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Posted 1/26/2012 7:52 AM (GMT -6)
www.foxnews.com/health/2012/01/26/mens-hopes-for-robot-prostate-surgery-unrealistic/

My uro doc is in total agreement with this article. In fact, he strongly believes that the robotic surgery is a handicap to achieving clear margins. He stated emphatically to me that the ability to "feel" as he is removing tissue offers his patients an advantage.

He also believes that his patients, especially younger patients(under 60), recover faster with open surgery.

As for me, i obviously had open surgery, recovered quickly, and am 99.9% continent. However lost both nerves due to extensive pni, and the G9.

Interesting article though.

K
Posted 1/26/2012 8:19 AM (GMT -6)
If I wasn't a G6 with a psa of 4.7 and was a 4+3 instead, I would have gone with open for the same reasons you just listed. My doctor listed a statistic that in the years before 2005, post surgery radiation treatments due to positive margins was running 2% nation wide. Since the intro of the Davinci in 2005, the issues of positive margins have increased to 6%. Some of this is due to the learning curve of the robot. After all, everyone of us starts using our hands as soon as we are born so using our hands is naturally very intuitive. Operating with zero tactile feedback though a 3D imaging veiwer using joy sticks instead ones hands has to be learned and have one hell of a learning curve at that. If it takes 100 open surgeries to become proficient with the open, it probably takes three to five hundred davinci surgeries to become as proficient. A good tool in the hands of an unskilled surgeon means a foolish job IMHO. The only real advantage with the davinci is recovery time and do you want to make a decision based upon maybe getting back to work two weeks earlier when the real issue is you own life's longivity.

I'm sure this has been debated to death on this forum and will continue to be debated and the above statement is simply my opinion as a cancer patient and I am no way a medical professional on even a low level. If I was a 3+4 I probably would have decided with a coin toss.
Posted 1/26/2012 8:53 AM (GMT -6)
If there has been a rise in positive margins with the advent of the robot, I wonder if it might have something to do with overconfident surgeons taking too great an advantage of the precise movements of the robotic instruments. Maybe instead of "peeling grapes" when doing these operations and making fine cuts and preserving nerve bundles, they should be cutting a bit wider for safety.

I can imagine a situation where a surgeon using the DaVinci machine says to himself, "I'm good, and this machine is so great....I can save that nerve bundle...look at these precision cuts I can make," when in reality he should be cutting a bit wider swath to better ensure a clear margin.

I don't know if this makes sense or not, since I've never been in the O.R. while awake.

In my own case, I remember asking my Davinci surgeon if the nation's best DaVinci guys might have saved my left nerve bundle, to which he replied, "Yes, if they didn't care if you had a recurrence." In spite of my continuing ED problems, I'm thankful that he chose to do the sensible thing and cut wider.
Posted 1/26/2012 9:06 AM (GMT -6)
For a long time I was angry that my Dr convinced me to have open surgery. Not sure if I was angry at him or at myself. After 3.5 years and reading how others have faired with the robot. I think it is just about a toss up. I am as kabota said 99% continent and getting better in the ED world. Not as good as some of my DeVinci buddies but better than many.

I guess I have resolved my grief of the situation and happy to be in the Zero Club.

Live is good in my world for today.

Cajun Jeff
Posted 1/26/2012 9:46 AM (GMT -6)

clocknut said...
If there has been a rise in positive margins with the advent of the robot, I wonder if it might have something to do with overconfident surgeons taking too great an advantage of the precise movements of the robotic instruments. Maybe instead of "peeling grapes" when doing these operations and making fine cuts and preserving nerve bundles, they should be cutting a bit wider for safety.

I can imagine a situation where a surgeon using the DaVinci machine says to himself, "I'm good, and this machine is so great....I can save that nerve bundle...look at these precision cuts I can make," when in reality he should be cutting a bit wider swath to better ensure a clear margin.

I don't know if this makes sense or not, since I've never been in the O.R. while awake.

In my own case, I remember asking my Davinci surgeon if the nation's best DaVinci guys might have saved my left nerve bundle, to which he replied, "Yes, if they didn't care if you had a recurrence." In spite of my continuing ED problems, I'm thankful that he chose to do the sensible thing and cut wider.


My surgeon informed me up front that he would be cutting wider because of the nature of my cancer. He warned that nerve sparing would not be a high priority, but would rather try to get all the cancer.
Posted 1/26/2012 12:12 PM (GMT -6)
I had robotic on January 3rd.  It was performed by a skilled surgeon having performed over 1200 surgeries.  I'm now 3 weeks post-op and doing well.  I had clear margins on my one week follow-up and was 99.9% continent from day 1 of catheter removal.  Still no signs of life with ED but I'm told that it could take up to a year (fingers crossed).

