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This is my first technique that I will be adding to a new section of the blog.
After watching many videos and trying different ways to approach an intravesical median lobe, I found a new way to take care of it.
The following video was uploaded to google video and shows the dissection of a median lobe.
In simple terms: The bladder holds the urine and then the urine passes through the prostate on its way out. The prostate needs to be removed completely in prostate cancer surgery. The prostate is separated from the bladder routinely during the operation.
The median lobe is the part of the prostate that sometimes pushes into the bladder. This is the main reason why some urologists elect to place scopes into peoples bladders prior to surgery. This is one of the most difficult parts of the operation for beginners and experienced surgeons. The video shows the prostate (yellow) being separated from the bladder (green). The stitch is placed into part of the prostate to lift it off of the bladder.
Instruments used: PK dissector (bipolar), hot shears (monopolar- setting coag only 30), 2 needle drivers
Suture: 2'0 vicryl on an SH needle. (I have used 0'vicryl on a CT-1 for larger median lobes)
Color scheme- Yellow- Prostate; Green bladder and bladder opening; Orange arrrow- foley
Key points:
1) Approach anterior bladder neck as you prefer. Hints that there may be a median lobe are difficulty in appreciating the catheter or the balloon being off of midline. Preoperative cystoscopy or prostate ultrasound often shows this as well.
2) Once the median lobe is seen, the mucosa from the lateral lobes should be taken down until the median lobe is near.
3) The suture can be placed multiple times until the entire median lobe is out of the bladder.
4) Indigo carmine can be given IV if there is any doubt of the ureteral orifices.
5) The median lobe is done first in this video, but the lateral lobes can be done part way if the median lobe is very big.
Ease in learning the technique: Easy
Projected use is for all urologists. I believe this is the most efficient way to tackle an intravesical lobe and allows the best bladder neck sparing with the least amount of cautery needed.
How I developed it: I was trying to develop a better way to expose the median lobe during a robotic simple prostatectomy for BPH and tried suturing the median lobe. To my surprise, a very large median lobe was lifted out of the bladder and I had an excellent view of the posterior bladder neck.
Editors note: I thought long and hard about new techniques that I was developing and how to introduce them. I had planned on publishing this work to a journal, but I did not have the time (or didn't want to put in the time) to make a journal submission. I also thought the interactivity of the blog would help to spread the word quicker and allow others to modify or add to my technique.
I have decided to introduce some of my new techniques through the robotic surgery blog and have it stored on google video for ease in viewing.
I apologize to any surgeons who may feel that this is not the best way to introduce new work.
If any other urologists (or other specilaties) would like to contribute their work, I will be glad to link to it if you add it to google video or blog about it if it is on another site.
This is one of the most common questions that patients ask me, especially if the cancer is confined to one area on biopsy.
With robotic surgery I am able to remove part of a prostate if I want to, and I often do that for BPH operations.
For prostate cancer it is not the correct thing to do. The prostate is made up of an inner part that usually grows and causes BPH and the outer, peripheral part that is usually where the cancer starts. Once you have cancer in one area, it is likely to be in several areas. All prostate glands are at risk for developing into new cancers. I recently presented an abstract at the prostate cancer symposium in Orlando entitled:
Extent of prostate cancer in patients presenting with presumed minimal tumor burden.
This was a study I did by looking at my robotic prostatectomy database. I found patients that only had 1 area of gleason 6 cancer and a PSA of less than 10. The results and conclusions were as follows:
 On radical prostatectomy, all cancers were organ confined and 34 of 35 cancers showed negative margins. Despite having been selected for presumed minimal tumor burden, the majority of the cases were found to be multifocal (24 cases or 69%). The pathological stage based on final pathology was most commonly T2c reflecting bilateral disease (26 cases or 74%), while the remaining 9 cases (26%) were at T2a. Lymph nodes were not assessed on these patients. The Gleason's score was upgraded to 7 in 4 patients and to 8 in 1 patient. Tumor volume was > 2 cc in 14 patients and > 5 cc in 2 patients.
