Help with my decision

I have given it much thought and have decided to proceed with a
Radical Prostatectomy. Now I have another decision to make. I was not
aware that I would be able to choose between the normal retropubic
procedure, laproscopic, or the Davinci robotic laproscopic for which I
would have to wait another 45 days. I would appreciate any advice
offered to help make this decision.

Aloha

Mike

On January 3 on the mainland, Maui Mike wrote:

> I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.

It would likely be helpful to read what some medics have to say on the
subject.

The Prostate Cancer Research Institute's webpage at

http://prostate-cancer.org/education...#local_therapy

has such information. Scroll about halfway down the page to the section
"Local Therapy", where links to papers on the various forms of
prostatectomy will be found.

Best of luck.

Regards,

Steve J

On Wed, 03 Jan 2007 21:58:12 -1000, Maui Mike wrote:

>I have given it much thought and have decided to proceed with a
>Radical Prostatectomy. Now I have another decision to make. I was not
>aware that I would be able to choose between the normal retropubic
>procedure, laproscopic, or the Davinci robotic laproscopic for which I
>would have to wait another 45 days. I would appreciate any advice
>offered to help make this decision.
>
>Aloha
>
>Mike

Hello Mike, it appears to me that there is a growing trend towards
Laparoscopic and Robotic Laparoscopic surgery - I read posts here from
time to time and remember only one poster here recently going for the
plain vanilla RP (I could be wrong!). Of course ascp is a tiny
microcosm of PCa-world but I do sense this change. Perhaps it's a
fashionable blip? Since both LRP and RLRP are relatively new there's
not yet data mature enough to compare long-term outcomes. Briefly,
this was my reading:
RP - nice big hole, the surgeon is more hands-on but there's more
blood. Longer recovery time. Substantial stats available.
LRP/RLRP one medium hole + 4 tiny 'stab' wounds, less hands-on, less
blood, shorter recovery time. Fewer stats.
There was a post here recently claiming negative margins in approx
half of RPs compared to approx one third of LRP/RLRPs (please correct
me for errors).
The impact of your 45 day wait is incalculable and as a patient on WW
for 2.5 years my advice will be less cautious than that of others,
but, for you as a gl6, my vote on a straw poll would be to wait the 45
days if that is the procedure you want. Of course, you must use a
surgeon who has plenty of experience and who inspires confidence.

I chose an LRP 2 months ago (UK) and was soon up and about. Bar the
odd stress-dribble, I'm fully continent, and had an unmedicated
erection firm enough for penetrative sex (80%-ish) at 4 weeks and even
better erections now with cialis. Of course I can't say anything
about my prognosis but, for the moment anyway, I am very happy with
the outcome.

Maui wrote:

> I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.
>
> Aloha
>
> Mike

I had a laparoscopic radical prostatectomy (LRP) done at Johns Hopkins
about 8 weeks ago. I was hospitalized for two days, and on a catheter
for about a week afterwards. (I'm getting blood drawn for my first
post-surgery PSA today.) I chose the laparoscopic procedure because of
minimal blood loss and shorter recovery time.

I lost only 100cc of blood during the procedure (~ 2 tbsp), and so
required no transfusion. I was lecturing my classes two weeks after
the surgery, I am slowly regaining continence, but have had no
erections yet. I am patiently waiting, though my wife and I have
resumed a sex life that includes orgasms for the both of us.

If I recall correctly, my surgeon (Pavlovich at Johns Hopkins) had
learned how to use the robot, but decided that he preferred doing the
surgery without it. Since he has over 450 LRPs under his belt, I felt
very comfortable in his hands. Apart from what he said, I don't know
anything about the robot.

Probably the most important recommendation I could give you is to get
the very best and most experienced surgeon you can. It seems that
there is a high variability in the success rates and side effect rates
from surgeon to surgeon. Don't worry so much about the time frame;
remember that prostate cancer is usually very slow-growing.

Mike, whatever you decide, all the best! You will get through it.

--charlie

I can only pass along that my boss chose robotic as he should only miss 2-3
weeks of work.

Good luck.


<Maui Mike> wrote in message
news:07cpp2htcj48u1t8c6dp7r67r29d5oftrc@4ax.com...
>I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.
>
> Aloha
>
> Mike

My husband had the DaVinci method surgery done in Sept. From the time he
hit the recovery room post-surgery to the time he was released was 39 hours.
His catheter was in for nine days and he went back to work on day 10.
Played golf on day 11. No leakage at all. And now at 3 1/2 months post-op
the erections are coming back, which is wonderful considering 30% of the
nerves on one side were compromised and had to be removed. (And re-built.)

Choose your surgeon well. Make sure you do as much research into him or
her's surgery record as you do in every other aspect of this disease. If
you are anywhere near Houston we highly recommend Dr. Brian Miles. He was
instrumental in the bladder sling procedure for men and he has done
thousands of robotic surgeries. The man is good. ;o}

Good luck and make sure to let us know what you decide.

Jean & Larry

Hello Mike,
I have to be the one to have had RP. Radical Prostatectomy. 1999. The
Surgeon choice is important.
I was building cabinets in my garage 10 days after surgery. I did not leak
a drop, and erections took about 1.5 years to come back.....I lost many
nerves in the surgery......I am fine, and looking back was glad to have a
professional experienced surgeon who took great care of me. I did have
blood drawn for surgery but did not need any. Good wishes, and choice.
John Loomis
<Maui Mike> wrote in message
news:07cpp2htcj48u1t8c6dp7r67r29d5oftrc@4ax.com...
>I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.
>
> Aloha
>
> Mike

Maui Mike wrote:
> I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.

Most people would agree that the choice of the procedure is less
important than the skill of the surgeon in performing the procedure.

