Selecting a Surgeon - Robotic vs. Open

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Pembroke
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Date Joined Oct 2010
Total Posts : 3
   Posted 10/17/2010 9:23 AM (GMT -6)   
I'm trying to decide between 2 good surgeons.  Both are based at centers of excellence for cancer treatment.  One surgeon does only Robotic.  The other surgeon does both open & Robotic ( 70/30 ) and recommends that open is preferable for me due to my particular prostate characteristics and his general preference for the tactile benefit of open.
 
I'm in a quandary --- I'm drawn to the obvious procedure benefits of Robotic and I'd like to avoid the possible downside effects of open.  If I choose Robotic I'll go with the guy who does them exclusively.  On the flipside I like the fact that the open surgeon has made a judgement call that he thinks open would be best for me, and I give this opinion some weight because he does both procedures.   Both surgeons are the same age,  seem to have equal excellent skill sets, and equivalent high reputations.
 
I'd appreciate any input on evaluating the pros & cons of these 2 procedures.
 
Another consideration is timing :  both surgeons, my urologist & GP all indicate that treatment is better sooner rather than later, i.e. within the next 2 months, due to tumor visibility close to capsule wall.  But, I'd like to reach a solid comfort level with the choice of procedure & surgeon without feeling that I made it under time pressure.  Again I'd appreciate any comments.       
 
   

Age 57
Dx - Aug 18, 2010
PSA - 4.7; Gleason 3+3; Stage T1c
Biopsy 4/12 - 10% in 3 cores, 5% in 1
MRI shows tumor confined in prostate but visible close to capsule wall

dacama
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Date Joined Oct 2010
Total Posts : 11
   Posted 10/17/2010 1:39 PM (GMT -6)   
I had the same decision 4 months ago. After considerable thought and prayer I went with the Doctor I had the most faith and confidence in and not with the procedure they advocated.

Hope that helps.
54
Late 07 PSA UP/Early 08 First Biopsy - Neg
Late 08 PSA Higher/Early 09 Second Biopsy - Neg
Early 10 PSA UP/Early 10 Third Biopsy - Positive
26 Cores...4 positive
8/23/10 RP Gleason 6+ 5% of Prostate Cancerous Wide Margins
Nodes negative/Vesicles negative
Tumor contained in capsule
NO post surgery PSA test as of yet.

BillArb
Regular Member


Date Joined Jun 2010
Total Posts : 35
   Posted 10/17/2010 3:25 PM (GMT -6)   
My doctor did open surgery almost exclusively. When I queried him as to why, he responded that there have been no long-term studies as to the efficacy of open vs. robotic...and...he preferred having the ability to feel surrounding tissues with his hands. He has done more than 400 surgeries and this was what convinced me to look no further.

MrGimpy
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Date Joined Jul 2009
Total Posts : 504
   Posted 10/17/2010 3:38 PM (GMT -6)   
1st problem you will have is with the Dr that ONLY does robotic

If things are not going along well, they will switch from Robotic to open DURING the surgery. What do you do them with the Dr that only does robotic ? Who is taking over for him ?

As for the Dr that has performed 100 surgeries in total, wow thats not much. There has to be Dr's that you can find that have done 100 every year ( at least that many) for a few years on both procedures

142
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Date Joined Jan 2010
Total Posts : 6896
   Posted 10/17/2010 4:01 PM (GMT -6)   
Is the 70/30 meant to be a ratio, or a count?
 
I selected a surgeon who had done open for many years, and switched to DaVinci. He did tell me that in the event of problems, there were reasons that they would switch to open.
He did not subscribe to the "feel" argument.
 
I had multiple viable and practical options to go with open, but stayed with the DaVinci decision based on my comfort level with the surgeon.

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6896
   Posted 10/17/2010 4:04 PM (GMT -6)   
Sorry to have not noticed this was your first post. Welcome. As much as we don't want you to have a reason to join us, please feel free to ask questions, and let us know as you choose a path.

proscapt
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Date Joined Aug 2010
Total Posts : 644
   Posted 10/17/2010 4:12 PM (GMT -6)   
I would move quickly on this, since you say it is close to the capsule wall. The downside of not getting it while it is still inside the capsule is greater than any likely difference in outcome between the two surgeons you are considering. Pick the procedure that you think you want, and get yourself on the calendar a month or so out. That will start the clock ticking; you can always research it further and if you find a strong reason to change your mind, then go ahead and change your mind. But it will stop you from endangering yourself by procrastination and inaction.

