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Study ties weight loss to prostate cancer risk | Chicago Tribune
Study ties weight loss to prostate cancer risk
By Daniel Yee
Associated Press
Published December 27, 2006
""ATLANTA -- A new study has found that losing weight reduces the risk of an aggressive form of prostate cancer.
After tracking the weight of nearly 70,000 men between 1982 and 1992, researchers from the American Cancer Society and the Duke University Prostate Center found that men who lost more than 11 pounds had a lower risk for aggressive prostate cancer than men whose weight remained the same over a decade.""
Multiple studies have shown that obese men have higher risks of more aggressive prostate cancer. This study shows that men may lower their risk of developing aggressive prostate cancer by loosing weight.
Men should also remember that their risk of dying from heart disease is usually higher than their risk of dying from prostate cancer after they have been diagnosed with cancer.
I also think that things that prevent prostate cancer may slow down recurrent cancer.
UroToday - The Pathophysiology of Lower Urinary Tract Symptoms After Brachytherapy for Prostate Cancer
""BERKELEY, CA (UroToday.com) - Lower urinary tract symptoms (LUTS) following brachytherapy are usually considered to subside within a few months of treatment.
However, a subset of patients experience persistent LUTS and Dr. Jerry Blavias and associates from Cornell University characterize this group of patients in a report in the BJU International. ""
This is one retrospective study that examined a subset of patients who had significant urinary side effects at least 6 months after seed therapy (brachytherapy). Only 10% of the private practice patients were included and a subset of the academic patients as well.
This reminds us that a small, but very significant amount of patients have significant urinary problems after brachytherapy.
There is a decent website from a pharmaceutical company: prostateinfo.com.
It does a decent job of going over the basics involved in screening and explaining the treatment options.
My one big criticism is that is out of date when it comes to robotic surgery and how accepted it is, making up about 30-35% of all radical prostatectomies currently.
I would add HIFU as an experimental therapy and make laparoscopic and robotic procedures an accepted form. I know that there are more robotic prostatectomies done than perineal ones, and pretty sure there are more laparoscopic prostatectomies done in the US than perineal.
Straightfromthedoc: JAMA Study Confirms Prostate Cancer Treatment is Preferable over "Watchful Waiting"
According to Endocare President, Chairman and CEO Craig T. Davenport:
"This study offers further scientific evidence that 'watchful waiting' may not be the best option for many patients, particularly when there are effective, minimally invasive treatments like cryoablation available. Based on the results of the study, 'watchful waiting' patients should consider some kind of treatment.
We believe cryoablation is an excellent option for many patients given its proven, long-term cancer control rate, low morbidity, and typically fast recovery time. Additionally, we believe cryoablation is a particularly good option for 'watchful waiting' patients who are not able to tolerate surgery or radiation, or for men with very small amounts of cancer in their prostate."
Straight from the doc reported on a press release from endocare, a company that is a leader in cryosurgery.
I am a supporter of cryosurgery and discuss it as an option for all prostate cancer patients, but I thought that some of the conclusions were not supported by the paper.
The JAMA article that I have previously discussed only looked at surgery and radiation, bot cryosurgery. The press release did not state this.
Elderly men with very small tumors are candidates for watchful waiting and cryosurgery is not without side effects.
November 2006 robotic breakdown
For November I performed 21 robotic operations: 15 robotic prostate removals (dvP), 2 removals of a part of a kidney (robotic simple nephrectomy), 1 kidney (robotic nephrectomy), 2 removals of parts of a prostate for BPH (simple prostatectomy), and 1 reconstruction.
This was the 1st month that I performed 20 robotic surgeries.
The operations of note were:
The removal of a 27 cm kidney tumor. I think this was the record for largest kidney removed by a robotic system. This was for a benign tumor.
2 robotic simple prostatectomies for BPH. One was done with a new intravesical technique and also had many bladder stones removed.
The other was our 2nd largest prostate.
We removed our first prostate over 100 gms in less than 2 hours (122 gms in 100 minutes). I have developed a new technique for these large prostates that is less traumatic on the bladder and quicker than the usual way. We did a record 200 gram prostate in December using the same technique.
Robotic Prostate Surgery - What Men Need To Know
I came across this article on the web and can answer this for my practice:
"If you are considering robotic prostate surgery over traditional open surgery, you should make the following questions part of your doctor-screening process:
* How long have you been performing prostate surgery in general?"
I have been in private practice since July of 2003 and trained at Indiana University for urology for 6 years. The bulk of my prostate surgery started in 1999 as a urology resident.
"* How long have you been using the da Vinci robot?"
My first operation with the 4-arm standard was in December of 2004 and with the daVinci S, March of 2006.
"* How many of these surgeries do you perform each year?"