RP involves al onger recovery time in general, but not greatly so. I
had a RP in 2000, was pretty much able to do normal tasks, except for
pads, by the time the catheter came out two weeks after surgery. I was
continent a month after the catheter came out and regained erections
some 18 months following surgery, despite my age 67 at the time of
surgery. I've been PSA free since then. My surgeon seems to do
pretty well with the RP technique he has developed. A friend recently
had RP with the same surgeon, and so far the results are promising.
Apparently, our surgeon has decided to remove the catheter a week after
surgery rather than two weeks after, as in my case. I would still
highly recommend him to anyone considering prostate surgery.

>
> Aloha
>
> Mike

I agree with Charlie and Jean. Choose your surgeon well!

I have read that most studies show that the single greatest
factor in the success of a surgery is the skill of the surgeon.
You want a doctor that specializes in prostate surgery, not
a general urological surgeon who does 20 different kinds of
surgery on men and women and only does a handful of
prostatectomies each year.

I personally think that, along with having lots of experience,
it's important for a surgeon to have a serious commitment
to patients. You want a guy that doesn't hurry in order to get
out in time for his lunch appointment.

Commitment may be hard to judge, but I think you can tell
a lot from how much time the surgeon is willing to spend
with you to answer your questions, how well he listens, and
whether he gives careful answers or just blows off your
questions with a "leave everything to me" attitude.

Now, as for your original question, assuming equal skill
and commitment from the surgeons, I think I'd choose one
or another form of laparoscopic surgery because of the
smaller incision and reduced trauma to peripheral areas.
However some of the more skeptical folks will rightly
point out that open surgery has a longer history and is
therefore more of a known quantity with regard to
effectiveness.

Alan

"John Loomis" <jloomis@mcn.org> wrote in message
news:459d128a$0$80107$235e9798@corp-news.dsltransport.net...
> Hello Mike,
> I have to be the one to have had RP. Radical Prostatectomy. 1999.
> The Surgeon choice is important.

It is, as Alan said, one who will give you time, patience and full answers
to all your questions - and those you didn't ask - is the best choice for
you.

> I was building cabinets in my garage 10 days after surgery.

LOL! So was Spouse, after his RRP.

> I did not leak a drop, and erections took about 1.5 years to come
> back.....

He didn't leak after the catheter was removed (a week after discharge) and
erections returned almost as soon as he was back in bed with me. They're
getting better. Leaking and erections seem to be the most variable after any
kind of surgery but, really, they're not as important as your life.

> I lost many nerves in the surgery......I am fine, and looking back was
> glad to have a professional experienced surgeon who took great care of me.

Same here on both counts.

The surgeon is the key thing, not the process. A good surgeon will advise on
the best he can do for you.

Mary

Maui wrote:
> I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.
>
> Aloha
>
> Mike

Hi Mike...Here is a collection of articles relevant to your question.
Good luck with whatever technique you choose!..Best wishes and good
health, ron
---------------------------------------------------------------------------*--------------------------------------------------

This is from Medscape's review of the 2005 AUA meeting
http://www.medscape.com/viewarticle/507264?src=mp
"The positive surgical margin rate continues to be higher with
laparoscopic and robotic prostatectomy compared with the open
approach.[54,69,70] It is unclear how this will translate into
disease-free and overall survival, since the laparoscopic and robotic
experience is still immature. Nonetheless, it is cause for concern."

At the same meeting, Dr. Guillonneau, one of the originators of the
lap-procedure for RP said (in his abstract), "eradicating positive
margins at the distal prostatic apex remains a challenge."

Robotic-Assisted Laparoscopic Prostatectomy: Do Minimally Invasive
Approaches Offer Significant Advantages?
Joseph A. Smith Jr and S. Duke Herrell
Journal of Clinical Oncology (JCO),Nov. 10, 2005
"Separating hype from reality is sometimes difficult with many medical
procedures and this is particularly applicable to RALP. Patients who
appropriately research treatment options so that they can participate
in their own medical decisions may have difficulty interpreting
marketing efforts by hospitals and physicians. The lack of randomized
trials or even balanced prospective studies limits the ability to
analyze comparative results of RALP versus open surgical approaches."

On the subject of "the improved visual field vs. loss of tactile
feedback" discussion, here is a piece from one of Walsh's papers...
J Urol. 2005 Feb;173(2):446-9; Radical retropubic prostatectomy. How
often do experienced surgeons have positive surgical margins when there
is extraprostatic extension in the region of the neurovascular bundle?
Hernandez DJ, Epstein JI, Trock BJ, Tsuzuki T, Carter HB, Walsh PC.
"Visual and tactile assessment during open surgery by an experienced
surgeon provides valuable information on when and where it is safe to
preserve the neurovascular bundle in patients with EPE in the region of
the NVB. Surgical approaches in which tactile sensation is muted or
absent, laparoscopic and robotic, need to undergo a similar evaluation
to determine whether magnification of the operative field is sufficient
to overcome the lack of haptic feedback and ability to palpate the
tissue"

and finally, Dr. Catalona's view on the subject...
http://www.drcatalona.com
Question: I have been hearing a lot of good things about DaVinci
Robotics for removing the prostate. I know that you do not practice
the procedure, but what would you say about its benefits for preserving
potency and continence? And which patients should consider it as a
treatment alternative?

Answer: In my opinion, the robotic prostatectomy (often called the
DaVinci prostatectomy) is not as effective as the traditional open
prostatectomy for simultaneously accomplishing complete removal of
cancer and preserving potency.

One of the reasons is that the robot lacks the "human touch" and it is
not possible to appreciate how the prostate gland feels and how readily
it separates from the nerves and other surrounding tissues. The robot
does not handle the prostate gland as gently as the human hand, and not
infrequently the robot punctures the capsule of the prostate, leading
to positive surgical margins.

