Nerve sparing robotic prostectomy?

lapilot said...
Does nerve sparing surgery increase ones risk for biochemical failure down the road?

In principle yes, because positive surgical margins increase the risk of recurrence and one place PSMs often occur in resecting the neurovascular bundles off the prostate (either because of undetected extra capsular extension into the NVB or iatrogenic incision through the prostate capsule into tumor) and, in principle, resecting the nerves widely could avoid these PSMs. However in practice bilateral nerve sparing (at least partial) is usually attempted unless clearly contraindicated by established risk factors.

lapilot said...
Does removing the nerve on one side great effect my chances of ED?

Yes, at least in the short term. There is some data (www.ncbi.nlm.nih.gov/pubmed/18419221) to suggest that in the longer term (2yrs+) the potency outcomes for unilateral sparing approach that of bilateral due to crossover innervation:

Most all surgeons (including both open and robotic) will make on-the-fly nerve sparing decisions independently on the right and left based on what they find while they are operating. So a guy could end up with bilateral sparing, unilateral sparing or neither.

There are also degrees of partial sparing that can be done on each side. Just because you had tumor on the right, does not mean you won't be able to have at least some sparing done safely on that side.

In my case I had partial sparing on the right (where the tumor was) and maximum sparing on the left.

An MRI could be useful to help stage and pre-plan what degrees of sparing would be safe. These may be of interest:

www.moffittcancercenter.com/CCJRoot/v17n4/pdf/233.pdf
onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10565.x/pdf

One of the doctors I consulted with, Arieh Shalhav from U of Chicago explained that there is a “very lonely moment for the surgeon” when he is teasing the neurovascular bundle off the prostate capsule and may encounter some "stickiness" and then needs to make the in-flight decision as to whether this is due to ECE of the disease (in which case he must resect the nerves widely) or residual benign inflammation from the biopsy (in which case he can safely spare the nerve). He indicated that there can be some very close calls and for this reason it can be helpful for the patient to be explicit about his personal priorities.

I took that to heart and did discuss with my surgeon shortly before the operation explaining that as a 40 year old with a family I was very risk adverse about compromising cancer control and confident that in the long term my potency could be restored one way or another so in the event of any such close call I wanted him to know that I would fine if he told me afterwards that he only saved one nerve.

On the other hand, someone like Hugh Hefner would likely have different priorities...

lapilot,

I was going to weigh in, but njs gave you the "A" answer.

Good luck with the surgery, and let us know how things work out for you.

Jonathan

Oh Id make an appt at a topnotch Brachy center. SEA is one of the best. Talk to them specifically all ab out every thing including ED concerns. I know you are one who wants it out. What you really want is a cure with minimum amount of side effect.We all did/do. I have no idea what your stats are since you have no signature. Having it up once or twice doesn't cut it . Sorry a pet peeve. the software should disallow posting , without a signature, after 3 initial Howzit postings. imo.

The nerves that run along each side of the prostate have runners that go into the prostate, so if you have an aggressive cancer the cancer cells can invade the nerves. Best to have a discussion with your surgeon on this topic and make sure you are fully apprised of any risk factors.

logoslidat said...
I believe you are wrong on your runners statement. Where did that information come from. If you are not sure of your info, you should qualify to some extent. I am 99.9% sure you are wrong . the .1% is my qualifier. How could a surgeon spare a nerve going into the prostate. Judge Judy " if it don't make sense it ain,t true"

The nerves going in are not spared. Only those going around.

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Post Edited By Moderator (Tudpock18) : 11/4/2013 4:43:28 AM (GMT-7)

tony with respect , I do not see the connection with your post to the main Issue here, which is the invasive misunderstanding on this forum twixt PNI and Erectile nerves.

Logoslidat

It is important each member consult with their surgeon and fully understand the risk before making decisions that could effect the outcome of their life.

It is my understanding that PNI is a mechanism for prostate cancer cells to escape the capsule. When this happens a wide excision is necessary to get any cancer that has escaped and unfortunately a wide excision includes the nerve bundles. I think understanding PNI, the mechanism cancer cells escape the capsule and thorough and thoughtful consultation with medical experts is all part of understanding risk. The treatment decisions we make have risk and carry consequences, so we must seek to understand.

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Post Edited By Moderator (Tudpock18) : 11/4/2013 4:45:07 AM (GMT-7)

They do not enter the prostate, they are overlying the prostate but will allow they may in all the goop and goo be covered by capsule tissue superficially. To me this is why nerve sparing is so delicate and they have to tease, like in, here baby, come on, come on, nice and easy don't break, I can do this, I can do this as the good surgeon ever so lightly separates the bundle from the prostate, not clip them at the end thus causing even more trauma, If they could do that why not just clip them before at the point before the overlie and be done with it. Having said that,

That just gave me a revelation. Perhaps some surgeons do get exasperated and clip the stubborn little XXXX"s and that is why the recovery times vary so much regardless of age. Just another incoherent hypothesis. sorry NJs, couldn't resist. Ok you deserve one of those for me. but be kind. good fun yeh??

You mean the " protruding" ones are in fact part of the tease? or are they clipped in your opinion don't think so, but could be wrong. To clarify Pn i is agreed on by most specialists as prognostic in biopsy. Not in the way you state it tho. There are many nerves inside the prostate. None of them have anything to do with effecting a penile response, the exception being of course, the pleasure response of prostate fiddling during sex, mostly in "gay" men, but also in heterosexual couples who include anal play in their sexual activities. The path is in the free space around {peri} the nerves { neural}. Invasion refers to the invasion in to the that spacen not into nerve bundles. Yes its a pathway but nerves are , Im daily sure randomly placed inside and could escape near nerve bundle and escape and than invade the nvb and everywhere else, where ever they lead to. the travel way is the space around the nerve, not three the nerves. Im talking nonerectile nerves inside the prostate. Ok now we know why they are agreed to be prognostically significant in biopsy. Once the walnut is on the pathologists slides and no epe, neg margins etc is discovered, the agreement is controversial on its prognostic value hence forth. Now I could see where some could think cells might escape that way, but am not convinced. Purgatories medicos for the most part think they do and that it explains why a lot of clean pathology patients recure at some point later on. I think thats avery plausible explanation. My problem is that a vast majority of post ops have PNI in there post op path. But relatively speaking it no where matches up with the post op recurrences in clean path patients. It could be that the stats have so much clean gl 6 post ops, that don't survive. Also the post op pni reports never mention how far the pni has invaded the space INSIDE the prostate. It is usually just mentioned as PNI. Or , as in my case, extensive PNI. My hope and ace in the hole is that the main tumor was placed a full 1/2 inch from the prostate wall near the apex. I may indeed have some four and 5 cells floating around but hope and have faith that my healthy lifestyle, strong spirit and positive attitude will realize this hope and faith, and will keep my immune system strong enough to keep them in check. I believe the very late recurrence happens, when these data points of life are neglected. Merve Griffith had a very late recurrence. At least 10 to 12 years post op. You remember how he ballooned up i later life. I think he got scared from the initial diagnosis and had a what the heck attitude about life, after he thought he was cured. Im to spent to edit this, so hope it makes sense. Regards PS cancer cell are sticky and do not have a free fall in that perinueral space. Also it is better to not have pni at all but less forbodeing in post op path, specially for a bone fide gl 6