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| September 2006 »
I have heard the term Bloodless Surgery many times and am familiar with it. A google search will also give someone who may not be familiar with the term a better understanding of how it is used.
There are many things that can be done to help avoid blood transfusions such as minimizing blood draws, diluting the blood during surgery by giving extra fluids during surgery, and giving medicines to help replenish normal stores.
I personally do not like transfusing blood and feel that even giving a patient his own blood back, is not entirely without risk. There is a chance of bacterial infection and a small chance that the blood can be mixed up. A friend and former Chairman of Surgery at Saint Barnabas Medical Center recently wrote an informative newsletter about the disadvantages of blood transfusions:
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Just as the physical universe is changing so too is the health care
universe. I'm a great believer in the power of change; really the
acceptance of, and adaptation to, change. I remember a warning from my
days as a medical student. Someone told me that as I traveled through a
life in medicine the questions would remain the same but the answers would
change. How true! Here are some questions that have had their answers
revised in light of better understanding.
After a major operation a patient's hemoglobin is stable at 7.5 Gms. The
patient did not receive any blood during surgery. Should the patient
receive 2 units of red cells now or not? Old answer: Give 2 units of
packed red cells now. New answer: Do not transfuse if patient is stable.
Transfusions have many potential complications including an increased risk
for post operative infection. Another question: A patient is scheduled to
come in for an open radical prostatectomy. Should he put one or two units
of his own blood in the bank in case he needs to be transfused? Old
answer: Yes. New answer: No. Blood loses 2,3, DPG and red cells deform
during storage even for a week or two. The best place for his blood is
in his veins. In cardiac surgery risk adjusted morbidity, mortality and
length of stay are all closely correlated with the age of the blood
transfused.
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So all this sounds like I am in favor of bloodless surgery, which I am to an extent.
I have several issues. Any surgery which involves any incision has the potential to lose blood.
There is no such thing as bloodless surgery in the sense that blood will not be lost.
It is safe to lose blood and I think the term should be transfusion-less surgery as a more accurate, but maybe less marketable term.
The other issue is what I feel is my responsibility to inform the patient about what is likely to happen and what can potentially happen. My team at Beth Israel had an abstract presented at a national meeting earlier this year which concluded that we no longer had blood available for transfusion in the operating room. This was after 52 robotic prostatectomies. We are now past 150 robotic prostatectomies and have still not transfused a patient.
I still inform patients that a transfusion is possible, and other than several jehovah witnesses that I have operated on, I ask everyone to sign a blood consent. I am sure there will be a day when I feel one of my patients will need a blood transfusion and since the risks of receiving blood would be much less than the risks of the anemia they would have at the time which could lead to heart attacks and life threatening events, I would give the transfusion.
In conclusion, I tell my patients that it has been transfusion-less so far, but there is a small chance that they may need blood. I tell them I wouldn't advise donating their own blood since the counts they start with would likely be a little lower and it is uncomfortable and likely it will not be needed. If they still want to donate blood, I will be happy to help them arrange to have this done.
| Some smart
guys decided that if fentanyl patches worked, why not use the same
technology with a patient-controlled delivery system --- sort of a
fentanyl patch with an on-demand component. We have had for many years
patient controlled IV narcotic delivery systems (PCAs), and a transdermal
delivery system would theoretically be similar. The FDA has approved the
first such device, the
Ionsys: |
Source:
Blog of Aggravated DocSurg
A friend of mine is a manager at a pharmaceutical company who was excited about this product.
He thought it would replace the IV PCAs (patient controlled anesthesia) that we use.
I informed him that in my practice, most of my large surgeries are done minimally invasive (robotic or laproscopic) and I do not routinely use PCA pumps any longer.
I think among urologists the use of PCA pumps is on the decline.
I thought general surgeons would likely still use PCAs.
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Out of the
group of 510 patients, who responded to the side effect section, 299
patients (59%) stated that there had been side effects and 211 patients
(41%) stated that none had occurred. The following side effects were
mentioned: leakage (17%), alguria (14%), diarrhoea (13%), voiding
dysfunctions with residual urine (12%), proctitis (10%),urinary
incontinence (6%), urethral stricture (5%), cystitis (3%), anal
incontinence (3%), evolution of fistulas (1%), retention (1%). 123
patients made a reply on their degree of potency. In total 123 patients
reported erectile dysfunction (ED); 24 (8% out of 299)of these had a
preoperatively existing ED prior to BT. 99 patients (33% of 299) reported
a newly occurred ED post BT treatment |
Source:
AUA Abstract 1137- UroToday.com
This abstract was retrospective and only 1/8 of patients commented on erections, but there are obvious side effects with radiation that urologists should discuss with their patients.