Another limitation is that with the robotic prostatectomy, the prostate
is removed by burning it out with electrocautery or a so-called
harmonic scalpel that cuts by heat, and if the heat is too near the
nerves, it irreversibly damages them. Also, if the burning is too close
to the prostate gland, it risks cutting into the prostate, resulting in
positive surgical margins and possibly leaving cancer behind.

Advocates of robotic surgery say that there is less bleeding and
greater magnification with robotic surgery. However, excellent
magnification and visualization can be provided with open surgery, and
with an experienced surgeon, few patients require blood transfusions
from another person.

With robotic surgery, it is more difficult to suture and apply
hemostatic clips and it is more difficult to perform a lymph node
dissection.

Enthusiasts of the robotic procedure claim it is "less invasive" and
has a quicker recovery time. But actually it is more invasive because
the surgeon has to go through the peritoneal cavity to get to the
prostate (a more invasive approach associated for
greater risk for injury to the bowel, major blood vessels, and the
ureters and a greater risk for later intestinal obstruction from
adhesions). Usually 6 one-inch incisions are made for robotic surgery,
while for open surgery, one 4 to 5 inch incision is made
that does not enter into the peritoneal cavity. With the smaller
incision now frequently used for open surgery, there is no material
difference in the recovery time and return to normal activity. . .

The complications with robotic prostatectomy are more serious than with
open prostatectomy and they lead to more postoperative emergency room
visits, more
re-hospitalizations, and more re-operations.

I believe that with the robotic or laparoscopic prostatectomy, the
patient and the surgeon have to make more of a stark choice between
removing all of the cancer or preserving the nerves to maintain
potency. I believe that there is a greater likelihood
of accomplishing both objects with the increased access provided by the
open approach.

Most importantly, however, the robotic prostatectomy has no track
record in terms of long-term cancer control. If small amounts of
cancer are left behind, it may not become apparent for years.

Patients sometimes tell me that they know someone who underwent a
robotic prostatectomy a few months ago and seems to be doing fine.
However, the final outcome of the operation may not become apparent for
up to 10 years. Thus, long-term cancer cure rates are needed before one
can truly evaluate the effectiveness of the
operation.

In sum, I do not believe the robotic prostatectomy is as safe a cancer
operation as open radical prostatectomy, and I do not believe that
nerve sparing can be as readily or safely accomplished. For patients,
the most important outcomes of radical prostatectomy are: Is he cured
of his cancer? Is he continent? Can he have erections sufficient for
intercourse?

These questions have been well documented for open rostatectomy. The
jury is still out with laparoscopic/robotic prostatectomy.

The most important factor is the surgeon and not the technique.

LFC

Thank you everyone for all the great information and your continued
support. I wrote that post late in the evening after a very hectic day
and left out what may be the most important part. I have total faith
in my surgeon's ability to perform a LRP. My concern, and the reason
for the 45 day wait, is that the facility is just now purchasing the
DaVinci robot. I have been assured that he is completely trained in
the use of said equipment. None the less, 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". I still have some concerns that there may be a bit
of a learning curve before he becomes proficient with that "tool".

What do you think?

With Aloha

Mike


On 4 Jan 2007 09:02:26 -0800, "ron" <oitbso@yahoo.com> wrote:

>Maui wrote:
>> I have given it much thought and have decided to proceed with a
>> Radical Prostatectomy. Now I have another decision to make. I was not
>> aware that I would be able to choose between the normal retropubic
>> procedure, laproscopic, or the Davinci robotic laproscopic for which I
>> would have to wait another 45 days. I would appreciate any advice
>> offered to help make this decision.
>>
>> Aloha
>>
>> Mike
>
>Hi Mike...Here is a collection of articles relevant to your question.
>Good luck with whatever technique you choose!..Best wishes and good
>health, ron
>---------------------------------------------------------------------------*--------------------------------------------------
>
>This is from Medscape's review of the 2005 AUA meeting
>http://www.medscape.com/viewarticle/507264?src=mp
>"The positive surgical margin rate continues to be higher with
>laparoscopic and robotic prostatectomy compared with the open
>approach.[54,69,70] It is unclear how this will translate into
>disease-free and overall survival, since the laparoscopic and robotic
>experience is still immature. Nonetheless, it is cause for concern."
>
>At the same meeting, Dr. Guillonneau, one of the originators of the
>lap-procedure for RP said (in his abstract), "eradicating positive
>margins at the distal prostatic apex remains a challenge."
>
>Robotic-Assisted Laparoscopic Prostatectomy: Do Minimally Invasive
>Approaches Offer Significant Advantages?
>Joseph A. Smith Jr and S. Duke Herrell
>Journal of Clinical Oncology (JCO),Nov. 10, 2005
>"Separating hype from reality is sometimes difficult with many medical
>procedures and this is particularly applicable to RALP. Patients who
>appropriately research treatment options so that they can participate
>in their own medical decisions may have difficulty interpreting
>marketing efforts by hospitals and physicians. The lack of randomized
>trials or even balanced prospective studies limits the ability to
>analyze comparative results of RALP versus open surgical approaches."
>
>On the subject of "the improved visual field vs. loss of tactile
>feedback" discussion, here is a piece from one of Walsh's papers...
>J Urol. 2005 Feb;173(2):446-9; Radical retropubic prostatectomy. How
>often do experienced surgeons have positive surgical margins when there
>is extraprostatic extension in the region of the neurovascular bundle?
>Hernandez DJ, Epstein JI, Trock BJ, Tsuzuki T, Carter HB, Walsh PC.
>"Visual and tactile assessment during open surgery by an experienced
>surgeon provides valuable information on when and where it is safe to
>preserve the neurovascular bundle in patients with EPE in the region of
>the NVB. Surgical approaches in which tactile sensation is muted or
>absent, laparoscopic and robotic, need to undergo a similar evaluation
>to determine whether magnification of the operative field is sufficient
>to overcome the lack of haptic feedback and ability to palpate the
>tissue"
>
>and finally, Dr. Catalona's view on the subject...
>http://www.drcatalona.com
>Question: I have been hearing a lot of good things about DaVinci
>Robotics for removing the prostate. I know that you do not practice
>the procedure, but what would you say about its benefits for preserving
>potency and continence? And which patients should consider it as a
>treatment alternative?
>
>Answer: In my opinion, the robotic prostatectomy (often called the
>DaVinci prostatectomy) is not as effective as the traditional open
>prostatectomy for simultaneously accomplishing complete removal of
>cancer and preserving potency.
>
>One of the reasons is that the robot lacks the "human touch" and it is
>not possible to appreciate how the prostate gland feels and how readily
>it separates from the nerves and other surrounding tissues. The robot
>does not handle the prostate gland as gently as the human hand, and not
>infrequently the robot punctures the capsule of the prostate, leading
>to positive surgical margins.
>
>Another limitation is that with the robotic prostatectomy, the prostate
>is removed by burning it out with electrocautery or a so-called
>harmonic scalpel that cuts by heat, and if the heat is too near the
>nerves, it irreversibly damages them. Also, if the burning is too close
>to the prostate gland, it risks cutting into the prostate, resulting in
>positive surgical margins and possibly leaving cancer behind.
>
>Advocates of robotic surgery say that there is less bleeding and
>greater magnification with robotic surgery. However, excellent
>magnification and visualization can be provided with open surgery, and
>with an experienced surgeon, few patients require blood transfusions
>from another person.
>
>With robotic surgery, it is more difficult to suture and apply
>hemostatic clips and it is more difficult to perform a lymph node
>dissection.
>
>Enthusiasts of the robotic procedure claim it is "less invasive" and
>has a quicker recovery time. But actually it is more invasive because
>the surgeon has to go through the peritoneal cavity to get to the
>prostate (a more invasive approach associated for
>greater risk for injury to the bowel, major blood vessels, and the
>ureters and a greater risk for later intestinal obstruction from
>adhesions). Usually 6 one-inch incisions are made for robotic surgery,
>while for open surgery, one 4 to 5 inch incision is made
>that does not enter into the peritoneal cavity. With the smaller
>incision now frequently used for open surgery, there is no material
>difference in the recovery time and return to normal activity. . .
>
>The complications with robotic prostatectomy are more serious than with
>open prostatectomy and they lead to more postoperative emergency room
>visits, more
>re-hospitalizations, and more re-operations.
>
>I believe that with the robotic or laparoscopic prostatectomy, the
>patient and the surgeon have to make more of a stark choice between
>removing all of the cancer or preserving the nerves to maintain
>potency. I believe that there is a greater likelihood
>of accomplishing both objects with the increased access provided by the
>open approach.
>
>Most importantly, however, the robotic prostatectomy has no track
>record in terms of long-term cancer control. If small amounts of
>cancer are left behind, it may not become apparent for years.
>
>Patients sometimes tell me that they know someone who underwent a
>robotic prostatectomy a few months ago and seems to be doing fine.
>However, the final outcome of the operation may not become apparent for
>up to 10 years. Thus, long-term cancer cure rates are needed before one
>can truly evaluate the effectiveness of the
>operation.
>
>In sum, I do not believe the robotic prostatectomy is as safe a cancer
>operation as open radical prostatectomy, and I do not believe that
>nerve sparing can be as readily or safely accomplished. For patients,
>the most important outcomes of radical prostatectomy are: Is he cured
>of his cancer? Is he continent? Can he have erections sufficient for
>intercourse?
>
>These questions have been well documented for open rostatectomy. The
>jury is still out with laparoscopic/robotic prostatectomy.
>
>The most important factor is the surgeon and not the technique.
>
>LFC

Best wishes Mike and we're all here to support you.

oitbso (ron)...gave you a nice number of articles.

In 2005, I had an open RP by Dr, Catalona.

Things are going well as far as cancer removal...which was my main
concern.

The other methods have upsides in recovery times etc.

The fact that they don't have as long a track record compared to the
open method can be looked at a few ways.

I've always thought that there are great surgeons all over the
world...but they may not have the big reputations only because they
haven't been working so long.

When they DO have a long track record...THEY may be consdered the best.

I'm sure you'll make a good choice...thinking about what is important to
YOU.

We wish you the best.

Ron B.

Chicago

On Thu, 04 Jan 2007 07:50:19 -1000, Maui Mike wrote:

>Thank you everyone for all the great information and your continued
>support. I wrote that post late in the evening after a very hectic day
>and left out what may be the most important part. I have total faith
>in my surgeon's ability to perform a LRP. My concern, and the reason
>for the 45 day wait, is that the facility is just now purchasing the
>DaVinci robot. I have been assured that he is completely trained in
>the use of said equipment. None the less, 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". I still have some concerns that there may be a bit
>of a learning curve before he becomes proficient with that "tool".

Oops! I must admit that would worry me but then I am a worrier!

We're often counseled here to ask very direct questions. Can you meet
with the surgeon and ask him directly what the learning curve entails?
Is pilot error a possibility? If he's being supervised by a skilled
consultant then perhaps you should know who this will be?
Could you ask (without risk to his pride!) if you might just go with
the 'traditional' LRP since you are nervous about being one of his
'first' with the robot.

I'd be interested in what others have to say about this. It's always
left me feeling uneasy that in this ng, by insisting on the 'best', we
are condemning others to whatever remains...

