RICHARD: I watched two good friends go through a conventional radical prostatectomy, and compared to my own experience with a laparoscopic procedure, they are two entirely different experiences.

It’s too soon to know whether laparoscopic prostatectomy offers better preservation of sexual function than conventional radical prostatectomy, although some data suggest it might. I’d be interested to hear from some of the urologists how difficult an issue this is and how the Da Vinci robot may help.

DR LOVE: Could you tell us about your experience with that procedure?

RICHARD: It was extraordinary. I was in the operating room at noon on Tuesday, out of the operating room by 2:30 and home Wednesday evening. I felt a little weak, but had no pain and no blood loss.

My recovery was rapid — the catheter was removed after one week and I had my first erection at three weeks. Everything I had dreaded failed to come to pass.

I also have observed what seems to be some professional jealousy regarding this issue in the urologic community. I had seen friends go through significant blood loss and a lot of postoperative pain and significant debilitation. My experience was completely different. Other patients I’ve talked to subsequently have had similar experiences, so I don’t think I was an outlier.

DR SCHELLHAMMER: I’m out of the surgical business now, but I can say that at our center, in our department, laparoscopic radical prostatectomy was introduced four years ago and the ratio in that first year was 10 percent laparoscopic, 90 percent open. Now it’s just the reverse. In fact, it’s 95 percent laparoscopic and five percent open.

We now have three individuals doing laparoscopic surgery. They’ve all used the Da Vinci machine and say they probably will not go back to the conventional laparoscopic after using the Da Vinci because it’s very operator friendly and they avoid all the aches and pains of standing and holding their neck in a fixed position.

DR LOVE: Can you describe the Da Vinci machine?

DR SCHELLHAMMER: It’s a robotic machine that has a great deal of visual magnification. It has 3-dimensional perception, as opposed to the 2-dimensional view through the conventional lens.

It has the so-called degrees of freedom, whereby maneuvers can be done by the robot arm in small spaces that your wrist and fingers can’t accomplish. The operator sits in a console and operates remotely, away from the operating room table. It’s rather futuristic, but it works remarkably well.

DR MOUL: Paul and I were at the Mid-Atlantic AUA meeting earlier this week when the Hopkins group presented their experience with their first 350 laparoscopic prostatectomies, and the results are good — although not as good as the open prostatectomy experience reported by the main surgeon at Hopkins, with regard to continence and potency rates.

A lot depends on the expertise and experience of the individual surgeon. I think your point is well taken: it’s not clear whether the long-term cancer control will be similar. It’s likely, but it has not yet been proven.

With regard to the potency rates, I think it depends on how much electro-cautery is used. Obviously, you had a great outcome. Whether your case is the exception or the rule, you don’t know unless individual surgeons publish their own personal results. That is not commonly done in this country — not just for urology but for any surgical procedure.

RICHARD: An independently refereed study of my surgeon’s whole series is underway right now, and they’re comparing it internally.

DR MOUL: That’s the exact right way to do it. I can tell you that we are now embarking on the robotic at the institution I’m at right now, and the biggest challenge is financial. It is difficult to make ends meet doing that, because the operative times are longer but the reimbursement is the same.

We face a lot of pressures in that regard and, quite frankly, the surgeons’ profit-and-loss statements are going in the wrong direction. I don’t know what’s going to happen. The insurance companies don’t seem to want to pay more for it, yet it definitely requires more time to do.

DR LOVE: How available is the procedure? How many centers around the country are actually making it available, and how does it work in terms of paying for it?

DR MOUL: I can’t say exactly how many centers are doing it. I know a large number are doing it, and many centers are doing it kind of as a loss leader. They’re doing it to try to attract patients to their particular program to generate prostate cancer business.

But right now, most of the insurers are not willing to compensate more for the Da Vinci procedure than for the traditional open prostatectomy procedure. Even in the best of hands, the Da Vinci procedure takes longer to do. That’s where the challenge comes in.

DR LANGE: These details are not much different than the details I experienced when urology converted from open stone surgery to percutaneous and shock-wave approaches, with all the great angst about making money, levels of skill, who gets the best results, etcetera.

More centers want to claim themselves as centers for prostate cancer excellence — and it probably will cause more centralization of these skills. The only uncertainty right now is the potential five or 10 or 20 percent differences in potency.

In two years, if surgery is still an option, we’ll be doing it laparoscopically and probably with a robot — not because a skilled laparoscopist couldn’t do it without a robot, but it turns a good prostatectomy surgeon into a skilled laparoscopist without having to go through all the agony of learning from scratch. Financially, it is a problem, but in medicine anything that costs more is initially rejected, even if it’s better. I think it will eventually predominate.

DR LOVE: We talked about patients being made aware of options and urologists referring patients with lowrisk tumors to a radiation oncologist to be evaluated. Do you think urologists should also be saying to patients, “Listen, I don’t do laparoscopic prostatectomy, but I want you to be aware that it can be done and, if you want to find out about it, I can tell you about centers that do this”?

DR LANGE: It would be self-serving to say “yes” but the answer is obvious.

RICHARD: I’m chuckling at that answer because, at least in my local medical community, it was interesting that a couple of behemoth famous institutions were reluctant to give it equal credence or even to accurately present the details.

DR DEETHS: In Omaha, three Da Vinci units are in use. One is in the University of Nebraska; the second one is in a private hospital; and the third one is within 30 miles of Omaha. It’s going to be a ubiquitous procedure and a ubiquitous unit. It costs about a million dollars for one unit but hospitals in Omaha don’t seem to have a problem with that expense.

RICHARD: In oncology, if we have two regimens that are equally effective and one is a lot less toxic than the other, we know which one the best is.

DR LOVE: I’m curious what your thoughts are in terms of the Medicare changes that are coming about and the potential impact on the practice of prostate cancer medicine. Judd, you were commenting earlier about the fact that life is different outside of Walter Reed. What do you think is going to happen over the next year or so in the community?

DR MOUL: I think a lot of us are concerned about the changes in reimbursement and how it’s going to affect the bottom line for both urologists and medical oncologists.

One thing is clear. Some urologists are saying, “We’re just going to write a prescription and send the patient to the pharmacy,” and we can’t do that because these drugs are only reimbursable by Medicare if administered through a physician’s office. We have to find a way to make it work for our patients.

DR LONG: It is a difficult dilemma. I have 60 patients on Zoladex and if Medicare reimburses six percent more than cost, we’re going to lose money because some slippage always occurs. I don’t know what I’m going to do with my patients after the first of the year. I’m looking for help.