My Two Cents (longer than I planned)

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brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 9/18/2009 2:39 AM (GMT -6)   
[url]http://news.yahoo.com/s/nm/20090917/sc_nm/us_surgery_robotics_1

This is well worth a read. Speaking as a surgeon (not a urologist) who had a RALP 10 weeks ago for PC, had it done in a foreign country, was a former member of a hospital's credentialing committee, and a physician who went through the training and credentailing for use of lasers in neurosurgery, I believe some things should be said.

First, we are all best advised to learn as much as possible about our surgeon, the procedure, and the doctor's expertise before undergoing ANY surgery. This can be done by asking the doctor questions, asking other doctors questions, and even better, seeking out former patients to quiz. Most people love to talk about their operations. Give some a chance.

Second, going to another country to save money on an operation is, at best, unwise! I had my surgery done outside the USA because I knew more about the Swiss doctors and hospitals than I did the ones elsewhere. I do not think that I saved a penny.

Thirdly, be aware that hospitals do not plank down several million dollars for any new equipment unless they can see that it is used wisely and safely. Lots of reasons for that; reputation, patient volume, need to amortize costs, and last but not least liability. Credentialing for special privileges required specialized schooling in labs set up to teach and demonstrations of competence on an ongoing basis. Practice models are a must in training. When I was credentialed for laser surgery, I had a certificate signed by a known professor with his own reputation to protect.

In addition, be wary of any advice concerning any technique that comes from a doctor who does not do that technique. There is likely a hidden agenda somewhere. That said, also be aware that ANY surgery done has inherent risks, advantages, and disadvantages. My surgery took about twice as long as the local average, and as a result, I have had some secondary complications really related to the time spent and the diligence of my doctor. None of this leaves me with any resentment because, I had done my homework and the thickness of my omental fat pad and pelvic floor covering could not be foreseen. My surgeon sat with me and my wife to give us a detailed account of this afterward. I wanted a good job done, and I believe that I got one. I "demanded" RALP from my doctors, but I was on several occasions given the opportunity to opt out for other techniques by doctors who could do them all.

Last, every doctor that I ever met puts his pants on one leg at a time. We all have our faults and short comings. Just try to make sure that the doctor in question for you understands his own limits. Operating rooms are not places for surprises, and "oops" is a nasty word to hear.
70 years old USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0
Neg. CT and BS
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Potency: beginning tumescence??? at 3 weeks post-op


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/18/2009 8:07 AM (GMT -6)   
Thanks Doc for the link to the article and your insight as a surgeon yourself. Congrats on your recovery so far. Looks like you are actually ahead of the curve in recovery from most. When is your first PSA test?
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
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month Apr 2009 .06
                   9 month Jul  2009 .08


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 9/18/2009 8:12 AM (GMT -6)   
Doctor, good post.

I fully agree your sentiments about having operations outside of the US. In your situation, you were knowledgable to know what you were doing and what you were getting into. Most of us, non-medical , regular every day guys wouldn't have that advantage. Then of course, there are severe liability issues to consider once your leave the US with a medical situation.

I agree to where you talk about your own complications, not every thing can be seen or known ahead of time with a complex operation. My own open RP turned complex once I was "opened", because they discovered that I had a very deep and narrow prostate bed. Fortunately, most of my cancer, if not all, was on the left side. The surgeon basically couldn't reach all he wanted to reach on my right side, which could have been a bigger problem had the can been on the right side.

Thanks again, its good seeing the insights from a doctor going through what we go through. Hope you continue to heal well.

David in South Carolina


Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20%, Contained in capsule, 1 pos margin
2009 PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/09 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl., agreed to start radiation, does not rec. HT at this time, mapping on 9/21/9


brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 9/18/2009 8:58 AM (GMT -6)   
First post-op PSA will be in about 3 weeks. Like all, I am anticipating it with hope and a bit of apprehension.

