Help with my decision

I just want to echo what Curtis said. Mike, whatever decision you make
*will be* the right decision for you. Period! No second thoughts, no what
ifs. Our first urologist made that point repeatedly as he was spending over
an hour with us going over all the options. And he was absolutely right.

Larry was diagnosed in June and we spent the next three months researching,
reading, and talking to different docs. I understand you are in the middle
of the Pacific and your choices/locations may be limited, but do as much
research as you can. Talk to as many docs as you can. Talk to an
oncologist as well as surgeons. And then once *you* are satisfied you have
done as much research as you can, then make your final decision and be happy
with it. Well, as happy as you can be under the circumstances.

Good luck!

Jean

callalily wrote:
> Dear All,
>
> I.P. Freely wrote:
>> callalily wrote:
>>
>>> I believe firmly that if you have a cancer with a G of
>>> 7 or more you should have open surgery (RRP) . . . the biggest? doctor
>> > in the country, Partin of Johns Hopkins . . . will ONLY do OPEN
>> > surgery on a patient with a G7 or less.
>>
> GOD BLESS YOU, IP.
>
> You pointed out something I had mistakenly written in a rush. The
> sentence should have read: Partin...will only do Open surg. ...on a
> patient with a G7 or HIGHER.

Great! You had me worried there, Leah. Too much midnight oil?

I.P.

JerryW wrote:
>
> In my experience on other newsgroups, people generally surround a word or
> phrase with an asterisk (*bold*) to indicate an emphasis that would
> otherwise call for bold type, or italics, etc. People generally surround a
> word or phrase with an underscore (_underline_) to indicate an underlined
> word or phrase.

But don't bold and underscore require require HTML (which I disable in
newsgroups for security)?

I.P.

"I.P. Freely" <fuhgheddaboutit@noway.nohow> wrote in message
news:4ixnh.52$fb4.18@newsfe04.lga...
> JerryW wrote:
>>
>> In my experience on other newsgroups, people generally surround a
>> word or phrase with an asterisk (*bold*) to indicate an emphasis that
>> would otherwise call for bold type, or italics, etc. People generally
>> surround a word or phrase with an underscore (_underline_) to
>> indicate an underlined word or phrase.
>
> But don't bold and underscore require require HTML (which I disable in
> newsgroups for security)?

Read his answer again!! The symbols REPRESENT "bold and underscore"
without resorting to block caps as I have just done.

You would be tarred and feathered on *any* news group for usage of block
caps. We generally let it slide once, but then come down heavy on the
(usually) newbie and explain it means YELLING.

Perhaps that is why you ruffle feathers when you constantly use block
caps. It is grating to the eyes. And infers that you are yelling at
the people reading it. Ergo, it could tick some of them off.

And you are right......next to block caps, posting in HTML is bad form
and you will be pulled up short(er) for it. (VBG)

Heather

"Steve Kramer" <skramer@cinci.rr.com> wrote in message
news:459e849d$0$5247$4c368faf@roadrunner.com...

>
> And, Please.... Please.... don't let one guy run you out of a support
> newsgroup. I know you're not comfortable with newsgroups, but you'll find
> that one asshole doesn't come close to screwing it up for you when you are
> confronting a dangerous disease. And, maybe, just maybe, if you stick
> around, you might find that I'm not always an asshole.


There you go again---straying off topic. Now it's rectal issues ;-)

Maui wrote:
> On 5 Jan 2007 03:41:53 -0800, "kh" <tchtic@yahoo.com> wrote:
>
> >
> >Maui wrote:
> >>I voiced some concern about
> >> being treated with a brand new system, and he responded that it was
> >> really nothing more than the same procedure he has always done, but
> >> using a new "tool".
> >
> >The procedure being laproscopic prostate surgery and the "new" tool
> >means switching from a hand held blade to robotic manipulators? Is
> >that it?
> >
> >-kh
>
>
> Exactly

OK, then do this. Get two pair of scissors and using the pointed tips,
tie your shoes.

How does that feel?

Practice a little until you can tie your shoes, then switch to
channel-locks.

