When a doctor becomes a patient – A story of a doctor who underwent robotic surgery for prostate cancer….

I am quite touched by this comprehensive feedback from a senior doctor who was diagnosed with prostate cancer and underwent robotic surgery in my care.

WHEN THE DOCTOR IS THE PATIENT:
PERSONAL ACCOUNT OF TREATMENT OF MY PROSTATE CANCER

I’m writing this piece with the hope that patients diagnosed with prostate cancer will benefit from my experience in accepting the dreadful diagnosis and in choosing the mode of treatment and the doctor (and hospital) to treat me.

My Story: I am 62 year old medical doctor (consultant paediatrician) residing at family house in Hyderabad (AP). Until recently we had been living and working abroad. It has been seven months (today 31st October, 2014) since I had Robotic/Robot-Assisted (da Vinci® ) Radical Prostatectomy (RRP) for Prostate cancer on 31st March 2014 by a team of doctors lead by Dr. Gagan Gautam.

Diagnosis: My story started with occasional dripping of drops of urine after voiding six months prior to my surgery. It was rather a nuisance than a ‘disease’. I mentioned this complaint to a colleague (urologist) in the hospital I was abroad. He advised me to do Prostate Specific Antigen (PSA) as a marker for prostate cancer due to my age rather than a finding of enlarged prostate. We came home for vacation and paediaric conference held in Indore in January this year. Before the conference I saw a urologist at a ‘five-star’ hospital in Hyderabad. He did not think it was necessary to do PSA as he was under the impression that the enlarged prostate was benign (not cancerous); he advised for clinical follow up to monitor the enlargement. However, I personally opted to do the PSA at that hospital on Monday 10th February 2014; it turned out very high (3x upper limit of normal). The following week I went back to the same urologist and showed him the result of the PSA and discussed the next course of action. He then ordered for trans-rectal ultrasound-guided (TRUS) biopsy of the prostate which I underwent in that hospital on Friday 14th February. After two careful reviews of the prostatic tissue in their laboratory the final report was issued out on 24th February as prostate adenocarcinoma (cancer) of intermediate grade.

Dilemma on My Choice of Mode of Treatment: The urologist explained the nature of the disease and the various options for treatment. In his opinion the best and most suitable treatment option for me was radical prostatectomy either by open surgery or by robotic-assisted procedure. Surprisingly what helped me to make up my mind did not come from high peer-reviewed medical journal (even as I am a doctor); it came from a Health & Fitness article (as I am now a patient rather than a doctor). The article that took me to the decision was an online one titled “Robotic Surgery for Prostate Cancer: An Automatic Choice?” by Lisa Farino for MSN Health & Fitness. The key words of the article caught my attention “It’s essential to consider a surgeon’s experience when deciding on treatment”. In this article Farino reviewed a number of issues on RRP including what was ‘robotic’ about prostate surgery, patients’ misconceptions about the procedure, what research said and did not say about open vs robotic prostate surgery and then concluded on the final note on surgeon’s experience. She then wrote, “The bottom line: The biggest factor determining the key outcomes of prostate surgery isn’t whether or not the surgeon uses a robot. With a highly experienced, talented surgeon, both open and robotic prostate surgeries can be performed well. The trick is identifying that highly experienced, talented surgeon who’ll give you the best chance of curing your cancer and preserving your quality of life afterwards.” She concluded by quoting Dr. Eric Klein, M.D., a urologist at the Cleveland Clinic, who said, “The robot is a tool; to have the best outcomes, you want to choose your surgeon, not your tool.”

So I set out to find and decide on the right surgeon.
I flew to Medanta – The Medicity, Gurgaon with my wife and met Dr. Gagan Gautam – Head of Robotic Surgery in his office on Saturday 28th February 2014.
He took history of my condition and examined me. He reviewed the investigations I had done in the Hyderabad hospital. He concurred with diagnosis done there. He took me through the options for treatment taking into consideration my age, my African origin, my good state of health (freedom from co-morbidity like diabetes, hypertension/heart disease) and the stage of the disease (confined to the prostate gland). He did so in great detail with humour and compassion. He agreed with my Hyderabad urologist on the mode of treatment for me. He then asked me to take time the make the decision on mode of my choice; operative treatment is normally done 6 weeks after the biopsy. He however advised that the prostate tissue be re-examined in Medanta to confirm the pathologic diagnosis given at Hyderabad and that I should do MRI of the prostate/pelvis at Hyderabad before my next appointment. I returned home Hyderabad that afternoon. I later obtained my prostate biopsy tissue blocks and slides and mailed them to Medanta hospital; the diagnosis was confirmed there.
After due consultation with my family and my other medical colleagues/friends, I opted for robot assisted radical prostatectomy by Dr. Gautam and his team. As I waited for the 6 week window, I read a lot on prostate cancer, its modes of treatment and in particular the RRP. It was a most trying moment in my life. Waiting for the date of the surgery was like eternity.

