After a short term increase in PSA from 4.5 to 5.2, I had a biopsy performed in 9/2014. That biopsy found gleason 6 cancer in 16% of one core (out of 12). I elected to start active surveilance based on the initial biopsy result.
As part of the active surveillance protocol, I had a second biopsy performed in January 2015. That biopsy found cancer cells in multiple cores, graded Gleason 7 (3+4). Based on the second biopsy, I decided to proceed with treatment. After conversations with prostate patients, surgeons, and radiation oncologists, I elected to have a robotic radical prostatectomy. That was done at the end of March.
Pathology report post surgery confirmed Gleason 7 (3+4), and defined staging at T2C. That staging basically means that cancer cells were found in both sides of the prostate. The path report showed some perineural invasion. This is a somewhat controversial finding. Some research claims to find a high correlation between PNI (perineural invasion) and later bio-chemical recurrence (BCR). On the other hand, some doctors report that PNI is ALWAYS found post-surgery if the pathologists looks hard enough.
My post-surgery path report also showed positive apical margins. That means that the pathologist was able to identify prostate cells at the cut edge of the removed organ, and implies that some prostate cells were likely to be left behind. In this area the prostate surgeon is facing a delicate compromise. The surgeon can take too much tissue, and have negative margins (all prostate removed) but in the process damage the lower sphincter so much that the patient will never recover bladder control, or not take enough tissue, and run the risk of recurrence from the prostate tissue left in the patient. At best there is a fine line. My impression is that in many cases there is no line, but only a choice between adverse outcomes.
I stayed in the hospital overnight following surgery. Had a Foley catheter for ten days. It took about a month after surgery to restablish reasonable urinary continence, with a recovery to pre-surgery continence about three months post-surgery. In the transition period, events like lifting a heavy weight or passing gas might cause minor leakage, and I needed to urinate more frequently to keep ballder volume down to reduce leak events. I have made several trips lately that included 5+ hour airplane rides, and no issues with continence.
PSA 12 weeks after surgery was reported at 0.015 ng/ml. A retest at 24 weeks showed <0.014, which appears to be the lower detection limit at the local lab. Followup PSA at 36 weeks showed a PSA at 0.016. Moving back into detectable levels is causing some concern. Not much to do at this point but wait and see how it progresses.
I took relatively prompt treatment with a well-respected surgeon, with the "gold standard" radical prostatectomy. Prior to surgery my disease was estimated to be relatively low risk based on genomic analysis, so I expected that with the surgery completed I would be out of the prostate cancer woods. On further study, I find that perhaps a fifth of all RP patients see biochemical recurrence (BCR), defined as PSA rising above 0.2 ng/ml, within five years after surgery, and over half experience BCR by ten years. The gold standard of surgical intervention appears to me be be somewhat tarnished.
I experienced the expected total ED following surgery. Began using trimix injections to accomplish erections and maintain penile health and normal sexual relations at 14 weeks past surgery. Wish we had started that sooner. I find the injections to be minimally uncomfortable and a relatively minor nuisance. Now at ~40 weeks post surgery I am starting to see at least limited spontaneous erectile function recovery. Hoping for further iprovement in that area over the coming months..
Jerry's e-mail address is: firstname.lastname@example.org