Conclusions: Although prostate cancer is often diagnosed early, physicians should understand that it is difficult to predict solitary lesions based on needle core biopsy and PSA value. Our results suggest that prostate cancers are frequently multifocal and bilateral, and should be managed as such. Focused therapy that targets only a portion of the prostate gland may not be adequate for long term cancer control.
My main reason for doing the study was to show that I did not think treating part of the prostate by freezing or ultrasound was a good therapy from a cancer control standpoint.
The operation that I do currently is the same as what I did when I did open the open radical prostatectomy: I remove the prostate in its entirety, seminal vesicles, part of the vas deferens, and the pelvic lymph nodes for staging.
The main log term side effects are sexual, which I have discussed previously.
The other side effects are urinary leakage which usually gets back to normal with a better flow.
2 recent studies recommend lowering the psa velocity.
UroToday - Age Adjusted Prostate Specific Antigen and Prostate Specific Antigen Velocity Cut Points in Prostate Cancer Screening
Traditional recommendations for prostate biopsy have included a total serum PSA of 4.0 ng/ml or greater and a PSA velocity of 0.75 ng/ml per year or greater. While recent trends have moved towards a PSA threshold of 2.5 ng/ml or greater in men younger than 65 years, specific recommendations for PSA velocity thresholds in younger men have not been agreed upon.
In the February issue of the Journal of Urology, Moul, Albala, and colleagues from Duke University report the results of a cohort of 33,643 men who formed part of a prostate cancer early detection study. Of these men, 11,861 patients were identified with 2 or more serum PSA values over a 2 year period. Total PSA and PSA velocity threshold values with the highest sensitivity and specificity for prostate cancer detection were identified for men 50 to 59 years old.
In men age 50 to 59 years, a serum PSA threshold for biopsy of 2.0 ng/ml or greater achieved the highest sensitivity (84%) when compared to thresholds of 2.5 ng/ml, 3.0 ng/ml, and 3.5 ng/ml with sensitivities of 82%, 79%, and 77%, respectively. The specificity of a PSA threshold of 2.0 ng/ml in these men was acceptable at 74.4%, which was not significantly different from the specificity of using a threshold of 2.5 ng/ml (80%).
Using a PSAv of 0.4 ng/ml/year in men age 50 to 59 years achieved a specificity of 84% and sensitivity of 72%, compared with a PSA threshold of 0.75 ng/ml with sensitivity and specificity of 70% and 84%, respectively.
UroToday - Prostate Specific Antigen Velocity Threshold for Predicting Prostate Cancer in Young Men:
Using a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml. A PSA velocity threshold of 0.4 ng/ml per year or greater was independently predictive of cancer irrespective of age, total PSA, family history of prostate cancer, or race. What was most dramatic was that this criterion had the strongest association to cancer in multivariate analysis, even in patients with a total PSA less than 2.5 ng/ml. Using a PSA velocity threshold of 0.4 ng/ml/year was found to have a sensitivity of 67%, specificity of 81%, positive predictive value of 16%, and negative predictive value of 98%.
This study suggests that using a PSA velocity biopsy threshold of 0.75 ng/ml/year for men younger than 60 years may be inappropriate. Using a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml.
Urologists at Georgetown, Northwestern, Washington University, and Duke have been advocating lowering the PSA velocity which should trigger the recommendation for a biopsy. I admit that I often perform a prostate biopsy on young healthy men with a PSA of 2.5 or a lower PSA velocity of 0.4. I am performing more biopsies and finding more cancers. You certainly can make the argument that waiting for a higher PSA may not diminish the cure rate and may find cancers that are more clinically significant.
I understand that some urologists do not believe in PSA as a screen for prostate cancer at all.
I am sure that one day we will have better screening tests that are more specific and probably more sensitive.
I wonder what people think of a prostate biopsy done as a baseline study. I would compare this to a screening colonoscopy which likely has a similar rate of complication (low), can be done under local anesthesia, and will find some prostate cancers that we are not finding now.
The major obvious downside would be putting most men through a biopsy which will not reveal cancer and finding cancer that may not need to be treated for months to years.
IngentaConnect The incidence of high-grade prostatic intraepithelial neoplasia a...:
CONCLUSION:
Identifying multifocal HGPIN on first saturation biopsy is associated with an overall cancer detection rate of 80% on repeat 10-12-core biopsy. Although there were few patients, the detection of multifocal HGPIN warrants additional searches for concurrent invasive carcinoma by repeated biopsy.