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Prostate Cancer: Major Genetic Risk Factor Found: "Harvard Medical School researchers have identified a DNA segment on chromosome 8 that is a major risk factor for prostate cancer, especially in African American men. The paper appears in the August electronic edition of the Proceedings of the National Academy of Sciences (also see PNAS's
news tip below).
'This paper identifies a genetic risk factor that about
doubles the likelihood of prostate cancer in younger African American
men,' says principal investigator David Reich, PhD, Harvard Medical School
assistant professor of genetics with the HMS Department of Genetics and
the Broad Institute. 'This finding may explain why younger African
Americans have an increased risk for prostate cancer than do other
populations--and may also explain why this increased risk in African
Americans attenuates with older age.'"
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Source:
Medical
News Today
I came across this article today on the internet.
This reminded me about a recent discussion that I was having with one of my patients and then with a partner of mine.
Suppose you have a patient that has a strong family history of prostate cancer and a high PSA who has a biopsy. Lets also suppose that the biopsy does not show any evidence of definite prostate cancer, but has premalignant findings.
The patient asked me if I could take out his prostate. My answer was no, in that the side effects of the surgery were significant and that I did not feel any urologic oncologist would feel comfortable doing that.
Some statistics that are relevant include:
A mans lifetime risk of developing prostate cancer is about 1 in 8.
If you have a first degree relative (father, brother, son) who has prostate cancer, then you have about a 2.5 times higher chance of developing prostate cancer.
If you have a 2 first degree relatives (father, brother, son) who has prostate cancer, then you have about a 5 times higher chance of developing prostate cancer.
If your relative is under 65 years at the time of diagnosis, this gives you a higher risk.
If your brother has prostate cancer that is worse than if your dad has it.
Studies show than an identical twin has a 25% of having prostate cancer and a fraternal twin about 7%.
In the last few months, as I have performed more robotic prostatectomies and noticed more patients regaining sexual function and urinary function sooner, I am starting to reconsider my original answer.
One of my colleagues pointed out to me that women sometimes have mastectomies (removal of breasts) to prevent breast cancer if they are at a high risk genetically or have pre-malignant changes.
I wonder what peoples thoughts are on this. I wonder if other urologists had considered this or have done this.
I think my answer would still be to follow the patient closely and do frequent biopsies, but one day I think my answer will change. If there was a genetic test that concluded the patient had a 100% chance of developing prostate cancer that would change my answer to prophylactic prostatectomy.
Patient Poll
Urologist Poll
For urologists that subcribe to Contemporary Urology, there was a nice CME article where some of the above facts can be found that gave a nice review of genetic risk factors for prostate cancer.
A friend and colleague of mine has joined the blogging world.
Dr. Marc Greenstein has performed many robotic surgeries with me including robotic prostatectomies, nephrectomies, partial nephrectomies, and a bladder diverticulectomy at Newark Beth Israel.
He is a leader in laparoscopic and minimally invasive urology at St. Claire's hospital in Denviile, NJ.
You can read his blog: North Jersey Center for Urologic Care
Hopkins Researchers Find Better Blood Test for Prostate Cancer
Source: consumeraffairs.com
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New studies of a blood protein recently identified at
Johns Hopkins, early prostate cancer antigen-2 (EPCA-2), may change the
way men are screened for prostate cancer -- a disease that kills tens of
thousands of men every year.
Results showed that the EPCA-2 test was negative in 97
percent of the patients who did not have prostate cancer. Men with no
evidence of disease (regardless of their PSA levels), as well as the
control group of patients with other cancer types and benign conditions,
all had EPCA-2 levels below the cutoff.
In contrast, in a multi-institutional study published in
2003 in the Journal of Urology, PSA levels between 4 and 10 nanograms per
milliliter were shown to be accurate in identifying patients without
prostate cancer only 19 percent of the time.
In addition, 77 percent of the BPH patients had a level of
EPCA-2 lower than the cutoff point. Getzenberg says this is well within
the likely percentage range of BPH patients who are prostate-cancer free.
He says this result was encouraging since BPH is often associated with
elevated PSA levels, leading to misdiagnosis and unnecessary biopsies.
