Selecting a Surgeon - Robotic vs. Open

I'm trying to decide between 2 good surgeons.  Both are based at centers of excellence for cancer treatment.  One surgeon does only Robotic.  The other surgeon does both open & Robotic ( 70/30 ) and recommends that open is preferable for me due to my particular prostate characteristics and his general preference for the tactile benefit of open.

I'm in a quandary --- I'm drawn to the obvious procedure benefits of Robotic and I'd like to avoid the possible downside effects of open.  If I choose Robotic I'll go with the guy who does them exclusively.  On the flipside I like the fact that the open surgeon has made a judgement call that he thinks open would be best for me, and I give this opinion some weight because he does both procedures.   Both surgeons are the same age,  seem to have equal excellent skill sets, and equivalent high reputations.

I'd appreciate any input on evaluating the pros & cons of these 2 procedures.

Another consideration is timing :  both surgeons, my urologist & GP all indicate that treatment is better sooner rather than later, i.e. within the next 2 months, due to tumor visibility close to capsule wall.  But, I'd like to reach a solid comfort level with the choice of procedure & surgeon without feeling that I made it under time pressure.  Again I'd appreciate any comments.       

   

My doctor did open surgery almost exclusively. When I queried him as to why, he responded that there have been no long-term studies as to the efficacy of open vs. robotic...and...he preferred having the ability to feel surrounding tissues with his hands. He has done more than 400 surgeries and this was what convinced me to look no further.

Is the 70/30 meant to be a ratio, or a count?

I selected a surgeon who had done open for many years, and switched to DaVinci. He did tell me that in the event of problems, there were reasons that they would switch to open.

He did not subscribe to the "feel" argument.

I had multiple viable and practical options to go with open, but stayed with the DaVinci decision based on my comfort level with the surgeon.

I would move quickly on this, since you say it is close to the capsule wall. The downside of not getting it while it is still inside the capsule is greater than any likely difference in outcome between the two surgeons you are considering. Pick the procedure that you think you want, and get yourself on the calendar a month or so out. That will start the clock ticking; you can always research it further and if you find a strong reason to change your mind, then go ahead and change your mind. But it will stop you from endangering yourself by procrastination and inaction.

In general, for most prostate cancers, the two procedures show roughly equal results. "In general." Each PC is different.

You might be able to get some more useful feedback from this group if you ask the surgeon who recommends open why in your particular case, he thinks open might be better. Not the reasons in general, the reasons in your particular case. For example, if your pre-op information suggests that extended lymph node dissection is warranted, that can be done a bit more easily in open, I'm told. People here might have some reactions to the particular arguments the surgeon offers.

I had robotic FWIW, and I'm pleased with the outcome, but that doesn't mean it's necessarily best for you.

To Decama : Thanks very much  -- I think that'll be the deciding factor for me.

To BillArb :  Thanks for your reply.  There is one study I'm aware of out of  Boston in '09 reviewing 1300 + patients and also reported by the National Cancer Institute. The findings were that Robotic's overall results on continence & ED were slightly worse than open.  But commentators have noted that the patient universe in that study ( all Medicare patients so all over age 65 ) isn't truly representative of the entire Robotic patient population.

To MrGimpy : Thanks so much.  My original post was my first on this forum and I realize it was imprecise on several counts:  The surgeon who I indicated does only Robotics was trained & practiced in open, and he reverts to open during surgery if there is a medical need or some other situation where the Robot cannot be used.   He elects not to do open operations as a regular part of his practice only because he is such a firm believer in the advantages of Robotic, and he has performed more than 2500 Robotic procedures.   The surgeon who I indicated regularly does both procedures has also performed several thousand operations but his practice now splits between 70 % open operations to 30% Robotic procedures.  I believe that both surgeons are eminently qualified. My dilemma is whether I opt for the operational benefits of Robotic ( in which case I'd go with the guy who is passionate about Robotic ) , or choose the other surgeon who recommends open based on my particular prostate characteristics & the benefits of tactile sense during the operation.    

If you’ve come this far, you already know that your results are dependent on the skill level of the surgeon and not the type of surgical procedure you select. You’ve also read that the main benefits of robotic surgery are the faster recovery times, less blood loss, less pain, shorter hospital stays, and possibly fewer days with a urinary catheter. For all of these reasons I chose to have robotic surgery. There’s an added, more abstract, benefit as well. While the two procedures yield similar results in the hands of a skilled surgeon, robotic surgery yields consistent results over and over.

For me, the decision was easy. My Gleason score was 3+3=6 in 3 of 12 cores with less than 5% cancer in each core. (I was ultimately upgraded to 3+4=7 with negative margins post surgery). There was little that I could gain by a surgeon using his “tactile sensation.” I had no hard spots or lumps or bumps. And robotic surgery provides amazing visual acuity that far surpasses that available with open surgery.