I have not regrets and would do the robotic again.  As I discovered during my research stage, what ever procedure you decide to do, make sure that the surgeon is highly skilled with tons of experience.

IMHO.

Peter

Posted 1/26/2012 2:38 PM (GMT -6)
I read a recent study about high-risk cases, including Gleason 9 of course, which stated that better outcomes were had with more extensive removal of lymph nodes. It said that open surgery is better because the lymph nodes can be more easily removed.

Too bad my biopsy said I was Gleason 7, so I wasn't pushed to consider this option.

Nellie
Posted 1/26/2012 3:33 PM (GMT -6)
My surgeon told me he was a big time skeptic of the robotic procedure. He got so fed up with all the hype that he decided to learn the robot with the intention of de-bunking all the propaganda. However, after learning the procedure and becoming proficient; much to his surprise, he came to the conclusion that the robotic procedure is better (in his opinion). He believes the better vision realized using the robot trumps the tactile advantage that the open procedure has. At the time of my consultation (almost a year ago) he had performed over 2,500 open and over 1,200 robotic procedures.

The bottom line is this: no matter which procedure you choose; it is of utmost importance that your surgeon be experienced in that procedure. His experience will have the most impact on your outcome, more so than the type of procedure.
Posted 1/26/2012 3:41 PM (GMT -6)
My uro doc is in total agreement with this article.

does your doctor do robotic surgery?  my doctor would also agree but he does not do robotic surgery.  his partner does, though, and also has a very good reputation.

ed

Posted 1/26/2012 4:23 PM (GMT -6)
just curious, what is the cost difference between the two proceedures?               
Posted 1/26/2012 4:27 PM (GMT -6)
Hi there K

I should start by saying that I'm a native of Pollock, growing up right on Hwy 8 just west of Pollock.

We have been in central Il., for the past 28 years but my 2 brothers still live on the family property

and we hope to retire (partly) there in the near future. Hope we get to meet you at the Baton Rouge

event.

I don't really know how to answer your questions. We had RP in Aug. at one of the best hospitals ,

Henry Ford in Detroit and the result was that my psa was  higher after surgery. Had our first visit with

an oncologist this past Tuesday and he thinks I need RT now. Going to an actual prostate medical Onc.

up in Chicago next Tuesday. I am presently on Lupron and psa has been going down. The problem as you might guess is that if you have 3 doctors, each will have a different opinion. All the best to you.

Jim

Posted 1/26/2012 4:48 PM (GMT -6)
kobota,

my uro's practice does both. he only does open, his partner only does robotic. in 2008, only 15 prostate surgeries by robot had done in my area, so it was a no brainer, unless i had been willing to travel 150 miles or so for robotic, which i didnt.

there is still a lot to be said for a very experienced surgeon doing open surgery, my surgeon would support this article, because the robotic method (and i have nothing against it personally) will never replace the tactile nature of having the surgeon being able to feel with his fingers, what he is doing.

there were other early studies, that indicated, at the surface, that with robotic surgery, there were higher incidences of more serious incontinent and ED issues.

i think we would all agree, that with either method, the skill level of the surgeon is paramont in the matter.

david
Posted 1/27/2012 2:30 AM (GMT -6)
Hello Kbota
My Uro also does both, Robot and open, he prefers robot he says his figures are better, he does'nt shop patients either, during my surgery he took six biopsies and had them tested straight away, the anethestist rang my wife when results were in, excited all clear, I was still under the knife. at my post surgery follow up he said to me if I ever have any doubts about my treatment choice and going with the robot look at the pathology report and go and buy a lottery ticket, PCA had escaped capsule in a a very nasty location that was very close to the bowel wall. He said it was the most common area for leaving tissue behind as surgeons don't want to get to close, its one reason they also why they tip you up at 45degrees to let things fall away.
He said with the robot the gas inside your belly stops the bleeding and makes it easier to see. Tumor had escaped by 2mm and he missed it by .7mm he could see the suspicious bulge and went as close as he could to the bowel, he also said as good as he is, he dosen't think he could have done it the open method and doubts if there is a surgeon who could have. He also said surgery by feel is crap, you have to see what your doing and the 50 times magnification is a huge help. He films and times all his procedures and his average time is 42mins, the other surgeon closes and tidys up, the extra two stitches for continence takes 4 mins he said. Before surgery I went to a local continence nurse she urged me if I could afford it go to a good robot guy as the local Uro's have shocking figures in regards to continence her practice was doing very well.
Posted 1/27/2012 6:06 AM (GMT -6)

tigerfan53 said...
My surgeon told me he was a big time skeptic of the robotic procedure. He got so fed up with all the hype that he decided to learn the robot with the intention of de-bunking all the propaganda. However, after learning the procedure and becoming proficient; much to his surprise, he came to the conclusion that the robotic procedure is better (in his opinion). He believes the better vision realized using the robot trumps the tactile advantage that the open procedure has. At the time of my consultation (almost a year ago) he had performed over 2,500 open and over 1,200 robotic procedures.