Pre-operative Assessment: Eventually the date was fixed on 31st March 2014. I flew with my wife to Gurgaon in the morning of Saturday 29th March. I was reviewed again by Dr. Gautam in his office. He reviewed the MRI examination I did in Hyderabad. It guided him on the tissue planes for the operative dissection. He re-examined me and then explained to me his plans for the operation. Later in the day, I underwent general clinical (heart, vascular & lung functions) and laboratory assessment (esp liver, kidney and blood clotting functions) as outpatient so as to ascertain my fitness to undergo the general anaesthesia, surgery and post-operative convalescence. I was seen by the anaesthetist and cardiologist. The assessment confirmed my state of good health. I was then admitted into the hospital in the morning of Sunday 30th March in readiness for the surgery on the following day.

Admission & Surgery: Early morning of Monday 31st March Dr. Gautam and team visited me and gave me assurance and confidence to face the surgery. That afternoon I was taken, in the company of my wife, to the operating theatre (OT) at around 2.30pm. The moment had come. In transit from the ward to the OT I lay supine watching the ceiling; the lamps therein moved pass me in parallax as I was wheeled on down the corridor. Finally we arrived at the OT and my wife was told to stay back; she bid me good bye. She was hoping, but not quite sure, that she would see me alive again soon. It was an emotional moment. I was taken into the theatre and she departed. I kept on praying. In the next moments the anaesthetists made final assessment of me. Eventually they put a mask on my face and asked me to breath in the gas. That was the last thing I remember as I slept. I woke up in what I came to know to be the recovery ward. The actual operation surgery took about 3 hours (2hrs and 40 minutes console time).

I made good and quick recovery and was discharged with urinary (Foley’s) catheter in place on the 3rd day after the operation (Thursday 3rd April). I was given appointment to return to the hospital for assessment and removal of the catheter on 8th April, eight days after the operation. I was given the necessary medicines to use and was instructed on the care of the catheter, the need to ambulate and do respiratory exercises. I stayed in a paying guest house across the road from the hospital. My stay in the house was uneventful and I made speedy recovery. The urine being drained into a bag has become grossly clear of blood by the 4th day. On the appointed date, I was re-admitted into the hospital’s urology day-care-ward. The urinary catheter was removed. I was instructed on how to do (Kegel) exercise to improve my external sphincter (pelvic floor, pubococcygeal) muscles in order to enhance voluntary control of urine voiding; I had already known how to do this even before the operation. Thereafter underwent simple ultrasound examination of the urinary bladder to determine residual urine volume after voluntary voiding of the bladder; it showed only 12mL which indicate good voiding. I was discharged later in the afternoon after about five hours of admission. Over the next several weeks I made good recovery. Within two weeks I was able to control my urination voluntarily such that I rarely wet my pants. I was able to hold urine well and void voluntarily at regular intervals of two hours.

Seven Months On After Surgery…: After the surgery I remained in my home in Hyderabad with the family until 30th May 2014 when we returned abroad.

Bladder Control: I virtually have full bladder control. I void on urge with good stream and without efforts. I make no conscious control of my liquid intake but I still avoid intake at bed time. I hardly wake up to void until my usual wake up time of 4am. Except when I sneeze or cough I hardly have any spill of urine; when I can anticipate these I can still keep check on it. I go out wearing my regular underpants without pad. Until my return home after the day’s business I do not go to the toilet to void more frequently than ordinary.
Even before surgery I used to void with reasonably good (jet) stream. However, I realize that it now takes me shorter time to completely empty my bladder (with ease). This implies that before the surgery my urine outflow must have been partially compromised even as ultrasound examination showed only small (acceptable) post-voiding residual urine. This was most likely due to the tortuous course of the urethra within the enlarged prostate.
Erectile Function: I am satisfied with the surprising return of the degree of this function within these seven months of the surgery especially in consideration of what I had read of the guarded prognosis on erectile dysfunction post operatively in the initial months.
Prostate Specific Antigen (PSA): the level of this antigen in the body is taken as a diagnostic marker for the risk of prostate cancer and, after prostatectomy, serial levels are used to monitor the prognosis. Before my operation, the first indicator to the diagnosis of cancer, my level was about 3½ times the expected highest normal level. It was usually expected that within six to eight weeks after prostatectomy the level should fall below 0.20ng/mL.
Below were the serial levels of my PSA:
• March 31th (pre-op): 16.85ng/mL
• May 12th (1½ months post op): 0.071ng/mL
• August 12th (4½months post-op): 0.02ng/mL
• October 13th (6½months post-op): ˂ 0.01ng/mL
These results are interpreted to imply successful removal of the prostate/cancer tissue.

