Robot-Assisted Radical Prostatectomy.

[pjoshea13]

New study below.

I have never understood the early enthusiasm for robot-assisted radical prostatectomy. A friend in Kentucky had a biopsy about 5 years ago & was shown the da Vinci that had just been delivered. Would he have been the first patient had his biopsy been positive? A neighbor who had a robotic RP, woke up the morning after his return home, in a pool of blood. His wife rushed him to the ER. He had a clot in his lungs, as well as local clots. His wife was told she had saved his life. Sometimes not good to be an early adoptor.

There is so much hype about da Vinci, but the surgeon has to perform a much larger number of procedures before becoming proficient. And experienced surgeons sometimes never become proficient.

Here is a frightening statistic:

"In 2011, 70% of hospitals averaged 1 robot-assisted radical prostatectomy per week or less".

"Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) ..."

Perhaps those hospitals were doing so few because men were smart enough to be going to the high-volume places?

Even in the high volume places there will be less experienced surgeons.

When I was considering Johns Hopkins (for old-fashioned RP), I was informed that there would be an experienced person in the room. LOL (I didn't have the clout or $$$ to get Patrick Walsh.)

Hopkins was suffering from excess demand at that time. I heard that one man had been told that he would be operated on by one of their very top surgeons. & she was - but she had been co-opted from Gynecology, due to high volume. Seems to have turned out well, but what do most men really know at the start?

I suppose that this post doesn't belong here, but when asked for advice we need to say that it's important to get someone who has done a lot of them. Of course, some surgeons might not improve much after the 50th RP, but one can't readily obtain 5-year survival statistics.

-Patrick

jurology.com/article/S0022-...

Redefining and Contextualizing the Hospital Volume-Outcome Relationship for Robot-Assisted Radical Prostatectomy: Implications for Centralization of Care

Robot-assisted radical prostatectomy has undergone rapid dissemination driven in part by market forces to become the most frequently used surgical approach in the management of prostate cancer. Accordingly, a critical analysis of its volume-outcome relationship has important health policy implications. Therefore, we evaluated the association of hospital robot-assisted radical prostatectomy volume with perioperative outcomes, and examined the distribution of hospital procedure volume to contextualize the volume-outcome relationship.

Materials and Methods

We identified 140,671 men who underwent robot-assisted radical prostatectomy from 2009 to 2011 in NIS (Nationwide Inpatient Sample). The associations of hospital volume with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression and generalized linear models.

Results

In 2011, 70% of hospitals averaged 1 robot-assisted radical prostatectomy per week or less, accounting for 28% of surgeries. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications (0.6% vs 1.4%), postoperative complications (4.8% vs 13.9%), perioperative blood transfusion (1.5% vs 4.0%), prolonged hospitalization (4.3% vs 13.8%) and mean total hospital costs ($12,647 vs $15,394, all ptrend <0.001). When modeled as a nonlinear continuous variable, increasing hospital volume was independently associated with improved rates of each perioperative end point up to approximately 100 robot-assisted radical prostatectomies per year, beyond which there appeared to be marginal improvement.

Conclusions

Increasing hospital robot-assisted radical prostatectomy volume was associated with improved perioperative outcomes up to approximately 100 surgeries per year, beyond which there appeared to be marginal improvement. A substantial proportion of these procedures is performed at low volume hospitals.

[BigRich]

In 1999 ther was a surgeon who had just got the first machine in NYC; however, he had less then 100 surgerys on the machine. I decided he, at that time, did not have enough experiemnce.

Rich

[AlanMeyer]

I think you've highlighted two problems we face in many kinds of medical treatment, not just those for prostate cancer and not just surgery.

One is that inexperienced people are carrying out complex procedures and treatments. In PCa, we get urologists who do very few prostatectomies of any kind per year offering to perform the surgery on patients and don't even tell them that they are not highly experienced. I found out that the urologist who offered me surgery through my HMO was actually a specialist in female incontinence and only did maybe a half dozen prostatectomies per year. I shied away from him. This is a problem for open surgery as well as for DaVinci assisted surgery. It's also a problem for radiation oncology and medical oncology. In both areas we get doctors who treat every imaginable kind of cancer and can't possibly keep up with the latest science in all of them.

