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Robotic surgery?

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User
Posted 27 Sep 2018 at 13:34

Good morning.

Following my biopsy and diagnosis for PCa last week, my bone scan results showed no sign of metastasis (phew!). I am yet to have MRI in November.

Given my current health conditions (healthy apart from the PCa), and the localised cancer, my doctor strongly recommended robotic surgery. The other option that was initially given to me was radiotherapy but currently it looks like we will be going forward with the robotic surgery at the end of November.

Although I feel quite comfortable with going with the robotic surgery, I just wanted second opinions (especially since my urologist is a surgeon specialising in robotic surgery so I thought he might push for it).

What are you folks' thoughts? Those with localised PCa - which treatment did you opt for and how did it go?

 

User
Posted 27 Sep 2018 at 14:16
When are you having your mpMRI scan, that you should have had before your biopsy?

Cheers, John.

User
Posted 27 Sep 2018 at 15:19
Statistically, recurrence is slightly more likely after robotic RP than after open surgery but it is a tiny difference and many men are happy to take that risk for the convenience of faster recovery.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 27 Sep 2018 at 16:44
Key7, it is not true that RP cannot be done after RT. I am a living example of what I say. What is the case is that because of damage done by the radiation, the task is more difficult and many Urologists are reluctant to mess about in the fry up! Quite understandable!

AC

User
Posted 27 Sep 2018 at 16:47
Hi KEY7

Yes, I had robotic surgery.

I had all the percentage chances explained to me at every stage so was fully aware.

My advice is to concentrate on the next step and not worry about things beyond that.

Get / stay fit, physically and mentally and research your recovery process so that you are prepared for things like the catheter and wound management etc.

I had an MRI scan as part of the diagnosos process. I think it was to search for large metastates as these would rule out surgery. MRI cannot detect small ones so ti is all a bit of a guessing game.

Keep us posted!

P

User
Posted 28 Sep 2018 at 10:42

Most people on this forum will have faced the same decision. Just when your head is reeling from hearing there is evidence of cancer you are expected to make a choice.

The good news is that apparently research following real patients after treatment shows all options have the same success rate. Even active surveillance (doing nothing but monitoring carefully) comes out the same though those patients may have ended up having treatment only a few months later, however it is reassuring that in most cases you won't suffer by spending some time thinking about your decision.

So in the end it is personal. I chose surgery partly because of the argument about salvage radiotherapy being easier than salvage surgery if the first treatment doesn't succeed (though you are right to note that in most hospitals prostate investigations will be managed by urology departments, which means the person you are talking to will have a natural bias towards surgery). The other more tricky thing that I took into account about is side effects. By and large, surgery side effects are more immediate and probably most (but by no means all) patients overcome them with time. Some radiotherapy side effects (e.g. cancer risks in adjacent organs like bowel and bladder) develop slowly so you might think about whether your age and family history means you are likely to be otherwise fit and active in twenty plus years.

(And if it helps: my personal experience of side effects after surgery. Continence was an issue for many months but stabilised to the extent where any leaks are almost always managed by a single pad per day; irritating but doesn't affect what I do. Erectile function, having had only one nerve spared, took a similar period to recover with the aid of tadalafil and a vacuum pump but happily ended up with that part of life's enjoyment back again if a bit different. But you need to know that with surgery there is a real risk of one or other of these issues remaining a problem long term).

Good luck, there isn't a "perfect" answer because it isn't a perfect situation.

User
Posted 28 Sep 2018 at 18:24
Not a very easy or pleasant decision to make.

For me, being relatively young (50 at diagnosis) meant that I was always encouraged to take the RP route and being young means greater risks of long term side effects from RT. Other factors for me were that a large prostate pretty much ruled out brachytherapy, plus I already had fairly noticeable prostate symptoms which the various RT methods for likely to make worse.

I did have some fairly unpleasant (and very unusual) post op complications but even so now, at about 14 weeks post op, I'm sure it was the right way to go. I had the RP done via the still unusual Retzius sparing method by a very skilled surgeon and had full bladder control straight after the catheter was turned off.

A highly skilled "high volume" surgeon is a very important factor in the outcome.

The usefulness of the MRI is that it shows where the cancer is in the prostate and also gives indications of whether it has escaped the prostate. These are factors which might affect treatment choice. When given before the biopsy, which is becoming the norm, it also helps guide the biopsy to the affected areas and prevent false negatives.

Nick

User
Posted 28 Sep 2018 at 19:53
Best advice I have seen is to work through a priority list:

- is treatment actually needed?

- which treatment offers me the best chance of full remission?

