URO made an interesting comment

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kbota
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Date Joined Aug 2010
Total Posts : 487
   Posted 9/24/2010 9:24 PM (GMT -6)   
Visiting with a urologist recently who stated that any uro who performed a robotic RP on a man with a gleason 8 or over should have the snot beat out of him. His thinking is that a high gleason suggests the high probability of EPE, and/or node/vesicle involvement, all of which cannot be managed well with the robot, but CAN usually be managed when the patient is open.

I noticed on my path that while I was in surgery with my guts open to the world, my uro would send tissue samples to the path lab, and wait for results. If +, then another tissue sample would be forthcoming. If negative, then sew that one up and move on to the next.

Found that insight to be most interesting. He did not have a high opinion of true value of robotic surgery. He stated that generally speaking, patients who had the robotic had more (not less) recovery issues.

thoughts?

k
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 2010 - RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invasion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)
As of 9/3/2010, I'm 99% continent - only occasional stress incontinence !

Fairwind
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Date Joined Jul 2010
Total Posts : 3887
   Posted 9/24/2010 11:19 PM (GMT -6)   
I think the results of surgery show that surgeons of equal skill levels, be it robotic or open, get equal results..There are no published studies that I know of that favor open surgery over robotic for high-risk cases..

What may indeed be true, for really high-risk cancers, surgery does not often provide a cure, robotic or open. The Partin tables point that out. I knew going in that a true cure was a long shot but a 30% chance is a lot better than no chance.

If you visit the YANA site and arrange the case histories by Gleason score, you will see that less than half the high-risk men have surgery period..They mostly are treated with radiation and HT. Many of these men are from the UK where medicine is practiced a little differently..
Age 68.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA age 66 9.0 DRE "normal", 2ed biopsy, negative, BPH, Proscar
PSA at age 67 4.5 DRE "normal"
PSA at age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP performed Sept 3 2010

F8
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Date Joined Feb 2010
Total Posts : 3984
   Posted 9/24/2010 11:28 PM (GMT -6)   
my uro is an open guy.  his partner does robotic but i could tell my uro thinks open is better.  that said, he recommended combination radiation therapy for me, saying i was not a good candidate for surgery.
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Piano
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Date Joined Apr 2008
Total Posts : 847
   Posted 9/25/2010 12:49 AM (GMT -6)   
There was a thread here about 6 months ago which indicated that open gave better continence results than robotic. This was backed up by an informal survey among the members here at that time. (Probably covered ED too.)

But I have just done some searching and can't find it -- maybe someone else has a better memory than me...
Pre-op:
Age 63 at diagnosis, now 65.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores.
Operation:
Non-nerve-sparing open surgery 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?)
19-month: 0.09 (maybe)
25-month: 0.2 (yes, bummer)
27-month: 0.2 (not up; glad about that)
ED:
After a learning curve, Bimix injections (0.2ml) worked well. From 14 months, occasional nocturnal erections. At 18 months, "graduated" to just the pump.

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 9/25/2010 7:15 AM (GMT -6)   
Remember reading it too and have heard other opinions like that particular uro-doc, so where do they get their collective informations? The next thing about the lymphnode sampling is wild n crazy, some docs sample none, some sample a few closest to capsule, some take out alot.....ask in advance how many samples do you take and how do you determine such???

This is not pure science and alot of variables and randomness in treating PCa...makes one feel less than secure I would guess. Good you are questioning things, I always still do.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7078
   Posted 9/25/2010 8:27 AM (GMT -6)   
My Uro/Surgeon also mentioned that at a certain point, if the cancer was obviously out, they would sew me back up and send me to radiation only.
 
He took 12 lymph nodes (some from both sides) and did the "wait for a quick path check" as well. He explained this ahead of time.
 
Once the path report came back, it was much farther along that what the biopsy indicated. Revisiting, all that known, I possibly was not a "certain" surgery case.

Post Edited (142) : 9/25/2010 9:43:31 AM (GMT-6)


Ed C. (Old67)
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Date Joined Jan 2009
Total Posts : 2460
   Posted 9/25/2010 9:18 AM (GMT -6)   
I'm a Gleason 8 who had Robotic surgery (see my signature), so far I'm happy with my choice. I think the key to making a choice is the experience of the surgeon.

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 9/25/2010 9:59 AM (GMT -6)   
kbota,  It almost sounds as if you were talking to my former uro.  He told me that surgery was a poor choice, my surgeon was a charlatan just in it for the money, and quote "I can practically guarantee you a recurrence".   My new uro onc says surgery was a very good choice, that I chose an excellent surgeon and he was not surprised at my good outcome (so far).  My surgeon also used intra-operative pathology but I get the idea that not many do.
 