Maybe it's just me but this is precision surgery using a "new"
contraption. It doesn't feel quite right.

I'm sure that with a little practice, someone can be quite good at it
but how much is enough practice????

-kh

Dear Jerry--

I can't thank you enough for this info. I feel like an excited
schoolgirl bec. I learned something new today. I did know about the
shouting but not about the nuances of it. I really thought it was OK
to shout except in paragraphs or sentences. A word? Wouldn't think
anything about it. How else could you emphasize a point?

Only reason I let myself shout in this case was because it seemed to me
the poster was about to jump in front of a train. It just scared me
that the surgeon he had chosen didn't even own the machine yet. It was
clear that, at the very least, Mike needed to find out more specific
info abt the doc. He may yet end up being the perfect choice -- I hope
so. Plus, there was some "hot-off-the-press info" that I think I needed
to put in front of his nose so he could show it to his doc. (They don't
always read the paper).

JerryW wrote:
> "> Leah,
>
> I believe from an earlier post of yours that you had some questions about
> netiquette and appropriate postings on newsgroups. I understand that it is a
> generally accepted rule of netiquette that posting in all caps on a
> newsgroup is the equivalent of SHOUTING. I know there is a (probably?)
> minority opinion here that using all caps is an appropriate method to add
> emphasis to a word or group of words. Generally, it hurts my ears to read it
> and makes me subconsciously, at least, believe I'm reading an angry
> post...but that's just me.

You know, I don't get the same feelings you do about the caps. I think
bec. you've been doing this longer than I and have probably come to
associate shouting with bad things. To me, it says equally, "Something
wonderful or exciting has happened to me and I want you all to know
about it"! Seriously, putting something in bf or underscore emphasizes
it but it doesn't espress any real emotion. What's your opinion on
exclamation pts.?
>
> In my experience on other newsgroups, people generally surround a word or
> phrase with an asterisk (*bold*) to indicate an emphasis that would
> otherwise call for bold type, or italics, etc. People generally surround a
> word or phrase with an underscore (_underline_) to indicate an underlined
> word or phrase.

This is all news to me. I just posted something that had the
"underscore" in it and I thought it looked funny --- like it was a
mistake.

".He will do an RLRP if a patient requests it_and_ if ...

You see, the word "and" written this way looks really confusing to me:
it seems like you are trying to link a couple of words. And it's not
that easy to type _ symbol. Wouldn't something like -and- be better
because you don't have to hit the shift button?

> Just a suggestion, opinion. Don't mean to start a war. And, maybe you
> intended to shout in the first place.

Yes, I did intent to shout as I said earlier. Au contraire, you're not
starting a war, you're just being gracious and sharing some "insider"
information.

BTW, you are very fortunate to have done so well healthwise. I looked
at your stats and your psa levels posted below and it all makes me
*very hopeful*. My husband has very similar numbers to yours. Keep up
the good work.

Best to you,


Leah
>>
> 2/11/04 PSA 2.6, Suspicious DRE (age 62)
> 2/23/04 Biopsy: Gleason 3+4=7, T2a, left lobe
> 5/18/04 RRP, Path: Gleason 4+3=7, T2c, both lobes
> Fully continent by 9/04
> PSA <0.1 since

Heather wrote:
> "I.P. Freely" <fuhgheddaboutit@noway.nohow> wrote in message
> news:4ixnh.52$fb4.18@newsfe04.lga...
>> JerryW wrote:
>>> In my experience on other newsgroups, people generally surround a
>>> word or phrase with an asterisk (*bold*) to indicate an emphasis that
>>> would otherwise call for bold type, or italics, etc. People generally
>>> surround a word or phrase with an underscore (_underline_) to
>>> indicate an underlined word or phrase.

IIIII see. I've seen and used *asterisks* for years for emphasis, but
never seen nor used _underscores_ employed in this manner.

> You would be tarred and feathered on *any* news group for usage of block
> caps.

I've been doing USENET for 12-15 years, with caps for emphasis, and this
is the first forum to object. Thanks for the clarification.

