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Posted 12/3/2008 5:09 PM (GMT 0)

My wife and I returned yesterday from Dallas to our home in El Paso.  We had a consultative visit with Dr Morey, a highly regarded urological reconstructive surgeon, regarding my leaking.  His recommendation is surgical without specificity as to the type of procedure: AdVance Sling or Artificial Urinary Sphnicter (AUS) AMS 800.  I will be sheduled for surgery on a date to be determined in Jan 09.

With my degree of leaking he said he could not give me any assurances that the sling would cause me to be dry but that I could certainly expect improvement.  I had told him that my leakage was constant in all positions even sleeping on the order of 500 ml average 24/7 with a low of just above 200 ml and a high of 1 liter depending on my activity.  He said the improvment would probably be on the order of 50 % with a sling.  He qualified that statement with the disclaimer that each case is different and the order of magnitude of improvment could be as low as light pad usage during the day and dry at night.  I told him I could live with that if we were talking about a few dribbles in one light pad per day.  He said I probably have Intrinsic Sphnicter Deficiency (ISD) and the sling would help support the uretera (spell)by lifting up from a vertical position to a horizontal position thus supporting the internal sphnicter causing a decrease in leakage.  How much improvement is an open question to be determined by actual events following the surgery.  He gave me assurances that dryness could be achieved using the AUS.   My initial objection is the mechanical aspects of the AUS and the manipulation required to deflate the cuff by pressing a button on the pump installed in the scrotum.  In a model he had in his office I was able to manipulate the button nicely without any problem.  I have Neouropathy in my legs, feet, arms and hands and it is a deterioratiing process that will get worse the longer that I live.  I use a scooter now and/or a 4-legged walking cane...I will eventually go to a wheel chair should I live that long.  With the idea that less is best I have selected to go with the sling and hope for the best.  It is what a urological surgeon would call minor surgery so I haven't any reluctance to be cut on that way.  We talked about retention and he doesn't feel that my ability to void urine afterwards will be a major problem as the percentages are very low for men that have this problem.  We came up with a plan to do the sling first in Jan 09 and if it does nor satisfy then turn to the AUS.  (We also talked about penile implant as that is a requirement too...I had non-nerve sparing da Vinci so Mr Happy is not happy since the surgery.)

     Now my questions for those who had these type surgeries...

1.  Generally speaking, do you feel I am making the right decision in opting for the sling over the AUS.  I told him that I thought it better to concentrate on leakage first and take care of Mr happy at a later date.  He said we could do the sling first and based on the results do the penile implant and the AUS if required a few months later. Or do the implant in a separate surgery.

2.  I would like to hear comments regarding the sling.  Did it work for you.  Did you achieve the degree of dryness anticipated.  Are you satisified with the sling.  Any problems resullting from the procedure.

3.  As I wish to make "Mr Happy" happy am I making a mistake in my plan of surgeries  and move up the implant to the first surgery and have just one recovery period.  Perhap I should go directly to the AUS with the implant in one operation as I am told they use the same incisions.  I do not wish to do an "overkill" here as I feel my da Vinci with "wide margins" was a mistake and "overkill" by taking out so much nerves and tissue but it was based on a faulty biopsy report that gave me a gleason 4+4=8.  Post op report showed 3+4=7.  I do not blame my surgeon as he was basing his decisions on the biopsy report and he did an excellent job.  I feel I am free of cancer and it no longer is a problem for me thanks to Dr Fagin, my surgeon.

FYI corrective surgeries for incontence has been reduced from one year to 6 months as the minimum time permitted prior to surgery.

Thanks for any input that you choose to give me.  All responses are appreciated.

Salty

Posted 12/3/2008 8:17 PM (GMT 0)
Salty,
We were operated within less than a month of each other by the same surgeon and with similar prognosis. As I was a gleason 7 in 8 of 10 cores bilateral and showing perineural invasion he also cut a wider path on myself. As it turned out the pathology showed it all confined - I suppose it was overkill, but that is hind sight. I know at the time the issue was no positive margins, and for that I am grateful. I like you have thought the very best of our good Dr. and in everything I have seen he is at the top of the chart professional.

