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Old 12-09-2008, 05:40 PM   #1
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How common is ED after the DaVinci surgery?

I am trying to explain to my husband that it does happen even with the robotic surgery. He is under the impression that ED will not be an issue if he has this type of surgery. I am encouraging him to get more advice and not just go with what his MD suggests.

 
Old 12-09-2008, 06:29 PM   #2
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Re: How common is ED after the DaVinci surgery?

I considered robotic surgery first, but then as you know from my other posts, I chose proton beam radiation. My mindset at the time, had I gone for surgery, would have been the robotic route because I believed it was equivalent to open surgery but with some benefits- quicker recovery and possibly an easier procedure because there is less blood loss. I do not ever recall seeing any mention that the risk of ED was any different after robotic vs open. There will most certainly be ED at the outset, but given a successful nerve-sparing procedure, and your husband's young age, he would have a good chance at recovery somewhere around a year after the operation. I'm sure you'll hear from others on this board, since many have had a robotic-assisted prostatectomy.

 
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Old 12-09-2008, 09:28 PM   #3
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Re: How common is ED after the DaVinci surgery?

Those I've known who went the robotic route (about seven) had about the same incidence and duration of ED as with open prostatectomy for the same reasons mentioned by Daff. However ED is also commom with most forms of radiation with the possible exception of Proton Beam for which long term statistics aren't yet available as far as I know. The difference with radiation is that the onset isn't immediate but delayed although it tends to be more permanent depending on the intensity of the radiation dosage. In the case of radiation whether seeds or IMRT, the ED isn't caused by nerve trauma as much as damage to peripheral tissue.
Younger men with strong erections prior to surgery tend to have the best recovery statistics.

Last edited by shs50; 12-09-2008 at 09:29 PM.

 
Old 12-10-2008, 10:24 AM   #4
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Re: How common is ED after the DaVinci surgery?

Again, I would urge you to talk to men via e mail message boards and personally to men who have had various types of treatment. In many communities there are also support groups that provide a place to ask questions of those who have been or who are trying to figure this out too.

I did talk with many men and my take was that surgery, whether Da Vinci or regular caused more side effects than radiation. One of my friends had Da Vinci two years ago and is still having incontinent issues and cannot get an erection after trying the pills, etc. He is a young 60 year old and this is a problem for him. Another one has urinary issues and has had two roto rooters done since his Da Vinci.

So talk to men. Most are very open and candid about what they did and there is so much information out there that you can investigate.

Good luck in your pursuit. I am still working through what I want to do and there are no easy or slamdunk answers but there are viable options to look at.

 
Old 01-09-2009, 06:22 AM   #5
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Re: How common is ED after the DaVinci surgery?

Quote:
Originally Posted by Trace212 View Post
I am trying to explain to my husband that it does happen even with the robotic surgery. He is under the impression that ED will not be an issue if he has this type of surgery. I am encouraging him to get more advice and not just go with what his MD suggests.
I have recently been diagnosed with Prostate Ca and have gone for 3 opinions. Tow robotic DaVinci surgeons and one Dr Lepor in NY who does the procedure open retropubic method. I have gotten conflicting information regarding which is "better" the open surgeon telling me there is no difference in ED following open vs robotic surgery. It is very confusing. Every protocol is slightly different. It is difficult to say. Dr Lepor told me that Ed resolves in 75% of his patients and recommended using Viagra daily even before the surgery.

Does anyone have any information about Dr Edouard Trabulsi in Philly at Jefferson or personal experience with him as he is the surgeon that has been recommended to me?

 
Old 01-09-2009, 07:55 AM   #6
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Re: How common is ED after the DaVinci surgery?

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...Does anyone have any information about Dr Edouard Trabulsi in Philly at Jefferson or personal experience with him as he is the surgeon that has been recommended to me?
I'm sorry you've had to join our club , but the club has great members, so welcome!

I had not heard of Dr. Trabulsi, but prominent robotic surgeons often are involved in published research studies, so I figured he might show up in papers published in respected medical journals. Fortunately, our Government provides us with an online National Library of Medicine facility known as PubMed for Public Medicine, available at [url]www.pubmed.gov[/url], a site I consider it one of our country's great gifts to the world! Anyone in the world can access and search it for free, and we are allowed to use it on this board because it is sponsored by the Government.

