Open RP vs MIRP

This is from the National Cancer Institude:

The study was not a randomized clinical trial. Rather, the researchers used billing and diagnostic data from NCI's SEER-Medicare database, identifying 1,938 men who underwent MIRP and 6,899 men who underwent open surgery. After accounting for differences in physician and patient characteristics in men receiving MIRP versus open procedures, the researchers found that men who underwent MIRP had shorter hospital stays (2 days versus 3 days), far fewer blood transfusions, and a lower risk of respiratory and other surgical complications. But they also had more than twice the risk of genitourinary complications, a 30 percent increased risk of incontinence, and a 40 percent increased risk of erectile dysfunction 18 months after the procedure.

I thought the MIRP was supposed to give you a better chance of not being incontinent or have ED.

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Age: 55- good health. Exercise now and then.
DRE 02/2011- no lumps, just enlarged prostate
PSA checked regularly last 8 years, ranged from 0.7 to 1.2
Needle Biopsy 02/2011- 12 samples. 10 OK.
GS 3+3=6 2 cores involving 5%
Stage T2a
DaVinci R.P. scheduled ???

If this study is accurate, it would go along with some rumors and unsubstantiated reports that higher rates of incontinence and ED were starting to be noticed in robotic prostate surgery, as opposed to open surgery. I am sure this report is not the last word though, as in all things PC.

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Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

"The study was not a randomized clinical trial. Rather, the researchers used billing and diagnostic data from NCI's SEER-Medicare database, identifying 1,938 men who underwent MIRP and 6,899 men who underwent open surgery."

Read that sentence carefully..Robotic surgeries outnumber open by about 8 to one today..But the study looks at 4 times as many "open" cases as robotic..What time period was studied? Ten years ago? 15?...

I find it difficult to believe accurate information can be obtained by sifting through Medicare billing information..Men with no post-surgery problems generate no bills to study...

Were the results obtained at VA hospitals included in the study? That would explain the 4 to 1 open to robotic ratio..

The most useful information in these studies is who paid for them....Saddly, this information is seldom provided.

I can only go by my own case and I can assure you NOBODY cares about or is studying my post surgery, post radiation genitourinary condition...Perhaps those being treated in university affiliated hospitals are kept better track of, their progress followed more closely..

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Age 68.
PSA age 55: 3.5, DRE normal.
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 3rd 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. 2-15-'11 PSA 0.0

There have been many studies that indicate little differences between the two types of surgery. The main advantage in robotic according to Dr Walsh is the decreased blood loss. The skill of the surgeon will have more impact on potency and continence than the type of surgery.
The most gifted surgeons achieve a 65% rate of effectiveness, meaning cure, potency and continence, "the trifecta".
With 2 samples less than 5% and a psa that is fully explained by your enlarged prostate, this condition is shared with about 1/2 the men of your age and most don't even know it.
What was the reason your doctor suggested a biopsy?
JohnT

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65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

John T.

The reason my doctor suggested a biopsy, is because my younger brother was diagnosed with PC, about 1 year ago, at age 50, with a GS of 8, and being Stage 4.

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Age: 55- good health. Exercise now and then.
DRE 02/2011- no lumps, just enlarged prostate
PSA checked regularly last 8 years, ranged from 0.7 to 1.2
Needle Biopsy 02/2011- 12 samples. 10 OK.
GS 3+3=6 2 cores involving 5%
Stage T2a
DaVinci R.P. scheduled ???

Here is one article:

jco.ascopubs.org/content/26/14/2278.long

I don't think this one actually reports risks of incontinence or ED; it does discuss surgical complications.

Oh, this must be the followup article, which does:

jama.ama-assn.org/content/302/14/1557

This is a population based study, that is, it looks at a randomly chose portion of a whole population getting treated, in this case, Medicare patients from 2003 to 2007. It is affected by the fact that the treatments are not randomly chosen, and it includes all procedures regardless of the skill and experience of the surgeon. It doesn't show what happens under the best possible circumstances, but it is a snapshot of what is happening out in the real world. It is funded by a Dept of Defense training grant, so that should not be a source of bias. It's published in a major medical journal.

This seems like a good study that raises concerns that in everyday practice, around the US, robotic surgery during the years 2003-07 led to a higher percentage of ED and incontinence complications.

Post Edited (Postop) : 2/28/2011 11:28:32 AM (GMT-7)

I think it all depends on the skill of the surgeon.

Some like to feel their way around even with limited visibility. Others prefer the unobstructed and magnified view and assistance of a robot.

Hundreds of surgeons were learning to use the robot, many still are. I would suspect that their success rates are lower.

