Thoughts on treatment options?

@ireland1964 The Retzius method reduces your chance and/or duration of incontinence after surgery. Most RP methods can do nerve sparing, even the ones that leave you in Depends.

@jim18 It’s definitely a learning curve (at least for me). The 2 discussions I’ve had so far with Ralp surgeons are they don’t have a specific nerve sparring technique but do respect the nerve area with caution during the operation. Both further explain that there’s really no way of knowing how far the margins get cut etc until they’re in there.
Couldn’t the same be said for a Retzuis procedure?

@tattodice @jeff
thank you both and I’ll be making that call tomorrow. Hopefully I can get some clarity on the phone before setting up a consult. That whole Karmonas pitch was like hitting a wall but I’m back up :))

You will be assigned to a multi disciplined team, including a tumor board, and they will tailor their approach to your individual needs. Hope all is well!

@ireland1964 Search on Retzuis sparing. The older RP surgery cut the ligament to gain access from the front. The Retauis sparing avoids this by going in from the rear. So, less incontinence. Surgeons do not know the extent of the cancer that is outside the capsule until they open you up but at 3+4 there are good odds that the nerves can be fully spared, and even better that at least partially spared.

@tattodice That’s pretty much what Karmonas GU group advertised to do as well. Not trying to sound cynical but what a disappointment and waste of time that was.
Hoping UM works out and sincerely appreciate your input

@jim18 I think these facilities and surgeons should be prevented from discussing nerve sparring unless they utilize specific techniques in their Ralp.
My experience thus far is the NS just gets thrown out there without a deeper explanation of what they actually do differently than standard Ralp

@ireland1964
You are so right about nerve sparing. Definitely be aware that may or may not be possible depending on the severity of cancer spread and the cancer being out of the capsule. There are two nerve bundles, one on each side. Again depending on circumstances a skilled surgeon can avoid and save the bundles 100% or sometimes 50% or more. He might save both sides 100%, one side 100%, one side 50%, one side 100%, one side 0%, 50% each side, none at all. This is all depending. What is important is just because you hear the Surgeon say “I will do nerve sparing”, you need to ask to what extent or percent he expects to save of the bundles from his review of your MRI and biopsies. He generally has an idea based on the MRI and biopsy. Don’t just believe by his statement regarding the surgery you are in the clear and then be terribly disappointed afterwards with the results. It is better to know upfront what can be possibly saved. This depends if the tumor is deep in prostate or was on just one side or tumors on each side. The point is that there are limits due to the extent of your cancer in what surgeon’s are able to do regarding this and be prepared regarding nerve sparing and your expectations when you hear they will do nerve sparing. Some patients hear nerve sparing and just believe that keeps them from ED issues.

Also I am a believer in real time pathology while you are in surgery. It’s true they have no idea until they really get in their and unless they have your margins checked while in Surgery you could have positive margins when you get your post pathology report. The more margin they delicately try to get rid of takes time, real pathology takes time, lymph node dissections take time. I think many surgeons want in and out as quickly as they can.

@wheel1 Thanks for your input. I just read an interesting article comparing Retzius & standard Ralp
https://www.sciencedirect.com/science/article/pii/S295024702600068X
Biggest take for me anyway was although Retzius provided quicker continence results, the outcome was similar after 9-12 months. So although sooner is better I’m wondering how much effort I should give to search out this smaller group of surgeons
Also seems to indicate the tumor location and bladder neck plays a significant role as the Retzius is more limited by its posterior approach.

Sood et al. compared four RALP techniques: anterior, posterior, hybrid, and transvesical, and found that bladder neck preservation was the only independent predictor of early continence at both one week and one month postoperatively. Notably, the transvesical approach, which preserved the space of Retzius but not the bladder neck, resulted in the poorest continence outcomes.10 These findings challenge the assumption that Retzius preservation alone improves continence and instead highlight the critical role of bladder neck integrity.
The hood technique, developed by Tewari et al., reinforces this perspective.9 By preserving the detrusor apron, puboprostatic ligaments, and arcus tendineus using an anterior approach, the technique replicates the structural advantages of Retzius-sparing surgery while avoiding the technical complexity of a posterior dissection. In their single-surgeon series, 88% of patients were pad-free by 6 weeks, with a low (6%) positive margin.9 These results support the notion that targeted anatomical preservation, rather than the route of access alone, drives improved continence.

The mechanism underlying this benefit remains a topic of debate and, while traditionally attributed to preservation of the space of Retzius, emerging evidence suggests that specific anatomic preservation of the bladder neck and periurethral support structures may be the true drivers of improved functional outcomes

@ireland1964
Totally agree it must begin at bladder neck. I think the non cutting of the Puboprostatic ligament is significant to the reattachment of the urethra to the bladder neck and the remarkable quicker continence success with Retzius sparing. It just seems that knowing that now, I feel having learned it through these studies does not change the inability of a regular RALP having cut the ligament to protect the bladder neck. Since incontinence is one of the major concerns of patients, I would still want the best odds which are extremely high for fairly immediate continence with the Retzius sparing then possibly months and months up to a year for regular RALP to catch up without all the therapy, pads, kegels. Good luck but don’t rule out finding a surgeon that does it. I know Colleen published several studies on the Retzius sparing success with also quicker surgery recovery and ed recovery. I think she mentioned MAYO did it, which I think is close to you. It is possible their could be other factors that make it more likely to be successful, like a smaller prostate or not being obese. I have no idea about that.