Category: Prostate cancer

Decision regarding the surgery

Having ruled out active surveillance and radiation therapy, the final decision I needed to take was about the type of surgery and the timeline. I initially thought that I could wait a few weeks, but new information received on 23 May has prompted me to be a bit more aggressive about the surgery date.

However, various circumstances mean that the date is broadly as predicted, in mid-July.

I initially thought I’d undertake surgery in the public system, but finally decided on robotic surgery for a single reason.

I undertake open (not robotic) surgery in the public system at the earliest date (allowing around 4-6 weeks for recovery from the biopsy) and to undertake any feasible portion of the trip to Europe/India before the surgery.

QUALIFICATION: Given that I knew nothing about prostate cancer till 18 May, and have learnt everything I know about it in the past week, I will change my decision if new and more persuasive information comes in.

Reasons

1. Type of surgery

I will undertake open surgery (not robotic) given there is no difference in outcomes between the two, particularly after the first three months.

2. Timeline for the surgery

a) Waiting for biopsy surgery to heal

It is a good thing to wait 6-8 weeks for the biopsy surgery to heal (details here).

b) Going only my biopsy results and PSA, it is OK to get surgery within 75 days from biopsy

The table, below, from a major study on this issue is very useful (Study: Delay From Biopsy to Radical Prostatectomy Influences the Rate of Adverse Pathologic Outcomes William T. Berg,1 Matthew R. Danzig,1 Jamie S. Pak, et al. -PDF is available online)

The table above shows that PSA is more influential in determining the severity of the cancer than the Gleason pattern score, alone. Further PSA is more reliable (being objective, compared with Glaeson scores which are subjective). My cancer is ranked Gleason 7 (but 3+4, not 4+3). Since this is a milder form of Gleason 7, a delay of between 105 and 150 days should be OK.

But even if biopsy has been poorly done and a portion of the tumour with Gleason 8 was accidentally excluded, I have up to 75 days.

Data from the biopsy suggest that a delay of 75 days is ACCEPTABLE (i.e. till 25 July 2017, given the biopsy took place on 11 May 2017. Surgery between 5 July and 25 July should not meaningfully impact the spread of cancer.

c) Relevant data: My tumour is located in the transitional zone and is pushing the edge

My MRI report is shows that the cancer is located in the transition zone (abutting it for 1 cm) and is causing a slight bulge in the body of the prostate.

 

There is evidence in the literature [see this] the the location of a cancer is related to the prospects of metastasis. Although there may be some time, I should not wait unnecessarily.

d) Relevant theory: At my age the cancer may become aggressive

It is a fact that even after radical surgery, prostate cancer returns (having probably spread prior to the surgery). All it takes is one aggressive cell to get out.
An oncologist from Mumbai told me that at relatively younger ages, cancer can mutate into the aggressive varieties more quickly, compared with what happens in one’s 70s and 80s. This, too, suggests, not waiting unnecessarily. 

There is contrary evidence that “in the vast majority the cancer is born with a particular Gleason score.”  “You might see progression in an individual, but we think that it’s uncommon,” she says. “We just can’t rule out this possibility in our study.” [Source]

“advanced cancers [that have spread] are not being found as much because PSA testing has identified them earlier, but aggressive cancers (high Gleason score) are being found at the same rate. The aggressive cancers are being found early (i.e., when they are “born”), rather than transforming into aggressive cancers over time.” [Source]

However, on balance, the logic does suggest that there remains a risk of metastasis given my age profile. Medical science doesn’t have all the answers.

CONCLUSION

I am now processing the surgery in the public system (which is free compared with $10,000 or so for robotic surgery through private health insurance). There is a wait time of around 30 days for prostate surgery in Victoria (such as here).

This is likely to take some time and might allow me to undertake a part of the planned trip.

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MRI report for prostate

My MRI report dated 20 April 2017

MRI PROSTATE

Clinical Notes: Elevated PSA 3.95.

