Open vs. Robotic

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   Posted 1/26/2011 8:50 AM (GMT -6)   
From the Johns Hopkins Health alerts this morning:

When it comes to prostate cancer surgery, are best results achieved with open surgery or with minimally-invasive procedures? Alan W. Partin, M.D., Ph.D., a world-renowned expert in the study and treatment of prostate cancer, addresses this important question in an excerpt from our Special Report, Choosing the Right Treatment for Prostate Cancer. 

There are three ways to remove the prostate: One is the traditional operation through an open incision, while the others involve a laparoscope or robot. Here is the bottom line: It's the same operation done three different ways. To date, there has been no single randomized study to fully evaluate the key issues. 

Our Hopkins experts have looked at all of the critical variables regarding the different surgical approaches, including blood loss, need for transfusion, pain, erectile dysfunction (ED), cancer cure, side effects related to the surgery, and return to work. We found no differences. 

How can you counsel a man to look at all of the options for prostate cancer therapy when robotic surgery is so heavily marketed as the best choice? 

It's not hard. I sit down with the patient and explain the marketing and advertising behind robotic prostate procedures and how they often help sway patient decisions. I also explain the fact that right here at Hopkins, where we are on the front lines in prostate cancer treatment, there does not appear to be any difference between the open and robotic procedures. 

Speaking for the Hopkins surgeons who perform both open and robotic prostatectomies, we don't care which procedure a patient ultimately picks. For us, it's a matter of going to Room 6 or Room 18 to do the prostate surgery. One operation takes a little over an hour to perform the other a little over two and a half hours. The end results are similar. 

Some surgeons advertise the fact that they can do a robotic assisted prostatectomy in 90 minutes. Is that possible? 

If a surgeon says the procedure takes 90 minutes, then it comes down to the definition of "surgery." These surgeons are only counting the time that they are sitting at the robotic console and operating on the patient. However, at Hopkins we start the clock when the patient is first wheeled into surgery and stop it when he arrives in the recovery room. This takes into account all the extra set-up time necessary to prepare the patient for surgery, and not just the time the doctor spends actually removing the prostate. 

How can a man choose between a surgeon who performs the open procedure and one who uses a robot or laparoscope? 

Here is what I tell all prospective patients: You don't want to bring a plumber into your home to do electrical work. If your surgeon says he feels confident that he is going to provide the best operation for you with a certain technique -- open, laparoscopic, or robotic -- and you like that surgeon, you should choose him for your surgery. 

Tudpock (Jim)

Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:

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   Posted 1/26/2011 9:10 AM (GMT -6)   
I liked this quote within that piece:

"Speaking for the Hopkins surgeons who perform both open and robotic prostatectomies, we don't care which procedure a patient ultimately picks. For us, it's a matter of going to Room 6 or Room 18 to do the prostate surgery. One operation takes a little over an hour to perform the other a little over two and a half hours. The end results are similar."

Good they didn't say the 'same' for end results, we have studies done and posted here before to look at and make judgements on. I can see why they don't care which method you is a win-win situation.
This quotable is also interesting and not without debates:

"Our Hopkins experts have looked at all of the critical variables regarding the different surgical approaches, including blood loss, need for transfusion, pain, erectile dysfunction (ED), cancer cure, side effects related to the surgery, and return to work. We found no differences. "

This has been hotly debated and referenced herein on the forum. I am not the knowledgable surgery guy and have not traveled that route. But, learned to pickup on statements made to us and question everything, well you can see why we do so. So, is Hopkins the last word on PCa or do you analyze statements and question everything and always???
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

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   Posted 1/26/2011 9:29 AM (GMT -6)   
What patients do not realize is that they can go in getting robotic but the surgeon can switch mid-operation and perform an open.

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Date Joined May 2010
Total Posts : 264
   Posted 1/26/2011 10:30 AM (GMT -6)   
The main debate seems to always focus on which type of surgery.

For me, a bigger issue than open vs robotic is how to pick a great surgeon vs a so-so surgeon. Too bad there isn't a more clear cut way of finding this out.

