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UroToday - Renal Artery Occlusion During Nephron-Sparing Surgery: Retrospective Review of 301 Cases
 The authors report on 301 patients who underwent nephron sparing surgery for a localized renal tumor. Of these, 181 patients had renal artery occlusion with cold ischemia, while the remaining 120 patients were managed with external compression alone to control hemorrhage. Mean tumor size was 3.56cm and there was a higher incidence of centralized tumors in the arterial occlusion group (p less than 0.05). The authors noted no difference in blood loss, transfusion rates, tumor size, or complications between the two groups. Two renal units (1.2%) were "lost" due to ischemic damage in the renal artery occlusion group, which was not a complication in the external compression group. More importantly, there was a significantly higher incidence of positive margins in the external compression group (4.2%) relative to the group with renal artery occlusion during resection (0.6%), (p less than 0.05).
Renal artery occlusion during partial nephrectomy may result in ischemic damage to the remaining renal parenchyma, particularly if prolonged, but is clearly superior for optimal visualization during tumor resection. This study demonstrates that external compression (the "grip of death") does not significantly minimize morbidity over renal artery clamping, and may, in fact, be associated with an increased positive margin rate due to poor visibility during tumor resection.
This was from an open surgical series, but points out the balance between better visualization to remove the cancer which can be done by stopping the blood supply, but the chance of permanent injury to the kidney.
I have usually favored complete blockage of blood flow to the kidney (artery and vein) in my open, as well as minimally invasive approaches.
The other actor that is important is the importance of positive margins, that was once considered an indication to remove the rest of the kidney, but now can often be observed.
UroToday - Phase II Study of Neoadjuvant Androgen Deprivation Followed by External-Beam Radiotherapy With 9 Months of Androgen Deprivation for Intermediate- to High-Risk Localized Prostate Cancer
Testosterone returned to normal in 69% of patients with a median time to recovery of 9 months. Testosterone returned to it baseline level after ADT in 37% with a median recovery time of 11 months. Patients who recovered testosterone to normal levels after ADT were not more likely to fail BDFS or CDFS at 5 years. Due to the small numbers of deaths, cause of death analysis was limited but there was no difference in cause of death between those who did and did not recover testosterone to normal levels. The majority of patients lost potency during treatment, but up to 65% recovered some potency after treatment.
This study looked at the recovery of testosterone and potency after hormonal therapy.
As the authors pointed out, the timing and duration for maximum benefit for hormonal therapy is not yet known. I usually advise patient's that choose external beam radiation to have adjuvant hormonal therapy. This study gives a better understanding of how long it takes to recover.
The 1st quarter of 2007 was my busiest for da Vinci Prostatectomies (dvP) for prostate cancer (52 operations), as well as my busiest total robotic surgery 3 month period (60 operations).
My dvP volume increased 63% from the previous year and 24% from the previous quarter, which was then a record.
My total robotic surgery volume increased 50% from the previous year and 15% from the previous quarter, which was then a record as well.
For March I performed a total of 22 robotic operations, which brought the total to 321.
17 of them were dvPs.
2 were robotic simple prostatectomies for BPH.
1 was a partial nephrectomy for a small kidney tumor.
1 was a radical nephrectomy for a tumor.
My expectations for the 2nd quarter are similar to the first quarter.
I expect the growth to increase for the 3rd quarter due to several reasons:
Saint Barnabas Medical Center in Livingston, NJ will likely have the newest high definition da Vanci S system installed.
I will also have privileges at St. Clares in Denville. These 2 hospitals will likely lead to an increase in referrals in the towns closer to these hospitals.
I will also have my new partner, Dr. Brent Yanke, starting in July which should allow my program to grow tremendously. Dr. Yanke is finishing his fellowship in endourology and minimally invasive urology at Thomas Jefferson in Philadelphia.
