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Is robot prostate surgery best for quality of life?

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Joined: Jan 2010

For the newbie’s here there is a lot of information to digest to make an informative decision... I would suggest that one of your sources of information would be to get on the Prostate Cancer Foundation ( www.pcf.org) email list for new stuff that is coming out all of the time plus review all of the good information already there...Here is the article that is in referenced to the Subject line above....btw I hade the old fashion open surgery 8 weeks ago…Best to all and remember your decision is always the best decision for you …

Study looks at long-term quality of life after various treatments
By Amy Norton
Monday, April 5 (Reuters Health) - Despite the popularity of robot-assisted procedures for prostate cancer, when it comes to men's long-term quality of life, patients with earlier stage cancers generally fare better with non-surgical approaches than with surgery, according to a new study.

Researchers say the findings, reported in the Journal of Urology, offer men more information to consider when deciding on treatment.

Men with earlier stage prostate cancer have a number of treatment options, from "watchful waiting" to radiation to surgical removal of the prostate gland.

When it comes to surgery, robot-assisted laparoscopic surgery -- where the surgeon sits at a console, operating robotic "arms" that extract the prostate gland through small cuts in the abdomen -- has become the dominant approach in the U.S.

After hospitals invest the roughly $1.5 million for the machines, plus the costs of surgeon training and annual service contracts, they often aggressively market robotic surgery. That may include claims that it carries lower risks of long-term incontinence and impotence than traditional open surgery. Actual study data to prove that, however, are lacking.

In the new study, researchers at the Sentara Health System/Eastern Virginia Medical School in Norfolk followed 785 men who received one of four types of treatment for localized prostate cancer (cancer confined to prostate gland) at their center between 2000 and 2008.

Overall, 135 men underwent traditional "open" surgery to remove the prostate gland, while 447 had robotic surgery. Another 122 patients had radioactive "seeds" implanted in the prostate gland to kill the cancer cells. The remaining 81 patients had cryotherapy, where the doctor uses thin metal rods inserted through the perineum to freeze prostate gland tissue and kill the resident cancer cells.

In general, the researchers found, men treated with radioactive seeds tended to fare best in terms of quality of life, based on standardized questionnaires they completed before treatment and periodically for three years afterward.

Patients who had received either radioactive seeds or cryotherapy had higher average scores when it came to urinary function, versus men who had either type of surgery. And together, men who had radioactive seed implants or cryotherapy were three times as likely as surgery patients to return to at least 90 percent of their pre-treatment score for urinary function.

When it came to sexual function, radioactive seed patients reported a greater quality of life than those who had received any of the other three treatments. Three years after treatment, radioactive seed patients' scores for sexual function and "bother" -- the degree to which they thought their sexual side effects were a problem -- were higher than they were before treatment.

In contrast, scores remained below pre-treatment levels for men in each of the other treatment groups. Cryotherapy patients had the poorest scores long term.

However, there were no significant differences in quality of life between men who had undergone open surgery and those who'd had robot-assisted surgery.

"I think data like these give men more information to use in their decision-making," Dr. Michael D. Fabrizio, one of the researchers on the study, said in an interview.

As for the lack of difference between open and robotic surgery, Fabrizio said that while there are advantages to the robot -- including far less blood loss during surgery and shorter hospital stays -- that may not necessarily translate into better long-term quality of life.

He noted that there is a "big push" to promote robotic surgery, and many patients "assume it's the way to go."

But the current findings, the researchers write in their report, "serve as a reminder that popular enthusiasm for robotic prostatectomy merits temperance."

Nor do the findings come down in favor of any single therapy, however. "This study doesn't tell patients what's right for everyone," said lead researcher Dr. John B. Malcolm, and men still have to talk with their doctors about which treatment might be best for them.

The study did not look at the four treatments' effectiveness against the cancer, Malcolm told Reuters Health, but other research has suggested that surgery is more effective than radioactive seeds.

The study had a number of limitations as well, including a lack of information on any other patient health problems that might have been affecting their sexual or urinary function.

