Results for prostate cancer surgery can significantly vary based on the surgeon that is performing the operation and individual patient characteristics. My surgical team does not include residents or fellows, which allows me to perform the robotic surgery myself. The disadvantage of not having residents is that I analyze all my data without assistance from physicians in training.
After starting to perform robotic surgery in 2004, I periodically have updated my results in terms of cancer control (positive margins), urinary control (how many pads do my patients use to control their urinary leakage), and sexual function. The last time I went through my database completely was in June of 2007. I would have hoped to update these every year, but due to a busy schedule, the addition of hundreds of surgeries per year, and the desire to spend time with my family, I do not plan on having a complete set of data in the future. Below is a list of my results as of 2007 with partial updates in each area.
In my practice I routinely perform robotic prostatectomy on patients that may lead to poorer outcomes including aggressive cancers, very large prostates, prior pelvic and prostate surgery, morbid obesity, and many others. This data should not be taken by anyone as their expected results since it can change from surgeon to surgeon and from patient to patient. I explain how each patients particular situation will impact recovery and prognosis during the consultation.
Cancer control– The best long term marker of cancer control is the mortality due to prostate cancer. This takes decades to follow. PSA recurrence after surgery is a good marker for cancer recurrence, but often takes years. The amount of positive margins (meaning cancer cells that are at the margins of where the prostate was removed) is a good short term estimate of cancer control. Although not all patients with positive margins recur and patients with negative margins can have a cancer recurrence, this is our best short term test.
I have tabulated my positive margin rate for patients who were found to have cancer contained to their prostate. I have also shown the total number of cancer recurrences as measured by a PSA > 0.2.
For the first 50 patients, the positive margin rate was about 20%. For the next 50 patients, the positive margin rate was about 10%. Recently the positive margins have ranged from 3-10% for organ confined disease.
Blood loss– None of my 2000+ patients have received any blood during surgery or the immediate postoperative period. I have had a few men who received a transfusion after 1-2 days. The main risk factor for this is needing a blood thinner for a pre-existing condition.
Hospital Stays– Most patients go home the next day.
Urinary control– Most men have some leakage after radical prostate surgery. Starting in 2007, I have used new techniques to help minimize the chance of leakage after surgery. This involves reconstructing the urinary anatomy so the support of the urinary muscles is similar to before surgery.
Starting at dvP number 245 I added the “Rocco” stitch, which adds support behind the urinary tract. This helped some patients have rapid return of urinary control. After 275 operations, I added several other sutures and modified the Rocco stitch and have seen even better urinary control for some patients.
The following chart, created in 2006, depicts how many men pads per day patients number 50 to 260 had to wear.
|Number of patients||0 pad||1 pad||2 pads||>2 pads|
|1 month ( 174 pts)||32%||30%||20%||18%|
|3 months (107 pts)||65%||21%||9%||4%|
|6 months (57 pts)||86%||12%||2%||0%|
|12 months (14 pts)||93%||7%||Not enough time|
After 50 patients, I started to see better urinary control. I believe the results for the first 50 were similar to my open results.
As I have performed more dvPs, the control has been considerably improved to my open results. The majority of this is too technical improvements in the operation, but I also have been stressing that patient’s perform preoperative Kegel exercises more recently. I believe the addition of the reconstruction sutures has also helped significantly.
The following chart reveals urinary recovery times in 2010.
Return of erections– Most men have temporary lost their erections after radical prostate surgery. I think in 2004 the early results from robotic surgery were similar to open surgery. As I have developed more experience and adopted some newer techniques to spare nerves I have had better results. The data below, from 2006, only includes men that have normal erections to start and had both nerve bundles spared during surgery. Most urologists judge the ability to have erections with the addition of medicines such as viagra, levitra, and cialis.
Capable of Intercourse +/- PDE5 inhibitors
As more time has passed, we have seen better results, but not all men will recover normal sexual function. Men that have normal erections prior to surgery and can have both of the erection nerves saved, have a 90% chance of recovering normal erectile function, although many will need medication like viagra or cialis to have erections.
Catheter removal- Removing the catheter sooner helps patients return to work sooner. I often was able to remove the catheter after 1 week at the beginning of my robotic experience. After 200 cases I have been able to remove the catheter more reliably within 5-6 days. I also stopped performing x-rays routinely after 200 operations.
An area that I have continued to concentrate on is the early removal of the catheter, with most patients having their catheter removed after 3-6 days.