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Newer surgery technique
In reply to someone’s post I wrote about this new surgical procedure but realize if it is not a stand alone post, many may not have seen it unless they decided to read that person’s post and comment’s which can fade fast. This post is not to try and dissuade anyone from the treatment they are leaning towards, it is just to make sure that any surgery leaning members evaluate and know surgery options.
Most patients , myself included believed all robotic laparoscopic prostatectomies were the same procedure. They are NOT! A key factor in choosing your Surgeon during consultation’s, if going with Surgery is to be aware that technologies and techniques are advancing in the field. The most up to date and advanced robotic surgery is done with the DaVinci single port robot. If your surgeon is not using the latest DaVinci Robotic model it does not change his ability in performing an outstanding surgery, but it can affect a quicker recovery, and not have the ability for state of the art surgical techniques that can alleviate the severity of possible side effects by using the newer robot.
The newer DaVinci Robotic single port (latest) makes one small incision for entry as opposed to the older widely used DaVinci model making as many as 6 small incision entries. The single port barely leaves a scar and you can leave the hospital the same day as your surgery. My surgery was in the morning 7:30am and discharged around 5:30pm. I am now 18 months post surgery and the single tiny scar is almost unnoticeable.
Nerve sparing is very important but even more important today is the newer Retzius sparing surgical technique which generally gives immediate continence upon the catheter removal and improves ED.
In the newer surgical technique the surgeon leaves intact and does not cut the puboprostatic ligament holding the bladder in place and this maintains urethral length upon reattachment to the bladder which substantially improves the likelihood of minimal post leaking if none at all. This is very important and most surgeons are not trained in this latest technique. It is called Retzius sparing. The part of the surgery in which the surgeon reattaches your urethra to your bladder is a significant part of the completion of the prostatectomy surgery. In this Retzius sparing technique the surgeon accesses the bladder from behind allowing the ligament not to be cut. You are positioned differently than in a normal robotic prostatectomy because of coming in reverse. Most patients after a prostatectomy comment on the loss of penile length. This is typically caused by the need to cinch up and reattach the urethra to a bladder that had its Puboprostatic Ligament cut and not where it was. Almost all Surgeons cut this ligament to do surgery because it is how they need to access the prostate from the normal prostatectomy surgery, however the new surgery procedure, not really new, it has been around a number of years now having come from Europe is that they go in to remove the prostate doing surgery from coming in behind the bladder, to gain access to the prostate and do not need to cut the ligament . Not only as previously reported that you do not lose penile length as the reattachment is right back to the place where the stable bladder is still positioned and the urethra was cut from, but it seems according to most literature on this, most patient’s have almost immediate continence. These certainly are the two major concerns of patients I hear about regarding surgery. The third concern is the sexual function more involved with nerve sparing and alot of that involves a surgeon’s skill around the nerve bundles. Even if the cancer has seemed to leave the capsule, a surgeon can spend extra time delicately getting to a negative margin and as in my case , nerves spared one side, half the other and 18 months post surgery, early 70’s, I am good to go fully erect penetration in the morning on an empty stomach after 4 pills sildenifil (20mg a piece) total 80mg and waiting 75 minutes. Many patients don’t realize or even know of this new surgical approach, I did not. This really shows how important it is to research your surgeon and see what robotic laparoscopic prostatectomy surgery he performs. You really have to look for this specific surgeon and consult with or call around the major hospitals to see if they have surgeons doing this technique. This still by far is not the common surgery technique but is gaining substantially more traction each year as newer surgeons who are staying up to date on the latest technology and techniques are performing it. It will likely become the standard over time due to the success in reducing side effects especially of incontinence, ed and penile length. Many major hospitals still don’t have a surgeon trained this way, it’s just finding that Surgeon and not just relying on the surgeon referral you are given by your urologist after your cancer diagnosis.
Also another very important factor in surgeon consideration is whether during surgery while you are on the table he will send the sliced prostate bed tissue and lymph nodes immediately to Pathology for inking and staining to rule out whether the cancer has left the capsule, even if the PET says it had not entered the bed or lymph nodes and is localized to the capsule. Then if pathology reports positive margin in the bed the Surgeon can go back in deeper while your are on the table to try to eliminate the positive margin. This happened in my case adding an additional two hours to my surgery with the initial positive margin coming back. Even my surgeon was surprised from his visual of inside me and the of hundreds of surgeries he has seen, and said on occasion he gets surprised. That is even though the PET suggested everything was contained. Most surgeons don’t do this and accept that the PET says it is contained and the surgeon cuts the normal surgical margins and removes some nodes and closes you up. Then at your post surgical appointment you may be told, sorry there was positive margin. Well it’s a little late I would say to hear that. In mine at that post appointment I was told final pathology with negative margin had been achieved. This additional step can really mess up a surgeon’s operating schedule, not only the time waiting for Pathology but additional time back in surgery if necessary. On their surgical day surgeons often have a morning and afternoon procedure scheduled if they need to go back in unexpectedly for several hours that was not planned, it substantially delays the afternoon procedure and for the day adds that much extra time to the Surgeon’s day. This is a major reason they don’t even if they have pathology available. For this to be done the surgery needs to be performed at a major hospital that has Pathology inhouse.
I hope this is informative for many.
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@heavyphil
This is very good information; people can compare options and choose the best treatment for themselves.
