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Does the surgeon have to take the nerves using Davinici when no cancer is seen during surgery?

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Posted 4/23/2013 12:50 AM (GMT 0)
I wanted my BF to get a second opinion because I feel young at age 53 and worry about relationship afterward.

The surgeon says the nerves have to go during surgery. But couldn't that decision be made during surgery? If no cancer is seen outside the prostate; then why take the nerves? Just because of scores? I don't understand.

Could someone help me understand?
Posted 4/23/2013 1:06 AM (GMT 0)
I'd ask the doctor for a very specific justification for his statement. It could be that your BF's situation warrants nerve removal. If so, the surgeon should be able to explain. (Did your BF have a prostate MRI that indicated that the cancer had spread outside of the prostate?)

Of course, it never hurts to get a second opinion. I recommend it, if you are not comfortable with how the first surgeon is handling your BF's care.

-Gedman
Posted 4/23/2013 1:10 AM (GMT 0)
No MRI. He had CT body and CT bone scans. The doctor told me they were all clear except for the prostate.

No time for second opinion. Surgery took place last Thursday, April 18th.
Posted 4/23/2013 1:11 AM (GMT 0)
if he's having surgery the cancer is there. At least I'd hope so.

Often they can tell by tests done before surgery how far they'll have to go.

I have heard of many surgeons, however, who have gone in and sparred the nerves that work on erections after having a full understanding of the extent of the disease.

I agree with Gedman, I'd get a second opinion. and ask this question to both of them.
Posted 4/23/2013 1:53 AM (GMT 0)
Cowgirl,
It depends. Everybody's physiology is different. Sometimes it's not possible to do a nerve sparing procedure because the nerves cannot be separated from the surgical area. In addition, should he have chosen radiation, it's also possible that same condition would still prove to be a problem with nerve damage situations from the procedure. Tough situation for a surgeon to determine until he is doing the work.

Tony
Posted 4/23/2013 1:59 AM (GMT 0)
My understanding is this; often the nerves are sacrificed in the interest of surgery time.($) The surgeon is paid the same if he/she spends one hour removing a prostate or three hours. This same burden is shared with the surgical staff and the hospital overhead costs. Saving those nerves requires some delicate and time-consuming surgery. It's one of medicines dirty little secrets. This is especially true in regional surgical centers.

It is easier to obtain nerve sparing surgery at university hospitals. I don't like this aspect of medicine, and wish I were wrong. This was explained to me by a close friend who is in a position to know.

Having said all that, there are situations where it is medically necessary to remove the nerves in an effort to improve the patients survival outlook. Many gleason 8,9, and 10's. fall in this group.

K
Posted 4/23/2013 2:17 AM (GMT 0)
Kbota,
I know of no surgeon that will rush a surgery but it's possible. A little study of the procedure to spare the "Veil of Aphrodite" would show that it's not a lot of time saved. And the follow-up after removing them would also probably show terrible urinary incontinence issues post surgery that make any time saved burnt in the clinic. And that would COST the surgeon time in the OR.

But I do agree that "assembly line" surgeons are the BEST place to go to get a good nerve sparing procedure. These guys deal with the most circumstances and that is why guys like Samadi, Kawachi, Carroll, and so many more are best at the procedure.

Anytime a doctor has to take those nerves, the complications will outweigh the benefits.

Tony

Post Edited (TC-LasVegas) : 4/22/2013 8:27:10 PM (GMT-6)

Posted 4/23/2013 2:18 AM (GMT 0)
confused, why are you asking if the surgery is already over with, too late for any second opinion, or am I missing something here?

what was his "numbers" based on his diagnosis, that could make a big difference why no nerve sparing was done.

david
Posted 4/23/2013 2:21 AM (GMT 0)
Hi Cowgirl,

In my case my original surgeon said that he would decide once he was "in there". If the nerves looked like they might be involved he would take them out. I heard that same answer a couple of times. When I consulted with the surgeon who ultimately did my DaVinci he said, "If I get in and it looks suspicious, I'll put the operation on hold and get an emergency biopsy on a nerve sample. That will tell me if the nerves can stay or have to go."

As it turns out, that is exactly what happened. The biopsy was performed, all was clear, my nerves were spared and I was "back in business" within a few days of catheter removal. That was over 7 years ago and I have had no issue with ED.

I did have positive margins and my PSA began creeping up a couple years ago (now 0.13) so I may be headed for SRT but other than that I've had no issues.

So do your homework, ask a lot of pointed questions and find the surgeon that you are comfortable with.

Good luck!!

