Prostatectomy Follow-up

Short Summary

Mr Vance is a 64-year-old man who is 6 months post-RALP for pT2cN0R0 Gleason 3+4=7 prostate cancer presenting with an undetectable PSA of < 0.01 ng/ml. He has achieved complete urinary continence and is transitioning from daily tadalafil to on-demand sildenafil for improving erectile function.

Chief Complaint

Mr Vance is a 64-year-old man presenting today for office follow-up after prostatectomy on 10/14/2024 for pT2cN0R0, Gleason 3+4=7, negative margins. He is 6 months and 1 week postop.

Prostate Cancer History

Mr Vance was initially referred by Dr Richard Miller in 06/2024 for an elevated PSA of 6.8 ng/ml. Multiparametric prostate MRI demonstrated a 1.2 cm PI-RADS 4 lesion in the right peripheral zone without extracapsular extension. He underwent a transperineal MRI-fusion biopsy on 07/18/2024, which revealed Gleason 3+4=7 (Grade Group 2) adenocarcinoma in 4 of 12 cores, prompting a staging PSMA PET/CT that was negative for metastasis. He subsequently underwent an uncomplicated bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (RALP) with pelvic lymph node dissection on 10/14/2024. Final surgical pathology confirmed pT2cN0 (0/14 nodes), Gleason 3+4=7 (15% pattern 4), with negative surgical margins and no lymphovascular invasion. His postoperative course was unremarkable, his Foley catheter was removed on postoperative day 7, and his initial 3-month PSA was < 0.01 ng/ml.

Recovery Milestones

• Urinary continence: 0 pads per day as of 03/15/2025 (previously 1 security pad per day at 3-month visit).

• Urinary stream: Strong and uninhibited as of 04/21/2025.

• Erectile function: Preoperative SHIM score 23/25; latest postoperative function on 04/21/2025 shows partial tumescence (40% rigidity) insufficient for penetration; currently using tadalafil (Cialis®) 5 mg PO daily and a vacuum erection device (VED).

HPI Today 04/21/2025

• 6 months and 7 days post-prostatectomy.

• Since his 3-month visit, his stress urinary incontinence has completely resolved and he no longer wears a security pad. He reports occasional mild terminal dribbling but no leakage with coughing, sneezing, or heavy lifting. Erectile fullness has slightly improved with daily rehabilitation, though erections remain inadequate for intercourse.

• Denies dysuria, gross hematuria, frequency, urgency, pelvic pain, or bone pain.

• Renal and bladder ultrasound performed on 04/10/2025 at Metro Imaging Center showed normal bilateral kidneys without hydronephrosis and a pre-void bladder volume of 250 ml with a post-void residual of 15 ml. I personally reviewed and independently interpreted the scan and concur with findings.

• Latest PSA is < 0.01 ng/ml on 04/14/2025.

• Urinalysis on 04/14/2025 was negative for leukocyte esterase, nitrites, and blood; microscopy showed 0-2 RBC/hpf and 0-2 WBC/hpf.

PMH, PSH, MEDS, ALLERGIES, SH, and FH

PMH, PSH, MEDS, ALLERGIES, SH, and FH were reviewed with the patient and in the EMR, with appropriate updates made.

• PMH: Hypertension, hyperlipidemia.
• PSH: Bilateral nerve-sparing RALP (10/14/2024), right inguinal hernia repair (2018).
• MEDS: Lisinopril 10 mg PO daily, atorvastatin (Lipitor®) 20 mg PO daily, tadalafil (Cialis®) 5 mg PO daily.
• ALLERGIES: Penicillin (maculopapular rash).

Physical Examination

Constitutional: Well-appearing, well-nourished, in no acute distress, alert and oriented x3.

Psychiatric: Normal mood and affect, cooperative behavior, intact judgment and normal thought content.

GU: Well-healed laparoscopic port-site scars without incisional hernia. Normal circumcised phallus without plaques or lesions. Testes descended bilaterally, normal size and consistency without masses or tenderness.

Assessment And Plan

Mr Vance is a 64-year-old man who is 6 months and 1 week status post bilateral nerve-sparing RALP for pT2cN0R0 Gleason 3+4=7 prostate cancer. He is doing well clinically with an undetectable PSA, complete recovery of urinary continence, and ongoing penile rehabilitation.

1. Prostate Cancer (Prostate cancer, C61)

• Assessment: Biochemical remission at 6 months postop with PSA < 0.01 ng/ml and negative surgical margins on final pathology.
• Plan: Repeat ultrasensitive PSA in 6 months (1-year postop mark).
• Counseling: Discussed the favorable prognosis given organ-confined disease, negative margins, and undetectable PSA. Reviewed the standard surveillance schedule.

2. Stress Incontinence (N39.3)

• Assessment: Resolved. Patient is pad-free and completely dry during physical exertion.
• Plan: Continue maintenance pelvic floor muscle exercises (Kegels) as needed. No pharmacologic or surgical intervention required.
• Counseling: Reassured patient that occasional minor terminal dribbling is common and benign.

3. Erectile Dysfunction (N52.31)

• Assessment: Post-prostatectomy erectile dysfunction, gradually improving with penile rehabilitation (40% rigidity).
• Plan: Continue tadalafil (Cialis®) 5 mg PO daily for basal endothelial support and initiate sildenafil (Viagra®) 100 mg PO PRN 1 hour prior to sexual activity (do not take tadalafil on days sildenafil is used). Continue VED exercises daily. Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to continue tadalafil 5 mg PO daily based on the patient's condition and response to treatment. Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to initiate sildenafil 100 mg PO PRN based on the patient's condition and response to treatment.
• Counseling: Discussed the natural history of cavernous nerve recovery following nerve-sparing surgery, noting that maximal recovery typically takes 12 to 24 months. Reviewed potential side effects of PDE5 inhibitors (flushing, headache, dyspepsia) and discussed intracavernosal injections (ICI) as a future second-line option if oral therapy remains insufficient at the 1-year mark.

Orders

• Labs: Ultrasensitive PSA ordered for 10/2025.
• Medications: Sildenafil (Viagra®) 100 mg tablet, take 1 tablet PO PRN 1 hour prior to sexual activity, #30, 3 refills.

Follow Up

Return to clinic in 6 months with a repeat PSA drawn 1 week prior to the appointment.

Short Summary

Mr Vance is a 64-year-old man who is 6 months post-RALP for pT2cN0R0 Gleason 3+4=7 prostate cancer presenting with an undetectable PSA of < 0.01 ng/ml. He has achieved complete urinary continence and is transitioning from daily tadalafil to on-demand sildenafil for improving erectile function.