da Vinci v open surgery

I have tried to do a search on the advantages of both but could not find anything so here goes over the last two weeks I have been trying to decide between open surgery with an experience surgeon or da Vinci with not such an experience surgeon the trouble that I am having is whether 100 robotic operations gives a surgeon enough experience in this type of surgery and whether the advantages of the robotic out ways the possible lack of experience of the robotic surgeon I am going to see him again on Friday when I will have to make up my mind one way or the other and would like to hear any comments that you may have

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Age 64 From UK now in Thailand  Baby boy born 2/14/2009   First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08  1/28/09 Biopsy carried out 12 core results were findings Both specimens show no adenocarcinoma   MRSI done on 5/8/09 No signs of any cancer 5/15/0924 Core biopsy results Gleason'S Grade 3+2=5 Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified One side PIN High Grade Bone scan clear

I think the usual advice is to go with the more experienced surgeon. Skill trumps technology almost every time. 100 operations, particularly if it's spread over a couple of years, seems hardly enough to see all that can go wrong.

Then again, big numbers are no guarantee of success--some surgeons don't learn from their mistakes!

Good luck.

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Larry Shick
Personal homepage incl. PCa story: www.sv-moira.com.
01/09: Diagnosed (age 60) biopsy PSA 4.4, free PSA 9%, T2c stage, Gleason 7 (3+4), 7 of 14 cores; 6'2", 200 lbs.
03/09: Robotic surgery (Dr. Kawachi, City of Hope) 47 gms, 10% involved, staging/Gleason unchanged (pT2cNXMX), margins clear, no ECE/sem ves involvement, fully continent from day 1, some success w/Viagra 50mg/day.
Followup: 05/09 0.006

 This ^

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Age 62, Sex Male
PSA - 3-20-08 2.7; 4-17-08 3.1; 9-18-08 3.6; 1-22-09 3.8
DRE negative
Ultrasound/biopsy 2-12-09, 50cc
4 of 12 samples positive 3+3=6, Right mid-medial <5%, Right mid-lateral 10-20%, Right base medial 10%, Right base lateral 10% adenocarcinoma

open RRP completed 5-5-09
Post surgical pathology report:
Gleason 3+3=6
Lobes involved - left and right
Extraprostatic extension - none
Surgical margins - very small area of margin involvement in right lobe
Seminal vesicles - Free of neoplasm
Vascular/Lymphatic invasion - none
J-P drain, staples and catheter removed on 5-13-09
pT2cpN0MX
No incontinence issues, no ED issues.
Back to work (desk job) in 9 days from surgery.
Surgeon: Dr. Gary B. Bokinsky

Remember, don't let the bastages get you down !!!

With your low gleason scores, maybe raditaion ala brachytherapy might also be a consideration.

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Age 58

First: Go with your gut. You have two good choices and the one that will make you more confident and secure IS the right one.

open Surgery: There is a reason that this is considered “the Gold Standard” for prostate surgery. An experienced doctor can see more and make more choices with this method. The drawbacks are longer healing time and possible greater blood loss.

Robotic Surgery: With your low Gleason and low involvement you are probably a very “easy” case. I read someplace that forty was the number of robotic surgeries needed to develop reasonable skill.

Some Very Personal Thoughts: At about your age I opted for robotic because I am a very bad invalid and because I feared that, at my age, too long a period of inactivity would affect the rest of my life. I picture you as having a much younger wife and wanting to be involved in as much of your son’s growing up as possible. In your situation I would go for open to maximize both nerve sparing and cancer clearing success.

Whatever you choose, this group is here for you.

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Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7
At 6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.

Dear Colin:

I previously posted the only quantifiable data that I know of.  It's from Johns Hopkins written materials and I have copied and pasted this for your reference.

The importance of surgeon's experience as it relates to prostate cancer outcome is underscored by the results of a study reported in the Journal of the National Cancer Institute (volume 99, page 1171).

Researchers analyzed the outcomes of 7,765 radical prostatectomies performed by 72 surgeons between January 1987 and December 2003 at four major academic medical centers. "Biochemical" recurrence was defined as a postsurgery PSA level greater than 0.4 ng/mL followed by a subsequent higher PSA level. The analysis took into account patient and tumor characteristics, such as pre-operative PSA level and Gleason grade. The men's PSA levels were measured every three to four months in the first year after surgery, twice in the second year, and annually during the following years.

The researchers found that surgical outcomes improved along with the number of radical prostatectomies a surgeon had performed, leveling off only after about 250 surgeries. The five-year probability of experiencing a recurrence of prostate cancer was 18% for surgeons who had performed only 10 operations compared with 11% for surgeons who had performed at least 250 surgeries.