I had the DaVinci done Nov. 17th with both nerves being spared. I also
chose Dr. Miles after visiting several doctors at MD. Anderson Cancer
Institute. The doctors at M.D. were great but Miles' personality and
experience won me over. I came back to work January 2nd because I was
in no hurry. There was NO pain when Jan (Miles' nurse) took the
catheter out...whew and I was so nervous that Jan would rip it out

Leakage when I laugh and sometimes when I get up to stand, but I feel
I'll be fine in a few weeks. I took 3 months to interview doctors and
to decide on my treatment. I had one doctor to tell me he would spare
one nerve and I ran away from him. Doctors are not all knowing.


Jean wrote:
> My husband had the DaVinci method surgery done in Sept. From the time he
> hit the recovery room post-surgery to the time he was released was 39 hours.
> His catheter was in for nine days and he went back to work on day 10.
> Played golf on day 11. No leakage at all. And now at 3 1/2 months post-op
> the erections are coming back, which is wonderful considering 30% of the
> nerves on one side were compromised and had to be removed. (And re-built.)
>
> Choose your surgeon well. Make sure you do as much research into him or
> her's surgery record as you do in every other aspect of this disease. If
> you are anywhere near Houston we highly recommend Dr. Brian Miles. He was
> instrumental in the bladder sling procedure for men and he has done
> thousands of robotic surgeries. The man is good. ;o}
>
> Good luck and make sure to let us know what you decide.
>
> Jean & Larry

<Maui Mike> wrote in message
news:07cpp2htcj48u1t8c6dp7r67r29d5oftrc@4ax.com...
>I have given it much thought and have decided to proceed with a
> Radical Prostatectomy. Now I have another decision to make. I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days. I would appreciate any advice
> offered to help make this decision.

I'm quite sure you were often told here that you need to research this
disease, it's treatments, and their consequences. Not knowing that RRP was
one of several surgery options, including RPP, LRP and RLRP, shows that you
have done very litt... no... make that no research. So, you want to make a
decision that will have effects for the rest of your life based on your
physicians opinion and attendant vagaries and our opinion?

Okay by me. Get the robot. It's the best thing going for a 55-year-old
with a T1c and Gleason 6.

But, I'd sure feel better if you'd read at least one book to find out why.




