Making Decisions Regarding Surgery

randy_in_indy said:

pwright613
Sorry to hear you had a bad experience with surgery. Many do not have a bad experience me for one. Most often it has a ton to do with the experience and skill of the surgeon....also at what stage you are with the desease. Can you give some further information...here's mine:

52 years old
PSA 9/09 7.25
PSA 10/09 6.125
Diagnosis confirmed Oct 27, 2009
8 Needle Biopsy = 5 clear , 3 postive
<20%, 10%, 10%
Gleason Score (3+3) 6 in all positive cores
11/09 Second Opinion on Biopsy slides from Dr. Koch
(4+3) = 7 5%
(3+4) = 7 10%
(3+4) = 7 10%
Endorectol MRI with Coil - Indicated the Palpal tumor was Organ confined
da Vinci 12/29/09 - Dr. Hollensbee & Scott
Post Surgery Pathology:
Prostate size 5 x 4 x 3.5 cm Weight: 27 g
Gleason: Changed to (3+4) = 7
Primary Pattern 3, 80%
Secondary Pattern 4, 18%
Tertiary Pattern 5, 2%
Tumor Quantitation:
Greatest Dimension, Largest tumor focus: 19 mm
Additional Dimension 18 x 15 mm
Location, largest tumor focus: Right posterior quadrant
Multifocality: Yes
Greatest dimension second largest focus 10 mm
Location: second largest focus: Left Posterior quadrant
Extraprostatic extension: Yes
If yes, focal or non-focal: Nonfocal
If yes: location(s) right and left antero-lateral
Seminal vesicle invasion: No
Cancer at surgical margin: No
If no, closest distance with location: less than 1 mm, right posterior quadrant
Apex involvement: No
Bladder involvement: NO
Lymph-vascular invasion: No
Perineural invasion: Yes
Lymph nodes: 9 from right pelvic 0/9 positive
Stage: pT3a, pNo, pMX
All nerves sparred - found two additional pudendal arteries

FIRST PSA TEST 2-11-10 <0.1 NONDETECTABLE
Virtually Pad free 2-20-10
Next PSA scheduled for 5-26 Results 6-2-10
Early on started on Viagra 100mg pills cut into 4ths so 25mg per day dose then a full 100mg on every 7th day.
Also bought pump and used sporadically to get blood flow to member. Within about three weeks or 5 weeks from surgery had usable erections. Currently only need ¼ pill to get usable .</p>

Kongo said:

Agree too, but...
Like Swingshiftworker, I have yet to decide on a course of treatment but have determined that surgery is not a course I am likely to puruse. For men with early stage cancer (Stage T1, PSA < 10, Gleason <7, and small involvement) the literature is pretty clear that there is no difference in outcome between radiation and surgery with respect to survival rates at 15 years. Active surveillance also has high survival rates only slightly behind surgery and radiation. I have consulted with five specialists in the month since my diagnosis and they have all reiterated these facts yet my urologist and one oncologist both recommended surgery because of its ability to eliminate cancer with a low chance of recurrence.

What the doctors I've consulted with are reluctant to talk about it unless pressed are the side effects of surgery. Almost 50% of men with surgery have some sort of incontinence issues, either outright loss of control or occasional stress incontinence. A high percentage have ED issues and many remain completely impotent, particularly if the cancer site is near the apex where most of the erectile nerves are. The measure of sexual potency following RP is "the ability to achieve an erection sufficient for penetration at least once a month." (Huh? Once a month?!!) As indicated by many, many posts in this forum many men cannot achieve an erection post surgery without pumps, injections, implants, or Viagra-like drugs. There are also issue with the atrophy of the penis, the apparent shrinkage of the penis due to the shortening of the urethea when the postrate is removed which tends to draw the penis up into the body. There's also the sterility issue, the dry orgasms, and the difference in orgasms without the prostate spasms that men without RP enjoy.