Bottom line on prostate cancer surgery: The results suggest that you can improve your odds of a successful outcome from radical prostatectomy by taking time to find a surgeon with extensive experience.

They each have their good points, the skill level of the surgeon is definitely more important than the methodology in this case. Some men go to open because of weight issues, some because of other health issues. I went open, because at the time, the only certified surgeon to do it robotic in my area had only done 15. He was a partner to my surgeon, and my own surgeon said that wasn't enough. I don't feel that you have to have a surgeon that has done thousands, but at least hundreds. In my case, they ran into problems due to the deep and narrow prostate bed they discovered, and had it been robotic, they would have aborted it and swtiched to open.

I do feel that some of the larger robotic facilities push a little too hard on convincing men that they will somehow have less side effects such as incontinence and ED by going robotic. From being on this site a while, I can't see where one or the other has an advantage or disadvantage in those areas. It still comes down to the dynamics of your own body, and the skill level of a particular surgeon.

The blood loss thing is also overblown in my opinion, they banked 3 units for my open, and needed none. My surgeon said if done properly, an open shouldn't be a major bleeding event, and in my case, he was right.

Go for the best surgeon you can get with whatever financial and insurance resources you have, that is my advice.

David in SC

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Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5

Thanks so far for your advice my first feeling was to go for open surgery but I noticed that the blood loss was far greater in the open surgery this could be important in my case because when I had my appendix removed I was told that I bleed a lot I had many test taken at the time but the results showed no problems I have seen a Radiolgist and he advised me to go for surgery due to my age. It seems watchful wait seems to be a no go here which I think in my case I do not want to do any how, the Robotic surgeon has done about 200 LARP operations and before that he was doing open surgery which he does not do now I have concidered going to another country to have the surgery but the cost of travel and the time involved and taking into account I do not think it is a good idea to pick a surgeon without face to face contact which means even more travel and time made me think against it

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Age 64 From UK now in Thailand  Baby boy born 2/14/2009   First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08  1/28/09 Biopsy carried out 12 core results were findings Both specimens show no adenocarcinoma   MRSI done on 5/8/09 No signs of any cancer 5/15/0924 Core biopsy results Gleason'S Grade 3+2=5 Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified One side PIN High Grade Bone scan clear

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Age 55

Hi Colin,

IMO:

Your Gleason is low and volume appears low out of total cores...even though a biposy can miss a lot.  It's still cancer but I think you have at least one very good option, and that is some time to research your treatment more. If it was me, I would wait and research and have more tests and/or biopsies done.

As far as surgeons go, I would rather go with an experienced open surgeon than an inexperienced robotic one. I had open without any (surgical) complications and minimal blood loss. A good lot of surgical outcome depends on the (skill of the) surgeon and procedures. 

I see you're from the UK. I am sure there are lots of good surgeons and facilities there. If it was me, I'd be headed there. I don't know the UK rules but, I think if you were born there or are a citizen, your procedure would be covered. Finding the facility and the surgeon right for you would be up to you.

You may also be a candidate for other treatments such as HIFU or seeds. For me, they weren't an option that were on my short list.

Mike 

Greetings, Colin.  2 Points.

1.  I would not hesitate to have surgery in Thailand at the right hospital.  There are a couple of hospitals in Bangkok that are world class and offer as a good or better care than you can find anywhere.  I considered going to Thailand for my surgery but decided since my family was all here, to go ahead and have the surgery in the states.  Had I been living in Thailand at the time (I lived there for about 7 years), I would not have hesitated to have the surgery there.

2.  Go with the experienced surgeon.  My research said 300 procedures was minimum.  Anything less and you need to find a new surgeon.  I agree with what others have said - ask for references and contact them. 

Make your decision and don't look back.  Trust you will do great and please keep us posted. David

I had open surgery and my recovery seemed much the same as those who have DaVinci. No blood transfusion needed.

I echo the advice of others here: if you are committed to surgery, go with the type recommended by the surgeon you choose.

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Pre-op:
Age 63 at diagnosis, now 64.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores.
Operation:
Non-nerve sparing RRP on 7 March 2008.
Two nights in hospital; catheter out after 7 days.
Post-op:
Continent; no pads needed from the get-go.
Pathology showed organ confined and negative margins. Gleason downgraded to 4+4=8.
PSAs:
6-week : <0.05
7-month: <0.05
13-month: 0.07 (start of a trend?)
ED:
After a learning curve, Bimix injections (0.2ml) are working well. VED also works but we find it inferior to Bimix.

