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Old 06-08-2011, 02:15 AM   #1
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Radical Prostatectomy - in depth questions

Hello, I have some questions about the Radical Prostatectomy (open, not robotic) surgery details:

1. What is PLND?
I've read that it relates to lymph nodes test, but could't find if it's something that is done during the surgery or after?
And what does this test mean? how accurate is it?
Is it being done on every surgery or is it according to surgeon decision?

2. Does in every open Radical Prostatectomy the patient needs blood?
How the surgeon decides whether to give blood?

3. Is there only one surgeon performing the surgery, or does he have any assistant (besides the anesthetic, nurse)?
I mean - does the actual surgery is performed by one surgeon or more?

4. What is the average recovery time which the patent is able to walk by himself without pain?

5. How accurate is the post surgery pathology report in predicting the recurrence of the tumor?

6. According to what the surgeon decides whether to do the nerve sparing??
Does he decides before surgery or after?


Thank you all for your support and informative help !!

 
Old 06-08-2011, 05:02 AM   #2
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Re: Radical Prostatectomy - in depth questions

Quote:
Originally Posted by Perineum View Post
Hello, I have some questions about the Radical Prostatectomy (open, not robotic) surgery details:

1. What is PLND?
I've read that it relates to lymph nodes test, but could't find if it's something that is done during the surgery or after?
And what does this test mean? how accurate is it?
Is it being done on every surgery or is it according to surgeon decision?

2. Does in every open Radical Prostatectomy the patient needs blood?
How the surgeon decides whether to give blood?

3. Is there only one surgeon performing the surgery, or does he have any assistant (besides the anesthetic, nurse)?
I mean - does the actual surgery is performed by one surgeon or more?

4. What is the average recovery time which the patent is able to walk by himself without pain?

5. How accurate is the post surgery pathology report in predicting the recurrence of the tumor?

6. According to what the surgeon decides whether to do the nerve sparing??
Does he decides before surgery or after?


Thank you all for your support and informative help !!
Hi Perineum,

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. 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.ncbi.nlm.nih.gov/pubmed/14532779)

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.

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.

Baptista

 
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Old 06-08-2011, 07:54 AM   #3
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Re: Radical Prostatectomy - in depth questions

Hi Perineum,

Baptista has given some great information about open surgery. I had robotic, so my experience wouldn't apply.

I'd like to address a little bit your question:

Quote:
5. How accurate is the post surgery pathology report in predicting the recurrence of the tumor?
Of late, this has been a great concern to me with my Gleason 9 condition, as I'm watching my PSA tests every two months to see if my PSA becomes detectable. So far, 8 months and still undetectable, with my 10-month test results due this week.

Your first PSA test after surgery will determine whether recurrence is a factor. If PSA is detectable, metastasis can be assumed, unfortunately. If your PSA is undectable (under .01), then you can concern yourself with recurrence.

Your pathology report will address several issues that will have a bearing on your chance for recurrence. But already you know that you have a GS of 5 +4 = 9. This one metric is a strong indicator of potential recurrence, giving you (and me) a much greater chance for recurrence. Depending on what report you read or nomogram you use, chance for recurrence can be as high as 46% based on this metric alone, although I've seen the chance go as low as 27%.

This assumes organ-confined disease - T2a or T2b. If the tumor has extended beyond the prostate or into the seminal vesicles, raising your state to T3, chances are higher for recurrence. Of course, any finding of cancer in the lymph nodes would be problematic, as would mention of cancer spread to the urethra or bladder neck.

Other indicia in the pathology report would be perineural invasion, positive margins, and percent of cancer. In studies I've read, however, a high Gleason score is predictive of perineural invasion (cancer cells in the connecting nerves tissue) and positive margins, each being more likely with Gleason 8 or higher. Also, those conditions haven't been found to provide meaningful prediction of recurrence in high Gleason cancers, as the Gleason score more or less trumps everything. One thing I saw mentioned is that the location of any positive margin and the length of the margin can be predictive of recurrence, with greater chance for more basal positive margins, and for longer ones (greater than 3mm).

Baptista mentioned a PITX2 test. From my reading, this is really only helpful with Gleason 7 cancers, which are of intermediate risk and could go either way (could be 3 + 4 or 4 + 3). The test would help determine when the G7 cancer is of greater risk. With G9, the risk of recurrence is "known" within a statistical range.

You ask about reliability of the pathology report. If you mean the reliability of the interpretation, I don't really have an answer. I've not heard of people asking for a second opinion on the post-op report, although I've thought of seeking one myself, just to see if a different pathologist might find some other things of note, such as the length of my positive margin.

