Open vs. Robotic

Hello!

My father was recently diagnosed with prostate cancer, and is greatly struggling with the decision between the open vs. robotic prostatectectomy.  To tell you about him, he is 63 years old, has a PSA of 5.8, a Gleason score of 6 (for small cores, a 7), and a small prostate because he was taking finasteride for many years.

For the robotic:

1) are positive surgical margins better?

2) is there less incontinence?

3) is there better preservation of nerves?

If anyone has any comments on their experience as to these issues, it would be greatly appreciated! 

Thank you!

A concerned daughter

 EB4710

With 2 daughters of my own, who I love more than life itself, I can tell you that things will be FINE!!!

Your Dad's numbers are good, and he is catching it early, so take comfort in the REAL fact that there is MUCH good treatment for our cancer.

My surgeon is about 52, and has done over 2000 open RP's. He feels that the human touch, being able to feel around with his own hands is a BIG plus. The Robotics is a lot less invasive, and in the hands of a skilled surgeon a great solution.  I am in the Philadelphia area and there are 2 excellent robotic surgeons I could have seen, but the wait was to long.  It really comes down to the surgeon, get all the info you can on your Dad's Doctor on his track record, and number of operations.  Thios is not a time to worry about any bodies feeling but you father's.

Good wishes are on the way, a daughter's love is beyond words.  HE WILL BE FINE!! Let us know how the bone scan, MRI, or Ct scan turn out.  Less than 10% die from PC, a lot of comfort in those numbers.

eb4710,

You might check some very good Robotic RP videos that Dr Tewari (Cornell/NY Presbyterian) posted on youtube. It is done in 6 parts and should be viewed in order. The videos are a combination of actual video of the operation and animation, plus explanation, etc. To find them go to youtube and search for "prostatectomy tewari". Be sure to view them in proper order.

Dr Tewari was trained at Henry Ford but practices several new techniques that some other doctors don't do. Such as bladder neck suspension to help in continence. He demonstrates his nerve sparing procedure. The video is an excellent educational source of information before talking to surgeons about Robotic RP.

Experience is an important factor for any surgeon, open or robotic.

Jim

Dear eb4710, I was diagnosed the normal way with a local urologist in a suburb of PA. This guy I found out later has a very good reputation in the Philly area. His initial recommendation was open saying that there were no long time clinical trials available to prove that robotic was as effective as open because it hasn't been around long enough. I told him that I was convinced through my research that robotic was the way to go and in seeing that I was pretty well set, he agreed to support me, but said that I should defer my decision until all the tests were done. I concurred and scheduled the myriad of tests required that took 2 weeds to complete. My urologist did say that he had received DaVinci training and had assisted on one, but felt that the precision improvement did not outweigh the ability to feel your way through an open surgery.

At any rate, while I did my tests, he got involved in a few more robotic procedures and by the time I came back for the final consult, he looked at my test results and being obviously pleased with what he saw immediately recommended me for DaVinci. He started to describe his reasoning, but I cut him short saying that he had me at hello. He did say though that all surgeons recommend what they are familiar with and its hard to get an objective view. My impression is that in doing enough robotic procedures, he had a major change of heart. He immediately scheduled me with one of the best surgeons in the city that only does robotic and he did a fantastic job. I was only in the hospital for a day and had the catheter out in 10 days only because that's his scheduled day for catheter removals.

All of that being said, I have met lots of survivors that have had open and they are perfectly fine. What I have learned is that the expertise of the surgeon is more important than the procedure (at least comparing these two options). I opted for the robotic on the main because I have blood clot issues and needed to get off and on blood thinners as soon as possible. That made it easy, but in hindsight I would choose robotic again regardless. Hope this helps. Good luck!

Broker 59, that's really interesting. Sounds like you went down the same path I did. I found that Dr. Lee and McGuiness couldn't even give me an initial consult until the middle of June, back in April. Many sources pointed me to these two. My urologist in West Chester though after he got around to believing that robotic was what I wanted got me into a consult in two days with Dr. Costas Lallas at Thomas Jefferson University Hospital. Lallas like Lee and McGuiness only does robotic and has done a ton of these procedures. He is like McGuiness though, doing only 2 a day twice a week vs. Lee who when he is in does more in less time. Either he is really good or does things too quickly. Lallas was awesome and very easy to talk to during all phases. I found out in my initial consult with Lallas that my guy in West Chester had some hand in placing a colleague out into his practice, so maybe that helped. You can see that I was diagnosed after you, but got robotic done prior to your open. I owe my local urologist, big time.