"Dude", I would disregard any advice coloured by mindless jingoistic nationalism. As CPA has stated there are very fine hospitals and doctors in Bangkok. Your main concern should be how many prostatectomies the doctor you are looking at has done........he may well have done a few thousand, the last 200 of which are robotic. If he has this experience then he knows his way around the gland and this number of robotic surgeries are more than enough to make him proficient in the use of the system. If your main concern is blood loss then the Da Vinci is reputed to be better as far as that is concerned although as you can see, many who had open surgery had no problem. (although they may not have had your bleeding history). There appears to be no difference in the outcome re. incontinence and ED if the skill of the open surgeon and the robotic surgeon is similar. Recovery is a little longer with open but this is only as far as the external wound is concerned. The internal surgery is much of a muchness. But given your biopsy pathology I would spend quite a while weighing up my options rather than rush a decision. I would have a careful read of that article linked in SHU93's post.

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1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07
4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)
PSA February 09 <0.01

Post Edited (BillyMac) : 6/17/2009 6:51:24 AM (GMT-6)

Billy Mac I looked at the site that you mentioned and went through one of the nanograms using my details that I know and it said that the chance that it is organ contained is 60% which is slightly in my favour and I would like to keep it that way I have been debating with myself which surgery option to use for over a month now and I think that it is about time that I got it sorted normally I am the type of person that makes decisions very quickly but this one has pulled me up in my tracks although one doctor did say that I should not have surgery till at lest one month after a biopsy but I do not know if this is correct I seem to get so many different answers from doctor sometimes I do not know what to think  

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Age 64 From UK now in Thailand  Baby boy born 2/14/2009   First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08  1/28/09 Biopsy carried out 12 core results were findings Both specimens show no adenocarcinoma   MRSI done on 5/8/09 No signs of any cancer 5/15/0924 Core biopsy results Gleason'S Grade 3+2=5 Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified One side PIN High Grade Bone scan clear

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Age 55

Colin...not to add to your thoughts negatively...but just because you have robotic...doesn't necessarily mean less blood loss. I had to have two units of blood and my hospital stay was 5 days...which is very similar to most going the open surgical route.

Again like all the others have already stated...make your decision based on what you feel is right for you. Personally for me, there are only three words that sum up which doctor to use...experience...experience...experience

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You are beating back cancer, so hold your head up with dignity

Colin, I agree with Les above completely, can't stress enough the experience part of your chosen surgeon.

Whether you are healing from one large incision like when I had the open surgery, or you are healing from 4-5 smaller ones, what they do inside you is basically the same, it is still a major surgery. Many men that have robotic come home in a day or so, but others didn't. With the open, we have men that came home in two days and never used any banked blood. I was in 4 days with my open, because my insurance paid for it and my dr. agreed with me that there was no reason to rush things, I could have gone home after the 2nd day.

Some surgeons, such as mine, strongly feel the need to physically have their hands inside you during the operation. Those that do robotics, are comfortable seeing everything on screens.

But go for the most experienced surgeon that does prostate surgeries that you have access to and the resources for, because you get one shot at doing it, and it needs to be done as right as humanly possible.

Good luck as you make your own decision.

David in SC

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Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5

I second "55 and healthy in NJ" as to waiting six weeks after a biopsy, but this is ultimately up to your surgeon. The blood loss issue is worrisome but as lay people it is hard to tell what your previous experience means. Be sure that whichever doctor you choose has as much information about your previous operation as you can provide. Given that you might be more likely to need blood than the average person, you might consider storing up a couple of units of your own no matter which procedure you go with.

Just for the record, you will be 82 when your son starts college and everyone will be impressed that his "grandfather" came along to help him get moved in!

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Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7
At 6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.

BillyMac:

I don't know if your smart alecky "...disregard any advice coloured by mindless jingoistic nationalism" remark was aimed at me, who suggested leaving Thailand for the surgery, or at mikey1955 who suggested that Colin might consider going to the UK for the procedure.  In any case, I suggest you refrain from attributing unsavory motivations to your fellow posters and stick to giving advice, sharing knowledge and providing support...which is what I certainly try to do when giving my honest thoughts to folks on this forum.

My suggestion had nothing to do with "mindless jingoistic nationalism", rather was based on family experiences with medical treatment in Thailand and other non-Western countries.  Yes, it certainly is possible to get excellent medical treatment in Thailand and other places and I would not suggest otherwise.  However, I believe you have to look harder to find appropriate experts with the desired experience, have fewer specialists available should problems arise, have more difficulity getting references from patients who have used a physician (because of language and/or culture) and may face language issues with support staff.  Furthermore, in the case of robotic prostate surgery, the first such surgery was performed in Thailand only 2 years ago...hardly a long track record.

