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Thread: New member of the "club". Trying to learn and then decide

  1. #11
    Newbie New User
    Join Date
    May 2019
    Posts
    5
    Wow! So much and so good information! I am overwhelmed and grateful for all your answers!

    ASAdvocate I already bought the book and I am reading it

    My urologists, which actually is the one that did surgery to my father 20 years ago, is suggesting me to do RP, but he does open surgery.

    I am opening two different lines of action. One with a surgeon specialized in RP. His team recommended me to have a second diagnosis of the biopsy (which I am already doing) and a MRI 3T (which i may do after discussing with the second line of action next week).

    If I decide to go through the RP I am considering Da Vinci with somebody with large experience. Any thoughts or advise there? I understand I need to discuss the nerves sparing in both sides, right? I need to keep progressing reading the book!

    Again, thanks for your kind words and support. I will keep you posted of my progress in this journey!
    DoB 1970
    PSA Oct 11 1.94
    Jul 16 1.87
    Nov 16 3.00
    Apr 17 2.10
    Dec 17 4.10 Took Minocin and went down (antibiotic)
    Feb 18 3.30
    Jul 18 3.40
    Dec 18 4.20 Took Minocin and kept going up (antibiotic)
    Mar 19 4.60
    April 19 Biopsy 13 cores 1 3% Gleason 3+3, other doubtful.
    Father and uncles wit PCa, father died from Urothelial Ca.

  2. #12
    Quote Originally Posted by Transiter View Post
    Wow! So much and so good information! I am overwhelmed and grateful for all your answers!

    ASAdvocate I already bought the book and I am reading it

    My urologists, which actually is the one that did surgery to my father 20 years ago, is suggesting me to do RP, but he does open surgery.

    I am opening two different lines of action. One with a surgeon specialized in RP. His team recommended me to have a second diagnosis of the biopsy (which I am already doing) and a MRI 3T (which i may do after discussing with the second line of action next week).

    If I decide to go through the RP I am considering Da Vinci with somebody with large experience. Any thoughts or advise there? I understand I need to discuss the nerves sparing in both sides, right? I need to keep progressing reading the book!

    Again, thanks for your kind words and support. I will keep you posted of my progress in this journey!
    A 2nd opinion on the biopsy results is a good thing in any case.

    As someone who had an open RP, I can say an open is fine; however, if you have two very good, equally experienced surgeons, one robotic, one open, the RALP has a couple of immediate surgical advantages and perhaps very slightly better ontological outcomes (but again only with a greatly experienced surgeon).

    Bilateral nerve-sparing is usually feasible for G6 men; however, in a small percentage of men, G6 can encroach on the nerve bundles.

    If your 2nd line of action is AS, I would have a genomics test (e.g. Oncotype dx) done on the biopsy tissue in addition to the mpMRI (I assume the imaging would lead to a repeat targeted biopsy if anything apart from the lesion already sampled comes back as PIRADS 3-5.)

    Djin
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) then 6-mo. checkups
    6-06-17 DRE: nodule R and PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1; Pomi-T (2/day)
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

  3. #13
    Newbie New User
    Join Date
    May 2019
    Posts
    5
    Thanks Djin Tonic next week I am expecting to get the second opinion for the biopsy report and then get recommendations. I will keep all of you posted. So far, I have 3 opened options:

    - My urologist of reference that I trust (great surgeon, very experienced, but does open RP and he is in Europe, with all the complications of that, me living in the US)
    - A Da Vinci "guru" in RP that is in a different state where I live (so, with the issue of traveling and follow up if complications), recommended by my urologist in case I wanted to go through the less invasive Da Vinci RP
    - A great, highly reputed institution in Houston where I live where they are going to give the second diagnosis of the biopsy (we will discuss all open options including AS, RP and others).

    I will keep you posted.

    Again, thanks for all your comments, you are all great! As a new member of this "club", let me tell you that all of you do such a great job helping others like me navigating through this so complicated journey!

    THANKS ALL!! You need to be proud of what you do in this forum.
    DoB 1970
    PSA Oct 11 1.94
    Jul 16 1.87
    Nov 16 3.00
    Apr 17 2.10
    Dec 17 4.10 Took Minocin and went down (antibiotic)
    Feb 18 3.30
    Jul 18 3.40
    Dec 18 4.20 Took Minocin and kept going up (antibiotic)
    Mar 19 4.60
    April 19 Biopsy 13 cores 1 3% Gleason 3+3, other doubtful.
    Father and uncles wit PCa, father died from Urothelial Ca.

  4. #14
    Senior User
    Join Date
    Feb 2017
    Posts
    136
    You are in the right place to get some very reasoned information on treatment options. My biopsy looked like mostly Gleason 3 + 3, the pathology post RALP was scary bad with some G9 and a few positive lymph nodes plus other ugly stuff. While I had a top guy at the DaVinci console, I elected to do a referral to Johns Hopkins. JH presented me with options that would have been scarce elsewhere.

