Surgery

I had a Consultation this morning with a Surgeon.

I recorded our conversation so I have to go thru the details.

I asked him about ECE. Also about sparing the nerves, my biopsy showed cancer on my right side lobe.

I asked if prior to surgery would he indicate if both nerves were to be spared and how he would determine that, I am concerned about the ECE and how they, surgeons determine how/if to spare a nerve bundle.

I will re-listen to his response but he said he couldn't tell me definitively before surgery, so I offered a 50/50 chance and his response was, probably better.

So I steered the conversation on this topic, specifically how he would make the decision once into the procedure, and I asked how he makes the determination? I asked, Can you see it "cancer" in the nerve bundle? He said no. I asked so if you remove it, you must have a good confidence level that there was cancer in it, but if you leave it, how do you know?

He said that they use a tool during the RALP and attempt to lift the nerve bundle off the capsule, something about having a good plane where it sounds like they fillet the tissue between the capsule and nerve bundle and if it co-operates and if it lifts easily, they spare the nerve and are confident(in their opinion) that it didn't have cancer thru the capsule. He said if the nerve bundles are involved they are difficult to lift or spare. Will re-listen to this.

This sounds like a gamble and your risking their judgement.

I also asked his margin rate for someone with my risk and he said his rate 15%. I also asked how many patients he has operated on had to have salvage radiation and he indicated about 10%.

So how often is cancer left in the nerve bundles and for people who have had surgery, how was this explained to you?

He also indicated there can be microscopic amounts in the bladder neck, will have to re-listen to that part. I think he said that was another difficult area at the anastomosis. I asked about Bladder neck Contracture and strictures and how many he sees, he indicated about a 1-2% can happen.


Anyhow will go thru my notes and listen to my recording and take more notes.

I asked about frozen sections and he started discussing it as pertaining to lymph nodes, will have to review. It didn't sound like he does that process. He does remove 8 or so lymph nodes and has them checked.

What concerns me is, that if they spare a nerve bundle, at least the way he explained, it has more to do with the ease of sparing it and concluding their is no cancer in it, ie if it was involved with cancer it wouldn't separate too easy, sounds dam subjective to me.

Do the surgeons adequately explain this to patients, to me if they cant see it, how do they know how wide to cut, wether to spare the nerves etc.

I am more concerned about leaving any cancer behind with surgery.

This person has been using the DaVinci since 2003 was responsible for bringing it in, before that did over 100 open laproscopic and has about 700 with the DaVinci. Columbia grad and residency at Standford.

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PSA 6/23/2017 12.4 ng/ml MidCoast Hospital Lab
DRE 8/15/2017 Subtle firmness right apex,
PSA 8/21/2017 8.1 ng/ml freePsa 5% Mayo Lab
Bx 8/11/2017 6 of 12 cores right side, Gleason 3+4, <50%
Stage T2A, 32 ccc gland
Slides to Dr Epstein, John Hopkins for 2nd opinion
2nd opinion, 2 cores R base 35% Inv Gl 3+3, 2 cores R Apex 20% Inv Gl 3+3
2 Cores R mid, 35% Inv 90% Gl3 10% Gl4

My husband's surgeon told us whether to spare the nerves was a "game day call'. He took frozen sections during the surgery and spared the nerves. It didn't make any difference, since he still ended up with total ED and positive margins.

island time said...
Have you had a 3T MRI?

Mine clearly showed where the cancer was before the operation.

You'll need a radiologist whose only job it is to read prostates. And one who'll spend some time showing and explaining the images to you.

Short of that...I'm a firm believer in Surgeons who use MRI's. Some don't.

I have not had one, MRI. I have had two Urologist indicate they were not good at showing small lessions and ECE.

I have asked one RO who did residency at Havard/Dana Farber indicate the same, he did say they could be of value to show seminal vesicle invasion. basically the confidence level in results is maybe 60%?

I have a few more consultations. leaning toward radiation, because I simply don't have confidence in the surgeries. Sounds like no matter who does them there is a lot of risk.

Turboz, yes you're counting on the surgeon to apply his skill and experience (and a little luck) to you for the best overall outcome. Yes there is a risk, and we all get to weigh it using our own personal score sheet. It's a highly individual decision, and while we can help point out what the upsides and downsides of the outcomes might look like, only you can decide what is best for you.

In spite of what you have heard, and I don't discount those who have had poor outcomes at all, there are many of us who have had excellent outcomes as surgery patients. It's far from random--there are even men out there who did loose one or even both nerves and are still sexually capable.

I'm sure you'll find out more when you have your consults with the RO's. I'll repeat the good news for you: with your stats, you have a high probability of cure with primary treatment, so the focus really does need to be on the question of cure probability vs side effects combined with things like time available for treatment and recuperation.

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Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

I've found that Tall Allen is a source for clinical studies and data related to prostate cancer treatments. You might want to search here, and include his name in your search.

When I read posts here I'm amazed at the information Tall Allen brings to this forum.

Good luck with your research.

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Age at diagnosis-66 Diagnosed 6/16
RALP 10/16 at U of Chicago, Dr. Shalhav. Experienced internal bleeding post op requiring transfusion of 2 units.
Pathology Gleason 3+4=7, tumor volume 15% Margins negative except for one focal margin, .1mm
pT2c,N0,MX,R1
PSA @ 6 wks <0.02;16 wks <0.02; 5/17 <0.02; 10/17 <0.02
My storywww.healingwell.com/community/default.aspx?f=35&m=3777359

I went into RP with my uro saying I may need to use cialis after operation. GL 7 on one side. Came out of RP with no nerves spared. Doc said he could detect cancer in the nerve bundle. He took them all and lypth nodes. PSA<.02 14 weeks and incontinence down to some dripping. Erections 0. Using bimix injections for erections. Still can not get a definitive answer even here about keeping oxygenated blood flow to my penis. The answers I get always go off into some other realm. Anyway, if all nerves are taken there is that problem. OR is it a problem. Right now I am injecting twice a week low dose and Vacum pumping daily just to keep blood flow going. PIA to stab wilber when your are not sure you even need to do it. You need to look into this. I never knew it existed.