Robotics or Open? Dr Olson or Tewari?

Howard12

Hi,
I'm 41 years old. Recieved a diagnosis of prostate CA in Nov 2005. PSA of 2.81 and a Gleason of 3 + 4. I have been scheduled to have Open surgery with Dr Carl Olson at Columbia University in New York City on 1/23/06 (a week from Monday). However, I just came accross Dr Ash Tewari at Cornell in NYC who does robotics. Dr. Tewari claims to have only a 2% positive margin rate. He has performed over 1200 of these. Dr Olson has been doing open Surgery for 25 years. - I'm not sure who to go with? Any thoughts?

JohnW55

I had robotic on Aug 18 05, then emergency open on the 19th since I was bleeding to death internally. I am still having problems with incontinence, impotence, and severe depression. I would not recomend robotics. John

jweindel

Howard, this is probably going to sound a little harsh...I don't mean it to be.

I would have thought that the research into the various treatment options, including the various surgical options (retropubic radical, perineal radical, laparascopic, and robotic laparascopic), including selecting a surgeon, would have been done before scheduling surgery. There are pros and cons to all the treatment options. My advice generally to men recently diagnosed with PCa is to study, learn all you can about your disease, research ALL the treatment options available to you, make a decision, and don't look back!

You are a young man to have to deal with this disease. If you are second-guessing your treatment option now, what happens after your surgery? Will you spend the rest of your life wondering if you did the right thing?

Presumably, you selected RRP for sound reasons. If you think you would be better served with RLRP now, and are unsure, you probably need to do some more research. I don't think any of us can make that decision for you.

I wish you the best in your treatment decision and outcome.

Jerry

Howard12

JohnW55 said:

I had robotic on Aug 18 05, then emergency open on the 19th since I was bleeding to death internally. I am still having problems with incontinence, impotence, and severe depression. I would not recomend robotics. John

I'm sorry you are having such a hard time. I hope things begin to get better for you.

Can I ask where you had the robotics done?
thanks
Howard
howard.becker@med.va.gov

Howard12

jweindel said:

Howard, this is probably going to sound a little harsh...I don't mean it to be.

I would have thought that the research into the various treatment options, including the various surgical options (retropubic radical, perineal radical, laparascopic, and robotic laparascopic), including selecting a surgeon, would have been done before scheduling surgery. There are pros and cons to all the treatment options. My advice generally to men recently diagnosed with PCa is to study, learn all you can about your disease, research ALL the treatment options available to you, make a decision, and don't look back!

You are a young man to have to deal with this disease. If you are second-guessing your treatment option now, what happens after your surgery? Will you spend the rest of your life wondering if you did the right thing?

Presumably, you selected RRP for sound reasons. If you think you would be better served with RLRP now, and are unsure, you probably need to do some more research. I don't think any of us can make that decision for you.

I wish you the best in your treatment decision and outcome.

Jerry

Jerry, Thank you for your reply. You're point is well taken. I have read a lot and met with 3 open surgeons, and 2 robotic guys and a RT guy. I initially concluded that the only advantage to doing robotics over open related to the short term recovery (post surgery recovery, quicker return to continence and potency) but that in the long term, the rates of recovery are the same. Additionally, and most importantly in my mind, the margin rates appeared similar as well. My only concern with robotics was that there is no long term (beyond 5 years) data. – Given that I'm 41 with small children, I thought that longer recovery from open surgery is ok with me given that there is no significant long term advantage to a robotics procedure that would outweigh the lack of long term research ( i.e. possible recurrence after later on) I therefore choose Dr Olsen (Open)- who has an excellent reputation.