Dr. Gagan Gautam: I am a fellow of, trainer/teacher and examiner in, two regional postgraduate medical colleges abroad, each with structured 4year training programmes. Most of my clinical/academic practice at home and abroad, since my medical graduation in 1978, has been in teaching and specialist tertiary hospitals. I have had the opportunity to head a largest state government-owned (1000-bed) hospital. I have also been appointed by both these colleges and national medical regulatory council to assess and accredit hospitals for postgraduate training across the country. I am therefore in good position to recognise a good hospital and to identify exceptionally talented doctors.
Dr. Gautam is a good doctor, an excellent clinician and a fine surgeon. He gave me good impression of himself from the very moment I first met him in his office on Saturday 28th February. In the course of his interviewing me, my wife and I sat across his desk. He took detailed history of my condition and made careful, thorough and relevant examination of me in a basic and professional manner. After the clinic examination he reviewed the laboratory investigation I had in Hyderabad. He then summarized his evaluation of, and opinion on, my case in a lucid and unassuming manner. He described the disease, its risks, modes of treatment and prognosis as was specifically relevant to me. He left open the choice of options of the treatment to me. In the course of the discussion, he made direct eye contact with us. I observed his good knowledge of the issues on the disease and his confidence in his competence to deal with its management. I also observed his calmness and composure. He moved his hands only when necessary and his fingers showed no tremors – features of a good surgeon. His humility as a doctor and respect for his patient and colleague (me) were obvious. We were satisfied with him and by the time we concluded the consultation we believed that we made the right choice of the surgeon I needed.
My second visit to his office was a day prior to my admission for the operation. He reviewed the MRI films and report done in my Hyderabad hospital. He re-examined me again and then made and explained his plan and extent of the surgery he will do for me. Even though the procedure for the operation is fairly standardized, the plan he prepared for me was customized to my condition. He was to remove all the prostate en-bloc including the regional lymph tissue while carefully sparing and preserving the nerves that regulate for bladder sphincter control and conserve erectile function. This tight-roped plan is aimed at removing (all or as much of as is possible and feasible) the cancer tissue leading to cure and ensuring good quality; the universal goals of the treatment are, first, to cure the patient (i.e., the prostate cancer is removed completely) and, secondly, to help the patient maintain urinary control (or continence, the absence of urinary leakage), and erectile function.
He performed my operation very well and successfully. My family and I appreciate the precision with which he did this. The serial level of my PSA over the past seven months is testimony to the success of the procedure. It is hoped that this marker will remain undetectable over time indicative of my cure. The overall quality of my life after the operation is beyond my expectation. I have been in close contact with him and he has remained consistent in his care and humility. I shall live the rest of my life appreciating how the operation he performed has turned around my life after the dreadful diagnosis. Medanta hospital is lucky to have him; he is a great asset.
I will not hesitate to recommend him to any patient on personal and professional grounds.

Sincerely,
Dr. B.A.U

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Recovery after robotic surgery for prostate cancer – What to expect?

‘Is this a big operation?’ ‘How much time will it take for me to recover completely?’ ‘Will it be painful?’ ‘How many days will I have to stay in the hospital after the surgery?’ ‘Will I be able to climb stairs after I am discharged?’ ‘When can I drive? Go for a walk….?’

These are some very practical questions that I am asked almost everyday during my initial counselNurse at Patient Cart da Vinci Siling sessions with gentlemen who have been diagnosed with prostate cancer and are considering robotic prostatectomy (robotic surgery for prostate cancer). Fortunately, the answers to these common questions are almost always better than what they expect to hear!

