Prostate Cancer Network

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Report about Prostatectomy

Hi guys

Since I last wrote, I had a robotic prostatectomy, and just today my catheter was removed (much to my relief). Obviously haven’t had my first PSA test, but I thought I’d update you on the results from the operation.

They weren’t as good as I’d hoped: pT3, N0, M0, GG2, PSA<10.

There was a positive focal margin in the anterior. As far as I can tell, that increases my risk of biochemical recurrence. No evidence if seminal gland or lymph involvement.

The next step could be focal radiation, but I’m hoping that I don’t need to preemptively so this before (and if) my PSA remains or rises.

Thanks

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There is no advantage to jumping the gun. Trials proved that waiting for PSA to rise has the same benefit as treating immediately.

That’s my sense as well, so good to see it confirmed

Did you get a cystography prior to catheter removal?

No. 8 days after the operation, my urologist just removed it. It seems fine. Mostly the urine is clear, although one day on, there has been still a little blood at times.

I just went through the same as you less than 2 months ago. A little blood in the urine as well, the doctor said not to worry, it's normal. In fact everything seemed fine for a few days and then I think a little clot made its way out and a little blood but by the next day it cleared up. Obviously if you see a lot of it then it would be time to call the doc. As far as the cystography, my doctor said it wouldn't be necessary, they check for a good seal between the bladder and urethra before they're done, I think robotic assisted lends itself very well for that. Good luck, I'm also waiting for my first post-surgical PSA.

The waiting for the PSA is definitely the hard part. The blood is less, although there is still a little at times, almost like small clots. They don't worry me too much, as things are settling down. Too much activity, though, does tend to make my penis ache!

Just take it easy. The first 3 weeks are the toughest, get enough walking, I was doing about 1/2 mile pacing around the house every day. Drove my dog nuts. LOL

so if it is pT3, that would mean there is extension outside the prostate, no? and if so, wouldn't it behoove you to get a PSMA scan and radiate it right away? Along with ADT for some period of time?

As far as I understand from talking to my urologist yesterday, I have a small positive focal margin. Someone's going to correct me, but my understanding is that this doesn't mean that the cancer is outside the prostate, but that there is a heightened risk that it some cancerous cells could be outside, and eventually spread. I don't think it could be said that there is an extension, but I will check with my urologist.

No corrections from me, Firefly, but elaborating a bit regarding why positive margins don't necessarily mean that viable cancerous cells remain: In my case, the pathologist reported adverse pathology in the form of focal extra-prostatic extension into the bladder neck, with positive margins of 2 mm linear length there and at the left anterior, but no involvement of the seminal vesicles or lymph nodes, resulting in a stage classification of pT3a pN0. The surgeon indicated that he used cautery in the areas of positive margins, which might have destroyed the cancerous cells remaining there. Anyway, so far, so good: Quarterly PSA test results through 22 months have been below the limit of detection (<0.014 ng/mL).

Best wishes for a good outcome!

Good to hear your PSA has stayed low. That's my hope. When I see my urologist about my first post-op PSA, I am determined to get all the information I missed at my catheter removal. One is the length of the positive margin, and also confirmation of post-op Gleason and also confirmation of no involvement of the seminal vesicles or lymph nodes. I'm guessing the 'a' in pTa is determined by having a positive margin under a certain number if millimetres.

I hope that's right. We're all learning here, that's why I asked the question. the pT3 designation, when i looked up its meaning, sounded worse than what you were describing. Perhaps they are being overly conservative. In any event, the question I would have is when a PSMA scan and further treatment would be useful. I just don't like the concept of waiting.

Tall_Allen is right--the weight of the evidence is that there is no benefit to adjuvant radiation now compared with salvage radiation later if it becomes necessary.

medpagetoday.com/clinical-c...

That article seems to have some language in it that says many of the subjects had favorable characteristics. Am I reading that right? And that very unfavorable might be treated differently?

The trials mentioned (RADICALS, RAVES and GETUG-AFU17 ) all enrolled only men with at least 1 high-risk feature. The GETUG-AFU17 specifically mentions positive surgical margins as an inclusion criterion. No, they didn't require all the possible high-risk features in every case; most of these would probably be on ADT as well.

Thanks, I tried to re-read it and then got a signup page.

