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DaVinci prostate surgery scheduled Jan 24

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Posted 1/16/2011 8:20 AM (GMT 0)
 

Surgery scheduled for Jan 24 for DaVinci radical prostatecomy.

 PSA April 2008, 2.2 -- MAY 2010,4.8--Oct 2010, 7.5

Biopsy Dec 9 2010:

2 cores of 10 positive  both with gleason score of 8. One positive core right base with 30% of tissue, One core positive in left lateral base less than 10% of tissue. Bone scan clear, Ct scan clear. Clinical staging T1c, Prostate normal on DRE. Prostate size 39.4 cm3

Age 63

With the Gleason 8 , PSA 7.5, and 2 cores positive at the base, the surgeon recommends that we do not attempt a nerve sparing  surgery on either side .  This was not what I was expecting. He thought that a nerve sparing surgery would compromise our chances for a cancer cure. This urologist has done over 300 open surgeries,  around 150 DaVinci surgeries and has a very good reputation and good success rates. I was expecting that this procedure could be done with the nerve sparing procedure. What are the thoughts out there? 

Posted 1/16/2011 8:52 AM (GMT 0)
Welcome to the site.. Good luck on the surgery.

All surgeons try to spare the nerves... But they never know for sure what's going to happen till there get inside.

Posted 1/16/2011 10:05 AM (GMT 0)
Hi Robs,

Welcome to the site.

Dr Strum who write "The primer on Prostate cancer" is fond of saying that you need to fully understand your status before working out your treatment strategy. Questions like "Is my cancer really 4+4?" and "What is the likelihood that the cancer is still in my prostate?" will help define your status and this in turn will help work out what the strategy should be.

Can I suggest that the very first thing you do is get an expert to review your biopsy slides. All pathologists are not equal. There are probably a handful in the US that are experts - Bostwick Laboratories and also Epstein are two of the experts. It is possible that your cancer is either more serious or less serious than you and your doctor think and this is the way to know is to get an expert to review your slides. If you are in Australia then Dr Cohen from Western Australia or Dr Delprado from Sydney are also two such experts.

There are a variety of tools such as the Partin tables or the MSK nomograms (google msk nomograms) that would help you work out what the chance is that the cancer is organ confined. If there is a low percent chance of the cancer being in the prostate a radical prostetectomy may not be a good idea - seeds or other treatments may have a better chance of success. The reason I say this is that a radical prostetectomy is not minor surgery, it has many potential side effects like incontinance or erectile dysfunction so you really do not want to do it unless you are confident it has a good chance of fixing the problem.

Also, given your high risk 4+4 cancer, I would definately get a second opinion (and maybe a third) from experienced urologists, and also an oncologist. If you continue with the surgery route it worries me that your surgeon has done only 150 Da Vincis - this is just about the most complicated surgeries there is and surgeons hit their stride when they do about 500. If you cannot find a surgeon who has done 500 Da Vincis it probably is better to go for an open procedure with someone who has done more than 500 open procedures. You don't really want a surgeon with training wheels on for a surgery that could leave you incontinent. If you are concerned about the nerve sparing issue, bring it up with the second and third urologists - now is the time to ask.

Rescheduling your surgery until you have answers to some of these questions could be a good idea. You only have one shot at this very complicated surgery and there are many examples of people on this forum for whom the surgery did not go well due to inexperienced surgeons and hasty decisions made about treatment paths without a good understanding of their status.

All the best, I am sure this is a very scary time for you and if you continue to visit this site you will find many people to support you through whatever decisions you decide to make.