Well, Dr. Trabulsi is well-published and well connected! I just did a search using " trabulsi e [au] AND prostate cancer " as the search string. Most of the following papers will have abstracts that give key information about the paper, and we can access that simply by clicking on the blue hypertext list of authors at the PubMed site.

I'm including some comments about the colleagues I see in these papers. Robotic surgery has not been my therapy, so others will hopefully comment who know more than I do, especially shs50 (Bob) who knows about the docs at Memorial Sloan Kettering (MSK). I'm impressed that Dr. Trabulsi is the first author of a number of the papers ; in published studies, the first and last authors are the ones who get the lion's share of the credit. Usually the first author is the quarterback, and typically the last author is the senior author, the producer, under whose auspices the study was done. I'm sure I am not recognizing some of the prominent physicians/researchers below, but, that said, it is clear to me that Dr. Trabulsi runs in highly accomplished company!

(I'll insert comments in green so you can tell the difference between what's in PubMed and what I'm adding.) I don't usually go into detail on PubMed findings like this (what a lot of clutter if we did it frequently!), but hopefully it will not only help you but also be an example how you can use PubMed to get clues to questions like yours.


1: A multi-institutional matched-control analysis of adjuvant and salvage postoperative radiation therapy for pT3-4N0 prostate cancer.

Trabulsi EJ, Valicenti RK, Hanlon AL, Pisansky TM, Sandler HM, Kuban DA, Catton CN, Michalski JM, Zelefsky MJ, Kupelian PA, Lin DW, Anscher MS, Slawin KM, Roehrborn CG, Forman JD, Liauw SL, Kestin LL, DeWeese TL, Scardino PT, Stephenson AJ, Pollack A.

This appears to be about something other than surgery, but the list of authors in the group Dr. Trabulsi is leading is highly impressive. Drs. Zelefsky (MSK?) and Kupelian (Cleveland Clinic) are extremely highly regarded radiation doctors, and Dr. Scardino (MSK) is one of the world's top surgeons.

Urology. 2008 Dec;72(6):1298-302; discussion 1302-4. Epub 2008 Jul 30.


2: The addition of robotic surgery to an established laparoscopic radical prostatectomy program: effect on positive surgical margins.

Trabulsi EJ, Linden RA, Gomella LG, McGinnis DE, Strup SE, Lallas CD.
I've often seen the name Gomella. Perhaps someone else can comment about Dr. Gomella. This paper appears to right on target for what you want, and it is current - less than a year old. I just read the abstract, and it compares laparoscopic prostate cancer surgery with robotic prostate cancer surgery at Jefferson. It relates that fifty robotic surgeries had been done up to the time of the report submission, and results were clearly superior for robotic on the surface (case characteristics not apparent in the abstract, but no doubt presented in the full paper). I have a strong hunch that Jefferson brought in Dr. Trabulsi from MSK to launch a robotic program there. I'll bet he did most of the robotic surgeries, and I'll bet he had great experience with the technique while at MSK. Maybe Bob can confirm that.

Can J Urol. 2008 Apr;15(2):3994-9.

3: Contrast enhanced ultrasound flash replenishment method for directed prostate biopsies.

Linden RA, Trabulsi EJ, Forsberg F, Gittens PR, Gomella LG, Halpern EJ.
Ditto.

J Urol. 2007 Dec;178(6):2354-8. Epub 2007 Oct 22.

PMID: 17936814 [PubMed - indexed for MEDLINE]

Related Articles
4: Dose escalation with proton-beam boost for low-risk prostate cancer.

Trabulsi EJ, Valicenti RK.

Nat Clin Pract Urol. 2006 May;3(5):256-7. No abstract available. (My underlining)


5: New imaging techniques in prostate cancer.

Trabulsi EJ, Merriam WG, Gomella LG.
With Dr. Gomella again.
Curr Urol Rep. 2006 May;7(3):175-80. Review.


6: Laparoscopic radical prostatectomy.

Trabulsi EJ, Guillonneau B.
This is a really key credential, in my view, as Dr. Guillonneau is THE robotic surgery pioneer, first in France, and now at MSK, though as Bob has told us before, he now has gone back to laparoscopic surgery vice robotic as he personally finds it works better for him. Obviously Dr. Trabulsi has worked closely with him.


J Urol. 2005 Apr;173(4):1072-9. Review.


