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June 20, 2006
June 18, 2006
Sexual life after prostate removal
This post is for all the men who have prostate cancer or are worried about prostate cancer. One of the most feared side effects of therapy for prostate cancer is the impact on sexual health.
Hopefully this will give men a better idea of what to expect and take some of the fear of the unknown away.
The prostate makes the liquid in the ejaculate. This is necessary for the sperm to work and therefore to have children. Other than having children, the prostate is of little use later in life and only causes problems with urination (BPH) and is a leading cause of cancer.
The "nerves" that go to the penis course very close to the prostate. They are only a few millimeters from the prostate and can be affected by surgery or radiation. These nerves are solely responsible for erections, or the ability of the penis to get hard.
The net effect of someone having their prostate removed is:
1) He will lose the ability to have an ejaculate, and will be sterile. You can still have children with your own sperm by artificial means.
2) He will maintain full sensation of the penis. With masturbation or other stimulation, he will still have the ability to have an orgasm.
3) He will probably lose the ability to get a firm erection after surgery. I have had many patients who kept their erections with robotic surgery, but this is not the rule. With time he will hopefully get his erections back normally.
Factors that are responsible for the ability to get erections are:
1) Preoperative function- Surgery can not help erections. If they are not that good to start, then they are less likely to come back.
2) Age- The older the patient, the more they need the nerves working perfectly to have erections.
3) Other medical problems- Illnesses that affect erections such as diabetes and high blood pressure will not help.
4) Frequency of intercourse- The more sexually active the person is, the better the recovery rate.
5) The ability of the surgeon to spare the nerves. If the cancer is such that the nerve shouldn't be spared, erections are less likely to come back. If the cancer is such that the nerves are able to be spared, then technical factors such as how much tissue is saved, using less cautery in the areas of the nerve bundles, and stretching the nerves less all play a role in recovery.
The following video was from a surgery done at Newark Beth Israel and demonstrates the nerves being separated from the prostate. The da Vinci robot that was used for this procedure gives 10 times magnification of the anatomy and a near high definition, 3D picture. Click on top of the picture to watch the surgery (Warning- this is somewhat graphic pictures of surgery.)
October 2007 Update: I have a new post that may help men that are looking for insurance companies to help cover the cost of penile rehabilitation PDE5 medicines.
June 17, 2006
I have prostate cancer: Do I have to wait 6 weeks to have my surgery?
One point that is debated among urologists is the time a patient has to wait between a prostate biopsy and surgery. While I was at Indiana my chairman taught me that time didn't matter. The changes after a biopsy should not affect surgery after several days.
I took this with me to New Jersey and routinely perform robotic prostatetectomy within 6 weeks of biopsy. I havent had any problems with this and I have done surgery as soon as 2 weeks after biopsy. I would appreciate urologist or patient comments on this topic.
Evidence based medicine affirms my position: Urologists and epidemiologists from the University of Iowa have studied this topic.
The other points about waiting to have prostate cancer surgery is usually its not a rush. Most patients with early prostate cancer and a favorable gleason score can wait 3 months after diagnosis.
I usually tailor the timing of the operation to a patients needs:
Are they in a rush to have surgery done for social issues?
Are they going on vacation in 5 weeks and its better to wait until they get back?
Are they very anxious and loosing quality of life waiting at home?
Is there cancer more aggressive (gleason 8-10) and I should get it done as soon as my schedule allows?
Most patients get scheduled within 4 weeks in my office. It is the advantage of having 3 robots at NBI where I perform the surgery.
June 16, 2006
Prostate size: Not all prostates are created equally
A normal sized prostate is roughly the size of a walnut. This weights about 20-30 grams. Prostates all have different sizes and shapes. This has important implications for patients with benign prostate problems, as well as patients with cancer. It has an impact on the side effects expected with radiation, the need for hormones prior to certain therapies, as well as the difficulty in removing a prostate.
My robotic prostatectomy series has allowed me to remove prostates ranging in size from 22 grams to 185 grams.
The important implication of prostate size is as follows:
For BPH (benign prostate problems)- larger prostates are more likely to lead to urinary trouble, not being able to urinate (urinary retention), and needing surgery.
If your prostate is very large, over 100 gms, then office therapies and laser ablative therapies are more likely to fail long term. I like performing a robotic simple prostatectomy in this setting.
For Cancer:
If you are thinking of seed placement, cryosurgery (freezing the prostate), or HIFU (using ultrasound to heat the prostate), and your prostate is over 50 gms, you will likely need hormonal therapy to shrink the prostate.