However, after meeting with Dr. Tewari ( Robotics) last week , he claims a significantly better margin rate (2%) than any open or robotic surgeon I have heard about. If that is true, and his rate of impotence and continence are also as claimed, then I would use him. ( and make my concern of no long term date secondary).
Has anyone heard of Tewari? Few MD’s in NY know him. He comes from Ford in Michigan- He is only here 1 ½ years.
Thanks
Howard

jweindel

Howard12 said:

Jerry, Thank you for your reply. You're point is well taken. I have read a lot and met with 3 open surgeons, and 2 robotic guys and a RT guy. I initially concluded that the only advantage to doing robotics over open related to the short term recovery (post surgery recovery, quicker return to continence and potency) but that in the long term, the rates of recovery are the same. Additionally, and most importantly in my mind, the margin rates appeared similar as well. My only concern with robotics was that there is no long term (beyond 5 years) data. – Given that I'm 41 with small children, I thought that longer recovery from open surgery is ok with me given that there is no significant long term advantage to a robotics procedure that would outweigh the lack of long term research ( i.e. possible recurrence after later on) I therefore choose Dr Olsen (Open)- who has an excellent reputation.

However, after meeting with Dr. Tewari ( Robotics) last week , he claims a significantly better margin rate (2%) than any open or robotic surgeon I have heard about. If that is true, and his rate of impotence and continence are also as claimed, then I would use him. ( and make my concern of no long term date secondary).
Has anyone heard of Tewari? Few MD’s in NY know him. He comes from Ford in Michigan- He is only here 1 ½ years.
Thanks
Howard

Howard,

Just a couple more points to ponder. While the recovery time for RLRP is certainly quite a bit shorter than open RRP, I am not aware of any empirical evidence of any quicker return to continency or potency between these methodologies. If Dr. Tewari is making such a claim for robotic laparascopic surgery over open surgery, absent any data to this effect that he can show you, it is only a claim. I would be interested in knowing of any studies that support such a claim.

As far as rates of positive margins, correct me if I'm wrong, but I thought that positive margins were more probably related to how far the disease has spread within or without the prostate. In other words, a prostate with capsular or extra-capsular penetration would be more likely to show positive margins upon pathological examination, regardless of type of surgery or skill of surgeon, assuming the entire prostate was properly removed. Also, in the case of robotic surgery, I always felt that length of surgery and time under general anesthesia was one of the drawbacks to consider. In most surgeries, the higher risk to the patient is generally from the anesthesia, and the amount of time spent under anesthesia. I've been told that the open RRP generally takes about 3 hours (mine did), where the RLRP can take from 5 to 6 hours, particularly with the amount of time spent in setting up the patient and robotic arms, etc.

All that being said, I have talked with several men who have had RLRP. A couple have had to have salvage radiation, following a post-op rise in PSA. But all of them were pleased with the procedure, and the shorter recuperative period.

Best of luck to you. As young as you are and with the low numbers you have, I'm sure you will have a good result, whichever you decide.

Jerry

KMiyoko

Hi
If you look on the internet for Dr. Tewari, he has a very long list of his accomplishments. He also has years of experience doing prostectomies. I talked to Dr. Tewari over the phone when looking for treatments for my husband. We would have used Dr. Tewari, but we live in California and our insurance wouldn't pay for it. My husband went with the City of Hope and Dr. Timothy Wilson. He had the Da Vinci Robotic prostatectomy. He was in the hospital for 2 days, catheter for 8 days, and continent 12 days after his surgery. I think what you have to do is find a doctor that has years of experience doing both open, then laproscopic, and now the robotic. You also want to make sure the doctor has been doing the robotic on a regular basis. Our doctor does 8-10 surgeries a week. Dr. Tewari fits the description on all those accounts. The most important thing is for you to feel confident with your doctor. After our positive experience with the City of Hope and the Da Vinci procedure, we would do it all over again. Good Luck

JohnW55

Howard12 said:

I'm sorry you are having such a hard time. I hope things begin to get better for you.

Can I ask where you had the robotics done?
thanks
Howard
howard.becker@med.va.gov

Yes, by Urology of Indianapolis at Community North Hospital. To my knowledge most have very good results with robotics.However, whatever you decide upon, insist on nerve sparing. The nerve loss is devastating. incontinance and impotence, terrible psychological effects.
Sincerely John

JohnW55

jweindel said:

Howard,

Just a couple more points to ponder. While the recovery time for RLRP is certainly quite a bit shorter than open RRP, I am not aware of any empirical evidence of any quicker return to continency or potency between these methodologies. If Dr. Tewari is making such a claim for robotic laparascopic surgery over open surgery, absent any data to this effect that he can show you, it is only a claim. I would be interested in knowing of any studies that support such a claim.