In general, for most prostate cancers, the two procedures show roughly equal results. "In general." Each PC is different.

You might be able to get some more useful feedback from this group if you ask the surgeon who recommends open why in your particular case, he thinks open might be better. Not the reasons in general, the reasons in your particular case. For example, if your pre-op information suggests that extended lymph node dissection is warranted, that can be done a bit more easily in open, I'm told. People here might have some reactions to the particular arguments the surgeon offers.

I had robotic FWIW, and I'm pleased with the outcome, but that doesn't mean it's necessarily best for you.

Jazzman1
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Date Joined Sep 2010
Total Posts : 1160
   Posted 10/17/2010 4:23 PM (GMT -6)   
Welcome, Pembroke.

I was in a similar situation a couple weeks ago. Tough call, especially when choosing between similarly experienced surgeons.

I can't tell you what to do, but I chose open surgery. After speaking with a general oncologist about it, he agreed with my urologist and with Dr. Patrick Walsh (Get his book if you haven't already) that there are real advantages to open surgery. This is particularly true if you think there's much chance the cancer may not be organ confined. They all think tactile sensation is a big deal.

The oncologist I spoke with, who had no dog in this fight, thought that robotic surgery, while good, is oversold. He thinks the growth of robotic surgery is being driven by patient demand. Of course, who wouldn't want an easier recovery? I know I did.

One thing the oncologist told me that really resonated was this: A year from now, is it really going to matter to you that it took a couple extra weeks to recover from surgery? He got me with that one. I signed up with Dr. open.

Your mileage may vary. Good luck with your decision.
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

Pembroke
New Member


Date Joined Oct 2010
Total Posts : 3
   Posted 10/17/2010 4:37 PM (GMT -6)   
To Decama : Thanks very much  -- I think that'll be the deciding factor for me.
 
To BillArb :  Thanks for your reply.  There is one study I'm aware of out of  Boston in '09 reviewing 1300 + patients and also reported by the National Cancer Institute. The findings were that Robotic's overall results on continence & ED were slightly worse than open.  But commentators have noted that the patient universe in that study ( all Medicare patients so all over age 65 ) isn't truly representative of the entire Robotic patient population.
 
To MrGimpy : Thanks so much.  My original post was my first on this forum and I realize it was imprecise on several counts:  The surgeon who I indicated does only Robotics was trained & practiced in open, and he reverts to open during surgery if there is a medical need or some other situation where the Robot cannot be used.   He elects not to do open operations as a regular part of his practice only because he is such a firm believer in the advantages of Robotic, and he has performed more than 2500 Robotic procedures.   The surgeon who I indicated regularly does both procedures has also performed several thousand operations but his practice now splits between 70 % open operations to 30% Robotic procedures.  I believe that both surgeons are eminently qualified. My dilemma is whether I opt for the operational benefits of Robotic ( in which case I'd go with the guy who is passionate about Robotic ) , or choose the other surgeon who recommends open based on my particular prostate characteristics & the benefits of tactile sense during the operation.    

MrGimpy
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Date Joined Jul 2009
Total Posts : 504
   Posted 10/17/2010 5:46 PM (GMT -6)   
Hi Pembroke,

A lot of your info that will help you make your decision is what they found in your Biopsy and other tests

Also your

1) general health plays a big part

2) how soon would you like to return to work/normal activities

3) Your age

What was right for me is different that what may be best for you

Trevor T.
New Member


Date Joined Aug 2010
Total Posts : 9
   Posted 10/17/2010 6:20 PM (GMT -6)   
If you’ve come this far, you already know that your results are dependent on the skill level of the surgeon and not the type of surgical procedure you select. You’ve also read that the main benefits of robotic surgery are the faster recovery times, less blood loss, less pain, shorter hospital stays, and possibly fewer days with a urinary catheter. For all of these reasons I chose to have robotic surgery. There’s an added, more abstract, benefit as well. While the two procedures yield similar results in the hands of a skilled surgeon, robotic surgery yields consistent results over and over.

For me, the decision was easy. My Gleason score was 3+3=6 in 3 of 12 cores with less than 5% cancer in each core. (I was ultimately upgraded to 3+4=7 with negative margins post surgery). There was little that I could gain by a surgeon using his “tactile sensation.” I had no hard spots or lumps or bumps. And robotic surgery provides amazing visual acuity that far surpasses that available with open surgery.

