Does it matter who performs biopsy?

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tivmod1
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Date Joined Jul 2010
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   Posted 11/5/2010 10:14 AM (GMT -6)   
Is there skill involved when taking cores and what should one consider when seeking a doctor for this specific purpose? In another thread I've described my experiences to date with my high PSA and first biopsy. I had a conversation with the pathologist from Mayo who analyzed my slides and he made the comment that my next biopsy would ideally generate many nice long tissue cores. The "many" could apply to anyone but I'm wondering if it takes skill to get "nice long tissue cores".

My first biopsy was only 10 cores and it appears only 7 slides were sent to Mayo. During the last visit with my urologist he raised the prospect of doing a saturation biopsy so I guess my question would pertain to both conventional and saturation biopsies.

Fairwind
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   Posted 11/5/2010 11:26 AM (GMT -6)   
I personally feel the urologists skill has a lot to do with his ability to zero in on areas suspected of harboring cancer..Some are better than others...Your urologist should have the "search pattern" of your last biopsy. For the second one, he should shift the pattern to sample slightly different areas. The critical areas, up around the bladder neck, are very hard to reach using the TRUP wand...a saturation biopsy uses a different entry point and can easily sample these areas..

Scattered around the country are doctors who use a Color Doppler Ultrasound machine that in skilled hands can zero in on areas that look suspect making any needed biopsy more accurate and less invasive because it is focused on suspect areas..

Some urologists are MUCH more skilled at performing a DRE than others..I had a DRE performed by 4 different doctors over a weeks time...Only one could detect 'a little nodule" . By aiming for this "nodule" during my third biopsy, the suspected PC was found....
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

clocknut
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   Posted 11/5/2010 11:51 AM (GMT -6)   
My wife made an interesting comment the other day that it may have been fortunate that I was at the stage when a "bump" could be felt by the urologist during the DRE, because he then knew exactly where he wanted to focus during the biopsy.  All six cores taken from that left side area showed cancer.  When there is no "bump" or "nodule," it seems to me there is no area of focus and that cancerous areas could be missed more easily.  After surgery, just two months later, cancer was found also on the right side, where the biopsy had found nothing wrong.  He didn't have a specific target on that side during biopsy.

fulltlt
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Date Joined Nov 2010
Total Posts : 264
   Posted 11/5/2010 3:03 PM (GMT -6)   
I sure wish I would have had a stereotactic transperineal prostate biopsy. There are so many advantages to going that route. The standard transrectal biopsy was the worst.

Post Edited (fulltlt) : 11/5/2010 2:15:38 PM (GMT-6)


mycroft
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Date Joined Oct 2010
Total Posts : 54
   Posted 11/5/2010 4:42 PM (GMT -6)   
fulltlt said...
I sure wish I would have had a stereotactic transperineal prostate biopsy. There are so many advantages to going that route. The standard transrectal biopsy was the worst.


Sounds as if the uro was one of those who doesn't bother with such trivia as his patient's comfort. Those who do bother can and do perform biopsies with little or no pain.

Something we should all learn is that we are in charge. Be insistent. Be unpleasant if necessary. Or just fire the medic and go elsewhere. I've done all these and know that it works.

Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 11/5/2010 11:40 PM (GMT -6)   
It's silly to suggest someone can take "charge" when they're lying on the table undergoing the biopsy and the procedure becomes uncomfortable. Let's live in the real world, not television soap operas. Use your internist to recommend the best urologist for your situation and trust that advice. If you don't have that trust then find someone else who you can have that type of relationship. I felt the needle priks, some of them, during my biopsy. I was lightly medicated, though, and though uncomfortable for maybe a minute ... the results were essential in determining the extent of my prostate cancer and my eventual successful removal of the cancer. Not everything in life goes smoothe. Going to the dentist is more troublesome than a prostate biopsy, IMO. We learn to 'get over it.' Thanks.
Age: 61 (58 at diagnosis - June, 2008)
April '08 PSA 4.8 ("free PSA" 7.9), up from 3.5 year prior
June '08 had biopsy, 2 days later told results positive but in less than 1% of sample (Gleason's 3+3=6)
Developed sepsis 2 days post-biopsy, seriously ill in hospital for 3 days
Dr. recommended robotic removal using da Vinci; Surgery 9/10/08
Northwestern Memorial Hospital, Chicago, IL; Dr. Robert Nadler, Urologist/Surgeon
Post-Op Gleason's: 3+3, Tertiary 4; Margins: Free ; Bladder & Urethral: Free
Seminal vesicles: Not involved; Lymphatic/Vascular Invasion: Not involved
Tumor: T2c; location: Bilateral; Volume: 20%; Catheter: Removed 12-days after surgery
Incontinent: Yes (1 to 2 light (woman's style) pad per day)
ED: Combination of Cialis and MUSE (alprostadil) once weekly: started 9-27-08
Returned to work 9-29-08 (18-19 days post-op)
PSA test result, post-op, 10/08: 0.0; 12/08: 0.0; 4/09: 0.0; 9/09: 0.0; 3/10: 0.0; 9/10: 0.0

