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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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@jeffmarc And another Colossus is revealed to have ankles of clay.
Really not surprised. A friend also had open surgery by Dr Walsh at a fairly young age. Don’t know his particulars but he has been totally impotent for the past 25 years.
Phil
Your detailed post was informative. I am continually amazed at the knowledge acquire. As a retired medical professional, it’s not uncommon for patients today to know as much or more about their condition than the doctor. Doctors are creatures of habit. They are taught in medical school and residency to portray a sense of superior knowledge. The dynamics of doctor/patient interaction continues to allow for narrative debate instead of blind acceptance of what the doctor tells you. We must be mindful that expertise is a trait earned. Medicine is always evolving. Your knowledge with robotic surgery seems to be spot on . But, what does that give you? There continues to be a fine line that many doctors put up to keep that aura of superiority. The latest and greatest procedure are mainly developed and performed in Centers of Excellence along with device manufacturers. In this case, most urologists are not trained in doing them. Instead of going to symposiums and possible fellowships are time consuming, so the common retort is, “I haven’t seen any evidence that this new procedure would give better outcomes from what I am doing”, (stand up, shake their hand, and walk out). COE’s have cutting edge technology. More importantly, they have teams that do an abundance of procedures. Your local city office of 10 urologists, 4 PA’s, 2 NP’s may have one doctor who might have preformed this new procedure at a hospital with the new DaVinci robotic device (Maybe a 6-week course). I would steer clear. Your knowledge of the procedure is commendable, although the foremost concern should be where to have it done. Companies like Intuative “need” COE’s that have a superior knowledge base and facilities to provide the best outcomes for new devices and procedures (Mayo, Cleveland Clinic, UCSF, UCLA, MD Anderson, Hopkins, etc.). Do additional homework on who does this procedure and how many. I had PCa and went to UVA for HDR Brachytherapy (90 minute drive, but well worth it). The local oncologist maybe performed 8/month. The Prostate Oncologist at UVA did 8/week and the facility did over 80/month. They had a specific “Prostate Oncology Center”. I can’t reinforce enough that who and where you choose will be your greatest asset for the best outcome. Good luck and keep searching.
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6 Reactions@cbball
You ask if other people have tinnitus. This has been discussed at the weekly advanced prostate cancer meetings at ancan.org. Rick, Who started Ancan.Org Has mentioned having the tinnitus problem and others have mentioned it as well. Not sure the reasoning is the same as yours, but I know he has only had radiation about 14 years ago.
@cbball
I totally agree, the expertise of the Surgeon is key. It is unfortunate there are patients before you that were part of the learning curve that brought that Surgeon to his level of expertise. I imagine today they might have state of the art simulator’s to assist Surgeons in their learning curve. The COE’s are certainly the places to first find the new cutting age technology. Here is something I found as more recent data comes out and I was two years back. I only share this information so everyone can be aware of what is out there. The evolution of prostate surgery is continuing to evolve.
Studies consistently show that Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is superior to standard anterior robot-assisted radical prostatectomy (S-RARP) regarding faster recovery of early urinary continence and improved, sometimes faster, return to erectile function. RS-RARP preserves key anterior anatomical structures, which improves functional outcomes while achieving comparable cancer control (oncological outcomes).
PubMed Central (PMC) (.gov)
PubMed Central (PMC) (.gov)
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Key Findings on RS-RARP Superiority
Faster Continence Recovery: RS-RARP patients demonstrate significantly higher early continence rates (at 1 week, 1 month, and 3 months) compared to standard RARP, with some studies finding it reduces time to continence by over 80 days.
Improved Sexual Function: Multiple studies and meta-analyses suggest improved preservation of erectile function compared to the standard approach.
Quality of Life (QoL): Due to faster continence and potency recovery, patients report improved QoL scores.
Comparable Oncological Safety: Despite higher visibility challenges, studies indicate no significant differences in biochemical recurrence (BCR) rates between RS-RARP and standard RARP.
Lower Complications: Evidence suggests RS-RARP may lead to a lower incidence of postoperative hernia and similar or lower overall complication rates.
PubMed Central (PMC) (.gov)
PubMed Central (PMC) (.gov)
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Limitations and Considerations
Learning Curve: RS-RARP involves a smaller, more challenging workspace, which may result in a steeper learning curve for surgeons.
Positive Surgical Margins (PSM): Some studies have suggested that RS-RARP could be associated with higher PSMs (specifically in patients with anterior lesions) compared to the standard approach, though not necessarily leading to worse functional outcomes or higher recurrence.
PubMed Central (PMC) (.gov)
PubMed Central (PMC) (.gov)
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These results suggest that, particularly in the hands of experienced robotic surgeons, RS-RARP can offer superior functional results for patients undergoing radical prostatectomy.
PubMed Central (PMC) (.gov)
PubMed Central (PMC) (.gov)
Single-port (SP) RALP is generally considered better for patient recovery, offering less pain, shorter hospital stays, and superior cosmetic results compared to multiport (MP) RALP. Studies show SP-RALP provides similar cancer control and functional outcomes (continence/erectile function) while using a smaller 1-inch incision.
