If you are thinking of having minimally invasive (laparoscopic) surgery for prostate cancer, have a family member who’s had it or just want to *really* understand how it works, you will want to read this guest article by Arnon Krongrad, MD.
Dr. Krongrad is a prostate cancer surgeon in Aventura, Florida, and Chairman of the Board of the nonprofit Prostate Cancer Mission. He was a pioneer of laparoscopic PC surgery in this country.
I wanted to learn more about minimally invasive surgery for prostate cancer because I find the topic so confusing — and it is all-important. I asked Dr. Krongrad to write about it because he has the expertise *and* the desire to communicate directly with the online PC community. That’s one thing I’m trying to accomplish with this blog — build bridges between doctors and patients.
Dr. Krongrad tells the story in a comprehensible, straightforward way, without hype. There are ample illustrations, and the doctor has agreed to answer follow-up questions about the article. If you have one, email it to me: leah@malecare.com
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“An Introduction to Minimally Invasive Prostate Cancer Surgery”
by Arnon Krongrad, MD
If you have been diagnosed with prostate cancer, there are some things you ought to know. Among those is that in most cases prostate cancer is not an emergency. This means that you usually have time to review options and make informed decisions about your treatment.
Surgery is one option for you if you have early prostate cancer. The operation done for prostate cancer is known as radical prostatectomy. The word “prostatectomy” means that the prostate is excised. The word “radical” means that the entire prostate is excised. When we do prostate cancer surgery we take out the whole prostate, including the external layer, known as the capsule, and attached organs known as seminal vesicles. We do this because cancer can involve them also. Depending upon specifics, your surgeon may recommend additional removal of lymph nodes and/or some of the fat and nerves next to the prostate.
Prostate cancer surgery has been around for 100 years. In the last 25 years it has been modified to take into consideration better understanding of pelvic anatomy. For example, techniques have been developed to better preserve nerves that relate to erections. Over most of its existence prostate cancer surgery was done through relatively large, open incisions of the abdominal wall.
In the early 1990s, prostate cancer surgery was for the first time done through tiny holes and without large incisions. Integrating technologies from minimally invasive (laparoscopic) gall bladder and knee surgery, the new form of prostate cancer surgery was a dramatic technical shift. You can read the surgical details in the laparoscopic radical prostatectomy technical manual (pdf). The technical shift does not represent a new type of treatment, only a modern and more gentle way of excising the prostate. For seven years, laparoscopic radical prostatectomy lay dormant. Ultimately, it was revived and brought into clinical practice. You can read a more detailed account of some of the history of laparoscopic prostate surgery.
The emergence of minimally invasive prostate surgery reflected the development of new technologies and devices. Among those is the miniaturization of surgical instruments, which allows us to put them through tiny holes. Also there is fiber optics, which permits transmission of images from the operative field to monitors that are viewed by the surgical team. Some of these technologies are necessary. Others, including a class of devices broadly grouped as “robots,” are not necessary for minimally invasive prostate cancer surgery. “Robotic prostate surgery” is a type of laparoscopic prostate surgery and use of a “robot” reflects surgeon preference.
What are “robots?” Actually, if we accept that a true robot is a device that acts without human supervision, then to the best of my knowledge there are no robots in prostate surgery. Even so, the term “robot” has come to describe a broad range of devices. These include surgeon-directed camera holders (Lap Man, EndoAssist, AESOP) and remote-controlled sewing and/or dissecting machines (LaproTek, Raven, da Vinci, Zeus). Therefore, the use of the word “robot” in the context of prostate surgery is incorrect and nonspecific. More to your point, I am aware of no evidence that in experienced hands any of these devices is superior in terms of cancer control, blood loss, pain, hospital stay, erectile function, continence or anything else that would directly matter to you.
If you are considering prostate cancer surgery, your should focus on who will do your surgery, not which gizmo will do your surgery. You should find a surgeon who consistently has very high levels of clinical success and patient satisfaction however (s)he carries out the operation. If you are having minimally invasive prostate cancer surgery, find your “Tiger Woods” and don’t micromanage the “clubs.”
We will review in a future posting why your surgeon matters and how to find a great surgeon. In the meantime, you might wish to learn more from these presentations:
There is a Lot of Hype Out There. A lecture by Dr. Jeff Cadeddu, Director of the Minimally Invasive Surgery at the University of Texas Southwestern Medical Center, to a 2007 seminar of Miami’s Prostate Cancer Mission. (15 minutes)
Robotic Radical Prostatectomy An interview by Arnon Krongrad, MD with Virgil Simon’s Prostate Net; how patients should approach prostate cancer treatment with a focus on prostate cancer surgery. (15 minutes)
Guest blogger Arnon Krongrad, MD is a prostate cancer surgeon. He is Chairman of the Board of the not-for-profit Prostate Cancer Mission and the author of “Behind the Mask,” essays about prostate problems and more.
