Surgery or not?

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Regular Member

Date Joined Nov 2009
Total Posts : 212
   Posted 12/14/2009 8:04 AM (GMT -6)   
When someone is diagnosed with PCa, how does the Dr decide whether or not to do surgery?
My father has Gleason 10 found in prostate and seminal vesicles. Bone and Cat scans were otherwise clear. He is on hormone therapy now, and I believe they plan to do radiation in January.
But no one has mentioned the idea of removing the prostate, etc (he has had a TURP though, to open things up).

Veteran Member

Date Joined Jul 2009
Total Posts : 504
   Posted 12/14/2009 8:25 AM (GMT -6)   
Thats easy, if the Dr is a Surgeon, then guess what they will recommend !! Thats why you need multiple opinions from different specialty Dr's. Those that specialize in Surgical, Radiation, and other treatments

A Dr will factor in the overall health of your father in their recommendation. If they feel he will not be strong enough to even survive anesthesia then Surgery will be the last option. It depends on many factors, some have nothing to do with the PC
Age: 52
PSA (2008)=1.9
Biopsy on Jan 09, 2009
One (1) out of twelve (12) cores was positive, plus external nodule found
Gleason Score = 3+3
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA 7/09 undetectable, under .0

Steve n Dallas
Veteran Member

Date Joined Mar 2008
Total Posts : 4849
   Posted 12/14/2009 8:27 AM (GMT -6)   
And when it gets outside the prostate - surgery isn't the best option.

Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.

Regular Member

Date Joined Nov 2009
Total Posts : 212
   Posted 12/14/2009 8:48 AM (GMT -6)   
Why is surgery not a good option if it has spread to the seminal vesicles??
Is it not possible for the prostate to allow more cancer cells out? Or is the hormone therapy that effective at stopping that?
Thanks again

Veteran Member

Date Joined Jul 2008
Total Posts : 966
   Posted 12/14/2009 9:09 AM (GMT -6)   
Like Steve said, if it has already invaded the seminal vessels or lymph nodes (based on his CT scan), then surgery is usually not recommended. Surgery is done when a cure is the main goal of the treatment. Once the cancer has escaped the prostate, then a cure isn't possible. They can keep the cancer under control for many years with the hormone therapy.
You are beating back cancer, so hold your head up with dignity
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month Apr 2009 .06
                   9 month Jul  2009 .08
                 12 month Oct 2009 .09 

Veteran Member

Date Joined Dec 2008
Total Posts : 3149
   Posted 12/14/2009 9:15 AM (GMT -6)   
It is a reasonable question, unfortunately has unreasonable bias for us patients and especially in the very high risk groups of patients....if you have towards a zero chance of successful surgery should it be your only option???? Look at Partin tables, nomograms, Bluestein, Narayan tables or whatever and multitude of possibles tests..if you wish too. Some patients have little or no chance for successful surgery/being cured, so should they be lead to believe it is the correct protocol or best protocol for them to submit too. It is life altering and changing in many of the possible modalites to choose from on this.

I was in this ridiculous stats area and as a newbie in 2002 and uneducated totally in this at that time(but not for to long), got atleast 8 opinions from various types of docs and walked away and fired one or two. Was not looking for the word cure, 1st expert told me that..I was looking for truth, frankness and what might be the best protocol for the death sentence I was given. Probably nobody would understand such until you walked this in someones shoes...I heard good-bad-ugly and agenda and bias was obvious enough for me to figure out. Also heard righteous words from some...not all of these experts.

Two surgeons with completely opposite opinions on my status, nice scenario for new patient whom is zombied up knowing he has cancer and head is not clear at the time. Nobody would ever want to cash in on a patient???

First surgeon says curative and 1% of incontinence and could do a lapro (non-robotic) and had the gonads to write it down on paper and hand it to me (LOL-LOL).

Second surgeon (one day later I had these lined up), this is from Dr. Mani Menon (1st LRRP doc in USA)....I will not do surgery on you (end of his discussion), he assessed me and my stats and history and knew it would be for nothing and useless...I valued his honest opinion and decided upon other possibilities to atleast extend my lifetime and so far very pleased to be here almost 8 yrs. later and still in very good condition, working, playing music, can work on things etc.

