Are all Robotic Prostatectomy's Considered "Nerve Sparing?"

My team (Uro, MO, RO + a bunch of nurse practitioners) told me that the side effects of both surgery and radiation are similar, but the surgical side effects were immediate while radiation SE's came on over a period of years. My subsequent radiation SE's confirmed that for me.

A PSA of 10 or above means the cancer is pretty serious and could be nasty/aggressive. Gleason of 7 underscores that. (I went in at G 3+4, later path said G 4+3) My surgeon said he wouldn't know how bad mine was until he was in there doing the job (real bad ones are "sticky"). They went in to do RA nerve-sparing, but extensive perineural invasion ruined that plan. My tumor was much like a sea urchin, covered with spike-like extensions into the surrounding tissue, including nerves, blood vessels and lymph vessels (it was "sticky"). When the PCa later came back, it was in nearby lymph nodes. I am 2 years into the 3 & 1/2 year radiation SE rise to nadir from the last round of radiation treatments, looking forward to those backing off.

As for the 'surgery versus radiation versus 'hormonal' chemotherapy...I went for the whole bundle. So far so good, details in my sig line.

Good luck.

See your own radiologist

"My team (Uro, MO, RO + a bunch of nurse practitioners) told me that the side effects of both surgery and radiation are similar, but the surgical side effects were immediate while radiation SE's came on over a period of years. My subsequent radiation SE's confirmed that for me"

i'm 14 years out and if anything my radiation SEs have decreased. i have never once been incontinent and my mild ED is easily corrected with cialis

i think the ole sayings are largely myths. and if they weren't why would anyone in their right mind opt for immediate SEs like incontinence and erectile disfunction?

i'll answer that question: because at first we are in shock and we "just want it out" and our first point of contact is a surgeon

John, whatever treatment you decide, I wish you all the best for optimal cancer control, minimal side effects, and a speedy recovery!

Everyone's specifics are different — age, general health, diagnostics— so your treatment decision carries its own matrix of unique factors. But make sure you’re prioritizing up-to-date information as you ask questions & weigh your options — the treatments have been evolving at exponential rates. PCa is considered an “indolent” disease and researchers like to cite 5 or even 10 year metastasis or survival rates, which makes newer technologies difficult to fully assess. But a lot can be understood from careful research:

side effects can vary from person to person but there are documented trends, and they can be evident on shorter timescales than the long-term cancer control.

- new technologies and the novel treatments they enable are often incremental, building on past successes; a novel RT treatment becomes more pinpoint-precise than its precursor (Proton Beam.) A surgical approach with new laparoscopic robotic tools avoids previously unavoidable structures (Retzius Sparing, Pre-Peritoneal.) These innovations can have a huge impact on side effects, with minimal or no effect on cancer control.

- you’re in charge of your treatment, and doctors generally appreciate a patient who asks questions based on their own research and particular circumstances. Show up with a notebook with your questions, priorities, concerns — and write down the answers! It’s easy to get overwhelmed with the torrent of complicated information, so take your time and make sure you cover the key issues on your punch-list during your consultations.

- it’s okay to make decisions based on your gut. As others have said here, once you drill into the information and carefully consider your options, make your call. Get input from your spouse / partner / family / close friends on what your medical team is telling you, then choose your path and get on with it. There are no wrong choices.

- there are lots of guys here who have been through what you’re facing, and while they have a variety of opinions, their first-hand knowledge is invaluable. Don’t hesitate to ask questions, post entire texts of biopsy reports etc. — there’s a very good chance someone here has insights that you won’t hear from a doctor or from anyone who’s not been through this journey. After providing me with an opinion on a treatment approach, one of my doctors added, “But I’m not sitting in your chair.” There are guys here who *have* sat in your chair!

best of luck,

nels

Hello everyone.
Update:
I decided to go with Robotic Prostatectomy. My surgery was 9/22.
Dr Finley at Kaiser Los Angeles (Sunset) performed the surgery. The urologist at Panorama City wasnt doing it for me.
Dr. Finley was great. He was able to spare both nerve bundles and the following biopsy was very favorable.
By the way, I'm already getting solid and spontaneous erections, but leaking small amounts of urine when engaged in foreplay and sex. I'm just lucky and grateful that I'm able to do this. My wife is absolutely overjoyed!

