Radical Prostatectomy - in depth questions

Perineum, you should find answers in your doctor's office too
Hi Perineum,
I read your post in another forum, but you should find answers in your doctor's office too. A second opinion from an oncologist is always recommended, particularly in high risk cases (Gs 8).

To answer your first question;
PLND stands for pelvic lymph node dissection. This is a procedure most of urologists use to verify metastasis at the nodes. A series of nodes from the pelvic, are removed and analyzed under a microscope by a pathologist. The procedure can be done alone, before any treatment, for diagnosis purposes (laparoscopic) or it can make part of the surgery procedure.

PLND, however, is not recommended by the NCCN guidelines for low risk cases (PSA ≤10 ng/ml, Gleason score 6, cT1c/T2a). In that contrast, high risk cases (PSA>10, Gleason score 8,9 T3/T4) are usually not recommended for surgery, which would make laparoscopic a tool for diagnosis only.
Nevertheless, some Gleason score 8 patients are recommended for surgery and in such cases, extended PLND is done as santdard. Look at this; http://www.renalandurologynews.com/extensive-plnd-may-improve-prostate-cancer-outcomes/article/202919/

Intermediate cases, Gleason score 7, fall into a group that surgeons take other relevant data to consider PLND, such as PSA density and biopsy core involvement. Particularly if such case is recommended for radiotherapy (as prime or as salvage treatment) where proper lymph node involvement diagnosis is needed to determine the radiation field.

There are also preoperative nomograms to predict lymph node involvement, which is used in some instituitions based on PSA, biopsy Gleason score, and clinical stage. This means that guys falling into the low percentage risk would not be subjected to PLND.
http://www.eu-acme.org/europeanurology/upload_articles/Briganti June PP.pdf

In surgery, before cutting off the prostate gland, some surgeons dissect few lymph nodes firstly and wait for the instant analysis results from the laboratory of the hospital. If cancer is found to exist then the doctor stops the operation because they consider surgery not the proper treatment due to the presence of metastases.
On the other way, many doctors just do the surgery and complete pelvic lymph node dissection and get a total pathological analysis on the parts removed.
In my case (PSA=24.2, Gs=5, T2b), the doctor removed 9 nodes during PLND, sent them to analysis and waited. All the nodes were negative so that he continued the operation.

It should be noted that, there are reported cases (maybe mine as one of them) where negative nodes have been found to harbor occult micrometastases, which leads to biochemical recurrence after RP/PLND or even radiotherapy.

Question 2;
Transfusion is always required in surgery of the prostate. Many vessels are cut and a proper blood supply is needed. In my case, I gave 800cc (2x400) of my own blood one month in advance. That would avoid mismatches or other complications.

Question 3;
In my surgery the team consisted of 5 doctors including the anesthetist. The surgeon was assisted by three doctors (second surgeon and two assistant young doctors for stitches, medication, etc). The whole operation took over 5 hours.

Question 4;
The time to recovery varies from patient to patient. Many report being in recovery (in bed) 24 hours. In my case, the surgery ended at 6pm, awake at 10pm, and was walking 10am on the next day with the help of a tripod (and medicine of course).
From day two I was walking along the corridors of the hospital. It helps in the heeling process and it feels good.

Question 5;
There is lots of controversy regarding nomograms to predict recurrency from a pathological report after surgery. However, all recommendations are based on findings from past cases so that we should assume it correct. Salvage treatments are all based on those statistic data. Unfortunately, the “Silver Bullet” to kill cancer does not exist yet.
In recent studies, genes have been identified in cases of recurrence. The PITX2 gene was associated with cancer recurrence in cases where the prostate has been removed. A test named “hyper-methylation of PITX2 gene” was found accurate in predicting recurrence in cases with organ-confined and non-organ-confined disease.
You can read about details by using a net search engine and typing its name.
http://blue.regence.com/trgmedpol/lab/lab61.html

Question 6;
Nerve spare procedure is decided before surgery. We have to agree (yes or no) and sign the “contract” (my wife signed for radical). However, in a case where nerve spare has been judged to be valid before surgery (by diagnosis), and found to be in “bad-shape” while in surgery, the surgeon may change procedure and remove it without a word (we will be sleeping).