Robotic surgery has had such a positive impact on postoperative recovery that it is sometimes hard to believe that it still is ….and will always remain…. a major cancer operation.

When I talk to my patients about this, I just tell them the sequence of events that they are likely to go through before, during and after the surgery. I tell them that there is a 95% chance that they will be able to stick to this pathway. Roughly, a 5% chance does exist, for having some problems or complications during the recovery phase. However, the vast majority of these can be managed effectively, albeit, with extra medications or procedures and hospital stay.

What follows is a step by step description of what to expect after robotic surgery for prostate cancer:

Step 1: Admission

You will be admitted to the hospital the evening prior to the date of surgery. In some circumstances you may be asked to come in the same day early in the morning. Before admission, all the relevant investigations are reviewed and a clearance for surgery is taken from the anesthesiologists. This is called the pre-anesthesia check up or PAC. At this time, if necessary, further advice and clearance may be sought from other specialists like cardiology, endocrinology etc. This is to ensure that all potential risk factors are assessed and mitigated prior to the surgery. This is done with the sole intention of keeping you safe during and after surgery. The night before the surgery you will be provided a normal dinner and some medications to help you have a relaxing sleep before the day of the surgery. You will be asked not to eat or drink anything after midnight and will be requested to sign the consent form for the operation.

Step 2: The operation

You will be moved to the preoperative holding area about an hour prior to the time of surgery. Here you will receive antibiotics to decrease chances of infection and will be reviewed by anesthesiologists. You will then be moved to the main operating room and anesthesia will be administered. Robotic prostate cancer surgery, on an average, takes about 3-4 hours to complete.

Step 3: After the surgery (Postop day 0)

After surgery, your surgeon will meet your next of kin and provide them with information about your surgery and expected recovery. You will be able to meet your loved ones in the post operative recovery room after 1 or 2 hours when you have recovered from the effects of anesthesia. Thereafter, you will be moved to your room. You will be able to have a full liquid diet starting 4 hours after the completion of your operation, although some fluids will also be given intravenously for support. You will be encouraged to move all your limbs and do deep breathing exercises. You would be expected to be reasonably comfortable with the help of painkillers that would be administered to you. At this time you would have a urinary tube and a thin abdominal drain to remove fluids from the body.

Step 4: The day after surgery (Postop day 1)

On the day after the operation, you will be served a normal diet for breakfast and intravenous fluids will be discontinued. You will be encouraged to walk about outside your room for a total of 60 minutes during the day, in splits of about 10 minutes each. The abdominal drain will be removed and medications tapered down. Deep breathing exercises (incentive spirometry) and steam inhalation are very important components of your ‘home work’ on this day. This keeps your lungs healthy and prevents infection. You should be quite comfortable with the help of medications.

Step 5: The next day (Postop day 2)

This is the day you go home! You will be relatively pain free such that you can manage easily on oral medications, without the need for any injections. Your confidence in moving about and doing all your daily activities should be back. You can take regular meals, travel in a car, go for a walk and climb stairs. You can also take a shower on this day. You will be discharged with clear instructions on how to manage the urinary tube, which would be removed after 1 week. You will be prescribed some medications to ease your visit to the washroom and to keep you comfortable. Although you would likely have passed some wind by now, passage of stools may take another day or two in the course of a normal recovery.

Step 6: A week later 

You will be asked to come into the hospital and stay there for 3 – 4 hours in the daycare ward. Here your urinary tube (catheter) will be removed. You will be taught pelvic floor exercises (Kegel exercises) to promote early recovery of full urinary control. You will be advised on the proper use of continence pads, water intake etc. and sent home on the same day after you have comfortably passed urine a few times. If the pathology (biopsy) report from the surgery is available by that day, your doctor will discuss the findings with you. After this time, you should be well on your way to a full recovery. You can rejoin your work in about 2 -3 weeks. Most men are comfortable enough to start driving around the same time.

Step 7: A month later 

You will likely have fully recovered by now, except that you may be needing a couple of pads to control leakage. Even this is likely to rapidly improve in the coming few weeks. You should get your first PSA test 1 month after the day of your surgery. This will give you and your doctor an excellent idea about the control of the disease and the chances of requiring further treatment, if any. You will need to be in regular follow up with your doctor to ensure that you remain trouble free. Initially it will be once every 3 months. As the years go by, you are likely to require a visit to the clinic only once in a year.