I'll post the portion outlining the included studies:

"The RADICALS trial included 1,396 men with localized prostate cancer associated with at least one high-risk characteristic (pathologic T-stage 3 or 4, Gleason score 7-10, positive surgical margins, or preoperative PSA ≥10 ng/mL) and randomized them to either adjuvant radiotherapy (697 men) or early salvage radiotherapy (699 men). Five-year biochemical progression-free survival (bPFS) was 85% with adjuvant therapy and 88% with salvage therapy, representing a nonsignificant 10% increase in the risk of biochemical progression in the adjuvant group (95% CI 0.81-1.49, P=0.56).

A second trial – RAVES – included 333 patients with high-risk features. Results there were also a toss-up, with 5-year bPFS of 86% with adjuvant radiotherapy versus 87% with salvage radiotherapy (HR 1.12, 95% CI 0.65-1.90, P=0.15).

GETUG-AFU17 included 424 patients randomized to immediate or delayed radiotherapy after radical prostatectomy. After a median follow-up of 75 months, patients receiving the adjuvant radiotherapy had a 5-year EFS of 92% versus 90% for those who underwent delayed radiation therapy (HR 0.81, 95% CI 0.48-1.36)."

thanks, it does seem where the evidence is pointing. A French randomised study supports this: thelancet.com/pdfs/journals...

Yes, though I jumped to the interpretation section, "Although our analysis lacked statistical power", and I didn't look at the actual statistics.

I take your point. My urologist was saying everything was good, and it was only when i pressed him on the pT number that he said that technically it was pT3, because of the focal point. He seemed under concerned, which is why I'm less concerned than I might have been. I suspect they wouldn't start radiation for 6 weeks anyway, to settle down the area after the operation, so if the PSA test shows biochemical recurrence, I probably haven't lost anything. Tell me if I'm wrong on this.

That's what the weight of evidence seems to indicate.

ibb.co/album/601d6j Hope this helps you too.

I waited until my PSA rose to 0.18 which took 2.5 years after my prostatectomy. Most studies show benefit to start radiation around the 0.2 PSA level but less than 0.5.

I am now almost 4 years out after radiation and PSA is undetectable <0.1.

Welcome aboard. The two weeks after my catheter came out were the worst of the whole process. I was convinced I would be pissing myself forever. Didn't happen. My MO and RO were very eager to start "salvage radiation" plus ADT right away. I was not. I wanted to see evidence that there was anything needed "salvage." I am now two years post-op with non-detectable PSA. Glad I waited. It was a battle of wills between me and the MO/RO. The RO dropped out but I see the MO now every six months. At the last visit he was able to bring himself to acknowledge that it looks like my instincts had been correct!!! Trust your instincts. It is easy and tempting to give into the "do something/anything" frame of mind. It is much harder to sit on the fear and see how things go.

Thanks. We'll see after my first post-op PSA, but I'm almost in the opposite, my urologist seems unconcerned, so that makes me think, maybe I should be!!

Would be good to get confirmation from your Urologist Firefly. I know I had the following rating and I was told mine had not spread, clean margins is what they stated. While they did say I have a 50/50 chance of additional treatment in next 10 years. They didn't recommend any further treatment, just monitor PSA.

Primary Tumor (pT): pT3b

Regional lymph Nodes (pN): pNO

What did they mean by "b" in the pT3b, as far as you know?

pT3b: Seminal vesicle muscle wall invasion

Firefly I am 3 years ahead of you and went through everything you have already gone through and many things that you are about to go through. I have been cancer free since October 2019 and I truly believe that my success was due to a combination of chemo, radiation, complete change of diet and holistic supplements that I still take today. I have prepared a very detailed list of what I took if you are interested. All my best to you Firefly and remain very positive in your thinking.

I am interested in your list. Please post it. TIA.

I apologize but I do not know how to post it on this site.

The easiest way is to take a picture of it, or alternatively scan it if you have a scanner, and start a new thread where to you will be allowed to upload it as a picture. A bit more complex is uploading said picture to imgbb.com/ and posting the link here.

I could send you my email, but I fear there will be others also interested in having it that will lead to more work to be done.

ibb.co/album/601d6j

Very detailed. Will study it thoroughly. Many thanks.

I wish you good health and all my best.

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