Here are some of my stats:
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA tested on 7/15/10: Zero Club membership card issued (trial membership with 90 day renewal)

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Date Joined Jul 2009
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   Posted 1/26/2011 10:39 AM (GMT -6)   

Picking a highly respected hospital is a step in the right direction. The best hospitals will not risk their reputation on hiring less than A+ surgeons

Of course there is always the risk that the A+ surgeon is having an off or so-so day but that is human nature. Its not a computer controlled assemble line procedure, there are very many variables

When picking a surgeon the support staff is also important, which goes back to the hospital. A great surgery can be botched but a nurse missing a change of a soiled bandage which develops into a staph infection

Regular Member

Date Joined Nov 2009
Total Posts : 98
   Posted 1/26/2011 1:11 PM (GMT -6)   
I've seen so many people make decisions based off the perception that robotic was less painful or required less recovery time, etc. I agree with others that the factor should be the skill of the surgeon. In my case, I selected an open procedure by a Doctor who had performed well over 1,000 procedures with great success.
Aug 09 PSA 8.7, DX 3 Nov 09 , Age 52, Biopsy-4/12 cores (2-20%), Gleason 3+3=6, T2b, Prostate 35gms, CT/Bone Scan Negative
Elected Dual Nerve Sparing open Prostatectomy performed February 3, 2010 at St. Mary's Hospital in Richmond, VA
12 Feb Post Op Path Report: Prostate 39gms, Gleason 3+3(6) but stage upgraded to T2c, negative margins and negative extension or invasion
15 Days Post Op - Minor Incontinence (standing up, coughing, sneezing), fully functional - no ED
1yr Post Op PSA - <0.1, no leaking, no issues with ED
Winston the Wonder Dog (11yr old Golden) diagnosed with cancer Oct 09, surgery on the 26th and now home fully recovered.

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   Posted 1/27/2011 12:09 AM (GMT -6)   
I thought cost might be an issue so I asked my surgeon about it..he said most prostate surgeries were done under Medicare and they paid a flat rate for the procedure no matter how it was performed..So a higher profit margin can't be the motivation for pushing robotic surgery..

Partin and Walsh are the old guard cornerstones of Hopkins prostate cancer research and treatment. They are both open surgery guys...Walsh invented the nerve sparing technique and is regarded as one of the best surgeons in the business. Partin developed the Partin Tables, Both are nearing retirement...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT NOW

Regular Member

Date Joined Jan 2011
Total Posts : 78
   Posted 1/27/2011 3:45 AM (GMT -6)   
The analogy given by my surgeon was:
"If you are going to have work done on your house, are you going to pick a contractor based on whether he uses Dewalt or Kraftsman? No.  You are going to pick someone based on their resume and references."
He went on to explain that while he has done the robotic, he has completed 3400 open procedures and is more comfortable with the open procedure. 
I can't speak for my results yet.  I do believe, however, that in the long run, if I get the results that I want, the slight difference in recovery between the two methods will be a nonfactor.
PSA 3.9 - October 2010 at annual physical
PSA 4.1 - November 2010 after a month of antibiotic, DRE Normal
Age 41 in December 2010 at Dx of 6 of 12 cores positive T1C and Gleason 3 + 3

Scheduled for open RP on 2/14/11 at Mass General

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   Posted 1/28/2011 12:28 PM (GMT -6)   
On the Datolli website he quotes a 2008 Duke Univ study that indicates an increased early failure rate (first three months to three years) for robotic surgery when compared to open surgery.

My urologist and his practice only do open. They say the ability to feel tissues is extremely important and they don't think that robo has proven to be better. If I wanted robo, he had referrals.

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Date Joined Jul 2009
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   Posted 1/28/2011 1:22 PM (GMT -6)   

I would be curious to know if your URO has access to the Robotic device ? It is quite costly and only a relative few are able to afford its cost

But then that poses another question. If a hospital is going to pay millions of $$ for a machine they better well use it as much as possible.

If Medicare is paying the same regardless if its open vs robotic and a facility can do more surgeries in a day robotic vs open, and surgeons are required to generate more revenue for the hospital,,,,,

Someone posted that medicare pays the same,, does that also mean the hospital stay is paid the same. I stayed one overnight and was discharged with robotic. open would require a few days if I am not mistaken, would that mean the hospital gets no more for those extra days ?

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   Posted 1/28/2011 2:05 PM (GMT -6)   

My urologist is young, mid 40s, and currently is not going through the learning and experience curve to do the robo because he isn't convinced he can be better with the robo. Like most, he is very busy and in addition to his surgeries he performs 4-6 HDR procedures each week. A couple of his partners are more senior and, like Walsh, are closer to retirement, so they are sticking with open.

They have access to and can use the robos, but they choose not to at the present time. Further, my urologist is like Walsh in that he won't operate on any but the very early cases. If he thinks the case may result in positive margins or unspared nerves, then he takes the patient the HDR brachytherapy route as he believes it to be better and less traumatic for the intermediate and advanced patient.

As to the cost. It may be that the surgeon's charge is the same either way, but the hospital is going to be different. With open and a longer stay there will be more in the way of room and services charges. While these should be less with robo, the hospital will charge dearly for the rent on the machine.