compiler
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Date Joined Nov 2009
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   Posted 11/6/2010 11:07 AM (GMT -6)   
Mavica said:
" Not everything in life goes smoothe. Going to the dentist is more troublesome than a prostate biopsy, IMO. We learn to 'get over it.' "
 
Oh, give me a break! I got to love those folks who post with so much authority, stating things like they are absolute facts.
 
If you read reports, experiences range from a walk in the park to excruciating. I had them put me out (twilight) and it was not a problem. I have 2 friends who said if they had to have another biopsy, they would do it only under those circumstances. It's different for every one. Telling someone to just get over it is uncalled for.
 
Mel

Ziggy9
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Date Joined Jul 2008
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   Posted 11/6/2010 11:44 AM (GMT -6)   
compiler said...
Mavica said:
" Not everything in life goes smoothe. Going to the dentist is more troublesome than a prostate biopsy, IMO. We learn to 'get over it.' "



Oh, give me a break! I got to love those folks who post with so much authority, stating things like they are absolute facts.



If you read reports, experiences range from a walk in the park to excruciating. I had them put me out (twilight) and it was not a problem. I have 2 friends who said if they had to have another biopsy, they would do it only under those circumstances. It's different for every one. Telling someone to just get over it is uncalled for.



Mel


I assume Mel you know that IMO is an abbreviation for in my opinion. That qualifies his statement. Personally IMO I rather have a prostate biopsy that go through another root canal. I would also guess here through the years that those who need to be sedated or suffer excruciating pain during a biopsy may at best total 10%. I've also seen a number of guys scared to death by some here about an upcoming biopsy to only return and agree with the 90% it was not that big a deal. I think being the fact I've had a total of 4 biopsies 3 regular 1 saturation that my IMO does have some credibility behind it.
Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A

2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study

4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal

7/30/08 - Psa: .32
11/10/08 - Psa.62 -
April 2009 12 of 12 Negative Biopsy

2/16/10 12 of 12 Negative Biopsy

F8
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Date Joined Feb 2010
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   Posted 11/6/2010 12:10 PM (GMT -6)   
i freaked out over the biopsy and tho i tried didn't get the level of sedation that i wanted, but i am in the 90% that thinks the biopsy really wasn't that bad. however, i would much rather get a root canal because i can get any level of sedation i'm willing to pay for.  and then there's the potential complications from prostate biopsy.
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

compiler
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Date Joined Nov 2009
Total Posts : 7269
   Posted 11/6/2010 12:19 PM (GMT -6)   
It is one thing to say that in my experience a biopsy was no problem. I read that differently than the IMO qualifier.
 
I can say that IMO a G6 will never cause a future problem with PC. That is still a misleading statement.
 
I won't split hairs on that score. From my readings (and, remember, I did ask specifically about a biopsy way back before I had one) it did seem like 90% of the folks did NOT feel it was excruciating. Within the 90% you had a range of better than going to a dentist to very unpleasant. I was admittedly squeamish about it. But, actually, I was ready to do it the "routine" way. However, that would have required something like a 4-week delay. By some quirk, there was an almost immediate opening in the OR if I was willing to do it with the sedation. Needless to say, I jumped at it as I was anxious to get things going.
 
I still don't care for the "get over it" idea.
 
Mel

cooper360
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Date Joined Jul 2010
Total Posts : 161
   Posted 11/6/2010 12:19 PM (GMT -6)   
It mattered to my husband and I. He decided, with my research to have a potential biopsy done only in conjunction with color doppler and only by a Dr who was highly skilled in reading CDU. In the end [no pun intended] no biopsy was required.  Cooper

Ziggy9
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Date Joined Jul 2008
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   Posted 11/6/2010 1:03 PM (GMT -6)   
F8 said...
i freaked out over the biopsy and tho i tried didn't get the level of sedation that i wanted, but i am in the 90% that thinks the biopsy really wasn't that bad. however, i would much rather get a root canal because i can get any level of sedation i'm willing to pay for. and then there's the potential complications from prostate biopsy.


ed


A root canal may be a poor example top compare it with. A regular biopsy is over like in 15 minutes compare that to a multi visit molar root canal and if you want to mention potential complications those arising from sedation although rare can be very serious. I know I know it's not heavy sedation required but if we're talking about rare and worse case scenarios now.