When it came to correctly identifying patients with
prostate cancer, EPCA-2 levels at or above the cutoff were detected in 90
percent of the men with organ-confined prostate cancer and 98 percent of
the men with disease outside of the prostate. Overall, in this study, the
EPCA-2 test detected 94 percent of the men with prostate cancer. |
I have currently been using a test called pca3 Plus, which is a urine test done after a rectal exam to help determine if I should perform a biopsy. If this test is as good as it sounds, it will likely replace PSA. I look forward to seeing how the studies come out.
A structured process for achieving optimal port placement for robotic transperitoneal renal surgery
From the World Congress of Endourology
Source: UroToday
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M.J. Fumo1, K.K. Badani
, S. Kaul , A. Shrivastava , S. Dusik-Fenton , F. Ogunfitidimi , S. Murali
, N. Ashani , K. Arumunga , R.H Littleton , J.O. Peabody , R.M. Sahabudin
, A.K. Hemal ,M. Menon
1Vattikuti Urology
Institute,
Henry
Ford
Hospital,
Detroit,
MI,
Institute of
Urology and
Nephrology, 2Hospital Kuala Lumpur
Introduction:
The DaVinci robotic
system has the advantages of 3D imaging, magnification, and precise
movements with many degrees freedom; however, it is hampered by size
making optimal port placement essential to prevent loss of range of motion
from robotic arms colliding with each other or the patient's body. We seek
to clarify optimal port placement for transperitoneal renal surgery.
Conclusion:
Robotic
port placement for renal surgery can be optimized to eliminate loss of
range of motion. Placing the camera port laterally and robotic ports
antero-medially resulted in considerable flexibility of robotic movement. |
I came to similar conclusions as this team did as regard to port placement after several cases. The ports for robotic renal surgery are different than for laparoscopic surgery.Â
Â
I found the camera you planned on using was also important. The 30 degree down camera works best in this position. If the angle of the patient is 60 degrees instead of 90 it would put the 0 degree camera in the same position relative to the patient.Â
Â
I place my ports more in a straight line, with the upper 8 just below the costal margin and use at least 8 cm of space, preferably 10.Â
Â
I also have been using the daVinci S since March and with the S, collisions are not much of a problem and port placement is much more forgiving. I think when more urologists have access to the S, more of us will perform more renal surgery with robotics.Â
From the World Congress of Endourology
Source UroToday
Saturday, 19 August 2006
O Elhage1, AP Shortland , BJ Challacombe , D Murphy , A Sahai , P Dasgupta 2 1 1 1 11Department of Urology, Guy's Hospital and GKT School of Medicine, London, UK, One SmallStep Gait Laboratory, Thomas Guy House, Guy's Hospital, London, UK.2
Introduction: Considerable controversy surrounds the benefits or otherwise of robotics in urology. Sceptic laparoscopic urologists believe it to be just another expensive tool due to the lack of robust scientific evaluation. In addition to the effect of robotics on patients we have been carefully studying its effects on the surgeon.
Method: The Da Vinci robot underwent real time ergonomic analysis in our motion lab. Multiple high definition cameras tracked the motion of the surgeon seated at the console as opposed to standing during laparoscopic surgery. Motion sensors and EMG electrodes were attached to the torso, arms and a head band with continuous recordings during five standardised, repeated laparoscopic tasks in a dry lab to assess overall and specific muscular fatigue.
Result: Due to reduced head and body movement in the seated position with eyes fixed to the stereoscopic view finder, overall fatigue and specifically that of the trapezius seems to be reduced by robotic surgery allowing surgeons to perform complex laparoscopic procedures for longer periods.
Conclusion: It is time to start thinking about the well being of surgeons in addition to their patients. Robotics may just be the answer.
Evidence based medicine involves a practitioner using the best available clinical studies and their clinical judgement.
There have been several websites that have helped assimilate all the available information and give a conclusion in easy to read format for physicians and patients alike.
The Cochrane Collaboration is an international not-for-profit organisation, providing up-to-date information about the effects of health care.
They have several reviews about prostatic conditions including screening for prostate cancer.
| Currently,
no robust evidence from randomised controlled trials is available
regarding the impact of screening on quality of life, harms of screening,
or its economic value. Results from two ongoing large scale multicentre
randomised controlled trials that will be available in the next several
years are required to make evidence-based decisions regarding prostate
cancer screening. |
This site applies appropriate strict criteria to choose which papers to use. As more clinical trials enter the literature, the conclusions should be more helpful.
My feelings about PSA screening were previously discussed, but as I state in my thoughts, my views are not unanimous.