The diagnosis of high grade PIN is an area that once required a repeat prostate biopsy. Recently, with an increase the number of biopsies that are done initially, there has been feelings that patients who only have high grade PIN do not need another biopsy. This article suggests that these patients should have a repeat biopsy. I believe follow-up with a PSA is a recent option in older patients with high grade PIN.
UroToday - Positive Surgical Parenchymal Margin After Laparoscopic Partial Nephrectomy for Renal Cella: Oncological Outcomes Carcinom
Thursday, 15 March 2007
BERKELEY, CA (UroToday.com) - Positive margins following supposedly curative surgery can be devastating for patient and surgeon alike.
The implication that cancer was "left behind" implies a continued biologic threat, although little is known about the impact of positive margins following nephron sparing surgery, because, thankfully, it is a rare finding. Here, two leaders in laparoscopic renal surgery (Gill and Kavoussi) combine their experience to examine oncologic outcomes in patients undergoing laparoscopic partial nephrectomy found to have positive surgical resection margins.
These 2 surgeons are among the best in the world in minimally invasive partial nephrectomy. I would think that there margins were very close to being negative and management should be dictated by close followup of these patients if the surgeon felt he had removed the whole tumor. It is certainly a controversial topic.
UroToday - Surgery, Radiation Treatment Double Life Expectancy of Patients with Aggressive Prostate Cancer
Thursday, 15 March 2007
BERKELEY, CA (Newswise) - After being diagnosed with aggressive prostate cancer, many men are told that their disease is untreatable and that less aggressive treatment is best. Often this means patients are told to watch and wait -- that is, to do nothing at all. A new study by physician-scientists at NewYork-Presbyterian Hospital/Weill Cornell Medical Center turns conventional wisdom on its head, finding either surgical removal of the prostate (prostatectomy) or radiation treatment more than doubles the life expectancy for these patients when compared with those receiving the conservative approach.
Patients with the most aggressive non-metastatic prostate cancers (Gleason scores 8–10), if treated with prostatectomy or radiation, can expect to live more than 14 years; those treated conservatively will live, on average, less than 7 years. The study appears in the March Journal of Urology.
I've been aggressive at treating high grade prostate cancers with surgery. These patients tend to have more side effects after surgery (I am sure with radiation as well) than lower grade cancer patients. I will look forward to reading the actual study. A study like this is prone to selection bias.
UroToday - Laparoscopic Versus Open Radical Nephrectomy for Xanthogranulomatous Pyelonephritis: Contemporary Outcomes Analysis
BERKELEY, CA (UroToday.com) - It was not until 9 years after the initial laparoscopic nephrectomy, that the first report on using this technique for xanthogranulomatous pyelonephritis (XGP) emerged from Washington University.
At that time, we noted the procedures were much longer than the open, with no benefits in pain control or hospital stay, and were associated with a high rate of complications. Over the years, has the laparoscopic approach to this condition improved? The answer is "a bit" but only "a bit". In this sobering report the authors compare 6 laparoscopic to 6 open nephrectomies for XGP. The procedure time was 2 hours longer in the laparoscopic group (p = 0.03). One of the 6 laparoscopic patients was converted to open and 2 cases were converted to hand-assist. Complications were higher in the laparoscopic group (3 vs. 2).
I performed 1 hand assist lap nephrectomy for XGP. It was one of the most difficult operations I have ever done. I would recommend starting with a hand assist and this is probably 1 operation I would not think I could finish robotically. Starting robotically and converting to hand assist laparoscopy early on is an option for experienced robotic renal surgeons.
Genengnews.com: Robot Spurs Men's Recovery After Surgery, Urologist Says at
NCCN Annual Conference
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Even surgeons who once favored traditional 'open' methods of cutting and
suturing during prostate or bladder-cancer operations have learned to
love the joystick-operated robot, said Timothy G. Wilson, M.D., director
of the Prostate Cancer Program at City of Hope Cancer Center, at the
National Comprehensive Cancer Network's 12th Annual Conference, March
14-18.
