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I asked my doctor about nerve bundles

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Posted 4/22/2010 3:20 AM (GMT 0)
I had a visit with my Uro surgeon today and after receiving the good news that I reported yesterday I asked him about a post from BB-Fan that I saw 2 days ago. BB_Fan was DXed in 12/08 (same as I), had surgery on 3/09 (one month after I did), he was Gleason 8 with negative margins and no EPE yet his PSA started going up at 10 months post surgery. My question to him was whether it was pure bad luck or just the nature of PCa. He told me that because my nerve bundles were not saved, he was able to go wide and remove adjacent tissues. In the case of BB_fan, he had his nerve bundles preserved which may have prevented the surgeon from going wide. I post this because a while back, I asked whether preserving the nerve bundles may have an effect on recurrence for those with high Gleason. What do you think?
Posted 4/22/2010 5:00 AM (GMT 0)
Sometimes there is confusion between what is involved in perineural invasion and what we here usually think of when referring to nerve saving. They are in effect different sets of nerves. What we are talking about when mentioning perineural is the nerves located within the gland and are a part of the gland itself. Often there is tumour invasion of these nerves as well as vascular invasion (tumour within the blood vessels inside the gland). The "nerves" we usually are speaking about with "nerve saving" are external for the most part and are responsible for the altering of the blood flow that enables an erection. These are attached to and can be slightly within the surface of the prostate gland. The aim of the surgeon is to tease these nerves away from the gland without damaging them which is no mean feat. Think of your spinal cord........simply bruising the cord can be enough to cause permanent damage. These nerves also weave through the tissue around the gland, tissue which sometimes has to be removed to get a "safe" margin. A surgeon cannot know going in if he can save the nerves but it should really be a judgement call once he gets in there. In my own case, once in, the the gland was removed and immediately sent for a frozen section. The surgeon was told there was substantial tumour close to the surface of the gland so he took a wider margin which unfortunately precluded saving the nerves. If the amount of tumour was on the smaller side and away from the surface I should not think that there was any additional risk in saving the nerves. By the way Ed, a most excellent result.
Congratulations yeah
Bill
Posted 4/22/2010 1:18 PM (GMT 0)
BillyMac,
When my biopsy report showed a Gleason 8, I instructed my surgeon not to spare the nerve bundles and instead to take out as wide a margin as necessary to improve my chances of success. What I meant by my question to the doctor was to see if saving the nerve bundles can sometimes increase the chances of recurrence by leaving few renegade cells lurking around. This is probably true for those of us with aggressive PCa. The example I sited was the case of BB-fan who had similar pathology report with no EPE and with negative margin but he did have the nerve bundles preserved, contrary to my case but he his dealing with elevated PSA.
Posted 4/22/2010 1:38 PM (GMT 0)
Ed & Billy,

I have the logic from the other side - my uro/surgeon told me before surgery that it was very widespread and very aggressive (biopsy result 7 of 9 4+4; 2 of 9 3+4; 3 indeterminate) .
He said that in order to take a wide enough margin, and improve the chances of a cure, he had no choice but to take the nerves on both sides, as they could harbor cancer as well. The margins were positive anyway.

That tells me my doc believes that the nerves, if left, are a real danger.

Post Edited (142) : 4/22/2010 7:46:46 AM (GMT-6)

Posted 4/23/2010 2:14 AM (GMT 0)
Ed,

Thanks for your post. It's quite interesting about the nerve bundles. The nerves on both sides were spared in my surgery and as you can see in my signature, I was tossed from the zero club about 4 years post surgery. In February 2010, I decided to start having the more sensitive PSA assay done. My next test is coming up in a couple of weeks. I've asked my urologist (he did not perform the surgery) if there is a remote possibility that the PSA reading is due to benign prostate tissue left behind from sparing the nerves and he said, yes, it is definitely a good possibility. We'll see - time will tell.

Fred
Posted 4/23/2010 3:56 PM (GMT 0)
At Cleveland Clinic, the resident who came in during the pe-op session to explain the procedure, said that with a Gleason 9, the doctor would cut both nerves.

I asked the surgeon, and he said no. If he feels the nerves can be saved, he will, and he did, altho he carved them up pretty good.

I guess there is no pat answer.
Posted 4/24/2010 2:05 PM (GMT 0)
My Uro told me going in that he was taking the left nerve bundle and leaving the right one. He says that's what he did, but how do I know?

27 month's later, Junior never woke up from the surgery. Maybe it depends how close to tee time it is to determine what can and cannot be saved.
Posted 4/24/2010 2:59 PM (GMT 0)

Ed,  Dr. Tewari at Cornell, has an article about nerve sparing surgery at www.prostate-cancer.org/pcricms/node/178.  He uses the patients risk factors to determine the degree of nerve sparing.  I copied a table from his article below. 

What stays on the patient side What is removed with the specimen Indication
Extensive nerve sparing All of prostate fascia and nerves Prostate capsule only Very low risk cancer
Regular nerve sparing All of the nerves Capsule and prostate fascia Low risk cancer
Partial excision (Incremental) Partial excision of nerves Partial nerve bundles Intermediate to high risk cases
Non nerve sparing Total excision of nerves Total nerve bundles (wide excision)

Suspected ECE (extra capsular extension)

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