I am really doing well. I feel great and am getting a grip on continence. Did Kegels a month ahead of surgery which I think might have helped. I have met a bunch of guys in the area though who had open and are really doing well. If you took the time to discover McGuiness and Lee, you must have done your homework on a good open guy/gal. I wish you the best of luck with your journey. Keep us posted.

 I elected the open procedure based on (1) I could handle a little extra pain, so that wasn't a big factor, (2)  I would have to travel to get the DaVinci done somewhere, (3) I had no way of knowing the experience level of the surgeon "elsewhere", (4) the robotic surgery time is longer, possibly with more blood loss and (5)  I really am not convinced that the [b]long term[/b] results are any better with the robot.

FWIW, I awoke with no pain, did not require any narcotic medication any time post op, left the hospital the next day, had the catheter out in 7 days, and have had absolutely no problems with incontinence.  I'm working on the ED part, but get what my wife calls a "soft on" already at this point (2 weeks).  Everyone's individual experience is different, of course, which is what makes this such a hard topic to fully comprehend.

Post Edited (aviator) : 6/14/2007 1:53:30 PM (GMT-6)

Broker 59, my local urologist is Dr. Donald Anderson, whose practice is out of West Chester right near the hospital. He is a really great guy. I live up above the Turnpike above Eagle off Route 100. I got referred to McGuinness by one of daughter's friend's father, who had robotic out of Bryn Mawr. He raved about the urology practice down there, but I agree with you. Its no fun driving down Route 30 or 202 to Schuylkill and then back roads. West Chester is a better bet for you and Anderson is a great open surgeon, soon to be great robotic per Lallas.

Aviator, I agree with you on all counts except 4]. The surgery might take a bit longer, but its not like you have any clue as you are out. I opted for robotic mainly because it is virtually bloodless and I have had clots in the past. They didn't even take any of my blood prior to the operation which I understand is standard practice for many hospitals for open. A buddy of mine used 3 pints of blood during his open, but that was several years ago. Again, whether it is open or robotic, if you get a great surgeon that has done many of these procedures, you are probably going to be OK either way. I kind of liked getting out of the hospital in just a little over 24 hours though. Gotta admit though that getting the catheter out in 7 days would have been nice and absolutely no incontinence issues is way more than admirable. Congratulations!

Why I chose robotic:

1. My urologist, who has performed over 3,000 open surgeries, said that he could not guarantee nerve sparing, due the comparitively smaller size of my prostate (which I have learned is fairly common among men in my age group).

2. I watched a video of an actual surgery broadcast live on the internet. Very impressive. 

3.  Part of the reason for the large incision with the open is simply the size of the human hand. How else can they get in there?  BTW, I think the reason that many non-robotic surgeons talk about how they rely on their ablility to "feel" the cancer is because they cannot see the surgical site because it is surrounded with and covered by blood.  Think of how slippery things are with your hand in a latex glove, covered with blood, holding onto a scalpel!

4. With robotic, the surgeon has a magnified, clear, bloodless view of the surgical site. The  motions of the scalpel and paddles are extremely refined and allow for superb control.  Consider that I got my catheter out in 4 (yes, 4!!) days. The anastomosis was sealed and solid and my surgeon has had enough experience (1700+ robotic surgeries) to know that his patients are typically physically well enough to have the catheter out in 4 days.

5. In my particular case he mentioned that the nerve on the right hand side was difficult to free up.  He suspected that this might be due to the location of one or more of the biopsy cores causing an adhesion.  He uses a so-called retrograde nerver sparing approach. But, he took his time and was able to spare the nerve.  Would a traditional surgeon have been able to do this?  I don't know.

Where I live, the DaVinci is rapidly becoming THE way.  Barnes Jewish Hospital just now, this year, has finally ordered a davinci robot.  The other local center has had theirs for about 2 or 3 years.

Ohio State, where I went for my surgery, started out with two robots about 4 years ago and has now ordered another two.

As my surgeons said, during our follow-up telecon the other night, after hearing about my excellent healing and progress on the incontinence front, "All the other guys I operated on the same day as you are doing equally well.  We feel we've got most of the bugs worked out of this surgery now."

For me, no question  which is better.  I hope you can track down an experienced robotic surgeon for your father.

Good luck with your father's treatment, whichever method he eventually chooses.

 

Hey Eb,

As soon as I was diagnosed I asked my family doc (not the urologist) who he would go to if he had PCa. His immediate answer was "Dr. W, but he only does open surgeries." So Dr. W it was and at our meeting he showed real confidence and answered all our questions. I was in the hospital for 45 hours and had the catheter out after 6 days. I could immediately hold my pee and threw the pads away the next day.

You can find good and bad stories with any treatment. Like Swim said, pick the artiest not the brush. Make a decision and don't look back...

Jim