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Open vs. Laparoscopic

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Posted 10/3/2010 7:57 PM (GMT 0)
I haven't found a recent discussion regarding which is better. I thought I at least had this decision squared away, but just read some conflicting info on another thread. I am having a consultation this week with a surgeon that does robotic and laparoscopic. I am also trying to decide whether to push for the robot.

History: 2 brothers with prostate cancer
Age 56
PSA at age 40: 2.5
PSA at age 45: 4.7. DRE normal. No biopsy yet
PSA at age 52: 8.0. DRE normal. 1st biopsy 12 cores, negative
PSA at age 55: 9.5. DRE normal. 2nd biopsy positive 2 of 14, gleason 3+3. both cores <5%
PSA at age 56: 9.2. DRE normal. 3rd biopsy positive 4 of 14, 3 cores <5%, 1 core 7% Gleason 3+4 in 1 small core, prostate 81cc

Post Edited (rick27) : 10/3/2010 2:01:52 PM (GMT-6)

Posted 10/3/2010 8:11 PM (GMT 0)
the method of surgery needs to be secondary to the quality and experience of the surgeon.

i had open surgery, and many here have had robotic

open surgeries typically need 2-4 days in the hospital, i needed 4

robotic surgeries are typically 1 day, but several here stayed 2 or more days

blood loss as a con for open surgery should be ruled out in our age, as that is rarely an issue in reality, and can still happen with robotic

if a person is too large or heavy, they may rule out robotics. or previous surgery may deny robotic. i had a deep and unusual prostate bed, so had i chosen robotic, the process would have been aborted and changed back to open regardless

magnification advantage of robotic is both true and not true. modern open surgerons have great magnification via screens as well

big advantage - open - tactile feel. in the hands of a very experienced surgeon, nothing replaces the touch and feel of the surgeons feel, though many will argue that point away.

come back to the start - most important thing - get the best and most qualified surgeon you can get, with hundreds of quality ops under his or her belt, still more important than the methodology.

good luck

david in sc
Posted 10/3/2010 8:15 PM (GMT 0)

Rick,

Your question is an excellent one. I reserched this issue prior to surgery 1.5 years ago as my Doc has extensive experience in both. The data is simply not out there regarding whether there are better outcomes between the procedures though the research centers where they do both are collecting the data. You must consider these factors:

1) The surgeon's experience with either procedure. Laproscopic maintains the "minimally invasive" aspect of surgery and also the surgeon can "feel" the gland and other things that some proclaim are important, e.g. Dr. Walsh at Hopkins discusses the importance to him in "the feel" of the various things that he handles in his procedures. He, however does the "open" method.

2) The use of robotic techniques to many in the medical world is embroiled in massive marketing of the daVinci machinery. I do not want to take away the fact that it is effective (with an experienced surgeon) but it gets alot of panache due to it being "new and innovative." Some hospitals, in order to gain patients are "selling" it as the only way to go. That is not the case.

 I ultimately chose laproscopy as my Doc had done 1600 of them and that was most important to me. Recovery from either is going to be the same, though daVinci requires one more incision I believe.  Keep asking and reading about it and once you make up your mind you will feel alot of (mental) relief. The hardest part of the journey for me was trying to figure out what to do. When you choose, just do it.

Best wishes,

Ted

Posted 10/3/2010 8:15 PM (GMT 0)
They are equivalent in curtive results.

It appears to come down to comfort level of the doctor. The older doctor with less robotic experience is more compfortable with the open, and therefore probably better. Many of the open guys claim better tactile feel.

The younger doctor is more comfortable with robotic, therefore probably better. They seem to claim better view of the situation with the lack of hands and instruments in the surgical field, and the 10x magnification of the camera.

Try to look for a doctor of either technique with several hundred under his belt.

The robotic is termed bloodless, which of course is a relative term, but the open requires slicing through a lot of veins as they get down to the prostate. This appears to be one of the biggest advantages of robotic. In todays world, tranfusions seem to create a bigger risk of having a problem.

