RP - LRP Discussion

Thread view:

Enable EMail Alerts

Start New Thread

Thread rating:

ron - 03 Feb 2004 16:17 GMT

There has been a fair amount of discussion around the LRP, but I'm not
sure that any consensus has been reached. I have gone out and read
some of the literature comparing RP and LRP and have list below my
findings, along with the supporting reference where available. Many
men on this NG have selected LRP and I am not trying to be judgemental
of their decision - it was right for them. But rather, I am thinking
of the newcomer who seeks advice, what would we collectively
recommend? Perhaps this thread will allow us to develop a position.

I realize that there are many exceptions to what the literature
reports, some people do better some worse. This highlights the
problem with individual testimony, the people who do worse tend to
remain silent, and so it is often difficult to get an accurate picture
of reality from personal testimony. I also realize that we each tend
to champion the path we’ve chosen, we’d like it to be the
“best.” Some of what follows may be wrong, and if not
today, maybe tomorrow when new studies emerge. So if you read this
post and see something that is, or may be, wrong, let’s discuss
it in a constructive way. If you have references to support your
point of view, that would be helpful. At the end, I summarize and
draw a conclusion. What do you think?..Best wishes and good health,
Ron

Here are the facts I’ve found.

Over the last 5 years the average hospital stay for RRP was 1.5 days
(J. Urol., 167, 224-228, 2002), hard to do a lot better.

The duration of bladder catheterization is shorter for LRP than RRP
(LRP = 5.8 days, RRP = 7.8 days, Urol., 62 (2), 292-297, 2003).

The French surgeons who have pioneered LRP have said that LRP is a
technically demanding procedure, even more so than open surgery, and
takes the practitioner hundreds of operations before mastery is
achieved. So if you choose this route, make sure you pick a very
experienced LRP surgeon.

The LRP procedure is still evolving (J. Urol., 169, 2049-52, 2003).

The advantage of tactile evaluation of the prostate is lost in the
LRP.

The positive margin rates appear the same for the two procedures (J.
Urol., 169, 2049-52, 2003).

Urinary continence and erectile function at 1-year post-op appear the
same for the two procedures (Urol., 62(2), 292-297, 2003).

The average operating time was 92 minutes longer in the laparoscopic
group, which, the authors state, “is a limitation of this
technique” (Urol., 62(2), 292-297, 2003).

Guillonneau, the French LRP pioneer, started practicing the technique
in the late 90s. He has recently published a paper on LRP where he
uses his 1,000 consecutive cases to actuarially project 3-year
biochemical free rates (J. Urol., 169 (4),1261-1266, 2003). I have
not seen any 5-, 7-, 10- or 15-year projections from LRP to compare
against the corresponding RRP data.

So from what I have read, I do not see any major advantages to the LRP
approach. This is not to say that it won’t be the method of
choice in 5-10 years, but we are discussing men seeking treatment
today. I do see one significant disadvantage to LRP. I suspect most
men, certainly younger men, are seeking PCa treatment with the primary
goal of lengthening their life. There is no published, that I am
aware of, that says LRP is equivalent to or better than RRP in terms
of being biochemical recurrence free in the longer term. If
Guillonneau is only projecting out to 3 years, I don’t see how
any other surgeon can have treated more patients over a longer time
and be in a position to make a more definitive longer term statement
about reccurrence. If I’m primarily seeking life extension and
LRP cannot comment on this subject, why would I select it today?

Reply to this Message

JohnG - 03 Feb 2004 16:51 GMT

> I realize that there are many exceptions to what the literature
> reports, some people do better some worse. This highlights the
[quoted text clipped - 9 lines]
> draw a conclusion. What do you think?..Best wishes and good health,
> Ron

It looks to me like you've done a real service not only in providing
current research results, but also in helping people find a good way to
think about the alternatives. Thanks!

JohnG

Reply to this Message

c palmer - 03 Feb 2004 18:08 GMT

hi ron - you can add to the LRP side that there usually is less blood
loss and that they can pipe light down to the point of where they are
operating as compared to the standard RP using outside lighting. also,
the LRP can use magnification lenses to see something and put it on the
screen so that more than one doctor can see the same problem at the same
time.

on the RP side, you are laid open to where the surgeon as you said has
tactile feel but also a greater view of the overall situation and can
draw a conclusion as to what he sees.....like an aerial view versus
being on the ground approach - the LRP.

i posted the question earlier as to what is the major advantage of one
type of RP over the other.......for example......does one lend itself to
nerve sparing better, etc. but nobody has responded to that and i
haven't found a comparison of the RP's and which is better other than by
what we have mention.