Regular Member

Date Joined Jun 2010
Total Posts : 416
   Posted 1/28/2011 2:56 PM (GMT -6)   
Partin and Walsh nearing retirment, there's a good reason they would not advocate for Robotic. Just as my grandfather wouldn't know how to start a Nintendo game, yet my son doesn't know how to turn it off.

IF AND ON IF everything is otherwise equal, less blood loss, less pain, less time in hospital, less total recovery time, sounds to me like the robot makes sense.

Not to mention the difference between 3 small incisions and a 6 inch stab wound.

Tony Crispino
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Date Joined Dec 2006
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   Posted 1/28/2011 3:15 PM (GMT -6)   
Robotic surgery offers some unique advantages. 360 degree field of vision allows for a more precise surgery. Some say that this is the reason for higher incidence of positive margins, but the best doctors do not all agree on that. I have heard the argument before about how the doctor feels the cancer and that is important. But not all tumors are palpable, in fact many are not. A robotic or laparoscopic surgery would tend to state that the visual advantage supersedes the ability to feel a tumor. Robotic surgeons can still feel the tissue they remove and if necessary they can "scrape" more tissue if after they remove the prostate and feel a palpable tumor. My surgeon's repost stated that he did not feel a palpable tumor but rather he could visually see where a positive margin was likely. He stated that he removed suspect tissue as far as he could without risking damage to my rectum. In fact when he gave me my pathology results (margins near the rectum were positive) he stated if prostate cancer is still present it would be more challenging to radiate because the area was scraped to the rectal tissue. We have since done radiation as an adjuvant to the surgery. To date all is well including the disease control.

I think it has been well stated in this thread ~ it is not the paint ~ it's the painter that matters.

Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog :

Worried Guy
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Date Joined Jul 2009
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   Posted 1/28/2011 3:26 PM (GMT -6)   
I had Robotic. When I awoke there were 4, 0.5 inch incisions in my abdomen and a .75 inch near my navel, covered with regular band-aids.

The sling surgery I just had, left me with 2, 3 inch incisions in the creases where my legs touch the scrotum and a 5 inch incision across my perineum and down the back of my scrotum. (Thus ending my career as a shaved, p*rn star stud-muffin.) They are rather "uncomfortable".

If all things are equal, why would anyone select larger incisions unless that is the surgeon's specialty?

Jeff (looking for work in another field.)

Regular Member

Date Joined Dec 2009
Total Posts : 154
   Posted 1/28/2011 3:41 PM (GMT -6)   
My regular doc gave me the best advise ever when he said"I`m sending you to see the surgeon that other surgeons go to". Cant argue with that and so far good results.
Dx at 50 in 12/09 Merry Christmas its cancer....
3 of 12 positive, right side only, psa at dx 2.6 free%14
gleason 3+3=6
routine physical, no symptoms
Da Vinci performed Feb 2k10 by Dr Marc Milsten [hes got mad skills]
99% continent from cath out, mr happy fully functional at 2 weeks out!
path showed same gleeson with no other blips other than one slight margin, organ confined 20% right, 5%left, 34grams
Hernia repair Mar 2k10, hernia was side effect of the surgery
30 day psa 0.03- 90 day psa 0.01

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Date Joined Sep 2010
Total Posts : 225
   Posted 1/29/2011 2:06 AM (GMT -6)   
The debate will go on but we patients were voting with the method we selected. If robotic outcome were inferior, it would not have the wide acceptance it is enjoying today.

Every year, more and more prostate surgeries are being done by robotic assist. I do not believe it is purely because of marketing by hospitals or equipment manufacturers. When we chose which options to pick, we asked patients, doctors, surgeons and they recommended what they thought was the better approach. More and more patients are having positive outcome from robotic surgeries. Like, if anyone were to ask my opinion, I would recommend robotic because of my personal experience.

open surgery probably reaches its limit in terms of skills, tools, etc. For robotic, there is still rooms for improvement. Technology marches on, the robotic surgeons' techniques are getting better and the equipments are getting better - 3D vision, higher magnification, more precise motions, etc. It is the same in other fields too, like flying an airplane. Pilots fly better with the help of autopilots, GPS, fly-by-wire, etc.
65 Dx June-2010 PSA: 10.7, biopsy: Adenocarcinoma, 1 core Gleason 6, 3 cores atypia; Clinical stage T2; CT, Bone Scan, MRI all negative

8-23-10 Robotic RP; Pathology: Negative margins; Lymph nodes, Seminal Vesicle clear; PNI present; multiple Adenocarcinoma sites Gleason 3+3 with tertiary Gleason grade 4. Stage: pT2,N0,Mx,R0

Catheter out 8-30-10 no incontinence, no ED. Jan PSA: <.1
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