Report: Routine multi-parametric 3T imaging of the prostate. Prostate volume 35ml.

There is a large PIRADS 5 lesion centred within the right anterior transitional zone involving the mid gland apex. This measures 20 x 8 x 15mm in size (AP x CC x trans). Anteriorly, this abuts the anterior fibro-muscular stroma, with subtle bulging of the capsule but no visible tumour extending beyond the gland. The tumour has more than 10mm of abutment of the capsule and has at least moderate likelihood of microscopic extra capsular extension. The left side of the transitional zone shows mild nodular change and BPH, with no suspicious lesion.

The peripheral zone shows mild diffuse low T2 signal change without a focal nodule or restricted diffuse and there is no lesion involving the peripheral zone.

The prostate contour remains smooth and the recto-prostatic angles are preserved.

The seminal vesicles are normal. There is no pelvic lymphadenopathy. Bone marrow signal within the imaged field is normal.

Conclusion: 20mm PIRADS 5 lesion, right anterior transitional zone in mid gland and apex. There is capsular abutment with minor bulging and abutment of the anterior fibro-muscular stroma. Moderate likelihood of ECE.

Seminal vesicles, lymph nodes and bone marrow are normal.

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Which is better for prostate surgery – open surgery or robotic?

CONS OF USING ROBOTIC SURGERY

This doctor does not recommend robotic surgery http://www.drcatalona.com/qa/faq_initial-treatment.asp

Reasons: “it is far more difficult to get consistently good results because it does not afford the surgeon as much control as with the traditional operation. Also, it does not provide tactile feedback, and it is more difficult to suture laparoscopically.  The surgeon cannot tell how hard the robot is grasping tissue, or, if the angle of the needle is wrong and if the needle does not pass through the tissues easily, the robot continues to “muscle” its way through. With tactile feedback afforded by open surgery, the surgeon would “feel” the mistake and make the necessary adjustment.

Having seen laparoscopic and robotic surgery performed by most of the world’s most experienced experts, I don’t believe it allows nerve-sparing to be performed with the same degree of fine control without risking thermal damage to the neurovascular bundles, and I do not believe removal of the cancer is as consistently complete.

STUDY

the most significant outcomes (cure, continence, and potency) are no better with LRP or RALRP than with conventional ORP. Therefore, in experienced hands, ORP remains the gold standard procedure [ Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US  experience – Julia Finkelstein, BSc, Elisabeth Eckersberger, MPA, Helen Sadri, MD, Samir S Taneja, MD, Herbert Lepor, MD, and Bob Djavan, MD, PhD]

STUDY IN AUSTRALIA – no real difference in outcomes

Expensive robotic prostate surgery, marketed as “ground breaking”, “revolutionary” and “nerve sparing”, has been found to be no better at preserving men’s urinary continence and sexual function than traditional surgery. A landmark Australian study made the finding after comparing the advanced surgery, which can cost more than $10,000, with traditional open surgery three months post operation.  Patients who had the open surgery lost more blood during the procedure but none of them needed transfusions. Patients who had open surgery had a longer hospital stay post surgery and experienced more pain doing day to day activities one week after the operation but, on average, both groups spent the same number of days off work.

President of the Urological Society of Australia and New Zealand Mark Frydenberg said the study, published in The Lancet medical journal on Wednesday, showed both techniques were “equally effective”.

Professor Frydenberg said “patients without access to robotic surgery should not feel in any way disadvantaged or be concerned they will have an inferior outcome”.

“Our view is that both robotic and open surgery are very valid treatments for prostate cancer but what is of most relevance to outcomes is the skill and experience of the surgeon,” he said.

[Source]

MY CONCLUSION

Robotic is new and potentially OK, but because there is no longer term difference in outcomes, I think open is OK. At least at this stage, when surgeons trained in open surgery are still available. In the future such surgeons may become fewer and fewer.