UroToday - Outcomes of Cryotherapy for Prostate Cancer
The mean follow-up was 20 months. A total of 4% of patients who were continent pre-procedure were incontinent after therapy. A total of 39% of patients reported being potent pre-treatment and all men were impotent immediately after cryotherapy. The probability for a man potent prior to treatment to regain his ability to have intercourse with or without PDE-5 inhibitor assistance at 1, 2, and 4 years was 29%, 49%, and 51%, respectively. Nearly 80% of men achieved a PSA nadir of less than 0.4ng/mlwith a 4-year biochemical freedom from disease rate of 80%. In those experiencing disease failures, the mean time to failure was 4.2 months. Of 168 patients who underwent a prostate biopsy, 10% had CaP at a mean of 10 months after treatment.
I wonder if the way the penile rehabilitation is done is the best way, but I will blog on my thoughts later on penile rehabilitation.
This was a relatively large study. A 10% failure rate on biopsy is rather high, as it likely underestimates the true persistence of cancer.
UroToday - EAU 2007 – Session on Open and Laparoscopic Radical Prostatectomy Tumors
Interestingly, in prostate volumes less than 30gm, lap RP was associated with a PSM in 44%, while no such association existed for open RP.
I have never thought of this before, but a quick look at my robotic data shows that 4 of my 18 prostates that were 30 gm or less had positive margins. This 22% figure is higher than the rest for me as well compared to my 11.8% overall for T2 cancers. It may be with minimally invasive surgery the smaller prostates may be less well defined. I will pay closer attention to these in the future.
Johns Hopkins Magazine
Robotics, along with stem-cell research, will drive much of the innovation in medicine in the coming decades. Mohsen Mahvash Mohammady, an assistant research professor at the Engineering Research Center for Computer-Integrated Surgical Systems and Technology (ERC CISST) at Johns Hopkins, and a fixture in the haptics lab, says that collaboration is the key to the lab's success. "Without a doctor's input, I would be able to develop a nicely controlled robot, but I wouldn't be able to incorporate what surgeons need," says Mohammady, who is working on developing haptic scissors, as well as finding the best ways to retrofit the daVinci with the most useful types of force feedback.
Update from John Hopkins engineering school. Haptics for robotic surgery is being investigated in the form of tactile feedback. I think the need for haptics for experienced robotic surgeries is less than most people would think, but it can help. I think for beginners it will help a great deal. Other forms of feedback were discussed as well, the most promising one being visual feedback in the form of color changes as tension increased.
It is likely a few years away, but on the horizon.
UroToday - European Urology - Preoperative and Intraoperative Risk Factors for Side-Specific Positive Surgical Margins in Laparoscopic Radical Prostatectomy for Prostate Cancer
Suspected ECE on endorectal coil MRI had neither protective effect nor increased risk for PSMs, which means that, whereas this variable may help with surgical planning, its capacity to decrease PSM rates remains to be prospectively investigated. Although increasing BMI may impact PSMs [17], we did not find such an association, possibly because individuals with high BMI were underrepresented. Of the 407 patients, 79 had a BMI between 30 to 35, and only 10 had a BMI >35.
It is well established that tumour volume is associated with higher PSM rates [1], [12] and prostate biopsy data may help to predict tumour volume and risk of a PSM. Although overall percentage of cancer in the biopsy specimen (total millimeters of cancer in the biopsy specimen divided by total millimeters of biopsy tissue) is a more accurate predictor of cancer volume, we used the maximum percentage of cancer in any core of the specific side because not all prostate biopsies were done at our institution. Of interest, 201 (28%) of the 728 prostate sides that harboured cancer had a negative ipsilateral preoperative biopsy. A PSM was identified in 4% of them, compared with an 8% PSM rate among the 527 prostate sides with a positive biopsy. In other words, surgeons should not become overconfident about dissecting the NVB extremely close to the prostate side where the biopsy was negative.
This was an excellent paper that made several observations that I have seen as well:
Smaller prostates tend to have a higher level of positive margins.
Positive margins often happen on sides where there is no cancer on biopsy.
I do not personally order preoperative MRIs, but this showed it did not make a statistical difference in positive margin rates. I would be curious to see how many of the patients with preoperatively suspicious MRIs for extracapsular extension actually had it at the time of surgery.
