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Radical Prostatectomy Question

JFG2019
Posts: 13
Joined: Aug 2019

I met with a surgeon on Friday.  He is one of the most experienced and top surgeons in the mid atlantic area (over robotic 2,700 RPs).  I have a gleason score 9 lesion and many other lesions (volume is high), especially in lower right periphery.  If he performed the RP, he would have to "go wide" in his words, meaning remove the prostate and additional tissue outside the capsule.  He said this would mean the nerve that controls erections on the right side underneath the prostate would be cut or otherwise cease to function.  He would intentionally not spare this nerve.  Is this common with aggressive and high volume lesions such as mine?  I am confused because I thought that the objective of nerve sparing surgery is to spare the two nerves bundles (right and left sides underneath) that control erections.  He did not mention the nerve that controls urinary continence but I am wondering about its location and whether it could be touched or severed by the "go wide" approach.  

Steve1961
Posts: 250
Joined: Dec 2017

ask your surgeon he is the expert ...not the people here .

icemantoo's picture
icemantoo
Posts: 3227
Joined: Jan 2010

I am waitng for a date from Dr. Patel in Orlando who has done oner 10.000 RPs. I am 76 and have a Gleeson 5 plus 3. I had to sign an ackbowledgfmant that I will no longer be able to fathwr children. So far my 2 chuldren in their 50's and wife who will be 75 in 3 weeks are taking thhis as well as can be expected.

 

 

 

 

icemantoo

JFG2019
Posts: 13
Joined: Aug 2019

Did Patel say whether in your case he would need to cut one or both of the nerve bundles that control erections?

lighterwood67's picture
lighterwood67
Posts: 218
Joined: Feb 2018

I am 68 and my wife is 67.  We two came to the conclusion that our baby making years are in the past and our only child (48) agreed.  Good luck on your journey.

lighterwood67's picture
lighterwood67
Posts: 218
Joined: Feb 2018

Is your surgeon telling you your cancer has not escaped the prostate gland?  If the cancer has escaped the prostate gland, it is my understanding there is no need to remove the gland.  The treatment option is nuke (radiation).  In my opinion, if your primary concern is the loss of erectile function, I would say nuke it.  That is not saying that you will not experience ED.  Please understand that I am not a doctor.  Good luck on your journey.

JFG2019
Posts: 13
Joined: Aug 2019

I understand and accept that removing the prostate means loss of fertility.   I am just wondering if it is common or most of the time that nerve sparing robotic surgery results in loss of the left and/or right nerve bundle under the prostate that controls erections.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

JFG,

'Go wide' sounds more like a football order to a receiver than medical terminology.  Undoubtedly it is lay parlance for some medical lingo that most are unfamiliar with.  IF I had RP, I would indeed go-wide in your circumstances.  While likely metastatic cases are usually recommended to R.T., one of the advanntages of RP is that when the gland is analyzed by pathology, they will very likely know if you need follow-on IMRT (radiation) for safety.

I have not seen this addressed in much detail here over the years, but high-dose RT essentially turns the gland into a charcoal briquette, and I do not see how a piece of charcoal would be more potent,sexually, than the removed gland.  I was fortunate to have full nerve sparing in my DaVinci, and have full potency today.  I know I was fortunate in this, and that not every man is.  

Regardless, so far your case sounds very managable with reason to hope for cure,

max

Georges Calvez
Posts: 304
Joined: Sep 2018

Hi there,

Yes that is normal, I had quite an advanced tumour and my prostatectomy was non nerve sparing, the surgeon fished out the prostate and all the associated tissue.
I have no problems with urinary continence as the bladder neck, etc was spared but obviously I can no longer have an erection.
You may or may not have urinary problems afterwards but I doubt that you will be able to get an erection.
You may also be looking at post RP radiation plus six months or more of hormone therapy if it turns out that some cancer cells have escaped and are hiding in the bed of the prostate, etc.

Best wishes,

Georges

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

JFG,

Welcome to the board. I think you doing well in investigating the details and consequences involving prostatectomies. You should only chose a treatment when totally confident that it will work as you would want or in your favor. This decision process is not easy because of the various modalities and the risks they involve. Survivors here can help you in understanding the facts but the surgeon that created your doubts is the best person to consult on the matter, as suggested by Steve above.

In any case, the decision on a treatment should have the ultimate goal of cure. It is not like using a bandaid to seal the wound. For such a reason one needs to know his clinical stage (the best one can get it), check what is most appropriate to his condition and then decide on the one that gives him the comfort to go ahead. The choice of a good physician to perform the therapy comes in the end of the above process. The outcome does not depend only on the skills of the doctor but on the capabilities of the treatment. And I question; is prostatectomy your best choice?

Regarding the nerve bundle serving the prostate and urinary sphincters, they interweave with each other. However, only the portions dissected will affect the tissues/muscles where they run. The local nerve network is not affected and, latter, the body’s natural system will try to repair the damage or substitute the signaling pathways via a separate bundle but it never gets to the same status. The finishing job depends on how much cutting is involved.