When I asked him about nerve sparing he told me it was never all or nothing. I guess with that regard I have hoped in time I might have some recovery. I have no recovery at the present, but I also had to get beyond a 4 month Lupron shot. I am currently in the early stages of injections. They work but I have not found the right measure yet.

Now, I don't know the relationship between cutting a wider swap and incontinence. I also have incontinence at 6 months although mine is minimal compared to what you have described. I am near dry. I wear one pad a day, and have just a little squirting here and there - none-the-less I have not been able to push it to completely dry. With this too I am still hopeful.

I hope someone can help you with the questions you asked about your surgery and whether to go all out or move in stages. Please keep us informed.

RB
Age 61 (now 62)
Original data - pre-operation
PSA: 5.1
T1C clinical diagnosis, Needle biopsy - 10 cores, Gleason 7 = 3+4 in 1 core (40%), 7 cores Gleason 6 = 3+3 ranging from 5% to 12%
All scans negative
Lupron administered 4/9/2008 for 4 months (with idea I would undergo external beam radiation followed by seed implants - then I changed my mind).
Robotic DiVinci surgery - Dr. Fagin (Austin) May 19th
Post operative - pathology
pT2c NX MX
Gleason 3+4
Margins - negative
Extraprostatic extension - negative
seminal vesicle invasion - uninvolved
1st Post PSA <.04
2nd Post PSA <.1 10/30/2008
Posted 12/4/2008 4:04 AM (GMT 0)
Salty,

I may have some beneficial information.  Dr. Morey performed both an AUS and a penile implant (at the same time) back in July on me.  Another member of this forum, KW, had the male sling several months ago and it just did not work for him.  I'm sure he will be along pretty soon to post, also.  After lots and lots of investigation, he too settled on Dr. Morey for his AUS.  So as far as the surgeon is concerned, you are, in my opinion, in very good hands.  He is indeed considered the the leading surgeon (at least one of them) here in the DFW area.

The doc is right, of course.  We are all different.  Personally, I am very glad I had both surgeries at the same time. I am now continent (except for a few drips each day, which is normal for the AUS.  I use a very, very light pantiliner each day).  I am also now fully ED free.  I can have an erection any time I want one... and it is a very, very good and hard erection.  

Again, all I can say is that we are all different.  But for me, and for others whom I know who have the implants, they work very well.  So I would say:  Go for it.  Except, it's your decision and you must make your own informed decision. 

There are other things regarding these implants you need to consider.  You can scroll down a couple of pages and find a post from me that I called Questions and Answers about Penile Implans, or something like that.  As a matter of fact, I will bump it up so you can find it easily.

I will be glad to speak with you over the phone or via email.  My email address is avialable over on the sidebar if you wish to contact me.

Gene214

Posted 12/4/2008 4:11 AM (GMT 0)
Those of us who had non-nerve-sparing shouldn't beat ourselves up -- taking wide margins gives the best chance of a "cure". PCa likes nerves and even though the pathology may report clear margins, there's no knowing if there are undetected microscopic cancer cells lurking in the margins. Even with Gleason 7 and clear margins, it is still possible for the cancer to return, so it comes from somewhere, most likely around the margins.

My Gleason preop was 9, later downgraded to 8. I also sometimes think I should have had nerve-sparing, but then I think, what if I did and the cancer later returned? Would I feel so clever then? Put in that light, I am happy to accept the trade-off of certain ED, at least in the medium term, for the improved chance that the cancer is gone.

In any case, what is done is done, and it doesn't do us any good to dwell on the "what ifs".

I don't think wide margins means incontinence -- I also had wide margins, but have been fully continent.

Salty, have you considered penile injections? With your neouropathy it may not be feasible for you to self inject, but perhaps your wife would be willing to do it. I am a first-order chicken, and my wife, a non-medical person, does mine without any problems.