The bottom line is this: no matter which procedure you choose; it is of utmost importance that your surgeon be experienced in that procedure. His experience will have the most impact on your outcome, more so than the type of procedure.

Tiger, this is almost exactly what my URO thought about Robotic surgery until he joined the Davinci fan club 5 years ago and now he 100% believes it is the better option with higher % of positive recover from side effects. Their practice has 4 robotic surgeons and 1 open and the 4 robotic surgeons have over 6000 davinci surgeries under their belts. 

Posted 1/27/2012 11:54 AM (GMT -6)
Like many of you I made the decision based upon the number of surgeries the Dr. performed. I met with a robotic surgeon who had performed several hundred and with the open surgeon who had done several thousand. I opted for open and do not have any regrets.
You want the Dr. who has the most experience whether it is open or robotic.
All the best.
Posted 1/27/2012 12:22 PM (GMT -6)
i'm extremely satisfied with the results of my robotic. Perhaps because I am a pessimist by nature, but they exceeded my expectations.

What I was told all along by everyone is that moreso than the actual procedure, it the surgeon we have to worry about. In other words, the more qualified the surgeon the better results regardless of procedure.

I personally was sold on robotic immediately. I truly believed that huge visual magnification in the hands of a top notch expert was better for me that touch and feel in a pool of blood. That is just my instinct and means little more than that.

I also understood that actual recover from the the procedure was easier and I liked that.

I think ther eis one thing we have to consider, a ton of surgeons, specially those of a certain age, just didn't adapt to changing technology. So they may feel threatened by the robotic surgeons as I understand these have monopolized the procedure.

The guy who discovered my cancer told me he couldn't operate on me robotically because he was just too lazy to learn how to when the technology came out but that he would gladly recommend me to someone he trusted. I think there ar eprobably many surgeons just like him.

edit to add - my surgeon had also started on open and did many before switching to robotic. He was also an oncologist. Thought I had the best of all worlds with that choice.

Cepas - Way too early, man. You don't even want a boner at this stage as you could damage your healing urethra. Talk to your surgeon, but he'll probably have you start on meds in a few weeks and tell you to start experimenting and getting the blood flowing. Be patient.

Post Edited (davidg) : 1/27/2012 11:30:43 AM (GMT-7)

Posted 1/28/2012 12:35 PM (GMT -6)
I would like to say that Dr. Moul is my Dr. and feel with all his experience I personally would put a lot of stock in what he says. He is a world renowned researcher too and a nice guy to boot. My PC surgery was my third surgery and was the least stressful of them all. Spent two and a half days in the hospital. The day of surgery, I was out of the bed in a couple of hours and walking the halls by that afternoon. I wanted to got back to work after 3 weeks but the wife said, "remember what Dr. Moul said, six weeks", so I was a good boy. I used pads about 2-3 months but have to use the shots, but he told me he could not make any guarantee's before surgery. He was honest with me but told me it was my decision. I think I made the right one especially having Dr. Moul treat me.

Mika
Posted 1/28/2012 1:16 PM (GMT -6)
My choice was going robotic but with a different slants on why. For about 20 years I programmed robotic measuring systems for a wide variety of metal, plastic, and rubber parts for all sorts of products. It is true that this kind of work is entirely different than doing surgery but I could easily picture in my mind how the surgeon would use magnified images from cameras and the hand operated controls that duplicated his hand and finger movements to control the surgical tools. Another reason is that I had quadruple heart bypass surgery two months before I was diagnosed with prostate cancer. I didn't feel that AS or radiation were right for me and I really didn't want to go through another major open surgery if there was a satisfactory alternative.
Posted 1/28/2012 4:43 PM (GMT -6)
I'll add a couple of data points to the discussion. These favor the robotic side - but I don't disrespect any one who's made a different choice. Everyone's situation is different. I had an early stage cancer. I live in a major city with a highly-rated cancer center and a top PC surgeon, who I refer to below as "Dr. X" .

