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Re: salvage robotic surgery

It is not advisable to try a second surgery. I had a DaVinci and later found out that the surgeon left half of my prostate behind. When I discovered that, I wanted him to go back in to get the rest of it. After many consults with other surgeons, he refused. He said that the nerves were now embedded in scar tissue and could not be easily identified. Going in again would probably destroy my bladder control and decrease the chance of future erectile function. I wound up having radiation instead.

Paul A., USA

Re: salvage robotic surgery

Thank God that a lot of surgeons ain't car mechanics...we would have to walk to get our p.s.a. tests done. I tend to think that both you and I would of been better off without the robot...so a good old fashioned surgeon with a knife could cut and feel things with their hands and realize that cancer has broke through a margin or in your case left 1/2 the prostate inside their patient. All the best!

Re: salvage robotic surgery

Well, purelife52, I have to say that I think you have the wrong end of the stick in some of your views, so here’s my 2 cents worth:

1. You say 85% of t3 cancer creates p.s.a. failure within 5 years. I don’t know where you got this figure from, how accurate the study was, what the definition of failure was etc etc, but to make such a statement with such certainty goes against everything I have learned in 13 years since I was diagnosed. There is simply no such certainty in the PCa world. There may be a relevant study that indicates, in the group of men studied, that 85% of men stage T3 who had surgery and a Gleason Score of 8 had a PSA failure (however defined) but that certainly doesn’t mean that 85% of man with a Stage T3 GS 8 will have such a failure.

2. You also say Lets say the PSA fails in a month. Why do you think it will fail in a month – you just said 85% fail in five years: how many fail in a month? Then you go on to say I will get radiation and that might work for 5 years if I'm lucky Again, where did you get this time limit of five years? And you go on Then chemo....Lucky to make 62 this way. Why chemo, what happened to ADT (Androgen Deprivation Therapy) and although you don’t seem to sure of your age, why do you think you will only live four or five years from now? There is a big difference between a rising PSA after treatment, which is how ‘failure’ is often defined and dying from the disease.

3. You say I want salvage surgery or a real good reason why it can't be done…….I think that the fat to the right of the margin is a pretty easy target. Please correct me if I'm wrong. I believe you are wrong for the reasons that some of the men have advanced on this thread and which no doubt some of the doctors you have spoken to have advanced. There will be scar tissue in the area, where your first surgery has healed, it will not be at all clear just where any spread might have taken place – there are no arrows down there saying ‘cut here’; ‘scrape there’, because what you are suggesting has not been done (or has been done so rarely that no one seems to be aware of it as an option) how can any surgeon be expected to go in without any guidance.

4. Finally you say …..a good old fashioned surgeon with a knife could cut and feel things with their hands and realize that cancer has broke through a margin or in your case left 1/2 the prostate inside their patient. You haven’t shared precisely what your pathology report said about positive margins, but I’m guessing that it will show that there is microscopic evidence of the probability of spread beyond the gland – and that is something that no surgeon could feel with his hands in surgical gloves.

To my mind you are over-reacting to something that may never happen,

Good luck, wherever your path may take you. But I’d suggest your journey may be easier if you read up a bit more about the disease and gained a greater understanding of the issues.

Terry in Australia

Re: salvage robotic surgery

Thanks for the consult Terry! Your answer was very well put and has answered most of my questions, thank you. The invasion is microscopic, and the endo mri and the needle biopsy kinda said ITS RIGHT HERE! SCRAPE IT OUT! but I guess it's not that easy. Would a top gun surgeon of got it? I guess I'll never know. Watchful waiting for the time being I guess. Surgeon said the statistics are showing much better results if radiation is started before any p.s.a. failure. Urologist said that the surgeon is nuts and to wait as long as possible, or at least until max continence and the other thing are working ok. Radiation stalls the healing process, often permenently I've heard, and I aint there yet.

Re: salvage robotic surgery

I had a "top gun" surgeon operating the robot. He got blinded by scar tissue from my earlier TURP. I asked him if he could go in again and get the 6 grams that he left behind. He said that scar tissue had caused him to lose his landmarks. He couldn't go in again and find his way now that there was even more scar tissue.

Take a breath. Wait and see. To me your post op position does not look like you need urgent action. But in any case, IF you need further treatment at some point I doubt anyone will offer or suggest further surgery.