Message in my experiences is question everything on PCa and if you trust (verify is your best friend). I am not the only sob that found the maze and quest unreal in this, now some others everything was supposedly beautiful day in the neighborhood (probably the way it should be) but beware of the thorns surrounding the roses. So, now you get to consider your own scenario maybe your eyes and ears will serve you better, perhaps.

So what can others learn from such, if you have the very high risk scenario (especially) think it through could still have surgery to "debulk" the tumor burden....cure should be totally a non-guarantee..if it happens shout it to the world.

(The "curative" stats: dx-2002 (Feb/Mar) bpsa 46.6 12/12 biopsies all 75-95% findings, gleasons scores found 7,8,9's (2 sets and about equal parameters), total urinary blockage in emergency room prior to uro-doc and prognosis, ct and bone scans appeared clear (appeared))      If you can find me evidence of a patient that is cured with stats like this I would like to see the data and story.

Post Edited (zufus) : 12/14/2009 7:25:02 AM (GMT-7)

Elite Member

Date Joined Oct 2008
Total Posts : 25393
   Posted 12/14/2009 9:54 AM (GMT -6)   

With your father's stats of a Gleason 10 and invasion at the seiminal vesical level, I can't imagine a good, experienced, and/or caring surgeon reccomending surgery. Despite what some thing, all surgeons do not push surgery. THey look at the patient in front of them, if they know that surgery wont/cant work, and/or if the patien'ts stats are beyond any hope of a surgical cure, they will not operate and they will send them to a radiation oncologist.

The reason it wouldn't be reccomended in your father's cases, in the simplest of terms, is because the cat is already out of the bag. His PC has already spread. While it probably is no longer cureable at ths point, as other posters stated, proper hormone treatments can slow down the cancer and prolong his life. Still not a death sentence by any means, just a harder path to follow. We have several advanced case brothers here they are holding their own over the years.

My best to him and to you. Please keep us posted of his journey.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys ,cath #8 33 days, Cath #9 in 35 days, 12/7/9 - Cath #10 in place

Regular Member

Date Joined Nov 2009
Total Posts : 212
   Posted 12/14/2009 10:02 AM (GMT -6)   
Thanks for the replies. I think I just naturally assumed - prostate has cancer....remove it!.
I guess I'm still not completely clear on why removing it might not help prevent further spread from the prostate itself, but I'm new to all this.
They are still trying to figure out how to get him off the catheter, and I think radiation is in January..

Veteran Member

Date Joined Dec 2008
Total Posts : 3149
   Posted 12/14/2009 10:45 AM (GMT -6)   
Sister & Bro-Gibson (great guitars by the way)
Can we assume you have not read "A Primer on Prostate Cancer-the Empowered Patients Guide "(Dr. Sturm & Donna Pogliano authors)??????  It explains more than you probably need to know and with patients examples, pictures, information from various gathered sources etc.
Call it the education of a life a time, you can read other books too and should. Make sure if you are a high risk level patient that you read this one, in your case I will refund you the money if it lacks big time and will back up it with paypal or money order, you have my witnesses herein.
Youth is wasted on the Young-(W.C. Fields)

Post Edited (zufus) : 12/14/2009 9:12:43 AM (GMT-7)

Regular Member

Date Joined Oct 2009
Total Posts : 314
   Posted 12/14/2009 10:50 AM (GMT -6)   

Your father's prostate has cancer in it.  Unfortunately, that cancer has already started to spread outside of his prostate too.

If they thought that the cancer was completely contained in the prostate, then they could take out the prostate by surgery (and with it all the cancer) and hopefully that would be a cure.  They can never say with 100% confidence that they got it all, because some cancer cells might have escaped already through the bloodstream or lymph system and are sitting quietly in some other part of the body waiting to grow later.  But surgery would be a good option - not the only option, but a good one.

Unfortunately, they have good reason to believe that your father's cancer has already spread outside his prostate.  If they take out his prostate by surgery, there will still be some cancer cells left in him and that is not good.  Your father will have had major surgery but it still didn't fix the problem.

