A few miscellaneous questions regarding treatments

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April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 12/5/2010 10:48 AM (GMT -6)   
Here are a few things I have been curious about but haven't been able to find the answers for.

1) My Gleason was 3+4 prior to surgery. The post op pathology report was 3+3. Of course I was happy about this, but my question is: Am I considered a 3+3 or a 3+4 now? It would be logical that I would be considered the worse of the two, even though the more thorough pathology report is the post op one which is the lower one.

2) I have a friend who got the seed implants and he said he had no side effects other than a little blood in the urine for 1/2 a day afterwards. Why is it a prostate biopsy will give most men bloody semen for a few weeks and the seed implants don't? It seems as though have those seeds inserted in the prostate would be as intrusive as a biopsy.

3) When gas is pumped into the abdomen during a robotic surgery (to improve the access to the prostate), what keeps the abdomen inflated since there are 5 unsealed holes through the skin?

4) Why do robotic surgery patients usually get the catheter out in a week and open surgery patients get it out in 10-14 days. In other words, why does it take a little longer for the urethra to heal for open patients--or is that not the case?

5) If someone is still working on incontinence, why are they more likely to leak late afternoon or evening, than morning or mid day.

I did find the answer to an earlier question I had--why is the operating room so cold? It is not for the patient's (direct) benefit. According to a couple of sources, it is so the operating room staff is more comfortable once the operating room lights start warming up things. I had heard theories that a cold operating room lessened the chance for infection or that it reduced blood flow at the patient's skin (reducing bleeding) but couldn't find anything to back this up.

Dan

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/5/2010 11:11 AM (GMT -6)   
On your number one: you would be considered a Gleason 6, not a Gleason 7, based on the post surgery pathology.

On your number five: the muscles you are working so hard to control, get tired as the day wears on, its a very common situation

On your number four: catheter time really isn't based on open/robotic surgery, its based on what the surgeon feels best for the situation. there are open guys that have them out in a week too, and have seen a few robotic guys with up to 30 days, just depends case by case.
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

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3748
   Posted 12/5/2010 11:13 AM (GMT -6)   
1) Gleason scores occasionally get down-graded after surgery, a different lab, a different pathologist. In your case, a second, expert opinion might be worthwhile,, as this is important..

2) The biopsy procedure penetrates the urethra, perhaps multiple times, to get the samples the U-doc wants..With seed implants, they stay away from the urethra..

3) The gas (nitrogen) is kept at very low pressure, they seal the incisions up as best they can, there is some leakage but the slight pressure is maintained..

4) One of the advantages to robotic surgery is the ability of the surgeon-robot to join the urethra back to the bladder. The machine can do this with great precision...

5) After standing all day, pressure builds on the sphincter muscles which are tiring anyway..Those of us who indulge in a little afternoon libation compound the problem...JMHO..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 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 SRT, HT, Dec

tarhoosier
Regular Member


Date Joined Mar 2010
Total Posts : 487
   Posted 12/5/2010 11:25 AM (GMT -6)   
Dan:
1.) The pathologist opinion is just that, an opinion. It is quite likely that the biopsy pathologist and the surgery pathologist were different. The biopsy provides less than 1% of the gland. The access to the entire gland (one hopes it was all removed) provides a full view of the tissue and there are no reasons to be in error if the pathologist is experienced and the results are re-read by a colleague, as is common. Thus any future concerns will be based on the post surgery path report. That is good news to you.
4) Catheter removal is different for different people. I had open RRP and scheduled the removal of catheter for 8-9 days later. This fell on the day before a 4 day holiday for the urologist and he waited until 14 days to do this so that if there were complications his office could be available. I was fully in favor of this. I think that it depends on the age of the patient, the experience of the surgeon and his office, the healing and complications seen at the hospital. The surgical technique for the anastomosis (closing the urethral opening after surgical incision) is similar in the Robot and open type.
5) if this pattern is true then it likely is related to the stress and fatigue of the muscles in the urethral area. Fresh from rest in the morning and with an empty bladder this builds stress and tension during the day. Hours of standing and sitting and walking and changing position create fatigue in the small control muscles. I guess that if there is a siesta during the day this afternoon/evening issue would diminish.

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3806
   Posted 12/5/2010 11:59 AM (GMT -6)   
i had more "severe" side effects from BT, like urinary frequency that had me getting up to pee 7-8 times a night.  i was also taking flomax at that time which made me very dizzy.
 
