Struggling Over Final Choice of Surgeon

This is my first post, 2 months after my pc diagnosis. I am so impressed with the level of knowledge, experience, and compassion on this site.
I make my living advising people, and am normally decisive myself. But I am really agonizing over my initial treatment decision in spite of ----or maybe because of--- having two excellent options. I would appreciate any input or suggestions.
I’ve decided to have surgery, and have narrowed the choice to two superb surgeons, each at a different comprehensive cancer center of excellence.
Choice A is an open radical prostatectomy by an extremely experienced surgeon who does only the traditional open procedure. Choice B is the DaVinci procedure by a surgeon who does both open and Davinci but recommends the robotic technique in my case (Gleason 6, normal DRE, small prostate).
Both of these guys have top credentials, loads of experience, and have multiple recommendations on this site. location is not a factor, as I’ll need to travel to either. So I’m struggling with the better of two good choices, not the lesser of two bad ones. (And I’m really thankful for that).
Based on my reading, I’d originally concluded that the open procedure was best for me. But after considering choice B, I’m re-examining the DaVinci and whether that is an equal or even better choice for me than the open technique. I’m pretty sure that I’ll feel better once I make a decision and move on, but am tormenting both my supportive and patient wife (who likes both, but probably prefers choice B) and myself.
Any words of wisdom on this issue?
Thanks in advance!

Hi Hank,

One good thing to be aware of is that the cure rate for open surgery and robotic surgery is about equal. So there is probably no advantage in that area.

I recently made a post in another PC forum to someone asking the same question, so being very lazy, I will copy/paste my reply down below..... LOL

One way to consider the differences between open and robotic surgery is the size of the cutting. Would you rather have one long, deep cut or a small series of short, keyhole cuts? The general answer would be the latter. With the robotic way, you are being spared from the long deep cut, which takes a short time longer to heal than the smaller incisions.

With that being said, the success rate between both surgeries is pretty much equal and, as with all surgeries, largely dependant upon the skill, experience and competence level of the surgeon.

With THAT being said, some say the open method has somewhat of an advantage of the surgeon being able to "feel" around the prostate and have a better idea of where to make the cuts. At the same time, there is a greater chance of blood loss and need of a transfusion in the open method.

With the Da Vinci robotic system, the surgeon's hands NEVER have to invade the body cavity because the dime sized incisions are where the robotic instruments go in instead. This allows several things that could be considered advantageous.....

First, the abdomen is pumped full of CO2 to present a larger surgical field for the instruments.
The instruments, including the cutting knives, are absolutely steady because they filter out the natural micro-tremors associated with the human hand holding a scapel.
The camera inserted into the abdomen gives a 10-15x expanded view of the surgical area that is also very brightly lit.
The image presented to the surgeon on the screen is also in 3-D.
The camera is able to go all the way around the prostate so that the surgeon can literally view behind the prostate instead of having to feel his/her way around.
The recovery time with the robot is generally about a week shorter and less painful than with the open process.
There is less chance of accidentally hitting the bowel and causing an injury.
There is much less chance of blood loss with this method.

NOTE: I don't know if this is standard everywhere, but my da Vinci surgeon at Mayo Clinic did NOT require me to do the colonoscopy prep stuff to empty the bowel before the surgery since the chance of hitting the bowel is very, very small. I loved that!! LOL

Once again, however, there is NOTHING wrong with the open process. It was the gold standard of cure before the advent of da Vinci.

So you could not go wrong in either case. IMHO, however, I would go with the robot if you choose surgery as your choice of treatment -- as long as the surgeon has done a MINIMUM of 300-400 such surgeries to assure that the learning curve has been completed.

ADDITIONAL NOTE: I am a "surgery guy," but would still advise you to learn the pros & cons of surgery -- and of any forms of radiation treatments that might also have the potential to cure you.

Good luck!!
Chuck

July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
Local uro DRE revealed significant BPH, no lumps.
PCa Dx Aug. 2011 age of 61.
Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
Gleason 3+3=6. CT abdomen, bone scan negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
Surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
doctor says this is insignificant.
Prostate 98 grams, tumor 2 grams.
Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1
Semi-erections with continued improvement.

