Announcement

Announcement Module
Collapse
No announcement yet.

RPLND surgeon

Page Title Module
Move Remove Collapse
X
Conversation Detail Module
Collapse
  • Filter
  • Time
  • Show
Clear All
new posts

  • RPLND surgeon

    Hi guys,

    I think I am deciding on an RPLND for treating my post-orch stage 1A embryonal-predominant TC. I would love to go to IU, but my insurance won't pay it because it's out of network. They claim we have someone in network who can do the RPLND. Our in-network guy is Dr. Jason Abel (http://www.urology.wisc.edu/profile/jason-abel). He claims that, though he doesn't do too many RPLNDs for TC (1-2 a month, he said), that he does many lymph-node dissection for kidney cancer and others, where they remove the kidney as well as the exact same lymph nodes. I'm not 100% sure what to make of this, though he did seem confident. He also does the RPLND robotically, which I would like, if possible. After all, if it's equally curative and it takes less time to recover, that sounds like a win. Anybody with info/advice is appreciated.

    Thanks,
    -Uno

  • #2
    Seems like a well-trained guy. I know the same lymph nodes are removed for other cancers and I have spoken to urologists that state this. I don't think robotic is equally curative, but it may be close to equal and that may be enough. Saves you from a big mid-line incision that can cause a lot of problems like hernias etc. This is the route I would go with. Curious, have you seen Dr Hanna, Oncology from IU?
    Canadian. Diagnosed at age 31. Treated in NYC. Now living in Columbus, OH.

    7/1/2015: felt tiny lump on side of R testicle
    7/30/2015: Ultrasound shows 2 intra-testicular masses.
    7/31/2015: tumor markers normal, CXR clear
    8/5/2015: R orchiectomy
    8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
    8/14/2015: CT abdomen/pelvis clear, Stage 1b
    8/24/2015: started 1 x BEP

    Comment


    • #3
      Hi, RJKD. I just posted my Dr. Hanna visit post on the other thread. I thought it made sense to put this question in a new thread, since it has nothing to do with the RPLND vs Adjuvant chemo question. The short version is that Dr. Hanna is great and inspires confidence in the face of some daunting topics. I'm leaning towards RPLND now, but really wish I had a better idea of the side-effects/risks of 1xBEP. Previously, I thought that maybe I could somehow get at this info. Now, given that Dr. Hanna doesn't know and that he seems to know everything that there is to know, I guess I am coming to accept the necessary uncertainty of this decision. Not having all the info you need to make the decision is really frustrating, but it's worse to feel like you're making a huge decision without first thoroughly doing your homework. I guess it's telling that you did 1xBEP and now recommend the RPLND.

      Comment


      • #4
        I usually lean towards RPLND for stage 1a patients and even stage 1b patients (although I will admit that in stage 1b it's a much harder case to make!). I hated my BEP experience with all the unknowns, the hair coming out, the neutropenia. However, I also know that an RPLND may have found lymph node involvement and if that happened then it's hard to argue against 1 x BEP which brings the relapse risk WAY down as opposed to an RPLND with pN1 disease (which I think was highly possible that I had...who knows?!). You're doing the right thing seeing all these great doctors.
        Canadian. Diagnosed at age 31. Treated in NYC. Now living in Columbus, OH.

        7/1/2015: felt tiny lump on side of R testicle
        7/30/2015: Ultrasound shows 2 intra-testicular masses.
        7/31/2015: tumor markers normal, CXR clear
        8/5/2015: R orchiectomy
        8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
        8/14/2015: CT abdomen/pelvis clear, Stage 1b
        8/24/2015: started 1 x BEP

        Comment


        • #5
          Regarding robotic RPLND, I e-mailed Dr. Hanna asking his opinion. He wrote back with some quotes from the surgeons at IU. They were generally against it. This leaves me really confused as to whether a robotic RPLND is a reasonable option or not. Also, I don't know if I should trust the surgeon here (who was going to do the robotic version), but just ask him to do it open instead. Quotes from Hanna's e-mail quoting surgeons at IU.

          “We tend to avoid robotics for this operation due to a significantly higher risk of major vascular and ureteral injury, as well as an uncertain impact of altered metastatic spread. Morbidity short and long-term with open approach in experienced hands is minimal.”

          “As you know, we are not in favor of robotic surgery for this disease for a variety of reasons. That being said, people around the country are doing this. My personal opinion is that we will likely see more of these referred in for recurrences, but only time will tell.”

          “From a data perspective, I will say this about robotics -- From robotic abstracts presented recently, the success of nerve sparing in VRPLND is lower than our experience here (83% vs. 99%). The hospital stay is 18-24hrs shorter with robotics. In the abstracts, patients were given 2 cycles of adjuvant chemotherapy for positive LNs up to 60% of the time (which as you know we would not routinely do here). The rate of chylous ascites is higher with robotics than here (4% vs. <1%). There are no long-term oncologic results….”

          Comment


          • #6
            My general impression has been in line with the quotes you have presented. But with an experienced robotic surgeon, I know many people happy with the results. Many of the old time surgeons (Foster and Sheinfeld) were not trained with this method so I believe they do have a certain bias.

            However, with primary RPLND, I suspect the rates of complications are far lower than the numbers you are getting. Remember, primary RPLND procedures have significantly declined over the last decade and most RPLND's are post-chemo RPLND's. RPLND's done after chemo are an entirely different ball-game. It's much more difficult.

            My main concern is, how many lymph nodes are removed in a robotic primary RPLND versus in the full-open method? In my research, the numbers are not as impressive as with the open method. We know more lymph nodes removed means more likely full cure. Remember, you are looking for a cure here, not just staging. Maybe it's better to have a little bit of extra pain for a few days and do the full open method? I personally would want the surgery done as well as humanely possible. If I was stage 1b, I would certainly do the full open method. But with stage 1a, where I think you have a higher chance that you're fully cured already, I can make the argument that perhaps you don't want to be so aggressive (full-open) and rather do the robotic.
            Canadian. Diagnosed at age 31. Treated in NYC. Now living in Columbus, OH.

            7/1/2015: felt tiny lump on side of R testicle
            7/30/2015: Ultrasound shows 2 intra-testicular masses.
            7/31/2015: tumor markers normal, CXR clear
            8/5/2015: R orchiectomy
            8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
            8/14/2015: CT abdomen/pelvis clear, Stage 1b
            8/24/2015: started 1 x BEP

            Comment


            • #7
              “We tend to avoid robotics for this operation due to a significantly higher risk of major vascular and ureteral injury, as well as an uncertain impact of altered metastatic spread."

              That's the most worrisome statement to me. I suspect the risk of vascular and ureteral injury in the primary RPLND is FAR lower than with the post-chemo RPLND. I would ask your surgeon, what is the risk of this in his hands? He should be showing you research articles if you ask for them. I'm a numbers guy, so I like to know all the details.

              The altered metastatic spread is obviously concerning. I think it's unlikely though. However, I'm not a urologist and I would like to know the techniques used in the robotic surgery to get a better idea of this.
              Canadian. Diagnosed at age 31. Treated in NYC. Now living in Columbus, OH.

              7/1/2015: felt tiny lump on side of R testicle
              7/30/2015: Ultrasound shows 2 intra-testicular masses.
              7/31/2015: tumor markers normal, CXR clear
              8/5/2015: R orchiectomy
              8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
              8/14/2015: CT abdomen/pelvis clear, Stage 1b
              8/24/2015: started 1 x BEP

              Comment

              Working...
              X