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What type of Surgery

meiztg
Posts: 4
Joined: Nov 2009

I visited Jefferson Hospital and Fox Chase Cancer Center both in Philadelphia PA, after having recently been diagnosed with prostae cancer and I am trying to decide on which method of surgery the "open" or robotic. Any comments on how you decided would be helpful to me.
Did you know how many surgeries your surgeon performed prior to your own surgery? How are you doing now.

William Parkinson
Posts: 60
Joined: Oct 2009

In the most sweeping study to date, men who underwent RALP (Robotic Assisted Laproscopic Prostatectomy) had worse rates of incontinence and impotency, while cancer control is generally better with the open procedure; that is, if the man has more adverse clinical features (e.g., extraprostatic extentions of the cancer in particular). The reason for the latter is due to the fact that the surgeon can feel the prostate and can detect the so-called 'desmoplastic' response which tells him that the cancer is already in the prostatic capsule( i.e., as the cancer grows into the capsule is becomes more fibrous and even 'sticky ' feeling). So, the open procedure is superior for these three things, at least if this recent study is to be believed on the first two points. On the other hand, RALP patients tend to go home sooner, have less pulmonary complications, less blood loss, and less anastomosis strictures. I had the open done this last 17th of Nov. I was released 36 hours later. I am continent and this last Sat., just 11 days after surgery, I had a very positive response already to 100 mg of Viagra. But you can easily find men here who underwent RALP who have similar success stories. Now, studies done at Memorial Sloan-Kettering show that for optimal cancer control a surgeon will need at least 250 procedures under his belt in order to maximize his cancer control rates. Honestly, the usual advice is very sound and it is this: go with the best, most experienced sugeon you can find and don't worry too much on which approach he uses. Although I opted for the open procedure, I would gladly rather have a top notch RALP surgeon working on me than a less-than-experienced (or talented) surgeon who uses the open procedure. The better the surgeon, the better the outcome, no matter which type of surgery is used. I wish you the best in your treatment choice and please let us all know how you doing when you finally get it done.
Cheers
Bill

William Parkinson
Posts: 60
Joined: Oct 2009

For those of us who are interested, I will include a summary of the article which appeared in the Journal of the American Medical Association.

Comparative effectiveness of minimally invasive vs open radical prostatectomy
JAMA. 2009 Oct 14;302(14):1557-64
BERKELEY, CA (UroToday.com) - Minimally invasive radical prostatectomy (MIRP) for prostate cancer (CaP) is the most common treatment modality for localized CaP in the United States. The popularity in part is due to marketing and patient driven desire for the procedure. This encompasses both pure laparoscopic radical prostatectomy and robotic-assisted radical prostatectomy No randomized trial has compared it with open radical retropubic prostatectomy (RP). In the October 14, 2009 issue of the Journal of the American Medical Association, Dr. Jim Hu and colleagues compare outcomes of MIRP and RP using the SEER database.
A total of 8,837 men met inclusion criteria for having undergone radical prostatectomy between 2002 and 2005, with follow-up through 2007. RP was performed in 6,899 and MIRP in 1,938 patients. Post-operative outcomes were compared. There was a 5-fold increase in the use of MIRP during the study period (9.2% to 43.2%). African-American and Hispanic men were more likely to undergo RP than MIRP, but the opposite was the case for Asian men. MIRP patients were more likely to reside in areas of higher educational and financial status.
MIRP vs. RP patients had a shorter length of stay (2.0 vs. 3.0 days), less likely to have a blood transfusion (2.7% vs. 20.8%), less likely to have postoperative respiratory complications (4.3% vs. 5.6%), and less likely to have anastomotic stricture (5.8% vs. 14.0%). MIRP patients had more genitourinary complications compared with RP men (4.7% vs. 2.1%). This included incontinence (15.9 vs. 12.2 per 100 person years), and erectile dysfunction (26.8 vs. 19.2 per 100 person years). As a surrogate for oncologic outcome, the need for additional cancer treatment was similar for MIRP and RP (8.2 vs. 6.9 per 100 person-years).
This study presents an important message in that the urologic community did not prospectively compare major forms of CaP treatments. However, the data has limitations. For example, during the study time frame, adjuvant radiotherapy was not a standard and secondary cancer treatments may not necessarily correlate with positive surgical margin rates. The study controlled for surgeon but not hospital volumes, both known to correlate with outcomes. In every SEER area, more RPs were performed than MIRPs, despite MIRPs presently outnumbering RPs in the US. This shows that MIRP was clearly in its infancy and learning curve across the US and may not reflect present outcomes. The authors attempted to control for this by adjusting for year of surgery.
Hu JC, Gu X, Lipsitz SR, Barry MJ, D'Amico AV, Weinberg AC, Keating NL

