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Are all Robotic Prostatectomy's Considered "Nerve Sparing?"

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Posted 7/6/2023 7:34 PM (GMT 0)
Hello
Diagnosed with Prostate Cancer on 6/14/23.
Gleason score 7
PSA 12
MRI scheduled for 7/11
Follow up consultation with urologist/surgeon 7/21

I'm learning and researching all of my options for treatment, and I keep reading about "nerve sparing robotic surgery".
I haven't had a chance to sit with my urologist/surgeon just yet for the follow-up consultation, but his profile page says he specializes in robotic prostatectomy. It doesn't say anything about "nerve sparing" and he himself hasn't mentioned it either during the few video calls I've had with him.

Can I assume that if he performs robotic surgery, it will automatically be "nerve sparing" or is this something that I have to make sure is included (sounds like I'm ordering something online LOL). I guess this might all depend on the MRI and where the cancer is situated in the prostate or surrounding areas. Not sure.

Anyway, thank you for your time and good luck to you all during your struggles with this.
Posted 7/6/2023 8:30 PM (GMT 0)
no. it you want a guarantee it's best to avoid surgery
Posted 7/6/2023 9:08 PM (GMT 0)
I had robotic surgery with nerve sparing. If he is a robotic surgery expert, I assume he has done over 600 of these procedures. I was told by my oncology urologist that performed the surgery that each surgery is different. He plans on doing nerve sparing, but depending on the location and degree of cancer he might save both nerves, maybe one nerve, or possibly neither of the nerves. In fact, he said there is always a small risk that robotic surgery might have to revert to open surgery. He also said there are no guarantees when it comes to biological systems.

In my opinion, robotic surgery s the way to go. Much faster recovery, far more precise, and far less blood loss (I lost less than 50cc of blood).
Posted 7/6/2023 9:41 PM (GMT 0)
They are nerve sparing unless they’re not.
The primary directive is to remove the cancer however wide they need to cut.
It’s in your best interest to be open to other less invasive treatment options.
Posted 7/6/2023 11:11 PM (GMT 0)
So you had a biopsy before your MRI?

Heads up, a biopsy basically shanks your prostate with many needle shots, and does damage and leaves artifacts that mess with reading the MRI. Also, you lose the ability for the MRI to guide the biopsy.

If true that the MRI is following the biopsy, I would not return to that urologist. I’d go somewhere else for further care.
Posted 7/7/2023 12:14 AM (GMT 0)
Hi John - Sure is fun visiting here? Are you are having your MRI after your biopsy? Was it proposed before biopsy and rejected by insurance? It is my opinion that urologists who are up to date would push for a MRI before the biopsy as it helps guide the sampling and is pretty standard nowadays.

A "good" prostate surgeon will be doing robot assisted prostate surgery every week for years and will perform nerve sparing surgery to the best of his/her ability with the cancer's permission. Sometimes the tumor engages one of the two nerve bundles, one on each side of the prostate, and the best that can be obtained is partial nerve sparing on the affected side if possible. The nerves still get manipulated during surgery which tends to cause problems even with best efforts of keeping them intact.

Do not assume anything when embarking on this journey. There are no stupid questions and you want to make sure you are confident in the doctor that is going to operate around your private parts. Bring a prepared list of questions to your visit on the 21st and insure that all are answered to your satisfaction. The doctor knows everything compared to you at this point so you want to get up on the learning curve quickly. Bring someone (spouse) with you to your consult to listen and take notes.The first meeting is pretty overwhelming and having two sets of ears makes sure that most things are heard right on the drive back home.

Ask about the doctor's experience and the experience of his/her patients with regard to erectile dysfunction and urinary incontinence.
Ask for a referral to a radiation oncologist he trusts for treatment alternatives.
and so on.
There are actual lists floating around on sites and in books that you can look for if you need ideas. Doctors actually like it when patients have questions as they get tired of giving the same speech over and over again to blank looks.
Posted 7/7/2023 12:28 AM (GMT 0)
John,

Welcome to our club that none of us sought until we needed it.
You've already gotten some good advice above, and I would add some thoughts...

First, before you make a treatment decision, make sure you consult specialists in radiation therapy. You urologist is a surgeon, and he will recommend surgery. He may even badmouth radiation or try to convince you that it's a bad idea.

Ask for referrals to radiation specialists in your area, and go talk to them.

