Post surgical continence, ED issues - is open, lap or robotic better?

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Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 2/5/2009 11:14 AM (GMT -6)   
Sloan-Kettering apprarently has data which shows that open RP yields somewhat better results than manual LAP and much better results than robotic LAP when it comes to urinary and ED post surgical complications.
 
Have any of you guys heard this from your surgeons?  I was under the impression that it was just the opposite - that robotic, with its 3D imaging and 10x magnification, allowed the surgeon to be more precise.
 
Tony
Age at diagnosis 61
Resides in SW Florida
12/07 PSA 2.6  12/08 PSA 4.0
Biopsy 1/09 - 6 of 8 nodes positive 
Left - 2 of 4 positive, 15% involved, 3+4=7 Gleason
Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
DRE small nodule on right - Prostate 22.6 cc's
Planning da Vinci - searching for surgeon


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 2/5/2009 11:53 AM (GMT -6)   
Good question Tony...my uro/surgeon said the same thing you just said. But I think that you can find all sorts of studies that will put you on either side of the fence with similar data to back up their thoughts. Honestly...I doubt very seriously that any one form of surgery is going to be better than another form of surgery. Surgery is all in the skill of the hands of the doctor...regardless of the method used to do the surgery.

Makes it tough to decide doesn't it...
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base) - Gleason (3+3) 6  Stage T1C
August 23 - Bone Scan - Hips, Spine and ribs marked uptake - X-Ray showed clear -Hooray
Sept 9 2nd DRE - questionable - TRUS...shadow in base - Gland now 41 cc
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (4+3) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
4 tumors in prostate - largest being 6 cm 
PSA 5 week Oct 2008 <.05
       3 month Jan 2009 .06


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4088
   Posted 2/5/2009 11:54 AM (GMT -6)   
Hi Tony:
 
Even though I did not choose surgery, I researched it a lot and would have chosen robotic had I wanted surgery.  The research I did showed just the opposite of what you are hearing from Sloan.  Here is an example from Henry Ford:
 
 
Before accept you what you are hearing as gospel, I recommend you ask to see the study in writing to which your source is referring....
 
Also, please remember that a very key point in any of the procedures is to make sure you get an EXPEIENCED (300+) practitioner.
 
Good luck.
 
Tudpock


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
2 of 16 cores cancerous
27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 1/31/09.


GarthK
Regular Member


Date Joined Feb 2009
Total Posts : 74
   Posted 2/5/2009 12:02 PM (GMT -6)   
I had my mind all made up to go the robotic route but my urologist, who I really trust/like, recommended RRP instead stating that he did both but preferred the visibility offered by the open surgery, particularly when it came to palpably-detected PC. Among all the studies I read was one by Duke Univ that stated that the ratio of men having second thoughts about the approach they took was higher for robotic that for any other of the approaches.

That's the prob. There are studies out there that will justify any choice made so I say go with the recommendation of a urologist you trust. My guess is that the final outcome will be about the same.

Good lick,
Garth
Vitae:
DOB: Q4'46, HT: 5'9", WT: 180
PC:
Biopsy: 12/08
Cores: 4 of 12+ positive
PSA: <2.5
DRE: Slight enlargement, one node
Gleason: 3+3
Surgery: RRP on 1/21/09
Catheter: 15 days
Pathology:
Adenocarcinoma occupying 5% of prostatic volume (right posterior aspect)
Gleason: 3+2
No extraprostatic extensions
Perineural invasion within prostate only
No angiolymphatic invasion
No seminal vesicle invasion
Clear margins
AJCC: pT2a


smc64
Regular Member


Date Joined Jan 2009
Total Posts : 40
   Posted 2/5/2009 12:11 PM (GMT -6)   
Tony,

Is this the study you are referring too?

http://prostatecancerinfolink.net/treatment/first-line-localized/comparative-data-treatment-early-stage-localized-prostate-cancer/lrp-vs-rrp/
Age 44, DX 12/08
Psa 2.6 free 11%
One of twelve cores pos. with 5% pc Gleason 6 3+3


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 672
   Posted 2/5/2009 1:25 PM (GMT -6)   

 

http://prostatecancerinfolink.net/treatment/first-line-localized/comparative-data-treatment-early-stage-localized-prostate-cancer/lrp-vs-rrp/#comment-572

When reading this link referred to above, be sure to read the critics comments.  What we are dealing with here is EGO...Some of these suppose great technical doctors are acting like a bunch of 12 year old boys.  It makes it more difficult for us to make good decisions. 

To me this kind of a self serving study would make me run away from Sloan Kettering as fast as I could.  I know, I know they have a great reputation, but when the doctors let their ego get in the way it can only hurt the patients.