I performed 60 robotic prostatectomies in 2005 (80 total robotic operations) and should perform about 140 in 2006 (175 total operations). I keep a monthly update on this blog.
"* What is your overall success rate with robotic surgery?"
I keep statistics on my personal website, roboticcancer.com
"* Are there any unique considerations to robotic surgery as compared to open surgery?"
There are a few, but the only real negative once you have learned and understand the technology well is the loss of feedback. This is counteracted by a 10 times magnification of the anatomy at about 2-3 inches away as opposed to in open surgery, where we can magnify the anatomy 2.5 times with loupes at about a foot away. I believe this gives a picture that is about 20 times better for robotic than open.
Fortunately I have developed techniques that has allowed robotic surgery even in patients with previous surgeries, very large prostate up to 200 grams so far, and in obese patients (up to a BMI of 43 so far).
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"It always helps to be able to feel what you are doing, to feel the tissue
tension and to feel the force when manipulating a suture," says Domenico
Savatta, chief of minimally invasive and robotic urology surgery at Newark
Beth Israel Medical Center. "Haptics would make it easier to learn robotic
surgery, operate on things that are very delicate, and be an overall
advantage to have in the system." |
Source: Technology Review:
Surgical Robots Get a Sense of Touch
This was a nice review in technology review, by Brittany Sauser.
I appreciate the chance to stress the importance of what haptics will mean to robotic surgery.
Currently I have learned to rely on a highly magnified image and what I call, "visual haptics". Having a 10 times magnified image with a camera that is a few inches away from the surgical field allows me to see the tension in tissue. I await the day when I can combine the visual haptics with touch.
I learned from this article that the team at John Hopkins is working on a visual haptic system that has dots that can change colors as a marker of tension.
I remember reading about a system that worked on auditory haptics, where a sound would increase in intensity with increasing tension.
I am starting a new blog series where patients can discuss their stories.
Please understand that anyone can view this and as always patient outcomes can be different.
The thoughts shared on this web site are not in any way meant to represent the surgeons, but are a way for people to share their experiences and hopefully help others.
Posts may be edited at the discretion of the moderator or deleted.
This site does not deal with direct medical advice, but rather general principles. All patients should seek advice from their own physicians.
I will leave this entry open for stories about robotic surgery for BPH.
I saw back my oldest robotic prostate patient today. He is 80 years old and had surgery 3 months ago. He looked great and felt equally well. He had minimal urinary leakage issues by 1 month and was not wearing a protective pad today. He is very active and had been regularly going to watch college sports since a week after surgery.
He was extremely pleased.
I was wondering if someone else had done surgery on octogenarians and came across the above piece from the Mayo clinic.
I think with robotics the near term morbidity is very low in the well selected 80 year old patient.
An important paper was recently published in JAMA that concluded that men between 65 and 80 may do better with surgery or radiation than with watchful waiting.
The authors did a good job with this observational study. They looked at all men with prostate cancer and compared those who had treatment with radiation or surgery and compared them to men who did not receive therapy for at least 6 months after diagnosis.
They found that there was a 30% lower mortality in the men that had therapy. The authors made an effort to compare the men with regard to other medical conditions and pointed out that without a randomized trial, there may be a selection bias since most urologists counsel men with good 10 year life expectancies to undergo therapy and men with poor life expectancies to have watchful waiting.
This is one study that I can use to help guide patients, but not an absolute decision maker in my opinion.
I reviewed my patients to see how many men I did robotic prostatectomies on. Over my first 200 robotic prostatectomies I operated on 19 men that were 70 or older:
5 were 70
11 were 71-74
1 was 76,78, and 80
I typically counsel them based on their health, the aggressiveness of their cancer and tell these men they will likely be equally cured with surgery or radiation.
12 of the 19 went home in 1 day, 6 in 2 days, and 1 in 3 days. The only medical problem I had was one patient who was re-hospitalized with a pulmonary embolus (blood clot in lung) a few days after going home and did well on blood thinners.
I do feel that these men often have significant BPH symptoms that is greatly helped by surgery. They do seem to have more incontinence in the short run, but they have done well. 9 of the prostates were big (larger than 50 grams), 5 were very big (greater than 75 gms), and 1 was huge (123 grams).
As for continence, 8 of the 15 that I have data on had 1 pad or less incontinence at 1 month, and 8 of 11 had 1 pad or less incontinence at 3 months, and 7 of 7 were in 1 pad or less at 6 months.
Robotic Prostatectomy can reduce positive margins
Source- Surgery News p. 13
This was an abstract presented at SLS meeting in Boston in September.
The 2 urologists showed a dramatic improvement in positive margins from their last 100 prostatectomies done open to the first 93 done robotically.