Studies show that men undergoing radical prostatectomy go home sooner
and regain bladder control and sexual function weeks earlier when the
robot is employed, Wilson said.
'If you can save somebody three months of diaper time, that's
important,' he said, noting that patients' two top postoperative worries
are incontinence and impotence. Wilson predicted Food and Drug go-ahead
for other manufacturers' robotic devices in the next few years, bringing
competition to a field now dominated by Intuitive Surgical's da Vinci
device, approved in 2000 to perform advanced surgical techniques.
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Straus Newspapers - Advertiser News / News: Robotic surgery brings tomorrow’s surgical techniques to Saint Clare’s today
DENVILLE — As part of its ongoing commitment to provide the latest in medical
care and technology to its patients in the communities in which they live, Saint
Clare’s has announced that it performed its first robot-assisted, minimally
invasive surgery on March 1, following successful deployment of the da Vinci S
Surgical System at Saint Clare’s Hospital, in Denville.
This unique system, from Intuitive Surgical, the world’s leading innovator of robotic
surgery technology, couples advanced surgical instrumentation and 3-D
visualization with ergonomic comfort while bringing the future of surgery to our
community.
St. Clares is a very nice community hospital in Denville, NJ. It has the first daVinci S robot in Morris county, where I live. One of my friends is doing robotic surgery there now and I am awaiting privileges to bring some of my robotic cases to Denville.
My partner currently performs most of my ESWL (shock wave surgery) there for me currently.
Straightfromthedoc: Risk of Post-Operative Complications, Higher in Obese Patients:
Morbidly obese patients had a death rate nearly twice as high as that of all other patients, had higher rate of cardiac arrest and have significantly higher risk of complications following surgery, including heart attack, wound infection, nerve injury and urinary tract infection.
Such were the findings of a new study of a research team at the University of Michigan Health System.
Bamgbade and the other researchers found much higher rates of the following complications in obese patients: heart attack, with obese patients experiencing five times the rate of attack than non-obese patients (0.5 percent versus 0.1 percent); wound infection, with a 1.7-times higher rate (6 percent versus 3.5 percent); peripheral nerve injury, with a four-times higher rate (0.4 percent versus 0.1 percent); and urinary tract infection, with a 1.5-times higher rate (3.9 percent versus 2.6 percent).
This is another study that confirms that obese patients are at increased risk during surgery. I think minimally invasive and robotic surgery has the greatest benefit on obese patients.
Health Blog:
Welcome to the Journal’s Health Blog
From the skyrocketing costs of new drugs to showdowns over who should pay for health care to consumers’ confusion over their own medical bills, the pressures facing the health-care system have never been greater. Or more interesting.
My prostate cancer counseling sheet. This is meant to give an idea of
the major forms of prostate cancer therapy and are the main one I focus on at a
consultation for newly diagnosed prostate cancer. This should only be used
under the supervision of a urologist.
A printable form can be
found online.
This was my first venture into google documents and my original experience was extremely positive. My counselling sheet changes periodically based on new treatments or side effects that I want to add. This will be extremely easy to edit without the need for an editor on the computer and can be done anywhere. I will likely place most of my instruction sheets on google documents. It also makes an easy to print out document for patients and has an internal PDF creator built into the online google editor.
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Age |
Gleason |
Amount of cancer
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Size of Prostate (urinary
symptoms) |
PSA |
Bone Scan |
CT Scan: |
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Overview: Reviewed options of
watchful waiting, radiation (brachytherapy, external beam, combination
brachytherapy and external beam), cryotherapy, hormonal therapy and
surgery.
Watchful waiting.
Usually inadvisable in an otherwise healthy man with a greater than 10
year life expectancy. Prostate cancer that is found early and has a low
Gleason (2-6) may grow slowly and may be monitored rather than treated.
Advantages- No
side effects from therapy.
Disadvantages-
Cancer eventually may spread and be incurable.
Hormonal therapy.
Prostate cells need testosterone to maintain themselves. Removing a man’s
testosterone may slow down the growth of prostate cancer cells. Usually
inappropriate for long term therapy of localized disease. There is
evidence that the cancer can spread even during long term hormonal
therapy. Hormonal therapy is not curative. Hormonal therapy may be
given prior to radiation.