1.) After my GP sent me to a urologist for the biopsy, we discussed treatment options. This urologist is in his early 60's. After diagnosing me and telling me about all the options, I said "what would you do?" He said, "I would get surgery and go see Dr. X to do it." I asked him -- "Aren't you a surgeon? How come you are not recommending yourself? He said "I have a lot of experience in the open surgery, and it is too late in my career for me to get enough experience on the robot. But based on everything I have seen, the robot is better and that is what you should do. And Dr. X is the best robotic surgeon in the area." I was very taken by that advice, because what he sent went against obvious commercial interest

2.) When interviewing "Dr. X" who several other people also recommended I asked him about the merits of robot vs. open, and specifically the question of "feel" brought up by the original poster. Dr. X said he does mostly robot now and has about 700 cases under his belt. (or should I say "knife"?) He said "Ah.... the issue of interoperative palpation" (using the technical term for "feel".) He said he plans the surgery by doing a color doppler ultrasound, which looks for the increases in blood flow that always come with a tumor. Based on that he can tell if EPE is likely and whether the tumor is close enough to nerve bundles that the nerves need to go. He says this information is more accurate than what he can feel through a gloved hand. He said they had tested the value of endoscopic rectal MRI to plan the surgery but the doppler ultrasound was more accurate. Based on the ultrasound he plans the surgery in advance (how close they will cut and whether they will spare the nerves) and with rare exception does the surgery as planned. I can't speak for his statistics in general, but in my particular case the post surgery pathology report was very consistent with the pre-surgery planning.

Maybe it's analogous to flying. You can fly visually, and navigate and adapt according to the landmarks you see in flight. Or you can pick a flight plan in advance, and then fly by instruments, sticking to the course laid out.

Again - no disparagement of any decision is implied here; I'm just reporting personal observations from my particular experience.
Posted 1/28/2012 6:42 PM (GMT -6)
I initially went to a Urologist who only did open. He said that he wouldn't even try to save the bundle on one side. I eventually had robotic and the urologist managed to save both bundles but had to cut some of the nerves on both sides. My operation was on 16 Dec 2010. I was continent within a few weeks. I am still in the zero club. My ED is recovering and I can now achieve partial erections suitable for intercourse.

My surgeon managed to find and save my accessory pudendal artery. He said that he wouldn't have had a chance using open because of the blood and lack of magnification. Tactile feedback wouldn't have helped at all. He does both open and robotic and so I feel he gave me impartial advice. I feel sure I made the right choice going with robotic.
Posted 1/28/2012 7:01 PM (GMT -6)
The 6% positive margins and the recent increase in positive margins is way out of the reality ball park. MSK keeps accurate records by surgeon and the best surgeon has an 11% positive margin rate and the worst has a 48% with the average being about 23%. This is down from a historical average of 30% which was the reported positive margin rate of major institutions. In the current age it is reasonable to expect about a 20-25% positive margin rate from an experienced surgeon. Positive margins will also vary by risk classification and have historical been: low risk at 15%, intermediate at 30% and high at 40-50%.
Surgeons are getting more experienced and newer techniques are reducing the positive margin rate. The reduction in positive margins could also be due to men being treated earlier or the increase in treatment for very low risk cancer which rarely produces a positive margin. I have seen no evidence that robotic has any impact on the rate of positive margins positive or negative.
Regardless, "it's the indian and not the arrow". The surgeon and his skill level and experience are much more critical than the technology used. While the rates of positive margins may have declined, patient's expectations have skyrocketed and as the article points out there may be a disconnect from reality.
Posted 1/31/2012 6:38 AM (GMT -6)
I just got through watching Dr Samadi on FOX News this morning to answer the study referred to in the original post by Kbota. He said that the higher success with robotic surgery is directly related to the experience of the surgeon operating the robot. He said when looking for a surgeon you should find one who does a minimum of 150 RALP's a year as the lead or direct surgeon operating the robot. He pretty much said the same thing that John T said above the technology is only as good as the surgeon operating the robots.
Posted 1/31/2012 2:47 PM (GMT -6)
yes of course. you don't want to go to a guy who is using you to learn how to perform the procedure. That was one of my biggest concerns until I sat in front of Samadi.
Posted 1/31/2012 6:37 PM (GMT -6)
I had great success with the robot. But my surgeon has 1600 procedures below the belt (pardon the pun). I posted in John's other thread some key questions to ask your surgeon prospect.

#1> What version of the DaVinci Robot are they using (Should be above 3)
#2> How many times has the doctor used this particular machine for RALP?
#3> How long has this device been installed at the center you will be using? (Trick Question. if they say a couple hundred and the device was recently installed at the center there's something wrong with the answers)

A good surgeon will do over a hundred a year. A part time surgeon will say they have done a couple hundred over several years.

I didn't use Samadi, but my surgeon says he has done quite a few. I don't link the advertising he does but I bet he is solid with the robot. As I said my doctor was one that worked at a reputable prostate cancer center (City of Hope) and done 1600 procedures ~ he too is a good bet.

Tony
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