Dr Catalona's position on LRP and Robotic RRP

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Squirm
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Date Joined Sep 2008
Total Posts : 744
   Posted 12/2/2008 6:57 PM (GMT -6)   
I’ve read Dr Catalon’s position regarding Robotic RRP and LRP in his latest Quest issue. I’m was alarmed by what he had to say. Dr Catalona referenced three studies (Sloan Kettering, Harvard and Duke). The Harvard study (2003-2005) he stated that men undergoing minimally invasive vs open radical had 3 times the odds of requiring salvage therapy within 6 month. He stated that his concern was that the gland is not all removed during surgery or that the gland is cut during the laparoscopic procedure. He also stated that men were 40% more likely to develop scar tissue that would negatively impact continence. He stated that the Sloan Kettering study found similar results to the Harvard study. He also stated that in the Duke study, patients who underwent robotic were more than 4 times more likely to regret their decision. He stated this might be because expectations were higher for the “innovative” procedure.

He ended his position by stating that the jury is still our regarding these two new procedures, but stated that so far the much of the important evidence is not encouraging.

coxjajb
Regular Member


Date Joined Nov 2008
Total Posts : 184
   Posted 12/2/2008 8:02 PM (GMT -6)   
I wonder what a more current study would show? Like everything, there are a number of opinions or studies that suggest one option is better / worse than another. The attached article is an example that suggests the benefits of the da Vinci robot over open prostatectomy.

http://pucenter.com/resources/Davinci+robotic+prostatectomy.pdf

Gerbe
Regular Member


Date Joined Sep 2008
Total Posts : 42
   Posted 12/3/2008 9:49 AM (GMT -6)   
I read it too, and the bottom line for me is experience of the surgeon. I believe that there are a number of surgeons out there jumping on the bandwagon (heck, I have driven by a medical building with a billboard on it advertising nerve-sparing robotic procedures) and that there are not enough patients to go around for all of them to acquire sufficient experience. And not all 3 of those articles supported his position. I don't remember which one, but one showed essentially equivalency.

I'm going DaVinci, but my criteria was that the surgeon had performed more than 150 such procedures. I turned down one (50 procedures) and selected a Univ of Wash professorial type (we'll see, won't we) who does 1-2 a week and is north of 350 procedures.

Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 12/3/2008 10:19 AM (GMT -6)   
We almost can't win for losing.

Just last night, the NBC evening news had an article about hospital interns/doctors and how they are overworked. (don't get emough sleep)

1 in 5 admitted to injuring a patient
1 in 20 admitted causing a patient’s death.

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 12/3/2008 11:33 AM (GMT -6)   
You know Steve...this was the exact reason I didn't want the "assembly line" type surgeon. I didn't want to be #3 on surgery day or even #2. So I chose a surgeon that only does one on the day of surgery....mine

SHU93
Regular Member


Date Joined Aug 2008
Total Posts : 328
   Posted 12/3/2008 11:35 AM (GMT -6)   
can you provide a link to this quest report to read? Thanks
Age Dx 37, 7/2008
First PSA : 4.17 5/2008
Second PSA After 2 weeks of antibiotics : 3.9 6/2008
DRE: Negative 5/2008
Biopsy : 6 out 12 Postive all on right side, Gleason 7 (3+4).
Bone Scan/CAT Scan: Clear 7/2008
Cystoscope: Normal 7/2008
Prostate MRI: Normal 7/2008
Da Vinci Surgery 7/2008
PostOp: T2c (On Both sides), margins clear, seminal clear, nodes, clear. Gleason 6(3+3).
First PostOp PSA 9/2008: <0.01
2nd PSA 12/2008: Praying for <0.01
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/3/2008 12:32 PM (GMT -6)   
LV,

I agree with you 100%. On the day of my surgery, November 14th, my operation was the only one scheduled by my dr/surgeon. The surgeon that assisted him in my open RP, did, however, do a robotic in the morning window.

David in SC

Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 12/3/2008 1:22 PM (GMT -6)   
Here is the link to Dr Catalona's article. Had I known it was on the Internet, I would have posted the link also. Sorry.

http://www.drcatalona.com/quest/quest_winter08_1.htm

SHU93
Regular Member


Date Joined Aug 2008
Total Posts : 328
   Posted 12/3/2008 3:33 PM (GMT -6)   
Having read this and having the robotic surgery, doesnt make me fell that great sad especially from a long term perspective...I did have a very experienced surgeon...

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4275
   Posted 12/3/2008 4:49 PM (GMT -6)   
With all due respect to Dr. Catalona, there are also multiple studies that would disagree with the data he cited. 3 of these are shown below, done with a quick google of robotic prostate surgery.