- can I live with the certain side effects and the % likelihood of the possible side effects?

- if the answer to that is no, which side effects am I prepared to risk, and then

- which is the best treatment available within that parameter

In other words, what is your approach to risk?

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 28 Sep 2018 at 23:11

Kev, hi

i have just faced the same decision, and opted for surgery ra than brachytherap. I'm 53, had a PSA of 8 and no symptom. Stage T2c, so localised.  

Speaking to my consultant he was very open   He does RP, so admitted he was probably biased, suggested I see the brachytherapy team before making a decision.  

Whi waiting for the appointment I spoke to one of the nurses here   She really helped me decide   It was an easy choice.   I was very clear, I wanted the option that would give the best chances of complet cure. So I chose RP. Should completely remove the cancer as still localised.  If any remaining cancer this will show very quickly with a blood test showing any level of PSA.   If there is an on going issue the option for radiotherapy remains.  So it was an easy choice

my advice?  Work out your priorities and call the helpline here.  They will give you informed clinical advice with no agend.  They made my decision so easy that I called up right a au and got myself on the waiting list

Wish you all the best

Geoff

User
Posted 29 Sep 2018 at 11:47

I don't think you will find many (if any) examples where people recommend a course of action different to the one they themselves chose. Subconsciously and even overtly there's a lot of confirmation bias in people's responses.

The other thing to maybe consider is that using statistics to compare medical outcomes is fraught with danger, even if it's sometimes all we've got. It's difficult to get a true apples v apples comparison. An example would be comparing robotic and open surgery outcomes. The data does show a very small statistical benefit with open surgery. But open surgery has been around for over 100 years and robotic for 5 or 6. It follows Open surgery is at the peak of its efficacy with experienced surgeons practicing a perfected technique, whilst all the learning and mistakes that are inevitable in a new procedure pollute the comparitively tiny robotic record.

When the comparison is made in another, say, 20 years it will likely be different. This is true of lots of treatments and procedures, and points up the value of proper and detailed reading around the subject, as you have already found on here. Good luck.

User
Posted 30 Sep 2018 at 11:25
That shows that even with a prior mpMRI and template biopsy in the event of surgery it can be found that the cancer is more extensive than originally thought. Then there is also the possibility that micro cancer cells have escaped. So one can never be certain.
Barry
User
Posted 07 Oct 2018 at 15:23
It is easy to imagine the cancer cells running riot around the body but it doesn’t work like that - prostate cancer is more of a creeper so nothing is going to change in a few weeks. Very different to cancers like brain tumours or lymphoma where someone can be diagnosed and admitted / operated on almost immediately.

Our surgeon advised us to take the space between diagnosis and surgery as an opportunity to get a holiday, have loads of sex and generally gather our heads as it may be a while before any of those things happen again.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

Show Most Thanked Posts
User
Posted 27 Sep 2018 at 14:16
When are you having your mpMRI scan, that you should have had before your biopsy?

Cheers, John.

User
Posted 27 Sep 2018 at 14:20
Hi and welcome.

Bear in mind you can have salvage RT after RP but the reverse is a lot harder. RP side effects are immediate and RT ones can take much longer to manifest. Beyond that, age and health play a bearing.

Outcomes are about the same as far as I know.

I am sure that others here will add much greater insight.

Cheers

P

User
Posted 27 Sep 2018 at 14:28

@John, I never had the mpMRI scan performed. I had the PSA test, followed by 2 DREs (separate doctors), a biopsy, and bone scan. What can the mpMRI show?

@ProstatePete, thanks for your welcome. I think that was also what my doctor mentioned - that we could treat any 'remaining' cancer with RT should there be any after the RP, but this cannot be done the reverse order. I see that you had a RP and recurrence - may I ask if you had the robotic RP? Did your doctor warn you against chances of recurrence after your surgery?

User
Posted 27 Sep 2018 at 15:19
Statistically, recurrence is slightly more likely after robotic RP than after open surgery but it is a tiny difference and many men are happy to take that risk for the convenience of faster recovery.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 27 Sep 2018 at 16:44
Key7, it is not true that RP cannot be done after RT. I am a living example of what I say. What is the case is that because of damage done by the radiation, the task is more difficult and many Urologists are reluctant to mess about in the fry up! Quite understandable!

AC

User
Posted 27 Sep 2018 at 16:47
Hi KEY7

Yes, I had robotic surgery.

I had all the percentage chances explained to me at every stage so was fully aware.

My advice is to concentrate on the next step and not worry about things beyond that.