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Medical care can be a gamble--and patients often don't understand the
odds. University of California researchers aim to change that, with an
interactive Web-based tool that they are calling the roulette wheel. This
color-coded visual model uses a computer algorithm to help patients and
their doctors assess the possible outcomes of different treatments. |
Source:
Time.com
Original paper:
The Roulette Wheel: An Aid to Informed Decision Making
I like this as a way to counsel prostate cancer patients. I think number percentages are hard to comprehend as most patients think the less likely things are unlikely to happen.
Seeing a wheel for possible outcomes may be a little easier to comprehend. For example, plug in my data for erection rates at 6 months and show them these are the possibilities.
I recently saw a patient who had been biopsied by another urologist, found to have cancer and sent to a second urologist for evaluation for surgery. That second urologist does not do robotic prostatectomies and did not mention the option. He was also put off by the size of the prostate as estimated by ultrasound at the time of biopsy, 172 cc's. (A normal prostate in a man in his 20s might measure 25 cc's +/- and a volume of 50-100 cc's is not uncommon in men in the age range of 50-70 that constitute the majority of cancer patients being considered for radical surgery.) The second urologist recommended open surgery, but only after at least 4 months treatment with hormone deprivation (blocking the production of testosterone) to shrink the prostate. He gave him a shot to accomplish reduction (leuprolide) and planned to see him back in 4 months. The patient is now experiencing the side effects of the shot, hot flashes and progressive erectile dysfunction, while he waits for his surgery. Is this necessary?
My partner and I have removed prostates roboticly as large as 167 grams (1 gram in weight is approximately equal to 1 cc in volume) and Dr. Savatta I know has had similar experience. The larger prostates are somewhat more challenging but I think the procedure, done roboticly, is easier with large prostates than it is open. But then I think that radical prostatectomy done roboticly is overall an easier, better operation than open. I suppose there is an upper limit of what is possible to remove safely by any approach. I am reminded of my patient with a prostate that measured more than 450 cc's by ultrasound. Fortunately he does not have cancer as far as I can tell, so radical surgery never became an issue but I would hesitate to recommend surgery in his case.
If you are a patient with prostate cancer and you are told it is too large for surgery or that you have to undergo hormone treatment for months to reduce the size, please consider getting a another opinion from a surgeon with experience in robotics. It can be done and it can be done well with the da Vinci.
Perhaps Dr. Savatta or Dr. Yew have some comments on the subject?
New Jersey
Urologist with interest in Robotics
Associates in Urology, a 9
urologist group located in West Orange, NJ, is seeking a BC/BE urologist for a
position on a partnership tract. The applicant should have a strong interest
in minimally invasive urology including robotics. Fellowship or residency
training in robotics and laparoscopy is preferred.
This is a unique opportunity to join a dynamic
group concerned primarily with patient care. Our physicians focus on appropriate
and high quality patient care and have subspecialties in infertility, female
urology, oncology, and minimally invasive and robotic surgery.
Our practice is one of the busiest robotic
practices in the northeast. We are searching for a physician who can work well
with others and can become the second high volume robotic surgeon in our group.
We perform the majority of the robotic adult urology at Newark Beth Israel
Medical Center in Newark, NJ and are responsible for the robotic training course
for urologists at the hospital. The group also has a strong presence at Saint
Barnabas Medical Center in Livingston, NJ and is well respected in the New
Jersey.
Our office is located in West Orange, NJ,
about 30 minutes from NYC. The practice website is
www.njurology.com.
Call Dr. Dominic Savatta or
our office manager, Leslie Davis at 973-325-6100 to inquire about practice
details. You may send your CV to
dsavatta@njurology.com
for consideration or to ask questions.
Associates in Urology, LLC
741 Northfield Avenue, Suite 206
West Orange, NJ 07052
Phone: 973-325-6100
Fax: 973-325-1616
Website: www.njurology.com
I am in the process of putting together a personal website that wil be dedicated to prostate cancer and a resource for my patient's and for urologists visiting the training center.
I have updated my statistics for my davinci prostatectomy patients at www.roboticcancer.com
Low Blow - One man's battle with prostate cancer: MSNBC.com
This is one mans story about his bout with prostate cancer and his recovery from robotic prostatectomy. Mr. Stuckey should be commended for sharing his story, as it will help thousands of men deal with their cancer more effectively. Much of the anxiety men deal with cancer is from not knowing what to expect and the fear of the unknown.
There is a message board that people can post at and read from other people's experience.
Remember when reading people's story, there is a wide range of results that depend on patient factors, surgeon factors, and to an extent luck. I have one patient who has had a perfect result who has been discussing his recovery on the site, but I also have patients that I have expected to have full recoveries who have not.