Accordingly, you comment above that the doctor wants to go wide; it means that he will not spare anything. Typically, a wide surgery includes dissecting the whole gland (+SV), a portion of the urethra, the nerves serving these tissues (the urethra sphincter will be affected but the bladder sphincter will be spared) and the localized lymph nodes. In the end they will vacuum the perineum cavity to avoid leaving behind cancerous cells. Surgeries done using robot have limits on the reach of the robot arms. Far places are not covered.

I wonder why the surgeon wants to go wide. Can you provide us with more details on your diagnosis?
Have you the results of image studies? What is your age? Did you get second opinions from other specialists?

Gleason 9 signifies high risk for existing metastases (it includes: extraprostatic extensions plus positive seminal vesicles plus lymph nodes and maybe bone involvement). If the case involves a biopsy with many positive cores then it is classified as voluminous in which cases lead doctors to recommend a combination of treatments with intent at cure; Such as; surgery plus radiotherapy or radiation plus hormonal treatment, etc. More therapies mean more risks and more side effects.
Typically surgery is chosen when the cancer is contained (whole within the gland). Risky cases for metastases are usually directed to radiotherapy. Nerve-sparing prostatectomies are only recommended for low risk cases.All cases require the patient to be fit so that age and other health issues matter in the choice.

Here are links with practical information;

https://www.healthline.com/human-body-maps/prostatic-plexus#1

https://www.cancerresearchuk.org/about-cancer/prostate-cancer/treatment/surgery/surgery-remove-your-prostate-gland

https://www.cancer.org/cancer/prostate-cancer/treating.html

 

 Best wishes and luck in your journey.

VGama

     

 

JFG2019
Posts: 13
Joined: Aug 2019

Thanks much.

J

Steve1961
Posts: 250
Joined: Dec 2017

but really do you think this man needs to hear all that reallyyyyyyy.like he isn’t worried enough .he most likely will have surgery and now he will be thinking about everything you told him .that dr is an expert ..I would rather lose an erection to have a chance at a cure . surgery  beck up radiation and hormone to be cured ..then do it ..you don’t know if radiation alone will work it’s all a guessing game ..you take it out u know for sure ....that alone is a great feeling ..that  I don’t have 

lighterwood67's picture
lighterwood67
Posts: 218
Joined: Feb 2018

Yes, folks need to know.  Just like you so vividly describe your treatment side effects.  I remember telling you about my journey and exchanging CSN-mail.  At the time, you wanted to know as much as possible from folks who have experienced radiation and surgery as treatments for PC.  Most of the folks on this site use it to tell their stories and so they do.  That is what this forum is about. Front line experiences with their prostate cancer treatments.  With that said, stay positive my friend with a common enemy.  My gut feeling is that you have better days coming.

Georges Calvez
Posts: 304
Joined: Sep 2018

Hi all,

 

That is all.
We are saying that the gas is a bummer and it can hurt like hell but it will go away, the catheter is not a good experience but it will come out after a week or two, abdominal pains can get to you but mine were all gone after a few weeks.
But most patients come out of a RP cancer free, which has to be a winner.
Radiation can be OK as well.
At the end of the day this is cancer treatment it is not pulling a milk tooth that wants to fall out anyway.

Best wishes,

Georges

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3323
Joined: May 2012

Steve,

Exactly as Lighter replied, YES, all patients need to hear it all.  They did not come here for 'safe space' or to be coddled.   They need hard information, to make life-saving decisions. Of course responses should be thoughtful and with no hysteria, but Vasco and the others responses were perfect in tone and content.

max

Clevelandguy
Posts: 470
Joined: Jun 2015

Hi JFG,

Sounds like from what your doctor said that the cancer might already be outside of your Prostate.  If it was me I would want to meet with a Radiation Oncologist and see if surgery or radiation is the best treament plan. I would want to look at both sides of the two major treatments(surgery vs radiation) to see which benefits your unique situation to get you the best results. Don’t be afraid the completely research your situation to come to a treatment plan that is right for you based on your diagnosis.

Dave 3+4

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

Steve,

I do not intent to create worries to anyone when posting my opinions. In fact I am careful on what I write and try to make it sure that all is correct. I do not touch in sensitive matters but like to alert the poster on the issues he may consider and give a though. Exchanging experiences and knowhow from researches is the motto of forums like this. I believe that there are more benefits in knowing the details behind the facts than just from a solidarity comment.
I also was careful in my answers to you (threads and CSN-mail) as I know that you surfer from the fears in having still prostate cancer in your body, in spite of the present successful results from your radiotherapy. Those fears may have been initiated from too much knowledge and information you gathered while in the period of the decision process and thereafter. I think it to be the reason for your indignation on very informative posts.

However, as the years pass by, we see more and more information readily available to those who inquire. It will be difficult to turn a blind eye on the facts. The mystic apes of Japan who pretend to "see no evil, hear no evil, speak no evil" will have a hard time in keeping their commitments.

I take the chance here in congratulating your last PSA of 2.5 ng/ml down from the previous 4.0.