Ted from England

Re: salvage robotic surgery

My surgeon (in the summer of 2007) said the same thing, that radiation treatment given early for t3 cancer is more effective than later. He told me to wait three months after the surgery though, to get well healed. I followed through on that plan and recommend it to you.

Re: salvage robotic surgery

Thanks for the post Bill G. 3 months after surgery you started radiation. How did it effect your continence Etc. Do you know if you had the 60 something RADS or the stronger dose 70 something? Your psa during treatment? Did it jump up? What is it now? Thanks in advance!

Re: salvage robotic surgery

The doc told me to wait till I regained continence but not to start sooner than 3 months after surgery. By that time I had just regained full continence, and the radiation caused no problems for continence. I got the lower 60 Gray dose, I think the 70 is usually for when you wait till later and the PSA is rising. My PSA was 0.1 after surgery and still 0.1 when I started the radiation. It was undetectable when first checked a few weeks after finishing radiation. And has remained undetectable since then. Only problem from the radiation was some strong pain when beginning a bowel movement. That problem was only for a week, never have had a problem with bowels since.

Re: salvage robotic surgery FROM ANOTHER WEB SITE

dx Jan 2001 gleason 4 + 3 PSA 16.5
Seed implant and conformal radiation and Lupron from Jan 2001 to Jan2002
2005 Dec PSA began to rise from .5 to 8 within 6 months
Salvage surgery at MSK 9/06 Dr. Eastham
Fistula operation 2/07 MSK Dr. Wong
Many cystoscopies and ER visits with strictures
Catheter for one year....Catheter taken out Sept 07..
Total Incontinence since then....
PSA .52 3/08
AUS Operation at MSK Sept 8 2008 Dr. Sandhu
Activated Oct 28th Dr. Sandhu..MSK
Some difficulty with AUS arising Nov 10 2008
Meeting with Dr. Sandhu to discuss AUS problems and new PSA test Dec 11, 2008
PSA .6 12/08
AUS improving..only 2 pads a day and one at night
Complete hip replacement surgery Dr. Waters Gainesville, FL 1/9/09
Hip replacement total success..pain gone!!
PSA .7 2/10/09

Re: salvage robotic surgery

finally found a salvage surgery. ON ANOTHER FORUM. Perhaps my desired type of salvage robotic surgery needs a different name. Pre-emptive cleanup or something like that. The more I read about my age and staging etc, I'm starting to feel lucky to of gone 6 months {so Far} with a non-detectable P>S>A<.

Re: salvage robotic surgery

I am a member of that forum as well and the poster is the very fine wife of the PCa patient whose story you mention. The salvage surgery followed relapse after initial treatment by radiation and if you contact her via that forum she will undoubtedly describe the misery he found himself in. I am pleased to say she has posted that he has much improved.

Re: salvage robotic surgery

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SALVAGE SURGERY FOR BULKY LOCAL RECURRENCE OF PROSTATE CANCER FOLLOWING RADICAL PROSTATECTOMY

DAN LEIBOVICI*, LANCE PAGLIARO, CHARLES J. ROSSER, LOUIS L. PISTERSCorresponding Author Information‡email address

ABSTRACT
Purpose:

We report our experience with salvage radical surgery as palliative treatment in patients with bulky recurrence of prostate cancer following radical prostatectomy (RP).
Materials and Methods:

From files at the department of urology we identified 5 patients who had biopsy confirmed, bulky recurrence of prostate cancer after initial RP and subsequent salvage radiation therapy (4), prior to presentation at our cancer center. Positive surgical margins were present in all 5 patients. All received androgen ablation and 4 also received systemic chemotherapy. Due to persistent bulky tumors in the 5 patients and debilitating unrelenting symptoms, including refractory hematuria, obstructive uropathy and pelvic pain in 4, salvage radical surgery was performed. Total pelvic exenteration was done in 4 patients and wide tumor resection with continent urinary diversion was done in 1.
Results:

Four patients were permanently relieved of local symptoms following surgery and another had entero-urethral fistula formation. Revision of a continent urinary diversion was necessary in another patient who was otherwise free of cancer and of local pelvic symptoms. Long-term symptom-free survival was achieved in 2 patients following surgery at 26 and 56 months, respectively. One patient died of metastatic disease 3.5 months after surgery but he had been rendered free of local symptoms by surgery. The other 2 patients are currently free of local symptoms 5 and 7 months following surgery, respectively. Wound infection, delirium and prolonged ileus occurred in 1 patient each. Otherwise surgery was well tolerated.
Conclusions:

Salvage radical surgery is feasible and it provides effective palliation in patients with bulky local recurrence following RP.
Key Words:: prostate , prostatic neoplasms , prostatectomy , salvage therapy , radiation therapy , pelvic exenteration , palliation , radiotherapy

From the Departments of Urology and Genitourinary Medical Oncology (LP), University of Texas M. D. Anderson Cancer Center, Houston, Texas

Re: salvage robotic surgery

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Abstract | References | Full Text: HTML, PDF (Size: 234K) | Related Articles | Citation Tracking
Robotic salvage retropubic prostatectomy after radiation/brachytherapy: initial results
Jihad H. Kaouk, Jason Hafron, Rajk Goel, George-Pascal Haber and J. Stephen Jones
Section of Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
Correspondence to Jihad H. Kaouk, Director, Robotic Urologic Surgery, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic, 9500 Euclid Avenue, A100, Cleveland, OH 44195, USA. e-mail: kaoukj@ccf.org
Copyright © 2008 BJU International
KEYWORDS
robotic prostatectomy • prostate cancer • salvage

Study Type – Therapy (case series)
Level of Evidence 4
ABSTRACT

To report on the initial four patients who had robotic salvage retropubic prostatectomy (SRP) for biochemical recurrence after radiation therapy, and to review the surgical outcome of robotic cystoprostatectomy for bladder cancer in two patients who previously had prostate cancer.
PATIENTS AND METHODS

Since February 2006, four patients had SRP for biochemical failure after radiation and/or brachytherapy. Transrectal biopsy of the prostate confirmed locally recurrent disease and a metastatic evaluation including bone scan and computed tomography of the abdomen and pelvis were negative in all cases. The SRP was done using a six-port transperitoneal approach. An additional two patients had a robotic cystoprostatectomy for bladder cancer, in whom radiation was provided previously for prostate cancer. A retrospective analysis of the immediate and short-term surgical outcome was reviewed.
RESULTS

SRP was completed in all patients with no major complication or conversion to an open approach. The mean operative duration was 125 min, the mean (range) blood loss was 117 (50–250) mL and the mean hospital stay was 2.7 days. Of the four patients undergoing SRP, three had extracapsular extension and the first two had positive margins, while no patients had rectal injuries or significant blood loss. The lymph nodes were negative in all the patients. Three patients were continent within a month while one continued to use two to three pads/day at 3 weeks of follow-up. In the two patients who had cystoprostatectomy there were no major complications or increased surgical difficulty.
CONCLUSIONS

SRP is technically possible and with limited perioperative morbidity. Further studies are warranted to validate the oncological and functional outcomes of SRP after radiation and/or brachytherapy. Moreover, the robotic approach for radical cystoprostatectomy in patients who have had prostate radiation is feasible, with no increase in perioperative morbidity.

Accepted for publication 5 December 2007
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1464-410X.2008.07570.x About DOI
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Re: salvage robotic surgery

I really don't understand the point of posting these two Abstracts of very small studies involving less than 10 men, but perhaps purelife52 can explain that.

If he, or any one else, wants to post Abstracts of studies, would they please

1. make sure that they are relevant – that is to say they advance the knowledge of men who read them or raise questions for discussion.

2. Edit them so that all extraneous matter is removed before posting


It is well known that salvage surgery is possible after other therapies have failed. What is also known that it may not be the best option for the patient - and these studies seem to reinforce that view. They put me in mind of my dear old Dad who always used to quote the apocryphal surgeon saying I am pleased to say that the operation was successful. Regrettably the patient died.

Just look at the results reported in the first study:

Long-term symptom-free survival was achieved in 2 patients following surgery at 26 and 56 months, respectively. Now for me, that’s an interesting definition of long term survival – a little over 2 years in one case and a little over 4 years in another!

and

One patient died of metastatic disease 3.5 months after surgery but he had been rendered free of local symptoms by surgery. Gee, he must have been happy to have 3.5 months symptom free after the rigours of surgery. I wondered how many of the reported side effects, like Wound infection, delirium and prolonged ileus occurred in 1 patient each. Otherwise surgery was well tolerated. he had to tolerate before he died

And finally:

The other 2 patients are currently free of local symptoms 5 and 7 months following surgery, respectively Gee whiz – 5 and 7 months survival! Getting towards long-term in this study’s definitions.