I find this kind of misleading study to be very dangerous.  Shame on SK and some of their "great" doctors.


PSA up to 4.7 July 2006 , nodule noted during DRE
Biopsy 10/16/06 ,stageT2A
Aggressive Gleason 4+4=8  right side
DaVinci Surgery  January 2007
Post op confirms gleason 4+4=8
No extension or invasion identified
Few continence problems
PSA 90 day (-.01)  , (6 month -.01) , (9 month +.02) , (1 year +.02) ( 18 months +.02) (two years+.02)
One side nerve spared
success but some plaque with bimix 
born in 1941


Godfather
Regular Member


Date Joined Jan 2009
Total Posts : 64
   Posted 2/5/2009 2:08 PM (GMT -6)   
All:

Thanks for the feedback. As usual, it's very helpful and knowlegable. The Sloan study cited is a comparison between LAP and open RP and doesn't seem to include robotic LAP. The Henry Ford study is right on point and the results are pretty impressive. Makes you want to hop on a plane to Detroit.

Lots more consults and opinions to go - thanks.

Tony
Age at diagnosis 61
Resides in SW Florida
12/07 PSA 2.6  12/08 PSA 4.0
Biopsy 1/09 - 6 of 8 nodes positive 
Left - 2 of 4 positive, 15% involved, 3+4=7 Gleason
Right - 4 of 4 positive, 40% involved, 4+3=7 Gleason
DRE small nodule on right - Prostate 22.6 cc's
Planning da Vinci - searching for surgeon


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/5/2009 2:16 PM (GMT -6)   
My simple take at this point, is the skill and confidence of the surgeon, not the exact method. opens are still good for "large thick" men, and if there are any complications that weren't known ahead of time. From being on this site a few months, I am not sure there is any rhyme or reason to side affects when comparing open to robotics, correct me if I am wrong there.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


hb2006
Regular Member


Date Joined Nov 2008
Total Posts : 299
   Posted 2/5/2009 2:23 PM (GMT -6)   

My urologist/surgeon had the opposite opinion of robotic in that it was not as precise as open. He is a partner with two surgeons who have performed over 750 robotics. When they looked at my case, all three recommended the open RP.

My incontinence ended in 8 weeks and I am progressing very well with the ED.

 


mikey1955
Veteran Member


Date Joined Dec 2008
Total Posts : 672
   Posted 2/5/2009 3:42 PM (GMT -6)   

IMHO and in my case, I have chosen open (RRP) with a surgeon that has done over 2500 and done many RALP.

With high content and high number of hits on biospy, and numerous dx prostatitis (potential scar tissue affecting surgery), this is what I have chosen at this time. His and his dept comments were that IC seems to have better outcome with open than robotic...in cases like mine, particularly.

They usually try to save one if not both nerve bundles during procedure to retain some erectile function in the future. I would rather have that done by a very experienced surgeon open, than one less experienced on robotics.

I was sold initially on robotic. To me, it was tech's got to be better....the better and newer...the better.  After a lot of research, the shine came off that thought for me and I had to look at what was best for me. RRP will mean a longer recovery time than RALP. That is fine with me if I have a chance at better IC and perhaps ED...again...in my case...and with a very experienced surgeon having solid knowledge of both techniques.

If I had 1%-5% on one core of 8 or 12 or saturation, it would still be cancer. However, I would have more time to think of treatment and when...and would have chosen active survellience for at least the short term (other imaging and more biopsies) while I reviewed my options again.

My nickel's worth.

 

Mike

 


Lower left groin hernia: mesh and large scar: surgery early 2006
Nov/Dec 07 and March 08 and now Dec 08: Severe perineal pain (between scrotum and rectum). Septra/Bactrim for 8 months (Nov 07-Jun 08) for diagnosed prostatitis.
PSA start of 2008: 5.3..... PSA June of 2008: 7.3
8 DRE all benign or nothing felt
TRUS Biopsy Nov 08: Got copy of pathology recently (see below).
General Health: pretty good, 5' 10", 180 lbs, slim.
Bone scan Dec 08: Negative
Biopsy Pathology: 5 of 8 cores positive, adenocarinoma in both lobes. 30%-65%. One core perineural invasion. All cores, 3+3 GS 6.
 


sandstorm
Regular Member


Date Joined Dec 2008
Total Posts : 194
   Posted 2/5/2009 4:11 PM (GMT -6)   
My surgeon stated he trained for robotic at Henry Ford. After 500 open and 350 robotic procedures he doesn't do open anymore. One night stay in the hospital. Only asked for pain meds once in recovery none after that. It sure was nice to get that catheter out 6 days after surgery. After knee and gallbladder surgery, I'm pretty impressed with robotic.
Age at DX 57
5-18-07 PSA 7.7
5-06-08 PSA 4.6  8% free psa, but stable
10-23-08 PSA 5.65 4% free psa
11-04-08 biopsy
11-11-08 2 of 12 cores positive
Gleason 3+3  6  stage t1c / post-op 3+4  7  stage t2c
CT and Bone scan negative
Da Vinci RRP 01-09-09
Catheter removed 1-15-09
Pathology Report says it's gone!
First Post-op PSA due 2-17-09