    After 2 years my PSA has remained undetectable. I share this with you just to encourage you to widen your azimuth as far as you can to get the PCa “temples” in on your case and ultimate treatment. I was talking with the uro surgeon who did my RALP last week and he said that he is seeing significant increases in guys in your age bracket presenting themselves with PCa.

    The experts on here (and you’ve already heard from several of them), have educated a bunch of us on “questions to ask.” A hugely important service. You are in a great space for a cure.
    2010-PSA 3.59; 2011-PSA 3.58; 2012-PSA 5.28, 4.26; 2013-PSA 5.98, 7.37; 2014-PSA 5.90, 4.70; 2015-PSA 5.18, 7.35
    RALP 16 March 17, Wesley Long Hospital, Greensboro, NC
    Pathology: pT3a, pN1 Gleason 4+5=9 adenocarcinoma with + surgical margin at bladder neck; 3 of 16 lymph nodes positive; neg seminal vesicles, vasa deferens
    Referral to Dr. Ken Pienta, Clinical Dir Research, Brady Center, Johns Hopkins
    Enrolled in Clinical Trial IRB002120414 “Phase II Study of definitive therapy for oligometastatic prostate cancer post surgery"
    Completed: Docetaxel 12 Jun 17, 3 Jul 17, 24 Jul 17, 14 Aug 17, 15 Sep 17
    Lupron every 90 days. 1st injection 12 Jun 17, 2d 15 Sep 17, 3d 18 Dec 17, 4th 6 Mar 18, 5th 5 Sep 18; 17 Dec 18
    Bone/Body Scans - 15 Sep 17 - neg
    EBRT: 69 Gy total (46 to fossa, 23 boost to suspect areas) 1st treatment 28 Sep 17, last 22 Nov 17
    PSA: 25 May 17=0.2; 5 Sep 17=0.1; 18 Dec 17=0.1; 6 Mar 18=0.1; 29 May 18=0.1; 5 Sep 18=0.1; 17 Dec 18=0.1; 12 Mar 19=0.1; 25 Mar=0.1

  5. #15
    Newbie New User
    Join Date
    May 2019
    Posts
    5
    Thanks all for your comments, I keep learning every day after reading this amazing forum. Thanks you so much for sharing so much information.

    I am trying to get as ready as possible for my meeting on Tuesday.

    I will keep all of you posted.

    Warm regards to all of you.
    DoB 1970
    PSA Oct 11 1.94
    Jul 16 1.87
    Nov 16 3.00
    Apr 17 2.10
    Dec 17 4.10 Took Minocin and went down (antibiotic)
    Feb 18 3.30
    Jul 18 3.40
    Dec 18 4.20 Took Minocin and kept going up (antibiotic)
    Mar 19 4.60
    April 19 Biopsy 13 cores 1 3% Gleason 3+3, other doubtful.
    Father and uncles wit PCa, father died from Urothelial Ca.

  6. #16
    Quote Originally Posted by Transiter View Post
    Thanks Djin Tonic next week I am expecting to get the second opinion for the biopsy report and then get recommendations. I will keep all of you posted. So far, I have 3 opened options:

    - My urologist of reference that I trust (great surgeon, very experienced, but does open RP and he is in Europe, with all the complications of that, me living in the US)
    -

    Radical prostatectomy, whether done open or with the Davinci robot, is one of the most technically challenging surgeries commonly done nowadays.

    You definitely will want to see a surgeon who has considerable experience with the procedure- at least 300-400 procedures if not more.

    The Davinci machine offers no better results in the medium/long term than does the open. However the Davinci procedure offers a quicker recovery, quicker removal of the catheter and often a quicker return to work. The open procedure takes less time, and often costs less money, will also generally require less anesthesia.

    Most people go for the Davinci nowadays here in America and they are refining that machine all the time.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3

  7. #17
    Quote Originally Posted by Southsider View Post
    ...
    The Davinci machine offers no better results in the medium/long term than does the open. However the Davinci procedure offers a quicker recovery, quicker removal of the catheter and often a quicker return to work. The open procedure takes less time, and often costs less money, will also generally require less anesthesia.

    Most people go for the Davinci nowadays here in America and they are refining that machine all the time.
    A comparative study of robot‐assisted and open radical prostatectomy in 10,790 men treated by highly trained surgeons for both procedures [2019]

    Abstract

    Objective
    To compare oncological, functional and surgical outcomes of open retropubic radical prostatectomy (ORP) vs. robot‐assisted laparoscopic radical prostatectomy (RARP).

    Patients and Methods
    We identified 10,790 consecutive treated patients within our prospective database (2008‐2016) who underwent either ORP (n=7,007) or RARP (n=3,783). All procedures were performed by seven highly trained surgeons performing both surgical approaches regularly. Oncological (48‐month biochemical recurrence rate [BCR]), functional (urinary continence, erectile function) and surgical outcomes (rate of nerve‐sparing procedures, lymph node yield, surgical margin status, length of hospital stay, operation time, blood loss, transfusion rate, time to catheter removal) were assessed. Kaplan‐Meier, multivariable Cox and logistic regression models were used to test for BCR and functional outcome differences.