--
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

I would feel similiar....First time.....for machine etc....
Tough decision.
Does your Dr. speak with assurance that he can help you?
I went to many Dr.s
Finally I found one that spoke with assurance, handshake, etc.
If you have a gut feeling that you made the right decision, what else can a
guy do.
I am sorry, there is no real answer.....
You do have many choices...
I would trust your Dr. with all the new equiptment. He seems comfortable
with that.
John Loomis
<Maui Mike> wrote in message
news:m8eqp2d6u9ato69r4rkudgaeam6cp8e59q@4ax.com...
> Thank you everyone for all the great information and your continued
> support. I wrote that post late in the evening after a very hectic day
> and left out what may be the most important part. I have total faith
> in my surgeon's ability to perform a LRP. My concern, and the reason
> for the 45 day wait, is that the facility is just now purchasing the
> DaVinci robot. I have been assured that he is completely trained in
> the use of said equipment. None the less, 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". I still have some concerns that there may be a bit
> of a learning curve before he becomes proficient with that "tool".
>
> What do you think?
>
> With Aloha
>
> Mike
>
>
> On 4 Jan 2007 09:02:26 -0800, "ron" <oitbso@yahoo.com> wrote:
>
>>Maui wrote:
>>> I have given it much thought and have decided to proceed with a
>>> Radical Prostatectomy. Now I have another decision to make. I was not
>>> aware that I would be able to choose between the normal retropubic
>>> procedure, laproscopic, or the Davinci robotic laproscopic for which I
>>> would have to wait another 45 days. I would appreciate any advice
>>> offered to help make this decision.
>>>
>>> Aloha
>>>
>>> Mike
>>
>>Hi Mike...Here is a collection of articles relevant to your question.
>>Good luck with whatever technique you choose!..Best wishes and good
>>health, ron
>>---------------------------------------------------------------------------*--------------------------------------------------
>>
>>This is from Medscape's review of the 2005 AUA meeting
>>http://www.medscape.com/viewarticle/507264?src=mp
>>"The positive surgical margin rate continues to be higher with
>>laparoscopic and robotic prostatectomy compared with the open
>>approach.[54,69,70] It is unclear how this will translate into
>>disease-free and overall survival, since the laparoscopic and robotic
>>experience is still immature. Nonetheless, it is cause for concern."
>>
>>At the same meeting, Dr. Guillonneau, one of the originators of the
>>lap-procedure for RP said (in his abstract), "eradicating positive
>>margins at the distal prostatic apex remains a challenge."
>>
>>Robotic-Assisted Laparoscopic Prostatectomy: Do Minimally Invasive
>>Approaches Offer Significant Advantages?
>>Joseph A. Smith Jr and S. Duke Herrell
>>Journal of Clinical Oncology (JCO),Nov. 10, 2005
>>"Separating hype from reality is sometimes difficult with many medical
>>procedures and this is particularly applicable to RALP. Patients who
>>appropriately research treatment options so that they can participate
>>in their own medical decisions may have difficulty interpreting
>>marketing efforts by hospitals and physicians. The lack of randomized
>>trials or even balanced prospective studies limits the ability to
>>analyze comparative results of RALP versus open surgical approaches."
>>
>>On the subject of "the improved visual field vs. loss of tactile
>>feedback" discussion, here is a piece from one of Walsh's papers...
>>J Urol. 2005 Feb;173(2):446-9; Radical retropubic prostatectomy. How
>>often do experienced surgeons have positive surgical margins when there
>>is extraprostatic extension in the region of the neurovascular bundle?
>>Hernandez DJ, Epstein JI, Trock BJ, Tsuzuki T, Carter HB, Walsh PC.
>>"Visual and tactile assessment during open surgery by an experienced
>>surgeon provides valuable information on when and where it is safe to
>>preserve the neurovascular bundle in patients with EPE in the region of
>>the NVB. Surgical approaches in which tactile sensation is muted or
>>absent, laparoscopic and robotic, need to undergo a similar evaluation
>>to determine whether magnification of the operative field is sufficient
>>to overcome the lack of haptic feedback and ability to palpate the
>>tissue"
>>
>>and finally, Dr. Catalona's view on the subject...
>>http://www.drcatalona.com
>>Question: I have been hearing a lot of good things about DaVinci
>>Robotics for removing the prostate. I know that you do not practice
>>the procedure, but what would you say about its benefits for preserving
>>potency and continence? And which patients should consider it as a
>>treatment alternative?
>>
>>Answer: In my opinion, the robotic prostatectomy (often called the
>>DaVinci prostatectomy) is not as effective as the traditional open
>>prostatectomy for simultaneously accomplishing complete removal of
>>cancer and preserving potency.
>>
>>One of the reasons is that the robot lacks the "human touch" and it is
>>not possible to appreciate how the prostate gland feels and how readily
>>it separates from the nerves and other surrounding tissues. The robot
>>does not handle the prostate gland as gently as the human hand, and not
>>infrequently the robot punctures the capsule of the prostate, leading
>>to positive surgical margins.
>>
>>Another limitation is that with the robotic prostatectomy, the prostate
>>is removed by burning it out with electrocautery or a so-called
>>harmonic scalpel that cuts by heat, and if the heat is too near the
>>nerves, it irreversibly damages them. Also, if the burning is too close
>>to the prostate gland, it risks cutting into the prostate, resulting in
>>positive surgical margins and possibly leaving cancer behind.
>>
>>Advocates of robotic surgery say that there is less bleeding and
>>greater magnification with robotic surgery. However, excellent
>>magnification and visualization can be provided with open surgery, and
>>with an experienced surgeon, few patients require blood transfusions
>>from another person.
>>
>>With robotic surgery, it is more difficult to suture and apply
>>hemostatic clips and it is more difficult to perform a lymph node
>>dissection.
>>
>>Enthusiasts of the robotic procedure claim it is "less invasive" and
>>has a quicker recovery time. But actually it is more invasive because
>>the surgeon has to go through the peritoneal cavity to get to the
>>prostate (a more invasive approach associated for
>>greater risk for injury to the bowel, major blood vessels, and the
>>ureters and a greater risk for later intestinal obstruction from
>>adhesions). Usually 6 one-inch incisions are made for robotic surgery,
>>while for open surgery, one 4 to 5 inch incision is made
>>that does not enter into the peritoneal cavity. With the smaller
>>incision now frequently used for open surgery, there is no material
>>difference in the recovery time and return to normal activity. . .
>>
>>The complications with robotic prostatectomy are more serious than with
>>open prostatectomy and they lead to more postoperative emergency room
>>visits, more
>>re-hospitalizations, and more re-operations.
>>
>>I believe that with the robotic or laparoscopic prostatectomy, the
>>patient and the surgeon have to make more of a stark choice between
>>removing all of the cancer or preserving the nerves to maintain
>>potency. I believe that there is a greater likelihood
>>of accomplishing both objects with the increased access provided by the
>>open approach.
>>
>>Most importantly, however, the robotic prostatectomy has no track
>>record in terms of long-term cancer control. If small amounts of
>>cancer are left behind, it may not become apparent for years.
>>
>>Patients sometimes tell me that they know someone who underwent a
>>robotic prostatectomy a few months ago and seems to be doing fine.
>>However, the final outcome of the operation may not become apparent for
>>up to 10 years. Thus, long-term cancer cure rates are needed before one
>>can truly evaluate the effectiveness of the
>>operation.
>>
>>In sum, I do not believe the robotic prostatectomy is as safe a cancer
>>operation as open radical prostatectomy, and I do not believe that
>>nerve sparing can be as readily or safely accomplished. For patients,
>>the most important outcomes of radical prostatectomy are: Is he cured
>>of his cancer? Is he continent? Can he have erections sufficient for
>>intercourse?
>>
>>These questions have been well documented for open rostatectomy. The
>>jury is still out with laparoscopic/robotic prostatectomy.
>>
>>The most important factor is the surgeon and not the technique.
>>
>>LFC

ron wrote:
> ...
> Hi Mike...Here is a collection of articles relevant to your question.
> ...

Ron,

We've talked about this question a hundred times, but your posting
must be the most informative one we've had on this subject.

I don't know if our laparoscopic surgeon still reads this newsgroup,
but if he does, I'd be very curious to hear his reaction to these
excerpts.

Mike,

You might want to print out Ron's posting and show it to your
surgeon to get his reaction. If you do that, please let us know
what he says.

As for the Dr. using the DaVinci without a lot of experience with
it, my pure speculation is that this adds extra risk to the procedure
but does not, in itself, mean you shouldn't do it. Hopefully the
doctor will take his relative inexperience at this into account,
schedule more time than usual to do it, and do a very careful
job.

Or as the old carpenter says, "measure twice, cut once".

Alan

Maui wrote:
> Thank you everyone for all the great information and your continued
> support. I wrote that post late in the evening after a very hectic day
> and left out what may be the most important part. I have total faith
> in my surgeon's ability to perform a LRP. My concern, and the reason
> for the 45 day wait, is that the facility is just now purchasing the
> DaVinci robot. I have been assured that he is completely trained in
> the use of said equipment. None the less, 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". I still have some concerns that there may be a bit
> of a learning curve before he becomes proficient with that "tool".
>
> What do you think?
>
> With Aloha
>
> Mike

Mike...It is generally acknowledged that there is a steep learning
curve with the Da Vinci equipment. Many say that the curve plateaus
around 100-300 cases. Here is a recent reference on the subject...Best
wishes and good health, ron

World J Urol. 2006 Dec 28
>From proficiency to expert, when does the learning curve for
robotic-assisted prostatectomies plateau? The Columbia University
experience.