I know many, if not most, men who post here have had the DaVinci surgical procedure and seem happy with it yet a recent study of over 9000 men in the Medicare database indicates that robotic surgery leads to higher incidences of incontinence, ED, and nearly twice as many urinary and genital issues as open surgery. http://www.webmd.com/prostate-cancer/news/20091013/robot-prostate-surgery-more-ed-incontinence

One of my doctors told me that "this isn't going to kill you, but at your age you will eventually need to deal with it." At 59, she meant that given the histology of PCa and even the relatively long PSA doubling time and low PSA velocity that I have, at some point I will need treatment. I would rather have treatment while relatively young than later when some other unforseen issue may preclude an option.

I am considering Novalis Tx 5-day radiation treatment, Cyberknife (both are essentially the same procedure), and Proton therapy and will complete my consultations this week and then make a decision about what I think is best for me. Certainly, radiation has its downsides with respect to incontinence and ED but at much, much lower rates than surgery. The new technologies represented by Novalis and Cyberknife deliver the radiation at sub-millimeter accuracy which minimizes the potential damage to the colon, seminal vessels, bladder, and erectile nerves surrounding the prostate. But there is still risk.

I also investigated cryosurgery, hormone blockage, HIFU, tomotherapy, and homeopathic courses of therapy.

I would never question a man's decision in combating this disease as long as it was made deliberately, with his eyes wide open after doing the requisite research. We are all different and each of our cancer paths is unique. We all view the world from different perspectives. One may want the cancer out of them while another is comfortable with it inside knowing that it is slow growing and though 1 in 6 men will get PCa, only about 1 in 35 will actually die from it.

We don't get any Mulligan's on our decison so we need to be informed and knowledgable when we make it. But once we make our decision, those of us who participate in this forum owe it to each other to support our brothers in the course they have chosen.

Diagnosed March 23, 2010
Dx PSA: 4.3
Gleason: 3+3=6
Stage: T1c
1 of 12 biopsy cores positive with 15% involvement
Perineural invasion not seen
Prostate volume 47 ml
Bone scan, chest x-ray, and blood panel negative
DRE normal
PSA density: 0.092 ng/ml/cm3
PSA velocity: 0.23 ng/ml/yr
PSA doubling time: 9.28 years
No physical symptoms or issues with urinary or sexual function</p>

jminnj said:

Kongo said something in his
Kongo said something in his comments that I think we all need to keep in mind as we make our own posts:
"But once we make our decision, those of us who participate in this forum owe it to each other to support our brothers in the course they have chosen."

This is so true. Each of us has our own circumstances, our own thought processes. For example, I could have gone the Active Surveillance route, but I know the way I am. Waiting for those test results every few months would have been brutal for me. Even though my numbers were low (2.9, one core positive), my post op path report showed that 35% of my gland was cancerous. So for me surgery was the right course. I am 47, married for 20+ years we have two kids (19 and 16), no plans for any more. I have had some minor incontinence issues and some minor ED issues (meds work great). So I am pleased with my choice.

That may not be the right choice for everyone, we have so many factors to weigh. Age, general health, family, PSA level, biopsy results, what treatments are out there, what will give me the best chance for recovery with the least impact.

We are all brothers from a different mother as they say, united by something that I know each of would rather not be dealing with, but yet here we are.

Let us all continue to support one another, be there for one another, pray for one another. I thank God every day that I was able to find this group and talk to others who are experiencing these same problems.

God Bless and Good Luck to all of you,

Joe

Kongo said:

Agree too, but...
Like Swingshiftworker, I have yet to decide on a course of treatment but have determined that surgery is not a course I am likely to puruse. For men with early stage cancer (Stage T1, PSA < 10, Gleason <7, and small involvement) the literature is pretty clear that there is no difference in outcome between radiation and surgery with respect to survival rates at 15 years. Active surveillance also has high survival rates only slightly behind surgery and radiation. I have consulted with five specialists in the month since my diagnosis and they have all reiterated these facts yet my urologist and one oncologist both recommended surgery because of its ability to eliminate cancer with a low chance of recurrence.