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/5/2009 4:22 PM (GMT -6)   
Sandstorm,

In your case, you make a good case for robotic. I had 4 full days in the hospital and needed them all after my open (though I expected this), and was on regular doses of pain meds for the first 10 days at home, and was weaned off entirely before 3 week mark.

I had my gallbladder out in the old days (1981). I have a six inch incision to prove it, lol, was in the hospital 10 days, and took months after to fully recovery. I was only 29 at the time. See how things have changed so much, now I understand its a fairly simple day surgery with no overnight.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


Paul1959
Veteran Member


Date Joined Nov 2007
Total Posts : 598
   Posted 2/5/2009 4:31 PM (GMT -6)   
I interviewed Four surgeons in NYC for my surgery and they all agreed that open RRP had a faster continence than Robotic....even the doc I eventually went with and had Robotic said that this was the case. He felt that ED was faster recovery with Robotic.
BUT it is all in the skill of the surgeon and then each man is different. I was in an awful lot of pain after robotic...and i've had two back surgeries. Some guys are golfing in a week! My continence was fine. ED is a challenge, I was in perfect shape 10 weeks out, but it disappeared. Getting better now slowly. So, don't second guess yourself. Once you make the decision, it was the right decision for you. Don't let anyone make you doubt yourself. Go with your gut. Each of us have different baggage and feelings.

Paul
46 at Diagnosis.
Father died of Pca 4/07 at 86.
1/06 PSA 3.15
1/07 PSA 4.6 (Biopsy 3/07 just suspicious)
10/07 PSA 5.06 (Biopsy 11/07 1 of 12 with 8% involvment) (1mm)
Da Vinci surgery Jan 5, '08 at Mt. Sinai Hosp. NYC www.roboticoncology.com
Saved both nerve bundles.
Path Report: Stage T2cNxMx
-Gleason (3+3)6
-totally contained to prostate,
-10% involvement in L & R Mid lobes
PSA 0 at nine months.
Pad free on March 14 - (10 weeks.) Never a problem since.
ED - Took 100mg viagra every night. for several months
Totally usable erections at 10 weeks, which disappeared over the course of a month or two.
ED bounce is what they call it. Now, at one year, ED is fine with viagra.


Tobmeister
Regular Member


Date Joined Jan 2009
Total Posts : 41
   Posted 2/5/2009 4:34 PM (GMT -6)   
Personally, I think that the surgeon and the individual have more to do with recovery than the type of surgery.

At 51 I had robotic Dec 30 and had catheter in for 15 days and for all practical purposes had no incontinence to speak of after removal.

ED is a little different story but had one bundle of nerves taken. Using vacuum and 20mg Cialis every other day and it is slowly coming along after a month - but quite a ways to go. My doctor told me some of this is how hard you work on it daily to keep blood circulating.
Tom, age 51
Diagnosed 11/12/2008
PSA 2006 - 2.8, 2007 3.06, 2008 4.6 (remember the rate of increase is as important as the level), PSA free 8.7%
Family history - brother and uncle (remember family history is very important)
Gleason score 7 (4+3); 6 out of 19 cores sampled positive for cancer; perineural invasion present
Bone scan and CT scan both negative
Prostate mildly enlarged, DRE negative
DaVinci radical prostatectomy 12/30/2008 - left side nerves spared
Catheter removed 1/15/09 - no pain!

Post operative results:
Pathologic stage - T3aN0Mx
Post surgery biopsy - Bladder neck margin negative, lymph nodes negative, specimen confined, extracapsular extension positive, perineural invasion positive, seminal vesicle invasion negative, all margins negative, Gleason 3 + 3 = 6.

No incontinence problem within 1-2 weeks after catheter removal
1st post op PSA scheduled for 4/16/09

"Pick a good doctor and say your prayers"


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 2/5/2009 5:34 PM (GMT -6)   

Greetings, everyone.  I am inclined to agree with a couple of earlier posters in that the most important factor is the skill of the surgeon.  You  need to have confidence in your surgeon and make up your mind and go with what you are comfortable with.  For me, I was referred to a surgeon who spent considerable time with me going over options.  He said that he thought robotics was the wave of the future but not quite yet.  He indicated he had done it a few times and had partners who did robotics almost exclusively.  However, for now he still liked to open you up and have a good look around in doing RRP.  He has been doing this surgery for a little over 20 years.  He does 3 a day on Mondays and Wednesdays so does around 300 a year - very experienced. 

