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This is a frequently asked question by patients and physicians alike.
We know there are genetic risks for developing prostate cancer. For example, African American men are more likely to get prostate cancer and it is more often a more aggressive type.
There was a review by Dr. Eric Klein, of the Cleveland Clinic, that was one of the most read medscape articles last year. This review summarized the literature on medicines, vitamins, and other products that may lower the risk of prostate cancer.
The knowledge of the effects of these medicines, vitamins, and minerals is crucial to prevent and possibly even treat prostate cancer.
One thing that was not covered in this review is low fat diets. Low fat diets have been to decrease the risk of prostate cancer in some studies .
Studies are pending that should tell us the advantages of selenium and vitamin E in prostate cancer reduction. Until these studies are finished, my advice to patients is as follows:
Things that wont harm you, and may help you are beneficial.
A low fat diet is in this category.
Selenium is also in this category.
Vitamin E is probably in this category, but a recent study showed that Vitamin E in high doses can lead to more heart disease.
Tomatoes (lycopenes), green tea, and pomegranate juice are in this category as well.
Medicines such as finasteride or avodart may reduce the risk of prostate cancer, but also have side effects, and are costly and are not recommended for prevention at this time.
For my poll of the week I ask,
Assuming we knew a low fat diet reduced your risk of prostate cancer from 12% to 4%, would you alter your life style accordingly?
The new Davinci S made an appearance this week in New Jersey. I had a chance to trial it today.
The main differences for the nursing team are as follows:
1) Much faster setup times with 3 wires instead of 7 to plug into the console.
2) The sterile adaptors are fitted into the drapes, so they are much easier to load.
3) The robot has a battery power source which means my nurses wont have to push it anymore.
The main differences for the surgeon:
1) The robot is much easier to dock since the arms move much more freely.
2) the 4th arm is much more versatile since it can be brought higher up.
3) The arms dock very easily with new adaptors.
4) The most useful feature- The arms are more slender and the ports telescope, making collisions MUCH less frequent. Also the range of motion is much larger.
5) The console is enhanced with streaming images. They had it set up with a cardiac echo, but I was thinking of real time ultrasound for visualizing renal tumors in partial nephrectomies.
You can also get a live feed from a camera in the room to see what your assistant is up to.
6) The console has a TV screen for the assistant.
Overall I was very impressed with the unit. I think I will be capable of doing retroperitoneal surgery and robotic nephroureterectomies on 1 set up now. I can see it taking 10 minutes off of turnaround time and 10-20 minutes off of robotic case.
Overall, its more impressive in person than on the brochure.
For comparison sake, I will call it the standard and give it a score of 100.
That puts the 4-arm unit at an 80.
The 3-arm unit at a 70.
I think the best uses of the machine will be seen in cardiac and thoracic surgery, then general surgery, then urology and gynecology.
Debra Morrison, MD, anesthesiologist at UCI gave a talk on anesthesia and robotic prostatectomy. While many of the points she reviewed have been covered elsewhere, there were a couple of suggestions that she had that I had not heard of before. She mentioned that with the extreme Trendelenburg position not only is the diaphragm pushed up into the chest but the trachea can be displaced towards the head. This can result in the ET tube migrating into the right mainstem bronchus and an abrupt increase in difficulty ventilating the patient. She is a pediatric anesthesiologist so perhaps she has seen this in that age group but I have not seen or heard of it happening in an adult. Still, it is worth keeping in mind in case you ever experience a sudden deterioration in the patient's status. The problem may be corrected by simply withdrawing the tube a cm or two until ventilation is returned to normal. At least try that before aborting the procedure and breaking everything down.
The other interesting point that she made was with regard to the difference in somatic v. visceral pain. We make much of the reduced somatic pain with laparoscopy. Dr. Morrison has the unique perspective of having been a patient who has undergone both an open and a laparoscopic procedure. She agrees that the somatic pain is distinctly less but she did experience quite a bit of visceral pain. She recommends instilling into the abdomen at the end of the case 0.25% Marcaine at a dose of 1mg/kg of body wt.
Has anyone had problems with ET tube positioning or experience with intraperitoneal Marcaine?
I attended the PACRIM conference Sponsored by the Univ. of California, Irvine in early January. There were several interesting presentations and I plan to post a summary of different ones from time to time. The first in the series is regarding a presentation made by Dr. Randy Fagin from Austin, TX, on "Achieving a Time Efficient Procedure in the Private Practice Setting". There have been criticisms leveled at robotic prostatectomy stating that it isn't time efficient compared to open surgery. In our hospital my partner (280+ cases) and I (150+) are completing cases in 2.5 -3 hoursfrom the time the patient is wheeled into the room until he is wheeled out to recovery. That is already competitive with some other surgeons' times for open radicals. Dr. Fagin is doing even better than we are it would appear.