It was also not designed as a randomized, controlled clinical trial -- where patients are randomly assigned to receive a particular treatment, notes Dr. Stephan A. Boorjian, of Fox Chase Cancer Center in Philadelphia, in a commentary published with the study. Such trials are considered the gold standard for assessing a given treatment's outcomes.

A second commentary says that the findings point to a broader issue: the general lack of randomized clinical trials comparing prostate cancer treatments with each other -- in terms of cancer control or quality of life.

"If the standard for evaluating all treatments for prostate cancer were raised," writes Dr. Yair Lotan, of the University of Texas Southwestern Medical Center in Dallas, "then patients and physicians would be able to use more objective criteria in determining the optimal treatment."

Back to Treatment and Outcomes

SOURCE: Journal of Urology, May 2010.

Copyright © 2010 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.

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Wish they would post the actual stage of each patient so a true comparison can be made.

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Joined: Apr 2010

Unless I've missed something here, keep in mind that this thread/post cites info related to "low risk" PCa. The ACS (as well as other reputable sources) has info on defining low risk to high risk PCa, and how this translates into clinical staging for PCa. Not second guessing, but for what it's worth, perhaps a better title for this thread might be "Is Robot surgery best for your clincial stage of PCa?" The importance of accurante clinical staging cannot be stressed enough, along with the person's other health issues, tx side effects, and qualilty of life, when considering any of the many tx decisions. As pjd and I progress on our journey & war on this Beast, I hope to share more about just how important accurate clinical staging & testing (after the biopsy) was for pjd prior to arriving at a tx decision (which btw, has not been made yet).

Kongo's picture
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Robot Prostate Surgery: More ED, Incontinence
Robotic/Laparoscopic Prostatectomy Still on Learning Curve
By Daniel J. DeNoon
WebMD Health NewsReviewed by Louise Chang, MDOct. 13, 2009 - Minimally invasive prostate surgery -- often performed using a high-tech robot -- carries a higher risk of incontinence and erectile dysfunction than does open surgery.

However, the newer technique cuts patients' hospital stays, requires far fewer blood transfusions, and carries less than half the risk of leaving behind scar tissue necessitating a second surgery.

The findings come from an analysis of outcomes for men with prostate cancer who chose treatment with radical prostatectomy -- surgery to remove the prostate. There are two basic kinds of prostatectomy: the tried-and-true open surgery improved over 20 years or minimally invasive surgery, a much newer technique.

Today, as many as 70% of minimally invasive prostatectomies are performed using a surgeon-controlled robot, Brigham and Women's Hospital urologist Jim C. Hu, MD, MPH, said at a news conference. This appears to be driven by direct-to-consumer marketing by hospitals that have purchased the robots, which cost up to $2 million.

But does minimally invasive prostatectomy really work as well as open surgery? To find out, Hu and colleagues analyzed prostate surgery outcomes for nearly 9,000 men whose records are in the Medicare-linked SEER database.

Importantly, open and minimally invasive surgery (both manual and robotic) were equally excellent at ridding men of prostate cancer.

But there were big differences between the two surgical choices in other outcomes. Minimally invasive surgery had several important advantages over open surgery:

One day shorter hospital stay (two days vs. three days).
Far less need for blood transfusion.
Much less likely to leave scar tissue (anastomotic stricture), which often requires surgical correction.
Fewer surgical complications.
But minimally invasive surgery also had several important drawbacks compared with open surgery:

18 months after surgery, a higher rate of incontinence.
18 months after surgery, a higher rate of erectile dysfunction.
Nearly twice as many urinary and genital complications.
"Outcomes of minimally invasive prostatectomy are not uniformly superior to the open approach," Hu said.

He said the technique has been oversold to patients. But he noted that doctors have had decades to learn the best techniques for open prostate surgery.

"Dissemination of surgical technique takes years to unfold," Hu said. "Our study needs to be repeated in the future when teaching of proper minimally invasive technique has had time to diffuse."