The second one, I think, is that we patients make the mistake of believing newer is better and high tech is better than low tech. So we fall for sales pitches. I've seen men who wanted HIFU or cryotherapy at a time when the techniques were quite new and what statistics existed showed worse outcomes than for surgery or radiation. I've seen no evidence that proton beam is more effective than IMRT or brachytherapy but I saw a posting from a guy who mortgaged his house to pay $70,000 for the procedure at Loma Linda because his insurance would only pay for x-ray treatment, not proton beam.

A similar problem occurs with drugs. New drugs aren't always better than old ones - a real problem in blood pressure and other heart medications.

[Sisira in reply to AlanMeyer]

Thank you Alan for your eye opener and being a realist.

Sisira

[Darryl Partner]

Important post. Well done.

[Dr_WHO]

Very good point! From everything I have read the number one thing determining the otutcome is how many procedures the surgeon has done. I had DaVinci surgery about 18 months ago from the surgeon that did the first DaVinci surgery back in 2001 and does literally thousands every year. However, I would of gone for open surgery if I could of found one with more experience.

[jpenn1943]

I had robotic prostate surgery in 2015, remove prostate, seminal vesicles , and multiple lymph nodes. Cancer had already metastized. My surgeon performed 8 radical prostectomys that day. Last count I heard was he has surpassed 10,000 surgeries to date. It was kind of like an assembly line, they got up the next morning at 8:00 for a lecture on aftercare and release us by 9:00 AM . I had to check into motel as I was unable to rie 130 mi km es to get home.

[Break60]

I was scheduled for robotic in 2013 at JH by Dr Schaeffer who now heads up urology at Northwestern. He trained under Walsh at JH. The day before surgery he changed his mind and recommended open surgery for my Gleason 9. Felt he could do a better job preserving nerves and dissecting nodes if he could feel his way around. He assured me that recovery would not differ. I never had robotic so I don't know the difference. I stayed in hospital two nights and flew home the third day. No complications whatsoever but pathology was bad: EPE at base, bilateral SVI, pos. margin at base, but nodes clear. Cath and staples removed 11 days post RP. Golf three weeks later. Wore one pad a day for 13 weeks but barely needed them. I had mild ED before surgery due to meds for BPH and had worse ED after surgery. I have total ED four years later after multiple bouts of RT and ADT. Highly rec JH.

Bob

[pjoshea13 in reply to Break60]

Bob,

Once the equipment has been bought, there is pressure to use it. Good for Dr Schaeffer, who placed his patient before economics.

-Patrick

[herb1]

This issue occurs with all surgery; experience is critical. But as patients the issue really is how to find out the facts and what do we do with them. How many guys ask their urologist/surgeon or their radiation oncologist how many cases like mine they've handled in the last year? AND, what frequency of complications did they encounter? And we must, of course, believe the doctor! But we're lucky, prostate cancer is not usually an emergency situation and we can "shop around" a bit.

On the other hand, I just underwent triple bypass and only now am I asking myself what were the credentials of the surgeon who did (oversaw?) my surgery?

Herb

[pjoshea13 in reply to herb1]

Herb,

We often get no advance notice of the need for surgery. I'm sure that most of us think we failed to handle the situation optimally, in retrospect.

When my RP failed & I was deciding whether to get salvage radiation, the advice I remember from a couple of well-known doctors was "make sure you go to an artist"! Crazy! How does a patient find a radio-artist? Seems that experience will take a specialist only so far. One also needs to visualize placement of all internal organs? Scary idea.

-Patrick

[WendyL in reply to pjoshea13]

I think we find good practitioners by asking other good practitioners. If you like and trust your surgeon, ask him/her to which radiologist would he or she go -- or send a family member -- for that particular treatment.

