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« October 2006 | Main | December 2006 » November 23, 2006Robotic surgery in CanadaLondon Free Press - City & Region - People . . . You Know: I wonder how many daVinci robots the Canadians need? A single dose of prophylactic antibiotics may be enoughScienceDaily: Single Dose Of Antibiotics Before Surgery Sufficient To Help Prevent Infection: "Single Dose Of Antibiotics Before Surgery Sufficient To Help Prevent Infection I have been using 3 total doses on antibiotics for most of my robotic kidney and prostate operations. I will need to review this study and may switch to a single dose for prevention of infection. I have not had a single wound or deep infection in almost 250 robotic operations. I have seen urinary tract infections that I think is the result of the catheter and 2 men developed testicle infections 2-3 weeks after robotic prostatectomy. Congratulations to the Newark Beth Israel Cardiovascular teamNewark Beth Israel Medical Center Named One of Nation's 100 Top Providers of Cardiovascular Care: Financial News - Yahoo! Finance: "Newark Beth Israel Medical Center Named One of Nation's 100 Top Providers of Cardiovascular Care A full list can be found on the Solucient website. November 19, 2006Higher cholesterol may lead to more aggressive prostate cancerProstate Cancer Treatment and Symptoms > Prostate Cancer and Association With Plasma Cholesterol: "Prostate cancer patients who had lower levels of cholesterol in their blood had a significantly reduced chance of developing more aggressive forms of the disease, compared to patients with higher cholesterol readings. A basic principal for a healthy prostate was taught to me by an expert in preventive medicine, Dr. Mark Moyad, (University of Michigan): What is healthy for the heart is usually healthy for the prostate. Obesity and prostate cancerUroToday - Obesity, Diabetes, and Risk of Prostate Cancer: Results from the Prostate Cancer Prevention Trial: "These unique data obtained from a prospective randomized trial suggest that obesity may preferentially increase the risk of high-grade prostate cancer, while decreasing the risk of developing low-grade tumors. The authors suggest that this may explain why no association between BMI and prostate cancer has been found in studies that have not subdivided patients based on Gleason score." Original Abstract: Cancer Epidemiol Biomarkers Prev. 2006 Oct;15(10):1977-83 Obesity is considered by most to be a risk factor. This study showed a higher risk of more aggressive prostate cancer, but a lower risk of low grade prostate cancer in obese patients. This study was taken from the prostate cancer prevention trial, where patients were followed for 7 years to determine the effects of proscar on the prevention of prostate cancer. This database of over 10,000 patients should provide many studies in the future. Prostate cancer- How does one decide on therapy?A colleague of mine asked on a blog comment: "Do patients need to make there own decisions or should the urologist guide them to the best decision?" That's a great question and every urologist, medical oncologist, and radiation doc would have his/her own opinion. Personally, i try not to decide for patients. Being a high volume robotic surgeon, I tell my patients that I am biased towards robotic surgery. I feel that for most people with a good 10 year life expectancy it is the best treatment available. I also recommend that my patients obtain second opinions from another doctor. I usually recommend a radiation oncologist who will likely be biased towards radiation. It has been shown that physicians are more likely to recommend therapies that they perform. I think most urologists that do not perform robotics will not recommend robotic surgery and most urologists that perform robotics regularly, will not recommend open surgery. I think its up to a patient to due research, ask tough questions from their physicians, ask their physicians for patient references, get opinions from their primary care physicians or possibly medical oncologists. If a patient asks me to decide for them, then I would tell them what I would do if I was them or if they were my father. I also explain to them that there are several issues that may lead one to certain therapies. If they do not want to have any anesthesia, then external beam would be a good choice. Patients that want the best idea of their recurrence rate may choose surgery since you obtain more detailed information from the pathology report as to extent of disease. New changes to classification of kidney tumorsI was at a conferenence on Saturday, Current trends in genitourinary malignancies. This was a nice review of the newest advances in prostate, bladder, and kidney cancer. One thing I learned is that with he help of molecular markers, what had been previously diagnosed as sarcomatoid renal cell cancer is actually a high grade transformation of the other types of renal cell cancers (clear cell, papillary, or chromophobe). I thought this was an excellent one day conference