The Hu study appears in the Oct. 14 issue of The Journal of the American Medical Association.

DanKCMO's picture
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"Outcomes of minimally invasive prostatectomy are not uniformly superior to the open approach," Hu said.

It would be helpful if they could breakdown the complications of the robotic surgery (incidences of incontinence, erectile dysfunction, etc.) by surgeon experience, since this is a relatively new technique.

In other words, they lumped the surgeons who have done 250 robotic procedures with the ones who have done 2500 procedures to reach their general conclusion.

Also, I would like to know how the medicare-SEER database info is gathered before I would base a treatment decision on this info. I am not disputing the info, just that if it is medicare data, I think the data may be based on submitted claims and not in depth interview of the patients. Also, one doctor's or patients diagnosis of what incontinence is can vary from somebody elses experience. I wouldn't call wearing a pad because once a week when I laugh hard and pee a little bit incontinence, but somebody else might.

The working definition of erectile dysfuntion is even more vague. I would trust the data more on the erectile dysfuntion if it said it was based on Shim scores.


Kongo's picture
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Dan, you make several good points. My personal belief is that the lumping together of relatively inexperienced robotic surgeons with those who have completed hundreds of procedures is a likely cause of this statistic and that over time, I would be very surprised if these numbers didn't come down. It reinforces what many have said in this forum that if you're going to choose robotic surgery, make sure you go with the doctor with the most experience.

Since this data came from the Medicare database I am assuming that these men are over 65 who could well have urinary and ED issues apart from those caused by the procedure, particularly in older patients.

As I understand the standard the use for ED (not the SHIM questionaire) is that normal function is one who could achieve an erection sufficient for penetration at least once a month. Frankly, I think that is a pretty low standard.

mrshisname's picture
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As Kongo said, they are lumping together experienced versus inexperienced surgeons. Both Randy and my husband had very, very experienced DaVinci surgeons; they have done around 1300 - 1500 each. Dr Scott said that with their experience, outcomes also appear to be based on two factors:
1. age of the person at surgery (i.e. the younger man does better)
2. pre-surgical erectile function (as a predictor of post-surgical function)

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Just copied and pasted the subject as presented on the Prostate Cancer Foundation site

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and please don't take it personally. However, this just goes to show how some articles/studies sometimes need to have further clarity pointed out so that the info can be put in the proper context for an overall better understanding of the study results, as well as how it might be interpreted by the reader in considering his tx choices. Given an experienced and skilled doctor, most studies agree that many low risk PCa patients (Clinical T1, T2 staging) will have a favorable long range outcome of no recurrence, no matter what the tx choice. Tx side effects, quality of life, health prior to tx, etc, are of course other issues that must be considered. Unfortunately, not much out there in long range studies on tx choices/outcomes for Clinical T3.

randy_in_indy's picture
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The only problem with many of these studies are that they are particularly general for the results. What I mean by that is not specific to a specific surgeon, radiologist usually and that can mean night and day of the differences and effects of side affects following the procedure. You went with the person who has purportedly and probably has done the most opens in the WORLD in dr. Cantelona in Chicago. So I would expect his results to be better probably in all aspects than most any other result from any study... Sonny used Mani Manning, Larry used Joe Smith, some have used Atwari in NY - mispelled his name probably....all of which I mentioned probably have very different results currently today than the 1, 2 or older year studies now coming out...so all the studies do for me is show a topline generality to be taken with a grain of salt and therefore, I do not put much weight in picking one treatment over the other from those studies. It really always boils down to a more individual perception of the research/reading and meetings you have with all the different people you discuss plus your own bias of what you think is really important to yourself and your own life in trying to make this decision. And really the last statement in your post really says it all:

"If the standard for evaluating all treatments for prostate cancer were raised," writes Dr. Yair Lotan, of the University of Texas Southwestern Medical Center in Dallas, "then patients and physicians would be able to use more objective criteria in determining the optimal treatment."

Thanks for the good discussion and information!