Best,

VG 

graycloud
Posts: 38
Joined: Jan 2018

It's been a while since I've been on line here, but had to reply to your thread.  My husband was diagnosed with Gleason 9 in fall of 2017.  My husband's main concern was being cancer free but also side affects from the surgery.     He had robotic procedure January of 2018.  His surgeon was Dr. Behfar Edhaie with Memorial Sloan Kettering in NYC.  I cannot say enough great things about MSK and the doctors that treated my husband.  Dr. Edhaie knew my husband's concerns, and what should have been a 2-3 hour procedure was an 8 hour procedure to go ml by ml to preserve the nerve bundles. My husband went through a protocol 4 months before surgery to increase blood flow to key areas to help in preservation of nerve bundles.  This included losing weight, walking, exercising. Not only did this help physically - it helped mentally.  Facing prostate cancer is tough especially with diagnosis at a young age.    He also met with MSK's ED specialist (known as one of the top in the world) to discuss ED issues pre-surgery and post surgery.  He started taking generic Viagra for 3 months pre surgery to incresae blood flow to that area.  He knew the vast array of options that were available if he had ED issues post surgery.   He met with MSK's bladder oncologist to talk about ways to improve continence post surgery.  This included physical therapy post surgery.  I can't stress this enough.  We should have started PT before surgery to get baselines on where he was before, and to make sure the Kegels were being done properly.  In my opinion, PT is the key to success in getting the nerves awake and working after surgery for both incontinence and ED. 

Today, my husband is cancer free after a Gleason 9 diagnosis.  He was very lucky in that his lymph nodes were not involved, and all margins were clear.  He is in the best physical shape of his life, and has continued his path to being healthy.  His oncologist/surgeon and the other two specialists at MSK who helped are absolutely amazing.  We are at MSK in NYC every 6 months for testing.  He won't go anywhere else and will not let our local doctors do any testing.  We live in the SE, so it's a stretch to do this every 6 months but it's worth it.    If something does happen with cancer again, he's in the MSK network for their state of the art protocols to help in deciding what to do to keep him cancer free.   The ED and incontinence issues - there really aren't any.  ED issues were quickest to improve.  Incontinence took a little longer, but he did great after physical therapy.  We went on a vacation 4 months post surgery exploring 7 countries in Europe.  Walking 10-15 miles a day.  He traveled 2 weeks after surgery to client meetings about 2 hours away from home as well as attending our daughter's weekend volleyball tournament in another state.  He walked 2 miles the night of surgery.  As you can tell, post surgery, he faced Prostate Cancer like a warrior.  Before surgery, he worried himself sick over the "what if's". 

Stay positive.  Find the best surgeon you can - and I believe MSK has some of the best in the world.  Take your time to find the best options.  Get in the warrior mode before surgery, and tackle every obstacle that comes your way.  Lean on your family, and your faith.  Best of luck to you. 

Gray Cloud

 

You will get through this

VascodaGama's picture
VascodaGama
Posts: 3041
Joined: Nov 2010

GrayCloud (Patti)

Thanks for sharing your experience. It is great to know that all runs in your favor. Many reading your post will like to know that your husband's treatment comes from a risk case with an initial high PSA of 9.5. Your story is in here;

https://csn.cancer.org/node/314285

Best wishes for continued success.

VG

ufknkidding
Posts: 41
Joined: Aug 2019

Treatment decisions are very individual so please consider everything.  Age is a factor, family history is a factor, bone scans are a factor, etc. etc.  (Even race may be a factor as some studies are beginning to find). So one case can't speak to another case but can help with the decision making process.  However, commonalities across cases can help with decision making.  Quality of life is a HUGE factor for the individual and differs for all.  Some things matter more than others for everyone and we can't judge or criticize where another person places value.  I think lighterwood67 comments about radiation if the cancer is outside the gland versus removal if limited to the gland is consistent with current treatment protocols for gleasons 7 or higher.  I agree with VascodaGama you should only choose a treatment you are comfortable with = quality of life.  Hope everything works out well.

You can follow my (Sept 2019) story at https://csn.cancer.org/node/320408

fishinguy
Posts: 18
Joined: Dec 2017

When I was diagnosed two years ago, my Uro, who is also a surgeon, suggested that he would take the nerve bundle on one side.   He performed open surgery.  The reason was the 3T MRI showed one of the tumors to be right up near/against the wall.    He said to play it safe he would take the nerve bundle, most important factor to him, get all the cancer.    Surgeon # 2, Robotic, stated he would "go wide" to be safe, but didn't think he'd take the entire nerve bundle on that side.    Surgeon #3, Robotic, told me he would make the decision on full nerve sparing when he was inside and got a better look.

I went with surgeon #3, for other reasons as well.  Specifically a surgical process study.    I ended up with a positive margin of <.1 cm.   So yes, it was right up against the wall.   My pathology was also downgraded from 4+3 to 3+4, so I call it a wash.   Uro and I decided radiation would be over treatment at that time (3 month follow up), with the margin so small.     ED has not been an issue.

 

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