Results: A total of 250 dVP procedures were completed by a single surgeon in private practice between October 2004 and October 2005. For the first 100 cases and the second 150 cases average incision to band-aid time was 111 and 83 minutes, average console time 78 and 53 minutes, average blood loss 125 ml and 137 ml, and average case turn over time 55 and 30 minutes. Outcomes measures for the total case series yielded up to 90% negative margin rates, up to 90% of men getting down to 2 pads or less per day by 8 weeks post-operatively, up to 65% of men regaining potency capable of intercourse by 6 months.
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He demonstrates what is possible if one is careful about planning, about staff training and about thinking through all your moves in an operation to achieve maximal efficiency. His average blood loss was slightly higher than I would guess ours is and perhaps the shorter times came about at the cost of greater blood loss. But I don't think the increased amounts involved were significant.
Kevin, MD hosts this weeks grand rounds:
Welcome to Grand Rounds, the weekly best the medical blogosphere has to offer, and a hello to all the new readers from WebMD. I'm honored to be hosting for the third time - it has come a long way since Kevin, M.D. last hosted way back in 2004.
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Robotic general surgery guru will be in Dubai for Arab Health
Source: AME info
Dr. Susan Lim will be speaking in Dubai for Arab Health Conference
| Dr. Lim, who
is the pioneer in Robotic general surgery both in Singapore and in Asia
since 2004 and to date is the leader in the field, believes most respected
hospitals in the world will be using robots to perform some of the most
complex surgeries without making large incisions. |
One of the most difficult things that a urologist has to do is to tell his patient that he has cancer. I recently had a somewhat heated debate with my partner in robotic surgery.
Prostate cancer is the leading solid organ cancer in men and is diagnosed by a biopsy in the office. The reasons for a biopsy are given by the urologist when scheduling the procedure and the urologist is present for the biopsy.
I have had discussions with my partners about the two main ways of doing this for prostate cancer and there is a difference in opinion. The two ways are over the phone or face to face.
The first way that it can be done is to have the patient come back for an office visit and go over the results in person.
The advantages of this are:
The patient is with you and can be comforted in a controlled setting.
The patient can have ample time to accept the news and immediately ask questions.
The disadvantages are:
The patient will have to wait longer for the results.
The first reaction is often shock, and the consultation for the treatment options that is to follow may not be remembered.
The second way is to give the patient the news over the phone:
The advantages of this are:
The patient will have a minimum time to wait to obtain the results.
The patient will have time to absorb the information and will be better prepared for the consultation of treatment options that is to follow.
The disadvantages are:
The patient will have to wait to meet you to go over all the options for treatment.
The patient may not have as much support at home.
Please vote on what you would prefer and add comments below specifying if you are a physician or a patient that has had to deal with this.
My thought on this will be added as a comment.
Gruntdoc hosted this weeks grand rounds.
Thanks.
Note: Our patient has given permission to use his story and name in our article and we are preparing a press release to give more details of this incredible story.
At 94 years old, the diagnosis of invasive bladder cancer is devastating. The treatment of choice for invasive bladder cancer is a radical cystoprostatectomy- the surgical removal of the bladder and prostate.
At 94 most urologists would tell the patient they are too old for surgery, but with Dr. Lefkon's help I had performed this operation in a 90 year old woman and 94 year old man before and with Dr. Katz's help had performed the operation in a 92 year old woman and a 96 year old woman.
When Dr. Katz's diagnosed a recent patient with muscle invasive bladder cancer he recommended the removal of the bladder and prostate. To my partners surprise, the first question from the patient after understanding the implication of this life threatening surgery was:
How long will I be out of work?
It seems that at 94 he is not retired, but is in the process of marketing a lotion he designed. He has developed a lotion that is called Kling, a moisturizing and deodorizing lotion. He spent the last 2 years finishing the product and it is now ready for sale.
I was then asked about performing a robotic operation to try to speed up his recovery.
On Monday, Jan 9, 2006, in a little less than 4 hours and after loosing less blood than a person would loose from a transfusion, he was awakened in the operating room and spent the first night on a regular surgical floor, without an ICU stay.
He recovered over the next few days and was drinking by Wednesday and walking by Wednesday. His pain was minimal enough by Friday to stop taking pain medicine and he was discharged to home on Sunday, without needing an rehab stay.
At 94 years old, or 60 years older than I am, he still has risk until he is fully recovered, but his robotic surgery and hospital stay went as well as it possibly could have. I believe that he is the oldest person to ever undergo robotic surgery and probably one of less than 200 people to have this type of operation done robotically. Most robotic urologists don't have the cancer training and open surgical experience to perform this kind of operation.
This blog entry brings up several points including:
Heroic measures as patients get older. What patients are too old for what type of care. In any other country I do not believe he would have received this operation.