Randy in indy

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Good read and you got the point…and as most of us here post surgery no regrets with our choices… so the real message here is to select someone with great experience in the process you believe in…. Have a great weekend…My mother is here for a week and she has been a cancer survivor gong on 26 years and has lived every day….lots of wisdom to tap into this weekend

Hoosierdaddy's picture
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It is a reality that most of the doctors you will talk to have a substantial financial stake in your choosing one option over another. Just be aware of that.

DanKCMO's picture
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"It is a reality that most of the doctors you will talk to have a substantial financial stake in your choosing one option over another. Just be aware of that."

I hear ya! I was fortunate enough to have my diagnosing urologist (and open surgeon), really do no hard sell at all and gave me the name of the two robotic surgeons in town he thought were the best.

When I first was doing internet searches I was surprised to find what first appeared to be educational sites, were really run by robotic surgeons that biased their info towards their own procedure, but the info was presented as objective.


RRMCJIM's picture
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I did not have that occur in my case. I had my uro set me up with appt with the various specialist..And yes, each one talked about success in their field, pros and cons, then I talked further with my uro.....he didn't "push" me in any direction...no vested interest...this was at Kaiser. When I decided on my surgery with divinci, he then told me, that had it been him with this cancer, he would pick the same... at a young age, he is 45, getting it remove was the way he would know it was gone.. too many years yet to live for uncertainty...
Jim ( Big Ugly Biker)

griff 1
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There are a lot more studies available now then when I made my decision, and they all get me to second guessing my decison. The one that got my mind going in this one was, "The study did not look at the four treatments' effectiveness against the cancer, Malcolm told Reuters Health, but other research has suggested that surgery is more effective than radioactive seeds."

If research suggests surgery is more effective than radioactive seeds, and presumably a guys number one concern is beating the beast, why chose radioactive seeds?

I'm guessing for some guys Quality of Life concerns (ED) really are the number one concern.

I think a guy really has to knowingly set a priority for these concerns and then chose a treatment ... or you'll never know if you picked the right treatment.

Kongo's picture
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I would have to say that for me, my overall quality of life trumps the quantity of life. Once I set that priority it became a matter of balancing potential side effects for a treatment option. I am unaware of studies that indicate surgery has a better overall success rate than radiation for Stage T1 and T2 patients. An interesting facet of the surgery studies is that many men find their stage upgraded after surgery and frequently require additional radiation treatment if their PSAs begin to rise again, thus it seems to me that the numbers are inherently skewed toward surgery because in reality, many of these patients are lumped together in many studies and are actually receiving surgery PLUS radiation while the radiation cohort only gets radiation.

If all the studies actually compared apples to apples it would make our decisions so much easier. I understand why that can't be done, but its still frustrating.

RRMCJIM's picture
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I understand your frustration, as I underwent the same turmoil in deciding treatment. There are studies skewed towards any option you pick. For me it was the fact that I was only 54, I didn't want to only consider 10 more years of Quality Life...I am in excellent physical shape, and believe I have many more than that ( don't we all)....lol...My family members on both sides, lived well into their 80's and some ...90's...I have alot more living to do,plus wanting to see the grandkids grow up, and don't forget...#1....TRAVEL....wife and I love to travel anywhere and everywhere...and have the means to do it, thankfully....so to even consider the selfish ( my opinion and my feeling) act of worrying about keeping the cancer inside of me for the sake of a hard-on... unmentionable.... I will pray my ED continues to improve, it is usuable, but if not...I can still remember when... and can look forward to many more years with the family....because I KNOW they got it all.....I had no positive margins..we KNOW this...would rad, or proton, or CK or or or...got it all?? MAybe...but what IF...it only takes one cell...one viable cell...and it starts all over again...
Just my humble opinion.... only looking forward....not back....as was stated...No do overs....it was right for Me....
Thanks for letting me ramble-on....wasn't there a song by that name...sorry..
Jim ( Big Ugly Biker )

