Not Good News after prostate biospy when MRI didn't look too bad

@diverjer OK, so that’s something to tell the surgeon: no movement, normal urine color; movement causes bleeding.
He’s the surgeon, let him figure it out. Seems like that second surgery may not have fixed the problem?
Phil

@heavyphil

I can't believe why they did inguinal hernia repair which I didn't want or need. I think it must have been around 1998 when told O had one and told how to check it and see if it got worse. Never got worse and never bothered me. And that was back when I did lots of heavy work like concrete flat work, built a few houses. I helped a friend who had construction co for free, just to get out of office and do some physical work like I did prior to getting into information technology. Also, we heated wit wood, I cut many cords of wood every winter.

THERE WAS NOTHING WRONG WITH THAT AREA!

My balls have even got bigger and black, I can't sit. Bought some small jockey shorts as one suggested, but doesn't really help. Daughter suggest a jock strap, but that sounds painfull tight, but might stop me sitting on them.

Where they took out JP bulb is not good. It a real mess,

I think all issues are from JP pulled to early was still doing over 200 lm a day and 90 percent from doing nguinal. Rest of area not bad minor sore. No big deal.

@diverjer
You could get one of those donuts to sit on. They’re usually for hemorrhoids, but you probably could adjust how you sit to help with your pain.

Just really makes one angry to realize how poorly this Treatment has been.

Well doctor today said many men get inguinal hernia after prostate removal. Google seems to agree, Google says "Inguinal hernia is a recognized complication, with studies showing an increased risk of 12% to nearly 39% in men after the procedure, often occurring within the first 6–8 months due to weakened abdominal structures."

Since I already had an inguinal hernia, it needed removed as I was much more likely to have bowels move down into that area and strangulation or something like that was said.

I had a nice red bag and he said it was okay as it was plenty liquidity, gets thick, clots or really dark worry. Told him it was clear if I just laid around Get up and move around turns red like it is now. He said that normal- keep moving but don't overdue it. My 2 block walk was max I should do.

Said on my right side which didn't have any positive cancer biopsy he spared nerves, spared partial on left side. That left side was all positive and he said something about thing really being tight on left side. My biopsy report is way up one of first post. 9 lobes positive, but 3 on right begin.

Said aquablation had really messed up bladder neck, but he cleared it up and I would notice a much better flow. Said it was a mess. That is another story about a resident really did the aquablation and doctor may not have even been there?

Then I asked about incontinence. He said I should get some depends underwear, pads might work but said I should get depends underwear. I asked how long, said 2 - 3 months. Later I will asked for referral for PT pelvic exercise.

Said my black large balls and penis will take a few month, but will get down to normal. That from hernia repair and is what he usually sees. He said he see blue, they are not all black.

Second surgery they did 12 hours later was for an arterial bleeder.

That is about all I remember from appointment. I was stripped down, he seen all bruising, there is a lot, and wasn't concerned.

Doctor leaving this Friday on vacation and his APRN will pull cath on 12th.

Said my urine flow was good, didn't need to track it anymore.

Hopes my pathology will be back before he leaves on vacation, will call them to see if they will get it done. Thinks it should be done by Thursday, that would be a week.

@diverjer
I am sorry but I don’t think any of that is normal. You are continuing to bleed internally when you are up. Don’t hesitate while your Doctor is out of town if this continues to go to ER and then you will get other Doctors to review your “normal” side effects of prostate surgery, or “normal” no, side effects of hernia surgery. Why was there an arterial bleed. He cut something he was not supposed too?

Hi,
Got to agree with wheel1, I would go to another Urologist in another hospital network if possible for a second opinion. If I follow you the thing started in Feb and you still bleeding internally? That does not seem normal in my humble non medical opinion.

Dave 3+4

@diverjer If you had an arterial bleeder - that’s a big one. All that blood spilling out into your body, before the second surgery to repair it, has to go somewhere; gravity dictates that it goes to the lowest point - your testicles/scrotum and penis. This is called ecchymosis and it usually goes from deep blue-black to blue to green to yellow and then nothing.
These colors represent all the blood pigments contained in an RBC.
So he is correct about the length of time needed for it to resolve, but if pain increases go must go to the ER.
Aldo, avoid aspirin or blood thinners if you can - check with your physician first!
Phil

I won't hesitate to go somewhere else, but this blood is less and more urine in it than when I had the aquablation. The aquablation was much more bloody and not water down blood.

I wouldn't mind getting a UTI test and a hemoglobin, I may ask to get one.

I have all the notes from first surgery and what the saw, cut, trimmed and lots of technical terms, interesting but lots of things over my head. Also, have the same for 2nd surgery when they found the they arterial bleeder.

Thought about posting them, don't know if anyone has seen all the technical process or not. If anyone interested to see how they moved around, what the saw and cut on, let me know and I will post their notes.

Looks bad to me, but doc said not too bad., then left on vacation. Said lymph nodes negative as does report, then later said Lymphatic and / or Vascular Invasion: Present. That seems a contradiction! Said Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited) was good. All looks bad to me.
Final Diagnosis
View trends

A. PROSTATE AND SEMINAL VESICLES, RADICAL PROSTATECTOMY:

Prostatic acinar adenocarcinoma, Gleason grade 3 + 4 = Score 7 (Grade group 2, 40% pattern 4, cribriform glands present).
Left posterior margin is focally positive for carcinoma.
Carcinoma invades the left seminal vesicle.
Non-focal extraprostatic extension is present.
Lymphovascular invasion is present.
Background prostate shows high grade prostatic intraepithelial neoplasia (HGPIN) and nodular stromal and glandular hyperplasia.
See synoptic report below.

