Update: RP scheduled, still waiting for a 2nd opinion on biopsy

BruceinPA

My biopsy in early December showed 22% of one core with a Gleason 4+4 (up from 10% at 3+3 at last biopsy in 2019). Here’s what has happened since then:

• Met with both a radiation oncologist and surgeon to fully discuss both treatment options.
• Submitted sample slides for genomic testing to give a complete genetic picture for further cancer chances
• Also submitting slides to Johns Hopkins for 2nd opinion on biopsy results
• Had abdominal CT and bone scans
• Decided that RP surgery was my choice for treatment. (Otherwise healthy and active 67 year old with no prior history or conditions) Surgery scheduled for robotic nerve-sparing RP in late February.
• Pre-surgical appointments scheduled with cardiologist and surgeon, which is routine for a patient in my age range with this urology practice
• Should the 2nd opinion from JH differ from the original findings, I may decide to reassess these plans.

I think I’m in very good hands and have covered all bases. Any suggestions for additional actions I may have missed?

Old Salt

You have done your homework and made a decision. Congratulations! I hope that the long-term outcome will be great.

With respect to other issues, you can ask your surgeon if he plans to examine nearby lymph nodes (and how many).

How certain is he that the nerve bundles can be spared?

Also discuss the urethral length issue:

Impact of surgically maximized versus native membranous urethral length on 30-day and long-term pad-free continence after robot-assisted radical prostatectomy - ScienceDirect

You should also ask for his advice on after-care. You can find a lot of this on other prostate cancer forums.

Finally, ask him about recommendations to minimize ED and incontinence.

My recommendation is to start Kegel exercises now.

BruceinPA

I do have one question from the results of my CT scan. I'll discuss this when I meet with the cardiologist but just throwing it to the group in case others have seen something similar.

Among the findings of the CT: "Coronary arterial calcifications present."

I'm going to assume that this is something they'll want to investigate further, since there's nothing more in the CT report about it. Anybody ever had their RP delayed due to cardiac questions/problems?

Clevelandguy

Hi,

Sounds like you have done your homework and are secure in your selection. Just make sure you have experienced surgeons for your surgery which will maximize your long term outcome. Old salt offers a lot of good points. Some members also like the imaging definition of a PET scan, might want to look into that. Good luck in your journey………..

Dave 3+4

lighterwood67

You are doing all the right things. Remember it is always your decision. You may want to ask if they remove some lymph nodes and clip and seal. Will they use surgical steel clips, that will remain with you? Also, it is my understanding that one of two urinary sphincters will be removed (internal). I am giving you a copy of my surgery (March 2018). Gleason 4+3=7. Age 67. Status: PSA undetectable; continent; intimate with wife , if I can catch her (awfully fast). FINDINGS AND TECHNIQUE:The patient was taken to the operating room where he was placed under general anesthesia in the supine position. He was then placed in low lithotomy position,prepped and draped in the usual manner for a robotically-assisted radicalprostatectomy. The abdomen was entered through a periumbilical incision and adouble balloon 12 mm port was placed here. The abdomen was insufflated. The other five port sites were marked off and placed under direct laparoscopic vision. The robot was docked and the procedure was begun from the console.We began the procedure by releasing large bowel adhesions on the left side of the abdomen. This was done with cold sharp dissection. The space of Retzius was then developed by dividing the median umbilical ligaments bilaterally as well as the urachus. Both vas were divided as they entered through the internal ring. Once the space of Retzius was fully developed, the endopelvic fascia was opened close to the prostate. The dorsal vein complex was suture ligated with 0 Vicryl over the baseof the gland and then divided with the bipolar cautery over the bladder neck.A bilateral pelvic lymph node dissection was then done (obturator and hypogastric)including deep pelvic nodes on the left side. All longitudinal lymphatics were clipped or sealed.Bladder neck was dissected out anatomically and divided. We went wide anteriorly and obtained a negative frozen section here.Seminal vesicles and vas deferens were then identified, mobilized, dissected up and elevated. Denonvilliers fascia was then opened posteriorly and I dissected between the layers of Denonvilliers fascia all the way to the apex. The vascular pedicles to the prostate were taken with the ENSEAL device and large clips as we got close tthe neurovascular bundles. The bundles were well preserved bilaterally. Small metal clips were used as we worked under the posterior aspect of the prostate. An element of high lateral release was done, but I was not aggressive about getting too close to this capsule. I specifically went wide at the left apex to avoid capsularincision. As I dissected along to the apex I noted excellent neurovascular bundle sparing bilaterally.The dorsal vein complex was then isolated and taken with the ENSEAL device. The DVC was oversewn with a V-lock suture. The urethra was divided with cold sharp dissection. The prostate was put into a specimen bag.The anastomosis was then done in a two layer fashion using a Rocco suture toapproximate the urethra posteriorly. This was a single horizontal mattress.Continuous 3-0 Monocryl was then used employing a Quill suture to achieve awatertight anastomosis. The bladder neck was tapered with 2-0 Vicryl. Theanastomosis was sealed with Eviseal and stented with an 18-French Foley catheter. A Blake drain was placed in the abdomen through the fourth arm port. This was secured with silk.Marcaine was used to block all port sites.The right-sided 15 mm port was closed at the fascial level with 2-0 Vicryl. The prostate was removed in its bag through the umbilical port. The umbilical port sitwas closed with continuous #1 PDS in the fascia. All skin incisions were closed with Monocryl and Dermabond. The patient was awakened and taken to the recovery room in good condition. Estimated blood loss for the case was 100 mL. Sponge and needle counts were correct x 2.  Good luck on your journey.

Fleet Foot

Bruce, I wish I had been half as "on-top" of it as you are when I had my RALP. You've done great prep and I applaud you for it. As for the "coronary arterial calcifications present", I had them (and still do) at the time of my surgery and it was no big deal and never really entered the picture and I was five years older than you. Good Luck.