~ curtis

knowledge is power - growing old is mandatory - growing wise is optional

Reply to this Message

John Ruggiero - 03 Feb 2004 20:21 GMT

Iron,

It looks like you did more homework than I did in selecting LRP. I don't
think US hospital stays are as short for RRP as your original note states, I
was told to expect 4 days for rrp and overnight for LRP. There was also a
recent study done by Dr. Dahl comparing RRP to LRP in overweight men where
LRP had much better outcomes. The surgeon gets a much better view (according
to Dr. Dahl) and there is negligible blood loss.

My reasoning was that both procedures accomplish the same thing and you
recover faster from LRP.

-john

> hi ron - you can add to the LRP side that there usually is less blood
> loss and that they can pipe light down to the point of where they are
[quoted text clipped - 17 lines]
>
> knowledge is power - growing old is mandatory - growing wise is optional

Reply to this Message

Steve Kramer - 03 Feb 2004 23:59 GMT

My RRP was Friday 12/15 and I was scheduled for release Monday, 12/18.
Didn't work out that way, but that was what was scheduled.

Signature

Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000
PSA .1 .1 .1 .3 .4 .8
EBRT 05-07/2002 @ 47
PSA .3 .2 .2 .2 .3
Erection 05/12/2003 @ 48
HTbegins 07/21/2003 @ 48
PSA .1
Lupron 7/03, 8/03, 12/03

> Iron,
>
[quoted text clipped - 31 lines]
> >
> > knowledge is power - growing old is mandatory - growing wise is optional

Reply to this Message

JohnG - 04 Feb 2004 03:12 GMT

> Iron,
>
> It looks like you did more homework than I did in selecting LRP. I don't
> think US hospital stays are as short for RRP as your original note states, I
> was told to expect 4 days for rrp and overnight for LRP.

At the U of Michigan it was typically just an overnight stay for RRP.
My roommate had his surgery later on Tuesday than I did, and was
bouncing out of the place earlier on Wednesday than I did, feeling a lot
more chipper than I was. I probably should have stayed a 2nd night
because of my spinal headache, but at that point I didn't yet know what
was wrong and I wanted to get home, too.

I wasn't under the impression that overnight was all that uncommon,
though I know people are sometimes in for a little longer.

Four days sounds like a lot longer than typical.

JohnG

Reply to this Message

Wakeley Purple - 04 Feb 2004 04:08 GMT

> I was told to expect 4 days for rrp and overnight for LRP. There was also

I was scheduled for, and spent 3 nights for RRP. I didn't want to go home
any sooner than that.

Signature

Wake

PSA 3.8, 11/2003 @58yrs
Biopsy positive 5% in 1 of 10 cores
T1c Gleason 3+3
RRP 1/12/04
Pathology agreed with biopsy + Negative margins
Erection 1/30/04

Reply to this Message

Steve Kramer - 03 Feb 2004 23:52 GMT

Interesting, but what do you think about robotic LRPs. I really like the
idea of computer magnification of the walnut sized gland.

Signature

> There has been a fair amount of discussion around the LRP, but I'm not
> sure that any consensus has been reached. I have gone out and read
[quoted text clipped - 68 lines]
> about reccurrence. If I’m primarily seeking life extension and
> LRP cannot comment on this subject, why would I select it today?

Reply to this Message

Dave Perry - 04 Feb 2004 04:53 GMT

I had LRP last July and here are my two cents worth along with the
opinions of five urologists I talked to prior to surgery, only one of
whom did LRP. All five said RRP was the gold standard but only
because it had a long track record, LRPs had only been around about
three years. None spoke against the procedure and none indicated
there should be any difference in long term effects as has been
supported by the studies done to date. All of them downplayed the
advantage of the robotic approach by saying it was their opinions that
doctors who used the robot needed it because of lack of experience.
That statement was supported by my surgeon who had learned the
technique using the robot for his first 40 LRPs and abandoned the
device feeling more comfortable without it. Also, use of the robot
generally means an additional hour under anesthesia to set the thing
up. Based on all my research and the discussion with these doctors I
decided on the LRP with a surgeon who had done 125 LRPs and about a
thousand RRPs.

I did not give any blood beforehand and did not need any. I lost
400cc which is a little more than average for my surgeon. I was
balancing on my stomach on the edge of a dumpster at six weeks with no
difficulty (I had to retrieve something I lost - I am not a dumpster
diver). I had technically a positive margin but I do not believe it
is a real positive margin - just a 2 mm tumor growing at the edge of
the prostate at the inked margin. Would that have been noticed in an
open surgery? Doctors I talked to said most likely not - a 2mm tumor
is not obvious in either open or laparoscopic surgery. I am still
somewhat incontinent, much worse than average by both techniques
although that is coming around and I am nearly a one pad per day guy
now. Little Willy is showing life with Viagra but not yet stuffable
to any satisfaction.