Even though I have personally not chosen surgery, had I made the choice, I would have most certainly chosen da vinci for my particular case...of course, that's not necessarily the right choice for all men. I agree wholeheartedly with others who have cited EXPERIENCE as the key. I started a topic on the forum a couple of weeks ago titled "Experience Counts". It showed studies "proving" that results were better with surgeons who had performed 250+ procedures. I think this is particularly true with robotic surgeons where the techology is relatively new...and, of course, it's also just common sense.

Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 12/3/2008 5:02 PM (GMT -6)   
SHU93
I was actually hesitant to post about this article but felt it was necessary. I was pretty shocked to read it myself.

Frank1205
Regular Member


Date Joined Feb 2008
Total Posts : 308
   Posted 12/3/2008 5:20 PM (GMT -6)   
Oh man..

I first looked at Northwestern Memorial in Chicago where Dr. Catalona works. I interviewed a young Dr. that did the robotic and open procedures. This is the co-worker of Dr. Catalona. This Doc stated the benefits of the robotic and made several statements that it was equal to and may soon become viewed as the better choice. I choose University of Chicago where they said the same type of things. However, I did get the feeling that this robotic procedure was new and that there was some selling going on.

Now with a bad margin and the hope of a long life hanging in the balance I hope these good Doctors dont start second guessing this robotic procedure. My original Doc had a similar opinion as Catalona and I ran from him.

I hate it but we need to know this stuff.

Frank

RBinCountry
Regular Member


Date Joined Apr 2008
Total Posts : 270
   Posted 12/3/2008 5:23 PM (GMT -6)   
This is a most interesting conversation. There are several simple thoughts that go through my mind relative to the whole discussion of surgery / experience / which is best / etc.. I have always wondered who the person or persons would be who was the first patient, or even among the first 100 of those doing surgery of any kind. Who would say I want to be first? I have always wondered how the person gets started as everyone I have ever heard discuss this has surgery from someone at least fairly experienced. My point is not all of us can be on the experienced end. Relative to this the first surgeries are included in statistics the same as those at the experienced end. As far as DiVinci robotics goes - I watched (as it was videod) my surgeon do a surgery and talk through it from beginning to end via DVD. I know anything is possible, but what I saw looked very routine. If a surgeon has done more than a thousand of these doing basically the same thing every time it is done and especially if this is all those surgeons do, and they are conscientious, it is hard to see how extreme mistakes could be made. Ultimately though, I suppose we would not know. The same would be true with radiation - if they missed the target, or did not have the intensity set appropriately etc..

My urologist, who is a senior citizen, and has been practicing for many years and has done many open surgeries in the past told me the difference between robotic and open was just the opposite of what the article indicated. He says that any surgeon can have a bad day, but the DiVinci method lessens that possibility by magnifying and controlling surgeon movements to a finer detail. It is also less bloody so the surgeon can better view the area. The only thing I have heard is a detriment is the robotic surgeon does not have the sensation of feeling.

I suppose these kinds of discussions will be going on and on with no absolute resolution - ultimately it is a matter of confidence in the method of cure, or if surgery also the surgeon. All of us have to make the choice we make and then live with it. I do think it is interesting that by far the majority of people on this forum defend or support whatever method they chose and believe it is the best avenue. There are a few exceptions that wish they had done something different, but most do not.

RB
Age 61 (now 62)
Original data - pre-operation
PSA: 5.1
T1C clinical diagnosis, Needle biopsy - 10 cores, Gleason 7 = 3+4 in 1 core (40%), 7 cores Gleason 6 = 3+3 ranging from 5% to 12%
All scans negative
Lupron administered 4/9/2008 for 4 months (with idea I would undergo external beam radiation followed by seed implants - then I changed my mind).
Robotic DiVinci surgery - Dr. Fagin (Austin) May 19th
Post operative - pathology
pT2c NX MX
Gleason 3+4
Margins - negative
Extraprostatic extension - negative
seminal vesicle invasion - uninvolved
1st Post PSA <.04
2nd Post PSA <.1 10/30/2008

Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 12/3/2008 5:28 PM (GMT -6)   
Squirm it needs to be posted. There shouldn't be any self censorship here if whatever posted comes from a valid medical source. With that said this is not the first time DaVinci Robotic has ever been questioned or criticized. Many top urologists have long been on record preferring radical open surgery. For a number of reasons many wanting to feel the area who claim they can feel the PCa. Then other surgeons swear by the magnification of robotic. From my studying before choosing a treatment days I always viewed DaVinci as primarily being less invasive than open surgery and that being the only advantage. The doctor makes a good point when comparing 6 one inch incisions to a 4 to 5 inch one. DaVinci by far has been the most popular treatment here and most have been happy with it unless there were incontinence problems. I still feel these are the days of over treatment due to a new wave of early detections and will be looked back with some regret in time. Of course I'm referring to the majority of diagnoses of low threat PCa and not advanced. For those who are choosing treatment should read this article along with others. For those who have had either radical surgeries it's too late to look back just move on.