What the doctors I've consulted with are reluctant to talk about it unless pressed are the side effects of surgery. Almost 50% of men with surgery have some sort of incontinence issues, either outright loss of control or occasional stress incontinence. A high percentage have ED issues and many remain completely impotent, particularly if the cancer site is near the apex where most of the erectile nerves are. The measure of sexual potency following RP is "the ability to achieve an erection sufficient for penetration at least once a month." (Huh? Once a month?!!) As indicated by many, many posts in this forum many men cannot achieve an erection post surgery without pumps, injections, implants, or Viagra-like drugs. There are also issue with the atrophy of the penis, the apparent shrinkage of the penis due to the shortening of the urethea when the postrate is removed which tends to draw the penis up into the body. There's also the sterility issue, the dry orgasms, and the difference in orgasms without the prostate spasms that men without RP enjoy.

I know many, if not most, men who post here have had the DaVinci surgical procedure and seem happy with it yet a recent study of over 9000 men in the Medicare database indicates that robotic surgery leads to higher incidences of incontinence, ED, and nearly twice as many urinary and genital issues as open surgery. http://www.webmd.com/prostate-cancer/news/20091013/robot-prostate-surgery-more-ed-incontinence

One of my doctors told me that "this isn't going to kill you, but at your age you will eventually need to deal with it." At 59, she meant that given the histology of PCa and even the relatively long PSA doubling time and low PSA velocity that I have, at some point I will need treatment. I would rather have treatment while relatively young than later when some other unforseen issue may preclude an option.

I am considering Novalis Tx 5-day radiation treatment, Cyberknife (both are essentially the same procedure), and Proton therapy and will complete my consultations this week and then make a decision about what I think is best for me. Certainly, radiation has its downsides with respect to incontinence and ED but at much, much lower rates than surgery. The new technologies represented by Novalis and Cyberknife deliver the radiation at sub-millimeter accuracy which minimizes the potential damage to the colon, seminal vessels, bladder, and erectile nerves surrounding the prostate. But there is still risk.

I also investigated cryosurgery, hormone blockage, HIFU, tomotherapy, and homeopathic courses of therapy.

I would never question a man's decision in combating this disease as long as it was made deliberately, with his eyes wide open after doing the requisite research. We are all different and each of our cancer paths is unique. We all view the world from different perspectives. One may want the cancer out of them while another is comfortable with it inside knowing that it is slow growing and though 1 in 6 men will get PCa, only about 1 in 35 will actually die from it.

We don't get any Mulligan's on our decison so we need to be informed and knowledgable when we make it. But once we make our decision, those of us who participate in this forum owe it to each other to support our brothers in the course they have chosen.

Diagnosed March 23, 2010
Dx PSA: 4.3
Gleason: 3+3=6
Stage: T1c
1 of 12 biopsy cores positive with 15% involvement
Perineural invasion not seen
Prostate volume 47 ml
Bone scan, chest x-ray, and blood panel negative
DRE normal
PSA density: 0.092 ng/ml/cm3
PSA velocity: 0.23 ng/ml/yr
PSA doubling time: 9.28 years
No physical symptoms or issues with urinary or sexual function</p>

Kongo said:

Exactly
I do believe based on the pathological evidence in my individual case that the cancer is confined to the prostate. With Gleason <7, PSA <10, and stage T1 the odds of it having moved beyond tghe prostate capusle are less than 1%. I am having a second opinion on the biopsy but I do realize that many cancers are upgraded after removal.

If Novalis or Cyberknife "failed" I suppose a backup plan would be cryo but I am pretty confident that in my case at least, the radiation will get it the first time around.</p>

Swingshiftworker said:

Kongo, FYI, I was advised by
Kongo, FYI, I was advised by my CK specialist that, if CK fails, he would recommend brachytherapy (BT) as opposed to Cyro because Cyro is certain to cause permanent ED.

BT has it's own problems, of course, but between BT and Cyro, it is the least detrimental alternative. If BT fails, Cyro is still possible, as is, salvage surgery (depending upon the amount of tissue damage caused by the radiation) and HIFU (if you can afford to pay for it yourself since it is not yet covered by any insurance carrier in the USA).

This all assumes the cancer is still confined to the prostate. If not, then chemo and EBRT would probably be mandated depending upon where and how far the cancer has advanced.

Let's hope we never have to address these alternatives!