Would I do LRP again or would I go the other route? I know I am not
supposed to look back but I occasionally take a peek now and then. I
do not believe LRP is so significantly better that I would travel
across country to get one over an RRP. I might travel 200 miles but
not much more. Would little Willy be crawling up the catheter if I
went the other route? Maybe, maybe not - he was not very aggressive
before surgery so who knows?

Anyway, that is my story. Just one guy with PSAs <0.1 as of six
months out and hoping for many more. That is really the best we can
hope for no matter what route we take.
Dave Perry

> > There has been a fair amount of discussion around the LRP, but I'm not
> > sure that any consensus has been reached. I have gone out and read
[quoted text clipped - 68 lines]
> > about reccurrence. If I’m primarily seeking life extension and
> > LRP cannot comment on this subject, why would I select it today?

Reply to this Message

Alan Meyer - 04 Feb 2004 01:39 GMT

One fact to add is that, with LRP, there is less cutting on the
way in to the prostate. All other things being equal (and I
don't know that they are), that should lead to a lower rate
of complications, to faster healing, and to less scarring.

People choosing LRP should know however that complications
are possible with any procedure. I was in a hospital room with
a 55 year old man in excellent physical shape who had a 9 hour
LRP operation, and was still in the hospital 4 days afterwards
with a drain in his body and a bright rad Foley bag.

As they say, "s**t happens."

Alan

Reply to this Message

John Loomis - 04 Feb 2004 01:48 GMT

I had RP////
1999. I was in and out of the hospital in 3 days. Day one surgery, day 2,
nurses/dr. day 3 out......
Catherter came out as planned 2 weeks later...splunk.....
Did not leak a drop and was continent day one. Maybe a drip......but that
seemed about normal...
Took 2 years for erectile function. They cut one nerve off....
Today, I feel like I am ok, and waiting for my 4 year PSA and so far they
have been 0.01 or less.
I do have quite well satisfactory sexual arousal, and with 25mgs of Viagra,
I may have been back in High School!
I was about 7 on the richter scale, T2a, and gleason was around 6.
After surgery those numbers were re-evaluated. And I believe my PSA was 6
I was 49 at time of RP...I am 54 now.
I understand it is easier for a surgeoun to see all sides of the prostate,
remove all affecting parts, and I did not feel that I was in the hospital
for too long.
I did get path report back also, and he said all nodes were free......No
capsular penetration, albeit right here.........
My advice? You have to decide and look for the glimmer in the eye of the
Dr. you speak with to see if you and he connect.
I connected with my 3rd choice.
I do wish you well on this journey that will finally resolve your question.
Walk a lot......before during and after....It seems to help!
John Loomis

Reply to this Message

JohnG - 04 Feb 2004 03:31 GMT

> My advice? You have to decide and look for the glimmer in the eye of the
> Dr. you speak with to see if you and he connect.

Ha! That's sort of what it comes down to, isn't it?

In my case, it was the web site with these words caught my attention:
"Of patients who have had radical prostatectomy by Dr. [x], over 90%
have had no clinical recurrence, and a significant proportion have
recovered erections."

There is some weasel room in that last phrase, but I studied the rest of
his c.v. and saw that in his position he probably couldn't get by with
saying things like that unless there was good cause for it. And after
meeting him, I decided he had the right glimmer in his eye, so to
speak. I liked the fact that he was willing to go over the data on the
alternatives, and when I brought up points from studies I had read about
on the web, he was able to say why he did or didn't think it was a good
study, etc. In other words, we connected.

JohnG

Reply to this Message

Dave H - 04 Feb 2004 14:59 GMT

I had my LRP procedure last June. I realize that I am not impartial on the
subject, but of course, like everyone else I have my $.02 worth to throw in.
Sorry for rambling a bit.

The first thing that I'd like to just put out front is that any choice that
you make is a personal choice. You cannot have someone else make it for
you. Each of us has our own person list of priorities, fears, needs and
circumstances that will factor into the decision that we make. When we are
first diagnosed I think that life gets turned on its head and then we are
presented with the need to make a complicated, life changing decision about
a very complex subject which, before our diagnosis, many of us have little
or no clue about. The good news is that while the decision needs to be made
in good order, it is not something that one has to decide overnight. The
other good news is that there are resources like this news group, that we
can get good input from and pointers to resources. Thank God for that.