Here is the final pathology report

FINAL PATHOLOGIC DIAGNOSIS
A. PROSTATE, ANTERIOR FAT, RESECTION: NEGATIVE FOR MALIGNANCY

B. LYMPH NODE, RIGHT NODE OF CLOQUET, NODE DISSECTION: NO METASTATIC CARCINOMA IDENTIFIED IN 1 OUT OF 1 LYMPH NODE (0/1)

C. LYMPH NODE, RIGHT PELVIC, NODE DISSECTION: NO METASTATIC CARCINOMA IDENTIFIED IN 3 OUT OF 3 LYMPH NODES (0/3)

D. PROSTATE, RADICAL PROSTATECTOMY:
1. HISTOLOGIC TYPE: ADENOCARCINOMA
2. HISTOLOGIC GRADE (GLEASON PATTERN): 7
3. TUMOR LATERALITY: BILATERAL
4. MAXIMUM TUMOR DIMENSION: AT LEAST 1.5 CM (AS MEASURED ON SLIDE)
5. MARGIN STATUS: NEGATIVE
6. EXTRAPROSTATIC EXTENSION: NOT IDENTIFIED
7. SEMINAL VESICLE INVASION: NOT IDENTIFIED
8. PERINEURAL SPACE INVASION: PRESENT
9. PATHOLOGIC STAGE (AJCC): pT2N0



SYNOPTIC REPORTING SUMMARY
Procedure:
Radical prostatectomy
Histologic Type:
Acinar adenocarcinoma
Grade:
Grade group 2 (Gleason Score 3 + 4 = 7)
Minor Tertiary Pattern 5 (less than 5%):
Not applicable
Percentage of Pattern 4:
21 - 30%
Intraductal Carcinoma (IDC):
Not identified
Cribriform Glands:
Not identified
Treatment Effect:
No known presurgical therapy
Estimated Percentage of Prostate Involved by Tumor:
21 - 30%
Extraprostatic Extension (EPE):
Not identified
Urinary Bladder Neck Invasion:
Not identified
Seminal Vesicle Invasion:
Not identified
Lymphovascular Invasion:
Not Identified
Perineural Invasion:
Present
Margin Status:
All margins negative for invasive carcinoma
Regional Lymph Node Status:
All regional lymph nodes negative for tumor
Number of Lymph Nodes Examined:
4
Primary Tumor (pT):
pT2: Organ confined
pN Category:
pN0: No positive regional nodes
Additional Findings:
None identified
--------------------------------------------------------

John,

That's a really good pathology report, and the initial results are looking good as well. Do everything you can to keep your mid section fit, because your pelvic muscles now have to do more to keep you from leaking.

You're well on your way. Next step: the 12 week PSA. Let's hope for a non-detectable!

Agree - good path report.

Thanks John U for letting us know about the initial outcome of the process you went through. So far, so good and a 'nice' path report to boot!

John,

Nerve sparing sounds good, but it is important to remember that it is a goal not a promise. Even with the best scans, no responsible doctor would promise that they KNOW what they'll find once they start with the surgery. In my case, goal was nerve sparing RALP. However, when doc got in there it turned out the PC had spread to lymph nodes. To cut rest out some nerves were going to be damaged. That entire area is a huge bundle of nerves. So, even if there is no spread, the nerves are likely to suffer some trauma just from the activity in the area. Even with a successful no surprises RALP, it takes exercises, etc to restore control of those muscles. Best wishes going forward.
Bill

Wow, this is all such great advice. I only wish I would have known about this site before I had my RP in 2008. Lots has progressed since then. Every case is different but the best advice I saw above is to not limit you willingness to ask questions of your surgeon. Make a list and force him/her to take the time to sit with you and answer them. If not find another Uro.

John, it all sounds good. I would suggest that you request the 'ultrasensitive' PSA test, not the 'normal' test. This gives you multiple decimal points below 0, and is typically used for us prostatectomy patients. My next PSA blood draw is next week (almost 10 yrs since diagnosis), and I'm hoping for another <0.006.

Pratoman said...
John congrats on reaching the one year mark and being undetectable. Thats great news.

I do have one question, or maybe a comment. - I noticed that your PSA test came back <.1. That tells me that you are not being tested with the "ultra sensitive" PSA test, which tests down to a lower level. If it were me, with a G7 (3+4) and a pre-operative PSA of 12 , I would want a more sensitive PSA test.
I was a G7 (3+4) and after 2 years my PSA became detectable at .02. A year later it was .08, and thats when I pulled the trigger on Salvage Radiation (I am now undetectable 6 years later). If your PSA was detectable but very low, you wouldn't know it until it was above .1

I'm not saying this to scare you, everyone is different. But I think , especially with that pre operative PSA of 12, and 20% grade 4 in post op pathology, that you might want to ask about that extra layer of vigilance that comes with an ultra sensitive PSA

Got it. Will ask my erotologist about this next time. So, now that it's been one year since my surgery, what is the typical frequency of PSA testing? 3 months? 6 months?

I was every 3 months for the first year, then every 6 months until 5 years, then annually since. I was G7 (3+4) on final pathology, with no extensions.