Good luck with whatever course you decide.
Posted 12/4/2008 4:33 AM (GMT 0)

    Salty,  I was leaking at the rate of 8+ full pads a day when I decided to try the AdVance Male Sling first.  I too was worried about all the plumbing.  I was thinking if I could even get a 50% reduction in leaking I would be happy for a while.  My Sling was done by my local Doctor.  I'm not saying this is the reason I go no relief, but mine did not take at all.  That is why I opted for the AUS.  As far as working the device, It will take a firmer push than the model in the office.  But overall it works rather easy.  I normally only need one good squeeze of the pad to urinate.  I also use a light women panty liner to catch the drips and dribbles. 

    I can not tell you what to do but you can't go wrong going to Dr. Morey.  If you have any more questions or would like to talk on the phone send me a e-mail at the address that is listed on my HW profile.

    Good Luck,  KW

   

Posted 12/10/2008 2:09 AM (GMT 0)

Hi all...thanks  a lot for the input.  I considered the responses and after a lot of struggling with the decision I have decided to go for the artificial sphnicter.  I had a telephonic conversation with Dr Morey and he recommended that in my condition and the amount of my leakage it would be best to go with the AUS.  Also he recommended that the penile implant be installed at the same time through the same incisions.  I agreed and we set the 20th of Jan at 0930 as the operation date.  My wife and I will go to Dallas on 19 Jan for pre-op activity. 

So Gene looks like I will be doing the same as you did before.  Tell me Gene which types of cuts did he do on you to install both apparatuses.  He told me he would cut perioneal for the cuff and then just above the groin to install the ballons and pumps...I understand there is another method such as going in the scrotal approach.  Kelly I will be skipping the sling because I just don't feel it would cut my leakage sufficiently.

Reading your journey has helped me immensely in my decision.

Piano and RB I agree with your assessments about wider margins, our surgeons, non nerve sparing surgery...it is an individual thing that just simply can't be figured out ahead of time and we just kinda roll the dice with this cancer and the methods we take to combat it.  I am definitely hoping I get a home-run on this one.

 

Any other suggestions that you guys may have for prior to the surgery or afterwards I would appreciate.

 

P.S.  Gene the doctor told me an overnight in the hospital would be sufficient.  Is that what you did?

 

Later...and thanks

Posted 12/10/2008 2:42 AM (GMT 0)

    Salty,  I'm glad you are on your way to getting back to a "normal" life.  I know how hard of a decision it is to have all this "plumbing" installed.  At first you may wonder why you did.  But after the healing takes place and your devices are activated you will be glad you did.  I can only speak about the AUS but now I never think about leaking out.  I do still wear a light women panty liner but I will take that any day over what I was dealing with.  As I said before, feel free to holler at me if you have any quesitons.

    Good Luck,  KW

Posted 12/10/2008 6:05 PM (GMT 0)

Salty, part of the torment of incontinence and ed is the decision-making.  So I'm sure you feel somewhat relieved, having made the decision.

I'll try to address the specifics you addressed to me:  First, my two "cuts" were made perneal (between rectum and scrotum) and a small horizonal scrotal cut.  He did not discuss we me which cuts he would make and I didn't not know enough to ask him at the time.  I do know that sometimes the cut is an abdomen cut above the penis and that method is preferred by some surgeons whereas the scrotal cut is preferred by others.  So I suppose Dr. Morey does it both ways, perhaps depending on the way each patient is "built" (perhaps).  I could not suggest which way is best.  Everything he installed in me works good.  Very good. 

Yes, I had my surgery approximately 1:30 p.m., stayed overnight, and went home the next morning. 

Again, if you would like to email, I'll give you my phone number in the event you want to talk. 

Now, here's a question for you:  Which penile prosthesis will he install?  I think he uses two:  The AMS 700 CX and the 700 LXG.  That might be something you want to discuss with him.  I followed his recommendation and had the AMS 700 CX installed.  As I understand it, the CX produces more regidity and girth and the LGX produces a little more length with less regidity.  Some of the other guys might want to chime in with that.  All in all, I feel you can trust Dr. Morey to select the best possible for you.

