Some information on surgical outcomes -- open and robotic

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geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 3/21/2010 1:40 PM (GMT -6)   
The article discussed below was originally cited in a post by brainsurgeon. What follows are my impressions from reading the article. It is most definitely not an attempt to provide a full summary or a statistically valid analysis. I was drawn to this article because it summarizes the results of a large number of published papers, but this means that there are many issues with comparing data across papers. In this discussion I focused only on robotic and open surgery. There is also much data on laparoscopic surgery but my impression from this board is that, at least in the U..S., Laparoscopic has largely been replaced by robotic and so I do not discuss it.

What I think I learned.
In this summary I tried to put some numbers to issues which are frequently raised. In particular, I was encouraged by the longer term data on both incontinence and erectile dysfunction. When one looks at data for one year or more post-operation, continence levels seem quite encouraging. The data, although sparse, which suggests that it may take well over a year for erectile function to return is, to me, encouraging.

As a disclaimer, I have no training in medicine. I do have substantial training and experience in statistical data analysis which I hope informs this presentation

Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Systematic Review and Cumulative Analysis Of Comparative Studies
European Urology 55 (2009) 1037–1063

The operation
Average operative time in minutes:
open surgery tends to be faster, 100-130 minutes, than robotic by about 30 minutes but there is some suggestion that experienced robotic surgeons close this gap.

Average blood loss during surgery
Robotic has significantly lower blood loss – about 1/3 that of open, but still only 1/7 of the open patients needed a transfusion

Positive Surgical Margins
For open surgery, the rate of positive surgical margins, subject to fairly wide variation, was about 20%. Robotic surgery showed a somewhat lower rate. For both operations the rate of positive margins was much lower for early stage cancers.

Post operative
Pain, measured by the administration of pain killers.
There is very little data. The one study suggests no difference between open and robotic

Urinary Continence
Generally defined as needing no pad.
Most studies of open show 80%-90% of patients are continent after one year. With less data the continence rates after 6 months for open range from 40% to 80%.
There is little data for robotic but the pattern seems similar to the data for open

Erectile Function
Generally defined as erection sufficient for intercourse
With only two studies the evidence is inconclusive.
One study indicated that 60% to 70% achieve erections sufficient for intercourse within one year regardless of whether they had open or robotic.
A second study showed that the time for half of open patients to achieve intercourse was 700 days while for robotic the number was 340 days.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day
9 mo. PSA 0.00 -- 1 light pad/day ED remains


Redman55
Regular Member


Date Joined Jan 2010
Total Posts : 87
   Posted 3/21/2010 3:52 PM (GMT -6)   
A golfing buddy of mine had open and I had robotic. We compared notes on recovery, complications etc. I was back in the office in 2 1/2 weeks and on the golf course in 2 months. He returned to work in 5 weeks and had urethra blockage issues and had to self catheter for months. Scarring - no comparison. I had two surgeons tell me that the only reason a surgeon would opt for open is because they haven't learned DaVinci.
Age 54
PSA 8/2009 5.6 Gleason 8
DaVinci surgery 11/2009
Pathology - totally contained in margins -one bundle spared
PSA now undetectable at < .05
Continance: 1 pad and almost normal
Doing 3 P's and now using trimix


tatt2man
Veteran Member


Date Joined Jan 2010
Total Posts : 2845
   Posted 3/21/2010 4:07 PM (GMT -6)   
I hope this is NOT going open the "my surgery choice is better than your choice" again - there is enough bullying in the world.

Choose the best doctor for you - and his/her best method for treating your individual prostate cancer. Every individual is different and results will change from person to person.

My open surgery went smoothly - no blood loss, essentially back to work in two weeks - was able to resume lifting items over 10# after the required 6 weeks - no scarring - no blockage - improving ED and improving incontinence.