> We generally let it slide once, but then come down heavy on the
> (usually) newbie and explain it means YELLING.
>
> Perhaps that is why you ruffle feathers when you constantly use block
> caps. It is grating to the eyes. And infers that you are yelling at
> the people reading it. Ergo, it could tick some of them off.

I've explained many times why I use caps for emphasis, just as I use
Italics outside of newsgroups. I'll try to switch to * and _, but no
guarantees that I'll remember it, because I have always saved asterisks
for EXTRA emphasis beyond mere caps. e.g.,
Normal text = facts, opinions, chatter, humor . . . i.e., conversation.
Occasional capitalized words = emphasis.
*asterisk brackets* = greater emphasis.
*ASTERISKS BRACKETING CAPS* = even GREATER emphasis . . . i.e., this is
an important distinction.
*P*A*Y*A*T*T*E*N*T*I*O*N* => this is some serious $#!+; It's key to
understanding a vital point.

Since so few people know the official "rules" (besides all caps =
yelling, which everyone UNDER 50 knows), I wonder which emphasis
indicator works better . . . OCCASIONAL caps with higher levels for even
*GREATER* emphasis that anyone should be able to decipher, or canned
rules that few people know? E.g., how do USENET rules provide for
*S*E*R*I*O*U*S* *$*#*!*+* ?

I.P.

callalily wrote:
> Dear Jerry--
>
> I can't thank you enough for this info. I feel like an excited
> schoolgirl bec. I learned something new today. I did know about the
> shouting but not about the nuances of it. I really thought it was OK
> to shout except in paragraphs or sentences. A word? Wouldn't think
> anything about it. How else could you emphasize a point?
>
> Only reason I let myself shout in this case was because it seemed to me
> the poster was about to jump in front of a train. It just scared me
> that the surgeon he had chosen didn't even own the machine yet. It was
> clear that, at the very least, Mike needed to find out more specific
> info abt the doc. He may yet end up being the perfect choice -- I hope
> so. Plus, there was some "hot-off-the-press info" that I think I needed
> to put in front of his nose so he could show it to his doc. (They don't
> always read the paper).
>
> JerryW wrote:
>> "> Leah,
>>
>> I believe from an earlier post of yours that you had some questions about
>> netiquette and appropriate postings on newsgroups. I understand that it is a
>> generally accepted rule of netiquette that posting in all caps on a
>> newsgroup is the equivalent of SHOUTING. I know there is a (probably?)
>> minority opinion here that using all caps is an appropriate method to add
>> emphasis to a word or group of words. Generally, it hurts my ears to read it
>> and makes me subconsciously, at least, believe I'm reading an angry
>> post...but that's just me.
>
> You know, I don't get the same feelings you do about the caps. I think
> bec. you've been doing this longer than I and have probably come to
> associate shouting with bad things. To me, it says equally, "Something
> wonderful or exciting has happened to me and I want you all to know
> about it"! Seriously, putting something in bf or underscore emphasizes
> it but it doesn't espress any real emotion. What's your opinion on
> exclamation pts.?
>> In my experience on other newsgroups, people generally surround a word or
>> phrase with an asterisk (*bold*) to indicate an emphasis that would
>> otherwise call for bold type, or italics, etc. People generally surround a
>> word or phrase with an underscore (_underline_) to indicate an underlined
>> word or phrase.
>
> This is all news to me. I just posted something that had the
> "underscore" in it and I thought it looked funny --- like it was a
> mistake.
>
> ".He will do an RLRP if a patient requests it_and_ if ...
>
> You see, the word "and" written this way looks really confusing to me:
> it seems like you are trying to link a couple of words. And it's not
> that easy to type _ symbol. Wouldn't something like -and- be better
> because you don't have to hit the shift button?
>
>> Just a suggestion, opinion. Don't mean to start a war. And, maybe you
>> intended to shout in the first place.
>
> Yes, I did intent to shout as I said earlier. Au contraire, you're not
> starting a war, you're just being gracious and sharing some "insider"
> information.