txbarton's picture
txbarton
Posts: 85
Joined: Aug 2009

This study was on procedures conducted 2002-2005, as it says, when MIRP was in its infancy; the first US daVinci procedure was in 2000, it wasn't FDA approved until 2003. It also lumps laparoscopic and robotic-assisted together. Most daVinci surgeons today consider laparoscopic as a backup in the unlikely event of a robot failure, not as a primary procedure.

I wonder what the data would show if they studied more current activity and divided it in 3 areas; laparoscopic, robotic-assisted and open.

As a previous researcher and manager of researchers I realize that it is very easy for a researcher to prove the answer he wants with data selection.

VB

William Parkinson
Posts: 60
Joined: Oct 2009

The criticisms leveled at this study are unfounded. Having been served with just warrants to explore in more detail the inherent limitations of RALP, I shall do so now.
In the first instance, the criticism is based on a lack of understanding about the nature of the study, while in the second instance the criticism is based on a lack of knowledge about the differences in the two procedures, as well as a lack of knowledge about prostatic and periprostatic anatomy. As for the first concern listed, the strength of this study is that it is not institutional, but rather, that it surveys the extensive SEER (Surveillance, Epidemiology, and End Results) database of prostate cancer patients. Thus, it encompasses thousands of patients from numerous institutions. So, it is not meant to compare one doctor or one institution to another, but rather, it draws upon thousands of case histories of men with prostate cancer and their respective treatments. This is why I used the term 'sweeping.' It looked at thousands of men who have undergone a prostatectomy.
As for the second charge, that this survey relies on early results, the following limitations of RALP must be pointed out--limitations just as real today as in 2003.
In regards to ED following radical prostatectomy it must be observed that the cavernosal nerves have no protective myelin sheath, unlike other nerves, making them exquisitely sensitive to heat. In RALP electrocautery is used to stem blood flow, unlike in the open procedure where ligation is used more extensively (either through sutures or clips). Thus, it is quite easy to permanently damage the cavernosal nerves by exposure to excessive heat. It is for this reason that the highest rates of potency preservation is with the open procedure, the highest being 90% found among patients at John Hopkins, with Walsh as the surgeon. However, a true breakthrough in developing an athermal RALP technique has just been pioneered by Dr. Tewari, a well-known RALP surgeon at Cornell and by Li-Ming Su at John Hopkins. For those interested I have included a link to the announcement of this development (http://74.213.141.210/topics/treatments-procedures/robotic-prostatectomy-cornell-athermal-robotic-technique+?p=related). Those who advocate RALP should bear in mind though that at this point few surgeons have adopted Tewari's technique. And, as for all other parameters, RALP outcomes are not better, but only equal to the open procedure (90% potency retention is claimed by Tewari in the paper I read).
Now, as I mentioned earlier, in the open procedure the surgeon can feel for tumors that were not sampled by biopsy. The ability to feel for tumors and extraprostatic extensions is a very valuable tool. In turn, this can lead to less positive margins in patients with more advanced cancers. This greater cancer control can be seen in T3 patients in particular. As a recent comparison of RALP to the open procedure carried out at Memorial Sloan-Kettering by both of the chief robotic and laparoscopic surgeons at Memorial Sloan-Kettering, James Eastham and the originator of LRP Bertrand Guillonneau, noted, and I quote ". For both approaches, the risk of PSM increased as the disease severity increased, this was more pronounced for LRP than RRP in the high risk group." Surgeons who champion the open procedure, rightly in my judgment, place emphasis on this aspect of the open procedure. For those interested, I include a link where Catalona argues this very point, as well as against the use of electrocautery (http://www.urotoday.com/264/conference_coverage/aua_ny_2009__multimedia_lectures/aua_ny_2009__open_prostatectomy_is_best__multimedia_presentation11052009.html ). These limitations are as real today as they were in 2003. Thus, it is facile to argue that the results of this study are irrelevant.