Does that make open surgery the better choice - of course not - each person is different and their needs and stats are different.
Thank you for the interesting stats geezer99

BRONSON
.................
Age: 54 - gay - with spouse, Steve - 59
PSA: 04/2007- 1.68 - 08/2009 - 3.46 - 10/2009 - 3.86
Confirmation of Prostate Cancer: October 16, 2009 - 6 of 12 cancerous samples , Gleason 7 (4+3)
Doctor: Dr. Mohamed Elharram -Urologist / Surgeon - Peterborough Regional Health Centre
Radical Prostatectomy Operation: November 18, 2009 , home - November 21, 2009
Post Surgery Biopsy: pT3a- gleason 7 - extraprostatic extension - perineural invasion - prostate weight - 34.1gm -
ED Prescription: Jan 8/2010 - started daily 5mg cialis - girth back to normal -but not much length - will go for trimix in April when I see doc
Incontinence: 3-5 pads/1-2 clothes changes/day- finally seeing improvement - March 3, 2010 - week 14 after surgery -
location: Peteborough, Ontario, Canada
Post Surgery-PSA: to be announced - April 8, 2010
............


Redman55
Regular Member


Date Joined Jan 2010
Total Posts : 87
   Posted 3/21/2010 4:13 PM (GMT -6)   
Spot on that we each have to follow our own path with this.
Age 54
PSA 8/2009 5.6 Gleason 8
DaVinci surgery 11/2009
Pathology - totally contained in margins -one bundle spared
PSA now undetectable at < .05
Continance: 1 pad and almost normal
Doing 3 P's and now using trimix


Sunbird
Regular Member


Date Joined Apr 2008
Total Posts : 140
   Posted 3/21/2010 4:54 PM (GMT -6)   
If you visit www.henryfordhealth.com and their Vattikuti Urology Institute website, you'll find a chart showing their outcomes concerning Robotic vs. open Prostate Surgery. This chart lists Cancer Removal, Continence @ 6 months, Potency @ 12 months, Safety, Pain, and blood loss. Their measure of cancer removal (no detectable PSA @ 5 years) shows 97% for Robotic Surgery @ Henry Ford vs. 86% for open Surgery @ Henry Ford. This is somewhat disheartening for a person like me who underwent "open" surgery. I don't like the idea of having an 11% better chance of having my cancer recur due to the fact I had "open" surgery.

The big question is.......what in the surgical procedure, robotic vs. open, would make an 11% disparity in the outcome????? I left my phone number with their Urology Institute in an attempt to get an answer to this question, but have not received a call as yet.

Any speculation on where this 11% disparity would come from? It almost appears as the "open" surgery guys were more high risk patients to begin with, but that's hard to believe.

My Urologist performs Robotic surgery, but would only perform open surgery on me due to prior stomach surgery, so it's not like I had a choice anyway.

I think any newly diagnosed visitors to HW considering Robotic Surgery should take a hard look at Henry Ford's Vattikuti Urology Clinic if they're going the surgery route considering their outcome statistics.

Another plus is you do not receive a urethra catheter if you have surgery at their hospital, and they have an online consult form to complete if you wish to consult with their Urologists.
1996, Age 48, Stage III Colon Ca, Colon Resection followed by 18 chemo treatments.
 
2000, Colon Ca Metastasis to upper left lung lobe.  Lung lobe surgically removed.  24 chemo treatments scheduled.  Took 1, declined the rest.
 
9/08 PSA is 2.8, 12/08 PSA is 4.56??  Chalk it up to prostatitis due to urinary retention after Nissen Fundo Surgery.  VA docs prescribe 30 days of Septra.  Prostate feels normal.  PSA hovers around 4.1.  VA docs want prostate biopsy but can't seem to get me into the schedule.  Continue through Spring and Fall of 2009 thinking I have prostatitis.  Bacteria cultures are always neg.  PSA drops to 3.1 10/09.
 
12/09 Prostate Biopsy performed
3 of 10 cores positive, 5%, 25%, & 35%, 3 + 3= Gleason Six with perineural invasion.
 
Doc wants CT Scan due to prior Colon Ca. Findings: "The seminal vesicles are irregular & there is nodularity in the periprostatic fat such that local extension cannot be excluded.  Shotty lymph nodes in both groin measuring 2.3 cm."
 