I agree with every word you "speak" here, Leah. It's pretty obvious to
anyone, newbie or old timer, that when a poster capitalizes only
specific words or phrases, rather than the whole post, the intent is
emphasis. The YELLING hangup refers to people whose computer was
delivered with its CAPS LOCK button engaged and never figured out why
its LED is ON alla time. It's like the turn signals on Cadillacs in
south Florida: the cars were delivered with them ON or OFF, and their
blue-haired drivers were never told they're allowed -- let alone
REQUIRED *BY LAW* -- to move that little lever when appropriate.

I.P.

On 5 Jan 2007 12:57:48 -0800, "kh" <tchtic@yahoo.com> wrote:

>
>Maui wrote:
>> On 5 Jan 2007 03:41:53 -0800, "kh" <tchtic@yahoo.com> wrote:
>>
>> >
>> >Maui wrote:
>> >>I voiced some concern about
>> >> being treated with a brand new system, and he responded that it was
>> >> really nothing more than the same procedure he has always done, but
>> >> using a new "tool".
>> >
>> >The procedure being laproscopic prostate surgery and the "new" tool
>> >means switching from a hand held blade to robotic manipulators? Is
>> >that it?
>> >
>> >-kh
>>
>>
>> Exactly
>
>OK, then do this. Get two pair of scissors and using the pointed tips,
>tie your shoes.
>
>How does that feel?
>
>Practice a little until you can tie your shoes, then switch to
>channel-locks.
>
>Maybe it's just me but this is precision surgery using a "new"
>contraption. It doesn't feel quite right.
>
>I'm sure that with a little practice, someone can be quite good at it
>but how much is enough practice????
>
>-kh

Great analogy! I'm certainly not willing to sacrifice my future for
the sake of medical advancement.

Mike

>> "I.P. Freely" wrote in message news:4ixnh.52$fb4.18@newsfe04.lga...

> *S*E*R*I*O*U*S* *$*#*!*+* ?

Well, I've got this technicolor vision of a screaming lunatic (no offense
intended) with a beet-red face, about to have a cerebral hemorrage, in
serious need of some valium :-)

I.P., I've no doubt at all that you are quite articulate enough to convey
serious s--t without having to resort to signs and signals (or liberal use
of the Caps Lock key, for that matter). Even in Usenet, where the way
something is said is often difficult to detect. We've all been misunderstood
in posts before, and the smiley face and "LOL," etc. have been universally
adopted to try to prevent miscommunicating intent.
--
JerryW

Please respond to group; email address is not valid

2/11/04 PSA 2.6, Suspicious DRE (age 62)
2/23/04 Biopsy: Gleason 3+4=7, T2a, left lobe
5/18/04 RRP, Path: Gleason 4+3=7, T2c, both lobes
Fully continent by 9/04
PSA <0.1 since

"JerryW" <jerryw@seemysig.net> wrote in message
news:0VAnh.9103$x67.4836@newssvr17.news.prodigy.ne t...


> We've all been misunderstood in posts before, and the smiley face and
> "LOL," etc. have been universally adopted to try to prevent
> miscommunicating intent.

Geez, Jerry..... I already apologized once! :-)


--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA .1 .1 .1 .27 .37 .75
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32
Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05,
2/06, 6/06
PSA .07 .05 .06 .09 .08 .132 .145
Casodex added daily 07/06
PSA <0.04
Non Illegitimi Carborundum

JerryW wrote:
>>> "I.P. Freely" wrote in message news:4ixnh.52$fb4.18@newsfe04.lga...
>
>> *S*E*R*I*O*U*S* *$*#*!*+* ?
>
> Well, I've got this technicolor vision of a screaming lunatic (no offense
> intended) with a beet-red face, about to have a cerebral hemorrage, in
> serious need of some valium :-)

You paint a clear picture, but one also has to consider the words and
context.

> I.P., I've no doubt at all that you are quite articulate enough to convey
> serious s--t without having to resort to signs and signals (or liberal use
> of the Caps Lock key, for that matter). Even in Usenet, where the way
> something is said is often difficult to detect. We've all been misunderstood
> in posts before, and the smiley face and "LOL," etc. have been universally
> adopted to try to prevent miscommunicating intent.