It is easy to see why men think that RALP is better. It seems so futuristic and no one wants to believe that the surgery they underwent is no better than the old fashioned way. Who wants to get into a Lamborgeni Diablo and race it, only to be kept up with by a Dodge Viper? Indeed, it is this belief that leads men to be far more dissatisfied with the results of RALP than the open procedure. As the paper in European Urology notes,
"Patients who underwent RALP were more likely to be regretful and dissatisfied, possibly because of higher expectation of an “innovative” procedure. We suggest that urologists carefully portray the risks and benefits of new technologies during preoperative counseling to minimize regret and maximize satisfaction." ("Satisfaction and Regret after Open Retropubic or Robot-Assisted Laparoscopic Radical Prostatectomy" in _European Urology_, Volume 54, Issue 4, October 2008, Pages 785-793, Florian R. Schroeck, Tracey L. Krupski, Leon Sun, David M. Albala, Marva M. Price, Thomas J. Polascik, Cary N. Robertson, Alok K. Tewari, Judd W. Moul).
Moreover, James Eastham, former head of robotic surgery at Memorial -Sloan-Kettering concurs with this assessment, saying in his reply and I quote, "The goal of radical prostatectomy (RP) is to remove the entire prostate with negative surgical margins, without intra- or perioperative complications or blood transfusions and with full recovery of baseline urinary continence and erectile function. While no surgeon universally achieves these goals, there certainly is the suggestion, both in the published literature and on the Internet, that optimum patient outcomes after RP are more consistently achieved with robotic-assisted approaches than with open ones. Indeed, the manufacturer of the robotic system states on its Web site that the potential benefits of robotic-assisted prostatectomy are:
• Effective Cancer Control:
• Studies have shown that experienced surgeons have achieved excellent results in removing prostate cancer without leaving cancer cells behind.
• Improved and Early Return of Sexual Function:
• Studies have shown that most patients have a rapid return of sexual function.
• Improved and Early Return of Continence:
• Studies have shown that most patients have a rapid return of urinary continence [1].
Such claims are made despite a paucity of clinical data. There have been no prospective randomized trials comparing patient outcomes after robotic-assisted and open RP. Single-institution studies have their own inherent biases. Most ultimately conclude that the approach favored by the investigators has “better” outcomes. Few hospitals promote open RP, whereas the majority of centers with the robotic system advertise these services. Patients are given the distinct impression that robotic-assisted RP is superior in essentially every comparison—oncologic and functional—to open surgery.
Why, then, is patient satisfaction with robotic-assisted surgery inferior to open surgery? The simple reason is unmet patient expectations. Unsubstantiated claims are made about the benefits of undergoing a robotic-assisted RP rather than an open RP. (James A. Eastham, "Robotic-Assisted Prostatectomy: Is There Truth in Advertising?" in _European Urology_, 2008, V. 54:720–2).
Finally, it seems to me that those who tout RALP would be well served if they would cite studies which clearly demonstrate the superiority of RALP over the open procedure, rather than simply snipe at studies which point out its deficiencies. Furthermore, it would be useful if they could deliver a cogent argument on why the sense of touch is not a significant advantage to the surgeon, when he attempts to make a determination as to whether there might be other cancerous nodules not sampled by biopsy or capsular extensions. I hope this helps the reader to make up their own mind. Both are valuable approaches and as I mentioned earlier, the real key is to find the most experienced gifted surgeon you can and go with him, irrespective of the technique he uses.

Cheers
Bill

lewvino's picture
lewvino
Posts: 1006
Joined: May 2009

Could luck on your upcoming surgery and decision.
I am 55 and I chose Robotic in Aug. 2009. Doing really great with no urinary problems and having success with Levitra.

Yes, I knew how many surgeries my Doc had performed. If you go robotic make sure they have 250+. It has a steep learning curve.

