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  • #1

    Surgery Prep

    I had a good visit last week with a new surgeon. After speaking to two different radiation oncologists and two different surgeons, I have finally made a decision. I have surgery scheduled for Feb 20th. I was randomly looking at past posts and found a list of questions to ask the surgeon. I didn't ask 1/3 of them, but still feel good about the decision. Wife felt good about the visit as well. I know that from my MRI it may be possible that I need adjuvant therapy as well, but there is a possibility that I won't. there aren't any crystal balls with this stuff, so I will take the results either way once I have surgery. I found two questions in the post that I would like to explore:

    Any special preparations for surgery? (kegels; diet; store blood; bladder stretching to increase capacity, no sit ups, etc)
    What can I be doing TODAY to prepare my body for the surgery and to reduce side effects? (Kegel exercises? How much is too much? Exercises?)

    I think I know the answers: Kegals yes, store blood Not generally for robotic, bladder stretching? Situps? (I'm doing them)?, Exercise, I asked about and was told I'm or on. I plan on having my last workout 5-6 days prior. Diet, I've been eating less and eating healthier. I have lost 20 pounds since June. Wouldn't mind losing a few more between now and he 20th.

    As long as I'm asking I have a small umbilical hernia. Anyone else have experience with this on a robotic surgery?
    Tags: None
  • #2
    I can't say I did a lot of surgery prep for mine. I had lost some weight and cut sugar out of my diet. But that was more coincidental. Everything you listed sounds like a good idea. They worked around my fat prettty well. I was hoping they would do a little liposuction while they were in there... but no dice on that! My surgery lasted about 4 hours I think. Which was longer than some reported.

    The only surprise when I was at the hospital was that right before I went in they asked me if I wanted a Foley catheter or not (I never knew there was a choice?). But apparently they can put a tube from your bladder through your stomach. I opted out for that. I was glad I did. Apparently, that method is not as comfortable as it might sound. I know one guy that did that and didn't like it.

    I've been doing kegels after surgery. But my urinary tract isn't too bad. Almost back to OEM.
    born 1958
    PSA History:
    1/22/10 -7/16/21 1.7-2.3
    01/10/2022 2.2
    07/08/2022 1.7

    Biopsy 9/2021 slides read by local urology group
    unfelt small leasion found in 3 sectors
    I. Gle 3+3 (SUP Grp 1) .5mm involving(1% & PIN)
    K. a Gle 3+4 (SUP Grp 2)2 mm involving(10%)
    L. Gle 3+4 (SUP Grp 2)1.5 mm involving(5% patchy)
    Gle 3+4

    Decipher score .26 Low Risk

    Johns Hopkins, Dr. Epstein read of slides 10/14/2021
    I. Small focus of prostatic adenocarcinoma, Gleason Score 3+3 (group 1), involving less than 5% of one (1) core
    K. Gle 3+3 (group 1), involving 10% of one (1) core
    L. , Gle 3+3 (group 1), discont. involving 20% of one (1) core



    MP MRI 12/10/2021 results:
    1. No index lesion identified. MRI findings
    PI RADS 2 abnormality (low likelihood of clinically
    significant prostate cancer).

    October 2022:
    biopsy 16 cores. 2 G3+4 one G3+3
    MRI: pirads 4 now
    Decipher .46 Intermediate risk

    RALP 12-14-22
    pT2 pNX, adenocarcinoma, G7 (3+4), 6-10% Pattern 4
    EPE SM SVI LVI BNI all neg., no IDC or cribriform glands
    5.2 x 5.1 x 3.7 cm, 45 g, tumor involvement: 6-10%
    Largest of 3 nodules 2.3 x 1.4 x 1.0 cm, nodule with most Pattern 4: 30%​

    Comment

    • #3
      CE, whenever I have questions for my docs, which is most of the time, I always write them down. Otherwise you will never remember them all: you get into a discussion of one point and simply forget most of the rest. I would check these points with your surgeon ahead of time:

      1) I don't see a signature for you and don't remember your biopsy results, but I would discuss with the surgeon whether, based on your workup imaging, he/she thinks one or both neurovascular bundles can be spared. My surgeon specifically asked me (for the bundle on one side, near a prostate zone that showed cancer on the biopsy) whether, if it was a close call, I want to favor oncological control or potency. I said "Get the cancer out, does anyone say otherwise?" He said yes, some men do put that high a value on sex (even though one bundle is usually enough for erections). Anyway, something to double check before surgery.