ADDENDUM – CHANGE OF MIND

But there is a major issue that has low probability of occurring but can cause real problems. Scar tissue can be formed due to poor healing, causing enormous problems.

http://urology.jhu.edu/newsletter/prostate_cancer825.php

Worse thing is that the problem returns every three months once it starts:
Apparently, this is less of a problem with robotic surgery since it can apply a running suture (12 stitches). The manual surgery (open) is only able to apply seven, and not very well.
It has a few other advantages as well: “Cutting and putting in stitches is easier with the robotic assistance” (Source), recovery is quicker, etc.
“In a robotic removal the anastamosis is intraperitoneal and is supposed to be water tight. In an open prostatectomy the anastamosis is extraperitoneal and requires only 4 stitches and that the urethra and bladder neck be aligned correctly over the catheter.” [Source]
As a result I’ve gone for robotic.

Comparison of Prostatectomy Surgical Options: Open, Laparoscopic, and Robot-Assisted Laparoscopic

  Open Surgery* Robot-Assisted Laparoscopic*

 

Surgery Time 3 1/2 Hours 3 1/2 Hours
Hospital Stay 2 Days 1 Day
Total Incision Length 5 inches 2 inches
Estimated Blood Loss 375 cc 116 cc
Visualization 3 D 3 D
Magnification of Visualization up to 3X with magnifying glasses 10-12 X (utilizing a pair of high resolution cameras)

 

Instrument Handling Normal Normal (Optional Micro-precision)
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How much to wait between biopsy and prostate surgery. Ideal duration between biopsy and prostatectomy.

STUDIES SUGGEST A SMALL WAIT CAN IMPROVE SOME OUTCOMES

“Those who had a TP within six weeks of the biopsy were less likely to have a bilateral nerve sparing procedure.” [Source]  [Source is credible – a paper called Total prostatectomy within 6 weeks of a prostate biopsy: is it safe? by Kishore T. Adiyat; Manoharan Murugesan; Devendar Katkoori; Ahmed Eldefrawy; Mark S. Soloway of the Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA]

“Open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.” [Source] – NOTE: THIS LIMITATION DOES NOT APPLY TO OPEN SURGERY [paper: Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative
outcomes by George L. Martin, Rafael N. Nunez, Mitchell D. Humphreys, Aaron D. Martin, Robert G. Ferrigni, Paul E. Andrews and Erik P. Castle Urology, Mayo Clinic Arizona, Phoenix, AZ, USA]

DOCTORS WHO BELIEVE IN 6-8 WEEKS DELAY AFTER BIOPSY

Q: How long do I need to wait after my biopsy to undergo a robotic prostatectomy?
A: Dr. Miller recommends a minimum waiting period of 8 weeks following biopsy prior to proceeding with robotic prostatectomy.  Significant inflammation occurs after a prostate biopsy resulting in temporary distortion of the anatomy (particularly when operating under such extreme magnification).  Since prostate cancer is such a slow growing disease, this relatively short wait does not impose an appreciable risk.” [Source]

“repeated biopsies can make it more difficult to perform nerve-sparing surgery.” [Source] – meaning that biopsies do impact the ability to identify nerves.

The doctor below suggests 6 weeks (for inflammation to be healed).

What should you do during this six weeks?

KEGEL exercise should be conducted prior to the surgery [Source]

common sense:

This is a slow growing cancer so a few weeks here and there will make no difference now. If it turns out after the op that it has spread, it has in all likelihood already done that – and not in the few weeks since your pSA test. Cancer doesn’t wait quietly until it is diagnosed and then go on the rampage [Source]

 

how long to wait between biopsy and prostate surgery?

how long to wait for surgery after prostate biopsy?

Safe waiting time from biopsy to prostate surgery

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Kegel exercises pre and post-prostate surgery + Peter Dornan exercises

HOW TO DO IT

DON’T EVEN TRY TO LEARN THESE ON YOUR OWN. VISIT A HIGHLY TRAINED PHYSIOTHERAPIST.