The organ confined changes for each surgeon were 37% and 27.5% for their last open ones to 5.7% and 8% for their first robotic ones.
This is a study that showed a drastic improvement in margins for private practice urologists.
My questions would be if these patients were comparable.
Their open margin rate seems well above national averages and they had better than expected results for their fist 50 patients. Most surgeons see an increase in positive margins when they first start robotics.
I did not track my open results, but I would guess the organ confined results were in the 15% for open. My first 70 patients had a 20% positive margin rate for organ confined disease and the last 100+ have been under 5%. I also have performed all prostatectomies robotically and have not turned down anyone for surgery based on amount of cancer.
There is an excellent website on robotic pediatric surgery. The surgery is performed using robotic technology by John Meehan, MD and assisted by Anthony Sandler, MD of the University of Iowa.
They have a lot of videos of their surgical procedures available for viewing.
UroToday - Prostate Cancer Surgery Outcomes: Surgeon Dependent Factors
"Subgroup analysis showed superior recurrence free survival for patients treated by surgeons with greater than 1,000 operations compared to less than 50 operations. After 250 surgeries, the curves plateau."
This was a presentation by one of the worlds best prostate cancer surgeons, Dr. Peter Scardino.
Pertinent findings were that surgeon volume was a factor in outcomes, as was surgeon technique.
The number of cases that we do can not be changed, but technique can be improved. With robotics I think the learning curve can be somewhat quickened by reviewing surgeries on video. Ive found it helpful to review DVDs of robotic surgeries from such experts as Dr. Patel and Dr. Ahlering and review my own DVDs on cases that were difficult.
I also think it is important for surgeons to keep a database to see how they are doing and if anything can be fixed. In my robotic series, the outcomes have improved for the first 75 or so, but have been fairly stable since then over the last 100+. I think the most important reasons to have a relatively quick learning curve were my previous open prostate cancer experience of over 100 operations, as well as viewing expert video and my own video.
UroToday - What is the Best Approach for Screen-Detected Low Volume Cancers?
What is the Best Approach for Screen-Detected Low Volume Cancers?
BETHESDA, MD (SUO 7th Annual Meeting - December 1-2, 2006:NIH) - In a session moderated by Dr. Eric Klein, Cleveland Clinic, Dr. Laurence Klotz, University of Toronto presented the "The Case for Observation".
My patients know where I stand on this. I am certainly on the side of Drs. Blute (Mayo Clinic) and Montie (University of Michigan) favoring radical prostatectomy.
The Hudson Reporter - Science fiction surgery showcased
Robotic medical technology on display in Secaucus
"I used to do a lot of open surgery operations," he said. "Once I learned how to use the robot, I became able to do most of my big operations, including prostate cancer operations, in a way that is minimally invasive. With smaller incisions, there is a lot less pain for patients, as well as a quicker recovery. "
We had our train visits with the daVinci S last week.
I was at the Newark Penn Station on Wednesday and we had a nice crowd stop by and try the daVinci S.
Medical students treat dummies that bleed, speak, and die - Engadget
The University of Portsmouth is upping the ante on its training facilities for those making the rounds in med school, and doctors-to-be now have access to �135,000 ($266,706) dummies that "bleed, speak, and potentially die" depending on the level of care received.
Da Vinci puts magical touch on the prostate | Health | The Australian
One of the five robots in the UK is at the London Clinic. It has proved so successful that professor Roger Kirby, and his anaesthetist Peter Amorosa, now do most of the radical prostatectomies using a robot rather than hands-in and hands-on open surgery. Kirby did his 100th robot-assisted prostatectomy last week.
100 cases is an impressive milestone for one surgeon.
I wish Dr. Roger Kirby success on his next 100.
Jacky Lai: Here's The End of My Clerkship in Urology: "It's a 2-hour-surgery in traditional open surgery. Laparascopic surgery was invented to be faster and less invasive, but our robotic surgery - smaller wound but a lot more time. The major concept to prevent surgical complication is to reduce time consumption - do as fast as we could and make the wound as small as we could. The longer anesthetic time means the greater complication rate. Anesthetic time longer than 6 hours is by all means a critical risk factor in post-operative care, not to mention that patient with prostatic cancer in need of surgery is often old-aged. Quite frankly, I'm really disappointed with the Da Vinci Surgical System. It's so far an advertisement more than quality improvement."
I came across this blog entry online. From what I can tell, it was from a medical student observing a robotic prostatectomy.
I found several things interesting.
"Laparascopic surgery was invented to be faster and less invasive"- actually laparoscopy was invented to make things less painful and less invasive, but not faster. The first laparoscopic nephrectomy by Dr. Clayman took about 8 hours. As equipment improved and surgeons had more experience, the times improved to similar to open surgery, or in some cases, quicker.
