Radical Prostatectomy - in depth questions

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Perineum
Regular Member


Date Joined May 2011
Total Posts : 23
   Posted 6/8/2011 3:12 AM (GMT -6)   
Hello, I have some questions about the Radical Prostatectomy (open, not robotic) surgery details:

1. What is PLND?
I've read that it relates to lymph nodes test, but could't find if it's something that is done during the surgery or after?
And what does this test mean? how accurate is it?
Is it being done on every surgery or is it according to surgeon decision?

2. Does in every open Radical Prostatectomy the patient needs blood?
How the surgeon decides whether to give blood?

3. Is there only one surgeon performing the surgery, or does he have any assistant (besides the anesthetic, nurse)?
I mean - does the actual surgery is performed by one surgeon or more?

4. What is the average recovery time which the patent is able to walk by himself without pain?

5. How accurate is the post surgery pathology report in predicting the recurrence of the tumor?

6. According to what the surgeon decides whether to do the nerve sparing??
Does he decides before surgery or after?


Thank you all for your support and informative help !!

Piano
Veteran Member


Date Joined Apr 2008
Total Posts : 847
   Posted 6/8/2011 6:30 AM (GMT -6)   
I had RRP, just over 3 years ago and here are my recollections:

1. Pelvic Lymph Node Dissection (PLND) is removal of one or more lymph nodes at the time of surgery. If PCa is found in a lymph node, it means the cancer has probably spread. I had two nodes removed and both were clear. The extent of the dissection is a surgeon decision.

2. Whether you need blood depends on how the operation proceeds. My surgeon told me ahead of time that I probably wouldn't need blood but had me mentally prepared for it just in case. As it turned out, I didn't need blood ~ lost about 1.5 pints, and felt decidedly dizzy when standing for the following day, and my blood pressure was the lowest it had been for years!

3. As to number of surgeons, again it depends. I don't know in my case ~ I was asleep at the time. :-)

4. I was walking gingerly the evening of the operation. Because of the dizziness, I felt more comfortable using a walking frame, but again that was only for the first day. I don't remember any great pain, but I am sure there would have been some the first few days at home. I was soon out out on half-hour walks, and found the catheter and bag to be the biggest impediment.

5. There are no guarantees with the pathology report, only probabilities. I was organ confined, but Gleason 8, so a recurrence was on the cards and duly occurred.

6. My surgeon recommended non-nerve-sparing because I was a Gleason 9 at biopsy, and he wanted to take the biggest margin possible. Usually surgeons make the final decision during surgery, depending on how close the tumor is to the margins.

Good luck with your RRP if you decide to go that route.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4/12 cores
Non-nerve-sparing RRP 7 March 2008 age 63
Organ confined, neg margins. Gleason downgrade 4+4=8
Fully continent
Bimix worked well; now using just VED
PSA undetectable at first but then rose to 0.4, doubling time 7 months
Following diet change, PSA static at 0.4...

Snowbound
Regular Member


Date Joined Jun 2011
Total Posts : 224
   Posted 6/8/2011 7:38 AM (GMT -6)   
3. There were 5 people in my operation, including an second surgeon. I remember up to the point where they put me on the table and sat me up to put in the epideral. The assistant surgeon was the one who took out my catheter, it was the day after Christmas and my UR was on vacation.

4. I think most walk within a day. If you do a lot of walking like I did (I felt like a caged animal in the hospital) make sure you use lots of polysporin (or whatever they give you) for the catheter tube or the tip of your penis will get very raw and tender (the voice of experience)

5. There are no guarantees but the pathology will give you the best idea about what you're facing. Although they expected otherwise, I had an excellent pathology report. The UR said that it's unlikely to recur, there's always a slim chance.

6. Because of the size of my tumour, prior to the surgery the UR recommended that he take the nerves out to give me the best chance at success. It was a hard decision but ultimately I wanted the cancer out of my body more than anything else so I agreed.
Glen, age 50
PSA 5.43 at June 2010 physical
Biopsy: 8 of 12 samples positive, 75% in 1 core. Gleason 7
Radical Prostatectomy Dec 3rd, 2010
Pathology: 3.5cm tumour, no capsular invasion, lymph nodes negative
PSA currently undetectable!