      2) Ask for an estimate of the number of lymph nodes the surgeon expects to remove. Surgeons don't go by number but rather by anatomical template (the area bounded by specific landmarks such as muscles and vessels: the higher the Gleason score, the larger the template the surgeon plans to use and the more lymph nodes collected as a result. I've seen too many men whose Gleason score was upgraded after surgery and, in my opinion, for whom not enough lymph nodes were removed as a check for local cancer spread. From what I've seen, about half of all surgeons remove no lymph nodes for a G6 (3+3) biopsy. This is shortsighted, because the most important nodes--closest to the prostate--are right there for the taking, and you won't know about Gleason upgrading until you get your post-op path report.

      3) Your Gleason score probably wasn't an 8 or higher, but if it was, you can ask whether you surgeon plans on doing frozen sections during surgery to check for negative surgical margins.

      Be confident, relax, and smile the morning of your surgery: let you medical team work for you--they know what they're doing! Follow all your discharge instructions carefully. Use stool softeners to ensure you don't become constipated. If you can get by with OTC pain meds do so, because opioids are very constipating. Walking is your friend, but don't overdo it or anything else. Watch the weight limit for lifting that you are given. Be patient about regaining continence: men vary greatly in the time it takes. Think of your RP as an investment that you don't want to screw up once it's over.


      Best of luck!

      Djin
      Last edited by DjinTonic; 01-24-2023, 10:04 AM.
      69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
      7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
      6-06-17 Nodule on right + PSA rise on finasteride: 3.6→4.3
      6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
      Nodule neg. for PCa
      Bone scan, CTs, X-rays: neg.
      8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
      SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
      pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
      5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
      Dry; ED OK with sildenafil
      11-10-17 Decipher score: 0.37, Low Risk:
      5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%      		 9-16-17 (5 wk) PSA <0.1
      (3 m ) 0.010
      (6 m ) 0.009
      (9 m ) 0.007 (nadir)
      (1 yr.) 0.018 (?)
      (13 m) 0.013 (retest)
      (15 m) 0.012
      (18 m) 0.015
      (21 m) 0.015
      (2 yr. ) 0.016
      (28 m) 0.015
      (34 m) <0.014
      (40 m) 0.037 (?)
      (43 m) 0.020
      (46 m) 0.018
      (52 m) 0.023
      (5 yr) 0.038
      (63 m) 0.036
      (66 m) 0.049

      Comment

      • #4
        Originally posted by DjinTonic View Post
        CE, whenever I have questions for my docs, which is most of the time, I always write them down. Otherwise you will never remember them all: you get into a discussion of one point and simply forget most of the rest. I would check these points with your surgeon ahead of time: I went in with a list and did pretty well with getting answers. Some times I think of a question and do not have my note pad. Those are the wones I want to ask, or want more information on after I ask the initial question.

        1) I don't see a signature for you and don't remember your biopsy results,I will figure out how to post my bio at some time. My biopsy was 12 cores 6 with cancer highest was 4+3. MRI showed a 24 mm tumor on the right side. This surgeon did look at my biopsy slides and essentially came up with the same results. but I would discuss with the surgeon whether, based on your workup imaging, he/she thinks one or both neurovascular bundles can be spared. My surgeon specifically asked me (for the bundle on one side, near a prostate zone that showed cancer on the biopsy) whether, if it was a close call, I want to favor oncological control or potency. I said "Get the cancer out, does anyone say otherwise?" He said yes, some men do put that high a value on sex (even though one bundle is usually enough for erections). Anyway, something to double check before surgery. We had a very candid talk about nerve sparing. 1. Left side looks good for complete sparing. right side is a partial at best. I told him if he has to take it, then do it. Unlike the first surgeon who wouldn't talk to me at all.

        2) Ask for an estimate of the number of lymph nodes the surgeon expects to remove. Surgeons don't go by number but rather by anatomical template (the area bounded by specific landmarks such as muscles and vessels: the higher the Gleason score, the larger the template the surgeon plans to use and the more lymph nodes collected as a result. I've seen too many men whose Gleason score was upgraded after surgery and, in my opinion, for whom not enough lymph nodes were removed as a check for local cancer spread. From what I've seen, about half of all surgeons remove no lymph nodes for a G6 (3+3) biopsy. This is shortsighted, because the most important nodes--closest to the prostate--are right there for the taking, and you won't know about Gleason upgrading until you get your post-op path report. We didn't talk about lymph nodes at all. probably should have. In this regards, I am trusting that he will take out what he needs to. He has done 5000 operations, so I am at ease with his knowledge level.

        3) Your Gleason score probably wasn't an 8 or higher, but if it was, you can ask whether you surgeon plans on doing frozen sections during surgery to check for negative surgical margins.