Posted 4/23/2013 2:24 AM (GMT 0)
I had one nerve removed during my prostectemy and it was explained thus. Based on the biopsy Most of my cancer was on the rt side and and very little on the left side. My surgeon told me up front that he would be removing the nerve so as to cut a wide margin, cause, in his words, the cancer once out, does like to travel along that nerve. note, this has zero to do with PNI. He said he would try to save the left. I did not persue it with him, but did realize this was his protocol and felt it would be useless and ultimately possibly self defeating. I accepted his terms and he did in fact save the left and did cut a wide margin on the right, that was probably not needed as my cancer was capsule contained. other surgeons may as you say wait until there are in and make the call then. I know Walsh does not like the protocol call. Whatever, I took the bad with the good and was, am very pleased with my surgeon's skill and decision making. Having said that, if I were to do it over again, I would it least make a pitch to him to bend somewhat fro protocol and take a good touchy feely and see if the rt could be saved. I tend to disagree with Kbota's take though I would not be shocked if he had some truth there. I would think,by definition, a nerves paring operation would cost more than a non nerve sparing, as a cheese burger costs more than a hamburger. Its water under the bridge tho at this point. Short answer. Its the surgeon.
Posted 4/23/2013 2:30 AM (GMT 0)
Certainly A surgeon will take the nerves if he can identify that the tumor is intwined. So that point is also valid. But there's also where the "design" of the nerves makes it impossible to dissect the prostate without one or both of the nerves.

Tough call to make until they get in there. I do know that some surgeons will take them because they feel the "pathway" is always present. But I think in this one case nerve sparing was the intent, the disease was contained, and yet the nerves were taken. It sounds more like a physiological issues.

But the doctor would have to explain (as stated above)

Tony
Posted 4/23/2013 2:32 AM (GMT 0)
From the sounds of everyone's experiences, I was very lucky. My surgeon explained to my wife and I he would do everything to spare the nerves. All tests showed nothing but the prostate involved. Once in, he stopped the surgery and sent samples of all surrounding areas including the nerve bundles for a biopsy, then proceeded once he go the all clear. I'm like most of the others, can't see a surgeon cutting corners to save time when it comes to a patient's well being. Again, maybe I was just lucky...Art
Posted 4/23/2013 2:38 AM (GMT 0)
i've heard one of these high volume surgeons explain how he has a different approach (path) at accessing the prostate precisely so as to avoid hitting those nerves too hard.
Posted 4/23/2013 2:56 AM (GMT 0)
I am getting answers that I was afraid to hear. Because I was thinking the surgeon was taking the easy way out and taking the nerves. Just my thoughts.

We got to the hospital on Thursday at 10am. I told my BF I would stay by his side until they kicked me out. Well they didn't let me by him at all. I told the staff I wanted to talk to the surgeon before his surgery. The surgeon denied my request. Now my BF tells me that the surgeon and him didn't want the surgeon talking to me before surgery as I might upset the surgeon.

Ok, so now it is after surgery.

I specifically asked the surgeon 'when you are in there can you see the cancer?' He said 'Yes'. So, did you see any cancer? He said 'No.' Then I asked 'Did you take the nerves?' He doesn't answer the question. He says 'well there is injections and pumps'.

All that is going through my mind is how romantic is that. And they sound like a scam to me and wouldn't work anyways.

I am very sad that this situation and how this turned out. I have been divorced over 5 years and I thought this would be my 2nd marriage. I am going to counseling tomorrow to try and sort out my anger, sorrow and feelings.
Posted 4/23/2013 3:04 AM (GMT 0)
did you visit the surgeon with your bf when you meet him and discussed the surgery? That's when my wife was wife me and when she asked her questions. The day of surgery she waited in my room and listened to the surgeon when he came in after the operation to update her and my parents on my status and on how things went. I wasn't there, i know he said everything went well, but i'd imagine my wife and parents asking how I was, not if he sparred the nerves.

In fact, I believe i found out officially about the nerve sparring a week after the surgery when I met him again.

I think what is romantic is that you two can still be together and enjoy intimacy in whatever form it may come in.
Posted 4/23/2013 3:16 AM (GMT 0)
Cowgirl53,

The world does not end if the critical bundle of nerves. Post surgery, he can use a vacuum device for an erection or to temporarily help to have one (some men have success and some don't), then there are injections that he can give himself in the corpus cavernous which usually will give an erection or if those two methods don't work, there is also a surgery to have an implant installed where he would have a resevoir of fluid and a pump in his scrotum. He would simply pump it up 20+ times, have a great erection, last for hours and then he can depress the lever and the fluid drains out into the resevior and life continues. I had that surgery last December and it works great.

So if he has to have the nerves out, and lets hope he doesn't, there are great options available for him to pursue.

Good luck.
Posted 4/23/2013 3:58 AM (GMT 0)
The surgeon makes the decision on nerve-sparing based on the location and gleason they find during the biopsy and scans. From what I have been told, it is very difficult to "see" the cancer unless the tissue is heavily involved.

My surgeon had a pathologist on standby. He evaluated the tissue and lymph nodes, and more tissue was taken as a result. Even with that, I had multiple positive margins. The nerves were lost in that process.

I hate to see all of the doctor-bashing come out again. The best suggestion is always to get the best surgeon. They are certainly not all equal in experience. Once done, there is no point in looking back.