and would recommend it to general urologists or medical oncologists. Newark Beth Israel chosen for beta tests for daVinci upgradesI had the opportunity to beta test the newest additions to the daVinci S robot. The engineers have done an excellent job with minor upgrades. The 4th pedal which had been empty was fitted with a bipolar pedal. This was a nice much awaited for addition that will make setup much easier as we had been taping a pedal over this. The camera attachment was upgraded to an easier to click in piece. This didn't add much for my team, but will make it easier for new teams. My favorite upgrade was a John Madden type drawing feature on the patient side screen or a non-sterile screen on the cart. I termed this the "robo-strator". This works by allowing a surgeon not on the robot to draw on the screen and having this image seen by the operating console surgeon. An excellent teaching tool that will be a must have for all centers with residents or fellows. I had some thoughts on how to upgrade this such as adding suture needles into the display. There were also some minor console such as how to engage the robotic masters (joysticks). Overall, I was pleased with each of the additions. The one upgrade I didn't see yet was an arm on the patient side screen to lower it to a more user-friendly level. John Hopkins working on robotic advancesJohns Hopkins Gazette November 13, 2006: "Johns Hopkins researchers are trying to change that by adding such sensations, known as haptic feedback, to medical robotic systems. "Haptic" refers to the sense of touch. A video showing some of this research is online at www.jhu.edu/news/audio-video/medical_robotics.html." I thought this was an excellent video showing the davinci robot and some of the things that John Hopkins is working on. November 12, 2006One mans journey in deciding on robotic surgery for his prostate cancerThe ultimate deadline Chicago Tribune: "The ultimate deadline By Robert Jordan This story was given to me by a patient. Mr. Jordan has done excellent research and has hit on the important points that are overlooked by many patients and not stressed by all physicians. 1- Second opinions are a good thing. There are many opinions in choosing the best form of treatment for prostate cancer and a second opinion can help get multiple views. 2- In his decision making about choosing radiation, he writes: "Doctors there use tomotherapy, which targets radiation on the cancerous area. Patients can continue a nearly normal lifestyle during the course of the therapy, which is painless and non-invasive. It leaves most patients continent and potent, but subsequent scarring from the radiation, sometimes two to three years later, can cause problems in both those areas." You are trading in short term side effects for long term effects with radiation. 3- He understands the importance of cautery free surgery: "I read up on the da Vinci procedure in medical journals and discovered papers discussing the advantages of not using cautery-a technique that stops blood vessels from bleeding with an electrical arc, which immediately coagulates the blood. Zapping a blood vessel so near a nerve couldn't be good for the nerve, I thought, so I looked for da Vinci surgeons who did not cauterize." Even bipolar devices that do not spread electricity, will spread heat and I try to limit any cautery near the nerves including the prostate pedicles.
Truly "robotic" surgery in the future?MTB Europe - Robotic surgery guided by 3-D ultrasound scanner: "Surgery I discussed how the daVinci robotic system is a master-slave system several months ago. Researches at Duke have used the most advanced ultrasound to help guide biopsies. I can see this technology one day helping me perform robotic partial nephrectomies, when I am trying to remove part of a kidney with a small margin of healthy tissue around it. It can also help guide biopsies. I am not sure it will help that much with prostates, as the accuracy is within 1.5 mm and my nearest surgical margin is often closer than that. November 11, 2006PCA3 gene in detecting prostate cancer.There is a new company that is using the PCA3 gene that has obtained approval in Europe. In the US there are 2 companies that have the test, Ameripath and Bostwick laboratories, currently the PCA3-plus test. We have had a lengthy discussion about this test on another blog entry on my site. The test works by looking at the ratio of this PCA3 RNA to the total PSA RNA that is expected to be constant. The idea is that a higher ratio means that you are more likely to have cancer. I have found several cancers using this test as my basis for performing a prostate biopsy. da Vinci robot in Athensekathimerini.com The mechanical arms...: "The mechanical arms of the first robotic machine capable of performing surgery were seen yesterday when the Da Vinci robotic system was presented by the private Athens Medical Center." It is not very clear if the robot was passing through, but it appears that this unit in Athens may be the first in Greece. Muscle breakdown after