Technology and surgeon skills are advancing so fast that these studies cannot keep up and are often times flawed.

The hope would be that there were a bunch of surgeons just starting out to use robotic surgery from 2003-2007, and that they weren't very good at it back then, and now have gotten better at it. Still, not an impressive performance by Leonardo (da Vinci).

they say the learning curve is 150-200 surgeries. I've been told this by a surgeon who has done 400.

I wouldn't want to be in that first 100 or so personally.

A few months ago I would have gone in as #100, today, with what I know, I'd go to an accomplished open surgeon rather than be #100. Luckily I did find a high volume one that eased that concern for me while allowing me to choose the procedure I thought best for me.

Just to be upfront with biases, I had open and did well. The purpose of studies is too look objectively at the evidence, and not chose a treatment based on the fact that you talked to one person who did well with a particular treatment. This study was based on almost 9,000 men--that's a lot of prostates.

This study tells you that if you picked a surgeon randomly between 2003-7, you'd be out of the hospital quicker and less likely to have a transfusion with the robot, but would be more likely to have ED or incontinence. Of course, it's 2011. You wouldn't pick a surgeon randomly, but nonetheless, a lot of us pick a surgeon because they are close to where we live, they are covered by our insurance, or we like their personality. Those things don't necessarily predict surgical skills, it's kind of like picking one randomly.

It's likely that someone is going to update this study. At some point, there needs to be evidence of an improvement in long term results with the robot, so that it at least matches the outcomes seen with open surgery. I think most of us would trade a day in the hospital and a little extra discomfort for a good long term result.

I'm not sure how they can tell with any accuracy from Medicare billing records whether a patient was incontinent or suffered ED after a particular type of surgery..For instance, did they check to see if the person was being treated for ED before the surgery? How do these researchers gain access to thousands of detailed medical records? I thought that information was private...I was unaware doctors submitted detailed medical histories along with their payment requests to Medicare and that these records were available to anyone who fills out the right forms needed for a "research study".

Here is one surgeon who publishes figures that differ significantly from the ones in this study..

"Cancer Control
Nearly 95% of all organ-confined ART™ patients receive a negative surgical margin (no cancer is found on the specimen surface) on their surgical pathology report. In published long term follow-up studies performed by Dr. Tewari, this cancer control can translate to an over 90% 10-year survival rate in select patients.
ART™ Surgery
ART™ prostate surgery is minimally invasive. The instruments used are inserted through very small openings [more about ART™], transfusions are rare, pain medication is required sparingly, if at all, and the typical hospital stay is just 24 hours. The patient is discharged with instructions to get plenty of walking exercise and typically returns to our office seven days after discharge from the hospital to have his urinary catheter removed– in a five-minute outpatient procedure. Catheter removal may also be performed by the patient's regular urologist, should the patient be unable to return to Dr. Tewari's office.
Recovering After Surgery
The ART™ robotic surgical method is remarkable for its success in minimizing the effects treatment may have on bowel, urinary, and sexual functioning.

* Bowel symptoms, which can be a troublesome side effect of radiation treatment, are experienced by less than 2% of ART™ patients.
* Fully 87% of patients who experienced normal sexual functioning before surgery, and are candidates for nerve sparing, returned to function after ART™ surgical treatment.
* Recovery of urinary continence, which may be problematic any prostatectomy, is also improved with robotic surgery. Dr. Tewari's pioneering technique of bladder support reconstruction, a standard component of the ART™ procedure, is achieving continence in 80% of his patients at 1 month after surgery, and in 97% of his patients at 6 months after surgery!

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Age 68.
PSA age 55: 3.5, DRE normal.
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 3rd 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. 2-15-'11 PSA 0.0

It looks like that incontinence and ED were determined from Medicare claims. That is, when Medicare is billed, the doctor has to check off the patient's diagnoses on a billing form. You are right that this isn't as accurate as asking patients directly, although the differences in incontinence and ED between the two groups were pretty large. That's a limitation of the study. You are also right that individual surgeons might have very different results than this large group of patients that had many different doctors doing the operation. However, the stuff that you post about Dr. Tewari kind of looks like an advertisement.

Gee, Postop, you are right, that sounded just like a Commercial Telelvision Ad, must be a really amazing doctor with those kinds of results (if remotely true)

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Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Minimally invasive includes conventional laparoscopic which is like using chopsticks and tweezers. MUCH more difficult than with the robot. And yes the time period includes the early part of the learning and training curve for all surgeons. Also adjustments to the machine and technology as well. Like all studies of this broad kind, the difference in the time period adds as much to the results as does the focus of the study.
What is truly valuable is the results of any single surgeon, and of course I mean, by that, MY surgeon.