All the best

Terry in Australia

Re: salvage robotic surgery

I'm fairly certain that radiation, a.d.t, and most other treatments for this disease and all others began with small studys. You act like no one dies getting ADt radiation or chemo. Perhaps as we age one tends to get narrow minded and set in there ways. The treatments have been mor or less the same for many many years. To say a different approach is n/g is lame. What if next week a camera dude invents a lens that see's thru scar tissue? Salvage robotic surgery would be easy.

Re: salvage robotic surgery

You are quite correct when you say that the development of all forms of treatment – and the way in which they develop and improve – start with experiments on small numbers of people. I have always had admiration for the people who take part in such experiments (as long as they are fully aware of the risks involved) because without such bold volunteers, advancement would be impossible. Such experiments are written up in small studies and, if successful, encourage others to try similar experiments. The small studies you posted seemed to me to be demonstrating the lack of success in salvage surgery where the original treatment was surgery.

I have to confess being puzzled by your statement You act like no one dies getting ADt radiation or chemo. I don’t know if this is addressed to me personally or to others who have responded to your posts. If it is addressed to me, then your statement is absolutely incorrect. My personal belief is that very few men who die from prostate cancer have not been treated: that there is no guarantee of a cure from any treatment: that it is doubtful whether the majority of men gain any real benefit from being treated. I am not saying that there is no benefit from treatment. I am saying (and this is now supported by a number of studies) that the number of men who are treated unnecessarily vastly outweighs the number who benefit from treatment. One such study puts the ratio at about 25:1. But that is my personal belief. What I have tried to do with this website for 10 years now is to try not to let my personal beliefs get in the way of the stated aims of the site:

We want to provide comfort to any man diagnosed with prostate cancer, to offer thoughtful support to him and his family and to help them to decide how best to deal with the diagnosis by providing them with and guiding them to suitable information, being mindful at all times that it is the individual's ultimate choice that the path he decides to follow is his own and that of his family, based on his particular circumstances.

Then you make another puzzling statement:

Perhaps as we age one tends to get narrow minded and set in there ways. The treatments have been mor or less the same for many many years. To say a different approach is n/g is lame.

Again, I assume this is addressed to me. What I find puzzling is that it seems that you are ignorant of the treatments that have been developed over the years, like cryotherapy and focal cryotherapy, HIFU and the significant changes in radiation therapy including proton beam therapy. These newer treatments and variations in older treatments are all set out in the Choices page of the website and there are even references to experimental potential therapies – Photo Dynamic therapy being one, for example, and therapies which were stopped, like PC-Spes. Perhaps I’m not too narrow minded and set in my ways despite the ageing process.

All the best

Terry in Australia

Re: salvage robotic surgery

Well said Terry as per usual. I firmly believe that salvage robotic surgery can easily be done on a patient with positive margins and high gleason scores. This should happen on younger otherwise healthy subjects BEFORE the P.S.A. moves up and is still undetectable. If the salvage surgery fails after a few months, and The PSA goes up they can quickly start radiation or hormones etc. as if there never was a 2nd surgery. I asked my surgeon about this and he said that he could do it but the morbidity rate would be to high. I said that I would take that chance. Would it still take 4 hours? But that was then and this is now. If a positive margin causes a rise in PSA after more than 6 months is it still "local" ? p.s. feel free to delete the other 2 posts of mine about the small study's on 4 men.

Re: salvage robotic surgery

You ask:

If a positive margin causes a rise in PSA after more than 6 months is it still "local" ?

This is my take

1. It is not the ‘positive margin’ that causes any PSA rise. Depending on the degree of the PSA increase, the continuity of the increase etc ( all the points covered in PSA 101 ) the PSA might be due to prostate cancer and this might be due the disease having escaped from the gland prior to the surgery.

2. It is simply not possible to put any accurate time frame on the relationship between a rise in PSA and the positive margin in a post-surgical pathology report. It seems that there might be some kind of relationship between positive margins and progression (not all positive margins are associated with progression of the disease) and there might be an association between an early increase in PSA levels and confirmed progression.

3. It is not possible to say whether a PCa associated PSA movement is due to a ‘local’ extension or a systemic condition or a metastasized disease.

It seems to me that you have not yet grasped the fact that there is simply no certainty in any aspect of this disease: not in diagnosis; not in treatment choice; not in treatment outcome: not in the definition of failure: not in the consequences of failure. So no one can answer your multiplicity of questions with any degree of certainty – all they can do is provide their interpretation of what is known.

Hope that helps.

All the best

Terry

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