7: Quality improvement in laparoscopic radical prostatectomy for pT2 prostate cancer: impact of video documentation review on positive surgical margin.

Touijer K, Kuroiwa K, Saranchuk JW, Hassen WA, Trabulsi EJ, Reuter VE, Guillonneau B.
Again working with Dr. Guillonneau.

J Urol. 2005 Mar;173(3):765-8.


8: Laparoscopic radical prostatectomy: a review of techniques and results worldwide.

Trabulsi EJ, Hassen WA, Touijer AK, Saranchuk JW, Guillonneau B.
And again.

Minerva Urol Nefrol. 2003 Dec;55(4):239-50. Review.


9: Targeting metastatic prostate cancer with radiolabeled monoclonal antibody J591 to the extracellular domain of prostate specific membrane antigen.

Bander NH, Trabulsi EJ, Kostakoglu L, Yao D, Vallabhajosula S, Smith-Jones P, Joyce MA, Milowsky M, Nanus DM, Goldsmith SJ.
Dr. Neal (Neil?) Bander is a highly regarded doctor treating prostate cancer.

J Urol. 2003 Nov;170(5):1717-21.


10: Predictive factors in prostate cancer: implications for decision making.

Yossepowitch O, Trabulsi EJ, Kattan MW, Scardino PT.
There's Dr. Scardino again, and also Dr. Kattan, formerly at MSK, and very well known for some prognostic software, known as the Kattan Nomograms.

Cancer Invest. 2003 Jun;21(3):465-80. Review. No abstract available.


11: The utility of monoclonal antibodies in the imaging of prostate cancer.

Yao D, Trabulsi EJ, Kostakoglu L, Vallabhajosula S, Joyce MA, Nanus DM, Milowsky M, Liu H, Goldsmith SJ.
From this and other titles, it's obvious that Dr. Trabulsi has expertise in advanced imaging for prostate cancer.

Semin Urol Oncol. 2002 Aug;20(3):211-8. Review.

I hope this helps, but you may find some confidence-building information by checking the PubMed abstracts as well. (Your (and my) taxpayer dollars at work! )

Take care,

Jim

 
Old 01-09-2009, 08:30 AM   #7
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Re: How common is ED after the DaVinci surgery?

I believe the degree of ED depends on:
-- how advance is your cancer
-- Were the nerves saved
-- How good was the surgent
If one is in an anvance stage and the surgent need to remove all the nerves, then regardless of the method, ED will be there.

I had open surgery last year, and even though most of the nerves were saved, I am still at 60% erection and I use VED to help.

 
Old 01-09-2009, 08:59 AM   #8
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Re: How common is ED after the DaVinci surgery?

Thanks for the quick info Jim. I would still love to hear form some of his patients if possible. Have you heard about taking Viagra daily even before the surgery to help prevent ED? Want a cancer cure # 1 but the other issues are duanting as well and of course looking for the best outcome. Also got varying information on being able to fly postoperatively. Dr Lepor said no problem going across the Atlantic (my son is going for a semester in Europe in a week) and he told me that I could fly as soon a 10 days while Dr Trabulsi told me it would be at leat 6 weeks (DVT prevention) What do you know about this?

Trying to get a handle on all this information and stay positive as well. Best regards

Silkyt

 
Old 01-09-2009, 09:09 AM   #9
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Re: How common is ED after the DaVinci surgery?

Quote:
Originally Posted by Silkyt View Post
...Want a cancer cure # 1 but the other issues are duanting as well and of course looking for the best outcome. .
Obviously your age and physical condition going into this plays an important role too- as well as the diagnosis, staging etc- and the likelihood that your cancer is contained within the capsule. Some of this cannot be known for sure, but if there are doubts, there are tests that can help. You're only asking about surgery, so I'll assume that you either considered the other alternative treatments and decided against them, or you just went with your doctor's recommendation from the beginning.

 
Old 01-09-2009, 03:00 PM   #10
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Smile Re: How common is ED after the DaVinci surgery?

I am 54 and have a Gleason of 6 with 2 of 12 biopsies positive and Tc1 staged. I have been told that surgery is the best option for someone my age with my criteria. I am leaning towards robotic surgery and trying to get as much information about Dr Trabulsi at Jefferson Hospital in Philadelphia. Any tips would be greatly appreciated and thanks for the help

 
Old 01-09-2009, 03:43 PM   #11
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Re: How common is ED after the DaVinci surgery?