Gene214

Posted 12/12/2008 1:35 AM (GMT 0)

Gene...thanks for the response.

I asked Dr Morey on the phone when we discussed the penile implant (PPI) and he said he planned to use the AMS700CX.  Same as your model.  From what I have read about it, it seems it is the standard model for less problems and provides durability.  It doesn't add to length but has more rigidity and girth.

As for the incisions, he didn't exactly tell me he was going to use the above the groin approach...it just came up in the conversation.  I have read he favors the scrotal approach specially when he installs the AUS at the same time so I imagine he will use that with me.  I watched a video on the net of that approach and it was an eye opener to say the least...makes any sane man cringe to say the least.  But, I gratefully accept that if the results will give me the results that you have gained.  The PPI is secondary anyway to my goal which is to stop the incontinence.  I have quit trying to make gains by the ordinary methods like clock watching, diet and etc that I have used for the past 7 and half months and just change pads as often as they fill and even though I live a somewhat sedentary life as my neuropathy doesn't allow me to be too much on my feet and live an active life, I still leak between 600 mg and a liter 7/24.  So, you see, I don't have too much choice in the matter and the PPI is an add-on that if it works good I will have salvaged a great deal out of all this misery.

I will keep you guys posted as the situation develops.

 

Thanks

 

Salty

Posted 12/12/2008 1:44 AM (GMT 0)
Hi Salty,

Sorry to hear that you have to undergo another surgery. Have you talk to Dr Fagin about this surgery? I wish you had called me when you were in Dallas, we could have meet. Good luck and I'll call you later.

Posted 12/12/2008 1:45 PM (GMT 0)

KrisP,

I suppose you went from DFW area to Austin for surgery for a good reason.  I suppose it was because you felt more comfortable with Dr. Fagin than some in DFW?  In your research did you find he had more successful surgeries than those in DFW?  I make an attempt to keep up with these kind of surgeons in Dallas (DFW).  Does Dr. Fagin do AUS and penile implants? 

Gene214 

Posted 12/13/2008 1:29 AM (GMT 0)
Gene,
Yes, I was more comfortable with Dr Fagin because of the amount of surgeries he had done but that was not the most important reason. After I was diagnosed by my urologist in Dallas, he recommended a surgeon within his group of affiliates. I did a background check on the surgeon and found out that there was a lawsuit against him. I still met with him but I was not comfortable after knowing that.
Yes, in my research I found that Dr Fagin had done more surgeries than all the surgeons in the DFW area. I'm not sure if he does AUS and penile implants. What I can say is if someone in my family had to do this surgery, I'll recommend Dr Fagin.
Here is his website if you are interested.
http://www.urologyteam.com/
Posted 12/13/2008 3:49 PM (GMT 0)

Kris... I have looked all over and been unable to locate your phone number.  Back sometime ago I had a disk failure and I lost my history list of emails with your number.  Please send me by separate email and I will contact you when in Dallas again in Jan.

The trip to Dallas was a kind of whirlwind anyway as we were not on the ground long.  I plan to stay with my granddaughter in Jan at her place in Dallas and should be there maybe 3-5 days so should give us time to meet and renew acquaintances.  Hope everything is going well with you.

 

Salty

 

P.S.  I have not talked with Dr Fagin.  I think he specializes in da Vinci.  I am sure someone else on his team does do these type surgeries but I wanted to get a top-notch reconstructive surgeon and Dr Morey filled that requirement so I decided to go with him.

Posted 1/16/2009 7:53 PM (GMT 0)

Well...The long wait has passed and I am ready to travel to Dallas on Monday, the 19th.  It has been a long and fitful wait as I have not seen any improvement in my incontinence at all.  It only confirms that, even though I am only into my 9th month since my da Vinci, I have given it sufficient time to recover the natural way and the sphincter is too damaged to recover except through artificial assistance.  I still leak in all positions...I rarely have a bladder spasm to indicate its time to go to the bathroom because no sooner as the urine passes into my bladder it promptly leaks out into the pad.

