Gleason Grade 7 or Above: Why You Should Consider Open SurgeryBy
I want to pass on some information that newly diagnosed men absolutely should consider. It is from the excellent blog “Palpable Prostate” by A. Black. The gist of this is that for intermediate- and higher-grade PC pts (GL 7+, PSA 10+), *open* surgery for PC is considered preferable to laparascopic (which includes robotic) surgery by a number of notable surgeons. One reason is that it allows for more extensive dissection of the lymph nodes, which is very important in this situation.
I am NOT saying that if you are in an intermediate or high-risk category you should not have minimally invasive RP. What I am strongly suggesting is that you consult at least one open (traditional) surgeon to get a different point of view. Do some research and find the most qualified doctor in your area. Don’t settle for just anybody.
Dr. Alan Partin (of the famous “Partin Tables”), head of Urology at Johns Hopkins (top-rated urology faculty and top-ranked hospital in US by usnews.com), will not do a laparascopic RP on any patient with a Gleason grade over 7. This is also what I was told by Dr. Bertrand Guilloneau when I called about making an appointmentt for my husband a few years ago. Dr. Guilloneau pioneered the use of laparoscopic RP in France and was practicing it long before it was approved in the U.S. He is also head of minimally invasive PC surgery at Sloan-Kettering, the #2-ranked cancer hospital in the US . (I understand that Dr. G. has since changed the rules, but I’m not sure why.)
The website I referred to, Palpable Prostate, has a 4-part survey of the relative merits ot the different kinds of PC surgery. http://palpable-prostate.blogspot.com/2007/03/rp-vs-lrp-vs-rlrp-part-1-open-surgery.html. Then there is a wrap-up of “what surgeons and others say”. The information here is comprehensive and well-sourced, with links to all cited references. Here is a pertinent excerpt of doctors’ opinions:
Dr. Kevin Slawin of Baylor College of Medicine:
“Dr. Slawin recommends that [patients with] Gleason 6 and less extensive Gleason 7 [3 + 4] can have laparascopic surgery, while patients with more extensive Gleason 7 [4+3] disease and Gleason 8-10 patients have open surgery and are most effectively treated when a careful, extended lymph node dissection, that includes the removal of all lymph nodes situated in the iliac, hypogastric, and obturator regions, is performed as part of the prostatectomy procedure. This type of lymph node dissection can only be best performed using an open, rather than robotic-assisted, approach.”
“Patients with larger Gleason 7 – 10 tumors, situated primarily at the base of the prostate, who have a high risk of seminal vesicle invasion, can achieve a lower positive margin rate and higher cure rates than those with similar tumors treated with standard techniques, either open or robotic, when treated with “en bloc” resection of the prostate, SVs and bladder neck.”
David F. Penson
“An Evidence-Based Analysis (Feb 7, 2007) concludes that for low risk patients (all of: GS 6, PSA < 10, cT1 or cT2a) either open or robotic is reasonable, but for high risk patients (any one of: GS 8 or higher, PSA > 10, cT2b or higher) open surgery is preferred. For intermediate risk patients (GS 7) the proper approach is unclear.”
BTW, the results achieved of by minimally invasive surgeons (such as short recovery time), can often be equalled by an experienced open surgeon. Also, there is no evidence that the rate of ED is lower in patients who’ve had laparascopic PC surgery. Finally, I believe there are fewer urinary problems with open surgerey.
In any case, read the information for yourself. Always remember that the most important thing in choosing a treatment is saving your life, i.e., *cancer control*.