And do you have *any* concept how overused those are? Some people stick
LOL. VBG, and smileys after every paragraph, rendering it meaningless
and irritating.

I.P.

Dear Dave,

dave perry wrote:
>It is true that the long term impact on survival, etc. is not as well known for LRP and RLRP but both of these newer techniques have been around for some time now (almost ten years) with no indication to date that there is any difference among the three surgical methods. Who gets it out is much more important than how it gets out.

I'm glad you wrote this, Dave. I wasn't trying to frighten any former
or prospective pca patients about LRP or RLRP. I was only trying to
point out that questions have been raised. And you can't always
discern the motives of any given person who is rendering an opinion . .
.. there are, apparently, some doctors who feel that if a person has
anything other than the lowest-grade pca, he is not likely to benefit
from ANY surgery in the long term, so the reluctance of these docs to
operate on higher-risk patients may have nothing whatsoever to do with
the method. Presumably, they would choose another treatment altogether
(or none at all).

However, your post prompted me to do a new search and I came across
some very *encouraging* news about RLRP from the 2006 conference of the
American Urological Association (from "Urology Reviews). I, for one,
am heartened by it.

[However, it is unclear to me whether Partin, et al. just reported
these results at the conference or actually endorsed the findings, a
critical distinction for me, anyway. See, at end, Danil V. Makarov,
MD, Li-Ming Su, MD, Alan W. Partin, MD, PhD]

Here is the most relevant excerpt:

**These investigators also demonstrated, using Kaplan-Meier analysis,
that there was no statistical difference in PSA recurrence-free
survival between men undergoing RAP and RRP (the longest follow-up was
2500 days).**

Best to you all.

Leah

Full Text:

Oncologic Outcomes in Robotic-Assisted Radical Prostatectomy: Learning
Curves and Surgical Margins

Regardless of the approach used to perform a prostatectomy for cancer,
certain oncologic principles, such as achieving negative surgical
margins (especially in patients with T2 disease), must be achieved to
attain durable disease control. Compared with open radical retropubic
prostatectomy (RRP), there has been **little substantive data published
to date (and by only a few groups) describing outcomes from
robotic-assisted radical prostatectomy (RAP).99-102**

Some of the earliest data from the initial series of Menon and
colleagues100 described excellent results with regard to pathologic
stage and margin status, as well as decreased blood loss and
transfusion rates compared with RRP. Other investigators, such as
Joseph Smith, MD,101 chose to wait for the maturation of their data
before comparing surgical margins in patients undergoing robotic versus
open prostatectomy because of the selection bias involved: **men
undergoing RAP usually have lower-stage disease than those undergoing
RRP.**

At this year's meeting of the AUA, a number of groups published data
on their surgical margin rates and how these rates have evolved with
increasing experience.

Sarle and coworkers 103 reviewed the first 1452 cases performed by Mani
Menon, MD, and colleagues. The group reports excellent data on return
of erectile function and continence, which they attribute to
preservation of neurologic tissue along the anterior aspect of the
prostate ("veil of Aphrodite" technique), as well as to precision
of dissection afforded by the da Vinci surgical robot system (Intuitive
Surgical, Sunnyvale, CA). Regarding their positive margin rate, overall
they saw 11% of men with positive margins. Among men with pT2 disease,
only 5% had a positive margin, compared with 30% of men with pT3
disease.

Herrell and associates104 reported on 286 patients with pT2 disease
(out of a total of 484) treated by RAP at Vanderbilt University Medical
Center. Data were recorded prospectively. Prostates were analyzed as
whole-mount specimens, and tumor extending to an inked margin or to the
site of a capsular incision was recorded as a positive margin, even if
subsequent resection of additional tissue resulted in a negative
margin. Data were analyzed by groups of 100 patients. Overall a 17%
positive margin rate for T2 tumors was found; however, the rate
declined from 30% in the first 100 cases to 13% in the next 100 to 9.3%
in the final group. This represents a statistically significant trend
in decreasing positive surgical margins.

