Robotic Prostate Surgery: Am I a candidate
In my opinion most patients with prostate cancer are candidates for robotic prostate cancer surgery, or the daVinci Prostatectomy.
The ideal patient would be one with early prostate cancer that is likely confined to the prostate. The patient also needs a good chance of living at least 10 years.
Certain surgeries and medical conditions can make a patient less than ideal, but probably still a candidate.
Read on to find out my take on certain conditions and please comment if you can think of any others.
Medical Problems-
I have successfully completed robotic prostate surgery on patients with recent heart surgery, heart attacks, lung disease (COPD, asthma), insulin dependent diabetes, sleep apnea, prior strokes, prior blood clotting disorders, anemia, GI problems (inflammatory bowel disease), and multiple sclerosis (MS), and HIV.
By itself I haven't had to turn down anyone for robotic prostatectomy based on medical issues. It is important to make sure the patient has a life expectancy that warrants surgery however.
The advantages of robotics for some of the above include:
Less chance of infection, especially in diabetics.
Less trouble breathing postoperatively for the lung patients since there is less pain.
Less trouble getting around for patients with MS.
Less chance of getting a blood transfusion with the anemic patients. Several patients with anemia are included in my first 70 dvPs without a transfusion.
Less chance of a surgeon contracting HIV with robotics than open.
Past Surgeries
Prior TURP- prostate surgery- makes the surgery more challenging, but in my hands only adds about 15 minutes to the operation.
Prior Appendix removal- need to remove scar tissue, adds 5-20 minutes and a very small risk of intestinal injury (<1%).
Prior colon surgery for infection or cancer, adds a variable amount of time and a small risk of injuring the intestines (<5%) and a small risk of needing to convert (5%). One patient of mine had a colon surgery and a hernia left over from that surgery.
Prior hernia repair- no big deal unless it was done laparoscopically (in that case adds 20-30 minutes to expose the prostate.
Hernias
If a patient has an umbilical hernia this will be fixed at the same time and only adds 5 minutes.
If a patient has an inguinal hernia or if I find one, I fix it at the same time.
Obesity
This is an important point. Some surgeons do not feel comfortable operating on obese patients, but in my opinion these are the patients that are helped the most by this kind of surgery. The incisions would be larger, the risk of wound infections would be larger, and the overall complication rate would be larger.
My last 7 guys weighing between 230 and 290 pounds all went home the next day. The connection is much harder to make for the heavier patients and there is a greater chance they will need the catheter for more than 1 week. Most of my early guys have the catheters in for more than 1 week, but only 2 of the last 7 needed to for more than 1 week.
My philosophy is to offer these patients surgery and if they can loose weight, I think its much easier on me to do their surgery, but I have never refused to operate on someone for weight alone.
Age
The oldest patient I have done a dvP on is 74, but I think it woudl be reasonable to go to 80 years old if the patient has a 10 year life expectancy.
Prior Prostate Cancer Therapy
Hormonal Therapy- Makes the surgery a little more difficult.
Radiation or Cryosurgery- See previous blog entry.
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Comments
"Some surgeons do not feel comfortable operating on obese patients, but in my opinion these are the patients that are helped the most by this kind of surgery."
I would agree, but only after having gained some experience on thinner patients first. My largest patient weighed 280 lbs. when I spoke to him about the operation. I asked him to lose weight and he said he would go on a diet. He checked in the day of surgery at 285! I don't know what kind of diet results he thought I was hoping for.
I also agree that prior TURPs make it more difficult as there can sometimes be quite a bit of fibrosis and loss of planes. I did one patient who had been on leuprolide and the fibrosis was some of hte worst I have seen. It made it quite difficult.
Posted by: B. Dale Russell, M.D. | February 7, 2006 12:40 AM
I agree with Drs. Russell and Savatta. I think the robotic laparoscopic approach is better for the obese patient. It's still harder than surgery in thin patients, but the difference is not quite as pronounced as it was when I was doing open surgery.
Another point, I think robotic prostatectomy is a good front-line choice for some high-risk prostate cancer patients. In the past, I do not think open radical prostatectomy was offered, because it was felt that since it wouldn't cure the patient, why subject him to incontinence and impotence as well. I think now, we recognize that many of these high-risk patients will require multiple treatments, regardless of what their initial treatment choice is. And, with 0-1 pad continence following robotic prostatectomy now approaching 90+%, I think it's an excellent choice, especially for patients with ANY type of BPH symptoms. They will have improved urination, and may have undetectable PSA. If PSA recurs, they can be observed or receive adjuvant therapies that will be much better tolerated. If he gets radiation +/- hormones first, it'd be unlikely he would be offered surgery later (salvage prostatectomy).
I have performed robotic prostatectomy on 3 patients with Gleason 8 disease. 1 patient had extracapsular extension and positive margins and had post-op PSA of 0.3. He is continent and will probably be getting radiation. His voiding is much improved and he's very pleased with that. The other 2 have undetectable PSAs.. short-term. Time will tell..
Posted by: Jay Yew, M.D. | April 1, 2006 7:27 PM
I have seminal vesticle involovement. Will that affect my prospects for robotic surgery? Gleason 6/PSA 19
Posted by: david flanagan | June 13, 2006 1:25 PM
There are a few worthy points to discuss with seminal vessicle invasion.
I do not routinely perform biopsies of the seminal vessicles, although I know soem good urologists that do. There are false positives and false negatives with these results.
There is also false positives with a rectal exam showing extensive cancer.
Even if one has seminal vessicle invasion, they are candidates for surgery. There was a good paper out of Mayo clinic that concluded that the best cure rates for T3 disease was surgery. While I was at Indiana we had a similar paper that showed the cure rates were good as long as the PSA was less than 50.
As far as performing the procesure robotically, I personally would have no problem with that. I think my surgery is at least as good as open for higher stage prostate cancer with most of the robotic advantages.
Posted by: Domenico Savatta, MD | June 13, 2006 9:48 PM
Consult @ John Hopkins 4/11; 7.7 psa, 3+3 in 1 of 12 samples; leaning toward diVinci treatment, but...have seen only one study on long term (5+yrs) cure. Current fig. of 85% doesn't offer much confidence compared to GOLD STANDARD. Can you cite any studies?
Posted by: EDWARD RUSH | March 29, 2008 6:58 PM