UroToday - Prostate Cancer Progression in the Presence of Undetectable or Low Serum Prostate-Specific Antigen Level
Overall, 10 (22%) had undetectable serum PSA levels and 30 patients (65%) had PSA of less than 1ng/ml at the time of disease progression. Of the 25 men who had undergone radical prostatectomy, 7 were hormone na�ve at the time of progression. The median increase in PSA was 0.25ng/ml at the time of progression. In 19 patients, there was no increase in PSA from the nadir level at the time of progression. The median PSA doubling time for the cohort was 7.6 months.
Atypical variants of CaP were identified in 21 of 46 patients; including 9 with ductal CaP, 8 with small cell variant, 2 with neuroendocrine tumors and 2 men with sarcomatoid tumors. Metastatic progression was most commonly in the bones, followed by liver, retroperitoneal lymph nodes and lungs. Progression was identified by bone scans, CT or MRI.
In patients with CaP variants, monitoring in addition to PSA may have value.
Cancer 2006;109(2): 198-204
Occasionally prostate cancer cells make little or no PSA. As this study points out, it is usually the rarer forms that do this.
UroToday - EAU 2007 ABST[750] - Radical Prostatectomy: A non-randomized Comparative Analysis of Outcomes between the Open and Laparoscopic Approach
Conclusions:
In our institution and during the study period, laparoscopic and retropubic radical prostatectomy provided comparable oncological efficacy, functional and morbidity outcomes.
The laparoscopic approach was associated with lesser blood loss and transfusion rate and higher postoperative hospital visits and readmission rate.
This was a good study by a high volume prostate cancer hospital.
I thought they had a higher rate of laparoscopic readmission rates that I would have expected, although the transfusion rate and blood loss was much less in the lap group.
I look forward to seeing how the robotic results compare to the open and lap data.
UroToday - EAU 2007 - AUA Lecture at the EAU 2007 - “The Role of Robotics in Urology”
The market is primarily coming from patient "advertising" to other patients by word of mouth and use of the internet. The perceived benefit is likely based upon decreased blood loss and quicker recovery. He hypothesized that this leads to decreased surgical and medical complications. Complications have a negative impact on hospital reimbursement. Based upon Medicare data, Begg in the NEJM in 2002 found that the complication rate from open radical prostatectomy was 28-35%. In a study by Dr. Lu-Yao, the surgical complication rates were virtually identical and medical complications were about 13-20%. Pure laparoscopic prostatectomy series report complication rates of about 11%. In his robotic data, medical complications were <1%.
UroToday - European Urology - Vattikuti Institute Prostatectomy: Contemporary Technique and Analysis of Results
Results
Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12–66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function.
Conclusions
VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.
Excellent outcomes are seen from Dr. Menon's group. It is interesting that even at the most experienced institution, only 51% of their patients had return to baseline sexual function. I believe this number is important and urologists should not only track how many patients can have intercourse with viagra and such, but also how many do not need it anymore and track patients SHIM scores.
First heart surgery performed by robots in CzechRep - Prague Daily Monitor
First heart surgery performed by robots in CzechRep
By Prague Daily Monitor/ČTK / Published 16 March 2007
Prague, March 15 (CTK) - The first robotic heart operation was performed in the Czech Republic in Prague's Na Homolce hospital this week, hospital spokeswoman Jitka Kalouskova told CTK today.
Six patients suffering from heart failure underwent the unique operation using robotic systems.
The hospital, which holds an international quality accreditation, ranks among pioneers in robotic operations in the Czech Republic. It opened a robotic operating theatre in October 2005.
Robotic Assisted Laparoscopic Radical Prostatectomy
Conclusion
Our review of the data for RALP shows a promising procedure in evolution. The limitations of robotic technology such as lack of haptic feedback seem to be outweighed by the advantages of improved visualisation and miniature instrumentation. While economic considerations are paramount the procedure is continuing to grow because of patient benefit and demand. The short-term data are growing quickly and are encouraging when compared with the current gold standard in terms of functional and oncological outcomes. As robotic technology evolves and becomes more prevalent we expect to see continued innovation and improved surgical outcomes.