Posted 4/23/2013 4:02 AM (GMT 0)

TC-LasVegas said...
Kbota,
I know of no surgeon that will rush a surgery but it's possible. A little study of the procedure to spare the "Veil of Aphrodite" would show that it's not a lot of time saved. And the follow-up after removing them would also probably show terrible urinary incontinence issues post surgery that make any time saved burnt in the clinic. And that would COST the surgeon time in the OR.

But I do agree that "assembly line" surgeons are the BEST place to go to get a good nerve sparing procedure. These guys deal with the most circumstances and that is why guys like Samadi, Kawachi, Carroll, and so many more are best at the procedure.

Anytime a doctor has to take those nerves, the complications will outweigh the benefits.

Tony

Sorry Tony, but surgeons rush surgery often, and for reasons that would really piss most of us off. Not being a surgeon, I'm not up on the time difference of nerve sparing, but I've been told that its substantial, but the difference is becoming less every year, as experience and technology advance.

Both of my nerves were sacrificed due to high Gleason, and suspected epe, but I'm totally continent.

K

Post Edited (kbota) : 4/22/2013 10:09:00 PM (GMT-6)

Posted 4/23/2013 4:08 AM (GMT 0)

142 said...
The surgeon makes the decision on nerve-sparing based on the location and gleason they find during the biopsy and scans. From what I have been told, it is very difficult to "see" the cancer unless the tissue is heavily involved.


My surgeon had a pathologist on standby. He evaluated the tissue and lymph nodes, and more tissue was taken as a result. Even with that, I had multiple positive margins. The nerves were lost in that process.



I hate to see all of the doctor-bashing come out again. The best suggestion is always to get the best surgeon. They are certainly not all equal in experience. Once done, there is no point in looking back.

Dr's are just people. Some are great...some are average...and some are no good. They are simply a cross section of society. To think otherwise is to be an ostrich.

It's difficult for the patient to know how competent their dr is without doing a lot of research.

K
Posted 4/23/2013 4:23 AM (GMT 0)
Ah let's not forget here that a guy (like me) can have nerve sparing robotic surgery but not nerve damaging robotic surgery. Basically the nerves for erection are in a cellophane wrapping around the prostate and even with a nerve sparing surgery they have to "tease" the nerves or pull them away from the prostate to remove the prostate. So in the process of removing the prostate the nerves can be damaged simply by moving them away from the prostate. Mine weren't cut but were damaged in the process. I went in ok but now have to use trimix, I guess forever. Cowgirl, I'm not too happy about the outcome but I did know the risk going in, 50/50. Maybe we all should have had seeds or just done nothing at all. We all can't afford to go to Samadahi for surgery, I know I couldn't anyway............:(
Posted 4/23/2013 4:42 AM (GMT 0)
kbota,
I can't disagree with you more on this topic. It's cynical and it generalizes this experience. Doctors are people, they do make mistakes. But they all passed the 8 year program rather than our opinion qualifications. You are suggesting that it's clear and concise that this doctor for this patient in this case cheated and sped up the procedure and that's beyond reasonable.

There are more ostriches among us than the doctor community and be careful to not step into that fray. You do not know what these circumstances were. Your suggestion falls well short of support.

Tony

Post Edited (TC-LasVegas) : 4/22/2013 10:45:51 PM (GMT-6)

Posted 4/23/2013 5:04 AM (GMT 0)
Tony,
I can't disagree with you more on this topic. My comments were not intended to be, nor were they cynical. I was not offering an opinion. We read about surgery screw ups often, and those are just the ones that make the headlines.
I wasn't suggesting anything about this patient in particular, and I strongly resent your stating the opposite.

I deeply apologize to the op if my post was interpreted as "falling well short of support". I've been a member of HW for several years, and have always tried to be supportive to everyone in every circumstance.

Tony, please be careful not to assume that you always know what a poster is meaning. Sometimes an email requesting clarity might be called for.

Okay, I'm done, and its way past my bedtime.

G'night all

K
Posted 4/23/2013 5:07 AM (GMT 0)
I don't like this entire "we are smarter than doctors" tone that seems to be oozing out of this place lately. Not just on this thread, but on others too. What kind of message are we sending to people? Especially newcomers? To distrust the advice of their doctors? To second guess everytime something goes wrong or not according to plan? Think people are better off sticking to support, then all this dispensing of medical advice. It takes a lot to become a medical doctor. Looking up stuff on the net and passing it on isn't of the same caliber as true medical advice. Think its something to think about.

david in sc
Posted 4/23/2013 5:07 AM (GMT 0)
Cowgirl53,

If you would like to talk with another female dealing with this beast, feel free to email me.
Speaking to other ladies has helped me tremendously. Don't get me wrong, these guys are great, but sometimes chick chat rules. :)
Posted 4/23/2013 5:19 AM (GMT 0)
K,
We need to take it off line. You have been a great contributor here and that is a fact. I do think we can accomplish more between us privately. I feel called out too. I know a little about this prostate cancer experience as well. I don't think it's appropriate to assume anything. And we can probably both do better than this thread.

Tony
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