Regards,
An


Posted 1/16/2011 3:57 PM (GMT 0)
An gives you good advice. It might be somewhat awkward to reschedule the surgery -- and I am sure you just want it over with so you can move on with life -- but the most important thing is to make sure you make the right decision and get the best treatment. So here's my suggestion: (1) get second opinion on your biopsy slides from a prostate-cancer-expert-pathologist; (2) find the best radiation oncologist in your area and get an appointment with her (or her) to talk about whether radiation (IMRT, seeds, or a combination) is a viable alternative to surgery, and (3) also get an appointment with a surgeon who has done a huge number of prostatectomies (750, or 1000, or 2000, etc.). You might decide you like the first guy better but it is worth this sort of due diligence before you commit. You would go to 3 or 4 car dealers before buying car, and this is more important! If you tell us where you are located, someone here can probably recommend a super-experienced surgeon and a prostate-expert radiologist. (And, of course, if you can travel, then there are loads of options). Best wishes, medved
Posted 1/16/2011 4:22 PM (GMT 0)
Sorry to hear that you need the RP. Good luck
Ron
Posted 1/16/2011 4:41 PM (GMT 0)
Hi Robs, and welcome to HW.  I think you have received excellent advice from both An and medved and hope you will seriously consider it.  Good luck.

Tudpock (Jim)

Posted 1/16/2011 4:51 PM (GMT 0)
Robs,

Hello and welcome. Good luck with your upcoming surgery, hope you got the best and most experienced surgeon you had access to. Look forward to seeing you on the other side, so to speak.

Never too late to change your mind on a treatment decision, kind of like walking down the aisle to get married, I whispered to my daughter, if you want to stop this, and turn around and walk out, I'm with you.

Please keep us posted,

David in SC
Posted 1/16/2011 7:05 PM (GMT 0)
Robs,

Welcome to HW - as always, we hate to see new members come through the portal, but we are all here to help where we can.

Check the lab that did your biopsy report. If you have not yet done so, get a copy of the report. At least in my case, it turned out I was with Bostwick, but did not know that until someone suggested I ask for the copy. I did not find HW until long after my DaVinci surgery.

You might also check at the top of the forum - there is a list of suggestions (posted by English Alf from contributions by many members) that cover all sorts of things that you will want to ask about, and a lot of good pre-surgery preparations ranging from what you can expect to tips on dealing with a catheter. There are also a number of threads on preparation and other useful sites, but you will have to search a bit.

I'd have to look up the book, but one by a urologist who is also a surgery patient reminds us that what is best for completely curing the cancer may not be what is best for the patient and his quality of life. My uro had less than the magic number (whatever you choose - 1000, 2000) DaVincis, but has been doing open surgery for almost 20 years. He also said that in my case, based on the location and Gleason, that nerve-sparing was not the best approach, as the tumors found via biopsy were dangerously close to the areas that the nerves would cross. Even with a wide margin (beyond the area that the nerves would be in) and extra work, I still had positive margins.

There is no definitive answer for you, as you will have seen in talking to different specialists - all love their treatment. Just be sure the one you choose satisfies your questions and confidence levels.

 

Posted 1/16/2011 7:21 PM (GMT 0)
i think An's advice is excellent too.  i think radiation is most likely a given in your case.  whether it be primary, adjuvant or SRT...you have to make that call.  good luck to you brother in whatever you decide.

ed

 

Posted 1/16/2011 7:58 PM (GMT 0)

After surgery I asked my uro/surgeon if the most skilled surgeon in the world could have saved my left nerve bundle.  His honest reply was, "yes, if they didn't care if  you had a recurrence." 

Sure, I'd like to have both nerve bundles, but I'd rather take the safest possible approach. 

I iintend to start asking surgeons if they really think there's a learning curve that extends beyond the number of surgeries your guy has performed.  I remain to be convinced that any significant learning takes place at that level of experience.  I suggest that if this concerns you, you ask your surgeon for his honest answer on this question and see what he says. 

I'm honestly wondering if we do people a favor when we tell them a surgeon with 300 opens and 150 DaVinci's may not be sufficiently proficent.  Who's making this claim?  Where's it coming from?  So there are only 5 or 6 surgeons in this country (the Dr. Samadi types) who deserve to operate via DaViinci?  Can someone please quote some objective analysis that proves this?