Wendy

[Shepard]

We probably need to recognize that we are pioneers, especially if you begin treatment with advanced aggressive cancer. I received the robotic procedure in 2011 and found to be Stage 3 "aggressive." My "operator" had completed 300 procedures prior to mine. Except for a redundancy in the bowel, recovery was quick and satisfactory. I considered the "experience" factor in selecting this procedure. However, in Little Rock AR there are not many choices. My acceptance of the procedure over alternatives was base upon expected outcomes. Performance of the robot seemed more likely to be stable than that of surgeon fingers. As it turned out I was not on a cure path. IMRT failed, now on Lupron and bicalutamide and PSA is rising from 1.1 three months ago to 3.0 now. Now checking for mets. I am six years from the robotic procedure. Have functioned far differently from life pre-treatment, but life continues to be rewarding. Looking forward to what is "next."

[herb1]

Shepard: The following may be taking us in an unexpected direction. You wrote: " Have functioned far differently from life pre-treatment, but life continues to be rewarding. Looking forward to what is "next."

I'm 81, just had triple bypass, my psa has plateaued at 1.4 for the last 6 months after 15+ years of control on IADT3. How do you see life as "rewarding"? I would have been happy with my chosen DNR path but failed to have a medallion on me when my latest disaster occurred.

herb s

[ctarleton in reply to herb1]

Hi Herb,

I saw your question to Shepard. From my own experience of being diagnosed 3 years and 8 months ago as "incurable" at age 65, with numerous bone and lymph node mets and a starting PSA of 5,006, I can attest to the personal difficulties of coming terms with the implications of all that. I feel I would be very fortunate to live into my 80s.

I may never be "cured" of my disease, but I feel like I have already been "healed" in many ways as I have had a new awareness of my mortality, and have been able to make some incremental changes in the ways I live, love, communicate, and interact in this world. I will always be living "at the will of my body", but, in some ways, having an ultimately incurable cancer has given me new opportunities for living a deeper, more authentic life - despite my individual disease or past/present/future treatments or sufferings.

For me, the deep pains, anguish, sadness, sense of loss, fears, and some anger are still there, and there is no way around "living with them" for a while as part of my human experience. But, they have also been balanced by some new-found sense of wonder of this world, some more humbling, some gratitude & forgiveness, unexpected openings as I have opened up myself and asked for help, some more hugs in my life, some more patience, a closer family life, some good experiences in support groups, and some better acceptance, a bit more calm when I am calm, and a letting go of a lot of the small stuff that no longer matters.

I'll take it all.

Charles

[herb1 in reply to ctarleton]

Charles, thanks for the reply. I'm glad...at least for you. You sound like you have come to peace.

herb s

[adlerman]

Too many guys don't bother researching alternatives and just go for "cut it out". Most of them are probably told the nerve sparing technique will be used and wake up to

hear "we ran into some problems". Cryosurgery is the only procedure that is repeatable.

I picked that one 15 years ago and my psa has been 0.07 ever since.

[Hidden]

I was told that, after TURP surgery, I was not a good candidate for a radical prostectamy, Da Vinci or open. I had no problem with that. The thought of having things in my urinary path cut and stitched back together without damaging nerves was scary. They did recommend external beam radiation. After research and reading entries on this forum that seemed iffy to me. I opted for HIFU. My surgeon was involved with the FDA in getting HIFU ablation approved so I was confident that I had found a very capable practitioner. To each his own, I guess. As others have said it is imperative to find an experienced and capable surgeon. All the choices involved are what makes prostate cancer difficult to deal with.

[jmurgia]

We all want to fly with "Sully". Since he's retired the best I can do is fly with experienced mature pilots. I only fly on the larger planes cuz that's where the experienced pilots are. It's not the plane but the pilot that matters most.

[Hidden in reply to jmurgia]

In the movie you might have heard Sully mention firing up the APU. I worked many years as an engineer for a company that manufactured Auxiliary Power Units. They can restart the main engines in flight when they flame out -- unless they have been destroyed by a bird strike and such. So you need a good pilot and having good engines help.