In your case, it appears that you also will have very little to gain from the surgeon’s tactile sensation. Your tumors were discovered only because of a needle biopsy so, theoretically, you have no lumps or hard spots to feel. I’m not familiar with how accurate MRI scans are in locating a tumor inside of the prostate. However, this is a slow growing cancer, yours is a bit more aggressive than mine, but chances are good that it has not grown outside your prostate. Your doctor can give you the best advice about that.

I’m troubled when I see Walsh quoted as a reason for proceeding with open surgery. I read his book and I learned a lot from it. But, he only performs open surgery and so he’s biased toward that procedure. For him, it’s as if one size fits all. And, that’s just not the case. Every patient is different. If you’re having trouble deciding you might want to try a third, independent expert. Your individual biopsy results should dictate your decision and not what anyone here writes.

In my own case, I’m very happy with my decision - so far. But, time will tell as I’m only two days after catheter removal. I can say that I was out of the hospital in 24 hours and that I’ve had literally no pain. As for side effects, I had full control immediately after the catheter was removed - I think. Since I’ve been told over and over that I’ll need pads for at least a month or two, I’ve been wearing one. But, today I did not and I’ve had no issues with incontinence.

It’s unfortunate that we have to make these decisions, but it’s also wonderful to have so many good options. Good luck in whatever you decide.

If you go robotic, get a doc that has done several thousand. Mine had done more than 10,000.

Wow, 10,000? That's four a day, week in and week out, for 10 years. How long have they been doing robotic surgery? Not that I'm a sceptic or anything, but you've gotta wonder if some of these guys pad their numbers just a tad. For all I know, maybe my guy does it too.

On the other hand, I think the experience curve flattens out after several hundred. By the time a surgeon has done 1,000 he's probably as good as he'll ever get. Quantifiable experience and excellence is a good thing, but I think it's possible to get carried away with the numbers.

All that said, I think a great surgeon is a great surgeon, and whether he does it open or robotically is of little consequence. I'm persuaded that the whole tactile thing can make a difference for some patients, just as there's something to be said about the easier recovery that laparoscopic surgery can provide. But in my view, nothing trumps experience and excellence.

I haven't been participating in this forum all that long, but I've read over and over again that one should find a surgeon who has performed thousands of DaVinci procedures.  I've been trying to convince myself that is a plus, and maybe it is, but my particular surgeon has done just under 50 surgeries with excellent results.  I couldn't be more pleased if I had traveled a thousand miles to Johns Hopkins.  He has also done many, many open surgeries over the years as well.  Friends of ours who know the ins and outs of the operating theaters here in the northern suburbs of Chicago all agreed that our doctor is an excellent surgeon, both for open surgery and for the DaVinci procedure.  I trusted the opinion of the doctors, nurses, and operating room technicians with whom I spoke, and I am completely satisfied with the results.  Plus, I had the advantage of surgery just 20 miles from home, no hotel stays far from home, no airplane trips, no long automobile rides. 

I would rather be the surgeon's only DaVinci procedure on a given day than number three or four.  I valued a surgeon who spent as much time with us as we needed on the day the diagnosis came back and during the pre-surgery visit; who returns phone calls personally; who knows me when I come back for post-operative visits; whose general bedside manner inspires confidence; and who has a sense of humor as well.

The number of procedures performed is certainly worthy of consideration, and I don't think I would want to be a surgeon's maiden attempt, but the doctors with whom I spoke generally said that if the guy has done 40 or more, he certainly must be doing things right. 

Jazzman---He laughed when I told him I had just played 18 holes of golf at five weeks and thanked him for removing my slice along with the prostate. I guess that qualifies as a sense of humor.

If you have a good primary care physician and he concurs with the selection of your Urologist who's making a recommendation, then I'd opt to go with the judgment of the medical professionals who know me best.  I don't see this as an analysis of the procedures, but, rather, an analysis of in which professionals you have the most confidence of receiving the most accurate diagnosis and treatment recommendation.  If you don't take the advice of the primary team, fire them and get yourself someone new, different to advise you as the years moe forward.  My own situation was that my primary care physician thought my PSA test result was suspicious and he suggested I see a Urologist he had strong confidence in.  I had a biopsy which disclosed cancerous cells and the Urologist/Surgeon recommended removal of the prostate via the da Vinci procedure.  I accepted the advice, which my primary care physician thought was good, and I didn't second guess the Urologist, didn't have scans or further tests or a visit to one or more other Urologists.  It's been two years since my procedure and I think I made the best decision.  The slight side effects are worth the bother as compared to haveing the cancer in my body.  Best wishes for a successful outcome.