I am Dr K’s 13th patient and can attest to the success of the procedure and support received from Dr K, his staff, and the fraternity of past patients who have been there to support those facing the realities (patients, friends and families) of prostrate cancer.
The need for familty and friends to have support is also a reality and I think a blog/virtual support group is a nobel effort.
Jack
What Dr. Krongrad says about the importance of finding the right surgeon and not worrying about what “gizmos” the various surgeons use does not, however, apply if you are thinking about having any form of radiation therapy for treatment of early stage disease. The quality of outcome of external beam radiotherapy and of radioactive seed implantation (brachytherapy) can be significantly affected by the technical “gizmos” that are used and by how well they are used by the physician and his/her team. In external beam radiation therapy, and in brachytherapy, the technical “gizmos” are used to determine exactly how much radiation is going to be delivered to which parts of your prostate, the accuracy with which this can be done, and the total dose of radiation that can be safely delivered. So … you need to learn at least a little about the gizmos if you want one of these types of treatment. And then … whatever type of radiotherapy you decide on, you still need to find the physician and the center that really has the very greatest level of skill in using those “gizmos”!
How does one go about choosing a surgeon for either the robotic or the
open procedure?
On behalf of Hugh
This is the central question, Leah and Hugh. And it’s one needing more than I can produce with a shot from the hip. Please ask Hugh to start his quest with the two links at the bottom of the article. Thank you.
Dear Leah,
How nice of you to have Dr. Krongrad contribute. He is well known in our community as an innovator in prostate cancer prevention, interdisciplinary care and minimally invasive surgery.
His dedication changed the world of many who thought that prostate cancer was “the end”.
It will be most reassuring to have him as a regular contributer to your web site.
I, too, am the recipient of Dr. Krongrad’s talent and skill. My surgery was almost six months ago, and aside from what I consider a minor sexual side effect, I am quite literally back to normal (although most people think I have never been “normal” 🙂 )
I was on “high alert” for prostate cancer since my older brother had been treated for it 10 years ago. He opted for the seeding and external radiation and has suffered many different side effects, including scarring from over-radiation. The scarring has caused pain and constriction of the urethra, which he must physically open a surgical tube. Not fun.
At the time of his cancer, he did not have the option of lapiroscopic surgery. It was seeds or the far more invasive open surgery. I could not and would not opt for these two methods.
As Dr. Krongrad was the pioneer of this new, less invasive surgery in America, and was located right here in Miami, my choice was simple. In fact, it seemed as if it was “destined” to be, as just about everyone I spoke to said “Go see Krongrad”. So I did. Less than two months elapsed between my biopsy and my surgery.
The surgery was relatively painless. The recommended two Tylenol for pain came in handy for the sore back I experieinced from lying in bed so long! The next day I was back home. Exactly one week after my surgery, I was sitting at the board of director’s meeting for the Prostate Cancer Mission Foundation. Dr. Krongrad’s newest patient was there, a 37 year old. So much for this being an old man’s disease! I think when he saw me (I’m 57), just a week out of surgery, it helped him understand what to expect.
That is really what I am all about today. Spreading the word. Guys, it is so easy to get tested, and if you do have prostate cancer, it doesn’t automatically mean you are going to die. But early detection is the key.
Many of you may have to ask your primary care physician for the test. The PSA blood test can use the same sample of blood they take for your cholesterol. The digital rectal takes all of 10 seconds in most cases. Some physicians may try to tell you that you are too young, you don’t need the test yet. Oh really? Since last Fall, Dr. Krongrad’s newest patient is only 30 years old! Let your doctor know if you have a family history of prostate cancer. That is so critical! Had my brother not had it, I don’t know that I would be writing this today. I am not crazy about needles and blood, so left to my own irrational phobia, I might never have been tested.
So, please, do this for yourself and your family. Feel free to write me if you would like any other information about this surgery from a patient’s point of veiw. I actually looked forward to the surgery! Maybe that’s why some people think I’m not normal!
Jim Borgmann
City Manager
Miami Springs, FL
As the daughter of one of Dr. Krongrad´s patients, all I can say is that you (the patient and the patient´s loved ones) need to get as many information as you can about all the options available. But then it gets confusing, so if you can, reach out to others who are going through the same. In my father´s case, surgery was the best option available and he is doing great, but please explore all options and make your own decisions.
Re: Mike’s comment: When ARE gizmos important?
My husband had salvage radiation 6 mos. ago and my only goal was to get him treated by the best doctor at the best hospital. We chose MSK. I don’t know the details of his rad.
The other day a woman who lives about an 1 2/ hrs. from Chicago whose husband needs salvage rad was asking my advice. Should he go to the local radiation oncologist or travel 3 hrs a day to be treated at U. of Chicago hospital?