In your case, it appears that you also will have very little to gain from the surgeon’s tactile sensation. Your tumors were discovered only because of a needle biopsy so, theoretically, you have no lumps or hard spots to feel. I’m not familiar with how accurate MRI scans are in locating a tumor inside of the prostate. However, this is a slow growing cancer, yours is a bit more aggressive than mine, but chances are good that it has not grown outside your prostate. Your doctor can give you the best advice about that.

I’m troubled when I see Walsh quoted as a reason for proceeding with open surgery. I read his book and I learned a lot from it. But, he only performs open surgery and so he’s biased toward that procedure. For him, it’s as if one size fits all. And, that’s just not the case. Every patient is different. If you’re having trouble deciding you might want to try a third, independent expert. Your individual biopsy results should dictate your decision and not what anyone here writes.

In my own case, I’m very happy with my decision - so far. But, time will tell as I’m only two days after catheter removal. I can say that I was out of the hospital in 24 hours and that I’ve had literally no pain. As for side effects, I had full control immediately after the catheter was removed - I think. Since I’ve been told over and over that I’ll need pads for at least a month or two, I’ve been wearing one. But, today I did not and I’ve had no issues with incontinence.

It’s unfortunate that we have to make these decisions, but it’s also wonderful to have so many good options. Good luck in whatever you decide.

julios
Regular Member


Date Joined Jun 2010
Total Posts : 38
   Posted 10/18/2010 12:46 PM (GMT -6)   
I was in your shoes 3 months ago, and did a lot of Internet research. The most recent studies I found concluded that neither had a significant advantage over the other in terms of cancer reacurance, but robotic, when performed by a very skilled surgeon, had better results for minimizing erectile and urinary disfunction. With robotic every thing they see is magnified 10 times.

I agree you should schedule surgery now, but give yourself 6 weeks to prepare (kegals). Schedule both if you haven't decided. FYI, my cancer is way more aggressive than yours and three differant urologists told me 6 to 8 weeks would be fine.

Also, there was recent research showing benefit in getting a trans rectal coil MRI prior to surgery to help plan what would and would not be removed. So I had that done at UCLA, which is where the study was done. Then discuss the results with both your uro and radiation oncologist, and get them to agree on what will be removed.

If you go robotic, get a doc that has done several thousand. Mine had done more than 10,000.

Best wishes
Age 52

At Diagnosis of PCa, had Gleason 9 and normal PSA

Radical Prostatectomy on July 7th, 2010 by Dr. Fagin using daVinci

25% to 50% nerves spared on left, 100% spared on right.

Continent from day one.

Pathology showed postive margins and extension beyond gland, including seminal vesicals and lymph nodes. Stage upgraded to T3b.

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 10/18/2010 1:40 PM (GMT -6)   
If you go robotic, get a doc that has done several thousand. Mine had done more than 10,000.
 
Wow, 10,000? That's four a day, week in and week out, for 10 years. How long have they been doing robotic surgery? Not that I'm a sceptic or anything, but you've gotta wonder if some of these guys pad their numbers just a tad. For all I know, maybe my guy does it too.
 
On the other hand, I think the experience curve flattens out after several hundred. By the time a surgeon has done 1,000 he's probably as good as he'll ever get. Quantifiable experience and excellence is a good thing, but I think it's possible to get carried away with the numbers.
 
All that said, I think a great surgeon is a great surgeon, and whether he does it open or robotically is of little consequence. I'm persuaded that the whole tactile thing can make a difference for some patients, just as there's something to be said about the easier recovery that laparoscopic surgery can provide. But in my view, nothing trumps experience and excellence.


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7197
   Posted 10/18/2010 2:01 PM (GMT -6)   
I did a lot of research before making my decision. I had decided that the skill/experience of the surgeon was of tantamount importance.
 
I found a robotic surgeon, Dr. Menon, with impeccable credentials and went that way. Had he been an open surgery expert with the same stats/reputation, I still would have gone with him.
 
Of course all things being equal the quicker recovery is a plus.
 