randy_in_indy's picture
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My priority at age 52 was quantity of life over quality of life...not to say I didn't yearn for both just about equally...but forcing to make a decision I wanted to have at least 30 more years of life left...and if I had quality of life issues I would deal with them as they happened. I am a very adaptable person by nature and able to be planted in a very good or bad situation and adapt to actually find joy and good things no matter the circumstances...so...knowing that about myself...my first concern was to do what ever I had to in order to remove the beast COMPLETELY!. Hopefully I have achieved that. I consider myself a very lucky person and have practically all my life. I never had any real traumatic situations in my entire life except for my father dieing at age 71 of complications due to Alzhiemers most likely induced by a head injury in the Korean war. Other than that all my grandparents have lived happy and long lives ranging from 84 to 98. With that family history God willing I expect to be here for at least another 30 to 40 years. In order to do that I need to be cancer free.


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Quantity over quality…

Like Randy quantity of life at my stage of life is more important that quality…and at my age quality can real be argued. If I were 70 I would have another definition of “quality” than at my current age of 55. For example chances of me planning to climb Half Dome at 70 is a little more out of reach for the typically 70 year old but in my shape and age today seems reasonable…. So this feat at 70 would not be a quality issue or discussion but is for me at 55 (and btw 8 weeks 3 days from surgery I am ready)..

Granted because of surgery I no longer ejaculate but for me my orgasms are more intense than they were post surgery (and I had no issues prior to surgery)…I guess I could dwell on the lack of fluids and consider this a “quality” issue but I do not see it as…Something changed oh well…

Ok so for me 8 weeks 3 days out form surgery what are my “quality” issues-

1.I was dry the day the cath came out on day 12 (I have a few drops sometimes at the end of my stream that I pad with a tissue but that will correct itself and it not it’s a couple of drops I pad with a tissue)
2.Like above it is true that I no longer ejaculate fluid at my orgasm and right now I need help to get an erection (injections and Cialis) but I also have almost hour long erections (I can never remember have erections this long…can you)
3.I am in great physically shape
4.I have improved my diet
5.I have changed my priorities what is important to me
6. I am more connected to my family
7. etc., etc., etc.,

Hey I really do not see any quality of life issues but I see a lot of positive changes in my life… Is the glass half full or half empty and yes I know I am blessed with my outcome so far…

The real negative (at least for me) that I see is wondering at times when or IF my PSA will rise with my pathology outcome and other treatments and challenges wait me down the road… From my belief only G*d knows….and worrying about it will not prevent it…I hope it never comes back and hope and belief is a good thing with cancer…

I guess my point is that we are all the masters of thought process and what we choose to believe and I believe that surgery was the best for me and my quality of life was really improved and this process also gave me the best changes of quantity of life as well at my age…thing about it..

G*d bless, best to all and live life

griff 1
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good post man, i am new here and have surgery sceduled on the 23rd of june. too much stuff to take in and read. any way now i am wondering what way to go da vinci way or open surgery. thanks griff 1

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Griff1...All personal choices and what you believe work best for you but I elected to do the open procedure for reasons and my reasons only…. My only advise is that you have got to research, research, research and then pray or meditate on the subject and then make your decision and never second guess yourself as you will never know the “what if” outcomes from other procedures …Just believe you did the best for you…Enjoy the journey and learn to “dance in the rain”

Welcome to the reluctant brotherhood

Skid Row Tom's picture
Skid Row Tom
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bdhilton gave an excellent response. I also had open surgery. As far as treatment choices -- it's like asking which is the best motor oil. No consensus, only personal and passionate opinions. You'll find successful and not-so-successful outcomes with any approach to PC -- daVinci, open surgery, seeds, hormones, etc. The decision is agonizing. You're looking for the "right" answer -- the "definitive" answer. But there isn't one (damn it!). Like dbh said, do your homework, make a decision, don't second guess, and don't look back.

Your among friends here. Good luck.