Good Luck.
Posted 10/3/2010 8:40 PM (GMT 0)
What about the recovery times? I had robotic surgery on 8/20 and yesterday played in a 36-hole golf outing. I actually played 18 holes just before the four-week recovery mark and felt great both times. Could I have done that after an open surgery? A quick recovery was one of the reasons I chose robotic surgery. Also, I felt there would be considerably less trauma without all the retractors and extra tools needed during traditional surgery. I realize both methods can claim very good success rates.
Posted 10/3/2010 8:59 PM (GMT 0)
I don't think Rick was asking about open vs Da Vinci: I think his question was asking about open vs laparoscopic. There is open surgery, laparoscopic surgery and then robotic labaroscopic surgery(Da Vinci). As the others have indicated, whatever method is chosen, the experience of the surgeon is paramount. Between open and robotic there is much debate. Robotic has indeed been well marketed. The difference in the two surgeries is mainly external with the larger incision of the open surgery adding perhaps a week to recovery time. The internal surgery is much of a muchness. Blood loss is less with robotic because of the smaller incisions and the ability of the micro instruments of Da Vinci system to cauterize bleeding blood vessels as they go. Vision is better because of the 3D magnification of the Da Vinci equipment. On the other hand there are benefits to open surgery. The surgeon can feel the texture of the tissue and has feel as to how hard he is pulling or pushing on tissue and his instruments. On the other hand, (and this is only my opinion for what it's worth), laparoscopic falls in the nether region. It does not have the vision and instrument capabilities of the robotic method but neither does it have the advantages of the surgeon having a true sense of touch.......his sense of touch is akin to you feeling something with a stick. With something like nerve saving an excellent sense of touch or a very good field of view is essential. However with a lot of experience undoubtedly the straight out laparoscopic surgeon could become very capable and efficient. I had robotic myself but with all I have learned over the past 3 years I would now elect to have open surgery (albeit with the same surgeon).
Bill

Post Edited (BillyMac) : 10/3/2010 3:05:59 PM (GMT-6)

Posted 10/3/2010 9:43 PM (GMT 0)
Thanks guys. Nothing comes easy in this process.
Posted 10/3/2010 11:22 PM (GMT 0)
If you have plenty of surgeons to choose from, and have found an "open" and "robotic" surgeons of equal (high) skill level, I would choose the robotic..But if the open surgeon had more experience and higher skills then I would favor the open method. In this game, it's the skill of the surgeon that counts, not the method used...

Many U-docs and surgeons offices have full-size molded models of the male lower abdomen. Look for one that includes the pelvic and pubic bone..Not much room for a pair of human hands down in there. The situation is so difficult that it was not that long ago, many surgeons chose to go in through the perineum feeling it gave them better access to the prostate..In Denver today, where I had my surgery, 90% of all Prostatectomies are performed roboticly and you would have a hard time finding someone who had the perineal procedure..

While my PC was not cured by the surgery, (Gleason 9, positive margin) I was probably not curable by surgery alone and I don't blame the surgeon for that. The operation itself (4 hours) went very smoothly and I have recovered very quickly from it, never any pain or incontinence. ED however is an issue, but it is with most men regardless, some more, some less...
Posted 10/3/2010 11:32 PM (GMT 0)
Thanks Fair. The surgeon that was recommended to me does either LRP or Robotic. I was told that he will decide which is better for me. I would prefer the robot but I'm not sure if I should insist on it and maybe override his opinion.
Posted 10/3/2010 11:42 PM (GMT 0)

What a contentious question, but the $64,000 one..

First - I would wonder the distinction between ROBOT and Laproscopic..   To me they are the same..  ie. Small cuts and arms that do the work.  Whether ROBOT or MANIPULATORS, they amount to the same thing.

Just prior to my RRP, I attended a formal seminar on PC and they covered both Laproscopic (Robot) and open Cut...  The emphatic comment was made , that there three were differences:

1.  Laproscopic gave a markedly shorter 'down time'..

2.  open Cut gave a better oncological result, as a skilled surgeon can fully see in 3D and can twist and turn bits and hence get a finer result.   and suprisingly

3.  Less 'post-operative' complications from open-Cut RRP.

Those that I had spoken to first, questioned themselves as to WHY they were having the procedure - 'to cure CANCER'..  and so questioned which was the most important  --   On your feet fastest, or on your twig the longest ! shocked      I like the view from my twig !

So my response was to go for the procedure that gave the greatest promise of complete recovery.  I suspect that my surgeon shaved my bladder with a 5 blade Guillette, to ensure that NO prostatic tissue was left.

In the end, the results are in the hands of and controlled by the skill of the surgeon, but the percentages are always there.

PS - My younger Surgeon, with hundreds of RP a year to guide him, would never use LRP, because he does not have the tactile/visual response that he has with open-Cut.


Posted 10/3/2010 11:58 PM (GMT 0)
The magic number where surgeons really start to get good at it is around 300 procedures. I asked my surgeon about this, he said they get paid the same either way so that's not an issue...I would go with what your surgeon feels is best for you...But ask him how many prostatectomies he has done total, and how many roboticly. That should tell you which method he favors..Also, how many has he done this year..Hopefully more than 20...But not less than 10..

Your scorecard looks very similar to mine except you are 12 years younger...