I have not looked in detail at the study that another member posted but I would be curious if the study took into count how many surgeries the Doc had performed in part of the questions asked. The local Prostate Cancer support group has numerous men that all had robotic with the same Doc I did and all are doing really well. This includes one man at age 72.

I'm a firm believe that the doc's experience level with the robot counts.

Larry

NM
Posts: 214
Joined: Jul 2009

Hi I am 52 years old and researched both as my doctor was very experienced at both. I choose Davinci simply because this same doctor after doing more than 1000 open and about 300 Davinci said he felt better about my recovery if he did use the robot.

I am not getting into which one is better as I believe its a personal decision but either way please remember one thing. If you have Cancer GET IT OUT. Either way works but recovery with Davinci is quicker and I also needed to return to work ASAP.

Hope this helps ....Nick

WHW's picture
WHW
Posts: 189
Joined: Jul 2009

There has never been an Ultimate and conclusive study done on anything, be it medical or otherwise. There is always point and counterpoint.

Each of us jumping into the deep end of the PCa pool approaches the subject of how to deal with it based on what we need as individuals. This decision is made after we have done all the research we deem is enough and based on the circumstances in our own lives.

As you talk to the different doctors you will encounter, they will to some degree express that their expertise and method "may" be the right one for you. Each has defined their own career path and realm of study and practice. Each operates within their own parameters of comfort zone.

I chose da Vinci not because there was any study that said it was the only way. It fit into my needs. I wanted minimal down time, I wanted the cancer out, I wanted a recovery that would not sap me of my energies.

I was discharged from the hospital the day following surgery. I was walking 2-3 miles per day from that day forward. I never took a pain pill or had any discomfort that I would express above a 2 on the 1-10 pain scale. I was completely continent from the day the catheter was removed just 6 days after surgery.

It all boils down to you doing your "due diligence" of study and research. You sit down with your loved ones and come to a collective decision on what's right and comfortable and confident for you and them.

Once this decision is made, a sense of serene peace falls over you and you turn it over knowing that you have done everything you can do to make the "Right Decision For You".

I know that this sounds simplistic, but it is true. As with any decision in life the truly great pitfall is "Analysis Paralysis". That is the one path on this journey that you must attempt to avoid. That path is fraught with it's own unique set of dangers.

Good luck with your research.

Blessings to you and your family as you travel this road,

Sonny

JohnK11
Posts: 23
Joined: Nov 2009

Depends on your Gleason score, and chance of metastasis.
(Just my opinion)

I think that if you are Gleason 6, and the chance of
metastatis (i.e., spreading) is very very small, Robotic is
easier, since the recovery time and damage to
your body is likely to be smaller (less blood loss, less
chance of needing transfusion, faster body recovery time,
etc.). Of course, an experienced surgeon is essential.

However, if you are Gleason 8 or higher, or even Gleason
4+3=7, you should probably consider open surgery, since
the chance of metastatis is much higher, and open surgery
could give a better feel of where the spreading is, and
likely remove as much as the bad areas as possible (Robotic
can do it also, but probably less well). You will have to
take the extra damage to your body though. Again, an
experienced surgeon is crucial.

Having said that, I went against those suggestions, and
chose Robotic with Gleason 4+3=7--though mu PSA that triggered
the biopsy was only 4.2 (the velocity being 2 years doubling).

Unfortunately, in my case, there were metastasis --T3b
(right seminal vesicles cancerous, which was removed), but
my PSA 6 weeks after sugery was as high as before (7). So, I'm
being diagnosed right now (Prostascint/MRI scan--Bone scan
was negative, though it will only find advanced cancer)--if it
finds an area next to the prostate that could have been
removed by Open surgery, I lost the gamble. If it's far
away, then it would not have matter (I'll update when I
find out next week). I think my case is one or two in a hundred
or even less, though--I just won the booby prize. I'm still
hopeful that Hormone (or radiation) will keep me going for
years or even decade(s)--I'm 65 with a family history of Prostate
cancer.

On the positive side, even though much more than the prostate,
right seminal vesicles, adjacent lymph nodes (not cancerous),
and additional surrounding tissues (margin) was removed--
I was walking within days (though still not playing tennis after
2 months), and my continence is finally coming back (my surgeon
said that my recover would be slower since there was lot of stuff
removed), my BM was fine, and impotence will take longer (one
set of nerves removed).

