Open vs. Robotic

From the Johns Hopkins Health alerts this morning:

When it comes to prostate cancer surgery, are best results achieved with open surgery or with minimally-invasive procedures? Alan W. Partin, M.D., Ph.D., a world-renowned expert in the study and treatment of prostate cancer, addresses this important question in an excerpt from our Special Report, Choosing the Right Treatment for Prostate Cancer. 

There are three ways to remove the prostate: One is the traditional operation through an open incision, while the others involve a laparoscope or robot. Here is the bottom line: It's the same operation done three different ways. To date, there has been no single randomized study to fully evaluate the key issues. 

Our Hopkins experts have looked at all of the critical variables regarding the different surgical approaches, including blood loss, need for transfusion, pain, erectile dysfunction (ED), cancer cure, side effects related to the surgery, and return to work. We found no differences. 

How can you counsel a man to look at all of the options for prostate cancer therapy when robotic surgery is so heavily marketed as the best choice? 

It's not hard. I sit down with the patient and explain the marketing and advertising behind robotic prostate procedures and how they often help sway patient decisions. I also explain the fact that right here at Hopkins, where we are on the front lines in prostate cancer treatment, there does not appear to be any difference between the open and robotic procedures. 

Speaking for the Hopkins surgeons who perform both open and robotic prostatectomies, we don't care which procedure a patient ultimately picks. For us, it's a matter of going to Room 6 or Room 18 to do the prostate surgery. One operation takes a little over an hour to perform the other a little over two and a half hours. The end results are similar. 

Some surgeons advertise the fact that they can do a robotic assisted prostatectomy in 90 minutes. Is that possible? 

If a surgeon says the procedure takes 90 minutes, then it comes down to the definition of "surgery." These surgeons are only counting the time that they are sitting at the robotic console and operating on the patient. However, at Hopkins we start the clock when the patient is first wheeled into surgery and stop it when he arrives in the recovery room. This takes into account all the extra set-up time necessary to prepare the patient for surgery, and not just the time the doctor spends actually removing the prostate. 

How can a man choose between a surgeon who performs the open procedure and one who uses a robot or laparoscope? 

Here is what I tell all prospective patients: You don't want to bring a plumber into your home to do electrical work. If your surgeon says he feels confident that he is going to provide the best operation for you with a certain technique -- open, laparoscopic, or robotic -- and you like that surgeon, you should choose him for your surgery. 

 

Tudpock (Jim)

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What patients do not realize is that they can go in getting robotic but the surgeon can switch mid-operation and perform an open.

April6th

Picking a highly respected hospital is a step in the right direction. The best hospitals will not risk their reputation on hiring less than A+ surgeons

Of course there is always the risk that the A+ surgeon is having an off or so-so day but that is human nature. Its not a computer controlled assemble line procedure, there are very many variables

When picking a surgeon the support staff is also important, which goes back to the hospital. A great surgery can be botched but a nurse missing a change of a soiled bandage which develops into a staph infection

I thought cost might be an issue so I asked my surgeon about it..he said most prostate surgeries were done under Medicare and they paid a flat rate for the procedure no matter how it was performed..So a higher profit margin can't be the motivation for pushing robotic surgery..

Partin and Walsh are the old guard cornerstones of Hopkins prostate cancer research and treatment. They are both open surgery guys...Walsh invented the nerve sparing technique and is regarded as one of the best surgeons in the business. Partin developed the Partin Tables, Both are nearing retirement...

On the Datolli website he quotes a 2008 Duke Univ study that indicates an increased early failure rate (first three months to three years) for robotic surgery when compared to open surgery.

My urologist and his practice only do open. They say the ability to feel tissues is extremely important and they don't think that robo has proven to be better. If I wanted robo, he had referrals.

MrGimpy

My urologist is young, mid 40s, and currently is not going through the learning and experience curve to do the robo because he isn't convinced he can be better with the robo. Like most, he is very busy and in addition to his surgeries he performs 4-6 HDR procedures each week. A couple of his partners are more senior and, like Walsh, are closer to retirement, so they are sticking with open.

They have access to and can use the robos, but they choose not to at the present time. Further, my urologist is like Walsh in that he won't operate on any but the very early cases. If he thinks the case may result in positive margins or unspared nerves, then he takes the patient the HDR brachytherapy route as he believes it to be better and less traumatic for the intermediate and advanced patient.

As to the cost. It may be that the surgeon's charge is the same either way, but the hospital is going to be different. With open and a longer stay there will be more in the way of room and services charges. While these should be less with robo, the hospital will charge dearly for the rent on the machine.

Robotic surgery offers some unique advantages. 360 degree field of vision allows for a more precise surgery. Some say that this is the reason for higher incidence of positive margins, but the best doctors do not all agree on that. I have heard the argument before about how the doctor feels the cancer and that is important. But not all tumors are palpable, in fact many are not. A robotic or laparoscopic surgery would tend to state that the visual advantage supersedes the ability to feel a tumor. Robotic surgeons can still feel the tissue they remove and if necessary they can "scrape" more tissue if after they remove the prostate and feel a palpable tumor. My surgeon's repost stated that he did not feel a palpable tumor but rather he could visually see where a positive margin was likely. He stated that he removed suspect tissue as far as he could without risking damage to my rectum. In fact when he gave me my pathology results (margins near the rectum were positive) he stated if prostate cancer is still present it would be more challenging to radiate because the area was scraped to the rectal tissue. We have since done radiation as an adjuvant to the surgery. To date all is well including the disease control.

I think it has been well stated in this thread ~ it is not the paint ~ it's the painter that matters.

Tony

My regular doc gave me the best advise ever when he said"I`m sending you to see the surgeon that other surgeons go to". Cant argue with that and so far good results.