Excellent review at medscape explaining surgical times and dvP outcomes written by Dr. Vip Patel of his State.
Length of Hospital Stay Similar for Robotic Assisted and Conventional Prostatectomy
The current study prospectively compared length of hospital stay in 374 patients who underwent conventional RP and 629 who underwent LRP between 2002 and 2005. These authors reported that 94.3% of patients undergoing RP and 97.5% undergoing LRP were discharged on or before postoperative day 1. The mean stay for patients receiving RP was 1.25 days compared to 1.17 days for those receiving LRP. Readmission rates were 7% for the RP group and 5% for the LRP group. None of these differences were statistically significant. Unscheduled visits to the emergency room occurred in 10% of both groups. The major cause of hospital visits was ileus. These authors concluded that both groups of patients could be treated on the same clinical pathway as they had similar problems.
This is one study that shows similar hospital stays among open and robotic prostatectomy. In my experience this hasn't been the case. The reason the hospital stays were similar is that they were able to shorten the hospital stays to 1 night in most patients.
I remember following this. Vanderbilt is excellent at creating clinical pathways and they have significantly cut their open hospital stays after the robotic stay started out shorter. I think Vanderbilt's open stays are now among the best in the country.
UroToday - EAU 2007 - Session on Prostate Biopsy 1
The 7,074 biopsies were performed in 5,153 men. Minor complications included hematuria >1 day (13.8%), hematospermia (35.8%), and rectal bleeding (2.1%). Major complications were prostatitis, epididymitis, fever >38C, rectal bleeding >2 days, and urinary retention, all <1.0%. This study validates the safety of TRUS biopsy of the prostate.
This is a lower number than I would have guessed for blood in the semen (hematospermia), but a nice study to advise patients of possible side effects from a prostate biopsy.
This is what we need to consider when I asked the question of doing biopsies on everyone.
UroToday - EAU 2007 - Minimally Invasive and Other Treatment Strategies in Localized Prostate Cancer
The authors conclude that this treatment modality is appropriate for patients with localized CaP who are not candidates for surgery. The oncological outcomes appear inferior to rates reported for radiotherapy and surgery.
2 abstracts were summarized from the EAU's meeting: The HIFU one showed relatievly safe results, but cancer cures that were less than radiation or surgery. This is the first generation device they were using and I expect the results to improve.
I think HIFU will be FDA approved in the US in the next 2-3 years.
The cryosurgical study was for radiation failures and gave the following results and side effects:
The 5-year biochemical recurrence free survival was 73% for low-risk patient, 45% for intermediate-risk men and 11% for high-risk patients. The reported complications included incontinence (13%), erectile dysfunction (86%), LUTS (16%), prolonged perineal pain (4%), urinary retention (2%) and rectovesical fistula (1%).
Testosterone Replacement May Be Safe After Prostate Cancer
NEW YORK (Reuters Health) Mar 23 - Testosterone replacement therapy (TRT) appears safe for men who experience hypogonadal symptoms after brachytherapy for prostate cancer.
"Men who have undergone potentially curative treatment for prostate cancer but also suffer from severe effects of hypogonadism may benefit from a trial of testosterone replacement, with close monitoring of the PSA," Dr. Michael F. Sarosdy from South Texas Urology and Urologic Oncology, San Antonio, told Reuters Health. "In our experience, most have done well.
This is the first study that I have seen that recommended testosterone replacement after brachytherapy for prostate cancer.
The concern is that testosterone can help make any viable cancer cells grow faster. Since patients with hypogonadism (symptoms of low testosterone) have benefit from having normal levels and most patients with prostate cancer have normal levels of testosterone that we do not suppress, the true risk of a normal testosterone is probably low.
I usually do not like recommending testosterone replacement in any of my prostate cancer patients.