Samadi D, Levinson A, Hakimi A, Shabsigh R, Benson MC.

Department of Urology, Columbia University, 161 Fort Washington Avenue,
New York, NY, USA, robotmd@aol.com.

To describe our single-institution experience with our first 70
consecutive robotic-assisted laparoscopic prostatectomies (RLPs) with
particular focus on effect of learning curve on operative time, length
of stay and blood loss. We also report our short-term outcome data in
this heterogeneous cohort of men with prostate cancer (PCa). We
reviewed our institutional database for the first 70 consecutive RLPs
performed by a single surgeon (DS) over a 21-month period (March 2003
to December 2004). Surgical, pathologic and postoperative outcomes were
analyzed. In order to evaluate the impact of the surgeon's and
institution's learning curve on outcomes, the cases were divided into
quartiles and stratified accordingly to identify trends. Ninety-nine
percent (69/70) of all procedures were successfully completed
robotically. Mean blood loss, operative time and mean length of stay
were 231 ml, 264 min and 1.9 days, respectively. At follow-up, 76% of
all patients were fully continent (no pads) and 93% (62/67) had
undetectable PSA. The most dramatic improvement in surgical outcomes
was seen within the first quartile of cases; however a statistically
significant improvement trend existed throughout the series. This
included a downward trend in operative time (P < 0.00001), estimated
blood loss (P < 0.00001), and length of hospital stay (P = 0.003). This
trend continued when controlled for in a multivariate analysis. Our
results compare favorably with other RLP series as well as conventional
laparoscopic series. Proficiency is achieved within the first 20 cases;
however surgical outcomes continue to improve for RLP throughout the
first 70 cases and perhaps beyond.

PMID: 17192816

Steve Kramer wrote:
> <Maui Mike> wrote in message
> news:07cpp2htcj48u1t8c6dp7r67r29d5oftrc@4ax.com...
>> I have given it much thought and have decided to proceed with a
>> Radical Prostatectomy. Now I have another decision to make. I was not
>> aware that I would be able to choose between the normal retropubic
>> procedure, laproscopic, or the Davinci robotic laproscopic for which I
>> would have to wait another 45 days. I would appreciate any advice
>> offered to help make this decision.
>
> I'm quite sure you were often told here that you need to research this
> disease, it's treatments, and their consequences. Not knowing that RRP was
> one of several surgery options, including RPP, LRP and RLRP, shows that you
> have done very litt... no... make that no research. So, you want to make a
> decision that will have effects for the rest of your life based on your
> physicians opinion and attendant vagaries and our opinion?
>
> Okay by me. Get the robot. It's the best thing going for a 55-year-old
> with a T1c and Gleason 6.
>
> But, I'd sure feel better if you'd read at least one book to find out why.

Oohhh, harsh, Steve.

And just the way I'd have written it, to make SURE it sinks in. I'd
rather make some poor guy blush for a while than fail to get a point
that important across.

I.P.

On 4 Jan 2007 18:37:40 -0800, "ron" <oitbso@yahoo.com> wrote:

>Maui wrote:
>> Thank you everyone for all the great information and your continued
>> support. I wrote that post late in the evening after a very hectic day
>> and left out what may be the most important part. I have total faith
>> in my surgeon's ability to perform a LRP. My concern, and the reason
>> for the 45 day wait, is that the facility is just now purchasing the
>> DaVinci robot. I have been assured that he is completely trained in
>> the use of said equipment. None the less, 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". I still have some concerns that there may be a bit
>> of a learning curve before he becomes proficient with that "tool".
>>
>> What do you think?
>>
>> With Aloha
>>
>> Mike
>
>Mike...It is generally acknowledged that there is a steep learning
>curve with the Da Vinci equipment. Many say that the curve plateaus
>around 100-300 cases. Here is a recent reference on the subject...Best
>wishes and good health, ron
>
>World J Urol. 2006 Dec 28
>>From proficiency to expert, when does the learning curve for
>robotic-assisted prostatectomies plateau? The Columbia University
>experience.
>
>Samadi D, Levinson A, Hakimi A, Shabsigh R, Benson MC.
>
>Department of Urology, Columbia University, 161 Fort Washington Avenue,
>New York, NY, USA, robotmd@aol.com.
>
>To describe our single-institution experience with our first 70
>consecutive robotic-assisted laparoscopic prostatectomies (RLPs) with
>particular focus on effect of learning curve on operative time, length
>of stay and blood loss. We also report our short-term outcome data in
>this heterogeneous cohort of men with prostate cancer (PCa). We
>reviewed our institutional database for the first 70 consecutive RLPs
>performed by a single surgeon (DS) over a 21-month period (March 2003
>to December 2004). Surgical, pathologic and postoperative outcomes were
>analyzed. In order to evaluate the impact of the surgeon's and
>institution's learning curve on outcomes, the cases were divided into
>quartiles and stratified accordingly to identify trends. Ninety-nine
>percent (69/70) of all procedures were successfully completed
>robotically. Mean blood loss, operative time and mean length of stay
>were 231 ml, 264 min and 1.9 days, respectively. At follow-up, 76% of
>all patients were fully continent (no pads) and 93% (62/67) had
>undetectable PSA. The most dramatic improvement in surgical outcomes
>was seen within the first quartile of cases; however a statistically
>significant improvement trend existed throughout the series. This
>included a downward trend in operative time (P < 0.00001), estimated
>blood loss (P < 0.00001), and length of hospital stay (P = 0.003). This
>trend continued when controlled for in a multivariate analysis. Our
>results compare favorably with other RLP series as well as conventional
>laparoscopic series. Proficiency is achieved within the first 20 cases;
>however surgical outcomes continue to improve for RLP throughout the
>first 70 cases and perhaps beyond.
>
>PMID: 17192816


Ron

Thanks for the great information. I have decided to fly to the
hospital next Wednesday for a consultation with my surgeon. Like Alan
Meyer's suggested, I will take a copy of this data with me and try to
include it in our discussion.