For a very negative viewpoint of daVinci, check out Dr. Catalona's web site.  For a negative viewpoint on all PCa treatments other that BT and IMRT check out Dr. Dattoli's web site.  Eastern Virginia Medical Center published a paper comparing the two surgical outcomes at their hosopital but I can't find it.  If anyone knows where to get good unbiased info, it would be refreshing.
 
Carlos

Diagnosed 2/2008 at age 71, PSA 9.1, Gleason score 5+3, stage T1c.
Robotic surgery 5/2008, LFPF at 6 wks.,nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3
PSA <0.1 at 26 months and at all tests since surgery.

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 708
   Posted 9/25/2010 10:15 AM (GMT -6)   
Urologist at Clinic gave me option of open or robotic, and quickly followed with "99% of his are robotic." Dumb me I should have checked his specialty which is robotic prostatectomy.  All you can do is give it your best shot.

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 708
   Posted 9/25/2010 10:18 AM (GMT -6)   
  How in heaven's name are we supposed to know all the questions to ask.... It's like John Wayne once said "there's a few things they didn't tell me about this outfit before I signed on."

John T
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Date Joined Nov 2008
Total Posts : 4268
   Posted 9/25/2010 10:56 AM (GMT -6)   
There was a survey of Uro docs last year asking if they had pc which procedure would they choose. If it were low grade the majority chose robotic; if it were high grade the majority chose open.
Of course these were all surgeons. I would think that an unbiased doctor would say that with confirmed or high probability of EPE, radiation would be the perferred method.

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Jazzman1
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Date Joined Sep 2010
Total Posts : 1162
   Posted 9/25/2010 11:12 AM (GMT -6)   
Hell, I didn't even know I had signed on!

The more I read and the more I talk to people, the more convinced I become that the advantages of open surgery vs. laparoscopic are real and substantial.

My Uro says he used to do robotic, but when he took an honest and hard look at his patient outcomes, he decided he could do better with open surgery. Walsh seems to agree, as does a general oncologist I recently met with. Of course, the experience and professionalism of the surgeon are key.

The main advantage of robotic surgery seems to me quicker recovery. I understand very well the appeal of that advantage, and it's one that had me wanting robotic surgery initially. This is a very popular choice, but I think it's being driven largely by demand from patients who want a relatively easier ride. And who can blame them? But what I'm hearing is that open surgery is the more conservative choice, both in terms of curing cancer and minimizing long-term side effects. In my view, that trumps most everything else.

Fairwind
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Date Joined Jul 2010
Total Posts : 3887
   Posted 9/25/2010 11:34 AM (GMT -6)   
A few days ago, in the office of a physical therapist who sees all TUCC's prostate surgery patients to help with recovery and incontinence issues, I noticed a full size plastic model of the male pelvis and it's muscles and organs, which were removable, like a big 3D puzzle..The prostate gland is tucked into a near impossible location, down inside the pelvis, in a cave between the two hip joints, covered by the pubic bone.. This space is shared with the bladder and rectum and part of the colon..

From a layman's perspective, I can see why, today, the majority of surgeons prefer the robotic method..To perform this operation using your own hands would require a watchmakers skills and abilities...For open surgery, perhaps a female surgeon, with her naturally smaller hands and fingers would be a good choice...

F8
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Date Joined Feb 2010
Total Posts : 3984
   Posted 9/25/2010 11:57 AM (GMT -6)   

my uro, an open surgeon, has small hands but you'd never know that from the brutal DRE he administered the first time i met him cool .

ed


age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1162
   Posted 9/25/2010 12:02 PM (GMT -6)   
Yeah, the uro docs do DREs differently than regular docs. I'm pretty sure those guys go clear up to the elbow.
Age 55

PSA:
8/09 2.69
7/10 4.00
8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C
Gleason 6

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1162
   Posted 9/25/2010 12:06 PM (GMT -6)   
Fairwind,

I can see why a lot of docs prefer the robotic method too, patient demand aside.

The 3D view, the heightened magnification, the ability to both see and cut from practically any angle, the precise and controlled movements of the robot, shorter hospital stays, shorter recovery times... there's a lot to be said for the robot.

We have slightly different viewpoints on the relative merits of open vs. robotic surgery, but you make a good point.

Jonathan
Age 55

PSA:
8/09 2.69
7/10 4.00
8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C
Gleason 6

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1162
   Posted 9/25/2010 12:38 PM (GMT -6)   
BTW, is beating the snot out of him an approved medical procedure???
Age 55

PSA:
8/09 2.69
7/10 4.00
8/10 4.11

Biopsy 8/10
Three of 14 cores positive: 10%, 60% & 80%
Stage T1C
Gleason 6

daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 9/25/2010 1:22 PM (GMT -6)   
Fairwind said...
Snip

.For open surgery, perhaps a female surgeon, with her naturally smaller hands and fingers would be a good choice...


Gotta laugh at that one, there were 2 deciding factors in my decision to go local and open.