So they are proposing to radiate your father's prostate area, that is, his prostate and the immediately surrounding area.  Hopefully that radiation will kill the cancer cells in your father's prostate and the cancer cells that are outside the prostate but still near the prostate.  If that happens, they believe that will be better than surgery and may buy your father a lot of time.  Again, they can never be 100% certain.

There are alternatives to radiation (other than surgery) and treatments in addition to radiation but I will let others talk to you about them.   

Good luck.  It's very normal to worry, but your father may very well live a long time yet.

No family history of PC.  PSA reading in 2000 was around 3.0 .  Annual PSA readings gradually rose; no one said anything to me until my PSA reached 4.0 in September 2007, at which point my internist advised me to see a urologist.   
Urologist advised a repeat PSA reading in six months = 4.0 .  Diagnosed May 2008 at age 56 as a result of 12 core biopsy.  Biopsy report by Bostwick Laboratories = Gleason 3 + 3. 
Interviewed two urologists - the one who did the biopsy and another - the latter had the biopsy slides re-examined = Gleason 3 + 3. 
Then went to M. D. Anderson Cancer Center in Houston in July 2008 and met with a urologist and a radiologist.  Biopsy slides re-examined yet again, this time by MDA's internal pathology department = Gleason 3 + 4.   
Chose da Vinci surgery over proton beam therapy; surgery performed at M. D. Anderson Cancer Center on August 15, 2008.  Post-operative pathology report = four tumors, carcinoma contained in prostate, clean (negative) margins, lymph nodes clear, seminal vesicles clear.  Gleason = 4 + 3. 
Minor temporary incontinence; current extent of ED uncertain due to lack of sexual partner; refused treatments for ED as being pointless under the circumstances. 
PSA readings: 
November 2008 = <0.1 ["undetectable"]
June 2009 = <0.1   
December 2009 = <0.1

Post Edited (Zen9) : 12/14/2009 9:09:41 AM (GMT-7)

James C.
Veteran Member

Date Joined Aug 2007
Total Posts : 4463
   Posted 12/14/2009 10:50 AM (GMT -6)   
I think in the simplest terms the answer may be that once it escapes from the gland surgery can only remove part of the existing cancer. That part that has already escaped is gone, sadly, and removing the gland won't get it back. The next normal routine- radiation and hormone treatment- will give a one-two punch of trying to kill the cancer in the prostate, seminals and prostate bed, effectively doing the same thing as surgical removal , and the hormone treatment will be fighting the cancer beyond the gland and bed, to shrink and slow the spread. This one-two combo tries to get the same results as surgery would, except it will cover a larger area, ie: the seminals, the bed, and adjacant tissue.
James C. Age 62
Co-Moderator- Prostate Cancer Forum
4/07 PSA 7.6, referred to Urologist, recheck 6.7
7/07 Biopsy: 3 of 16 PCa, 5% involved, left lobe, GS 3/3=6
9/07 Nerve sparing open RRP 110gms.- Path Report: GS 3+3=6 Stg. pT2c, 110gms, margins clear
24 mts: PSA's: .04 each test since surgery, Bimix .3ml PRN or Trimix .15ml PRN

Regular Member

Date Joined Nov 2009
Total Posts : 212
   Posted 12/14/2009 11:01 AM (GMT -6)   
Thanks again, the explanations make sense, and I'll look into the book.

Veteran Member

Date Joined Apr 2009
Total Posts : 990
   Posted 12/14/2009 11:11 AM (GMT -6)   
Yours is a good question. I don't have an answer, only an observation.

It makes sense to think that fewer cancer cells is always better than more. But this is not the way that good doctors react so our model must be wrong.

If he is going to radiation, they will zap the prostate anyway and that will take care of the nasty guys there as well as in surrounding tissue.

If the treatment is only hormone therapy then we might think about cell behavior. If the PC cells are behaving like Gleason 2s and 3s then it may not matter how many there are. My picture is of a soccer match played before a crowd of 100,000 Mormon missionaries as compared to a crowd of 5,000 British soccer hooligans. It is the behavior, not the numbers that matter
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day

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