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 6/8/2011 7:44 AM (GMT -6)   
What piano says, but:

I had open almost 4 years ago.
2. My doc said I wouldn't need blood and I didn't.

3. I had the surgeon, assistant surgeon, and the usual OR gang.

4. I was walking 2 hrs after surgery, without pain. Of greater concern to me was I was very weak for a day or so, just totally exhausted after my little walks. I never really had any pain as such. I did have some discomfort about a week after, from soreness and stiffness. All a normal part of healing.

5. There's no way to determine future success from the post surgery path report. Just not possible, other than to make educated/or uneducated guesses. PSA tests will continue to remain the most important thing to tell you your current state as far as cancer is.

6. My surgeon told me that he would strive to spare, but he would take as much as needed if it appeared that they were involved. He made his decision (spared) upon opening me up and getting a look at them. He also told me that if it appeared that my cancer had visibly spread outside the organ he would not remove it, but close me back up and we would do something else. Our only point of contention during the whole process.
James C, 64, East TN
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% inv, lf. lobe, GS6
9/07: Nerve Spar. open RP, Path: pT2c, 110 gms., clear except:
Prob. microscopic inv.-left apical margin -GS6
3 Years: PSA's .04 each test until 4/10-.06, 9/10-.09, 12/10-.09, 2/11-.08, 5/11-.08
Bimix .30

rcroller
Regular Member


Date Joined May 2011
Total Posts : 326
   Posted 6/8/2011 8:05 AM (GMT -6)   
My open RP was three weeks ago today so here is what I can add to the responses above.
1. Pelvic Lymph Node Dissection - My surgeon removed those that were there. I wasn't bilaterally symetrical...had two on one side and three on the other. No involvement but lots of lymph fluid drainage post surgery...JP drain removed after two weeks. Everyone is different in this regard but not a big probelm either way as long as they are negative for PCa.
2. My surgeon told me the odds of needing blood were slim (5%) but offered me the opportunity to donate my own blood if I wished. I opted not to and didn't need any blood during surgery.
3. There were two surgeons involved in my surgery. My doc always uses an assistant surgeon. According to him, it is needed when they carefully hand off the specimen as it is removed from the body cavity.
4. I was allowed to stay horizontal the day of surgery but was up and walking the morning after. I had a PCA (pain pump) IV which I rolled along with me as I walked. If I needed a shot I could administer that as needed. I found that one press of the button before the walk was always sufficient for pain control.
5. According to my doc, no one can accurately predict the recurrence of PCa from the path report, although the risk of recurrence is obviously greater with EPE and/or positive margins. My doc said he has had patients who were organ confined that had recurrence and pateints who had EPE who did not.
6. My surgeon knew that my tumor was located on the left apex and therefore we knew going in that the nerves on the left side would not be spared. I was a Gleason 8 going in. He gave me a 40% chance of having EPE and as it turned out I fell into that 40%. He planned to save the nerves on the right and he did since the right side was not involved. I don't know what decision making was done while I was under but it all went according to the plan we had going in.

I have found this forum to be a wonderful source of information and support. Best of luck to you in your open RP, if you decide to go that route.
Age 53- PSA 2/11 3.5
4/21/11 BX Path Report: 3 of 12 Left PCa , 3+3, 3+4, 4+4
4/29/11 Received PCa DX, G-8
5/18/11 open RP Performed, Right nerve bundle spared
5/24/11 Post Op Path Report: G-7(4+3) 7%, pT3a N0M0, EPE, PNI+, SVI-, Left margin <0.1mm from inked margin
6/1/11 Cath removed - 99.9% Dry.

Post Edited (rcroller) : 6/8/2011 8:11:12 AM (GMT-6)


Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2299
   Posted 6/8/2011 9:08 AM (GMT -6)   
I had an open prostatectomy 5 years ago this month.
 
2.  I asked my surgeon a couple of months ahead of the surgery if he wanted me to donate my own blood (autologous transfusion) ahead of time to be used if they needed it.  He said that he had never had to do a transfusion for the open procedure and it was better to go into the surgery with a full tank of blood.  As it turned out I lost about 750 mL (1.5 pints) during the surgery, but was still way above the numbers where a transfusion would be needed.
 