If your guy has done a total of 450 prostatectomies, and if he can honestly tell you he can deliver as good or better an outcome via DaVinci as he can by the open procedure, I'd put your trust in him and go for it.  The fact that he's upfront about the fact that he'll probably have to take both nerve bundlles is, I think, a sign that you're dealing with an honest, very careful surgeon.  I wish your nerve bundles could be spared, but it's far more important to do whatever's necessary to "cure" you, if possible.

Posted 1/16/2011 9:19 PM (GMT 0)
Consider also radiation with either High Dose temporary brachytherapy or permanent low dose. Both have results on par with surgery with less side effects. With your statistics and a surgeon saying he will not spare the nerves consideration of radiation should be a given. My urologist suggested against surgery as my probability was high that I would have positive margins. He will not operate if he thinks things are too far along to spare nerves. He works with a rad-onc and they do the HDR with over 1000 done to date. I had HDR with IMRT and am on Eligard and Jalyn. So far so good and very thankful that I checked out surgery and radiation. Most thankful that I learned about HDR.
Posted 1/17/2011 2:11 PM (GMT 0)
This may not be what you want to hear , but have you gotten a second opinion from a more experienced surgeon or sought other avenues of treatment.  Regardless of saving the nerves or not, I would urge you to find a surgeon who has done at least 500 robotic surgeries. 

I dont know your situation so there may be a sense of urgency and the surgery cannot wait, but if you can possibly explore other treatments and surgeons I think it would be wise. 

Best of luck

Ray

 

Posted 1/18/2011 3:36 PM (GMT 0)
I appreciate the considered replies.

 I have an appointment this afternoon with my surgeon, maybe I will get some further information.

Posted 1/18/2011 3:45 PM (GMT 0)
Good luck with your meeting today.  It's not a bad idea to make a list of questions you want to ask.  It's easy to forget an important question once things get going. 

 

Posted 1/18/2011 3:47 PM (GMT 0)
Robs,

I carry a small recorder, and with permission of the doctor, record our sessions.

It is amazing to me, listening later, of how much I missed of what was said the first few appointments.

Posted 1/18/2011 4:26 PM (GMT 0)
Robs -
- best wishes for your appointment today - it is a scary time for you and so easy to forget what was said - asked and any answers -
-if you can have someone with you to help with notes ( I printed out my questions and have a (X) check box too ) - that can be a benefit.

-wishing you all the best for finding the BEST treatment for YOU - and may the meeting help you cope with this new journey in your life.

hugs
BRONSON
Posted 1/20/2011 7:06 PM (GMT 0)
An Update:
After the consultation with my urologist on Jan. 19, we agreed to a slight delay for my surgery. Rescheduled my Jan. 24 surgery for slightly later.
I have an appointment with the department head at one of the major urologic centers on Monday, Jan 24 instead of my scheduled surgery.
After my consultation with my urologist this Jan 19 I think I have my mind wrapped around my probable need to proceed with a non-nerve sparing surgery.
On the table for discussion this coming Monday morning with the new urologist will be the possibility of nerve grafts as an alternative. This can be done at this center.
Any comments or experience out there about nerve grafts. It seems insurance companies like to consider them experimental, and I have not been able to find much information about nerve grafts. It appears that several of the major urologic centers do nerve grafts, but what is the success rate?
I would like to say Thank You for the thoughtful comments and consideration you all have given me.
Posted 1/21/2011 12:04 AM (GMT 0)
Best of luck

Ray

Posted 1/21/2011 5:22 PM (GMT 0)
When I first came here, there were a couple guys who had had the nerve grafts. I don't recall who they were, but I seem to recall they maybe were not that successful. I would ask any 'center' that does them for concrete, definite stats on their success, partial success and failure rates. That was 4 years ago, so techniques may have improved since then. Be sure and let us know your decision and results, we all would be very interested in hearing the details.
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