He also keeps track of ED and Incontinence issues in his patients. He indicated that short term he expected all his patients to have issues with both.  However, at the 2 year point after surgery 90% of his patients who could get erections before surgery could get them again and that 92% of his patients did not have incontinence issues (at the 2 year point).  My experience was even better - no incontinence after 3 days post catheter and erections right after catheter removal.  Yes, I did as he requested and took Cialis/Levitra (settled on generic Levitra from ADC) and continue to do so 2 times a week. 

Find the surgeon that you are comfortable with and listen to him. David


Age 55
Diagnosed Dec 2007 during annual routine physical
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 positive with 2 marginal
Gleason 3 + 3 = 6
RRP 4 Feb 08
Both nerves spared
Good pathology - no margins - all encapsulated - Gleason 4 + 3 = 7
Catheter out Feb 13 - wore pad for couple of days - pad free Feb 16
Great wife and family who take very good care of me


JerseyG
Regular Member


Date Joined Feb 2009
Total Posts : 65
   Posted 2/6/2009 11:30 AM (GMT -6)   

I agree that the skill of the surgeon is the most important factor. I had robotic August 08, one day stay in the hospital. I only took three of the pain pills. I had the catheter in for 8 days. Incontinence was a small issue for about 2 months then dry as a bone.

ED was an issue immediately after the surgery but at the five month mark I'm back to 90 -95% with 20mg cialis.

If I had to do it again I'd go the same route with the same doctor.

George


Age now 44 (43 when dx)
 
Pre-op PSA:  0.9
Biopsy: 3/12 cores pos  20% 30% 50%
Gleason 3+3=6
Open RP:   Aug 08 1 day hospital stay, cath out on 8th day.
Post Surgery Pathology Report: Gleason 6, pT2c, tumor 10% contained in prostate gland, all margins negative. Negative lymph nodes
Post Op PSA: Dec 08 <0.1


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/6/2009 12:23 PM (GMT -6)   
Jersey, you might want to change your signature, above, you say you had robotic, but your signature says open.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


JerseyG
Regular Member


Date Joined Feb 2009
Total Posts : 65
   Posted 2/6/2009 1:11 PM (GMT -6)   
Thanks Purgatory, it is done.

Age now 44 (43 when dx)
 
Pre-op PSA:  0.9
Biopsy: 3/12 cores pos  20% 30% 50%
Gleason 3+3=6
Robotic RP:   Aug 08 1 day hospital stay, cath out on 8th day.
Post Surgery Pathology Report: Gleason 6, pT2c, tumor 10% contained in prostate gland, all margins negative. Negative lymph nodes
Post Op PSA: Dec 08 <0.1


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 2/6/2009 1:14 PM (GMT -6)   
jersey, cool, wasn't try to nit pick, just thought i might confuse somebody new
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Non-nerve sparing, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9/9
 
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4188
   Posted 2/7/2009 7:04 PM (GMT -6)   
I recently read a statement from Dr Sardino at Slone Kettering. He states that the data from all prostate surgeries done at Slone Kettering only 60% were considered effective, defined as PC cured, no complications, and no long term side affects. Which means that 40% were not effective. If these results are from Slone Kettering we can only guess at the effectiveness of lesser known surgical centers.
JohnT

I had a psa of 4.4 in 1999 and steadily increasing psa every 3-6 months before reaching 40 in 5-08.Free psa ranged from 16 to 10%

I had biopsies every year, 13 total in all. I saw 5 different doctors, all urologists or urological oncologists at Long Beach, UCLA, UCSF and UCI and had an MRIS at UCSF in 2007. All tests were negative and I was told that because of all the biopsies I most likely didn't have PC, but to keep getting biopsies every year.

in Oct 08 my 13th biopsy of 25 cores indicated 2 positive cores, gleason 3+3 less that 5% in 2 cores. Doc recommended surgery.

2nd opinion from a prostate oncologist, referred by my wife's oncologists said cancer found wis indolant and statistacally insignificant, but PSA histor was a major concern and ordered a few more tests.

Color Doppler ultrasound with targeted biopsy found a transition zone tumor 18mmX16mm, gleason 3+4 and 4+3. CT and bone scans clear, but Doc thinks that there may be lymph node involvement (30% chance) because of my high PSA, and referred me for a Combidex MRI in Holland, currently scheduled for Feb 14.

Changed diet and takiing supplements while I wait. The location of the tumor plus the high psa make surgery an unlikely option. I'm still evaluatiing all treatment options and will make a decision once I get the results of the Combidex scan.

JohnT

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