Disadvantages-
Hot flashes, osteoporosis, etc.
Radiation: High energy
x-rays are used to kill cancer cells.
Brachytherapy.
Procedure: Performed as
outpatient, under anesthesia. Places radioactive seeds into the prostate
to burnout the cancer from within.
Concerns: Seeds may migrate
during placement leading to over or under treatment of certain areas of
the prostate (and cancer). Therefore, as a sole modality, may be less
effective than external beam or combination radiation therapy.
Side effects: Radiation
cystitis and proctitis (probably will be worse than other forms of
radiation); erectile dysfunction (may be less so than external beam or
combination radiation therapy).
Advantages:
Short duration of therapy. Few side effects up front if the prostate is
small.
Disadvantages:
Least effective treatment,. Side effects can occur even years after
therapy and may be underappreciated by some radiation oncologists.
Bladder outlet obstruction can occur and be difficult to treat,
especially if the prostate is enlarges.
MAY NEED OTHER
FORMS OF THERAPY TO SHRINK THE PROSTATE.
External Beam:
Procedure: Cast is made of
the body. Radiation is applied to the prostate through many ports,
5d/week for 7-8 weeks. Each session lasts about 20 minutes.
Side effects: Radiation
cystitis, proctitis, and erectile dysfunction.
Advantages-
Cure rates similar to surgery at 10-15 years with hormones added
Disadvantages-
Daily therapy for 2 months causes a systemic effect. Side effects can
happen later. Radiation effect in long term is unknown- new study shows
a 70% higher rate of rectal cancer after XRT.
Combination External
Beam and Brachytherapy
Combination of above, but
external beam will only last about 5 weeks. Same Side effect profile and
cure rate as external beam alone.
Surgery:
Procedure involves removal of
the entire prostate and seminal vesicles. The goal of this procedure is
to completely remove the cancer while it is contained within the
prostate. Surgery is typically about 3 hours long, and is considered
major surgery. Average blood loss is 2 units, but may be higher.
Patients are usually asked to bank blood for themselves prior to surgery
(“autologous blood”). Average hospital stay is about 3 days. A catheter
remains in the bladder for about 1-2 weeks. Back to work is usually no
sooner than 1 month after surgery.
Small risks of injury to
rectum or ureters, blood vessels, nerves.
Side effects: Incontinence,
usually lasting a few months. Erectile dysfunction.
Advantages: We
can more accurately predict your prognosis. Best long term cure rates.
Least amount of bladder outlet obstruction.
Disadvantages:
Major surgery with blood loss and recovery.
Robotic Prostatectomy:
The Robotic Radical
Prostatectomy represents a quantum leap forward in prostate cancer
surgery. The da Vinci Surgical System enables urologic surgeons to
perform a radical prostatectomy with similar, or improved technique when
compared to the standard open
procedure, while maintaining all the advantages of minimally invasive
surgery.
The robot controls tiny
jointed instruments, which can move at the tip like the human hand.
Unlike conventional laparoscopy and its two dimensional image, the da
Vinci camera has two lenses that combine to provide the surgeon a true
3-D image with 10x magnification. Also, any position or movement of the
surgeon’s hands is enhanced with scaling and tremor reduction and is
mirrored in real time.
Advantages of the
minimally invasive procedure may include reduced pain, scarring, risk of
infection, and less operative blood loss. Additionally, these
benefits have translated into shorter hospital stays, faster
recovery times, and a quicker return to employment and recreational
activities.
The robotic radical
prostatectomy can be performed with minimal blood loss and patients are
no longer advised to donate blood for their operation. Patients
typically go home after one night and can return to work within one to
two weeks. The urinary catheter remains in place for approximately six
days and continence is achieved more quickly and completely than with
the other surgical techniques. Erectile function is regained more
quickly and with greater frequency.
Advantages:
Best therapy available with least amount of side effects overall in
experienced hands.
Disadvantages:
Blood loss is still possible, as are other side effects of surgery.
Surgery can be longer than open for inexperienced surgeons.
Requires a
general anesthetic.
Learning curve
is longer than open surgery.