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

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4229
   Posted 12/5/2010 12:26 PM (GMT -6)   
Dan,
A biopsy is done through the rectum and seeds are done with a templet through the perinium. There is much less discomfort with seeds than a biospy, none of that dull pain for 3 or 4 hours afterwards, really no pain at all.
JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 12/5/2010 12:31 PM (GMT -6)   
Thanks for the answers!

Dan
Here are some of my stats:
Age:54
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA tested on 7/15/10: Zero Club membership card issued (trial membership with 90 day renewal)

Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2302
   Posted 12/5/2010 12:56 PM (GMT -6)   
Dan,
 
I am one of those whose Gleason score changed from the diagnostic biopsies to the post-prostatectomy pathology:  Gleason 6 to Gleason 5.  The post-surgical pathology is more accurate because they are slicing and dicing the whole prostate rather than smaller sections obtained in the biopsies.  All the best!
 
Tim
PSA quadrupled in 1 yr (0.6 to 2.5)
DRE negative 1 of 12 biopsies positive (< 5%)
open surgery June 2006 at age 57
Organ-confined to small area, Gleason 3+2
Bilateral nerve-sparing, Prostate weight 34 grams
PSA's undetectable < 0.1

April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 12/5/2010 1:30 PM (GMT -6)   
Tim,

My understanding of the post op pathology is that, yes, it is more accurate than the pre-op biopsy because a lot more of the tissue is tested and viewed.

But even in the post-op path report, not 100% of the tissue is scrutinized under a microscope, so I am thinking it was possible that some of the gleason 4 that was found in the initial biopsy, was not viewed in the post-op path report, even though it was present in small qtys.

So, there are two scenarios for a lowered Gleason post op:

1) A similar tissue sample is interpreted differently by two different pathologists.

or

2) Even though statistically it is less likely, maybe the initial biopsy included Gleason 4 tissue that the post op path report didn't examine.

Tarhoosier mentioned that less than 1% of the prostate is sampled in the intial biopsy. Does anybody know what percent of the tissue is examined in the post op pathology report? Either by volume or number of slides prepared and examined?

Dan
Here are some of my stats:
Age:54
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA tested on 7/15/10: Zero Club membership card issued (trial membership with 90 day renewal)

Gordy
Veteran Member


Date Joined Jun 2005
Total Posts : 528
   Posted 12/5/2010 1:52 PM (GMT -6)   
Fairwind - "2) The biopsy procedure penetrates the urethra, perhaps multiple times, to get the samples the U-doc wants.."

Really?

Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2302
   Posted 12/5/2010 2:00 PM (GMT -6)   
Dan,
 
You're correct, that only representative sections of the prostate (not 100%) are viewed by the pathologist.  In addition to a gross anatomy and examination of lymph nodes, seminal vesicles, margins, etc., my pathologist examined 14 sections from different areas of the prostate. 
 
My initial biopsy slides were reviewed by Jon Epstein at Johns Hopkins, and the same local pathologist (with a consult) viewed both biopsy and organ-section slides. All examiners agreed on the Gleason score.  The only surprise, according to my urologist, was that the post-surgical examination found only one cancerous area.  He said that usually, because the biopsies are such a small sample, if cancer is found in one place, it will be in multiple locations. 
 
It's possible that there was still a miniscule amount of Gleason 4 tissue found on your pathological exam, but that the overwhelming majority was 3 +3.  You could call the pathology lab where you had your prostate examined and they may be able to provide you with additional review notes that indicate whether or not any G4 was present.
 
Tim

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4157
   Posted 12/5/2010 3:46 PM (GMT -6)   
Dan, I'll offer commentary on two of the questions:
 
1.  Is it possible that the readings were done by different labs?  There are some labs (e.g. Epstein) that use the "new" Gleason protocol and others (e.g. Bostwick) that use the original standards.  If your biopsy samples were read by a lab that used the "new" standards and your pathology slides read by one using the original standards that could account for the difference.
 
2.  I would say your seeded friend was lucky.  I had dark semen for a couple of weeks after both biopsy and brachytherapy.
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 12/5/2010 4:31 PM (GMT -6)   
Tim, Tudpock,

My pre op and post op were prepared and read at different places---whoever the doctors chose to use. This could have accounted for the difference. I can't remember the lab's names but it wasn't one of the famous labs like Bostwick or famous university hospital.

I'm not really worried if I am a Gleason 6 or 7, just curious about it. If I was one or the other, it wouldn't change my post op treatment (which is just blood tests every three months). Way, way more important for my peace of mind was the the cancer was contained to the prostate and I had a low percentage of tumor volume.

Dan
Here are some of my stats:
Age:54
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA tested on 7/15/10: Zero Club membership card issued (trial membership with 90 day renewal)
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