There has been one change in the schedule...the operation has been rescheduled from Tuesday to Wednesday at 1530.  We have a return flight on Sat, the 24th, so the change didn't cause much disruption in plans.

Thanks so much guys for your assistance.  I feel like I am "go for broke" as this is about the only alternative left to me.  I am anticipating success and looking forward to the experience.  Activation date for both devices is scheduled presently for March 9th.  I will have my fingers crossed that I will have a dry result along with a firm positive reaction to the implant.

Thanks for everyones support.

 

Salty

Posted 1/16/2009 8:07 PM (GMT 0)
The very best of luck to you, Salty, I wish you only the best success in these operations.
Posted 1/16/2009 8:19 PM (GMT 0)
Good luck with the procedures and hope you have a really good outcome for both. Come back and let us know how it went.
Posted 1/16/2009 9:52 PM (GMT 0)
God bless you Salty - let us know what is happening on the other side.
Posted 1/16/2009 10:11 PM (GMT 0)
Salty,

Somehow during the Christmas rush I missed your last posts, so I was glad to read it today and glad this thing will soon be behind you.  Dr. Morey did use the scrotal approach on me, by the way.  And, yes, the videos are frightening.  But, the surgeries work... at least for me they did and gave my independence back.  I can now pee on purpose (instead of dripping all the time) and also make love to my sweet wife.  It all boils down to returning to a normal life.

If you like, email me and I'll give my cell number so we can talk.  And if you feel up to it, I would look you up for a visit while you are here.  It looks as if you may have some time to kill while you are here, so would be glad to meet you both for a brief visit.

Gene214 

 

Posted 1/25/2009 5:23 AM (GMT 0)

Hi Everyone...Back home from Dallas with a very good result as far as I can determine at this point.  Dr Morey performed the surgery on Wed PM about 1600.  I was asleep from the time I was in pre-surgery until I woke up in my hospital room that evening.  The night was uneventful except for the constant stream of attendant nurses that was provided for me in checking and keeping me comfortable.  Great hospital (UT Southwestern.)  The last morphine injection into my IV was about 0200 that night and I haven't taken any pain killers since then.  Dr Morey released me about 1000 the next morning (Thursday).  I had ample opportunity to inspect Mr Happy and the boys and there was the usual expected black and blue trauma and a great deal of swelling.  In fact, when I tried to walk in my room it felt like I had a barrell down between my legs reaching all the way to my knees...well, mid-thigh anyway.  I have never felt that big in my life.  All of this was to be expected and it seemed to swell more the first day I was out of the hospital.  Ice pack has helped and I stayed lying down a great deal for the three remaining days I stayed in Dallas at my granddaughters home.  I have experienced blood in the urine but this was expected as Dr Morey cut a small ligament or tendon at the base of the glan that was preventing skin to be rolled back or forward.  It should clear in a few days. Kelly and Gene I am not telling you anything new when I say that I found this Dr Morey not only to be an outstanding surgeon but he a gentleman of the first order.  I had long conversations with him prior to the surgery and the morning he released me and I found him to be one of my kind...an Army man...a retired medical officer with 24 years service to our country.  He served a tour in Iraq helping our warriors there.  I'd have to say that we went a little further than just doctor-patient relationship...we bonded as soldiers and I was confident that I was in the best hands for this type procedure.  Its too early to tell if the procedures were completely successful or partially but I will lay my money on the fact that he did the best possible job he could do under the circumstances and I give him all the credit for my feeling as well as I do after the first three days and each day I am feeling better.  As a side note to emphasize the respect that we had and have for each other when he was about to leave the room after releasing me Col Morey and I exchanged salutes.  Only died-in-th-wool soldiers know how important this is and was for each of us...and this old soldier appreciated it. 

