Urology
Robotic Laparoscopic Prostatectomy Surgery
Transcript from a Online Chat with Dr. Jean Joseph
Questions & Answers
Q: I watched the webcast on your site.
My operation was on Aug. 24 and my experiences mirrored those
of the patient.
Dr. Joseph: "Thank You"
Q: I've heard that some people become
incontinent after the surgery--can you tell me what percentage
of patients have
this problem?
Dr. Joseph: "Less than 5% in our experience"
Q: How many of these procedures have you done
so far this year?
Dr. Joseph: "I started these in July
2003. To date, I have performed almost 200 procedures."
Q: Is this procedure covered by most insurances or
is it still considered investigational?
Dr. Joseph: "Most insurances do cover the procedure."
Q: What is the typical recovery time from the
incontinence?
Dr. Joseph: "Each patient differs, some as quick as the
first week, others may be take longer."
Q: On the patient in the video you had to take
the nerves on one side of the prostate - what are
the ramifications of this?
Dr. Joseph: "The best postoperative erections are seen
with bilateral nerve sparing. If only one nerve
is spared than the percentage could be lower."
Q: Do you know if most patients are able to
regain sexual activity after the surgery? How long after?
Dr. Joseph: "It depends on their age,
preoperative erections, whether the surgery was nerve sparing
or not.
In bilateral nerve sparing patient with good preoperative function
most can have
subsequent erections sometimes with medication.
Again the time varies with patient, some soon after, others
up to 1 year."
Q: When you recommend this surgery and when
would you recommend insertion of radioactive seeds (can't remember
the proper medical name for this)?
Dr. Joseph: "The decision for surgery
or brachytherapy (seed implantation) is dependent on age, medical
status and the specifics of your prostate cancer."
Q: Do some patients require radiation therapy after
the surgery?
Dr. Joseph: "Yes, if there is evidence of more extensive
cancer found outside the prostate or a postoperative
rise in the PSA on follow up, than radiation may be required
as a salvage
therapy."
Q: How is the patient seen in the video doing
now?
Dr. Joseph: "The videotaped interview
was his last follow up, 3 weeks after surgery. His next follow
up will be 3 months postoperatively."
Q: If the brachytherapy is done and then later
there is a re-occurrence of cancer- can
the robotic prostatectomy be done?
Dr. Joseph: "Salvage prostatectomy after
brachytherapy (radiation) increases the risks of rectal
injury and other side effects significantly. So robotic prostatectomy
would not be
recommended."
Q: Is there any point in time when you can
stop worrying about getting prostate cancer? My father-in-law,
who
is now 76, has had excellent PSA readings
for at least the last decade.
Dr. Joseph: "Prostate cancer is increasingly
common cancer in men as they age. If someone's life
expectancy is less than 10 years, than prostate cancer is less
likely to impact on their
longevity. If his PSA has remained
very low, than it is quite unlikely he needs to be concerned."
Q: Is there a correlation between a rise in PSA
and cancer?
Dr. Joseph: "Yes. PSA can be elevated
secondarily to prostate cancer, infection, urinary retention,
increased size.
So an elevated
PSA is an indication for biopsy but
does not mean that there is cancer."
Q: Is this surgery ever done other than for cancer?
If so, when?
Dr. Joseph: "Radical prostatectomy is
performed for cancer, but simple prostatectomy is performed for
BPH (benign prostatic
hypertrophy)."
Q: I understand not many hospitals are able
to do this surgery. How fast do you think it will be adopted
so it
will be widely available?"
Dr. Joseph: "It takes special training to perform this
surgery. The robot is a great
improvement on the technology. Learning how to use it is the
key. It takes a long time to learn
which a lot of surgeons may be
unwilling to do. The cost involved in buying the machine are
also the factors that guide the wide
spread use of this method."
Q: Have you ever had to abandon using the robot
and take over manually during a surgery?
Dr. Joseph: "No. If need to, we could
switch to a laparoscopic approach. We have not had to convert
to an open approach."
Q: I know each patient is different, but I
have not found a lot of information
on post operative instructions and the best way to deal with
gaining the continence and erectile
function - can you suggest any sources?
Q: Are there any cons to this type of
surgery?
Dr. Joseph: "You are relying on visual
cues which takes experience to become accustomed
too. You learn to operate without touching the organ. To some
people that may be seen as a con,
not being able to touch
it. However, with experience you can see all the planes in which
you are to cut or stitch."
Q: "Dr Joseph-I attended the simulcast
and lecture on Tuesday. It was very
effective. It made me happy and hopeful to be among so many skilled
and dedicated people. Dr. Patel made
the striking images you
were producing come home to all of us with his enthusiastic and
knowledgeable presentation. If you
do it again, you must have
him do his part again, too. Did you invite him knowing ahead
he would do such a good job? The testimony
from those who had the
surgery let me know I was not alone and that good outcomes are
possible. They left a lasting impression.
Many, many thanks!"
(This question refers to a live simulcast of a robotic laparoscopic
prostatectomy surgery that was presented by the Dr. Joseph and
the University Urology Associates on September 21, 2004.)
Dr. Joseph: "Thank you. We flew him
to Rochester from London to assist with the presentation. He
spent some time last year as a fellow in our program."
Q: Are there any downsides to the approach?
Dr. Joseph: "No. In experienced hands the outcome is
equivalent to the open approach.The only downside is getting
out of house
work for a shorter period of time."
Q: On biopsy, if cancer is present, is there
a risk that this cancer will be seeded to the rectum as the needle
is
withdrawn?
Dr. Joseph: "There is no evidence of this in the literature."
Q: How do people go about seeing you?
Dr. Joseph: "If someone has prostate cancer we recommend
they speak to their
primary care physician and urologist about the best way to proceed."
Q: Although the people who had the surgery
were called cancer survivors
in the handout, they were more accurately survivors of the prostatectomy.
How long must you follow them before you
can say the surgery truly made them survivors?
Dr. Joseph: "Survival from cancer is an on-going lifetime
process. After 5 years they can be followed on a yearly basis."
Q: Has the rectal biopsy method existed long enough
to test the seeded cancer question. If not, how long should we
wait?
Dr. Joseph: "Yes, this is how prostate
cancer has been diagnosed for
decades. There have been theories about the lining between the
rectum and the prostate (denonvier's fascia) having
a protective
effect. In fact, prostate cancer spread to the rectum directly
is exceedingly rare."
Q: If the PSA signal continues to rise, even
if no cancer is detected on first biopsy, is the plan for subsequent
biopsies different?
Dr. Joseph: "Repeat biopsies may be
necessary if the PSA continues to rise or the rectal exam becomes
abnormal. A
sufficient
number
of specimens need to be obtained with sonographic guidance
during
the biopsy."
Q: "I perhaps should have said protocol (number of
samples, etc) different. That was my last Q. Cheers!
Dr. Joseph: "If only a few specimens were obtained in
the first biopsy, than the different regions of the prostate
need
to be sampled
to a greater extent. Also, if there was any suspicion on the
initial biopsy it may also need to be repeated."
Dr. Joseph: "Thank you for all of
your
questions and your participation in this awareness program.
Prostate cancer
is very common. The latest screening methods
(yearly
PSA and digital rectal exams) have increased our ability to
detect this disease. As health care providers, we hope to
continue
to improve the treatment options and lessen the side effects
for patients and their families as they cope with this
disease. Contact your primary care physician for further information."
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