Originally Posted by Perineum
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 !!
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.
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.
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.
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.
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.
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.
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.