One was that there is no robot within several hundred miles and the local uro's won't treat anyone who travels for a period of one year, more if there are serious complications from the surgery.

The other was an internet search of my 2 surgeons which turned up some pretty good stats and backgrounds. When I met with my uro' for the decision I picked up one of her hands and said "we're going with you, you have small hands" wink

I only really have one personal experience with open/robot, my good friend traveled to Mayo Clinic in Phoenix a couple of weeks before my surgery to have a procedure done by a guy who has done over 800, to this day he is still using a cath' several times a day, is on injections for ED and has made numerous trips back and forth. My recovery is going very well, I almost feel guilty.

Granted there are huge differences in some people that make recoveries vary greatly but I'm really glad I went with my gut and stayed with my uro'. She said the tactile sensations are the big advantage of open and makes a large difference.

BTW my logic of going with surgery with my stats was to reduce the tumor load for future treatments, I did not expect a "cure", time will tell if I'm going to be pleasantly surprised.
Diagnosed 12-09 age 55
07-06 PSA 2.5
01-08 PSA 5.5 (PCP did not tell me of increase or schedule follow-up!!!!)
09-09 PSA 6.5 Sent for consult with Urologist
11-09 Consult, scheduled for biopsy, found out about PSA from '08 (yes I was pissed)
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5, ain't much but I'll take it.
01-10 Bone Scan, "appears negative"
03-01-10 RRP in Durango CO by Dr Sejal Quale and Dr Shandra Wilson, no naked eye evidence of spread, Vesicles and lymph nodes taken for microscopic exam.

03-16-10 Removal of cath' and pathology results of samples.
Multifocal carcinoma with areas of Gleason pattern 3, 4 and 5, Overall Gleason grade 4+4 with tertiary 5, Bilateral involving 21% of left lobe, 3% of right lobe, Invasion of left Seminal vesicle, Tumor focally present at left resection margin, 9 lymph nodes removed all negative, Tumor staging pT3b NO MX

04-23-10 PSA <0.04....... 06-07-10 PSA <0.04..... 08-03-10 <0.04
05-03-10 1 week without pads
06-28-10 ;-)

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 9/26/2010 10:27 AM (GMT -6)   
I'm one of those high grade cancers patients. Before surgery i had G9, low PSA, neg bone scan, trans rectal coil MRI that was negative for EPE. Two uros, a medical oncologist and a radiation oncologist (Harvard med school, residency at Cleveland) all strongly recommended the same thing; surgery. And they all tended toward robotic. Thus I picked Randy Fagin. Turns out I had EPE and will do radiation now, but the rad oncologist says i will need only 9 weeks RT and 6 months HT, which is less than if I had not had surgery.

Im satisfied with my decision, based on the research I've read before and since.

F8
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Date Joined Feb 2010
Total Posts : 3984
   Posted 9/26/2010 10:56 AM (GMT -6)   
>rad oncologist says i will need only 9 weeks<
 
only nine weeks?  i'm not sure that anyone does more than nine weeks.
 
ed

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7078
   Posted 9/26/2010 12:34 PM (GMT -6)   
F8,
Depending on  the circumstance (primary or secondary treatment), I have seen members quote 30-33, 39, and 45 sessions of radiation.
 
Mine was 39 sessions. The Radiation folks said that it had to do with how much radiation they want to deliver, and potential collateral damage.

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3984
   Posted 9/26/2010 12:38 PM (GMT -6)   

i agree.  five days a week, right?  nine weeks would be 45 session....or more likely 41 - 44.

ed


age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7078
   Posted 9/26/2010 1:06 PM (GMT -6)   
The "nine weeks" seems to be generally used as the comment by the Radiation folks. In reality they told me to allow a couple of weeks for my "eight weeks (39 sessions)" afterward just in case - there are a lot of reasons you might have to skip one or more sessions - sickness, holiday weekends, weather, etc. For example, they also mentioned that they prefer not to start new sessions the week of Thanksgiving if Christmas is on a Monday or Friday that year, as it creates extra gaps.
And there is the planning and later verification session, so total elapsed time will always be a little longer.
(My sig has the link to my post-DaVinci IGRT)
 
I tend to think that the "only" was a cursory comment, preaparing you for the overall period, but since each radiation plan is unique, it may be that the Rad. Oncologist sometimes has longer plans to use lower per day doses. 
 
In comparison, my doctors also used the elapsed time to prepare for, have, and recover from DaVinci versus the elapsed time Radiation as a primary treatment as "the same" for estimating time I would be impacted at work in one way or another. 
 
That is why I recorded everything, and strongly suggest others do the same. I found that what I heard and took notes on was very different from what was said. It was probably still the shock of the diagnosis.
My IGRT journey -
www.healingwell.com/community/default.aspx?f=35&m=1756808
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