Mel

clocknut
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Date Joined Sep 2010
Total Posts : 2649
   Posted 10/18/2010 3:01 PM (GMT -6)   

I haven't been participating in this forum all that long, but I've read over and over again that one should find a surgeon who has performed thousands of DaVinci procedures.  I've been trying to convince myself that is a plus, and maybe it is, but my particular surgeon has done just under 50 surgeries with excellent results.  I couldn't be more pleased if I had traveled a thousand miles to Johns Hopkins.  He has also done many, many open surgeries over the years as well.  Friends of ours who know the ins and outs of the operating theaters here in the northern suburbs of Chicago all agreed that our doctor is an excellent surgeon, both for open surgery and for the DaVinci procedure.  I trusted the opinion of the doctors, nurses, and operating room technicians with whom I spoke, and I am completely satisfied with the results.  Plus, I had the advantage of surgery just 20 miles from home, no hotel stays far from home, no airplane trips, no long automobile rides. 

I would rather be the surgeon's only DaVinci procedure on a given day than number three or four.  I valued a surgeon who spent as much time with us as we needed on the day the diagnosis came back and during the pre-surgery visit; who returns phone calls personally; who knows me when I come back for post-operative visits; whose general bedside manner inspires confidence; and who has a sense of humor as well.

The number of procedures performed is certainly worthy of consideration, and I don't think I would want to be a surgeon's maiden attempt, but the doctors with whom I spoke generally said that if the guy has done 40 or more, he certainly must be doing things right. 

 


Age 65
Dx in June 2010.
PSA gradually rising for 3 years to 6.2
Biopsy confirmed cancer in 6 of 12 cores, all on left side
Gleason 7 (3 + 4)
Bone scan, CT scan, rib x-rays all negative.
DaVinci surgery late August at Advocate Condell, Libertyville IL
Negative margins; negative seminal vesicles
Smooth recovery; 18 holes of golf at 4 weeks.
Continence OK after 7 weeks. ED continues

Jazzman1
Veteran Member


Date Joined Sep 2010
Total Posts : 1160
   Posted 10/18/2010 3:54 PM (GMT -6)   
Wow, clocknut, you found a surgeon with a sense of humor???
 
You might want to check his credentials, I'm pretty sure they remove that in med school. turn

clocknut
Veteran Member


Date Joined Sep 2010
Total Posts : 2649
   Posted 10/18/2010 3:59 PM (GMT -6)   
Jazzman---He laughed when I told him I had just played 18 holes of golf at five weeks and thanked him for removing my slice along with the prostate. I guess that qualifies as a sense of humor.
Age 65
Dx in June 2010.
PSA gradually rising for 3 years to 6.2
Biopsy confirmed cancer in 6 of 12 cores, all on left side
Gleason 7 (3 + 4)
Bone scan, CT scan, rib x-rays all negative.
DaVinci surgery late August at Advocate Condell, Libertyville IL
Negative margins; negative seminal vesicles
Smooth recovery; 18 holes of golf at 4 weeks.
Continence OK after 7 weeks. ED continues

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 10/18/2010 4:11 PM (GMT -6)   
I don't think there is any convincing data that robotic surgery has advantages in the risk of urinary incontinence or ED, or the length of time that a catheter is needed. There is a study that open surgery has better outcomes than robotic in terms of the risk of urinary incontinence or ED, but it's not convincing. The surgeon is the uncontrolled variable in these studies. It is also unclear whether one method has better cancer outcome. There is a bit of advertising hype surrounding the robotic surgery in the US.

The hospital stay is, on average, shorter with robotic. Because the abdomen is inflated with air, there is less bleeding. It's unclear if recovery time (weeks to full normal activity) is quicker with robotic. Maybe.

Chose the surgeon, not the tools. Your goal should be the best long term outcome.

Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 10/18/2010 8:04 PM (GMT -6)   
If you have a good primary care physician and he concurs with the selection of your Urologist who's making a recommendation, then I'd opt to go with the judgment of the medical professionals who know me best.  I don't see this as an analysis of the procedures, but, rather, an analysis of in which professionals you have the most confidence of receiving the most accurate diagnosis and treatment recommendation.  If you don't take the advice of the primary team, fire them and get yourself someone new, different to advise you as the years moe forward.  My own situation was that my primary care physician thought my PSA test result was suspicious and he suggested I see a Urologist he had strong confidence in.  I had a biopsy which disclosed cancerous cells and the Urologist/Surgeon recommended removal of the prostate via the da Vinci procedure.  I accepted the advice, which my primary care physician thought was good, and I didn't second guess the Urologist, didn't have scans or further tests or a visit to one or more other Urologists.  It's been two years since my procedure and I think I made the best decision.  The slight side effects are worth the bother as compared to haveing the cancer in my body.  Best wishes for a successful outcome.
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