when a surgeon is doing the surgery (whether robotially or open) does the surgeon know whether to take out additional tissue that could be cancerous?
I mean once they get into the surgery are there any indications to them that lymph nodes have been impacted or nerve bundles have been impacted by the cancer?
I know when my dad had the surgery at MD anderson 8 years ago they did not spare the nerve bundles and that was a decision my dad had to make before going thru with the surgery. (Is that still a question that is asked?)
I did see where in one robotic surgery, the prosate is removed and is quickly brought down to pathology to see if the margins were good before they completed the surgery. I guess if they were not then the robotic surgeon could sample lymph nodes and other tissues to try and get all the cancer.
Also does a robotic surgeon get a quick pathology report on the prostate while the patient is still under? If the quick pathology report looks good as far as margins then he can complete the surgery. If the margins are not good does the surgeon take more tissue out like nerve bundles and lymph nodes?...
Is there any reason why the surgeon would not go thru with removing the prostate during surgery? If the cancer has possibly spread elsewhere and the surgeon can see that (not sure if they can)? (I saw a video on the robotic procedure and it looked like the surgeon had a quick pathology report on the gland while the patient is under)?
Surgeons go by "look and feel".
In particular for nerve sparing (which, unless there is pre-operative evidence of high likelihood of ECE from Partin tables, DRE, MRI, ect., is an in-flight decision) both
open and robotic surgeons observe how the neurovascular bundles release from the prostate. If they fall away easily that is good and indicates that they are unlikely to be involved. But if they are "sticky" that is a concern and then the Dr. has to decide whether this is just residual benign inflammation from the biopsy or cancer (which is one reason to wait 6-8 weeks from biopsy to surgery) and how much, if any, nerve sparing to attempt.
open surgeons can palpate the gland in place and after it is removed and feel all around where the tumor is closest to the edge and may take wider margins in those areas.
Since robotic surgeons can't feel the tissues inside the patient during the operation, they instead must compensate by using the 30x magnified 3D vision to watch how the tissues respond as they tug and poke them. As Peter points out, it is hard for anyone but the surgeons themselves to say how well this really compensates. I imagine this and other facets of robotic technology (e.g. tremor filtering and scaled fine movements) probably make some
surgeons better than they would be
open but others worse. I did find it interesting that one of the few doctors (Schaeffer at Hopkins) who still does both
open and robotic recommends still
open surgery for palpable tumors.
Robotic surgeons can also examine and feel the specimen once it is removed and decide to whether to go back and take more, but I'm not sure how often this is done.
Lymph nodes are another issue. If they are grossly involved (enlarged or hardened) this may be apparent to the surgeon but often that is not the case. They can be sent for intra-operative frozen section but this somewhat uncommon and I believe only done when it is decided before hand to abort the surgery in the event of positive nodes, which is an important pre-operative choice for the patient -- whether he wants to go ahead with the surgery with a much smaller but still possible chance of cure and some likely benefit from debulking the primary tumor.
In principle, intra-operative frozen sections can also be used on other parts of the specimen besides lymph nodes but my understanding is this is very unusual nowadays (notwithstanding bluebird's report of Dr. Tewari doing that) and less reliable than final pathology on the formalin-fixed specimen.
Post Edited (njs) : 7/4/2013 1:35:58 PM (GMT-6)