PRE-SURGERY

Start 4 to 6 weeks prior to surgery to get into the habit of incorporating them into routine activities such as exercising. Practising even one day before surgery is beneficial.

Contract your pelvic floor muscles > Hold the contraction for two or three seconds, then relax > Repeat 10 times > Do this three times per day.

Make sure you contract gradually, then hold. Like turning up a dimmer. And DON’T pull at 100 per cent. Do at around 30 per cent of the maximum intensity.

Watch this at 4 minutes, 24 seconds:

“Kegel exercises the deliberate tightening or clenching of the pelvic muscles. Performed regularly, they tone and strengthen the external sphincter, the rings of muscles responsible holding in urine.” [Source]

The above recommendation is similar to this one: “my doc, out of a university hosp in the USA midwest, has a brand new way to do kegels. Take it for what its worth for I am trying it tonight. I stop all liquids early in evening around 830 or 900 p.m. I then do kegel and hold for 3-4 minutes and then rest same. I am to do 5 reps at first and then build to 10. I never heard of it this way before.” [Source]

EXERCISE WHILE URINATING: 

“Every time you urinate, do it standing up. You can’t practice the following exercises, which strengthen the external sphincter and speed up your recover of urinary control, while you’re sitting down.

Start your stream, and once it’s in full force, stop the stream by contracting then muscles in your buttocks– not your abdominal muscles, not the muscle up in front around the penis. Tighten your buttocks; imagine you’re trying to hold a quarter between your cheeks. Hold the urine back for five or ten seconds, and repeat as many times as you can. Note: Perform these exercises only when you’re urinating; if you keep contracting these muscles throughout the day, you’ll overdo it. The sphincter tires easily, and you’ll end up wetter than you would be otherwise.” [Source]

“When possible, use PFEs to defeat the urge to urinate. This will both improve muscle tone and do bladder training at the same time: “responding to the urge to go with PFE’s will satisfy the urge — until it next occurs. Rather than get up several times at night, do your PFEs, roll over and go back to sleep — It does work !!! Typically, incontinence may be a matter of discipline. I can get up 6-times per night or once.” [Source: Prostate Problems Mailing List]

“Do the Kegel exercises, and call me back in three months.” He dismissed both Dr. Walsh’s prohibition against doing Kegel exercises and the usual recommendation of doing a half a dozen of them two or three times a day. His patients did them by the hundreds, in series, and the relaxation between each contraction, I should remember, was as critical as the contraction” [Michael Korda in his book, MAN TO MAN]

 

I believe Peter Dornan‘s technique is very important and should form part of the overall exercise strategy (Conquering Incontinence 2003 – SUMMARY PDF HERE).

I developed a program to treat incontinence. This involved, basically, designing a strong exercise program for the pelvic floor muscles which were progressively overloaded by integrating the abdominal muscles, as well as developing a super-fit neuromuscular reflex circuitry. My experience led me to write a book outlining the program – “Conquering Incontinence” (see “books” on my website).  [Source]

POST-SURGERY 

NO EXERCISES WHILE CATHETER IS STILL IN

Doing pelvic floor muscle exercises after surgery (whilst a urinary catheter is in place) can irritate the bladder and cause discomfort. It is therefore recommended that you do not do any exercises during this time. However, once the catheter is removed you may start the pelvic floor exercises straight away.

IMMEDIATELY UPON REMOVAL OF CATHETER

When the catheter comes out and you empty your bladder for the first time, reconnect with
your ‘flow stop’ muscles and actually try to stop your urine flow.  Overdoing the pelvic floor exercises after surgery may cause pelvic floor muscle fatigue or pain. Rest the muscles completely when
you are sitting or lying.