A final comment on the study which debunks the Robotic surgery
(actually, if covers all orthoscopic, no just DaVinci--and
since it was for a period many years ago, Da Vinci was proably
only ~50% of those, and also with less experienced surgeons than
nowadays). THE RESULTS ON SURVIVAL WAS COMPARABLE--only the
satisfaction seems to be less for the Robotic. I'm quite sure
that much of it was due to lesser experience (many open surgeons
proably have 500-1000+ cases, while orthoscopic/Da-Vinc probably
have 50-200 case during the period of study) as well as lesser
expectation (Da Vinci was advertised to give you much better
continence and impotence results, so more people are disappointed
even if the results are comparable or even superior to open---
many people with open would have a lower threshold for accepting
limited continence/impotence as being satisfactory due to lower
expectations).

Hope this is useful, but you have to make your own choice
based on suggestions, web study, etc. Good Luck.

meiztg
Posts: 4
Joined: Nov 2009

Thank you all for taking the time to comment it just continues to amaze me how many men are dealing with prostate cancer. I have made my choice and will have robotic surgery on 1/14/2010 at Fox Chase Cancer Center in Philadelphia the surgeon is Dr. R. Greenberg. He has 20 years of surgical experience and spent quite a bit of time talking to me and learning about me as person. I am comfortabel with my decision and look forward to the Christams holidays and the New Year. Again thanks for the encouragement. All the best to you guys.

janeebe3
Posts: 26
Joined: Aug 2009

My husband is 55. Gleason prior to davinci 6 after davinci 9. Based on your scores, age etc I would recomend CT and bone scans before cutting anything out. I hate to say that sometimes drs are a little quick to want surgery. Get the facts first. Get a second opinion. When they wanted to remove my husbands lymph in his right pelvis after a CT scan showed a 4cm tumor, AFTER the robotic surgery they failed to tell us that due to the pelvic lymph location he would have lower bowel damage. GET A SECOND OPINION ! ! Try CTCA or MD Anderson. We are now at CTCA as I type. Will follow up.

meiztg
Posts: 4
Joined: Nov 2009

I did have a CT and Bone scan everyhing looked fine, I did have a difference in lab report from Fox Chase Cancer versus the original lab. I also had all three doctors review all tests and as well have their own lab review my slides. Curious what does CTCA mean?

kevinwise
Posts: 4
Joined: Oct 2009

I am 50 years old and was diagnosed with PC this past October. I had a 12 sample biopsy with 2 showing cancer. Gleason scores were 3+3 in each sample and my PSA was only 2.6. Like yourself, I struggled as to open or Da Vinci to remove the prostate. I did a tremendous amount of research and never found the exact answer. One report would site in favor of open while the next would clearly state robotic was the best choice. One of the biggest issues is there are no standard definitions for incontinence or impotence. That gets compounded by the age of the person. Usually, the results of these studies contain the gambit in ages (35-85) while you really need to know the data for a person similar to your age and with similar conditions.

After a lot of research, talking to various doctors, and praying a bunch I opted for the Da Vinci and never looked back. I had my surgery last Tuesday (1/12/10) and return to the doctor tomorrow to remove the catheter and get the pathology results.

I know you were hoping to get the answer, as I was when I went through this part of the process, but I hope this helps. I will be praying for you.

meiztg
Posts: 4
Joined: Nov 2009

I had my prostate surgery on 1/14/2010 it was Fox Chase Cancer Center in Philadelphia and it was with the daVinci equipment and it went as advertised no problem at all except for having the catheter which I got used to handling. I had no pain at all. On 1/26 I received my pathology results that were all negative no cancer anywhere and the cancer had not gone beyond the prostate. I am walking three to four times a day and have minimal leakage and it is just three days since the catheter was removed. The lesson I learned from this experience is to know family history and monitor your PSA numbers.

AVDuke03's picture
AVDuke03
Posts: 10
Joined: Jan 2010

Good news, hope everything continues to go well; keep everyone informed of follow ups

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