So, please be careful about your conclusions...they may be based on incorrect assumptions as they were in this case.

Tudpock

Please do not argue about the rights and wrongs about having surgery in Thailand I have to pay for my own surgery where ever I go (even in the UK) I know the language problem could be a factor which is why I have always been favoring the open surgery because the surgeon is in an international hospital and ALL speak good English the Robotics machine is in a State hospital which do not speak much English which is why I am going there tomorrow to see for myself, the advantage is that my other half and baby will be able to stay in the room with me which should help the language problem I also think that it is not as easy to just turn up one morning in the UK have surgery and leave 4 days later I am thinking that it would be a stay of at least 4 weeks and my other half being Thai would not be able to go with me (if I try to get her a Visa I would be doing Watchful Wait because it would take that long to come through)

 

Please keep the advice coming I do take note of it all I know that the more advice I get it makes the decision more difficult but it does mean it will be the right decision for me in the end

 

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Age 64 From UK now in Thailand  Baby boy born 2/14/2009   First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08  1/28/09 Biopsy carried out 12 core results were findings Both specimens show no adenocarcinoma   MRSI done on 5/8/09 No signs of any cancer 5/15/0924 Core biopsy results Gleason'S Grade 3+2=5 Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified One side PIN High Grade Bone scan clear

Well Tupock, if my interpretation that these words
"If it was my prostate, no way would I have surgery in Thailand". and
"I lived in Athens at one time and flew my daughter back to ths States to have her adenoids taken out"
did not smack of jingoistic nationalism and were not a general put down of the best quality of medicine and top doctors in those countries then I will withdraw my "smart-alecky remarks" and apologise.
Their inclusion was a pity because the rest of your suggestions were very sound and excellent advice.
Colin,
I understand your position. The implication that you travel overseas for the surgery perhaps to the US where you may have to stay for 2 months or commute back and forward while the preliminaries are sorted out (as well as the need to have about $60,000 in loose change in your pockets) is probably impractical. The suggestion that you travel to the U.K is sound on the surface but as you suggest unless you are prepared to wait for the NHS to schedule you, first for the preliminaries and then the op, then private payment there is the only way. As the majority of posters have said the key is experience, experience, experience. As I suggested before, while it takes about 100 ops to become technically proficient in the use of the robot, the surgeon would need to have done a great number (more than 500) of prostatectomies before I placed myself in his hands.
Bill

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1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07
4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)
PSA February 09 <0.01

BillyMac:

I have no wish to argue with you about your interpretation of what I know I meant.  It was straight talk, my opinion and I expained why I felt that way in my last post.  If you disagree that's fine but I maintain your comments are insulting and unnecessary on a forum of this nature. However, you obviously have a right to your opinion of me but I will repeat my previous advice that you stick to giving advice, sharing knowledge and providing support rather than attributing motives to well meaning members.

Colin:

I fear Billy and I have gotten off the track a bit with our little tiff for I'm sorry about that.  You are clearly doing the right thing by sifting thru different advice and perspectives so you can make the best informed decision possible.  I understand you are in a difficult spot, not only having PCa and having to deal with alternative treatments but also the issues of paying for it yourself and dealing with language/country issues.  From your last post, it sounds like you are having surgery in Thailand and are on track to find the best and most experienced team to perform the procedure.  I wish you the best of luck for a successful procedure and many zeros in your future!

Tudpock

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Age 62

I don’t know anything about Thailand but we did live in Hungary for 2 ½ years and both my father-in-law and my wife were treated in Hungarian hospitals. Yes, the physical surroundings may be different, but I believe that a surgeon learns as much from doing 100 operations in Thailand, or Hungary, or the United States. And, thanks to the internet, all of those surgeons have access to the same medical papers. If your condition were rare, or likely to be very complicated, then you would want to consider whether you could get the necessary specialists in Thailand. But a good doctor learns from experience regardless of location. That learning is what matters to you.

By the way, I was only 47 when my son was born, but his pediatrician, whom I had known for 20 years, was kind enough to calculate how old I would be when he entered college. That is why I passed the calculation on to you.

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Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7
At 6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.

Thank you Geezer I hope that I see my son for many more years to come but if it is not to be at least I will go with the feeling that I made 1 lady in my life very happy and she has the baby she so much wanted

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Age 64 From UK now in Thailand  Baby boy born 2/14/2009   First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08  1/28/09 Biopsy carried out 12 core results were findings Both specimens show no adenocarcinoma   MRSI done on 5/8/09 No signs of any cancer 5/15/0924 Core biopsy results Gleason'S Grade 3+2=5 Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified One side PIN High Grade Bone scan clear