes the amount of interstitial fluid you develop in your legs over the course of a day. Why does that matter? Interstitial fluid in your legs, i.e., you can push your skin in and around your ankle and it's kind of mushy.

1:39:49If you eliminate that, when you lie flat at night, that interstitial fluid leaves your ankles and your legs and it goes into your bloodstream and your kidneys produce urine. So by wearing compression socks, then you mitigate the amount of fluid that you have leaking out of your blood vessels in your legs and then you'll have less urine production at night. So basic stuff, yeah. The timing of when you stop drinking fluids, eliminating caffeine from anything in the afternoon or evening and then all day long compression socks, except for like if you're going to the beach or something like that, that's what I would say.

1:40:25So on weekends, if it's the summer and I'm biking a lot, I don't wear them, but otherwise I wear them. What should men understand or know when it comes to erectile dysfunction? You know, you're not alone. So a lot of guys think that they're the only guy around and you shouldn't be embarrassed to bring it up with your primary or for sure your urologist, because there's great medications that can help augment it. About 2 % of men annually over 50 develop erectile dysfunction. So that's, you know, 20 % of guys who are age 60 have it. at least, right? That's reported. So it's probably higher than that.

1:41:03So you're not alone. There's great medications that you can use to, you know, augment whatever performance you have. And I always tell my patients, there's, you know, urologists can get guys, you know, we can get you to wherever you wanna be. But we start with simple medications, over the counter stuff. In what case is an incident of erectile dysfunction, an alarm bell or sort of a canary in the coal mine regarding a larger circulatory or cardiovascular issue. Because if somebody comes in with that and you're just, they give a pill and it's like problem goes away, you're dealing with symptom, you're not actually getting at the root cause of what's that really needs for drugs.

1:41:45Yeah, that's definitely one of the concerns or considerations for these kind of online shops that offer it is, are you really thinking about the whole patient? So erectile, the concordant, you know, meta issues that you can have medically that can be reflected in ED would be diabetes. So diabetes, high blood sugars can have an impact on direct nerve function. And that's often first manifest in erections because the nerve for the erections are so small and they're so sensitive. The other is high blood pressure. So the small nerves have small blood vessels that go supply them with their nutrients.

1:42:22And so high blood pressure can cause erectile dysfunction and uncontrolled blood sugars, i.e. diabetes can do the same. So those are the two things that you wanna think about when you have a patient who has new onset erectile dysfunction is are there other factors that can contribute to that that we need to address also to help that person, you know, overall medically. Sure, I mean, your body's trying to tell you something is off, right? So if you just deal with that, take the Viagra or whatever, you're blind. You're gonna have a problem, a much bigger problem later. 100%. If somebody is gonna go into their urology, they've listened to this, they're like, wow, I just learned a lot.

1:43:00I better go to my GP and then perhaps my urologist. What are some guidelines that you could share around the questions that somebody should ask? Like the smart questions to know whether they're with the right person and they're gonna get the right kind of care? Well, I view medicine, modern medicine should not be paternalistic. It should be a relationship that the individual patient has with their doctor. So I try to be empathetic and I try to be there for my patients. I understand that there's some percent that just they don't care for me. So you have to have a good open relationship with your patient.

1:43:40And I think the patient should view it the same way. They should be able to have an open relationship. And then I think, yeah, Yeah, just having a frank conversation. Hey, I'm a 50 year old guy. Should I be thinking about screening for prostate cancer? I quit smoking five years ago. Do I have to worry about bladder cancer? My erections are good now. Is there something I need to do in the future? Just having an open discussion. But I think the main things that urologists wanna see patients for early is their cancer screening. And then certainly part of our specialty is to enable men to live out a full healthy life.

1:44:14and that for some people would include refinement in their urinary function. So they get up a lot at night, they have trouble urinating, we can fix that. And then also their sexual function. What would be an alarm bell that maybe you're not with the right practitioner? Is there something common that would come up that could let the patient know like, maybe this isn't the right person for me to be seeing about this? Yeah, I think just brushing off questions and shrugging off concerns or considerations. Like, oh, you don't need to get a test or something like that. That's right. I think, yeah, if they say that you have to say, well, why don't you think I need a test?

1:44:54And I sometimes tell people that, but that's because they're 97 years old and they don't need to get screened for a cancer that may be lethal for them in 15 or 20 years. So it's a little bit about context. And certainly I try to appease and really develop a good relationship with every patient, but there are some that you just can't because there's just a personality conflict. So I think, making sure that they're kind of available and trying to find people who are as empathetic as possible is always helpful. And then there's lots of online reviews that you can go to on the web to figure out, okay, what's this doctor really about?

1:45:30And those are quite powerful. And we now at Northwestern really fully respect and understand that medicine is not transactional. It's really like a lifetime journey that we try to establish with our patients and really kind of be there for them throughout these different intervals of care. And so thinking about it that way is something that we've been pretty progressive about, but frankly, our patients are our consumers and they're gonna be very, they're gonna shop around and be critical. They want the best. And I think, you know, individuals are pretty savvy these days about refining and finding out, you know, the best portfolio of doctors for them.