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1 Reaction@heavyphil
Great meta analysis. Constant more evaluations as it becomes done more. I agree on this analysis not much difference the treatment in eliminating the cancer except not as well with multiple tumors with a higher PSM, but BCR seems same, but the reducing of side effects immediately regardless whether at a year out the baseline is practically equal . As I mentioned for me a game changer alone is the continence. Would I rather have it fairly immediate in a couple days with no kegels or just gradually improving over months under one procedure whether the studies show at a year they are equivalent . The studies do show improved recovery time for erectile function because of better neurovascular protection. The higher level of PSM can be reduced by real time pathology. Also states a longer learning curve for this procedure which means as more meta analysis come on board they may have more results from more experienced surgeon’s. Results from surgeons still in their learning curve can skew the results in the analysis as nearly not around as much two years ago and the procedures were being done likely by surgeons in that learning curve. As I continue to say regardless of the procedure, a surgeon is only as good as his expertise in performing whichever one he does. I emphasize the reduction in side effects or the quicker recovery time regarding those as game changers for me all things being equal.
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2 Reactions@wheel1
I had Radical in 1989 by Dr Patrick Walsh @ John’s Hopkins.
Dr Walsh is the Dr that came up with the nerve sparing Radical Prostatectomy.
I have no incontinence but had to have a penal implant for ED
I SPENT 8 days in the hospital. Walsh was a very arrogant man and he never supplied me with after surgery rehab info.
I spent 11 years using pump and Caverject for sex. Finally I had the penal implant. Not impressed with it. I should have stayed with injections.
I alive after 36 years. For that I am thankful.
Prostate CA is wicked. You have to MAN UP in order to live with it.
I am so happy for the men who end up with no ED or in continence.
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4 Reactions@rpogatchnik1590
What issues have you found with the penile implant? Reports claim that it is very high satisfaction rates over 85%. When the Mayo doctor did the monthly talk about it, he said the same thing about the satisfaction rates.
Would definitely be interested in knowing what is the problem with it.
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1 Reaction@heavyphil
Yes- that is the whole point - not much difference and thanks for confirming that with a link, I read tons of those before surgery. I never talk about things before I do research or know the facts about both sides (or 3 sides ...) . I did my research about both kind of "ports" when we decided to do RP.
Our surgeon confirmed that yes, results are similar and added that he prefers multi-port but gave us a choice. He was also honest and told us that nobody can guarantee complete continence and no ED , no mater what technique is used but that in his practice it is rare event - 5 % for incontinence and 20% for ED but that ED can be helped by multiple ways.
He also explained that both results depend of many other factors and all research papers that I read confirmed all that he said. It is not always possible to spare the nerves since sometimes cancer invades that area and it can be seen during surgery. If gland is enlarged much bigger chunk of urethra has to be removed and sometimes even part of a bladder neck and that will cause longer recovery. There are techniques that surgeons use to repair neck on the spot while doing RP. He went into all details of possible events and which can be fixed immediately or later. He also explained that if patient already has any level of ED or any problems with urinary tract (like urgency, or similar) , that it predisposes a patient to having more pronounced SA.
Bottom line - so many factors go into success of a surgery that it is actually misinformation that anybody or any technique can guaranty full continence the first day after cath goes out or zero ED. I mean we have a member here that had single port with very bad results and very slow recovery. Now, he is not good representative either - again , one example. As always - the truth is in the middle.
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3 Reactions@jeffmarc Hi Jeff,
I am on my second one. The 1st was 20 yrs old.
The issue is I loss about 4”. It is not as stiff by any means. Sensitivity is way less.
The injections were way better. Just inconvenient for spontaneity
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1 Reaction@surftohealth88
Can’t argue with those statistics 95% + for continence and 80% for non ED. Those are pretty high guarantees by those statistics with no actual statement of guarantee
@rpogatchnik1590
My wife’s best friend’s husband had surgery by Doctor Walsh in 2001.
To say he is unhappy with the result is really downplaying it. He is furious.
He was an OB/GYN in Los Angeles. He searched all over the country and found Dr. Walsh who said that he could spare the nerves and he went to him to get that surgery.
As a Doctor he has reviewed surgery notes from doctors for decades. Frequently the surgery notes can be up to 10 pages in length.
When the surgery was complete, he found out that’s the nerves were not spared and when he asked to see the surgery notes, he was given a half page explanation of what happened. It had no useful information. Talking to the doctor was impossible, he was so arrogant.
He suspects the surgery was done by an intern with the doctor watching.
He is 90 now and has a 77 year old wife. He has had ED since the surgery, something he flew across the country to try to prevent.
After the surgery was complete, he was told that his Gleason scores was a very low 3+3. He should never have had surgery.
Dr. Walsh promised a lot and came up with nothing. It sounds like the same thing happened to you with nerve sparing failing.
@jeffmarc exactly! He was allowing students to do the cutting. The guy was the most arrogant man I ever met. He would get real nasty if you questioned home.
I later tried to get VA disability for agent orange. Ask Walsh for help. He flatly stated agent orange doesn’t cause Prostate CA.
It is now accepted as one of the biggest causes of Ca.
After 20 years the VA finally granted my disability.
I would never recommend anybody go to Johns Hopkins for prostate CA. Walsh was a nasty man, and I’ve talked to many urologist and surgeons that had to attend his lectures and studied under him and they all agree that he was a real bastard.
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1 Reaction@surftohealth88 Well said, Surf…we still don’t know what we don’t know and predictions are, at most, best guesses.
My surgeon found bladder cancer when he got in there - talk about a curveball!
Phil
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