Welcome to the forum. Sorry you need to be here but glad you found us. I'm not sure we can be much help except to keep you company while you dither. There really isn't a lot of differences in terms of disease control between the two as long as you are comparing very-experienced surgeons. I have heard that open surgeons may achieve a slightly lower rate of positive margins but the difference is tiny and you are comparing that against the easier recovery and less-intrusive scarring you get from robotic and ... it remains hard to decide.

I had robotic surgery. So that is all I know about from first hand experience. It went OK.

Hank,

Welcome to HW.

If you mention the names of the surgeons you are considering, there may be members here who have experience with them.

There has never been a study, ceteris paribus, that showed that any technique- open, lap or robotic - is better than any other. However, there are surgeons and facilities that have better records than others. Because the community surgery results are so poor, some Uros advocate that RP ought only be allowed at tertiary care facilities and teaching hospitals.

When I interviewed surgeons, my key questions were:

• How many of that technique have you performed?
  
• In the last year, what was your positive surgical margin rate? Among pT2? Among pT3?
  
• What is your "trifecta" rate?
  
• What kind of anastomosis technique do you use?
  
• Will the bladder neck be spared? How will you maximize the urethral sparing?
  
• Will you take frozen sections and have a pathologist standing by to determine margins and how much of neurovascular bundles can be spared?
  
• What measures will you take to assure the integrity of the neurovascular bundles?
  
• What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects and for how long?

I also asked if he would agree to close me up if sparing the neurovascular bundles was at all problematic, or if it seemed the disease had escaped beyond the prostate, so that I could be treated with radiation instead. I couldn't find a surgeon who would agree to that :-(

Hank T

There was one question that was suggested strongly by someone on this site that I should ask the surgeon or find out prior to my choosing one. The question has to do with their percentage of Positive Surgical Margins PSMs. You want someone who is both highly skilled, has done plenty of these procedures and has a low percentage of PSM. Mine was down around 2%. Many were higher. It just made sense to me and I embraced the concept and ran with it. Best of luck.

Hank deciding is tough. I've read pros and cons of open vs. the robot. Seems the biggest pro for open was that the surgeon can feel things when he's inside.

Hi Hank... I am in a similar boat should I choose surgery. I have talked to or met with Dr. Patel (RALP) in Orlando (just got back 30 min ago), Dr. Tewari(RALP) in NYC and Dr. Burnett (open) at John Hopkins. I spent about an hour with each of them. All of them said the same thing for me (and you are similar), is that there is really no difference in the expected outcome. In fact each of them said they would give 90%+ chance of no ED or Incontinence issues (given age, current PCa stats, physical condition). Of course, each of them leaned towards what they do best and cited their history, experience and number of surgeries. Dr. Burnett said he has gotten the incision down to about 3" for open most of the time and it could either be horizontal or vertical below the belly button.

Dr. Patel and Dr. Tewari both said that they have done so many surgeries that they know exactly what to do in order to minimize ED and incontinence. Dr. Burnett said the same thing but added if their are complications than being able to "feel around" gives him some additional insight.

Also, their margin percentages are very similar.

After all these discussions I've decided it really does not matter, especially since I don't care about the scar (kind of a manly thing to have anyway). So I would probably make my decision based on who I feel most comfortable with (which is still a tough one).

Maybe, I'll put their pictures on a dart board...

Good luck and ask away if there are more questions!

All,
Thanks very much for the responses, advice and encouragement. I have some more homework to do before making a decision!
Hank

If you have equal confidence in the surgeons skills, I'm delighted with the fact that, with DaVinci, I was home walking over two miles the day after surgery, I was at a college football game cheering like crazy 150 miles away three days after surgery, and I returned to work (not because I had to, but because I felt fine) 5 days after surgery. I suspect all those things would have been delayed a week or two with open and my outcome would be the same.
When my kids faced "dilemmas" like this I would say, "Aren't you lucky. This is a "Steak or Lobster" decision. You don't have a BAD option. Only degrees of goodness based on your personal preferences."
The odds are DRAMATICALLY in your favor either way.
Good Luck. We look forward to updates on your journey to join us on the other side - where the water is fine!
Mikey