Get / stay fit, physically and mentally and research your recovery process so that you are prepared for things like the catheter and wound management etc.

I had an MRI scan as part of the diagnosos process. I think it was to search for large metastates as these would rule out surgery. MRI cannot detect small ones so ti is all a bit of a guessing game.

Keep us posted!

P

User
Posted 27 Sep 2018 at 18:17
Hi Key,

Have you got the full results from your biopsy, e.g. your Gleason score, ?+?=?, your staging T?N?M?.

If you give us those figures people here can offer more informed advice.

Cheers, John.

User
Posted 28 Sep 2018 at 10:42

Most people on this forum will have faced the same decision. Just when your head is reeling from hearing there is evidence of cancer you are expected to make a choice.

The good news is that apparently research following real patients after treatment shows all options have the same success rate. Even active surveillance (doing nothing but monitoring carefully) comes out the same though those patients may have ended up having treatment only a few months later, however it is reassuring that in most cases you won't suffer by spending some time thinking about your decision.

So in the end it is personal. I chose surgery partly because of the argument about salvage radiotherapy being easier than salvage surgery if the first treatment doesn't succeed (though you are right to note that in most hospitals prostate investigations will be managed by urology departments, which means the person you are talking to will have a natural bias towards surgery). The other more tricky thing that I took into account about is side effects. By and large, surgery side effects are more immediate and probably most (but by no means all) patients overcome them with time. Some radiotherapy side effects (e.g. cancer risks in adjacent organs like bowel and bladder) develop slowly so you might think about whether your age and family history means you are likely to be otherwise fit and active in twenty plus years.

(And if it helps: my personal experience of side effects after surgery. Continence was an issue for many months but stabilised to the extent where any leaks are almost always managed by a single pad per day; irritating but doesn't affect what I do. Erectile function, having had only one nerve spared, took a similar period to recover with the aid of tadalafil and a vacuum pump but happily ended up with that part of life's enjoyment back again if a bit different. But you need to know that with surgery there is a real risk of one or other of these issues remaining a problem long term).

Good luck, there isn't a "perfect" answer because it isn't a perfect situation.

User
Posted 28 Sep 2018 at 18:24
Not a very easy or pleasant decision to make.

For me, being relatively young (50 at diagnosis) meant that I was always encouraged to take the RP route and being young means greater risks of long term side effects from RT. Other factors for me were that a large prostate pretty much ruled out brachytherapy, plus I already had fairly noticeable prostate symptoms which the various RT methods for likely to make worse.

I did have some fairly unpleasant (and very unusual) post op complications but even so now, at about 14 weeks post op, I'm sure it was the right way to go. I had the RP done via the still unusual Retzius sparing method by a very skilled surgeon and had full bladder control straight after the catheter was turned off.

A highly skilled "high volume" surgeon is a very important factor in the outcome.

The usefulness of the MRI is that it shows where the cancer is in the prostate and also gives indications of whether it has escaped the prostate. These are factors which might affect treatment choice. When given before the biopsy, which is becoming the norm, it also helps guide the biopsy to the affected areas and prevent false negatives.

Nick

User
Posted 28 Sep 2018 at 19:53
Best advice I have seen is to work through a priority list:

- is treatment actually needed?

- which treatment offers me the best chance of full remission?

- can I live with the certain side effects and the % likelihood of the possible side effects?

- if the answer to that is no, which side effects am I prepared to risk, and then

- which is the best treatment available within that parameter

In other words, what is your approach to risk?

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 28 Sep 2018 at 23:11

Kev, hi

i have just faced the same decision, and opted for surgery ra than brachytherap. I'm 53, had a PSA of 8 and no symptom. Stage T2c, so localised.  

Speaking to my consultant he was very open   He does RP, so admitted he was probably biased, suggested I see the brachytherapy team before making a decision.  

Whi waiting for the appointment I spoke to one of the nurses here   She really helped me decide   It was an easy choice.   I was very clear, I wanted the option that would give the best chances of complet cure. So I chose RP. Should completely remove the cancer as still localised.  If any remaining cancer this will show very quickly with a blood test showing any level of PSA.   If there is an on going issue the option for radiotherapy remains.  So it was an easy choice

my advice?  Work out your priorities and call the helpline here.  They will give you informed clinical advice with no agend.  They made my decision so easy that I called up right a au and got myself on the waiting list

Wish you all the best

Geoff

User
Posted 29 Sep 2018 at 09:41
It is great advice to call the helpline here. The nurses are excellent and I found talking to them very helpful.

