halbert said...
Bottom line is that it's all about the skill and experience of the surgeon. If he/she has done thousands of procedures, that's a good thing. Beyond that, nothing is really different on the robotic surgery front since this thread was created.
Well that key element of skill and experience is unchanged. (I am assuming surgery a given from here on: not always obvious, to be clear but that's a whole separate story). Find the best surgeon you can. By name. Ask surgeons who they would have do theirs. Obviously they might answer a partner, but you have a good chance of a great steer. They talk, watch each other online, allsorts: they KNOW. If they refuse, well that's one you can cross off the list. Maybe it costs you $200 or more a pop and if that is unaffordable I am sorry. But for most PCa suffers, the difference between good and bad surgery should be pretty well priceless.
But other key elements can change and have. They are MUCH less likely to take a load of lymph nodes now from non-high-risk men than 5ya and that is great news. (The idea is that imaging is so much better you can zap them later if needed - this PSMA-PET stuff is HUGE news). You have "in-theater" frozen-section pathological analysis now so more nerves are spared. No-one dreams of macellating anymore. The incisions have moved*. The space of Retzius is treated differently: some "spare" it with a posterior approach. Both things help continence. Little "hitch stitches" enter the picture eg Jim Porter in Seattle and his Dorsal Venous Structure suture which has spread round the industry. (He had RALRP at 43: I would regard that as a very, very serious incentive to go see him.)
These guys (and gals) are not standing still. But you need a GOOD ONE.
If we look at data like the Protect trial, surgery looks like the most harmful option but I think it is also to some degree the most idiosyncratic. i.e. - and the stories on here can be heart-breaking, especially the guys who look overtreated - you can get absolutely ruined by a bad or indifferent surgeon but really shouldn't be harmed too much by a good one, whereas with radiation, if it's going to kill cancer, it going to affect adjacent tissue to a fairly predictable extent. So surgery has fat tails compared to radiation I think.
* Intuitive are hyping a single-port system but it's not approved in Europe and I think is not doing so well Stateside. You give up a lot of access to save four I think it is of the SMALL entry points. I had surgery 2 days ago and these things are going to be invisible, I can tell. You're stuck with the main incision anyway.