"The major concept to prevent surgical complication is to reduce time consumption - do as fast as we could and make the wound as small as we could. The longer anesthetic time means the greater complication rate. Anesthetic time longer than 6 hours is by all means a critical risk factor in post-operative care, not to mention that patient with prostatic cancer in need of surgery is often old-aged."
This is simply inaccurate. there are many more factors important to reduce complications including blood loss, avoiding injuring other structures, preserving nerves and muscles. Time is not an important factor, especially in laparoscopy where there is minimal fluid loss.
Speed at all costs is often frowned on as it may lead to higher complications.
For lap or robotic prostate surgery I tell people that I am helping to train that they should try to keep the time to 7-8 hours when the patient has his head down as a general rule to help prevent problems from the positioning.
Prostate cancer patients are usually rather healthy since they usually would not have surgery unless they have a good 10 year survival.
I applaud your blogging and you certainly are entitled to your opinion, but the typical operation in my OR lasts 1 1/2-3 hours and is far superior than what I could achieve with traditional open surgery.
� A new ‘language’ for surgery? | Emerging Technology Trends | ZDNet.com
After watching surgeons using robotic systems for a while, computer scientists at Johns Hopkins University have decided to borrow ideas from speech recognition research to build what they're calling a 'Language of Surgery'. In speech recognition, basic sounds are called phonemes. For surgery tasks, such as suturing, dissecting and joining tissue, the basic steps have been named 'surgemes.' The mathematical models used by the researchers have several goals: evaluate a surgeon's work and help doctors to improve their operating room skills. They also want to 'enable robotic surgical tools to perform with greater precision.'
This was an excellent blog entry that gave more insight on how automated surgery may work. I have always been somewhat skeptical, but keep an open mind, about automated surgery.
Reading the original paper is recommended for scientists and enthusiasts of this topic.
I found it very interesting how they were able to take computer recorded motions and show a difference between expert and non-expert surgeons. I would like to know how they were able to classify these surgeons as expert.
My biggest problem with the concept of automated surgery is that surgery is not just science, but also art. I see this as a computer telling you if you are using correct technique, but the day is far away where it can be done truly automated. A fair comparison is to pitching in baseball. You can learn proper mechanics, but pitchers that have perfect mechanics do not always do well and pitcher s with poor mechanics or different delivery styles can thrive.
One are where I can see robotics helping in the near future can be to do some smaller steps that may be difficult to do, such as suturing a bladder to urethra, which can sometimes be difficult and is hard to learn.
UroToday - Significant Discrepancy Between Clinical and Pathologic Staging in Renal Cell Carcinoma: "These data suggest that nearly 20% of patients with clinical stage T1 tumors may be upstaged after nephrectomy. The observed differences in recurrence-free survival and disease-specific survival provide additional evidence supporting intact specimen extraction after laparoscopic nephrectomy in cases of suspected malignancy. These data suggest that nearly 20% of patients with clinical stage T1 tumors may be upstaged after nephrectomy. The observed differences in recurrence-free survival and disease-specific survival provide additional evidence supporting intact specimen extraction after laparoscopic nephrectomy in cases of suspected malignancy. "
I did not think that any surgeons morcellated kidneys that were being removed for cancer, but this study is another reminder of one of the reasons not to.
My other major concern is possible spread for morcellation.
I agree that the reimbursement for a radical prostatectomy should be more than it is, but that is true for nearly everything we do these days at the hospital. You are paid a little more for the code for a laparoscopic prostatectomy (the code for a dVP) than for an open radical and with experience you can do a dVP in about the time it takes many urologists to do an open (2-3 hours). Granted some folks can do an open in 90 minutes, but, given the lower positive margin rates with the da Vinci and slightly better potency and continence rates, I don't see how anyone can continue to justify doing opens.
Newark Beth Israel is bringing the daVinci S robot to 3 train stations in NJ this week from 7AM to 10AM.
Commuters will have a chance to see and possibly test-drive the newest robot.
I will be in Newark on Wednesday morning with the intuitive surgical team.
Tuesday, December 5
Secaucus Junction
26 County Road
Secaucus, NJ
Wednesday, December 6
Newark Penn Station
1 Gateway Center Raymond Blvd.
Newark, NJ
Thursday, December 7
Hoboken Train Station
40 Hudson Place
Hoboken, NJ
I am very pleased to announce a very nice upgrade to the robotic surgery blog.
I have installed a plugin that allows users who make comments to blog entries to subscribe to that entry.
You can then receive an email if someone else makes additional comments.
You will get an email to confirm that you did indeed, sign up for the entry and can easily cancel the subscription to the entry with each reminder.
Thanks to gruntdoc for introducing me to this feature from everitz.
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