B. LYMPH NODES, BILATERAL PELVIC, DISSECTION:
No evidence of metastatic carcinoma in ten lymph nodes. (0/10)

COMMENT: Racemase/34BE12 double stain performed on block A8 confirms the diagnosis of HGPIN. As part of our Quality Assurance, an additional pathologist has reviewed the histological material and concurs with the final diagnosis.

Synoptic Checklist
View trends
Value
PROSTATE GLAND: Radical Prostatectomy

PROSTATE GLAND: RADICAL PROSTATECTOMY - All Specimens

8th Edition - Protocol posted: 9/20/2023

SPECIMEN

Procedure: Radical prostatectomy

Prostate Size:

Prostate Weight (Grams): 91.8 g

TUMOR

Histologic Type: Acinar adenocarcinoma, conventional (usual)

Histologic Grade:

Grade: Grade group 2 (Gleason Score 3 + 4 = 7)

Percentage of Pattern 4: 31 - 40%

Intraductal Carcinoma (IDC): Not identified

Cribriform Glands: Present

Treatment Effect: No known presurgical therapy

TUMOR QUANTITATION:

Estimated Percentage of Prostate Involved by Tumor: 11 - 20%

Extraprostatic Extension (EPE): Present, nonfocal

Location of Extraprostatic Extension: Left posterolateral (neurovascular bundle)

Urinary Bladder Neck Invasion: Not identified

Seminal Vesicle Invasion: Present, left

Lymphatic and / or Vascular Invasion: Present

Perineural Invasion: Present

MARGINS

Margin Status: Invasive carcinoma present at margin

Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited)

Focality of Margin Involvement: Unifocal

Margin(s) Involved by Invasive Carcinoma: Left posterior

Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE): Not identified

Gleason Pattern at Margin(s) Involved by Carcinoma: Pattern 4

REGIONAL LYMPH NODES

Regional Lymph Node Status:

: All regional lymph nodes negative for tumor

Number of Lymph Nodes Examined: 10

pTNM CLASSIFICATION (AJCC 8th Edition)

Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician's responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report.

pT Category: pT3b

pN Category: pN0

ADDITIONAL FINDINGS

Additional Findings: High-grade prostatic intraepithelial neoplasia (PIN)

Additional Findings: Nodular prostatic hyperplasia

Additional Findings: Inflammation (type): Focal acute inflammation
Your value is PROSTATE GLAND: Radical Prostatectomy PROSTATE GLAND: RADICAL PROSTATECTOMY - All Specimens 8th Edition - Protocol posted: 9/20/2023 SPECIMEN Procedure: Radical prostatectomy Prostate Size: Prostate Weight (Grams): 91.8 g TUMOR Histologic Type: Acinar adenocarcinoma, conventional (usual) Histologic Grade: Grade: Grade group 2 (Gleason Score 3 + 4 = 7) Percentage of Pattern 4: 31 - 40% Intraductal Carcinoma (IDC): Not identified Cribriform Glands: Present Treatment Effect: No known presurgical therapy TUMOR QUANTITATION: Estimated Percentage of Prostate Involved by Tumor: 11 - 20% Extraprostatic Extension (EPE): Present, nonfocal Location of Extraprostatic Extension: Left posterolateral (neurovascular bundle) Urinary Bladder Neck Invasion: Not identified Seminal Vesicle Invasion: Present, left Lymphatic and / or Vascular Invasion: Present Perineural Invasion: Present MARGINS Margin Status: Invasive carcinoma present at margin Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited) Focality of Margin Involvement: Unifocal Margin(s) Involved by Invasive Carcinoma: Left posterior Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE): Not identified Gleason Pattern at Margin(s) Involved by Carcinoma: Pattern 4 REGIONAL LYMPH NODES Regional Lymph Node Status: : All regional lymph nodes negative for tumor Number of Lymph Nodes Examined: 10 pTNM CLASSIFICATION (AJCC 8th Edition) Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician's responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report. pT Category: pT3b pN Category: pN0 ADDITIONAL FINDINGS Additional Findings: High-grade prostatic intraepithelial neoplasia (PIN) Additional Findings: Nodular prostatic hyperplasia Additional Findings: Inflammation (type): Focal acute inflammation

@diverjer
One finding that is mentioned more than once is important because of the following

Non-focal extraprostatic extension is present" in a prostate cancer pathology report means the cancer has spread beyond the prostate gland's capsule into nearby fat or tissues and is more than just a minimal or single-point occurrence. This indicates a more established, or "extensive," (pT3a) disease than focal spread, indicating a higher risk for cancer recurrence and potentially necessitating further treatment like radiation.

You are pT3b because the seminal vesicles are also involved.

You should ask if the cribriform Is small or large. They should’ve mentioned it.

Another important finding

Vascular invasion (or lymphovascular invasion, LVI) on a prostate biopsy means cancer cells are identified within small blood vessels or lymphatic channels in the prostate tissue. It suggests a higher risk of cancer spreading beyond the gland and is linked to higher [Gleason scores], [PSA levels], and a higher chance of [biochemical recurrence].

The fact that you were a 3+4 makes it so that in general it should not grow or spread at any speed at all. A real positive thing.

A lot of important issues your doctor should’ve really discussed with you. It definitely looks like these aggressive issues would require ADT and an ARPI. If your doctor doesn’t discuss this with you, you should really try to get a second opinion from the center of excellence.