But if you're seeking a definitive answer about your chance of recurrence, I haven't found source. There are studies that give ranges and reasons for concern, but there are so many unknowns, even with individual test results, that it is just statistical guesswork. Micromets may or may not be coursing through your lymph system or in your body, or even beginning a colony somewhere, and not be detected by your PSA or other tests. Plus, the mechanics of cancer spread do not appear to be well understood as yet.

You might want to look for sites with nomograms so you can plug in your data and get statistics you may find useful. The Sloan-Kettering nomogram has an option for post-rp situations and I found it comforting in my case. The Sloan Kettering Nomogram for me gave the following percentages:

Progression-Free Probability After Surgery
2 Year 93%
5 Year 84%
7 Year 79%
10 Year 73%

I've seen mention of other nomograms under development that claim to be better, but I have no references.

Best of luck with your treatment.

Tom

Last edited by Gleason9; 06-08-2011 at 09:57 AM. Reason: Added nomogram results

 
Old 06-08-2011, 01:17 PM   #4
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Re: Radical Prostatectomy - in depth questions

Perineum
I did not require a blood transfusion during my Radical Prostatectomy. It is dependent upon the Surgeon's skill and how much tissue he needs to remove. If it comes out clean there should be no need for blood.

My surgery lasted 1.5 hours.

Nerve sparing is not guaranteed as this deals with extremely fine nerves which could be compared to angel hair and not every hospital has the proper viewing equipment.

Ultimately my surgery failed and after eight years I went to Loma Linda and received Proton Beam Therapy for salvage and so far I am good. I wish I had gone there in the first place. Search this treatment and consider it.
Bob

 
Old 06-09-2011, 04:34 AM   #5
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Re: Radical Prostatectomy - in depth questions

Since I so blithely mentioned my nomogram, I thought I would report that it was in fact an illusion for me. My test results came back showing my PSA at .03. Assuming that result will be confirmed, I will have taken my first steps into recurrence land. But as the nomogram said, only 93% wouldn't have a recurrence within 2 years, so I fell into the 7% of unlucky ones.

Prostate cancer remains a personal journey. It develops differently in all of us and responds differently to treatments.

I hope you have better luck.

Tom

 
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Old 06-09-2011, 01:45 PM   #6
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Re: Radical Prostatectomy - in depth questions

Quote:
Originally Posted by Gleason9 View Post
Since I so blithely mentioned my nomogram, I thought I would report that it was in fact an illusion for me. My test results came back showing my PSA at .03. Assuming that result will be confirmed, I will have taken my first steps into recurrence land. But as the nomogram said, only 93% wouldn't have a recurrence within 2 years, so I fell into the 7% of unlucky ones.

Prostate cancer remains a personal journey. It develops differently in all of us and responds differently to treatments.

I hope you have better luck.

Tom
Gleason9
The same thing happened to me. I was fine for eighteen months then my PSA jumped from non-dectectable to 0.08. Biochemical failure is 0.2 It took me three years after surgery to reach this level and then it bounced up and down between 0.16 - 0.24 until it was steadily over 0.2 after seven years. My doctor then suggested Avodart which cut the PSA in half almost immediately but it returned to the previous levels in four months. In 2004 I had a consultation with Dr. Critz at RCOG and he told me that I should seek treatment at 0.3 and certainly by 0.4.
I read a study which said that for patients with positive margins following surgery the rate of metastase is 50% after eight years and 67% after ten years. Watching your PSA is like living with a monkey on your back and after eight years I went to Loma Linda University Medical Center and had Proton Beam Salvage Therapy.
I hope there is something here to help you but I feel I was very lucky as they told me a Loma Linda, "You sure waited a long time". I met several people in treatment who had failed a RP and were being treated within six months.
Bob

 
Old 06-10-2011, 03:13 AM   #7
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Re: Radical Prostatectomy - in depth questions

Thank you all for your valuable information.

Another concern - how many days after surgery, the urine through the catheter is going to be red?
Is it OK that the urine will be sometimes red and sometimes yellow?

Any other info regarding the catheter is welcome!!

Thanks !!!!

 
Old 06-10-2011, 10:01 AM   #8
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Re: Radical Prostatectomy - in depth questions

Hello again, I have some out of topic question -
How is the surgery report written?
Is it written posteriori by the surgeon (after the surgery is completed), or
is it written during the surgery (like in court) such as the surgeon tells what he is doing and someone else writes it down?

Thanks !!

 
Old 06-10-2011, 03:20 PM   #9
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Re: Radical Prostatectomy - in depth questions

Perineum
My urine was yellow and I had another drain in my abdomen for a couple of days. Some people have the drain in longer and have more blood to be flushed out. It is dependent on the surgeon and what they have to do.
I believe the surgeon dictates the surgery and signs the report. The surgical pathology follows a few days later.
Bob

 
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