Purgatory, I am uncertain what liability issues have to be considered when leaving the USA with a medical situation. Help me out here. The male pelvis in a lot of us can be like an old scrub nurse once told me. "If the good Lord had meant for you to go in that place (hypothalmus of the brain), he would have made it a lot easier to get to".
70 years old USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0
Neg. CT and BS
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Potency: beginning tumescence??? at 3 weeks post-op


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 9/18/2009 9:23 AM (GMT -6)   
Simply meant, if something terrible went wrong, or if an operation were outright blotched, what liability and legal issues would a US citizen be dealing with if they had medical treatment or an operation outside of US law.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20%, Contained in capsule, 1 pos margin
2009 PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/09 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl., agreed to start radiation, does not rec. HT at this time, mapping on 9/21/9


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 9/18/2009 9:43 AM (GMT -6)   
Let's face it, even in the U.S. our liability and leagal issues are cloudy. Most of us have no idea if the job was botched or not. The doctor rarely comes and tells us. I wanted some video footage from my Davinci, which we all know would be a simple RS232 cable. They said it wasn't available. I am sure it was all for liablilty issues, not for techinical capability.

In the end, even if we do prevail in the legal/liability fight, it probably helps our family, not us, because we are probably dead by the time it is settled.

All that said, it is still excellent advice.
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)


brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 9/18/2009 9:48 AM (GMT -6)   
Liability issues would be sticky in some countries. Your grandchildren might win if at all. In Switzerland, medical liability issues are a lot simpler than in the USA. Basically, a criminal act has to be proven. Then there is no big pot at the end of the rainbow for the lawyers. The doctor?? He likely will go to jail!
70 years old USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0
Neg. CT and BS
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Potency: beginning tumescence??? at 3 weeks post-op


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 9/18/2009 10:37 AM (GMT -6)   
Yes, things are way different in Switzerland. In my former position as CFO of an FX company, we had offices in Zurich and Geneva. Employee benefits were huge over there and most of the employment laws much stricter than here in the US.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20%, Contained in capsule, 1 pos margin
2009 PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/09 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl., agreed to start radiation, does not rec. HT at this time, mapping on 9/21/9


Sleepless09
Veteran Member


Date Joined Jul 2009
Total Posts : 1267
   Posted 9/18/2009 11:39 AM (GMT -6)   
brainsurgeon, great post, and good to see you posting. I've not been here often enough to keep track of how you're doing, so it was also good to get an update.

I'll be looking forward to a report on the PSA --- being zero!

Sheldon AKA Sleepless
Age 67 in Apil '09 at news of 4 of 12 cores positive T2B and Gleason 3 + 3 and 5% to 25% PSA 1.5
Re-read of slides in June said Gleason 3 + 4 same four cores 5% to 15%
June 29 daVinci prostatectomy, Dr. Eric Estey, at Royal Alexandra Hospital Edmonton one night stay
Flew home to Winnipeg on July 3 after 5 nights in Ramada Inn  ---  perfect recovery spot!
Catheter out July 9, so far, so good
Final pathology is 3 + 4 Gleason 7, clear margins, clear nodes, T2C, sugeron says report is "excellent"  


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 9/18/2009 11:48 AM (GMT -6)   

Great post doc.  I agree with all you have said with just a little caveat.  I was very impressed with my surgeon when he told me he thought robotic surgery was the wave of the future and that someday he may want to go there but for now that was not his expertise and if that is what I wanted he would recommend a colleague.  Actually that just cemented the fact that I wanted him and his expertise in open surgery.

My one small caveat is that I lived overseas for several years - in Thailand.  There is excellent health care there and they have some great hospitals and medical professionals.  Had I still lived there, I probably would have opted to have my surgery there.  However, since I now live in the USA, I wanted my support group of friends and family to be close so opted to have the surgery here. 

Thanks for posting - always good to hear from you. David


Diagnosed Dec 2007 during annual routine physical at age 55
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 pos; 2 marginal
Gleason 3+3; upgraded to 4+3 post surgery
RRP 4 Feb 08; both nerves spared
Good pathology - no margins - all encapsulated
Catheter out Feb 13 - pad free Feb 16
PSA every 90 days - ZERO's everytime!
Great wife and family who take very good care of me


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/18/2009 3:59 PM (GMT -6)   
Love the post, Doc,
I really liked your perspective. Sounds like what I try to tell folks.

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 9/19/2009 11:07 AM (GMT -6)   
CPA said...
Great post doc. I agree with all you have said with just a little caveat.

Sounds like an honest doc to me. Also a smart one. Would hate to be the lawyer that tried to sue him.
70 years old USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0
Neg. CT and BS
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Potency: beginning tumescence??? at 3 weeks post-op

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