1:46:08In terms of male contraception, what should men understand about vasectomies? Well, vasectomies are done to help prevent you from having subsequent children with vaginal intercourse, but they're not. Thank you for that, public service. But sometimes I say it like that because some people confuse having a vasectomy as being an effective way to mitigate sexually transmitted diseases. and it's not that, right? So yes, you can have a vasectomy it's safe to do and it will really effectively eliminate your ability to impregnate an individual with intercourse. Okay. But not at all impede your ability to pass on an STD.

1:46:56Or acquire an STD. So, depending on the preferences of the individual patient, we will have discussions about PrEP, which is a medication you can take to prevent acquisition of HIV if you're in a high risk kind of population. So try to be proactive about engaging our patients and saying, hey, how can we serve you? What things are on your mind? And then trying to be safe for them as well. And the procedure from what I understand is safe. Vasectomy is totally safe. Yeah, yeah. And this is the era of the vasectomy. Everybody says on during March Madness, every guy will get their vasectomy on Wednesday, right before the opening weekend starts.

1:47:43So that's like the highest rate of vasectomy. Is that true? Yeah, yeah, yeah. But in general, it's totally safe. And most people usually get them on a Thursday or Friday, then they have the weekend and they go back to work and they have no issue. So not anything to be concerned about. It's highly effective in terms of a contraceptive approach, 100%. Is there anything that we haven't covered that you feel you want men to understand about not just the prostate, but reproductive health? I think men are afraid to talk to their doctors about their feelings on their health and how they're doing. And they should take a note from the playbook that women use.

1:48:31Women are very proactive in my opinion about engaging with their physicians and telling them how they feel and telling them what their kind of concerns are. Think about all these spectacular breast cancer survivors, they're champions, right? And as you mentioned, when we let off this piece, you said men are so afraid to talk publicly about their prostate cancer. And it's this very strange dichotomy where women are champions and men perceive themselves as failures if they talk about their vulnerabilities and one of their vulnerabilities they feel like is really their men's health function, their sexual function, their urinary function and their history potentially of cancer.

1:49:08So I would tell them to just try to be open with their physicians. And if we understand where they're coming from, that helps us kind of just break down those barriers. And it's part of what we try to do. I have a team that I work with. I have a great nurse practitioner who is, she's a great icebreaker with our patients. And so in that way, just being out there as a provider is helpful, but the patients need to understand that they should also feel free to bring it up too. Yeah, get tested, get your PSA test, yeah. Yes. I'm telling myself. Get your test and send it to me, I'll help you interpret it.

1:49:44Yeah, thank you. Is there anything, I mean, we covered a lot. There's certainly more that we could cover, but as we wind this down, is there anything that I've left off the table that we haven't covered that any misunderstandings, further misunderstandings or, you know, tropes that you'd like to correct. I think we did a great job. I mean, thank you so much for having me come on the show. I'm honored to be able to be here and talk a little bit about what I do for a living. Yeah, I mean, you perform an unbelievable public service and you're also an exceptional communicator of what you do and the importance of it, which is an added talent on top of your surgical hands and your ability to operate the Da Vinci.

1:50:30And I really, I appreciate it. Like I really wanted to make this whole episode, a public service announcement basically for men to also give them permission to do what you just said, which is talk about it and raise their hand. And I'm gonna take your advice as well. So thank you for that. If people wanna learn more about you, where should they go? where would you direct them? They can find me in the Northwest. I mean, I'm everywhere, but Northwestern Medicine's webpage and or tedschafermd.com will direct you to Northwestern to contact me if you wanna reach out and have a question. And we can go to that YouTube page and watch your procedures?

1:51:08Yeah, our YouTube channel is nm for Northwestern Medicine underscore urology. So nm underscore urology. And there's tons of my videos. And then we have a whole portfolio of different educational, urologically based videos that are put up there by our team of experts. Excellent. Thank you. Appreciate it. Thanks for having me. Next time, let's go on a ride. Let's do it. All right, cool. Thank you, Ted. Peace, Lance.

1:51:50That's it for today. Thank you for listening. I truly hope you enjoyed the conversation. To learn more about today's guest, including links and resources related to everything discussed today, visit the episode page at richroll.com, where you can find the entire podcast archive, as well as podcast merch, my books, Finding Ultra, Voicing Change, and The Plant Power Way, as well as the Plant Power Meal Planner at meals.richroll.com. If you'd like to support the podcast, the easiest and most impactful thing you can do is to subscribe to the show on Apple Podcasts, on Spotify, and on YouTube and leave a review and or comment.

1:52:35Supporting the sponsors who support the show is also important and appreciated. And sharing the show or your favorite episode with friends or on social media is, of course, awesome and very helpful. And finally, for podcast updates, special offers on books, the meal planner, and other subjects, please subscribe to our newsletter, which you can find on the footer of any page at richroll.com. Today's show was produced and engineered by Jason Camiolo with additional audio engineering by Cale Curtis. The video edition of the podcast was created by Blake Curtis with assistance by our creative director, Dan Drake.

1:53:12Portraits by Davy Greenberg Graphic and social media assets Courtesy of Daniel Solis Thank you Georgia Whaley for copywriting And website management And of course our theme music was created by Tyler Pyatt, Trapper Pyatt And Harry Mathis Appreciate the love, love the support See you back here soon Peace, plants Namaste

1:53:43Thank you.