This is a nice review that goes over different patients stories involving open surgery, seeds, HIFU, external beam radiation, and watchful waiting. I think its a good read for patients that are newly diagnosed as it points out there are many treatment options available.
It leaves out cryosurgery (freezing the prostate) and very importantly robotic surgery, which in my opinion will become the standard (or at least the majority choice for therapy among patients with 10 year life expectancies) in the next several years.
My best advice to newly diagnosed men is to seek out a few opinions, then find the therapy that you are most comfortable with and the hospital and doctor that you feel best with.
An excellent review on the abstracts presented at the AUA was done online at medscape.
It offers 1.5 credits for physicians.
One quote that I thought was interesting was:
These 2 studies taken together indicate that there is a steep learning
curve for laparoscopic prostatectomy, even if the robot is used. It is
probably medicolegally advisable for a urologist who has performed less
than 100 of these cases to inform the patient of this fact. |
I think there is a large variation between surgeons on their learning curve. All surgeons should keep statistics and share them with patients.
I stratify my results by patient number and explain the robotic results to patients.
The important factors are blood loss, hospital stay, surgical margins (marker of cancer control), urinary control, and sexual function.
The only factors that were not as good as open looking at the data retrospectively were surgical times and positive margins. I knew the times would be slower to start, the margins I thought would be as good, but were slightly worse than open.
Blood loss was much less than open on operation 1 and no one has ever had a transfusion.
Hospital stays were better immediately and much better after 25 operations.
Cancer control was as good by operation 26 and better by operation 60.
Urinary control was similar for the first 40 and better after, while getting even better after 80.
Sexual function was slightly better immediately and better after 30, and much better after 60.
This past month 2 patients of mine with prior laparoscopic hernia repairs with mesh had successful dvPs. I have done several of these now and do not get overly concerned with this finding in a patient. One of the patient's was from Florida and was advised against robotic prostatectomy from 2 urologists that performed robotics locally due to his prior hernia surgery. This patient actually had recurrent inguinal hernias that we fixed at the same time of his robotic prostatectomy.
I think the open approach will be much more difficult in patients with prior lap hernias and would advise against open prostate surgery, but I do not feel it is a problem for myself while performing robotics. Operative reports from the original lap hernia operation are helpful. If the lining of the abdomen (peritoneum) is not covered over the mesh, this would make the dvP much harder as bowel would likely be adhered to the mesh. If the lap hernia was done extraperitoneal (this is usually the case) or the peritoneum covers the mesh, it should not be a problem.
Lymph node dissections are much more difficult with prior hernia repairs, especially lap hernias and I performed my first of these for lap hernias this past week and found it to be safe even though the mesh was placed lower than usual and partly covered the vein. I inform patients with prior surgery in this area that I may not be able to remove the lymph nodes if the reaction is too severe and I don't feel its safe. The lymph nodes are more useful for staging and giving the patient their prognosis, but not for helping the cure rate. Fortunately I have always been able to remove the lymph nodes when I wanted to so far.
This is a monthly update on the growth of Robotic Surgery in my practice.
In July I performed 17 robotic operations. 14 were daVinci prostatetcomies for prostate cancer, 1 was a robotic simple prostatectomy for BPH, and 2 were kidney removals for kidney cancer. The total number of robotic prostatectomies I have performed is 143 and robotic operations is 182.
At the time of my robotic prostatectomies, my team also performed 3 robotic inguinal hernia repairs.
The highlights this month include:
2 patients with prior laparoscopic hernia repairs with mesh having successful dvPs. One of these patients had recurrent hernias on both sides and these were fixed at the same time as his robotic prostate surgery. He flew to NJ from Florida since his local robotic surgeons advised against surgery due to his previous lap hernia surgery.
My team also fixed a total of 3 hernias at the same time of dvP. We have performed 19 of these concomitant hernia repairs and avoided these patients to undergo another operation in the future to have the hernias repaired.
I also performed my first dvP on a patient with Kaiser Permanante insurance. Unfortunately Kaiser thinks that robotics is the same as open surgery and refused to pay for his surgery if done robotically. He had a very successful operation and his recovery should be better than anything he would have experienced with an open operation.
On a negative note: I experienced my 2nd robotic failure in 182 operations. I was performing a robotic nephrectomy and converted to a laparoscopic nephrectomy when the robot failed. The only other time this happened, we brought in one of the other 2 robots we have at Newark Beth Israel to finish the operation. With a kidney removal I think the recovery is similar to a laparoscopic operation, although I prefer performing them robotically.
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