Several studies report higher urinary problems with brachytherapy (seed placements) if the prostate is greater than 50 gms.
Men that have surgery with large prostates typically have improved urination when they are recovered from surgery, compared to before the operation. The surgery treats the cancer, but also removes the benign part of the prostate.
Technically robotic prostatectomy is more difficult to perform with a large prostate. In my experience:
The easiest is when the prostate is less than 40 gms.
Prostates from 40-80 gms are sometimes more challenging, sometimes not much harder, but take longer to remove (15 minutes).
Prostates 80-120 gms are harder still and usually take considerably longer (30-60 minutes). You are
Robotic Surgery Newsletter
I am starting a robotic surgery newsletter that can be accessed through the blog or my website. The newsletter is intended for primary care doctors, but is useful for general information for people intersted in robotic surgery and prostate cancer.
Comments are appreciated.
June 11, 2006
New "normal" PSA velocity
PSA screening has led to the earlier diagnosis of prostate cancer in many men. Most urologists feel that this will lead to less prostate cancer mortality in the future.
What is considered to be a normal value of PSA has changed over the years. A PSA of 4 is too high for men that are less than 60. Studies have shown that men with a PSA between 2.5 and 4.0 have a 20-25% chance of having prostate cancer.
Current recommendations by some organizations recommend prostate biopsies for men with a PSA of 2.5 or greater and a 10 year life expectancy. Age adjusted values are also in use.
PSA Velocity refers to the rise of PSA values from year to year. A rise of 0.75 ng/ml/yr or greater has been considered to be significant. Recent studies have been presented by urologists from Duke (2006 Prostate Cancer Symposium) and Northwestern (2006 American Urologic Association) that conclude PSA velocity for men less than 70 should be lower. As with PSA, lower values that are accepted to be normal will lead to the diagnose of more cancer (more sensitivity), but will lead to more biopsies performed that are negative (less specific).
The following PSA velocities have been recommended:
· Men age < than 60: PSA vel > 0.4 ng/ml/yr is abnormal and should trigger a prostate biopsy
· Men age 60-70: PSA vel > 0.6 ng/ml/yr is abnormal and should trigger a prostate biopsy
· Men >70: PSA vel > 0.75 ng/ml/yr is abnormal and should trigger a prostate biopsy
Nebraska team develops touch sensor
UNL News Release: High-resolution touch sensor could be boon to cancer surgeons, others
Source: Office of University Communications
University of Nebraska-Lincoln
I think this has the potential to be a great technology. I think the part about helping surgeons perform better cancer surgeries is a little exaggerated. When performing surgery, I can not reliably distinguish cancer from healthy tissue by feel alone. I could see this technology being used to help with haptics, a current robotic limitation.
June 3, 2006
Nerve sparing- When and how much?
Since Dr. Patrick Walsh described the nerve sparing techniques for radical prostatectomy, urologists have been trying to spare the nerves responsible for erections. There is a debate among urologists on who is a good candidate for nerve sparing. Id like to ask urologists their opinion. Please vote on the poll below and add a comment below if you have time.
Robotic Surgery Growth in New Jersey- Beyond prostate cancer
This is a monthly update on the growth of Robotic Surgery in my practice.
May of 2006 was my busiest robotic surgery month to date. I performed the most operations (17) and the most non-dvP robotic operations (6) to date. With 2 robots and a world class surgical assistant, my schedule is now only limited by how many operations I can do with my schedule.
In May I performed 17 robotic operations. There were many highlights this month:
I performed 11 robotic prostatectomies that were all discharged the following day.
One patient had the most difficult dissection of the plane between the rectum and prostate that I have ever seen in any of my 400+ prostate operations. It seems that he had picked up Schistosomiasis while in Africa and this made for an extremely difficult operation. I think it may be the worlds first diagnosis of Schistosomiasis in this fashion. He also had an umbilical hernia and a robotic inguinal hernia repaired at the same setting and was also discharged the following day.
On May 22nd, I performed the live dvP to the AUA.
After that operation, I performed my first fully robotic nephroureterectomy for ureteral cancer. The S had a much larger range of motion that made the operation easier than with the standard. I was able to remove the bladder cuff without having to open the bladder, which made the patient's recovery much easier.
I also performed 2 robotic radical nephrectomies for kidney cancer with excellent results (all with the S). One patient had a robotic gallbladder removal at the same setting.
I performed my 6th robotic partial nephrectomy, the first with the S.
I performed 2 robotic simple prostatectomies for BPH. One was in a man that was 88 years old and couldn't urinate due to an extremely large prostate.
For the month of June, I have 18 robotic prostatectomies scheduled.