radical open removal vs. laparopscopic /robot

I'm sorry to hear about your diagnosis. The first thing to do is breathe. This isn't something you have to decide right away -- in fact, it's much better if you take a breather. I hope you won't let your urologist rush you into anything. You deserve better treatment than that.

While,you're breathing, it's prudent to call your urologist and have the biopsy slides sent for a second opinion from a specialty lab like Bostwick or Epstein at Johns Hopkins. It's possible that the slides were misread, and this is something you'll want to be sure about.

If it's confirmed, then you are categorized as being of "intermediate risk" of recurrence after definitive treatment. Fortunately, there are many good treatments now that give an excellent (90+%) chance of a cure. Here's a list of 5 or more yrs of freedom from recurrence (as measured by no significant rise in PSA) for intermediate risk men:

Surgery (Johns Hopkins) - 77%
SBRT (multi-institutional) - 93%
HDR brachy monotherapy (GammaWest) - 94%
LDR brachy/seeds (Seattle) - 97%
IMRT- ultra high dose (MSK) - 86%
IMRT - high dose (MSK) - 78%
Proton (Loma Linda) - 65%

In general, you will see that radiation does better than surgery for intermediate risk because it treats a margin outside of the prostate where the cancer may have already spread to. There are advantages and disadvantages to each kind of treatment in terms of expected side effects. I hope you will take the time to investigate these options and conduct a thorough self-assessment of what you are looking for in a treatment before deciding.

DanchW said...
he says : lap. w/robot means it is more likely for tumors to reoccur and more likely to damage vascular bundle

I've never seen any data to substantiate this rather bizarre assertion. In fact, there's no convincing data that any one method of surgery is superior to any of the others. What does make a big difference is the quantity of the urosurgeon's experience in the technique he is most proficient at. In my opinion, he ought to have done at least 1,000 such surgeries and ought to have a positive margin rate of close to 10% in the last year-- if not, find another surgeon -- there are plenty out there. Doctors like Ash Tewari do a great job of preserving nerve function using a robotic technique, while doctors like Dr. Catalona prefer the "haptic feedback" they can only get with open surgery. Retropubic vs perineal entry is usually based on anatomical considerations.

- Allen

Danch, welcome to HW but sorry you have to be here.  I have not seen data that backs up the assertion of your urologist re da vinci.  What I have seen is that, for prostate contained cancer, both open and da vinci surgery done by a highly EXPERIENCED doctor will provide you with an excellent chance of cure.

Like Tall Allen said, however, your due diligence should also include reviewing options beyond surgery.  These options may provide equal cure but with less onerous side effects.  Even if you ultimately choose surgery you are well served to have educated yourself and investigated the full range of options.

Best of luck and please keep us informed about your journey.

Jim

P. S.  I did not vote because I think you need to look at other options.

Tall Allen said...

In general, you will see that radiation does better than surgery for intermediate risk because it treats a margin outside of the prostate where the cancer may have already spread to.

Of course, when surgery is chosen as the primary treatment, radiation is still available as a salvage therapy if necessary.

One also needs to be careful in comparing biochemical free survival rates for surgery to radiation, as different criteria apply (the undetectable PSA for surgery being a somewhat higher bar).

njs said...
Of course, when surgery is chosen as the primary treatment, radiation is still available as a salvage therapy if necessary.

In addition to Buddy Blank's very accurate comment, I wanted to add that radiation on top of surgery significantly adds SEs over if radiation had been done in the first place. If salvage is necessary after RT, I think salvage brachy or SBRT are better choices than salvage surgery.

njs said...
One also needs to be careful in comparing biochemical free survival rates for surgery to radiation, as different criteria apply (the undetectable PSA for surgery being a somewhat higher bar).

There are all kinds of reasons not to do that kind of monadic comparison. Sadly, randomized comparative treatment studies are lacking.

There is no evidence that the bar for biochemical failure is any higher for surgery than for radiation. In fact, they come up with that bar for each based on its correlation with clinical failure rates. The current (Phoenix) definition of biochemical failure (nadir+2) after RT accounts for the fact that PSA-producing non-cancerous prostate cells are left after RT, whereas with RP, none are supposed to be left, so even .2 may indicate failure. One would expect the failure rates to be higher with radiation based on the average age at treatment -- about 10 years older -- and the fact that virulence increases with age. So it's especially remarkable that the failure rates are so much lower with certain kinds of radiation.

- Allen

Its the practioner of treatment that trumps most other factors. BT will become the new gold std for those eligible in my view. Cant't remember the name, but Seattle has the best in the world for BT. I had open and am pleased with results.

Tall Allen said...

njs said...
Of course, when surgery is chosen as the primary treatment, radiation is still available as a salvage therapy if necessary.

In addition to Buddy Blank's very accurate comment [that it is a myth to suggest that surgery is not available for radiation patients], I wanted to add that radiation on top of surgery significantly adds SEs over if radiation had been done in the first place.

Hopefully no one thinks I was suggesting that salvage surgery is not possible. To the contrary, I have pointed out several times in other threads that it is an option. The point of my statement about salvage radiation being available was simply that, to the extent surgery may have higher rate of recurrence vs. radiation, there is still the opportunity to address any recurrence and approach or equal the cure rate of radiation.

But why would one not just have radiation in the first place if the risk of SEs are higher when done as salvage therapy? Many potential reasons: 1) Some desire the specific benefits of surgery (e.g. satisfying the "need to know" on final pathology) yet are happy to know they still have radiation as a back up if needed, 2) for those who are uncomfortable with the unique risks or hassles of radiation, surgery as a primary therapy offers an excellent chance of avoiding radiation completely.

Danch, would the urologist surgeon recommending this method of surgery be the one who is going to perform it??

He probably thinks so highly of it because it's the only kind he feels comfortable performing...

I would get a second opinion outside this doctors practice.. This guy might be fantastic, an excellent choice, but don't take HIS word for that.

DanchW I'd also make sure that this surgeon has nearly 1000 of them under his belt.

DanchW,

Your take away from this should be that you have time to make decisions but you have decisions to make. Before you make a final decision about treatment you should talk to a number of doctors who specialize in different specialties. You should talk to a radiation oncologist since many of the different radiation treatment options offer excellent results with easier recovery and usually fewer side effects. You might also talk to a surgeon who does robotic surgery since he may have different insights than your urologist.

There are lots of options and, actually, the odds are pretty good no matter what you choose.

Have any of you had experience with the Moffitt Cancer Center in Tampa ?

Danch, if you are near Tampa you are also not too far from Sarasota.  Dattoli Cancer Center is one of the best in the world and is a great place to review your radiation options.

Jim

English Alf said...
(Welcome to HW)
When I was done (which was nearly 4 years ago) they said that with the robot you can go home after about 36 hours and with open surgery you may have to be in hospital for a week.

Hospital stays for everything in general are much shorter in US. Everywhere is different, of course. At Northwestern I was told I would have been kept two nights for open. But at Johns Hopkins both open and robotic patients are on the same post-op plan to go home the next day, but I imagine the average stay may be longer for open surgeries vs. robotic if a larger fraction of open patients stay the extra day. I was an outlier who stayed 3 nights due to complications requiring a couple of transfusions on post-op days 1 and 2.

In any event, it seems crazy to keep the typical uncomplicated patient for more than two nights let alone a week. The hospital is the last place you want to be any longer than necessary due to infection risk, etc. Even with anemia and extra tissue trauma from my mesh hernia complication, there was no way I needed to be in the hospital more than four days...