I hope that you found this blog useful. I wish you a speedy recovery!

 

Dr. Gagan Gautam is the head of robotic surgery for prostate, kidney and urinary bladder cancer at Max Institute of Cancer Care, New Delhi, India. Besides being one of the leading specialists for prostate cancer in India, he is also an expert in nerve sparing robotic prostate cancer surgery, which has been shown to result in a faster recovery of urinary control and potency after prostate operation. To know more about him, please click here or visit his website http://www.roboticsurgerydelhi.com.

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here.

To contact Dr. Gautam or to seek an appointment, please click here.

To view his video on robotic prostate cancer surgery, please click here.

To read his blog on the cost of prostate cancer treatment in India, please click here.

To read his blog on robotic prostatectomy, please click here.

To read his blog on watchful waiting and active surveillance for prostate cancer, please click here. 

Watchful waiting and Active surveillance for prostate cancer

Contrary to what a lot of people believe, prostate cancer treatment options do not start and end with surgery, radiation or hormone therapy. There are two other treatment options for prostate cancer that need to be discussed and evaluated in almost every newly diagnosed gentleman with this disease. And these are – Watchful waiting and Active surveillance.

Watchful waiting implies withholding active treatment for prostate cancer (surgery, radiation or hormone therapy) in men with advanced age or multiple medical problems till they develop significant symptoms from the disease. It is considered in men with early prostate cancer, who have a limited life expectancy of less than 5 to 10 years and have not yet developed significant symptoms from their disease. It is based on the premise that a significant proportion of men with prostate cancer have slow growing disease and hence will not be affected by it in their expected lifetime. It is very important to note that AGE should not be the sole criterion for applying watchful waiting in patients. I have come across many patients even in their late 70s who enjoy excellent health and have a life expectancy of at least 10 to 15 years and more. These are the patients who are very likely to benefit from active treatment for prostate cancer with surgery or radiation.

Active surveillance, on the other hand, is a treatment option for very early stage of prostate cancer which is expected to be localised within the prostate and has not spread beyond it. It can be applied to men with less aggressive types of this disease and can be recommended as an alternative to immediate treatment with radiation or surgery. For active surveillance to be considered, ALL of the following conditions should me met in the evaluation of the patient:

  • PSA should be less than 10 ng/ml
  • Gleason score in the biopsy should be 3+3 = 6; Men with Gleason 7 or above prostate cancer are not good candidates for active surveillance in most circumstances
  • In the biopsy report, not more than 2 cores should be positive for prostate cancer
  • There should not be an involvement of more than 50% of any core with prostate cancer
  • Clinical stage should be T2a or less (This is determined by your doctor on physical examination of the prostate)

If all the above criteria are met, a serious thought should be given to proceeding with active surveillance and withholding immediate treatment for prostate cancer. Active surveillance involves regular physical examination and PSA tests every 3 months, and a prostate biopsy repeated every year to ensure that the cancer is not becoming more aggressive. In case it is found that the cancer is increasing in volume or aggressiveness, immediate treatment is indicated. It has been found that by following this strategy, up to 70% of patients fulfilling the above criteria can safely avoid surgery, radiation or hormone therapy for prolonged periods of time with attendant benefits in terms of improved quality of life and decreased complications.

In summary, it is important to have a discussion with your doctor about all the treatment options for prostate cancer including active surveillance and watchful waiting. It is also a good idea to seek a second opinion from another source to increase your knowledge and reach an appropriate decision for individualizing treatment for prostate cancer depending on the person’s medical conditions, disease status and preferences.

This article has been written by Dr. Gagan Gautam, Head of Urologic Oncology & Robotic Surgery at Max Institute of Cancer Care, New Delhi, India. Besides being India’s leading robotic surgery expert  for prostate cancer, Dr. Gautam is also closely involved in the counselling and individualised care of men afflicted with this disease. His major focus is directed towards helping men in selecting and receiving the best treatment option for prostate cancer based on their personal medical conditions and preferences.

View Dr. Gautam’s profile here

If you are seeking an appointment, please click here

To read about robotic surgery for prostate cancer, please click here

To read about recovery after robotic surgery, please click here

To read a patient’s first hand account on the experience of undergoing robotic prostate surgery, please click here

To see a video of robotic surgery for prostate cancer, please click here

To read about the cost of prostate cancer treatment in India, please click here