NOTE: Do the exercises lying down initially as this exerts the least pressure on the pelvic floor. When an improvement is noticed do them sitting or standing. [Source]

FIRST WEEK AFTER REMOVAL OF CATHETER

Do two sets of five-second contractions in the first three weeks after catheter removal. [Source]

SECOND WEEK AFTER REMOVAL OF CATHETER

The second week after the catheter is removed, increase the amount of time you contract the sphincter for 4 seconds. [Source]

THIRD WEEK AFTER REMOVAL OF CATHETER
The third week and beyond, increase the time of contraction to 5 to 10 seconds. [Source]

“Started in supine, then sitting, standing and during ADLs” [Source] – basically, start when lying down. Then move on to sitting exercises. Finally during walking, etc.

As your muscles get stronger, increase the length of time that you tighten and
hold the muscles to 10 seconds.

As the muscles get stronger, try to do 20 or more contractions at a time. Do them a few times a day. [Source]

The more PFME that can be performed on a daily basis, the better.  Urologists generally recommend a hundred or more a day.  Studies have demonstrated significant decreases in the time to continence in men performing such exercises after surgery.  In fact, randomized studies demonstrated that 74-88% of men regularly performing PFME were dry 3 months after prostatectomy as opposed to only 30-56% of men who did not perform the exercises.  [source]

This table shows the significant variation in prescription by different physiotherapists:

 [Source]

PRACTICAL EXPERIENCE OF ONE PATIENT

“Here are the exercise my therapist gave me:

  • One month after surgery. Seated. Squeeze 5 seconds, relax 15. 15 times, 2–3 times a day. Remembering to squeeze before coughing, laughing, sneezing, or lifting.
  • One month later. Seated. Squeeze 7 seconds, relax 15. 15–20 times 2–3 a day. Also. Seated. Squeeze 2 seconds, relax 4. 10 times twice a day.
  • One month later. Standing. Squeeze 7 seconds, relax 10. 10–15 times twice a day. Standing. Squeeze 2 seconds, relax 4. 10 times 1–2 times a day.” [Source]

“Do the Kegel exercises, and call me back in three months.” He dismissed both Dr. Walsh’s prohibition against doing Kegel exercises and the usual recommendation of doing a half a dozen of them two or three times a day. His patients did them by the hundreds, in series, and the relaxation between each contraction, I should remember, was as critical as the contraction” [Michael Korda in his book, MAN TO MAN]

BENEFIT OF THESE EXERCISES

“PFMT with or without biofeedback enhancement hastens the return to continence more than no PFMT in men with UI after RP. ” [Source]

Incontinence will usually improve with time but by learning how to control the pelvic floor muscles, you can speed up the recovery process and reduce the leakage faster. If you don’t strengthen these muscles, the leakage may persist. [Source]

“One man who commenced pelvic floor exercises a year after radical prostatectomy kept a chart
of his monthly urinary leakage” [Grace Dorey – Pelvic Dysfunction in Men]

HOW TO DO THESE EXERCISES

Identifying your pelvic floor muscles: The first step in performing pelvic floor muscle exercises is to identify the correct muscles. There are several ways to identify them.

  • When you go to the toilet, try to stop or slow the flow of urine midway through emptying your bladder. If you are able to do this you are squeezing the correct muscles. Do not do this repetitively. This is not an exercise, but a way to identify the correct muscles. In the early stages after prostate surgery this will be easiest during the night when the flow is likely to be strongest.
  • You can do the exercise lying down, sitting, or standing with your legs apart, but make sure your thighs, bottom and stomach muscles are relaxed.
  • Stand in front of the mirror (with no clothes on) and tighten your pelvic floor muscles. If you are tightening the right muscles, you should see the base of the penis draw in and scrotum lift up. The back passage will tighten too but it is not the focus of the exercise. When you relax your muscles you should feel a sensation of ‘letting go’.

Correct technique is very important when doing pelvic floor muscle exercises. You should feel a ‘lift and a squeeze’ inside your pelvis. The lower abdomen may flatten slightly, but try to keep everything above the belly button relaxed, and breathe normally.