Patel and Arends105 also reported their evolving experience with
positive surgical margins. In the first 500 patients, 78% had pT2
disease. The overall positive margin rate was 2.5% for pT2 disease and
31% for non-organ-confined disease. Examining the positive margin rate,
not corrected for stage, by 100-patient groups demonstrated a
decreasing incidence of positive surgical margins: 13% to 8% to 12% to
5% and finally to 8% in cases 401 to 500. Also noted was the finding
that positive margins were more likely posterolateral (56%) than apical
(8.5%). Although the investigators do not note this, this difference in
comparison with RRP, where positive margins are more common at the
apex, might be explained by a combination of the superior visualization
during apical dissection with the robot and the lack of tactile
sensation with the robot during nerve sparing.

Slawin and Guariguata106 also discussed the effects of increasing
numbers of cases on surgical margin rates. In a retrospective analysis
of 759 men treated with either RAP, RRP, or en bloc RRP (for
higher-grade and higher-stage disease), the investigators demonstrated
a 5.5% rate of pT2 positive surgical margins, regardless of technique.
When analyzed by surgical technique, positive surgical margins in pT2
patients were 3.1%, 6.2%, and 5.5% for RRP, RAP, and en bloc RRP,
respectively; these differences did not achieve statistical
significance. Whereas positive margin rates for RRP and en bloc RRP
remained constant through time, decreasing rates of positive margins
were observed when RAP procedures were analyzed by year: 5.9% to 2.5%
to 0% for pT2 disease and 0 (0 of 2 patients) to 35% to 14.3% in pT3a/b
disease.

**These investigators also demonstrated, using Kaplan-Meier analysis,
that there was no statistical difference in PSA recurrence-free
survival between men undergoing RAP and RRP (the longest follow-up was
2500 days).**

Gong and colleagues107 demonstrated that the expertise necessary to
perform a successful RAP can be acquired in a short period by a trained
open surgeon, to rival the outcomes of a fellowship-trained
laparoscopist performing RAP. In a nonrandomized study, 2 surgeons, one
a skilled open prostatectomist and the other a fellowship-trained
laparoscopist, performed 40 RAPs to overcome the initial learning curve
and then reported their outcomes with the next 100 patients they each
operated on. Neither surgeon had any open conversions, nor was there
any statistically significant difference between the 2 surgeons with
respect to operative time, hospital stay, estimated blood loss,
transfusion rate, complication rate, and rate of positive margins. This
study suggests that, given an adequate amount of practice, any
urologist, regardless of formal training, can successfully perform RAP.
However, this study and others have not evaluated the learning curve on
the basis of functional (ie, continence and potency) outcomes, which
would likely exceed the 30 to 40 cases routinely reported as the
learning curve for RAP.

Another interesting abstract discussed the vagaries of operating with
the da Vinci robot system. Kozlowski and associates108 reported that in
the first 200 patients undergoing RAP at their institution, there were
8 equipment failures necessitating abandonment of the robotic approach.
Malfunctions were related to joint setup (2), arm malfunction (2),
software incompatibility (1), "power off" error (1), monocular
monitor loss (1), and camera malfunction (1). The group wisely
concludes that multiple contingency plans should be set in place,
including additional da Vinci units, development of straight
laparoscopic skills, and counseling of patients to determine their
preference should the system fail.

Overall, this year's meeting included a great number of RAP-related
abstracts demonstrating that, at least for the time being, this
technology is here to stay and will likely continue to have a more
prominent role in the armamentarium of urologists in the United States
and abroad. Urologists should at least become familiar with RAP to
better understand the true merits and shortcomings of this approach, as
well as to consider providing this technique for their patients. In the
words of Ingolf Tuerk, MD, during his Take Home Messages talk on
Laparoscopic Oncology, "It is never too late to learn the skills to
perform laparoscopic or robotic surgery."

[Danil V. Makarov, MD, Li-Ming Su, MD, Alan W. Partin, MD, PhD]