Hi Silk:
While I can't add to Jim's detailed info on Dr. Tulisi who seems eminently qualified as a Robotic expert, I can offer some input on Dr.LePor who operated on one of my best friends about 7 years ago.
Dr. Lepor is a highly regarded traditional prostate surgeon at NYU Med.Center who specialises in the open procedure. I don't know if he's transitioned to Laparoscopic or Robotic though I'd doubt it due to the learning curve which could be more challenging for an older surgeon.
However my friend's experience with Dr. Lepor was less than ideal though his surgical proficiency is unquestionable. Dr.Lepor was somewhat callous when my friend experienced a complication (a blood clot causing a painful urinary blockage). When reached by phone since Dr.Lepor was in NY and my friend lived in NJ, the good Dr. suggested my friend self catheterize with a turkey baster. He was also cavalier in other respects and I would be cautious about his opinion that traveling overseas shortly after surgery is a good idea.
Few Dr's want to intervene in another Dr's problems or post-surgical complications here in the U.S. let alone in Europe.
Prudence would indicate waiting at least several weeks after surgery of this magnitude before any extensive travel out of the area.There are post surgical risks of infection, clotting, bladder spasms and urinary problems which should be handled where the surgery was performed.
Good Luck.
Bob

Last edited by shs50; 01-09-2009 at 03:45 PM.

 
Old 01-09-2009, 07:03 PM   #12
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Re: How common is ED after the DaVinci surgery?

Quote:
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...
I am 54 and have a Gleason of 6 with 2 of 12 biopsies positive and Tc1 staged. I have been told that surgery is the best option for someone my age with my criteria.
Just so you don't have any second thoughts later, it might be worth your while to look at other alternatives before making a final decision. The advice you received from your doctor is the overwhelming recommendation by urologists- that's what they get paid to do. While many do choose surgery, and often do well, there are other good choices.

I originally scheduled robotic surgery- and as I began to learn what else was out there, eventually cancelled the surgery in favor of proton beam radiation because I believe it has an equivalent cure but with few serious side effects (highly targeted radiation that dispenses its energy within the prostate and does little exit damage to nearby tissue). If you have any interest, the book that got me started down this road is by Robert Marckini, entitled "you can beat prostate cancer and you don't need surgery to do it".

 
Old 01-09-2009, 07:32 PM   #13
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Re: How common is ED after the DaVinci surgery?

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I am 54 and have a Gleason of 6 with 2 of 12 biopsies positive and Tc1 staged. I have been told that surgery is the best option for someone my age with my criteria. ... Any tips would be greatly appreciated and thanks for the help
Hi again Silkyt,

I have not had surgery and so am less aware of details, but Dr. Trabulsi's caution about flying because of potential DVT (Deep Vein Thrombosis) trouble sounds right to me. First, we PC patients are somewhat more prone to DVT just because we have PC. Second, several kinds of treatment increase the risk of DVT somewhat, including surgery. That's because almost all surgery results in clots, though they are so small for most that they are no trouble - never an issue. Still, third, long plane travel is known to highten DVT risk, and in combo with surgery recovery would not seem to be a good idea until the DVT risk from surgery is minimal. (My therapy - hormonal blockade, also heightens the risk slightly.) All of us are advised to avoid crossing our legs as that can reduce circulation, and to be sure to move around a bit on long plane flights.

Now, since you opened the door a bit by your "any tips" remark , let me just toss in the notion that active surveillance (AS) with deferral of therapy, with a goal of deferring forever, could be an excellent approach for you, depending on a full workup, with your age not a bar for at least two leading experts (though it would be for other respected experts who aren't yet comfortable with men that young - as with so many issues in PC, it becomes a personal judgement call). Your stage, Gleason, PSA and number of positive cores are fine. If that PSA did not jump by more than 2.0 in the past year to 3.46, you are okay there too on a new important prognostic factor from the D'Amico team. Was the percent of cancer in the two positive cores low? Was there any indication that the cancer was near a location where it is easier to exit the prostate?

The two leading doctors I know of who are comfortable with AS for someone your age are Dr. Fritz Schroeder (Schroder with umlaut) from the Netherlands, who is comfortable with patients of 55 or older (virtually your age), and Dr. Laurence Klotz of the U. of Toronto, Sunnybrook, arguably the world's leading acting surveillance expert, who is comfortable with patients of any age, though monitoring more frequently for younger patients. I just saw a report that 65% of his AS patients have been able to continue in the program, with the number of years growing, without needing to move to an attempted curative treatment . In the past few years quite a few major centers have enthusiastically reported their AS results. That's all I'll say unless you want to know more.