As far as rates of positive margins, correct me if I'm wrong, but I thought that positive margins were more probably related to how far the disease has spread within or without the prostate. In other words, a prostate with capsular or extra-capsular penetration would be more likely to show positive margins upon pathological examination, regardless of type of surgery or skill of surgeon, assuming the entire prostate was properly removed. Also, in the case of robotic surgery, I always felt that length of surgery and time under general anesthesia was one of the drawbacks to consider. In most surgeries, the higher risk to the patient is generally from the anesthesia, and the amount of time spent under anesthesia. I've been told that the open RRP generally takes about 3 hours (mine did), where the RLRP can take from 5 to 6 hours, particularly with the amount of time spent in setting up the patient and robotic arms, etc.

All that being said, I have talked with several men who have had RLRP. A couple have had to have salvage radiation, following a post-op rise in PSA. But all of them were pleased with the procedure, and the shorter recuperative period.

Best of luck to you. As young as you are and with the low numbers you have, I'm sure you will have a good result, whichever you decide.

Jerry

Howard,
Get as much information as you can and as many opinions as you can. You are young to be facing this and need to choose a doctor who is concerned with the quality of your life afterward. Right now just getting rid of the cancer will preoccupy you. Make sure they spare your nerves. Your numbers don't look that bad. Mine were terrible. I will pray That God helps you make the right choice and that He guides the surgeon's hand. I wish you well and a successful recovery.
Sincerely,
John

Benji48

Hi,
Am I missing something here?? A PSA of 2.81??? Have you had any "roto-router" prior surgery done? I'd get a second opinion on the PSA & biopsy results if I were you. At such an early age (41) you are embarking on a life altering pathway & I'd be sure of making the right decision hopefully no matter what kind of therapy you choose.
Best,Benji

KMiyoko

jweindel said:

Howard,

Just a couple more points to ponder. While the recovery time for RLRP is certainly quite a bit shorter than open RRP, I am not aware of any empirical evidence of any quicker return to continency or potency between these methodologies. If Dr. Tewari is making such a claim for robotic laparascopic surgery over open surgery, absent any data to this effect that he can show you, it is only a claim. I would be interested in knowing of any studies that support such a claim.

As far as rates of positive margins, correct me if I'm wrong, but I thought that positive margins were more probably related to how far the disease has spread within or without the prostate. In other words, a prostate with capsular or extra-capsular penetration would be more likely to show positive margins upon pathological examination, regardless of type of surgery or skill of surgeon, assuming the entire prostate was properly removed. Also, in the case of robotic surgery, I always felt that length of surgery and time under general anesthesia was one of the drawbacks to consider. In most surgeries, the higher risk to the patient is generally from the anesthesia, and the amount of time spent under anesthesia. I've been told that the open RRP generally takes about 3 hours (mine did), where the RLRP can take from 5 to 6 hours, particularly with the amount of time spent in setting up the patient and robotic arms, etc.

All that being said, I have talked with several men who have had RLRP. A couple have had to have salvage radiation, following a post-op rise in PSA. But all of them were pleased with the procedure, and the shorter recuperative period.

Best of luck to you. As young as you are and with the low numbers you have, I'm sure you will have a good result, whichever you decide.

Jerry

Jerry,

I'm sure Dr. Tewari has kept records on his patients since he started doing the Da Vinci Robotic surgeries. I know that the City of Hope keeps records of their patients that they have done surgeries on. The City of Hope has done many open surgeries for years before the regular laproscopic surgeries were available. Then they started doing the Da Vinci Robotic surgeries since July of 2003. When they did my husband's surgery in August of 2005, they asked if it was okay to use his statistics: (just as in age, race, height, weight and a few other things, but no names). So, I do know that although it is fairly new in the United States, some European surgeons have been doing a type of robotic surgeries for a long time now.
As far as how long it took the doctors to set up, it was about a half hour from the time they wheeled my husband into surgery from pre-op(I was with him during pre-op) and the nurse called me to say they started the surgery(2:30PM). The doctor himself called me at 5:00PM to say that the surgery was over. So, that was only 2 1/2 hours for the surgery. He was sent to recovery and I saw him at 6:00PM as they was transporting him to his room. But the City of Hope and Dr. Wilson has done a lot of these surgeries, so it doesn't take as long as doctors/hospitals that are just starting to do this procedure and not as experienced.
My husband was 43 years old when he had his surgery. All his PSA has since come back undetectable. He has had 3 PSA testing done since his surgery, because we are still going to the City of Hope and also went back to his primary doctor from our health insurance plan as a follow up.
Kay