Purgatory
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Date Joined Oct 2008
Total Posts : 25393
   Posted 11/6/2010 1:16 PM (GMT -6)   
To answer the question that started this thread: Doing a prostate biopsy is a very elementary urological procedure. If you don't trust your urologist to do it, then you need to find one that you do . It's considered a very routine procedure.

And to Mel, I think you are making too big a deal out of what Mavica said, and it was his opinion, and subjective opinions are what this place is all about. I agree, that for probably 90% of men, having the biopsy is uncomfortable and foreign to our normal thinking. Pain is subjective as is fear. I had 3 done, 1st without anything numbing, 2nd with numbing - the shots to numb hurt me bad, and the 3rd time, told the dr. forget the numbing, lets get it over. With all I have been through, the biopsies for pain rated a 1-2 on the scale. But that's me.

There are the rare exceptions, where it goes wrong, or there is a lot of temporary pain involved, but again, not the norm, but the exception. The fear part can simply get out of hand inside of the persons mind. I know men that are afraid of getting a simple shot like a flu shot, and my ex-boss literally faints at the sight at a drop of blood.

Mavica's IMO in terms of contract law, was all he needed to say to qualify and limit his post as his opinion. Case dismissed. lol.

david

English Alf
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Date Joined Oct 2009
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   Posted 11/6/2010 4:23 PM (GMT -6)   
How much pain we feel depends on what nerves we have, what gets done to them and what we feel (and on how much pain relief is given)
Some people will thus not suffer a great deal of pain during a biopsy others will, that's just the way it is. Mavica is lucky he was okay during his.

My biopsy was painful: the most painful thing in my life. I came this close to hitting the uro as a reflex! (I have had teeth drilled without pain relief and it was worse than that, also worse than dislocating fingers, coming off a bike, falling down stairs, getting nails ripped off, cutting off top of finger, getting electrocuted, etc.)

However, my uro did aim the biopsy needle in the right place and got good cores which detected my cancer which is perhaps more important, so that did at least make up for the bad side, and it was also okay that the biopsy gave me the bad news because it meant I didn't ever have to have another one.(see - I am even describing this in terms of the biopsy itself being worse than the results of the biopsy)

That said, yes, it does matter who performs the biopsy, but IMO the important thing remains having someone who has learnt to aim in the right place. The secondary aspect is to get someone who will realise that it may hurt you and will give you a jab etc first. Oh and it's also important that the cores go to a good lab.

Alf

mycroft
Regular Member


Date Joined Oct 2010
Total Posts : 54
   Posted 11/6/2010 4:55 PM (GMT -6)   
A bit of anesthetic is cheap insurance against pain. What's to lose?

Besides, if the patient is comfortable and not tensing up, the uro's job should be easier.

142
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Date Joined Jan 2010
Total Posts : 7082
   Posted 11/6/2010 5:10 PM (GMT -6)   
Alf and I must represent the opposite poles on this discussion. My biopsy was nothing I would choose happily to do again, but it did not hit the top, or even close to the top, of my "worst pain" events.
 
But to the original question, I think that you must choose a uro with a lot of experience to do the biopsy. If a minimal number of cores are done, and not properly targeted, it is (mentally) worse than not having it done at all. If they miss the target, and it comes back clean, you will be constantly torn between "there is nothing there", and "there has to be something there".
 
It all comes down to experience and trust.

tivmod1
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Date Joined Jul 2010
Total Posts : 18
   Posted 11/6/2010 5:54 PM (GMT -6)   
Purgatory, you answered my question regarding this being fairly routine.

I'm not sure how I feel about my current urologist which is one reason for me asking. He is a very nice man and isn't rushing me into anything. He talks frankly which I like. What I didn't like is the fact that he only wanted to do 10 cores when a few more seem to be standard practice. He is also only able to do open surgery and doesn't want to start with robotics due to his age and the number of operations it takes to get proficient (i'd estimate he is upper 50s). I also had a pretty unpleasant experience with the first biopsy. I wasn't given any type of sedative or even offered one. I did get a few shots to help numb the area but the cores were taken immediately after and the first half of them hurt like hell. At the dentist they usually take 4-5 minutes to let things numb but in this situation it was more about getting it done as quickly as possible perhaps to move on to the next room where the next patient was waiting.