Wishing my insight is of help.

VGama

SeattleJ said:

???
I have no idea but the question doesn't make much sense to me. If the surgeon is good and you feel that the treatment you selected is appropriate for you why would you care how he/she writes the report? What has that got to do with anything?

John

John, "...most of the time we have to write reports"
John
Your post made me laugh. Thanks.
Reading Perineum posts in this and other threads makes me think that he/she is not a patient of prostate cancer.

I recall when staying in the hospital for surgery, one young doctor who would come to my room every day just for chatting. He was preparing his thesis and wanted to listen about my researches that could give him ideas on prostate cancer diagnosis, treatments, etc.
His questions were so minoucious that made me return a question and said “what are they teaching you at the medical school, dancing?” to which he surprized me replying; “We learn that too but most of the time we have to write reports”.

VG

P,
I do not see any stats of
P,

I do not see any stats of your biopsy posted here? Perhaps if you included your Gleason score and PSA folks could provide more insight for you.

Perineum said:

My data
VG, Thank you very much for the information and support. I really appreciate it.

My PC details:
63 years old.
PSA elevated from 4.5 in 2004 to 9 in 2011.
Biopsy positive on 1/12 tissue cores. GS=8(4+4).
Biopsy revision was positive 1/12 tissue cores.
GS=9(5+4). Signet ring cell carcinoma (very rare).
CT, bone scan - negative
Endorectal MRI - negative (tumor not recognized in prostate nor other places like lymph nodes).
Prostate volume = 90

still considering Surgery or Radiation+Hormons.
The thing is that my oncologists deny surgery although tumor not recognized in CT, bone scan, MRI - because of the GS=9. They say that GS=8 or above should not do surgery since Radiation and Hormones will also be needed, and the surgery will not help.

I will have to make a decision very soon
What's bothering me most is the GS=9.. Oncologists say that high GS usually comes with low PSA, and it usually not seen in CT, MRI etc... so They think it already out of the prostate...

I'm thinking about surgery, but really not sure... Tough decision.

Perineum; I wish you peace of mind
Perineum

It is a tough decision indeed.
Gleason 9 is aggressive and if the signet-ring adenocarcinoma is present you could add another percentage on the risk.
The most concern aspect of your diagnosis is that, the cancer volume is small (1 out of 12), all tests are negative to metastasis, but the cancer may be located in the capsule of the prostate gland.

What I know about Signet-ring cancers is that they are tumours with epithelial cells whose characteristics are to infiltrate the surrounding tissue. In colon cancer they form micro tumors which are difficult to detect. It is difficult to diagnose a case similar to yours if one considers both, a high tendency for aggressivity (difficult to treat) and a high tendency for invasive of surrounded tissue.

I am not a doctor and you shouldn’t take my words in your decision. I recommend you to listen to your doctors and consult with your family.
In my opinion, Surgery is possible in all types of Gleasons, however, in your case other concerns are in play.
Surgery will require a very sharp cut to separate the gland from other organs without leaving behind any microscopic bit of the capsule. This is tricky at the bladder sphincter which sharp cut has lots to do with incontinence.
I also believe in the possibility of existing occult surrounding areas in the outer shell that cannot be seen with the tests due to the enlargement of the prostate (90).
High dosage RT may have a better choice in this case but it would probably require administration of neoadjuvant HT to shrink the prostate firstly. The radiation field close to the outer shell should receive a high dosage (isodosage) therefore to minimize damage to close organs the prostate should be smaller in size.

Surgery and radiation may work in your case but the weight is more on the side of RT.

I would recommend you to discuss the matter with your wife and obtain her opinion.
Your choice is the best and there is no look back because you really have done your homework with so many researches and consultations. No one could do it better as you did.

I wish you peace of mind.
Good luck in the treatment.
VGama