Posts: 169
Joined: Dec 2009

Each of us has just one primary treatment experience, and we all hope our choice was the best. I'm a DaVinci person - not because I chose that over open, but because I chose a surgeon I felt good with, and he only does DaVinci. His partners include surgery-only guys, so it was easily available.

just be sure you understand the incontinence and ED impacts, and know the experience of your surgeon. Don't let them gloss it over.

After that, we learn, we choose, and hope we are right. No second-guessing.

Kongo's picture
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Griff, I understand your frustration with all the information but frankly I think there's not enough information. Make sure you really know the pros and cons of your treatment choice. Many of the posts on this forum are from men who have difficulties after surgery (pads, erection aids, pain, etc.) but I suspect that most of the ones without complications move on. There are downsides with any treatment. One recent study I read indicated that DaVinci actually had more quality of life issues overall than open surgery but I'm sure most of the DaVinci graduates here would say that is a function of physician experience with the system. Make sure that if you choose DaVinci that you're not providing your prostate as a training experience for the surgeon. Go with someone who has done hundreds of them.

My urologist (a surgeon) recommended surgery and he only does open surgery saying that you pay a surgeon for his skill with his hands. He felt that the rapid increase in DaVinci machines is leaving too many surgeons with too little experience conducting the operations. A skilled DaVinci surgeon would probably say that their ability leads to further surgical complications than open surgery. To me it seemed like the difference between one six inch incision or six one inch incisions.

I elected to go another route and am about to begin treatment with Cyberknife radiation which is an appropriate treatment for my condition. Stage T1c, PSA now at 2.8, 1 of 12 cores positive with 15% involvement. Normal DRE and no other symptoms.

Depending on your pathology, radiation may also me an option.

If you do go the surgical route, be sure to ask about incontinence, ED, penile atrophy, pain, and so forth. Same with radiation.

Best of luck but I would urge you to get more information not less.

randy_in_indy's picture
Posts: 495
Joined: Oct 2009

If you go the Da Vinci route (I did) I would say pick a surgeon that has done over 1,000 procedures...otherwise you are taking a chance at what Kongo said in becoming a training patient for the surgeon.

There are many surgeons that have done over 1,000. Here in the small midwestern town of Indianapolis I know of three surgeons that have all done over 1,000 procedures in Scott, Hollensbe and Koch.

Find experience, grill them with questions about their success rates, and then go with your gut....that goes for any procedure you are looking into. This beast is a crap shoot no matter what treatment you pick...it's possible to lift up it's ugly head years down the road.

There are some very wise people on this board who have done extensive research into the treatments. As Kongo said many who have had successful outcomes might have moved on but some don't - I am prime example of one who has not moved on..and still posts. Here's my path.

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 performed 12/29/09 - Dr. Hollensbee & Scott
Sling installed at time of Da Vinci – not sure what name of it is but not the 800 that is causing all the problems. Attached to Coopers Ligament.

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


Virtually Pad free 2-20-10


Notes on Recovery: Was at my desk working (from home office – sales) 6 days following my surgery. No pain to speak of (very lucky as many have some pain) I think because I took the Tramadol they gave religiously and found it to be the best drug in the world. BM’s where the trickiest part and most uncomfortable in the early stages but improved with time – follow the diet they give you!...I strayed off and the next BM helped to get me back on track – I like food very hot and spicy - don’t recommend that for at least a month following surgery. Cream soups, mushroom, celery, and chicken worked great the first week following surgery. Mashed Potatoes…Ah the first time following surgery it was heaven!...the first really solid food I ate…..you will learn to appreciate food all over again as you add back your favorites following surgery when the time is right. Take all the help from everyone around you…it might be a while you get that opportunity again to be waited on hand and foot. Liquids are a concern but some affect people differently it seems reading through the discussion board…I found anything carbonated would cause much leaking…alcohol was not good either…but I justified doing it thinking It’s my training method to work on my bladder control!...lol I love homebrewed beers too much! And am an admitted hop head.

ED path:
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 (cannot remember but probably posted on CSN somewhere) had usable erections.

Currently only need ¼ pill to get usable . Day 150 am starting to get semi hard without any drug.
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Randy in Indy

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