3.  I had two surgeons perform my surgery, both urologic surgeons. My surgery took 4 hours.  
 
4.  I began walking the day after surgery.  Like Piano, I felt dizzy and wobbly.  My blood pressure (always low) was really low due to the morphine. I walked and walked and walked.  I agree  with Glen about keeping the penis/catheter tip lubricated.  I don't remember what product I used, but it wasn't an antibiotic like Polysporin.  I had little pain and stopped the pain meds (except for OTC) after day two.  I got used to the catheter quickly and had it taken out two weeks after surgery. 
 
5.  The pathology report (one of the reasons I chose surgery) gave a good prediction of future recurrence, since the cancer was confined to the prostate and had no extension anywhere, including margins.  It has proven to be that way as regular PSAs have always been <0.1 ng/mL
 
6.  My surgeon decided to  do the bilateral nerve-sparing procedure during the operation after determining that the cancer was confined to the prostate.  ( I can't pass up telling this old prostate surgery joke:  The surgeon sees the patient for the first time after surgery and the patient asks, 'Were you able to spare the nerves?  'Yes', replies the doc, 'they're under your pillow.')
Age 62 Pacific Northwest
PSA quadrupled in one year (0.6 to 2.6)
DRE negative Retested at 3 months (2.5)
1 of 12 biopsies positive (< 5%) G6
Nerve-sparing open surgery June 2006, age 57
Organ-confined to one small area, downgraded to G5
Prostate Cancer Foundation supporter
5 years PSAs < 0.1

Perineum
Regular Member


Date Joined May 2011
Total Posts : 23
   Posted 6/10/2011 4:13 AM (GMT -6)   
Thank you all for your valuable information.

Another concern - how many days after surgery, the urine through the catheter is going to be red?
Is it OK that the urine will be sometimes red and sometimes yellow?

Any other info regarding the catheter is welcome!!

Thanks !!!!

Piano
Veteran Member


Date Joined Apr 2008
Total Posts : 847
   Posted 6/10/2011 5:37 AM (GMT -6)   
You can expect some bleeding, but how much will be variable. I never saw red or pink urine, just an occasional small clot ~ no bigger than match-head size.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4/12 cores
Non-nerve-sparing RRP 7 March 2008 age 63
Organ confined, neg margins. Gleason downgrade 4+4=8
Fully continent
Bimix worked well; now using just VED
PSA undetectable at first but then rose to 0.4, doubling time 7 months
Following diet change, PSA static at 0.4...

rcroller
Regular Member


Date Joined May 2011
Total Posts : 326
   Posted 6/10/2011 5:50 AM (GMT -6)   
I never had any blood in the urine. The first day in the hospital the urine was a darker tea color, but once I started drinking it became light yellow. I had the very occassional small clot in the catheter bag but never had any bleeding, pink or red. The biggest issue with the catheter was the bladder spasms but that isn't a given for most. Otherwise, I would call it an annoyance for a couple of weeks post-op.
Age 53- PSA 2/11 3.5
4/21/11 BX Path Report: 3 of 12 Left PCa , 3+3, 3+4, 4+4
4/29/11 Received PCa DX, G-8
5/18/11 open RP Performed, Right nerve bundle spared
5/24/11 Post Op Path Report: G-7(4+3) 7%, pT3a N0MX, EPE, PNI+, SVI-, Left margin <0.1mm from inked margin
6/1/11 Cath removed - Incontinence-No, ED-so far, Yes.
6/15/11 4 Week Post-Op PSA Scheduled