Take care,

Jim

 
Old 01-12-2009, 08:29 AM   #14
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Re: How common is ED after the DaVinci surgery?

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Originally Posted by Silkyt View Post
I am 54 and have a Gleason of 6 with 2 of 12 biopsies positive and Tc1 staged. I have been told that surgery is the best option for someone my age with my criteria. I am leaning towards robotic surgery and trying to get as much information about Dr Trabulsi at Jefferson Hospital in Philadelphia. Any tips would be greatly appreciated and thanks for the help
I have exactly the same numbers as you except I am 62 years old. I too considered all forms of treatment, including robotic surgery. Both of the urologists I saw recommended robotic surgery, the radiologists recommended seed implants. I believe you will find a common theme that urologists recommend surgery and radiologists most time recommend radiology of some type. I went to a second opinion clinic at a large hospital in my city and they said either form would likely be fine for me.

So, I did hundreds of hours of research, talked to lots of men on the phone and via e mail who had all forms of treatment. Based on my research and talking to men, I pretty quickly ruled out any type of surgery. The stories I heard were not very pleasing. Most had either incontinent and/or ED issues. And it is major surgery with all those risks too. And when looking at clinical studies and you can find lots of data on the web, it looked to me like either radiation or surgery had very similiar outcomes.

In my research, I stumbled upon a radiation therapy called Proton radiation that is only done at 5 places, universities in the US. After much research I have chose that form of treatment after weighing all the pros and cons and hope to start treatment in April.

I would echo Daff's recommendation that you read Bob Marchini's book. I would also recommend you take your time to make the decision. You are low risk and have time to make a decision. I found out I had PC in late Sept. and just made my decision last week to have Proton treatment.

Good luck in your journey.

Last edited by panthersfan7; 01-12-2009 at 08:38 AM. Reason: Went into wrong message

 
Old 01-12-2009, 10:34 AM   #15
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Re: How common is ED after the DaVinci surgery?

I agree with most everything Panthersfan said in the prior post with one major exception. From my own experience and many others I've known its far from clear that the incidence of side effects is so clearly in favor of radiation. Thats simply not borne out by the evidence although the timing of the onset and type of side effects does differ between the the two treatments. In the case of surgery whether robotic, laparoscopic or the open procedure the incidence, severity and duration of ED is heavily determined by whether both nerves have been spared by an expert or either one or both nerves had to be excised in order to obtain clear surgical margins. With bilateral nerve sparing performed by a highly skilled surgeon recovery of full erectile function is a function of age and the quality of erections prior to surgery. The younger man with the strongest pre-surgery erections have the highest incidence of full recovery with the percentafes declining as age increases. You're at the young end so you have the best prospect. When one nerve is removed the percentage of full recovery drops by half and with both nerves gone erections can only be attained with a VED or other mechanical means. Incontinence is usually temporary again highly dependant on the skills and experience of the surgeon.
With radiation the incidence of long term control is highly dose dependant. Most specialists agree that the goal of radiation is long term control since its impossible to know whether every single cancer cell has been destroyed. Only surgery can offer a cure based on post-surgical patholology of the tumor, surrounding tissue and lymph node dissection and undetectable PSA's. Also with radiation the higher the dose delivered whether with seeds or external beam the higher the risk of peripheral tissue damage resulting in bladder and bowel complications. I believe this latter risk isn't present with Proton Beam Radiation although it hasn't been around as long as the older therapies.
Unfortunately, this doesn't make your choice any easier. I went through the same dillemma 8 years ago and opted for surgery because I wanted the chance for a permanent cure with a single treatment, more certainty of outcome based on post-surgical pathology which is not available with radiation and what I felt were comparable risks of side effects both short and long term. Admittedly surgical risks are significant both from anaesthesia and infection although the actual incidence of serious or fatal incidents with a top surgeon were acceptable to me.
Your decision will in the final analysis be based on your subjective determination of the risks vs the benefits of each option and no amount of research will be conclusive.
Good Luck, Bob

Last edited by shs50; 01-12-2009 at 10:36 AM.

 
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