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Men can be encouraged to tighten and lift the pelvic floor muscles as in the control of flatus and the prevention of urine flow and can practise in front of a mirror to observe a visible retraction of the base of the penis into the body and a testicular lift. The testicular lift may be sluggish initially. In some men with weak pelvic floor muscles only one testicle might rise initially. As the pelvic floor muscles strengthen both testicles will lift more quickly to a higher level. … The intensity of the contraction is more important
than the frequency as maximum voluntary effort causes muscle hypertrophy and increased muscle strength.

Men can be taught to lift their pelvic floor slightly whilst walking. Instruction to tighten the anal sphincter about 50 % of maximum whilst walking will achieve this supportive lift which can become part of good posture and way of carrying oneself. [Grace Dorey – Pelvic Dysfunction in Men]

Walking UI is particularly disturbing to men. It was discussed that asking a patient to maintain tension for extended periods of time is not realistic or accepted with concern of hip muscle dysfunction. However it may be helpful to ask for a low level, submaximal contraction to be held for 5 to 10 steps to restore the ability of the muscle to hold under these circumstances. [Source]

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“Craig teaches his patients palpation of the PFM contraction externally lateral to the base of the
penis at the perineal body. Others have men watch the penis move upward in the mirror or just
by looking down. One PT uses a video camera aimed at the rectal sphincter to show men the
inwards movement.” [Source]

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Pelvic floor muscle training: Once you master the art of contracting your pelvic floor muscles, try holding the inward squeeze for longer (up to 10 seconds) before relaxing. If you feel comfortable doing this, repeat it up to 10 times. This can be done three times a day. Make sure you continue to breathe normally while you squeeze in.

Putting the pelvic floor into action: Every time the pressure in your abdomen increases you are potentially pushing urine out of the bladder. Identify the activities that cause urine to spurt out such as coughing, standing up or lifting, and tighten your muscles first to prevent urine escaping. Practice this control until it is automatic. This is called ‘the knack’. You should also try to use your pelvic floor muscles throughout the day. Some examples of when you could use them are:

  • Whilst walking – try lifting your pelvic floor about 50% of maximum squeeze.
  • When you feel the urge to pass urine – squeeze your pelvic floor to hold on until you get to the toilet.
  • After you have passed urine – tighten your pelvic floor, which may help prevent the embarrassment of an after-dribble leak of urine as the squeeze expels the last few drops of urine from the urethra.
  • After opening your bowels – tighten around your back passage.

Once you identify your pelvic floor then start working on ‘the knack’. Also identify 2 to 3 regular times in a day when you can concentrate and spend 5–10 minutes working on your muscles. It is important that you give your muscles time to recover when getting back into a regular routine. Do this by making sure you ‘rest’ for as long as you ‘hold’. For example, if you hold for 5 seconds make sure you rest for 5 seconds. When your muscles get tired, give them a full minute rest.

As doing the exercises gets easier you can try doing them in progressively more challenging positions: from sitting to standing and on to walking. Over time you may only be leaking when you exert yourself.

By identifying the activities that cause you to leak, you can learn to tighten your muscles to try and prevent it using ‘the knack’. If it happens during your chosen sport you may need to practice the movement involved so that tightening your pelvic floor muscles becomes automatic.

FURTHER

During Kegel exercise the abdominal muscles must be totally relaxed otherwise they will push the organs from inside causing significant injury. In the first few weeks after surgery avoid doing these muscle activities while standing to minimise the pressure on the bladder while it is healing. At https://youtu.be/YkMcA6iDkMk the physio shows how these should be done lying down initially but after sleeping continence is achieved, then only while standing. Do not do excessive exercises as they will harm. Do not hold your breath while doing this exercises. Each time you get up hold your pelvic muscles. If you forget do this then do it five times till it is embedded in your head. That’s how you develop the knack.

How long will I need to keep doing the exercises? Your pelvic floor will remain a weak spot for life. It is therefore important that you keep exercising it for life. If you become sick with the flu and cough a lot you may start leaking again. This does not have to be permanent however, so revisit a pelvic floor training regimen once you recover.


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