Doc wants Endo-rectal MRI (OUCH!) Findings: Mild central zone BPH, no discrete focus of carcinoma is identified, no evidience of invasion into the periprostatic fat or seminal vesicles.  Normal size iliac chain lymph nodes.
 
2/08/10 Open RP surgery.  Findings: Gleason Six upgraded to Seven.  3 + 4, Stage pT2c, Bilateral w/perineural invasion, No pos lymph nodes,  margins uninvolved, no extraprostatic extension, no seminal vesicle extension,  39 grams, blood loss 1200 ml (didn't want a transfusion & didn't get one) nerve bundles spared bilaterally.  current age-61


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/21/2010 5:21 PM (GMT -6)   
Redman55,

I thought your post above was way too biased without merit. There are excellent surgeons that only do open surgeries by choice, having done hundreds and in some case, thousands of operations. There are surgeons that are only doing robotic, and they have to come up to their own learning curve with the technology. And there are surgeons that do both, depending on the patient's need and choice. There are plenty of high level surgeon's that just like to have their real hands inside their patient, and like to the tactile feel as they are operating. In our day and age, excessive bleeding is rare in an open surgery, and on the other hand, there have been rare cases of excessive bleeding even in robotic surgery. No way to generalize the choice.

As far as your buddy having stricture/blockage issues, that can come from either form of surgery, one isn't more prone than the other to cause it, there are other personal and internal issues that set the stage for strictures, and trust me, after fighting this issue for over 15 months, I am speaking first hand.

It still comes down to finding a skilled surgeon to handle your PC surgery if that is the treatment method a man is going with. Lots of experience by itself isnt the whole answer, it has to be about the quality of the surgery. I sure wouldn't want to be operate in the equivilent of a surgery mill, and let's see how many we can crank out a week.

The healing process is so individual and subjective, hard to ascertain what is really better. Both methods of surgery are major, one is less invasive at the onset, but the jury is out in my opinion, if there is any provable gain with incontinence and/or ED by choosing open or robotic.

David in SC
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% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, Caths #13 & #14 same time, 3/6 Cath #13 out - 4 days


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4274
   Posted 3/21/2010 6:01 PM (GMT -6)   

Sunbird:

Some time back geezer questioned the data published on the Henry Ford web site and said he would not believe it unless he saw it published in a respected journal.  I had some time on my hands that day after I read geezer's post and shown below is the reply I posted which I think speaks for itself.

Tudpock

Hi Guys:

In reference to geezer's comment that he wouldn't believe it until and unless published this in a respected journal, I decided to see if I could find such a publication.  As it turns out, Henry Ford DID publish results of a fairly extensive study of their robotic results in 2007 in the "Cancer" journal of the American Cancer Society.  Here is the link for those of you want to read it.

http://www3.interscience.wiley.com/cgi-bin/fulltext/116322982/HTMLSTART

From my analysis, the info published on their web site does appear to be a bit of puffery if compared to the results of their published study.  Now, it may be that this respected institution has other results that back up their web site stats but, if we use the "geezer criteria" of publication in a respected journal, here is what you get:

1.  Cure - defined as no detectable PSA at 5 years.  Web site said 97%, journal study said 84%.

2.  Urinary Function. Web site, defined as no pads needed said 96%. Journal study, defined as less than 1 pad per day said 93%, and said 82% if define as "no leaks".

3. Sexual function - defined as erections good enough for penetration.  Web site said 97%, journal study said 79% (with 44% of those using aids to get it up).  In fairness, the web site states that the 97% is with the "Veil of Aphrodite" procedure while the study included all robotic procedures done at HF.

So, using the "geezer criteria", which I think is excellent, the HF results are good...but not as spectacular as their web site promotes.  As usual, the devil is in the detail.

Perhaps HF will have an upcoming published study that proves their promoted results...in the meantime, it's probably wise to count on what they have pubished under the "geezer criteria".

 



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 12/09.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!
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