        Be confident, relax, and smile the morning of your surgery: let you medical team work for you--they know what they're doing! I have been 4 other offices and this is the first place that I feel had a real team approach, and it feels right for me. Follow all your discharge instructions carefully. I would really like my wife to be there at discharge for me. She will hear things that I won't unfortunately, she will have to have dialysis that day. Thinking of trying a zoom call so she can hear stuff as well. Use stool softeners to ensure you don't become constipated. If you can get by with OTC pain meds do so, because opioids are very constipating. Walking is your friend, but don't overdo it or anything else. Watch the weight limit for lifting that you are given. Be patient about regaining continence: men vary greatly in the time it takes. Think of your RP as an investment that you don't want to screw up once it's over. I agree with this. i had hernia surgery 5 years ago. I came back to work too soon. I am not doing that again. My company is behind me. Light duty phone support to my customers when i am up to it.


        Best of luck! Thank you. It sounds odd to say, but I am excited about having a treatment plan.

        Djin

        I added my comments in bold to your quote.

        Comment

        • #5
          Don't worry; your discharge instructions will all be printed out for you .
          69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
          7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
          6-06-17 Nodule on right + PSA rise on finasteride: 3.6→4.3
          6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
          Nodule neg. for PCa
          Bone scan, CTs, X-rays: neg.
          8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
          SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
          pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
          5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
          Dry; ED OK with sildenafil
          11-10-17 Decipher score: 0.37, Low Risk:
          5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%          		 9-16-17 (5 wk) PSA <0.1
          (3 m ) 0.010
          (6 m ) 0.009
          (9 m ) 0.007 (nadir)
          (1 yr.) 0.018 (?)
          (13 m) 0.013 (retest)
          (15 m) 0.012
          (18 m) 0.015
          (21 m) 0.015
          (2 yr. ) 0.016
          (28 m) 0.015
          (34 m) <0.014
          (40 m) 0.037 (?)
          (43 m) 0.020
          (46 m) 0.018
          (52 m) 0.023
          (5 yr) 0.038
          (63 m) 0.036
          (66 m) 0.049

          Comment

          • #6
            Don’t forget post surgery prep. You will want some incontinence pads for your bed and yourself on hand. Cortisone 10 for irritation from the catheter works well. Free samples are available from most manufacturers.
            YOB 1957

            DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &amp;lt;5%, Right side negative.

            3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
            T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
            7 Nodes, SV, SM, PNI, and BNI were negative.
            LVI and Cribriform pattern present.
            Decipher .86 High Risk.

            Post Surgery PSA
            3/25/19 .03. (25 days)
            4/25/19. <.03. (2 months)
            5/25/19 <.02 (3 month)
            5/20/22. < .02 (39 months). T=37
            11/7/22. <.02 (45 months) T=54

            3 Part Modality Treatment Completed

            2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery his #41st in US.
            ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
            ADT - 5/19- 5/21 Eligard and Casodex.


            3 Part Modality Treatment Completed

            2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
            ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
            ADT - 5/19- 5/21 Eligard and Casodex.

            ​

            Comment

            • #7
              I could probably send you a care package of stuff. To do the profile you go to the account section and then fill out the post signature portion of the conversation detail options with your pca specifics (see below).




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              ​
              born 1958
              PSA History:
              1/22/10 -7/16/21 1.7-2.3
              01/10/2022 2.2
              07/08/2022 1.7

              Biopsy 9/2021 slides read by local urology group
              unfelt small leasion found in 3 sectors
              I. Gle 3+3 (SUP Grp 1) .5mm involving(1% & PIN)
              K. a Gle 3+4 (SUP Grp 2)2 mm involving(10%)
              L. Gle 3+4 (SUP Grp 2)1.5 mm involving(5% patchy)
              Gle 3+4

              Decipher score .26 Low Risk

              Johns Hopkins, Dr. Epstein read of slides 10/14/2021
              I. Small focus of prostatic adenocarcinoma, Gleason Score 3+3 (group 1), involving less than 5% of one (1) core
              K. Gle 3+3 (group 1), involving 10% of one (1) core
              L. , Gle 3+3 (group 1), discont. involving 20% of one (1) core



              MP MRI 12/10/2021 results:
              1. No index lesion identified. MRI findings
              PI RADS 2 abnormality (low likelihood of clinically
              significant prostate cancer).

              October 2022:
              biopsy 16 cores. 2 G3+4 one G3+3
              MRI: pirads 4 now
              Decipher .46 Intermediate risk

              RALP 12-14-22
              pT2 pNX, adenocarcinoma, G7 (3+4), 6-10% Pattern 4
              EPE SM SVI LVI BNI all neg., no IDC or cribriform glands
              5.2 x 5.1 x 3.7 cm, 45 g, tumor involvement: 6-10%
              Largest of 3 nodules 2.3 x 1.4 x 1.0 cm, nodule with most Pattern 4: 30%​

              Comment

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