Wagner NEW Prostate Cancer patient Template

Urology
Referring Physician: Dr. John Smith
SHORT SUMMARY OF TODAY'S VISIT:
The patient, a 65-year-old male, presented with elevated PSA levels and a recent diagnosis of prostate cancer. We discussed treatment options including active surveillance and robotic prostatectomy. The patient is considering robotic prostatectomy due to its potential for cure and detailed pathological insights.
Chief Complaint: Elevated PSA levels and recent prostate cancer diagnosis.
History of Present Illness: This is a 65-year-old male with a history of elevated PSA levels over the past year, peaking at 8.5 ng/mL. Recent MRI showed a PIRADS 4 lesion, and biopsy confirmed Gleason 3+4 prostate cancer.
- PSA History:
  - 1 January 2024: 8.5 ng/mL
  - 1 July 2023: 7.2 ng/mL
  - 1 January 2023: 6.8 ng/mL
- Imaging Findings: MRI on 15 October 2024 showed a PIRADS 4 lesion in the right peripheral zone.
- Biopsy Findings: Gleason 3+4 in the right peripheral zone, 60% involvement.
- Urinary ROS: Reports mild urinary frequency, no dysuria.
- Sexual Function review: Currently sexually active, reports mild erectile dysfunction managed with Cialis.
Past Medical History:
- Hypertension, diagnosed 2015, well-controlled with medication.
- Hyperlipidemia, diagnosed 2018, on statins.
Past Surgical History:
- Appendectomy, right side, Dr. Jane Doe, 2005, uncomplicated.
Family History:
- Family history of prostate cancer: Father diagnosed at age 70, no metastasis.
Social History:
- Tobacco use: Quit 10 years ago, 20 pack-years.
- Alcohol use: Social drinker, 1-2 drinks per week.
- Occupation: Retired engineer.
- Social support: Lives with spouse, strong family support.
- Hobbies: Golf, gardening.
Allergies:
- No Known Allergies
Medications:
- Lisinopril 10 mg, once daily.
- Atorvastatin 20 mg, once daily.
- Cialis 5 mg, as needed.
Review of Systems:
General: No weight loss, fever, or night sweats.
Physical Exam:
- General Appearance: Well-nourished, alert, and oriented.
- HEENT: Normocephalic, no lymphadenopathy.
- Cardiac: Regular rate and rhythm, no murmurs.
- Resp: Clear to auscultation bilaterally.
- Abdomen: Soft, non-tender, no organomegaly.
- Genitourinary: Prostate enlarged, firm nodule on the right.
Laboratory Findings:
- PSA: 8.5 ng/mL on 1 January 2024.
Biopsy Results:
15 October 2024
- Right Peripheral Zone:
  - Gleason 3+4, 60% involvement, no perineural invasion.
Imaging Results:
MRI showed a PIRADS 4 lesion in the right peripheral zone, prostate volume 40 cc.
Assessment:
This is a 65-year-old male presenting with intermediate-risk prostate cancer, Gleason 3+4. We reviewed the options: including active surveillance, external beam radiation, brachytherapy, and radical prostatectomy.
We spent much of our discussion on the pros and cons of moving forward with robotic prostatectomy. Certainly, it will offer him a reasonable chance of cure, give us important pathological data including lymph node status, make post-treatment evaluation very straightforward with a PSA test of high sensitivity and specificity, and gives us the opportunity to treat secondarily with external beam radiation in the event of cancer recurrence.
We would approach this robotically which requires two to three hours of surgery and overnight hospital stay, <1% risk of blood transfusion, and one week catheterization. Other rare complications are possible including damage to other organs (ureters or intestine), DVT/PE, or MI. Ileus occurs in about 1 in 50 cases requiring readmission.
We will consider a pelvic lymph node dissection which does carry with it a slightly higher risk of DVT or PE in the postop setting, as well as small risk of lower extremity lymphedema.
Most men are able to resume normal physical activity and exercise in 3 weeks. Most men experience urinary incontinence that can continue on average for about three to six months. There is a 5% risk of permanent, socially significant incontinence.
We discussed and illustrated the anatomy of the prostate, including its relationship with the bladder, urethra, and rectum. I explained how separation of the prostate and the bladder disrupts the internal urethral sphincter, and that his urinary control is dependent almost solely on the external urethral sphincter during healing of the vesicourethral anastomosis, which results in temporary stress urinary incontinence. I showed him how cavernosal nerves that help control erections are intimately related to the lateral and posterior aspect of the prostate, and usually damaged or stretched during radical prostatectomy, resulting in temporary or sometimes permanent erectile dysfunction.
We mentioned that it is possible that he may require further procedures after prostatectomy to treat his prostate cancer. I reassured the patient that we focus on optimizing patients' quality of life and that I expect that he will be satisfied with his recovery, but that if he is not, that further medications or procedures to help him with his urinary or sexual side effects will be made available to him throughout his recovery. In particular, I explained our programs in pelvic floor physical therapy and sexual rehabilitation, which can accelerate recovery of both health domains, and would be made available to him both before and after surgery.
He would be a candidate for nerve sparing after which would have a fair chance of regaining erectile function suitable for intercourse, but probably would not regain baseline sexual function and he would likely need at least the help of PDE 5 inhibitors, if not other erection aids including penile vacuum device or penile injections.
Plan:
- Schedule robotic prostatectomy at St. Mary's Hospital.
- Consider pelvic lymph node dissection.
- Referral to pelvic floor physical therapy and sexual rehabilitation.
- Follow-up in 2 weeks to discuss final surgical plan.
Signed By:
Dr. Thomas Kelly, Urologist, 1 November 2024
Time Spent:
Total time spent for face-to-face and non-face-to-face care, excluding procedures and other services, on the day of this encounter is 60 minutes.
“Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools at future visits.”