James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4463
   Posted 12/3/2008 6:30 PM (GMT -6)   
RB, our local hospital just got their DaVinci 2 months ago. I wondered then who and what number of guys would be getting it done here, and how much experience the surgeons would have starting out. Tonights 6 o'clock news showed it setup at the local mall and letting people try it out using rubber bands, gravel and such. rolleyes
James C.
Co-Moderator- Prostate Cancer Forum
Age 61
4/19/07 PSA 7.6, referred to Urologist, recheck 6.7
7/11/07 Biopsy- 16 core samples, size of gland around 76 cc. Staging pT2c
7/17/07 Path report: 3 of 16 PCa, 5% involved, left lobe , GS 3/3:6.
9/24/07 (open) Retropubic Radical Prostatectomy performed
9/26/07 Post-op Path Report: GS 3+3=6 Staging pT2c, 110gms, margins clear
Present- 1 year: ED- Viagra, pump continues, no response- Trimix .10ml x 2 weekly continues
Post Surgery PSA's: 3 mts-.04, 6 mts.-.04, 9 mts.-.04, 1 Year-.02.


Gerbe
Regular Member


Date Joined Sep 2008
Total Posts : 42
   Posted 12/3/2008 6:36 PM (GMT -6)   
A quick caveat to this response regarding Dr. Catalona's web site and position on robotic procedures. If you were confused before, reading this reply may not help. If that is upsetting, best to skip it. There are no clear-cut answers in this struggle. I fully understand that Dr. Catalona is a pioneer and respected expert in this field; however, that does not mean that there are no differences of opinion even among his peers.

At Dr. Catalona's web site, the main article about poorer outcomes was the Harvard Study. Here is an article which discusses the Harvard Study (work of Hu et al) and points out some methodological shortcomings (mainly that they did not subdivide laproscopic prostatectomies into robotic and 'by hand', and I would expect the latter to skew results towards poor results): http://jco.ascopubs.org/cgi/reprint/26/30/4999.

The second study was the Memorial Sloan-Kettering Study. I can't be sure of what article Dr. Catalona is referring to, but I believe it is this one (abstract): The abstract summary reads "At our institution and during the study period laparoscopic radical prostatectomy and retropubic radical prostatectomy provided comparable oncological efficacy. Laparoscopic radical prostatectomy was associated with less blood loss and a lower transfusion rate [3% vs. 49%], and higher postoperative hospital visits and readmission rate [15% vs. 11%, and 4.6% vs. 1.2%, respectively]. While the recovery of potency was equivalent, that of continence was superior after retropubic radical prostatectomy (can't understand number given, ratio of 0.54?). I found it puzzling that no where in the abstract is the word 'robotic' used in conjunction with laparoscopic, which makes me think that the study is only referring to non-robotic laparoscopic procedures.

The Duke study about regrets has been widely publicized, but as others have pointed out, 80% of the men undergoing robotic prostatectomy were satisfied with their decision. Again, I would chalk this up (as others have done) to overblown hype surrounding robotic prostatectomys. A superficial read about nerve sparing, potency, etc., could lead one to believe hey a quick in and out and I'm back to where I was. The people on this board know that is not the case, but the outcomes with other choices are not necessarily better, just a question of trade-offs.

As I submitted earlier, I'm far more concerned about the experience of the surgeon as the single most important factor affecting favorable outcomes.

Its like the fog of war. Just keep your head down, focus on essentials, learn what you can but step back a bit from time to time to be able to bring some objectivity to bear.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/4/2008 10:13 AM (GMT -6)   
Before my decision was made, my doctor/surgeon basically made the same points as in the article here in contention. He was not opposed to the Robotic surgery approach, he just felt
that there were good reasons to do it open, which included the tactile feel issues, unforseen complications, etc. he said after my
surgery, that had it been done robotic first, they would have had to aborted it quickly an convert it to an open, based on a very complicated
situation he found in my pelvic bed. I am not smart enough or experienced enough to be able to argue the ohter side, it seems
like many men here, have done very well by robotic.

David in SC
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 7-2008 12.3
PSA 9-2008 14.9
 
3rd Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
Periunual Invasion noted & High Grade PIN noted
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Nerve bundles not able to be spared, awaiting pathology report, Cath scheduled to be removed on 12-15-2008, staples removed 11-24-8

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