Nick

User
Posted 29 Sep 2018 at 10:30

The issue of second cancers caused by treatment is an interesting one. Brachy would have been John’s first choice when he was diagnosed but at that time (and we are talking 9 years ago now) he was refused that option for being “too young” - our hospital (a centre of excellence for oncology, particularly urological oncology) did not offer brachy to younger men due to the risk of bowel / bladder cancer down the line. When I researched it later, second cancer due to pelvic radiation may emerge some 5 to 20 years later but the the risk is tiny (1%) 

I note that in recent years, opinion seems to have changed quite a lot and few hospitals seem to apply the lower age limit now. This may in part be down to some research published in 2016 that suggested men who have brachy have the same risk of bowel or bladder cancer as men who had surgery and a slightly higher risk of bladder cancer.

The men most at risk of second cancer were those who had external beam RT some years ago and the risk reduced sugnificantly when IMRT and then IGRT was introduced. Presumably, if they repeat the research in a few years they will find that SpaceOar reduces the risk of bowel cancers significantly?

Edited by member 29 Sep 2018 at 10:45  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 29 Sep 2018 at 11:47

I don't think you will find many (if any) examples where people recommend a course of action different to the one they themselves chose. Subconsciously and even overtly there's a lot of confirmation bias in people's responses.

The other thing to maybe consider is that using statistics to compare medical outcomes is fraught with danger, even if it's sometimes all we've got. It's difficult to get a true apples v apples comparison. An example would be comparing robotic and open surgery outcomes. The data does show a very small statistical benefit with open surgery. But open surgery has been around for over 100 years and robotic for 5 or 6. It follows Open surgery is at the peak of its efficacy with experienced surgeons practicing a perfected technique, whilst all the learning and mistakes that are inevitable in a new procedure pollute the comparitively tiny robotic record.

When the comparison is made in another, say, 20 years it will likely be different. This is true of lots of treatments and procedures, and points up the value of proper and detailed reading around the subject, as you have already found on here. Good luck.

User
Posted 29 Sep 2018 at 13:23
Sumdum makes really good points except I am not sure about the bias thing. There is undoubtedly a bias - posters will advise that their choice / decision is the best one (partly because they believed that when they made their decision and / or they need validation) but generally this will apply to men who had good outcomes. We also see some bias away from the poster's treatment choice where the outcome was bad, aftercare was poor or the side effects have been life-changing.

Even bias is biased.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 29 Sep 2018 at 16:50
I was told on the strength of my mpMRI scan and subsequent template biopsy with 42 samples that my cancer was T2a and organ confined.

I seriously considered Nano-Knife, which is little more than a glorified template biopsy. When after my surgery they found extra-prostatic extension and two lymph nodes involved and an ‘upgrade’ to T3, I was pleased I had not had Nano-Knife as I would still have a prostate and a big problem.

But then I think, what if I had HT & RT in the first place, which although I am an eternal optimist, suspect I will end up on? So many what if’s?

So for now, I am enjoying being cured with undetectable PSA. Now if I can only find what happened to that 2” that went missing during surgery🤣😂🤣

User
Posted 30 Sep 2018 at 11:25
That shows that even with a prior mpMRI and template biopsy in the event of surgery it can be found that the cancer is more extensive than originally thought. Then there is also the possibility that micro cancer cells have escaped. So one can never be certain.
Barry
User
Posted 30 Sep 2018 at 21:32

I agree about the confirmation bias identified by Sumdum. Any of us commenting individually inevitably have only real knowledge of the one treatment we personally experienced, which thus seems favoured above alternatives.

But beware also the risk from research evidence. A serious analysis of twenty year risks from treatment is by definition not comparing risks from the options you face, it compares the risks from what those treatments were twenty years ago. You can reasonably assume there have been significant advances in both radiotherapy and surgery since then.

Ultimately you are a worried individual, not a data point in a statistical analysis. You have to make a choice, and while it helps enormously to feel you are aware of all the relevant background information in the end it is a personal decision based on your situation and your preferences (whether or not those are entirely rational).

 

User
Posted 30 Sep 2018 at 22:50

Good evening all.

I decided to take a small break away from thinking about diagnosis for this weekend, so stayed away from everything related to it (including this forum) and I was very surprised to see so many valuable comments from you folks - a big thank you to all!

While we may be all be biased to some degree as Sumdum suggested, it's really useful to hear about different people experiences and the rationals behind the treatment option they decided on. I suppose one will never really have an answer to which treatment should have been chosen.

Like Nick pointed out, my urologist seems to qualify as a "high volume" surgeon with plenty of experience who performs such surgery 2-3 times a week. So that ticks the box.