I know that in my own personal experience (and I've observed it in others as
well) we tend to try to over analyze this thing to death. Just how much
information is needed to make this decision and where do we draw the line
between looking for enough information to make the right decision vs. the
perfect decsion is a difficult thing to find.

This data is good data, but I'm wondering how much of it is driven by a
search to find the perfect decision?? At some point one must balance
various factors and realize that there IS NO perfect decsion in this space,
only the right one for you, that you believe will address your priorities
the best, and that you feel comfortable with.

> Over the last 5 years the average hospital stay for RRP was 1.5 days
> (J. Urol., 167, 224-228, 2002), hard to do a lot better.

You don't compare the stay for LRP to this number. I suspect that, for most
folks, it will be about the same meaning that neither procedure has an
advantage over the other based on these numbers. My own experiences was
that I stayed 2 nights. I got out of surgery very late on the day that I
was admitted (surgery didn't start till mid afternoon), so two nights was
appropriate. I was more than ready to leave by day 2, but was very glad
that I had stayed that long. Again, these are all individual cases and one
cannot draw conclusions from the "average" for your own case.

> The duration of bladder catheterization is shorter for LRP than RRP
> (LRP = 5.8 days, RRP = 7.8 days, Urol., 62 (2), 292-297, 2003).

Mine was in for 1 week.

> The French surgeons who have pioneered LRP have said that LRP is a
> technically demanding procedure, even more so than open surgery, and
> takes the practitioner hundreds of operations before mastery is
> achieved. So if you choose this route, make sure you pick a very
> experienced LRP surgeon.

Yup, I agree and always emphasize this. In fact, I would suggest that you
find the most qualified surgeon possible that is available locally
regardless of the procedure that you choose. Those are pretty tiny
structures that he's going to be playing with and you want to make sure that
the guy (or gal) who is doing the work knows that area like the back of
their hand and has seen almost every variant possible. The urologist that
diagnosed my cancer did one or two a month. I ended up choosing a surgeon
that does 4 to six of these a week. Big difference in practice time and
that was important to me and it should be for anyone who is considering the
surgical alternative.

The problem with LRP is that, as the newer procedure, there are fewer LRP
trained surgeons around, although that story is changing quickly. I was
very fortunate to be near enough to Boston to be able to have Dr. Dahl do
the work. Others in this string have used him as well. I was, and continue
to be, very pleased with his work. The bottom line (and JohnG just
mentioned this as well) is that you need to feel totally comfortable and
connected with the doctor that you choose. Your life will literally be in
his hands.

I really can't comment on the Robotic vs. non-robotic LRP approaches. I
would certainly be wary of drawing the broad, sweeping generalization that
any doctor that uses the robot is doing so to compensate for lack of
experience. The robot is just another tool. You need to evaluate each
doctor individually.

> The LRP procedure is still evolving (J. Urol., 169, 2049-52, 2003).

Actually, the LRP surgury at this point is fairly well understood and
documented. EVERY procedure is evolving, even RRP. There is constant
review and tweaking of procedures by the major institutions. LRP is newer,
so it is probably reviewed a bit more often, but I'd be very leary of any
procedure that is this complex, that was not undergoing constant
improvement.

> The advantage of tactile evaluation of the prostate is lost in the
> LRP.

Yes, to some extent. I asked Dr. Dahl about this and his response was that
with the non-Robotic LRP method (which he uses) the fact that you can't
physically manipulate the organ with your fingers is more than overcome by
the fact that the field is virtually bloodless, well lit and magnified 18x.
He says that he is able to see details of the structures that he is
manipulating far better than any surgeon doing the traditional RRP. In
addition, the magnification allows him to use much smaller, more precise
instruments. So there is balance here. You loose something and gain other
things. Which factor is more important?? Depends on the doctor I would
say.

> The positive margin rates appear the same for the two procedures (J.
> Urol., 169, 2049-52, 2003).
>
> Urinary continence and erectile function at 1-year post-op appear the
> same for the two procedures (Urol., 62(2), 292-297, 2003).

All I can speak for is my experience. I had more than acceptable continence
almost immediately. I still have some stress related leaking (but it is
more than acceptable to me) but I am very pleased with this result. In
fact, my urinary function hasn't been this good for many years. Go figure.

On the erectile function side the story is not so good. There is some
movement in this area, but nothing "stuffable" as they say. Still, many
guys don't have sucess in this area for a couple of years, so I've still got
a long time to be patient.

> The average operating time was 92 minutes longer in the laparoscopic
> group, which, the authors state, “is a limitation of this
> technique” (Urol., 62(2), 292-297, 2003).

As far as I've read this is true. I'm not so worried about this. It is
certainly something to consider if you are older, have a heart condition, or
some other condition that would cause you to worry about being under a
general anathetic.