Your PSA 9.2, positive in 4 cores, Gleason 7, 81cc prostate, your surgeons job is to try and save your life, let him know that is PRIMARY, and to do it the way he feels he has the best chance...None of the other stuff counts at this point..JMHO...
Posted 10/4/2010 12:07 AM (GMT 0)

BuiDoi said...
What a contentious question, but the $64,000 one..



Just prior to my RRP, I attended a formal seminar on PC and they covered both Laproscopic (Robot) and open Cut... The emphatic comment was made , that there three were differences:

1. Laproscopic gave a markedly shorter 'down time'..

2. open Cut gave a better oncological result, as a skilled surgeon can fully see in 3D and can twist and turn bits and hence get a finer result. and suprisingly

3. Less 'post-operative' complications from open-Cut RRP.

Careful studies done at major cancer treatment centers do not support item 2 and 3 above.

Posted 10/4/2010 1:07 AM (GMT 0)
The only thing that matters is the long term outcome--urinary control and erectile function. Although there are a few studies suggesting these are a bit better with open than robotic, these studies aren't really convincing, because how do you know that the surgeons in the two groups had the same experience and skill?

I've heard that the reason for less bleeding with robotic is that the abdomen is inflated with air during the procedure. I had open surgery, they use a blood scavenging machine to suck up the blood from the operative field, filter it, and reinfuse it into you. No problem with that.

The open surgery incision is a little sore for a few days--hard to turn over. For the first 4 days, I learned to roll over like a log, without twisting my belly. After that, no problem. With robotic, the incisions are shorter, but there are more of them.

The robotic has a bit shorter hospital time, but mine was 2 days with open.

I found the worst part of the whole experience is being stuck with a catheter for 10 days. The greatest pain was when a nurses aide stepped on the catheter by accident. Ouch!

Recovery time probably depends on your health, not on the procedures. 2 weeks after surgery I was walking 5 miles a day, going up steep hills, no problem.

So, the only thing that matters is long term complications--incontinence and ED--not these short term issues. The long term complication risk is determined by your cancer, your anatomy, your health, and the skill of your surgeon, not by the equipment used.

Find the best surgeon that you can, use the method that he/she recommends.
Posted 10/4/2010 1:27 AM (GMT 0)
The surgeon I consulted with had done over 1000 open and 1000 robotic, and had strong preferences towards the robotic technique. I was comfortable enough with him to let him decide, and knew that if for some reason the robotic procedure would not work he had the expertise to switch to open. I also had some unusual anatomy which greatly impressed him. My wife said he was like a kid in a candy store when describing the surgery with her after it was over.
Posted 10/4/2010 1:54 AM (GMT 0)
Thanks all!
Posted 10/4/2010 4:24 AM (GMT 0)
Rick,

My uro/surgeon did open  for years in the past, now does only DaVinci. He claims the "feel" arguments are not as important as the flexibility of the tools.

If you choose open, they will probably have you come in (maybe twice) to have a unit of blood taken so that if you need any, it would be your own, limiting risks.

I was also told that there was a risk of complications that could cause a switch to open.

For all the hype about getting out of the hospital faster, I had DaVinci (10/2009), and spent 5 days total in the hospital. I walked with a cane for almost 8 weeks (yes, I walked a mile 10 days out, but it took 2 hours).

Get the best surgeon you can. (Do I need to repeat that?) The method should be a remotely secondary choice.

Posted 10/4/2010 6:26 AM (GMT 0)
nono The only thing that matters is the long term outcome-urinary control and erectile function> nono

 

Oh boy, would I disagree !

ONE     - Cancer Cured - NEVER to return

TWO    - Complete Continence

THREE  - NO  ED.

There would be a few guys out there who could not have a Nerve-Sparing  RP.  

Whilst being very disappointed with the ED, I am sure that they find life itself, to be a fair compensation...

I am sure their families have a preference too..

<Careful studies done at major cancer treatment centers do not support item 2 and 3 above.>

Don't forget that the comments were made by surgeons considered to be highly skilled,  It would be reasonable to suggest that their statistics may have been biased by THEIR results.

This leaves the final, and most appropriate suggestion...

 

Find the best surgeon that you can (afford).

.

.

Post Edited (BuiDoi) : 10/4/2010 12:29:18 AM (GMT-6)

Posted 10/4/2010 1:01 PM (GMT 0)
Note that you may choose Laparoscopic or Robotic, BUT if the surgeon feels he absolutely needs to change course DURING the surgery he will then do an open

While I was in recovery a patient next to me had that exact thing occur


--------------------------------------------
This had to have been said in jest

"The only thing that matters is the long term outcome-urinary control and erectile function"

Lets see ,,,, if your cancer leads to your short term demise then its a good thing you have long term urinary control and erectile function ,,,for what,,,, while you are under ground ???