Howard12

KMiyoko said:

Jerry,

I'm sure Dr. Tewari has kept records on his patients since he started doing the Da Vinci Robotic surgeries. I know that the City of Hope keeps records of their patients that they have done surgeries on. The City of Hope has done many open surgeries for years before the regular laproscopic surgeries were available. Then they started doing the Da Vinci Robotic surgeries since July of 2003. When they did my husband's surgery in August of 2005, they asked if it was okay to use his statistics: (just as in age, race, height, weight and a few other things, but no names). So, I do know that although it is fairly new in the United States, some European surgeons have been doing a type of robotic surgeries for a long time now.
As far as how long it took the doctors to set up, it was about a half hour from the time they wheeled my husband into surgery from pre-op(I was with him during pre-op) and the nurse called me to say they started the surgery(2:30PM). The doctor himself called me at 5:00PM to say that the surgery was over. So, that was only 2 1/2 hours for the surgery. He was sent to recovery and I saw him at 6:00PM as they was transporting him to his room. But the City of Hope and Dr. Wilson has done a lot of these surgeries, so it doesn't take as long as doctors/hospitals that are just starting to do this procedure and not as experienced.
My husband was 43 years old when he had his surgery. All his PSA has since come back undetectable. He has had 3 PSA testing done since his surgery, because we are still going to the City of Hope and also went back to his primary doctor from our health insurance plan as a follow up.
Kay

Thanks Kay,

I know every case is different, but there is an important similarity given my age of 41 and your husbands of 43. Would you mind me asking about incontenance and impotance issues?
Thank you
Howard

Howard12

Benji48 said:

Hi,
Am I missing something here?? A PSA of 2.81??? Have you had any "roto-router" prior surgery done? I'd get a second opinion on the PSA & biopsy results if I were you. At such an early age (41) you are embarking on a life altering pathway & I'd be sure of making the right decision hopefully no matter what kind of therapy you choose.
Best,Benji

Hi Benjy, I had 2 PSA's ; 2.71 and 2.81 and two institutions looked at the biopsy slides. Columbia NY Presbyterian read it as a 3 + 4 and Sloan as a 3 + 3. I received one suggestion to do watchful waiting, but that was outweighed by quite a few medical oncologists and surgeons at different institutions. Given the low PSA and apparent small volume (less than 5% of the problematic area) it does seem premature to operate. However, the doctors are concerned as they state they can not predict it's course.
Thanks
Howard

Benji48

Howard12 said:

Hi Benjy, I had 2 PSA's ; 2.71 and 2.81 and two institutions looked at the biopsy slides. Columbia NY Presbyterian read it as a 3 + 4 and Sloan as a 3 + 3. I received one suggestion to do watchful waiting, but that was outweighed by quite a few medical oncologists and surgeons at different institutions. Given the low PSA and apparent small volume (less than 5% of the problematic area) it does seem premature to operate. However, the doctors are concerned as they state they can not predict it's course.
Thanks
Howard

Hi Howard,I'm not a fan of watchfull waiting! 80yr old maybe,41 no way! Have you considered the seed option? Just asking. Seems like you'd be a prime candidate!With a skilled professional and no extracapsular penetration the results would be favorable with minor invasiveness! The 2 PSA checks were certainly done by reputable institutions & like you I'd respect their opinions.
Best of luck, Benji

Howard12

KMiyoko said:

Hi
If you look on the internet for Dr. Tewari, he has a very long list of his accomplishments. He also has years of experience doing prostectomies. I talked to Dr. Tewari over the phone when looking for treatments for my husband. We would have used Dr. Tewari, but we live in California and our insurance wouldn't pay for it. My husband went with the City of Hope and Dr. Timothy Wilson. He had the Da Vinci Robotic prostatectomy. He was in the hospital for 2 days, catheter for 8 days, and continent 12 days after his surgery. I think what you have to do is find a doctor that has years of experience doing both open, then laproscopic, and now the robotic. You also want to make sure the doctor has been doing the robotic on a regular basis. Our doctor does 8-10 surgeries a week. Dr. Tewari fits the description on all those accounts. The most important thing is for you to feel confident with your doctor. After our positive experience with the City of Hope and the Da Vinci procedure, we would do it all over again. Good Luck

Thank you
Howard

KMiyoko

Howard12 said:

Thanks Kay,

I know every case is different, but there is an important similarity given my age of 41 and your husbands of 43. Would you mind me asking about incontenance and impotance issues?
Thank you
Howard

Howard,
If you would like to talk to my musband, man to man about those issuses...he will talk to you. But I can tell you about the incontenance, he has been pad free since the 12th day after surgery. He had his catheter taken out on the 8th day. As far as the impotence issue, things work. But it works a little differently than normal. There are no ejaculations after the surgery. I feel that my husband regained potency sooner than some other men , because of the age factor,plus I think doing the Kegel exercises also gave him a head start on getting things working sooner. Plus the City of Hope gives their patients Viagra as soon as the catheter is taken out, to increase the blood flow to the area which helps things to heal sooner. Write to me at KMiyoko808@yahoo.com if you would like to talk to my husband.
Good Luck,
Kay

Photon

Howard

41 is awfully young to be undergoing surgery. By the way you can see endless oncologists and surgeons and they will all push their 'product'. With your psa and histology why can't you try for 3 months an alternative course organic diet, no diary, red meat, alcohol and Essiac Tea. Vitamins to boost the immune system. PC is a slow growing disease and 3 months of such a regime might just kill the tumour stone dead. Get a mri before the regime and after.

Google Essiac Tea and cancer diets. They do work for some people. It is keeping mine at bay after conventional surgery and salvage radiotherapy following failed to stop a rising psa.

I'm 62 so my kids are gone and I manage around the impotence and the occasional incontinence. But 41 is different - young kids, young wife, active life. Phone the surgeon/oncologist you most trust and ask what a 3 month wait would do.

Best wishes
David

TerryO

Dr. Tewari performed a radical robotic prostatectomy on me in Sept. 2005. I'd be pleased to share my experiences and opinions with anyone facing a decision. My email address is terry@oldberg.biz.

In brief, after getting a pathology report suggesting small volume, Gleason 3+3 adenocarcinoma, I spent a month in a medical library deciding what to do about the situation. One of my findings was that there was tremendous variability in surgical outcomes among surgeons. Another was that surgeons of average or lesser than average skill levels produced unpalatable, expected, surgical outcomes but surgeons at the highest levels of skill produced palatable, expected outcomes. Far more data were available for the open than for the robotic procedure but outcomes appeared to be better for the robotic. Statistics were available on the team that developed the robotic procedure at Henry Ford Hospital in Detroit and the surgical outcomes were very favorable. Thus, for me, the choice came down to one of the 3 members of this team: Drs. Menon, Peabody and Tewari. For no particularly good reason, I wound up with Tewari.

With the exception of one, relatively minor detail, he performed flawlessly for me. However, his employer, Weill Cornell Medical College, proved a difficult organization with which to do business. One needs to pin them down in advance on their pricing schedule but pinning them down proved difficult. This led to snags in getting the bills paid whose pain was far worse than that of the surgery. I'd be pleased to provide advice on doing business with Weill Cornell.

lardog

TerryO said:

Dr. Tewari performed a radical robotic prostatectomy on me in Sept. 2005. I'd be pleased to share my experiences and opinions with anyone facing a decision. My email address is terry@oldberg.biz.

In brief, after getting a pathology report suggesting small volume, Gleason 3+3 adenocarcinoma, I spent a month in a medical library deciding what to do about the situation. One of my findings was that there was tremendous variability in surgical outcomes among surgeons. Another was that surgeons of average or lesser than average skill levels produced unpalatable, expected, surgical outcomes but surgeons at the highest levels of skill produced palatable, expected outcomes. Far more data were available for the open than for the robotic procedure but outcomes appeared to be better for the robotic. Statistics were available on the team that developed the robotic procedure at Henry Ford Hospital in Detroit and the surgical outcomes were very favorable. Thus, for me, the choice came down to one of the 3 members of this team: Drs. Menon, Peabody and Tewari. For no particularly good reason, I wound up with Tewari.