THEN, make your treatment decision.

"nerve-sparing" means, quite simply, that every effort is made to preserve, and not damage, two major nerves that run along side the prostate gland. Keeping them greatly improves your odds of maintaining continence and erectile function after surgery--but there are no guarantees.

If the tumors are hitting, or around the nerve(s), then keeping them in place and operational is not the priority in surgery--removing the tumor is. If the surgeon feels he needs to cut the nerve to achieve cancer control, he will.

The key thing, John, is to be as thorough as you can during the consultation phase, and do your best to make an informed decision. I'd also suggest you try to stay away from Dr. Google as much as you can. Lots of good information there---but a lot of fluff as well, and some downright dangerous stuff.

Ask questions..we're here. And we've all been there.
Posted 7/7/2023 12:29 AM (GMT 0)
Hi John sorry we're both here but here we are. I just had sp-RALP ("single-port Robotic Assisted Laparoscopic Prostatectomy") two weeks ago and have been surprised at how low-impact it has been on me: first sign from the heavens was morning after the procedure when I awoke to a woodie straining painfully against the catheter. I was out of the hospital later that morning & off prescription painkillers 36 hrs post-op. Catheter came out at 5 days. I'm not fully continent yet but some days & nights I'm already pretty darn close, and it's improving every day.

My understanding is the newest robotic machines with the single port were only introduced 5-6 yrs ago. I lucked into having my surgery performed by one of the early adopters / researchers: Dr. Igor Frank at Mayo Clinic, Rochester MN.

I had very similar numbers in my diagnosis: GL 7 (3+4), PIRADS 4 MRI. My primary lesion was posterior / lateral -- this is one of the criteria which qualified me for the Hood Technique. If yours is anterior you may not, plus some other anatomical factors.

BTW there's research indicating that after they "shank" your prostate with the biopsy needles, you should wait 6-8 weeks to have surgery. The thing needs to heal & calm down for your best outcome. If you go too soon, you are less likely to have nerve-sparing. Dr. Frank co-authored this analysis:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786103/

Some other terms you may research & ask your surgeon about are "Retzius Sparing" and "Hood Technique." The new robot can do an incision below your navel, avoid the peritoneal sac ("pre-peritoneal" approach) then loop around to get at the prostate from the posterior rather than carving through your anterior stuff. Here's a summary of how that works:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7155805/

Good luck with whatever you decide. If you opt for surgery & can travel to one of the high-volume medical centers where they do the sp-RALP, I'd highly recommend you do it-- it was absolutely money well spent for me.

And I also am surprised you didn't have the MRI before your biopsy-- how'd they know where to aim the needles??

nels

Post Edited (nels) : 7/6/2023 4:35:13 PM (GMT-8)

Posted 7/7/2023 1:23 AM (GMT 0)
Based on the location of one of the two positive cores near the top of my prostate in my 14-core biopsy, my uro/surgeon said--when we were discussing my surgical option (which I did decide on)--that he was fairly sure he would be able to spare the neurovascular bundle one one side, but wouldn't know about the other side until the procedure is underway. Without hesitation, I told him to do whatever he felt was best during the surgery.

The morning of my RP, he stopped by while I was being prepped to go over things, and asked for confirmation that I wanted him to remove the bundle if he felt it was necessary. I said yes, but hadn't we already discussed this? He said yes we did, but he wanted to make sure. I asked him: didn't all men want to prioritize the oncological outcome? He said no, some men give priority to sex (I guess this comes up especially if the look and feel of the tissue only suggests cancer is there but isn't obvious).

After surgery he said he was able to spare both neurological bundles without any problem (since I had a Gleason 10 biopsy, he took frozen sections that were sent to the path lab during surgery to ensure negative surgical margins if possible). All of them came back negative, fortunately.

The bottom line is that you need to ask your surgeon about your lesion location and the question of nerve sparing. ("Nerve-sparing is bundle-sparing: the nerves that control the blood flow for erections run in the left and right neurovascular bundle along the top of the prostate).

Djin
Posted 7/7/2023 4:29 PM (GMT 0)

centralPAdude said...
So you had a biopsy before your MRI?

Heads up, a biopsy basically shanks your prostate with many needle shots, and does damage and leaves artifacts that mess with reading the MRI. Also, you lose the ability for the MRI to guide the biopsy.