    Results
    No statistically significant difference regarding oncological outcome distinguished between ORP vs. RARP. Regarding functional outcomes, one‐week continence rates were higher in ORP (25.8% vs. 21.8%, p<0.001). At three months, no statistically significant differences were observed. At one year, continence rates were modestly higher in RARP (90.3% vs. 88.8%, p=0.01). This effect was no longer observed after stratification for age‐groups. One‐year potency rates were similar in ORP vs. RARP (80.3% vs. 83.6%, p=0.33). Regarding surgical outcomes, no significant difference was observed in rates of nerve‐sparing procedures, lymph node yield, surgical margin status, and length of hospital stay. Conversely, operation time was shorter in ORP, and blood loss, transfusion rates and time to catheter removal were significantly lower in RARP.

    Conclusions
    Both surgical approaches, performed in a high‐volume center by the same surgeons, achieve excellent, comparable oncological and functional outcomes. However, a modest advantage for RARP regarding surgical outcomes was observed, most likely attributable to its minimally invasive nature, and better teaching capabilities. In consequence, more than the surgical approach itself, the well‐trained surgeon remains the most important factor to achieve satisfactory outcomes.
    [Emphasis mine]

  8. #18
    Experienced User
    Join Date
    Mar 2017
    Posts
    82
    Transiter bring an Avocate in with you at your meeting this could be a wife, friend, parent. So much of what is said is missed ussally right after the first sentence! Having a second set of ears is big on all your Appointments...
    steve
    Diagnosis 56: DOB 2/59
    PSA 01/14 2.0
    PSA 6/15/15 2.4
    Biopsy 6/23/15 5 positive very aggressive Gleason Score 8
    Bone Pet Scan & Biopsy of rib Neg
    Radical da Vinci 10/15/15
    Pathology 54g 5x4.2x2.8cm gleason's grade 4+3=7 Tumor location quadrants Bilateral
    Extent of local invasion: Extra-capsular extensions present,Semi vesicles no invasion
    Vascular invasion none, Perineural invasion identified ,Multicentricity : multifocal
    Margins involvement/Not present on inked margins lymph nodes : five negative Pathologic stage pT3a,N0
    PSA 10/6/16 .1 1yr PSA 02/02/17 .4 PSA 02/15/17 .5
    Pet Bone Scan 2/18/17 Neg
    PSA 03/08/17 .6
    03/17/17 Aximun trial 17.4mm recurrence rt. semi vascular bed
    03/29/17 Casodex + Triptorelin Pamoate Injections 2yrs Stopped Casodex 6/18
    04/03/17 SRT (42) completed 6/3/17
    08/31/2017 PSA < .1 Last 6 uPSA <.006 Last uPSA .030 ?

  9. #19
    Newbie New User
    Join Date
    May 2019
    Posts
    5
    Again, thanks all for your wise advises! I had my Dr. appointment yesterday (Radiologist) and I had my wife with me (thanks steve135), she has been great since my diagnosis helping me navigating all this journey! The summary of the meeting is, I need an MRI to confirm the extent of findings done by the biopsy (only one core G3+3 5%, which has been confirmed by 2 different pathologists) and I am considering to go through RALP (I have a meeting set up for next week with a Surgeon once my MRI is done this Saturday). After that, i will have a final picture and then decide.
    DjinTonic, thanks for the statistics between RALP and ORP, which is that it is more important the skills of who is undergoing the surgery, more than the technique itself for the long term results, which is what I have been reading all over this forum and speaking with my urologist "on the other side of the pond."
    But, considering equally experienced surgeons, it looks to be a better solution RALP, which by the way is close by and easy for me and my family!

    Thanks all once again, I will keep you posted of how things evolve.
    DoB 1970
    PSA Oct 11 1.94
    Jul 16 1.87
    Nov 16 3.00
    Apr 17 2.10
    Dec 17 4.10 Took Minocin and went down (antibiotic)
    Feb 18 3.30
    Jul 18 3.40
    Dec 18 4.20 Took Minocin and kept going up (antibiotic)
    Mar 19 4.60
    April 19 Biopsy 13 cores 1 3% Gleason 3+3, other doubtful.
    Father and uncles wit PCa, father died from Urothelial Ca.

  10. #20
    Newbie New User
    Join Date
    Jan 2018
    Posts
    9
    Quote Originally Posted by Transiter View Post
    Thanks Djin Tonic

    - A great, highly reputed institution in Houston where I live where they are going to give the second diagnosis of the biopsy (we will discuss all open options including AS, RP and others).
    My DaVinci RALP was performed in Houston. No regret on that decision.

 

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