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 6/10/2011 7:32 AM (GMT -6)   
You can expect to se almost anything, or nothing, It really is individual. There will be clots, chunks, debris, blood of varying shades or little visible sign. The key to it is to drink plenty of water while on the catheter, its free bathroom time, so take advantage of it. Flush the toxins, drug residue, surgery residue and such out quickly. Unless you have bright red and large amounts of blood in the bag, or later when the catheter is removed, then anything less than bright red is 'normal', just your version of normal. Expect to see more blood tinged urine with exertion, especially at first, and expect it to last a month or more until completely healed and the old scabs, etc, sloughed off.
James C, 64, East TN
Gonna Make Myself A Better Man tinyurl.com/28e8qcg
4/07: PSA 7.6, 7/07 Biopsy: 3 of 16 PCa, 5% inv, lf. lobe, GS6
9/07: Nerve Spar. open RP, Path: pT2c, 110 gms., clear except:
Prob. microscopic inv.-left apical margin -GS6
3 Years: PSA's .04 each test until 4/10-.06, 9/10-.09, 12/10-.09, 2/11-.08, 5/11-.08
Bimix .30

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2215
   Posted 6/10/2011 8:49 AM (GMT -6)   
Perineum,
Ask your uro how many surgeons will be there. As far as I know in my case the main guy was at the Da Vinci terminal and a junior surgeon was actually beside me, others present were nurses to attach/detach the da Vinci tools etc plus the anaesthetist. (But you could for instance have a party of trainee surgeons in there observing) With open surgery the main guy will be at your side, so he may not need an assistant, but it could be that he will do the major stuff and a junior guy will do things like closing things up.

Blood loss can be a risk with all surgery, and the hospital will have some sort of a protocol about having a certain number of units on stand by for every operation. I did not need any blood, but my blood pressure dropped a lot after surgery and I was on an IV drip and Oxygen for a few hours afterwards to get it up again. Blood loss during surgery can depend on the type of instruments used. A scalpel will cut through a blood vessel leaving the vessel open afterwards until it is stitched/tied off, whereas a self-cauterising "knife" should burn through it and seal it straight away. It can also depend on how big the blood vessels are that the surgeon has to work with. We don't all have identical blood vessels. Experienced surgeons know how to assess the volume of blood they are looking at. (same as paramedics etc). Indirect measures can, I believe, include counting the number of swabs used to mop up leaks. You will be connected to an IV and BP will be being monitored constantly and fluids including blood can be got into you within seconds of it being required.

Walking without pain is hard to define as you should never be walking with pain. If you are operated on in the morning, then you should be on your feet and able to walk across the room that evening (perhaps leaning on someone for balance to start with) and you should be full on meds at that point to stop you feeling any pain. After a few days your body will start to recover more and the amount of pain meds will reduce, thus you should still be walking without pain. I was for example able to walk up three flights of stairs without any pain 36 hours after surgery. (It's not walking that it is painful, but coughing laughing sneezing etc, and that pain is of a very short duration and often easy to avoid by clutching a cushion to the abdomen)

What gets removed and what gets left depends on an assessment of how much risk there is that the PCa is very close to escaping from the gland etc.

Removal of one or more lymph nodes during surgery is optional, and should be decided beforehand on the basis of your biopsy result, Gleason, staging etc. None of my nodes were taken.

Nerving sparing should also be agreed beforehand. And again on the basis of Gleason staging etc. I assume that a surgeon would set out to try to do do nerve-sparing, but could then have to cut at a bigger margin as a result of seeing something that made that advisable. (Mine told me he intended to do nerve-sparing, and then came to see me in recovery to tell me that he had actually been able to to that)

The post-op pathology is not about prediciting what happens next. it is just one of the fixed points that allows a nomogram to be used to make statistical calcuations about prognosis. Without being flippant it is sort of like this. The pathologist cannot tell if the cancer if it is a well-behaved Gleason 9 that is not going to spread for 20 years or a badly behaved 6 that is about to rush about after 20 months. The question should thus be: how accurate are the nomograms that will be used to make a prognosis, and I think that the consensus here is that they have a very good track record, but they are statistics, (ie they predict the chance of something happening and not if it actually will happen.)

Have a talk to the surgeon and perhaps also the anaesthetist about exactly what will be done by whom etc. (I'm just an amateur)

Alf

Perineum
Regular Member


Date Joined May 2011
Total Posts : 23
   Posted 6/10/2011 11:00 AM (GMT -6)   
Hello again, I have some out of topic question -
How is the surgery report written?
Is it written posteriori by the surgeon (after the surgery is completed), or
is it written during the surgery (like in court) such as the surgeon tells what he is doing and someone else writes it down?

Thanks !!
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