If true that the MRI is following the biopsy, I would not return to that urologist. I’d go somewhere else for further care.

Yes, both my referring urologist and this urologist that performed the biopsy went straight to biopsy once by second PSA test showed 12.1.
At this point, my insurance is through my job and it is with Kaiser. Not sure what options outside of Kaiser there are and I also don't want to waste time searching around.
Posted 7/7/2023 4:33 PM (GMT 0)

halbert said...


First, before you make a treatment decision, make sure you consult specialists in radiation therapy. You urologist is a surgeon, and he will recommend surgery. He may even badmouth radiation or try to convince you that it's a bad idea.

Ask for referrals to radiation specialists in your area, and go talk to them.

THEN, make your treatment decision.

The surgeon actually revered me to the radiation oncologist. I met with her last week. She said that based on my age and my gleason score, she would recommend surgery. She said that if I chose radiation, and if the cancer returned down the line, surgery would be risky because the tissue would have already been damaged by the radiation. Surgery would be complicated and risky, and additional radiation would not be effective.
Posted 7/7/2023 4:35 PM (GMT 0)

nels said...



BTW there's research indicating that after they "shank" your prostate with the biopsy needles, you should wait 6-8 weeks to have surgery. The thing needs to heal & calm down for your best outcome. If you go too soon, you are less likely to have nerve-sparing. Dr. Frank co-authored this analysis:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786103/


nels

Yes, doctor said the same thing. Waiting at least 8 weeks at this point
Posted 7/7/2023 5:20 PM (GMT 0)

** The surgeon actually revered me to the radiation oncologist. I met with her last week. She said that based on my age and my gleason score, she would recommend surgery. She said that if I chose radiation, and if the cancer returned down the line, surgery would be risky because the tissue would have already been damaged by the radiation. Surgery would be complicated and risky, and additional radiation would not be effective.**

Wow John, that's kind of a new one for me. I didn't catch your age, but I don't see that a Gleason 7 would make any difference for radiation. Out of curiosity, are the surgeon and RO in the same practice group?

I didn't see your biopsy report posted. Unless I missed it, can you post it for us?
Posted 7/7/2023 5:23 PM (GMT 0)
i would find another radiation oncologist. that sounds like such BS as if she's getting a kickback

>>The surgeon actually revered me to the radiation oncologist. I met with her last week. She said that based on my age and my gleason score, she would recommend surgery. She said that if I chose radiation, and if the cancer returned down the line, surgery would be risky because the tissue would have already been damaged by the radiation. Surgery would be complicated and risky, and additional radiation would not be effective.<<
Posted 7/7/2023 7:06 PM (GMT 0)
John:

The "radiation damages the prostate and makes future surgery difficult" is one of the most common half-truths in the PC world. Usually it's a surgeon who says it.

It implies a few things:
1. It implies that primary radiation will fail
2. It further implies that when primary radiation fails, there are no other radiation/medical alternatives

In other words, it's a scare tactic. You can have radiation after surgery if surgery fails. Absolutely true. And, if you're a G7 that is organ contained, the odds of primary treatment (surgery or radiation) failing is vanishingly low. In fact, primary surgery failure is way more common than primary radiation failure, because radiation treats a larger area.

Don't assume a what if it fails attitude. Find out the best treatment that will give you cancer control with minimal side effects.

Kaiser is an issue. We've heard this many times. Others may have good ideas about getting through their system.
Posted 7/7/2023 7:52 PM (GMT 0)
John, re your original question, I think it's been answered pretty well. The doc will try to spare the nerves but nothing is guaranteed until he/she gets in there. If you are choosing surgery make sure that surgeon has done 500+ procedures and he/she shares their ED and incontinence stats with you.

Beyond that, you should also get a second opinion on your biopsy pathology. Johns Hopkins is the place to go with Dr. Epstein. There is info in the sticky thread at the top of our forum that will help you do that. This is important...you need to know with some authority what you're dealing with.

Beyond this, if your pathology holds then there are various forms of radiation that might cure you. Get some RO's that are not associated with your urologist's practice to give you an independent opinion. Seek out experts in HDR Brachy and SBRT as well as EBRT. Do your homework. You may ultimately choose surgery but you want to make sure you have explored all of your reasonable options before making an educated decision.