With the exception of one, relatively minor detail, he performed flawlessly for me. However, his employer, Weill Cornell Medical College, proved a difficult organization with which to do business. One needs to pin them down in advance on their pricing schedule but pinning them down proved difficult. This led to snags in getting the bills paid whose pain was far worse than that of the surgery. I'd be pleased to provide advice on doing business with Weill Cornell.

Terry

I have sent you emails and they get returned. Have you changed your email address. I am scheduled to see Dr Tewari in June desperately need any information you may have.
Thanks Larry

Pumpkin18

TerryO said:

Dr. Tewari performed a radical robotic prostatectomy on me in Sept. 2005. I'd be pleased to share my experiences and opinions with anyone facing a decision. My email address is terry@oldberg.biz.

In brief, after getting a pathology report suggesting small volume, Gleason 3+3 adenocarcinoma, I spent a month in a medical library deciding what to do about the situation. One of my findings was that there was tremendous variability in surgical outcomes among surgeons. Another was that surgeons of average or lesser than average skill levels produced unpalatable, expected, surgical outcomes but surgeons at the highest levels of skill produced palatable, expected outcomes. Far more data were available for the open than for the robotic procedure but outcomes appeared to be better for the robotic. Statistics were available on the team that developed the robotic procedure at Henry Ford Hospital in Detroit and the surgical outcomes were very favorable. Thus, for me, the choice came down to one of the 3 members of this team: Drs. Menon, Peabody and Tewari. For no particularly good reason, I wound up with Tewari.

With the exception of one, relatively minor detail, he performed flawlessly for me. However, his employer, Weill Cornell Medical College, proved a difficult organization with which to do business. One needs to pin them down in advance on their pricing schedule but pinning them down proved difficult. This led to snags in getting the bills paid whose pain was far worse than that of the surgery. I'd be pleased to provide advice on doing business with Weill Cornell.

My husband is scheduled for surgery on September 15th with Dr. Tewari. My husband has had numerous unrelated surgeries, and he has always been a good patient. He hopes to have house guests two weeks after the surgery. I feel he is being a bit optimistic. I am interested in finding out what the two to three weeks after surgery are like in terms of the patient and the caregiver. Unlike my husband, I feel it might be too much for both of us two weeks after the radical prostatectomy. Can anyone help. What do we have to know to deal with NY Presbyterian Weill-Cornell?

Pumpkin18

TerryO said:

Dr. Tewari performed a radical robotic prostatectomy on me in Sept. 2005. I'd be pleased to share my experiences and opinions with anyone facing a decision. My email address is terry@oldberg.biz.

In brief, after getting a pathology report suggesting small volume, Gleason 3+3 adenocarcinoma, I spent a month in a medical library deciding what to do about the situation. One of my findings was that there was tremendous variability in surgical outcomes among surgeons. Another was that surgeons of average or lesser than average skill levels produced unpalatable, expected, surgical outcomes but surgeons at the highest levels of skill produced palatable, expected outcomes. Far more data were available for the open than for the robotic procedure but outcomes appeared to be better for the robotic. Statistics were available on the team that developed the robotic procedure at Henry Ford Hospital in Detroit and the surgical outcomes were very favorable. Thus, for me, the choice came down to one of the 3 members of this team: Drs. Menon, Peabody and Tewari. For no particularly good reason, I wound up with Tewari.

With the exception of one, relatively minor detail, he performed flawlessly for me. However, his employer, Weill Cornell Medical College, proved a difficult organization with which to do business. One needs to pin them down in advance on their pricing schedule but pinning them down proved difficult. This led to snags in getting the bills paid whose pain was far worse than that of the surgery. I'd be pleased to provide advice on doing business with Weill Cornell.

In rereading my posting, I realize that I did not make it clear that I am interested in the first few weeks of recovery after a robot-assisted laparascopic procedure. Thanks for any help you can give me.