Scheduled for Surgery - What can I expect?
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If I were you, I would be looking at all the options. Surgery is always serious. My surgery was done when I was 67. Currently, my PSA undetectable; continent; intimate with wife. Gleason 4+3 =7. But if you want to know what to expect. Good luck on your journey. My procedure is below:
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 radical prostatectomy. The abdomen was entered through a periumbilical incision and a double 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 base of 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 to the 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 capsular incision. 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 to approximate the urethra posteriorly. This was a single horizontal mattress. Continuous 3-0 Monocryl was then used employing a Quill suture to achieve a watertight anastomosis. The bladder neck was tapered with 2-0 Vicryl. The anastomosis 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 site was 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 andneedle counts were correct x 2.
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Hi ASAdvocate,
I have a 3+3 in three cores all in the same MRI targeted area. Two cores are 10% and one 20%. Single lesion less than .5cm. Currently confirming grade aggression with Prolaris. If Prolaris comes back suggesting no treatment I am going to try AS, at least for a while. I do find it hard to resist the instinct to treat but stories like yours help. Did you struggle with the psychology of it at first? I am 67 and wondering if I can run the clock out?
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Hi NeilM
The three cores in the MRI targeted area are really considered one core from a biopsy standpoint, since they are all grouped to sample that one lesion, so you have one core positive but not too much, and the rest negative. At that "low" of an indication there's not a lot to suggest that much worse cancer is lurking in the prostate undetected.
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i started researching when my biopsy was scheduled. On the various PCa support websites, I read many horror stories of men suffering with the side effects of treatment. So, psychologically I had no problems with going on AS.
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Hi, Thanks for your reply. I have cancelled my surgery for the moment. I am going to ask for some additional tests. 3T MRI or guided biopsy to see if there is anything else there. If I opt for surgery, I would rather know if there is anything else going in , than having found out after I go through with it.
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Hi Neilm,
Yes, I am struggling a bit with the psychology piece of AS, but initial panic led me to schedule surgery. Now that I have had time to learn more, I will make a decision, but will be asking for more tests so I have more information and hopefully make the best decision on next steps, whether continue AS, Surgery or some other form of treatment.
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Hi Carluvrj,
We are in similar positions, luckily I am in AS category of the disease with only grade 6 ( like you ). I am going to take advantage of my time. I have planted the notion in my mind that by all medical standards AS is appropriate and I have plenty of time ( certainly months maybe years ) to research what my next steps would be if and when required. I am older than you 67 so I am closer to radiation than ralp. One area I am exploring are focal ablative therapies ( ie HIFU ) as I have a single lesion. My sense is that ablation of the tumor is not as effective as radiation but there are positives. 1 ) minimal side effects 2) Easy treatment 3) Medicare is improving reimbursement Jan 1 to providers ( other insurance may follow ) 4) does not preclude ralp or radiation in the future. I may find something I don't like with this treatment but if it has a 70% chance of success and precludes no future curative options, maybe it makes sense. Data only goes out 8-10 years but it could be a final treatment. Also Proton therapy , Cyberknife, all of the things discussed here warrant exploration. Ablative therapies from my reading are likely to have a bigger role in the future, some are not ready for prime time but I do think about trading a lower probability of success for additional years to push out the decision. Lots to think about, but if you are AS there's time for homework!
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I am a healthy active 74 year old. In January of this year my PSA spiked to 6.77. Gleason Score of 7. I was re-tested 3 months later: 4.77. What followed next: CT Scan, MRI @ Cleveland Clinic, 14 core biopsy. (one of which was Grade 3 - intermediate aggressive. I clearly wanted a robotic prostatectomy, which the Urologist concurred with. I had my surgery 13 days ago and it was a 4 hour surgery due to the size of the tumor. The great news is that I met with oncology yesterday to review the pathology report.....NO cancer!! It was completely contained within the prostate. Recovery has been steady and strong! My pain level was never higher that a "2", though I have some discomfort. Incontinence is surprisingly minimal. The worst part was the catheter, especially thru days 7-4. I became totally tired of switching from the night bag to the day bag, but ya deal with it. Monitoring will be: PSA every 3 months (first year), every 6 months (2nd year), then once a year (3rd year). First two weeks: was 30 minutes a day, 2nd two weeks 90 minutes a day, 3rd 2 weeks two hours a day. Kegel excises for strengthening the pelvic floor muscles is very important and should begin prior to surgery. There's a lot on YouTube.
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Sorry for any confusion:
- I had an aggressive grade 3 tumor, in fact the surgery took 4 hours because the tumor was larger than the Urologist thought it would be. Fortunately the cancer was still contained with the prostate which was removed.
- "No Cancer" refers that the pathology report came back saying "No Cancer" was detected in surrounding sample tissue. The cancer had been removed and no further treatment would be needed.
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Hi Neilm,
I have had some further tests. 3TMRI and am scheduled for a CT scan. I also went to a cancer center for a consultation. MRI still showed Pyriads (sp) 2, that no significant cancer exists. Will see what CT scan says and probably will have one more biopsy. Now I am leaning more towards active surveillance depending on further tests. My PSA has gone down to a 5.33, not sure why. I have time, so not rushing.
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Carl,
Your choice makes a lot of sense to me. Gleason 6 IMO is very low risk, the greatest risk is that something more aggressive is missed but it seems you are working to confirm the Gleason 6 and extent of the cancer. I had an MRI, a targeted biopsy, a second opinion on the biopsy pathology, and finally a genomic test. All pointed to AS for me and it sounds like you are headed down that path as well. I will do a second biopsy a year from my first one ( I will ask for an MRI as well ) to be certain nothing is spreading. Beyond that perhaps two or three years for additional biopsy and MRI. One big advantage we have on this path is the rapid advancement in treatment, if we need treatment three years down the road there might be some new options for us. I was happy to watch you progress through the options and settle on a good path forward. Surgery is a very big step that you were speaking about early on and IMO an over reaction to gleason 6. I had the same initial thoughts, best advise in this business seems to be take a breath and do some reading!
Best of Luck Neil
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