I've identified someone else local that works in robotics, is a urological oncologist and came recommended from someone I know. This isn't to say that I'm sold on robotics if I need treatment but at least it is an option that can be discussed.

mr bill
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Date Joined Sep 2010
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   Posted 11/6/2010 7:58 PM (GMT -6)   
I was really stupid. I let the same urologist do three biopsies that all came back negative. I often wondered if the samples are still out in his garage on the workbench.  During the second biopsy the nurse, a new one, asked if he wasn't going to use a local numbing as the other doctors in the practice did? He replied very bluntly "no, just one more thing to cause infection." Then he pumped me full of Cipro. Next thing, after third biopsy, I end up in ER with urine retention after getting off aiplane. ER DR says this happens frequently with enlarged prostate. Uro wants to do open partial prostatetectomy after I wait two weeks with catheter from ER to get in to see him.  He wants to do Prostatectomy, I want second opinion. To which his surgery scheduler replies "If you get second opinion, don't come back to us with any problems."  End up at Cleveland and taught how to do self cath only when bladder is full, and have a photoselective vaporization about 1 1/2 month later, which is outpatient and lays me up for 1 day vs. 6 to 8 weeks.  Needless to say things did take a serious turn for the worse a few years later, and I wish I knew then what I know now.
 
Sorry guys just blowing off steam re: urologist, biopsies, etc.
 
We must all be our own advocates.
Age 66
BPH since 1996. at least three negative biopsies Erie. Uro did not prescribe finasteride
2007 acute urine retention photoselective vaporize Clev. Clinic
8-9-10 PSA rose to 10.14 with finasteride positive biopsy Cleveland gleason 9, cat & bone scan negative
9-8-10 Robotic prostatectomy at Cleveland. Biopsy 9 nodes, 2 positive,seminal & vas deferens
PSA 3 wk .06, 6 wk <.03

Trevor T.
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Date Joined Aug 2010
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   Posted 11/6/2010 9:57 PM (GMT -6)   
Why are they suggesting a saturation biopsy? You've only been diagnosed with PIN in one core. Saturatuin biopsies are very invasive and require a general anesthetic. You really need to find a new urologist. Go to Northwestern and see someone there, but not just anyone. Do research first and pick who you want to see. Be strong and make sure you do not let Nortwestern assign you a doctor. In the alternative, make the five hour drive to Mayo.

At this point, you want someone who is an expert in prostate relAted issues - a specialist. I'm not an expert or a physician, but I would think that you need a 12 or 15 core needle biopsy from someone who does many of these. Make sure you ask before hand about a local anethetic and a seditivelike Valium if you're truly frightened based on your last experience.

But please, dump this urologist and go to a cancer center. You're fortunate to bin Chicago. You have many convenient choices. And, ideally your urologist will not be the same person who performs the surgery should you need treatment and select surgery.

Herophilus
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   Posted 11/6/2010 10:20 PM (GMT -6)   

Ziggy9
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   Posted 11/6/2010 11:33 PM (GMT -6)   
Trevor T. said...
Why are they suggesting a saturation biopsy? You've only been diagnosed with PIN in one core. Saturatuin biopsies are very invasive and require a general anesthetic. You really need to find a new urologist. Go to Northwestern and see someone there, but not just anyone. Do research first and pick who you want to see. Be strong and make sure you do not let Nortwestern assign you a doctor. In the alternative, make the five hour drive to Mayo.

At this point, you want someone who is an expert in prostate relAted issues - a specialist. I'm not an expert or a physician, but I would think that you need a 12 or 15 core needle biopsy from someone who does many of these. Make sure you ask before hand about a local anethetic and a seditivelike Valium if you're truly frightened based on your last experience.

But please, dump this urologist and go to a cancer center. You're fortunate to bin Chicago. You have many convenient choices. And, ideally your urologist will not be the same person who performs the surgery should you need treatment and select surgery.



No you are obviously not an expert. A 3D saturation mapping biopsy along with color doppler is state of the art. True they require sedation and after mine I awoke with a catheter for a day. But in comparison to your normal 12 pin biopsy they make those seem archaic. They will locate the cancer more precisely and the amount of the PCA. For Targeted Focal Therapy for low risk PCa they are essential. TFT is a clinical study treatment that I was successfully treated with going on near 3 years now. I wish it were available for all along with saturation biopsies , but I digress. The reason saturation biopsies are far superior is the amount of cores taken which are decided by the size of the prostate. In my case 45 although I've heard up to 90 from others. They are also placed by a grid.