The use of an expensive technology- what kind of benefits really exist?
One of the criticisms of robotic surgery is that it costs more and is unnecessary. In properly trained hands, this story shows what kind of benefits can be achieved. My previous four nonagenarians all spent 9-14 days in the hospital and all needed rehab stays of about 2 weeks prior to going home.
Human interest story- Without the cancer, this gentleman is a story by himself. At 94 he is starting a business.
This week's Grand Rounds
I work in a large tertiary care center which is probably one of the
biggest and busiest hospitals in the world. There are doctors from all
sorts of subspecialties, nurses, supportive personnel and, of course,
thousands of patients who make this whole endeavor worthwhile.
This organization is glued together by the continuous effort of all these
thousands of people (30,000) who come to work and make a difference in
somebody's life because it is part of what they do everyday. |
Clinical cases hosted this years first grand rounds. This was my first entry into the grand rounds series.
Thanks.
The true robotic surgery pioneers were in Europe. Hospitals in Europe were buying robotic surgical systems in higher quantity than hospitals in the United States several years ago. The largest early series were from France. Recently most sales were going to hospitals in the United States.
From an article in The Prague Post, it seems that the future of robotic surgery is bright in The Czech Republic as well now. They have performed over 25 robotic procedures and other hospitals are considering purchasing the daVinci robotic system.
This is a frequently asked question and the answer will vary on who you ask.
PSA screening is recommended by the American Urologic Association . An excellent review of the original guidelines can be found at the American Family Physician website.
I came across a post on medlogs.com from a blog (retired doc\'s thoughts) by Dr. Gaulte. He summarizes that studies in the literature not only do not answer this question, but also are contradictory.
My views as a urologist are obviously slanted towards finding prostate cancer as early as possible.
The reasons why include the following:
1) Historically, a high percentage of men die from prostate cancer (about 3%).
2) Prior to screening for PSA many man (about 1/3) presented with cancer that was not contained to the prostate.
3) My feeling is if I find the cancer early enough, most men that would have died of cancer can be cured.
The argument against my reasoning, which I explain to patients as well:
1) Most men are diagnosed with cancer currently a long time before they would have any symptoms.
In treating them near the time of diagnosis, we are causing significant side effects and potentially diminishing their quality of life.
Some patients with very favorable characteristics may choose watchful waiting with curative intent, but this has its own risks and sometimes has a psychological burden on the patient.
2) Some men will be treated that may never had a problem from their cancer.
3) Some patients are diagnosed properly with screening, but still are not cured.
Fortunately with robotic surgery and newer radiation methods that may target tissue more precisely the morbidity of treating prostate cancer is becoming less. One day I think there will be a vaccine or gene therapy that will localize the prostate and treat the cancer without any significant side effects. Until that day I recommend screening with PSAs for any man who is at least 40-50 (depending on other risk factors) and has a 10 year life expectancy. Also men who have urinary symptoms or an irregular prostate exam get a PSA test as well.
As the retired doc put it in his blog "I am not sure if it is or not but I am sure that another case control study purporting to show either positive or negative results is not going to convince many physicians to change their minds."
I will be convinced in my thinking and another study wont change my mind because:
1) Prostate cancer probably develops at an earlier age than people realize.
2) Prostate cancer often grows very slowly, and I counsel patients that they may have 15 years or more before the cancer effects them.
3) The only study that would convince me is to follow all patients from age 40 - 50, depending when you would normally screen them, and screen half (rectal exams and PSA blood tests) and don't screen half (rectal exam only).
Then these patients would be followed for as long as they live. Following them until they were diagnosed with cancer or treated, even surgically, would not be enough. Many patients that have cancer recurrences after surgery will still die from other conditions.
This would allow us to see the lead time that cancers are diagnosed and the effects of treatment. It would also allow us to see how many people would suffer the consequences of untreated prostate cancer (blockage of bladder, kidneys, bone pain, etc). And most importantly it would tell us how many people less people die from prostate cancer with screening.
To be fair, there are some organizations including the American College of Preventive Medicine that counsel against the routine use of PSA for screening, but do suggest that a patient should be counselled about the pluses and minuses of screening.
The younger the patient, the more years he has to live. Cure rates are extremely important and long term side effects are equally important.
9 days ago I operated on my youngest prostate patient. He was diagnosed last month at the age of 39. He just turned 40 prior to surgery.
The main reason why I saw him in the first place is that he had prostate cancer and was scheduled for an open prostate operation by another surgeon. He then heard about robotic surgery and found me.
I was confident that I could cure his cancer (90% chance) and give him total incontinence (95% chance), but our main variable was the quality of his erections. Fortunately his anatomy allowed a very nice nerve sparing and after the operation I commented to my partner, "I give him a 90% chance of having normal erections in 3 months".