Jim
Posted 7/7/2023 7:57 PM (GMT 0)
John, welcome to the forum. Good information above. Surgery vs Radiation is an ongoing debate here, make your own decision. There is nothing wrong with Surgery as an option, most men, especially men in the hands of a competent and experienced surgeon, will not lose their continence, at least not permanently. They may be incontinent to one degree or another, but most eventually, within weeks or months, regain full continence, As far as sex, I believe the majority of men especially with nerve sparing, will retain their ability to get an erection, many with the help of a little blue or yellow pill (just my guess). Probably not to the same extent as men who regain continence, but I am guessing more than 50% maintain ability. So don't believe the hype against surgery. Of course, there is always the possibility of side effects, including incontinence, erectile dysfunction, even hernia. No treatment is without possible side effects

With that said, and I'm a surgery guy, if I was diagnosed today, I would seriously look into SBRT aka Cyberknife (just a brand name). When I was diagnosed, there were only track record going back about7 years, that wasn't enough for me. Today it's got longer term record of positive outcomes. Especially if your G7 is a (3+4) vs (4+3)

one more thing, and I think this is important... you made a comment... "I also don't want to waste time searching around.".... I understand that, but at the same time I think the worst thing you could do is rush into something without doing full due diligence and making an informed decision. Prostate cancer is different than most cancers. It grows very slowly. and another few weeks, or even a month, isn't going to hurt you, especially with a G7. You don't want to experience decision regret, aka shoulda woulda coulda. There are many options, and most have balanced pluses and minuses. Make sure you are informed.

Whatever decision you make, we are all here to support you, and will have your back and help as much as you need/want to get thru this.

Disclosure... I had surgery, then 2 years later, early salvage radiation. I have no regrets. But there are many radiation options available that make sense as well. Everyone is different

Good luck
Posted 7/7/2023 9:18 PM (GMT 0)

John U said...
Yes, both my referring urologist and this urologist that performed the biopsy went straight to biopsy once by second PSA test showed 12.1.


That genuinely angers me on your behalf, assuming it was their decision and not the insurance company’s to do the biopsy first. If it was the insurance company denying it, we’ll I am still angry, just at someone else. Arggh.

For example, I had an MRI first, that identified a potential lesion. My biopsy was 12 random samples plus 3 targeting the lesion. The 12 ransoms were negative, the 3 targeted were positive.

Water under the bridge now, but I would ask the doctors pointed questions on your ordering of things.

Good advice. Definitely read the useful tidbits at the top. Google on Dr. Mark Scholz, he has some great books on treating PCa.

Post Edited (centralPAdude) : 7/7/2023 1:21:32 PM (GMT-8)

Posted 7/7/2023 9:49 PM (GMT 0)
I was told my open surgery was nerve-sparing, but the results haven't demonstrated it.
If I had to start new treatment today, I would very carefully look at the radiation options. For me, the long term quality of life side effects of surgery have not been good. At the time of surgery, I did not investigate the radiation options, which was my fault. I just wanted it out.
But everyone has to make their own informed decision.
Posted 7/7/2023 9:51 PM (GMT 0)
Hi John and welcome to the forum. This is a great place to seek out information, ask questions and make an informed decision. For low and most low intermediate risk guys radiation is a great option that should be thoroughly investigated. I hope you take the time to fully investigate radiation as an option.
Although it can be a little confusing regarding the number of radiation options available they all are very effective and have much lower risks of urinary and sexual side effects. Brachytherapy comes in two forms. One is low dose permanent seeds (LDBT) while the other are higher dose ‘seeds’ (HDBT) placed and removed in minutes. Both have excellent outcomes.
Beam radiation also comes in several forums and the number of treatments can vary in number from as low as five to as many as forty five. I chose one called SBRT. It also go by other names including Cyberknife and Precise (by MSK). You may wish to do a search for “MSK Precise” and it should lead you to some great information from Memorial Sloan Kettering.
I don’t wish to turn this thread into a debate between those choosing radiation verses surgery since I believe both treatments can be effective; however, they can result in vastly different side effects and out comes. Treatment choice is extremely important and and I believe far too many men do not take the time to fully investigate their options. I can say I’m glad I made an informed decision and the information on this forum helped greatly. No matter what choice you decide on I always recommend taking the time to seek out the very best practitioner and team you can find. It’s an important decision and worth the effort. Best wishes Terry.
Posted 7/7/2023 10:01 PM (GMT 0)
I heard once that the default priorities of the surgeon are 1) get all of the cancer; 2) prevent incontinence; and 3) prevent ED. If those are not your priorities it would be important to have a discussion. I think that getting all of the cancer is the most important goal, and that if doing so would leave me either incontinent or with ED, I'd be okay. I can see that some people would rank preventing ED above avoiding incontinence.
Posted 7/7/2023 10:06 PM (GMT 0)
Here is a good website to compare your odds of cure for the major treatment paths. You have to determine your stage, low risk, intermediate, or high risk (risk of recurrence). So if you are intermediate, pull up the intermediate chart and you can see your odds of 10-20 yr survival, etc. based on the treatment you pick.