PubMed Central (PMC) (.gov)
PubMed Central (PMC) (.gov)
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Key Study Findings (SP-RALP vs. MP-RALP)
Patient Recovery: SP-RALP patients often report lower postoperative pain, reduced opioid use, and faster discharge (frequently < 24 hours).
Oncologic & Functional Outcomes: Early results show similar prostate cancer control and similar or better recovery of urinary and sexual function compared to multi-port.
Technical Aspects: SP-RALP offers improved precision in limited spaces, especially through extraperitoneal approaches.
Limitations: SP-RALP has a steeper learning curve for surgeons and generally higher procedure costs.
Perioperative: Some studies suggest SP-RALP may have shorter operative times but, in some cases, higher rates of positive surgical margins, though most studies show comparable results to multiport.
UroToday
UroToday
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Conclusion
While multi-port is more common and supported by two decades of data, single-port is rapidly proving superior in terms of postoperative pain and hospital stay duration, making it a highly attractive, less-invasive option for patients.
European Urology
European Urology
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Single-Port versus Multiple-Port Robot-Assisted Radical Prostatectomy
Dec 7, 2021 — Single-port robotic radical prostatectomy was associated with shorter hospital stays. Only 60.6% of single-port patients (109/180) required analgesia compared t...
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PubMed Central (PMC) (.gov)
UroToday.pngEuropean Urology.pngfaviconV2.png
Thanks for your comments and back up studies. I come from the days when cardiac stents were just being administered. I knew many thoracic surgeons that were appalled by Dr Jackson (out of Kansas City) and his brazen attempt to take away their “cash cow”. I sat next to world famous Dr Norman Shumway, of Stanford and all he could say was, it’s malpractice to do that. Funny though; over the next 5 plus years, those same surgeons went back and did fellowships and became cardiologists placing stent after stent in the Cath Lab. Don’t be fooled, doctors like to make money. In this category, urologists love to do prostatectomies (in the fastest safest way possible). Medicine is a difficult ship to turn. In the US, we have the most stringent regulatory system in the world, FDA. EUA’s have given some relief and the Republicans seem to be more inclined to make 510k approvals move faster. But, back to your point, robotics will change medicine in the most dynamic ways. I know device representatives more capable of robotic surgery than most doctors. Will that mean technicians will one day be doing these surgeries? Insurance companies will push for that and hospitals will see more profit. Doctors will need to become diagnostic facilitators. I’ll be gone when that happens.
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5 Reactions@wheel1
I might also add that too many doctors in the prostate specific category only rely on 5-year studies. Standard of Care is safe. Unfortunately, it also means unnecessary. Within a 5-year period there have been multiple advances in PCa. Certainly QOL should ALWAYS be on top of everyone’s concerns. I elected for HDR brachytherapy with 20 sessions of EBRT, and NO ADT. I’m going to say it…”studies show” that there is a 4% increase at 10 and 15 years (89 vs 85). That extra 4% was not worth the QOL with ADT for 18-24 months. The first local oncologist said to at least take it for 60 days prior to my brachytherapy, nope! He didn’t want to be my oncologist anymore, and I couldn’t leave fast enough. The team at UVA listened to my concerns and made sure that the final decision was mine to make. Of course with my background, I was aware of what was going on. The worst patients for doctors are doctors. But, right next to them are educated patients that do their own research. I feel sorry for men that just go with what the doctor says. I would stress, what’s the doctor’s motivation? We are in a litigious environment and stepping out of line is frowned upon. Go to a COE and see if you qualify for a new procedure that is being performed. Ethics plays a huge factor. I have a 93-year-old uncle retired cardiologist-internist-intensivist who’s fraction rate was falling (mitral valve prolapse). He knew a specialist that could do a minimally invasive procedure to correct it. There was a high risk/reward. It was done with great success. Not too many doc’s or hospitals would even allow it. That further emphasizes advocacy with any specialty. Everyone who reads this should take a step back and determine what is right for you. Good luck and God bless.
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3 ReactionsHi,
I have heard good results about the one incision technique. Wish it was around when I hade my 5 hole DaVinci procedure 11 yrs ago.
Dave 3+4
@cbball Absolutely! Robotics married to AI and supported by real time MRI imaging will allow skilled technicians to perform surgeries that only the most gifted can do today.
I remember my high school and college friend who went on to become a very busy ophthalmologist; his bread and butter was cataract surgery. One day he said, “ You can teach a monkey to do what I do, and he might even do it better.”
Most - certainly not all - surgeries are repetitive in nature and AI guided robots with a single human standing by for judgement or tweaking purposes might be able to oversee multiple surgeries simultaneously.
In the airline industry there used to be 3-4 people in a single cockpit. But when the advanced computer driven autopilots arrived it was jokingly said that all you really need is a single pilot and a large dog; the dog is there to bite the pilot if he tries to touch the controls!😂.
Not exactly the same, but you see my point.
Phil
@heavyphil
It’s already happening!
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