Mike

Maui wrote:

> I still have some concerns that there may be a bit
> of a learning curve before he becomes proficient with that "tool".
>
> What do you think?
>

It's hard to ask the tough questions, but you really should if it's a
concern for you. How many surgeries has your surgeon done with the
DaVinci? How many laparoscopic surgeries? Where did they learn to do
it? What problems have they encountered, or what mistakes have they
made? (And yes, I did ask my doctor those questions, and was pleased
to find that he hadanticipated my doing so and was ready with honest
answers).

If you've covered those things with your surgeon and you're still
uncomfortable ... I just went online and found an article on some of
the doctors in Honolulu who do prostate surgery; it looks like there
are several who do open and laparoscopic procedures. You have some
choices. And the time to choose wisely.

--charlie

On Thu, 4 Jan 2007 20:10:40 -0500, "Steve Kramer"
<skramer@cinci.rr.com> wrote:

>
><Maui Mike> wrote in message
>news:07cpp2htcj48u1t8c6dp7r67r29d5oftrc@4ax.com.. .
>>I have given it much thought and have decided to proceed with a
>> Radical Prostatectomy. Now I have another decision to make. I was not
>> aware that I would be able to choose between the normal retropubic
>> procedure, laproscopic, or the Davinci robotic laproscopic for which I
>> would have to wait another 45 days. I would appreciate any advice
>> offered to help make this decision.
>
>I'm quite sure you were often told here that you need to research this
>disease, it's treatments, and their consequences. Not knowing that RRP was
>one of several surgery options, including RPP, LRP and RLRP, shows that you
>have done very litt... no... make that no research. So, you want to make a
>decision that will have effects for the rest of your life based on your
>physicians opinion and attendant vagaries and our opinion?
>
>Okay by me. Get the robot. It's the best thing going for a 55-year-old
>with a T1c and Gleason 6.
>
>But, I'd sure feel better if you'd read at least one book to find out why.

Steve

I'm not sure what to say. While I thought this was a "support group" I
now regret showing my ignorance in my request for support. For what
it's worth, I am indeed aware of the treatment options available, but
I was not made aware until yesterday that the two laprascopic options
were actually available to me.

I have been told not to delay. I have made my decision to have my
prostate removed. I live in the middle of the Pacific Ocean were
resources are limited. My insurance requires me to be treated here at
home. I have little choice when it comes to hospitals and surgeons.
While I'm sure none of this matters to you, please understand I am
doing the best I know how in a situation that has been very difficult
for me.

I would like to thank all of those who have helped me get this far. I
feel I can't add much value to this group so I'll return to lurking.

Much Aloha, and good health to all.

Mike Eddy

Hello Alan.
Sometimes we measure 3 times.....
I would feel uncomfortable with a "new machine" and the 1st patient.
Anyway.....Maui Mike seems to be questioning..
Wish I had the answer...
John Loomis

"Alan Meyer" <ameyer2@yahoo.com> wrote in message
news:1167961627.301365.4580@v33g2000cwv.googlegrou ps.com...
> ron wrote:
>> ...
>> Hi Mike...Here is a collection of articles relevant to your question.
>> ...
>
> Ron,
>
> We've talked about this question a hundred times, but your posting
> must be the most informative one we've had on this subject.
>
> I don't know if our laparoscopic surgeon still reads this newsgroup,
> but if he does, I'd be very curious to hear his reaction to these
> excerpts.
>
> Mike,
>
> You might want to print out Ron's posting and show it to your
> surgeon to get his reaction. If you do that, please let us know
> what he says.
>
> As for the Dr. using the DaVinci without a lot of experience with
> it, my pure speculation is that this adds extra risk to the procedure
> but does not, in itself, mean you shouldn't do it. Hopefully the
> doctor will take his relative inexperience at this into account,
> schedule more time than usual to do it, and do a very careful
> job.
>
> Or as the old carpenter says, "measure twice, cut once".
>
> Alan
>

Maui Mike wrote:


> I was not
> aware that I would be able to choose between the normal retropubic
> procedure, laproscopic, or the Davinci robotic laproscopic for which I
> would have to wait another 45 days.

> "Steve Kramer" wrote:

>> I'm quite sure you were often told here that you need to research this
>> disease, it's treatments, and their consequences. Not knowing that RRP was
>> one of several surgery options, including RPP, LRP and RLRP, shows that you
>> have done very litt... no... make that no research.
>
> I'm not sure what to say. While I thought this was a "support group" I
> now regret showing my ignorance in my request for support. For what
> it's worth, I am indeed aware of the treatment options available, but
> I was not made aware until yesterday that the two laprascopic options
> were actually available to me.

> I would like to thank all of those who have helped me get this far. I
> feel I can't add much value to this group so I'll return to lurking.

Mike, surely you understand that Steve and I understood your opening
statement above to mean you were UNAWARE of those other forms of
prostatectomies -- which would legitimately lead us to conclude your
research was woefully inadequate. That often happens here, as evidenced
by people revealing some awfully limited knowledge -- as we THOUGHT you
did -- after claiming to have done a lot of research. It also often
takes a good slap across the chops to make that point. You'll get over
the misunderstanding -- a pitfall of written communication -- and will
learn a great deal by asking more questions.

I.P.

> Aloha Mike--

Welcome to the club. I'm sure things feel overwhelming for you now,
but they will get better. I just wanted to tell you that my
sister-in-law lives in Kauai (with her handsome 2 Hawaiian boys).
Well, she just sent me a photo calendar for the new year and I wish the
year were 1000 mos. in the year because those photos were just out of