https://www.prostatecancerfree.org/compare-prostate-cancer-treatments/

It is best viewed on computer or just print it on paper. Not so viewable on phone.
Posted 7/8/2023 2:20 AM (GMT 0)

groundhogy said...
Here is a good website to compare your odds of cure for the major treatment paths. You have to determine your stage, low risk, intermediate, or high risk (risk of recurrence). So if you are intermediate, pull up the intermediate chart and you can see your odds of 10-20 yr survival, etc. based on the treatment you pick.

https://www.prostatecancerfree.org/compare-prostate-cancer-treatments/

It is best viewed on computer or just print it on paper. Not so viewable on phone.

radiation or surgery will "cure you" but if you want to MAXIMIZE your chances of permanent, life-altering side effects -- eg, incontinence and erectile disfunction -- choose surgery
Posted 7/8/2023 4:33 AM (GMT 0)
Lots for John to digest here for making a decision on his treatment.

I'd only add, as a recent voice in this room, that there are a lot of continuous, rapid advances with the treatments available. New robotic devices are allowing the development of novel techniques for surgery. New 3D imaging & radiation delivery modalities allow precise targeting. These are moving targets, so the process to navigate a decision is therefore dynamic as well.

So check the dates on any reference materials you consider. If it is not inside the last couple of years, it may be obsolete information. Check your available providers, to see what they offer of the newest options for treatment.

I can personally attest to the advances in the surgical option. After considering Proton beam, I decided to go with surgery, partly because of my previous history of fast-moving aggressive oral cancer that was cured 100% by surgery, with no radiation or chemo, in 2010. Zero side effects, other than minor nerve damage that left me with a slightly crooked smile.

And partly I chose surgery for my PCa because a surgeon available to me had been at the forefront of utilizing the newest single-port robotic systems. This enabled him to do a new Retzius-sparing "Hood Technique" to avoid breaching my peritoneal sac and preserve anterior structures adjacent to my bladder & urethra. This shifted my odds significantly for the typical surgical SEs.

I woke up the morning after surgery with a stiffy straining against the catheter. Now that I'm 2 weeks out from the procedure I've been on low-dose Cialis for blood flow & "penile rehabilitation", and have spontaneous erections on almost a nightly basis. I'm very happy with my outcome in that department.

I'm not yet fully continent but I have dry days; I stick shields in my underwear for my leaky moments -- and I'm only 15 days out from the procedure. I will doubtless improve over the coming months. I don't think it's fair to say surgery invariably equates with life-altering side effects. Here in mid-2023, my mileage has varied.

I've got post-op pathology indicating I had focal EPE, Cribriform morphology, two more malignant lesions than either biopsy or MRI showed, and pT3. My cancer was also a moving target, which would have made primary RT more challenging.

But with negative margins I have confidence that I just might be done. 90 day PSA will be the next milestone.
Posted 7/8/2023 6:33 AM (GMT 0)
John, a lot of information here for you to digest. However, it is your body and your choice. I am sure you will soon make a decision on which way to go based on your own research and gut feeling. Make that decision and don’t look back regardless of the outcome. Just know that if either surgery or radiation doesn’t completely get the cancer to go away. You have many other treatments that will keep up the attack. I believe it has been said before, but no matter what you choose and the outcome, you have found the best place here for answers to any questions you may have. You will also find the best support from very knowledgeable veterans who have dealt with just about any and all treatments for PC. Many here keep up to date on all new research as well. The decision to move forward is the toughest part you are facing now. After the decision is made, you move forward with your life and that means living each day to the fullest.
My best wishes for you,
Jack
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