Gene thanks for the encouragement and help you gave me while in Dallas.  And KrisP, thanks for taking time out of your busy schedule to visit me in the hospital.  You guys are true friends.  And I want to thank everyone on this site that helped me on this long journey from pre-PCa surgery to present.  I will keep you apprised of my situation as I heal over the next 44 days until I go back to Dallas and activation of the devices on Mar 9th. 

 

Salty

 

Age 75 at DX 76 on 9 May 08
DRE positive with nodule 15 Jan 08
PSA 3.8 18 Jan 08
Biopsy 11 Mar 08 Gleason 8 (4+4) on the right 3 out of 12 positive <5%. Gleason 7 (4+3) on the left 1 out of 11 positive <5%.
Bone scan and CT scan Negative 12 Mar 08
Robot Assisted da Vinci prostectomy with Dr Fagin in Austin scheduled for 30 April 08.
- - - - - - - -
da Vinci successfully completed by Dr Fagin as scheduled.
Path Report:
Gleason downgraded to 3+4=7
Tumors confined to the prostate.
Bilateral tumor on right side 5 of 10 levels and on left side tumor present in 9 of 10 levels.
Margins Negative.
Extraprostatic Extension Negative
Seminal Vesicle Invasion Negative
Stage pT2c
As far as it goes between you, me and the fence post I am cured. 
06-24-08 <0.1 Undetectable.

09-23-08 <0.1 Undetectable.

Edited by request by TC-LasVegas

Post Edited By Moderator (TC-LasVegas) : 1/26/2009 5:20:37 PM (GMT-7)

Posted 1/25/2009 7:48 PM (GMT 0)
Salty,

Glad to hear you are back home. Hope you heal well all the best. It was great seeing you and your wife again and hopefully when you return to Dallas for your check up we can visit again.

Again good luck!!

Posted 1/25/2009 7:51 PM (GMT 0)
Salty, Im glad you made it through all that and are back home, heal well.
Posted 1/26/2009 1:12 AM (GMT 0)
Salty, Glad you are on the way to healing. I wish you well in your recovery and wish you the best as you await your activation dates.
Good Luck,
KW
Posted 1/26/2009 1:31 AM (GMT 0)
Salty,

New here and not familar with your situation, but I will be looking through your thread.

Glad you are out of the present proceedure and wishing you a speedy recovery.

Scott

Posted 1/26/2009 3:23 AM (GMT 0)

Thanks guys for the responses.  However, I might have been a bit premature in discounting my pain.  It caught up with me last night after retiring for bed.  The gosh-awfulest feeling of helplessness came over me as I regained the pain from my nether regions.  I lay awake til about 0400 and finally decided to try to find some pain killers left over from a fracture some 2 years ago. I located the medicine noting that the expiration was in April 2008.  I swallowed a tablet quickly and waited for the pain to be controlled.  about a half hour later I was fine.  The medicine still had some juice and permitted me to sleep.  Today I have been really taking it easy using the medicine and ice, ice, and a bit more ice.  I am not leaking like I normally do as the swelling has engulfed my urethera and my voiding is limited to drips and dribbles with a bit of straining.  I know I am not supposed to strain excessively when voiding and just let it flow but I think I am doing okay on it and without damage.  I am seeing some improvement in the appearance of Mr Happy and the boys...doesn't seem that they are quite as darkened with blood as they had shown before.  It is true that one can actually see improvement day-by-day.  I will be happy when the swelling has subsided somewhat and allows me to void normally without a lot of pain.  Hopefully the swelling will deminish considerably by next weekend.  Will keep you posted as changes occur.

Happy to answer any question that possible candidates might entertain for these surgeries.  Its a strange new world for the uninitated...

Salty 

Posted 1/27/2009 3:27 AM (GMT 0)

Salty...

Finally caught up with your new posts and glad you are having some relief from the pain... I was surprised you did so well in the pain department and not surprised when it finally caught up with you.  

I trust you will find the same satisfaction from your implants as I have received from mine.  It is literally a pleasure... a wonderful pleasure... to return to nomal after months and months of staying wet and flacid. 

Gene214


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