At his 1 week visit today (9 days), X-Rays confirmed his catheter could be safely removed and when I started talking about erections, he commented that he had already had an erection with the catheter in place although he tried not to.
My next comment was then "NO INTERCOURSE FOR 2 MORE WEEKS".
Every now and then I get a really good question from a patient that I have never heard before. I am making a new category on my blog for these type of questions.
A patient of mine who was recently diagnosed with prostate cancer asked me today if his wife could catch prostate cancer. His concern stemmed from the fact that his original presenting symptom was blood in the semen.
My usual workup for hematospermia (blood in the ejaculate) is a full physical exam, urinalysis, a PSA (blood test screen for prostate cancer), and a urine cytology.
Often the workup shows no significant abnormalities, but a high PSA or an abnormality on rectal exam will lead to a prostate biopsy.
The patient's concern was that prostate cancer may be transmitted through the semen with intercourse. The logic behind this is obvious, the prostate makes fluid, but could this fluid carry prostate cancer?
In my 9 years as a urologist I had never thought of this question or had anyone ask me it.
Fortunately the answer is NO. There have not been any case reports of prostate cancer being transmitted in any fashion.
Many patients are undergoing non-surgical therapies of their prostate cancer with curative intent.
These include seeds, external beam radiation, and cryosurgery. What are their alternatives if they fail therapy?
The first thing to assess after failure is the type of failure. Is it metastatic (spread away from the prostate), locally advanced (spread away from the prostate in an area that can not be removed), or localized (contained to the prostate or seminal vesicles)?
All of the patients history needs to be assessed including:
PSA BEFORE radiation
Original exam
Original biopsy
Timing of PSA failure
Any hormonal therapy- will drastically lower the PSA, but not curative
Current PSA and exam- A PSA after treatment is much different than a similar PSA before therapy.
Bone Scans and CT Scans
Possibly endorectal MRI and Prostascint scan
The main issues with prostate removal after radiation are that the surgical planes are a little glued together. This may lead to an increased risk of injuring the rectum, which will likely need a temporary colostomy if injured- this risk is about 5% vs 1% with no radiation (and likely no colostomy).
The other main problem is a 30% chance of significant urinary incontinence that doesn't get better. This is due to the effect of radiation on the urinary muscles.
I believe that the robotic approach visualizes the rectum better and limits the rick of injury.
The urinary muscles may be less effected than open surgery, but a higher incontinence rate must be expected.
For cryosurgery these risks should not be as high since the rectal plane should be less effected and the muscles for urination should be less effected by cryo than radiation.
The main options that need to be discussed for the treatment of radiation failures is cryosurgery, which probably has less side effects, but is probably not as curative.
Radiation sometimes leads to severe urinary incontinence and a small bladder. In this case the bladder and prostate are both removed and a urinary diversion is performed. I had one patient where this happened after cryosurgery and radiation 10 and 8 years prior. I performed open surgery which went well, although the cancer was much more aggressive at this point than originally and was locally advanced at the time of surgery.
Aggravated DocSurg posts his thoughts about the effect of an 80 hour work week on general surgery residents:
>>Tuesday, December 27, 2005
80 hour week Redux
This month's American Journal of Surgery contains an interesting article from the Dept. of Surgery at Baylor in Houston entitled Impact of the 80-hour work week on resident emergency operative experience. As I have written previously, I am not convinced the 80 hour work restrictions will deal an even hand to surgeons in training, or their future patients. <<
Although the intention of the 80 hour work week for residents is probably good, it certainly has its downfalls.
I was fortunate to finish my residency at Indiana University in 2003. This was the same year that the 80 hour work week was instituted.
As a urologic surgeon, I had a limited chance to learn how to operate and how to take care of patients.
I spent my first 2 years (6 total) of residency as a general surgery resident. Call was usually every 3rd night and there was a full work day to follow. I spent a fair amount of time in the operating room at night for emergencies and spent a lot of time taking care of patients. There was always someone above me to call if there were any significant problems. In fact, there were many instances where I would have to call the person above me or the doctor in charge of the patient.
The last 4 years at Indiana were spent exclusively as a urology resident. The time on call went to every 4th night for the first 2 years and then only at home call the last 2, as a backup to a lower level person.
This experience provided me as much time as possible to take care of patients, as well as to be involved with the maximum number of operations. There would have been times in todays environment where I would be at home instead of the operating room as a second assist.
As for patient safety, I think there are more patients being covered by less doctors at night in the current system.
In my current practice, I do not have urology residents (there are only 2 urology residencies in NJ and neither set of residents rotate through my hopsitals), so I cant speak from experience on the actual impact of the reduced work hour week, but I expect that there are more negatives than positives.
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