> Guillonneau, the French LRP pioneer, started practicing the technique
> in the late 90s. He has recently published a paper on LRP where he
> uses his 1,000 consecutive cases to actuarially project 3-year
> biochemical free rates (J. Urol., 169 (4),1261-1266, 2003). I have
> not seen any 5-, 7-, 10- or 15-year projections from LRP to compare
> against the corresponding RRP data.

Actually the French started to pioneer this in the early 90's. The
currently documented operation evolved in the late 90's however.

I do have to comment on the 5, 7, 10, and 15 year data. You won't see any
untill those of us who have undergone the procedures have had that many
years under our belt. If we all waited until we could see 10 year numbers
before we choose a procedure, then there would never be any new procedures!!
If clearly documented, proven beyond a shadow of a doubt, statistics are
important in your decsion, the I say choose RRP.

> So from what I have read, I do not see any major advantages to the LRP
> approach. This is not to say that it won’t be the method of
[quoted text clipped - 9 lines]
> about reccurrence. If I’m primarily seeking life extension and
> LRP cannot comment on this subject, why would I select it today?

Clearly you need that sense of security to feel comfortable with your
decsion and that's OK, but just understand that others will set other
priorities. Again, there is NO PERFECT ANSWER FOR EVERYONE. There are lots
of perfect answers for everyone, however, and for some of us the answer was
LRP.

There are advantages to LRP that I perceived for myself. One of my personal
issues was have a long, abdominal incision. I know, it's stupid, but it's
me. LRP won on that round. My recovery was extremely fast (I was basically
100% back within 3 weeks and almost 100% within 2). The only pain medicine
that I used after the day of surgury were some NSAIDs that were perscribed,
for the first few days and suspect that those were more for inflamation
control than for pain. After I got home I literally had NO PAIN. I am a
alcoholic in recovery so the use of drugs for pain management was a big
issue for me (there we go again with the personal priorities :^) ). I
really liked the doctor. I have worked in technology for my entire career
so far, so the idea of using a fairly new procedure that depended on
technolgy was a no brainer for me. See, there are lots of personal things
that factor into this that you just can't put into a formula to come up with
that perfect 1 size fits all recommendation.

Bottom line was that I did enough research to know my options. I understood
what my priorities were, and felt comfortable with my decision. In that
context I would suggest that there are as many guys for whom LRP is 'the
right" decision as there are for whom RRP is.

Bottom line is if you are looking for the magic life extension bullet, good
luck. Each of us is different, and every case will have it's own
variations. Some of us will have surgery and be cleared for life. Others
will look great after surgery but have a recurrance within a year. You just
can't predict. It's just life.

I agree that some procedures MAY have an advantage over others, but beware
of the data that is used to prove that. As Benjamin Disraeli said "There
are three kinds of lies; Lies, damn lies and statistics." Data is presented
by researchers with their own biases, often attempting to prove that their
own case is correct. Just beware of where the data comes from and the
tendancy to over analyse this decision.

I've rambled on more than enough....

Signature

Dave H (from NH)
Dx March 4, 03 at age 53
PSA 11.0
LRP June 10, 03

Post Op Pathology: Gleason 7(4+3)
negative Nodes & vesicles
positive margins
no extracapsular
PSA @+5 weeks 0.05, +5Mo 0.02

Reply to this Message

John - 04 Feb 2004 15:54 GMT

I had my LRP last week and I did a considerable amount of research
regarding LRP and RRP. Here is what I discovered. A good LRP surgeon
will not tell a patient that LRP will provide a better end result than
RRP. They are technically the same surgical procedure once you get
past the entry issues. Most use the procedure pioneered by Dr. Walsh.
A surgeon specializing in LRP will point out the advantages of less
recovery time which is pretty well documented. My personal,
non-professional opinion is that the operating field of view is better
in LRP which logically could lead to better results all things being
equal. There is very little blood loss during surgery which lets the
surgeon clearly see what he is doing. I actually have pictures that
were taken during my surgery and it is amazing how much you can see. I
recently read something that said that the laparoscopic procedure for
removal of the prostate was a natural because of the location of this
gland, ie deep in the pelvis. I also considered robotic LRP using the
Da Vinci surgical system. Like anything else experience is
everything. I heard somewhere that the learning curve is at least 50
surgerys. Use of this tool probably will likely allow more surgeons to
do LRP in the future, but in the meantime it may be difficult to find
very many experienced surgeons. In the end the most important
consideration is surgeon experience, that plus the patient getting
into the best possible condition pre-surgery will go a long way toward
a positive outcome.

Good Luck,
John

Reply to this Message