I pleaded with her to choose the latter because I think the details matter as well as the skill of the technicians and docs. The woman also don’t me the rad onc had just unwrapped a brand new IMRT machine. Who wants to be the first one?
Don’t know if it was the right advice.
I am the “the 37 year old” referenced above by Mr. Borgmann and he is right. When I saw Jim following his surgery bouncing around the office like nothing had happened, I was quite relieved. He looked great and I never would have known he had had such an operation. Weeks later, I had my own LRP, again perfomed by Dr. Krongard. I personally needed more than a couple of Tylenol to recover…Tylenol mixed with some real pain killers seemed to do the trick, but this was necessary for only a short time.
Due to a combination of my age and I believe Dr. Krongrad’s skill, I healed rather quickly and have virtually no side effects–sexual or otherwise. Without a doubt, I feel I made a wise choice. I found Dr. Krongrad and the male nursing staff who took care of me while in the hospital very thorough, respectful and competent. I found Dr. Krongrad through a friend while visiting Johns Hopkins where the open procedure was offered to me. As soon as I learned I would need to bank my blood or have my brothers standing by with an open vein for our rarest of blood, I got a plane back to Miami and called Dr. Krongrad’s office.
As far as I know, during my procedure, I lost minute amounts of blood. It was not an issue. Being the sixth man in my immediate family to have this diease, I have become quite familiar with every aspect of it and its treatment. The ignorance in the medical community is astounding and as a result, they alone can not be relied upon for up to date information and treatment options. We must educate. The goals of the Prostate Cancer Mission are ones that can not be ignored if we are to protect ourselves and those we care about. Unbiased knowledge is key to eradicating this disease, and for that matter, any other.
I strongly urge anyone newly diagnosed to take the time to do their own research. It is important not to rely on hearsay from friends and family. Seek the truth and be honest with yourself about treatment options with which you can live in peace.
I was diagnosed with prostate cancer in Dec 07.Psa was 63.At age 72 I was offered hormone therapy and radiation or seeds.Having spent 40 yrs.practicing anesthesia I have to say here that I am not impressed with radiation.I chose hormone therapy and nothing else.My daughter, who lives in Florida and works at Plantation General Hospital as an accountant,told me doing nothing was not acceptable.She said there is a Dr. Krongrad at Aventura Medical Center who does larp and I should check out his site on the internet.I did this and was impressed with the responce from Dr. Krongrad.His ladys Ruth and Hope are true angels.Hope made all the arrangements for preop testing.I flew to Florida in May 07.Dr. Krongrad did the surgery May 17th.I went home to my daughter’s the next day,had absolutely nothing for pain not even tylonal.One week after surgery I flew back to Maine and 2 weeks after surgery I was kyaking on my favorite lake.So far I am doing great.I have dealt with many surgeons in my life as an anesthetist and I must say that Dr. Krongrad is not the typical surgeon.He is most caring,kind,pleasant and above all skilled.When you have your 1st appointment with him it’s like he has all the time in the world to spend with you.If your prostate has to go,he’s the man to do the job
Joe
I am very glad I found this blog. I wish that I were in Florida, and moreover, that Dr. Kongrad was a member of the Kaiser urology department. Oh well, just hearing his views has put me more at ease…well as much as I can be at present. I know that the idea of a blog is to reach people and provide information regarding the blog subject. So, on that note, let me apologize for making this all about me me me. I am 46 years old and in the final stages of deciding on the type and date of my surgery. If Dr. Kongrad is not an option, how does one go about finding that great surgeon. I’ve been told that the surgeon available to me within the urology department where I have been seen, is a very good surgeon, and that those who recommend him, would do the same for their relatives. However, when I asked (trying to inject some levity into the consult) are you any good at this, he responded, I’m comfortable with it. I have been told that was his form of modesty. He has performed a Laparoscopic Prostatectomy 160 over five years, and said he has one scheduled every week. I would like to know what are some of the questions that should be asked to give me the best chances to find out if this doctor is one that will give me great chances of recovery (because at present, all is in working order). I am looking forward to being able to share my experience and hopefully alleviate any anxiety for those in my position in the future, but for now, I would appreciate any information, advice, and the like.
Your time is very very much appreciated.
Sincerely
Adam
P.S. I just went to the malecare website and found some of the questions I should ask, but I am going to post this anyway for much needed support.
Thanks
A major problem for many patients seems to be that the most experienced prostate robotic surgeons like Dr Krongrad don’t except Medicare and medicare supplemental insurance! That eliminates many of us patients who are on fixed imcome and/or have lost their retirement investment income through downturns of the ecomomy.
I will right away snatch your rss feed as I can not in finding your email subscription link or newsletter service. Do you’ve any? Kindly permit me understand so that I may just subscribe. Thanks.