1st priority get rid of the cancer, peeing all over yourself indicates that you are still alive, any other option other than alive is a poor one

Live is far better from the grass side than from the root side !!!!!
Posted 10/4/2010 9:25 PM (GMT 0)
<Also, how many has he done this year..Hopefully more than 20...But not less than 10..>

Re. the opinion of My Surgeon (and others) that open RRP is better than LRP.......,

My. Surgeon - Dr. Cozzi - does about 150 - RRP's a year, plus countless  TRUS-Bx,  and BPH Re-Bores. etc.

He would not look at LRP..

Would I feel confident with a surgeon who was similarly confident in RRP and LRP ????

Not sure, because I do have the feeling that as     CANCER--SURVIVAL     is the pronounced OBJECTIVE, then I suspect that RRP will always have the edge over LRP..

I am unsure of my choice , had I a Surgeon with 1000  LRP, and  1000  RRP's under his belt.

After my RRP, I was slowly doing light work after 2 weeks

There are UDocs and UDocs...

I spoke to a chap who had a TRUS-Bx.   The procedure was undertaken using a local anesthetic, and using a hand-gun..   That UDoc took  6 samples..  Three of the Prostate and three shocked of the Aorta shocked .

Within a day, he was 30Mins from death's door from internal bleeding..

The  ER were immediately suspicious of the swolen abdomen, and the statement of the TRUS-Bx the previous day.

There are UDocs and UDocs...   There are Surgeons and Surgeons.. 

.

.

Post Edited (BuiDoi) : 10/4/2010 4:42:02 PM (GMT-6)

Posted 10/4/2010 11:01 PM (GMT 0)
See the image of the anatomy of the prostate and aorta:

http://education.yahoo.com/reference/gray/illustrations/figure?id=539

They aren't close to each other; you'd need a needle 8 inches long pointed in the direction of the person's head to hit the aorta during a prostate biopsy.
Posted 10/4/2010 11:43 PM (GMT 0)
bui,

i am not convinced that last story can be true, or at least remotely accurate

david
Posted 10/5/2010 1:27 AM (GMT 0)
My doc used to do laproscopic but switched to robotic. He explained that because of the lack of touch in robotic he had to train himself to touch with the robot and use his eyes to see how it responded. Overall he seemed to believe that robotic, once he had mastered the touch issue, was better because it gave him better vision.
Posted 10/5/2010 2:10 PM (GMT 0)
I'm not sure if anyone still does non-robotic laproscopic RP. It is not the keyhole side of the da vinci that makes the difference but the robot assistance. Old style laproscopic almost involves holding the scope in one hand and the scalpel in the other as it were. Fine for a bit of knee cartilage but not so good for complex abdominal surgeries.

Your anatomy, health, weight and previous history of surgery etc will play some part in what the surgeon can do and wants to do as well. Some surgeons will want people to lose weight before the robot as you have to lie 45 degrees to the vertical for the op.

I effectively picked the best hospital I could, a good surgeon was an automatic consequence of that. Don't forget you need a good anaethetist and "team". My after care was excellent.
And a short stay in hospital has it's advantages. I know three people who have had (non PCa) surgery in the last year who were in hospital for several days and all of them picked up a bad hospital infection.

Alf
Posted 10/6/2010 11:24 AM (GMT 0)
Our surgeon does all three types of surgery: open, laprascopic and robotic (which is a form of laprascopic). He felt that John was an excellent candidate for the robotic and that's exactly what happened. However, he told us that he could not guarantee that he would not have to convert to open during the surgery. open works better in men whose prostate is tucked further back behind the pelvis or whose prostate is too large to be pulled through the laprascopic slit.

As to ED and preserving nerve bundles, my husband had both external nerve bundles spared yet suffers from ED...there is no guarantee on this one. His incontinence was never bad but occasionally he still needs a pad during the work week due to "squirting".

My suggestion is to go with a surgeon who has the best track record with removing the cancer since neither surgical method will guarantee quality of life results.
Posted 10/8/2010 2:25 AM (GMT 0)
Thanks to all for the replies. I really appreciate it. I met with my surgeon and told him I preferred robotic assisted LRP. He told me that while he does both RLRP and LRP, and would do the RLRP, he has done far more LRP and still prefers this method and has had stellar results. He is my preferred surgeon in my preferred hospital. He has done many hundreds of LRP's. I decided to defer to his preference and go with the LRP. Why is this whole process like a crapshoot? The date is set for Nov 4th. Is there a November group yet? lol
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