Consult with 1st Robotic Surgeon in Atlanta (Dr. Shah)

Hello,

I met with Dr. Shah in Atlanta this morning and went thru several questions with him. 

I asked him if a pathology is run while the patient is still under and he said that is old school.  He would just remove the prostate and get the pathology report a week later.  He worked with Mani Menon and was part of the pioneer team who has trained many.

He seems knowledgeable and has done over 4,000 robotic since 2002. 

He did state that his goal based on my scores was to remove the prostate and nothing else. (Nerve Bundles and Lymph nodes would not be touched based on my stats).  Is that a normal response?

Thanks in Advance

This sounds promising and I am sure you will do great. You are another young one...

Should you want to explore different possibilities in your area, a forum member called JNF is a wealth of knowledge on alternatives to surgery. Not trying to push you away from surgery as I consider it a magnificent solution and did fantastic myself with it. Just introducing you to a veteran who happens to know the ins and outs in your town.

kdeinv,
The removal of the catheter is a non event. It felt "weird" and I leaked on the floor at the moment it exited. But it was not painful.
The JP drain, now that is a different stroy. When it was removed, the morning after my surgery as I was preparing to be discharged, it was painful and unexpected. I startled the nurse because I let out a loud explicative (starts with F and ends in K). It was over in the blink of an eye but it made an impression on me. LOL

RickyD

removal of catheter was extremely uneventful to my surprise.

Removal of drain wasn't painful, but definitely FUNKY

I'd go through it all over again knowing what it was like. The day they take the cath out is blissful.

His reply was that there is no  more tissue to cut at the margin even if the initial pathology does show positive margins.

My worry is that the cancer is more widespread than the biopsy show (Happens 25 - 30%)  If it is more aggressive and they do not test the margins while under then they cannot take any additional tissue to get to a negative margin or perform other removal procedures.  Once the final pathology report comes out it seems to be too late to do anything if a positive margin is indicated.

He will not take lymph nodes and or nerve bundles (But what if it has spread to those areas?)  Am I SOL because an initial pathology report was not done?

Thanks

Hi Gedman,

Yes I got your email. Thanks for the idea of the pants. 

Thanks again

Drain and catheter were no big deal. Like most things, our own minds are sometimes the worst enemies. We all sweat out the margins, but with your stats and your doctor's experience, I think you can be very optimistic that this will all work out.

Best wishes,
Tom

kdeinv said...

My worry is that the cancer is more widespread than the biopsy show (Happens 25 - 30%) If it is more aggressive and they do not test the margins while under then they cannot take any additional tissue to get to a negative margin or perform other removal procedures. Once the final pathology report comes out it seems to be too late to do anything if a positive margin is indicated.

He will not take lymph nodes and or nerve bundles (But what if it has spread to those areas?) Am I SOL because an initial pathology report was not done?

You seem to be conflating two different issues kdeinv.

The Gleason score is upgraded about 30% of the time. When that happens it does not mean the cancer is more widespread, but does mean that it is more aggressive. This is why there is some risk in deciding to not remove lymph nodes based on the biopsy. If the cancer is upgraded, you may regret having left them in. If you are uncomfortable with this you may want to consider seeking a consult at Johns Hopkins, where their policy to to always perform lymph node dissection, which they have been able to do with an extremely low rate of complications.

As I understand the intra-operative frozen section pathology it has fallen out of favor because it has proven to have limited value but some extra risk (due to extending the duration of operation) and is not really used so much to access the aggressiveness (Gleason score) but just to check for cancer at the margin.

If the surgeon is really removing as much periprostatic tissue as he can then frozen section pathology of the margin would seen to be useless, however Dr. Shah's explanation obviously falls apart for the neurovascular bundles if you are a candidate for nerve sparing.

Yes here are his stats

I have performed over 3500 radical prostatectomies since 2001.

Our T2 patients represent about 78 percent of our robotic prostatectomy cohort and have a 7 - 9 percent positive margin rate.

Continence, defined as no leak on stress maneuvers and no pads, 50% at 6 weeks post surgery; 80% at 12 weeks and 98.5% at 24 weeks.

Men potent prior to surgery (defined as a SHIM score of > 21), achieve erections that they rate (both patient and partner) successful and satisfactory 88% within 12 months. That does not mean it takes 12 months to get an erection post surgery.

Thanks

Do you have a progressive PSA history? I mean have you had PSA tests done every two months or so to establish any pattern at the very least before opting for surgery? How much have you studied PC or gotten 2nd opinions from prostate specialists? Just asking my friend. 3.5 at your age MAY be your basis. Ask him about having your needle biopsys sent to Bostwick labs and have needles targeted by color dopplar sonic equipment run by a person that has much experience.

I do understand that you want it out but know all that you can before having surgery IMO. Removal of a drain or catheter are the least of your worries.

Dr Shah did my rp in April of 2010.  I was a Gleason 7 and during surgery he discovered the right seminal vessel was involved and removed also.  In the fall of 2012 my psa began to rise and I began 37 radiation treatments at Emory on December 3, 2012.  I also received  a 3-month injection of Trelstar (hormone) on 3 December and 27 Feb 2013.  I just had my 6-month follow-up at Emory yesterday and my psa is "undetectable".  Just thought I would share my experience with Dr Shah.  (I lurk here a lot and keep up with the guys but do not post frequently.)  Good luck on your journey!

Hi Chatuge,

Aren't the Seminal Vessels removed with the prostate in all cases?

Did Dr Shah know that the Seminal Vessels were involved prior to or during the surgery or was that discovered in the final pathology report after surgery.

Were your margin's negative on the final pathology report?

Glad to hear your hormone treatment from Emory is working and your PSA is undetectable.

Would you recommend Dr Shah to a newly diagnosed patient?

kdeinv

I'm not sure if the seminal vessels are always removed but Dr Shah told me in the recovery room the right one was involved and that he removed it.  I'm not sure I would give anyone a raving recommendation that cuts on me!  I guess, overall, things went fairly well for me-cath out in 10 days-continent within a couple of weeks after the cath was out-some rectal pain for about a month post-op and ed forever.  He said he was able to spare the nerves but all I know is before I could and afterwards I couldn't!!!It has now been 3+years and the wife of 49 years and I have accepted this fact.  At your age I certainly wish you better luck.  Michael, hope you are well.