Mets Day 8 - cysto and options

This morning I had a cystoscopy at Johns Hopkins by Dr. Mark Schoenberg.  He wanted to evaluate my bladder to see if there was any recurrence of tumor growth, and whether I would be able to tolerate surgery.  It was a relatively quick and painless procedure.  I had dye injected into my bladder so he could do a guided fluorescence cystoscopy -- somewhat more accurate than a regular standard white light cystoscopy.  Dr. Schoenberg observed that a tumor had regrown in the location where the big tumor originally was located.  It was about the size of a thumbnail, he said.  He also verified that there was no physiological reason to not have surgery, and that my ureters were not affected by the cancer.  All good news. 

Based upon this exam, and his review of the scans last week, and his long consultation with Dr. Aragon-Ching yesterday, Dr. Schoenberg recommends that I have nerve-sparing radical cystoprostatectomy (RCP) and a pelvic lymph node dissection (PLND) as soon as possible.  He is checking with his scheduler and hopes to know tomorrow when he can do the surgery.  He agrees that it should not wait until May 21.  My guess is that it will happen in early May, although there is an outside chance it could be next week.  Stay tuned for the actual date. 

We also discussed the type of urinary diversion that would be created during the RCP surgery.  He said that, in terms of the possible need for adjuvant (post-surgery) chemo, it made no difference whether I got a neobladder or an ilial conduit.  He said that a neobladder would require more physical therapy, but that would not preclude chemo.  We've decided to go with the neobladder, although he will still mark me for an IC and will do that if for any reason he can't do a neobladder. 

With regard to the metastases, Dr. Schoenberg tried to put the best spin possible on it.  He said that the CT and MRI scans put the size of the lymph nodes was under 1 cm (barely -- they were .9 cm on the short axis), and he said 1 cm is the rule of thumb for significant metastases.  It doesn't mean the cancer has not metastasized, he said, but that maybe it hasn't spread too far.  He said he was hopeful that, with immediate surgery, we'd be able to contain the spread of the cancer outside the bladder.  I took those comments as his way of peddling hope, and appreciated it for what it was.  But I'm also realistic about the odds.  

He also called surgery a "crude solution", since the idea is to cut out everything that might have cancer in it, and hope you got it all.  It reminded me of the first time that we spoke in December 2011, when he compared surgery to a hammer and said that, when surgery was your only tool, everything looked like a nail.  Guess who's about to get hammered.  I feel like Wile E. Coyote seeing the oncoming Acme anvil . . .