Cryosurgery: Involves
the use of liquid nitrogen to freeze and destroy cancer cells. Its main
use currently is for the control of local disease if primary therapy is
unsuccessful. Long term results using current technology are still not
known.
HIFU:
Similar to cryosurgery except
we are heating up the prostate with a focused ultrasound probe instead of
icing the prostate.
Advantages:
Probably least amount of side effects overall.
Disadvantages: It
is currently experimental in the US and available in Canada and Europe.
The worst cure
rates at the current time. |
UroToday - Perioperative Clinical Thromboembolic Events after Radical or Partial Nephrectomy
This study demonstrates that while the incidence of thromboembolic phenomena is low in patients undergoing renal surgery, there are specific subsets of patients that can be identified that are at increased risk and therefore deserving of more aggressive prophylaxis. These include older patients, those with a history of cardiac disease, those with a history of prior DVT, and those who have increased blood loss at the time of surgery. Prophylactic anticoagulation might be considered in addition to pneumatic compression groups in these specific subpopulations.
There has been a recent increased attention to DVT and PE in surgical patients.
There are no definite recommendations for urologic patients. We all agree that compression devices are necessary, but the risks and benefits of perioperative anticoagulation are not clear. With partial nephrectomies there is a tendency to have bleeding during and after surgery, so providing blood thinners will likely reduce the risk of complications from clotting, but may lead to increased bleeding.
I would be more likely to give anticoaguulation for patients undergoing a total nephrectomy as opposed to a partial nephrectomy.
Studies like this are important and need to be continued.
UroToday - PET Imaging Identifies Aggressive Kidney Cancers that Require Surgery
“Antibody PET could end up changing the standard of care for patients with kidney cancer,” said the study’s senior author, Paul Russo, MD, a urologic cancer surgeon at MSKCC. “The excellent sensitivity and specificity of this tool supports the utility of G250 PET imaging in the work-up and management strategies for clinically localized renal masses and as an alternative to biopsy for distinguishing renal lesions.”
In the study, 25 patients scheduled to have surgery to remove a renal mass received intravenous 124I-cG250. PET images obtained prior to surgery were graded as positive or negative for antibody uptake. A pathologist unaware of PET scan results then classified resected tumor specimens as clear cell renal carcinoma or otherwise.
According to the authors, G250 PET may ultimately be used not only to determine the aggressiveness and extent of a patient’s disease prior to any surgical intervention, but also to measure the therapeutic effects of a particular treatment, and predict the likelihood of recurrence.
“The promising results of this trial have stimulated interest in a larger, prospective multi-center trial to confirm our findings, and ultimately greatly improve the clinical management of patients with kidney tumors,” said Dr. Divgi.
I would not agree that I would consider a negative PET with the new antibody to mean that I would not operate on a renal mass, but this is an important study,
I look forward to hearing about newer studies for PET and to see if treating lesions with cryosurgery or RF ablation may allow for a followup with this type of study.
ProstateCenter.com: On ProstateCenter.com, you will find a wide range of sophisticated clinical tools, nomograms, databases and other useful information that enable the delivery of personalized, evidence-based medicine. These Web-enabled problem-focused decision making support tools allow users to forge the increasing amount and diversity of clinical data into real world solutions for patients, all provided in a timely, graphically oriented, colorful, and user-friendly environment, at no cost.
A friend of mine, and excellent robotic surgeon, Dr. Kevin Slawin from Texas has introduced me to a new site.
I liked the nomogram for prostate cancer recurrence after surgery and will find the PSA velocity doubling time very useful.
Thoughts from a robotic surgeon
I have started this blog to express some of my personal thoughts.
I started the robotic surgery blog (http://www.roboticsurgeryblog/) 16 months ago and will still write there along with several other robotic surgeons.
I wanted a forum that I could share my more personal thoughts, some maybe controversial or personal.
I also wanted a place to put my patient's testimonials and letters that was separate from the robotic surgery blog.
I also like blogger for quick-posting and to link easily to other blogger blogs.
After blogging for almost a year and a half here, I wanted a forum to express some of my thoughts that are not robotically based.
I started with an entry on where my patients have travelled from for minimally invasive surgery: 4 continents, 6 countries, and 10 states.
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