Your recommendation that he find a better urologist who won't give him a saturation biopsy is downright laughable. I advise him to stay with the doctor he has for many would love a saturation biopsy if it were available. After said biopsy he will know much better as to his Pca than you and most others here know/knew of theirs. That's an irrefutable fact. At that point he may decide on treatments and doctors with much better knowledge of his PCa.

http://alprostate.com/Documents/TFTMAPPING.pdf

I see you're fairly new here. If you feel the need to give future advice fine, but be sure you know what you are advising about.
Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A

2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study

4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal

7/30/08 - Psa: .32
11/10/08 - Psa.62 -
April 2009 12 of 12 Negative Biopsy

2/16/10 12 of 12 Negative Biopsy

Post Edited (Ziggy9) : 11/6/2010 11:21:10 PM (GMT-6)


Terry Herbert
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Date Joined Sep 2010
Total Posts : 92
   Posted 11/7/2010 2:28 AM (GMT -6)   
I was interested to see this definite statement

A 3D saturation mapping biopsy along with color doppler is state of the art.

and wondered in what institutions this 'state of the art' was practised and which studies demonstrated so clearly this this should be done, presumably in every case?

Apart from that, if the saturation biopsy with color doppler can identify very small positive material so very clearly, surely the same procedure should be applied where there is a rising PSA after a therapy, perhaps the first sign of biochemical failure of the original therapy?

If a twelve needle biopsy is not appropriate for an initial biopsy why is it appropriate for a follow-up biopsy?
Diagnosed ‘96: Age 54: Stage T2b: PSA 7.2: Gleason 7: No treatment. Jun '07 PSA 42.0 - Bony Metastasis: Aug '07: Intermittent ADT: PSA 2.3 Aug '10

It is a tragedy of the world that no one knows what he doesn’t know, and the less a man knows, the more sure he is that he knows everything. Joyce Carey

Trevor T.
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   Posted 11/7/2010 5:35 AM (GMT -6)   
I'm glad you feel that this invasive and risky procedure was right for you. I see that you're no expert either since this "state of the art procedure" is not recommended for a a person with a low PSA and a negative core biopsy. It's simply too invasive and too risky.

Using your logic, he'd proceed with surgery based on the recomendation of one urologist. The only thing laughable is your arrogance and your pseudo expertise. That's the scary thing about doctors who've obtained their medical degrees from the University of Google

Oh, and I did investigate having this procedure done as I was considering active surveillance for my own case. I investigated it thoroughly with a team of physicians from one of the best cancer centers in the country. But, you seem to be the real expert in risk taking as well as saturation biopsies. I see you were treated with a non traditional therapy. I'm glad it worked for you. Personally, I'm not comfortable with risk. Only a fool would subject themselves to an invasive procedure like a saturation biopsy without further advice and investigation and certainly not without a preliminary finding of cancer.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 11/7/2010 9:28 AM (GMT -6)   
ziggy, i reported the obvious flamer above to admin. i know you didn't ask me to, but enough is enough
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Ziggy9
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Date Joined Jul 2008
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   Posted 11/7/2010 10:46 AM (GMT -6)   
Trevor T. said...
I'm glad you feel that this invasive and risky procedure was right for you. I see that you're no expert either since this "state of the art procedure" is not recommended for a a person with a low PSA and a negative core biopsy. It's simply too invasive and too risky.

Using your logic, he'd proceed with surgery based on the recomendation of one urologist. The only thing laughable is your arrogance and your pseudo expertise. That's the scary thing about doctors who've obtained their medical degrees from the University of Google

Oh, and I did investigate having this procedure done as I was considering active surveillance for my own case. I investigated it thoroughly with a team of physicians from one of the best cancer centers in the country. But, you seem to be the real expert in risk taking as well as saturation biopsies. I see you were treated with a non traditional therapy. I'm glad it worked for you. Personally, I'm not comfortable with risk. Only a fool would subject themselves to an invasive procedure like a saturation biopsy without further advice and investigation and certainly not without a preliminary finding of cancer.

Your rudeness and arrogance are appalling. Your advice is frightening.


First of all I admit I was under the impression he had a single positive core. But other than that your arrogance is frightening and you really shouldn't be giving advice. Yeah yeah I know you checked with an unknown group of doctors from one of the best cancer centers. Where was that? At least my advice is based on a named university and includes my doctors presentation to the American Urological Association. As far as it being a risky procedure I will tell I know there's been over 100+ done with no adverse reactions or even an infection. My advice is from actual experience while yours is hearsay from an anonymous expert cancer center. But you're not comfortable with risk eh? It's a hell of a lot riskier going by a normal 12 pin biopsy in knowing its location or the volume of PCa to base your treatment decision on.
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