robotic kidney surgeryI recently had a patient who had muscle breakdown (rhabdomyolysis) of a buttock muscle after a robotic removal of part of a kidney for tumor. I found a nice review of this problem on urotoday's site that had an article from the BJU. The urologist that wrote the article were from the Department of Urology, Aberdeen Royal Infirmary in Aberdeen, UK. My patient was overweight, but not morbidly obese. I performed the robotic partial nephrectomy in a similar lateral position that the authors show. He needed 1 course of dialysis when his kidneys were not working well. The rhabdomyolysis led to significantly kidney problems since our surgery is done by temporarily stopping the blood supply to the kidney which leads to short term kidney malfunction in that kidney. He also had kidney problems to start with. I had performed over 40 robotic kidney surgeries in this positioning and over 150 laparoscopic ones prior to having this problem. There have also been reports of rhabdomyolysis after open surgery, but this rare complication should always be remembered even in experienced hands. Removing the kidney in advanced kidney cancerUroToday - Laparoscopic Cytoreductive Nephrectomy: The M. D. Anderson Cancer Center Experience: "Laparoscopic Cytoreductive Nephrectomy: The M. D. Anderson Cancer Center Experience Written by Ralph V. Clayman, MD The paper from MD Anderson shows a shorter hospital stay for these patients who have metastatic kidney cancer. Urologists have been removing these kidneys since there have been studies showing an increased survival with removal of the kidney prior to immunotherapy. I looked at our patients from Indiana University when I was a resident there and found similar shorter hospital stays, but most of our patients did not receive immunotherapy right away after removal of the kidney, sometimes observed for months. Although this study showed similar time to receiving immunotherapy (44 days), there may have been other factors as opposed to when patients were recovered enough to receive it. I recently operated on an elderly gentleman who we thought had advanced kidney cancer that had spread to his rib cage, but biopsies of the rib mass and analysis from the kidney that I removed revealed a localized kidney cancer and a lung cancer. He spent 2 nights in the hospital after a left robotic kidney removal and was able to start chemotherapy for his lung cancer within 2 weeks of his robotic surgery. John Hopkins researchers find over expression of a muscle protein in prostate cancer cellsUroToday - ‘Muscle’ Protein Drives Prostate Cancer: "Researchers at the Johns Hopkins Kimmel Cancer Center have for the first time implicated the muscle protein myosin VI in the development of prostate cancer and its spread.
November 10, 2006Firefighters may be at higher risk of developing prostate cancerFirefighters at High Risk for Cancer - Forbes.com: "'For testicular cancer there is a 100 percent increase in risk, for multiple myeloma there is a 50 percent increased risk, for non-Hodgkin's lymphoma it's a 50 percent increased risk, and for prostate cancer it's a 28 percent increased risk, compared with non-firefighters,' he said." November 5, 2006da Vinci robot makes top 10 list of all time robotsSoulCast - The 50 Best Robots Ever: "08. DA VINCI SURGICAL SYSTEM Robotic Surgery Growth: October 2006View chart of Dr. Savatta's robotic surgery growth For October I performed 15 robotic operations, 12 robotic prostate removals, 1 removal of part of a kidney, and 1 bladder and prostate for bladder cancer. I have performed 130 robotic prostatectomies in the last 12 months and 113 so far this year. In the last year I have performed 167 total robotic operations in the last 12 months and 143 so far this year. The growth is increasing and I have a record amount of robotic surgery cases scheduled, about 30. The operating room times I have decreased with even my newer techniques at nerve sparing to the point where we can comfortably do 3 robotic operations in 1 day. We are getting close to 20 per month, which will probably be as much as I can do by myself. Our group is recruiting a robotic surgeon to joining us next summer which should help the program grow further. The operations of note were: I also did a dvP on the largest patient. His BMI was 43. The surgery took a little over 3 hours with lymph nodes and went very well. His catheter was removed in 1 week. I performed my most difficult prostatectomy. I thought it was going to be easy, but found several congenital abnormalities including bilateral ureteroceles, extra bladder tissue at the bladder neck, and abnormal vasculature. It took over 4 hours, but I successfully was able to perform the operation robotically. I performed my first repeat robotic operation. A patient of mine who had a robotic partial nephrectomy now had a robotic prostatectomy. I have a second patient who had a robotic nephrectomy scheduled for a robotic prostatectomy as well. I believe these are the first patients who will have benefited from robotic surgery more than once. |