I am actually based in South Africa and the national health standards here unfortunately does not yet seem to recommend a mpMRI before a biopsy takes place, and I had never been offered one as well. Also one of the reasons why I hadn't really thought about calling the nurse helpline on this page, but after all the recommendations it looks it's the way to go.

My MRI will take place mid-November so I suppose I cannot really make my final decision until I get the result, but will keep doing my research and will also keep you all posted. Many thanks.

User
Posted 01 Oct 2018 at 16:28

Hi Key,

My mate Keith lives partially in Cape Town, and you can find him on the Macmillan cancer website, prostate cancer forum with the nom de plume: Caper 4.

Get in touch with him for his take on PCa trestment in ZA. I'm sure he will be happy to help, if he can.

Cheers, John.

User
Posted 01 Oct 2018 at 22:42

I was biased to surgery due to its speed, allowing better analysis and having better options for further treatment, but mostly because of my condition.  My tumour was said at diagnosis to be near the edge close to breaking out and I wanted it out fast.   I wasn't over concerned about side effects.

The surgeon gave me more information, saying it was 13mm at the apex which further increased my bias as the apex is at the opposite side to the bladder so a clean cut might have a good chance of taking it.  To my simple thinking anyway.

After the op it was upgraded to 4+4 although the margin was negative.  This gives me more evidence on my condition than any other treatment would have.  Although the upgrade to 4+4 isn't good, the negative margin is.  I also know it was T2a when I'd been told it might be T3 which is another useful piece of information for me and for anyone looking at my case.

I also think, though perhaps falsely, that being so focused on what I wanted helped to speed it up as the surgeon got me in 10 days after I'd seen him.

User
Posted 02 Oct 2018 at 12:52
It has been said earlier in this thread that all treatments have a similar success rate. This may be true as a generalization but an individual's diagnosis may make it preferable to have one treatment rather than another from a medical viewpoint. A case in point is where the cancer is in the process of breaching the Prostate in which case it may be better dealt with by RT which can reach further than the knife. Surgery could give a better result where the cancer is contained and the individual's cancer cells are more radio resistant.
Barry
User
Posted 07 Oct 2018 at 13:40

my husband is in a very similar situation,his is close to breaking out,of the capsule,he is 100 per sure he wants the operation,but it will take between 4 to 6 weeks,he is going out of his mind worrying that in this time,his caner might breakout,at a loss as how to reassure him 

User
Posted 07 Oct 2018 at 15:23
It is easy to imagine the cancer cells running riot around the body but it doesn’t work like that - prostate cancer is more of a creeper so nothing is going to change in a few weeks. Very different to cancers like brain tumours or lymphoma where someone can be diagnosed and admitted / operated on almost immediately.

Our surgeon advised us to take the space between diagnosis and surgery as an opportunity to get a holiday, have loads of sex and generally gather our heads as it may be a while before any of those things happen again.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Oct 2018 at 22:32

Thank you LynEyre

That is reassuring,he hasn't slept since his diagnosis,it's all  been a bit of a whirlwind to be honest,within 3 weeks of having a routine blood test,he' had.had a DRE,mpMRI,Biopsy and bone scan,followed by a diagnosis of advanced prostrate cancer Gleason level 4+5=9,sonow it's going to be a long 4 to 6 weeks,hoping it's nearer to 4 than 6 to be honest

 

User
Posted 07 Oct 2018 at 22:39
It would be better to start your own thread so that replies to you don't get mixed up with responses to Key7. But you should recheck your understanding of the diagnosis; if he is being offered radical prostatectomy in 4 to 6 weeks, he can't have been diagnosed with advanced prostate cancer.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Oct 2018 at 23:13

sorry the wording is localised advanced prostrate cancer ,The TNM stage is T3,the consultant said his only option was radical surgery or radiotherapy,he also said that ifhe chose radiotherapy first,and it didn't work then,what's left of theprostrate is harder to remove, up to 2 weeks for pre -op,then 4 to6 for op

Edited by member 07 Oct 2018 at 23:21  | Reason: Not specified

User
Posted 07 Oct 2018 at 23:37
Has he seen an oncologist? It would be wise to get a second opinion on whether surgery is the best idea with a diagnosis of locally advanced PCa. It is true that the prostate is harder to remove after RT but it may be that RT is more likely to be successful. You have a few weeks to make sure he is doing the right thing - if you haven’t seen an oncologist, there is still time to arrange it.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 07 Oct 2018 at 23:44

Yes we have,can't fault NHS,everything has been arranged so quickly the've been amazing

 
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