Prostatectomy Effective for SV-Negative Locally Advanced Prostate Cancer
At a mean follow-up of 37.2 months (median, 21.2 months), the pT3 (pT3a plus pT3b) patients' overall and disease-specific 10-year survival rates were 77% and 92%, respectively, and at 15 years, 52% and 75%. These results are similar to those of previous studies for overall survival of patients with advanced prostate cancer who undergo radical prostatectomy.
However, in the present study, Dr. Suttmann said, "The main issue is that you have 10-year disease-specific survival for those with pT3a of 92%, which is probably as much as those with pT2 tumors, while disease-specific survival is much worse for those who have pT3b disease, and so have seminal vesicle involvement."
Although Dr. Suttmann indicated that they had not included any specific analysis for prognostic factors, he said, "We would still conclude that radical prostatectomy [with or without hormonal therapy] is a pretty good therapeutic option for those with pT3 disease.
An important point in this study is that even patients with seminal vesicle invasion had a decent cure rate.
There were 2 articles summarized from the EAU 2007 conference on Urotoday.
They seemed to be conflicting, with one saying that delaying therapy did not seem to hurt many people and the other concluding that screening helped.
UroToday - EAU 2007 - Session on Prostate Cancer Screening:
Dr. Pelzer, Innsbruck presented data that the pathologic characteristics of PC detected in screened patients is favorable compared to PC detected in non-screened men. Of 997 RPs performed 1999-2006, 806 men were treated for screen detected PC and 191 were referred for surgery and not screen detected. Patient age and PSA levels were similar between the groups. The screen detected patients had statistically lower pathologic stages at surgery and lower Gleason scores. The rate of positive surgical margins was 11.7% in the screened group and 24.4% in the non-screened group. The worse pathologic variables suggest that the non-screened group is at higher risk for disease relapse compared to the screened patients. Dr. Pelzer, Innsbruck presented data that the pathologic characteristics of PC detected in screened patients is favorable compared to PC detected in non-screened men. Of 997 RPs performed 1999-2006, 806 men were treated for screen detected PC and 191 were referred for surgery and not screen detected. Patient age and PSA levels were similar between the groups. The screen detected patients had statistically lower pathologic stages at surgery and lower Gleason scores. The rate of positive surgical margins was 11.7% in the screened group and 24.4% in the non-screened group. The worse pathologic variables suggest that the non-screened group is at higher risk for disease relapse compared to the screened patients.
In the screening studies in Europe the screening only gets done every 4 years. They are still very useful and I look forward to seeing their results.
As the study I quoted points out, even though patients by be "curable" as defined by having disease confined to the prostate, there is still a higher volume of cancer and there is probably more people that will not be cured by surgery as evidenced by the higher positive margin rate.
Dr. Koop - Biopsy Underestimates Prostate Cancer in Overweight Men:
Researchers compared the biopsy grade to the cancer grade following radical prostatectomy, which is the removal of the prostate. In 1,113 men who underwent radical prostatectomy between 1996 and 2005 within the Shared Equal Access Regional Cancer Hospital database, 299 men, or 27 percent, had more severe cancer than suggested by biopsy. In 123 patients, or 11 percent, cancer diagnosis was actually less severe.
This was an interesting study that concluded that obesity is one of the risk factors for upgrading at the time of pathological analysis.
The last time I reviewed my database I found that 30% of my gleason 6 cancers were upgraded to 7. I have not done an analysis to see which patients are more at risk yet.
One of my favorite instruments for robotic surgery is the PK dissector.
As all daVinci instruments, It is made by intuitive surgical. It was developed in combination with gyrus medical.
It is a bipolar instrument that can be used instead of the maryland bipolar or precise bipolar.
The main advantages include:
Less charring and sticking to tissue.
A wider opening angle to grab tissue easier.
Sound feedback to tell you when the tissue should be coagulated enough.
The main disadvantage is the blunt tip which makes it less useful as a dissector than the maryland bipolar (but more useful than the blunter precise).
For surgeons interested in obtaining this you also need a gyrus PK generator to provide the input.
Scientists have identified several genetic risk factors for prostate cancer, shedding new light on the cause of a leading worldwide cancer killer among men that hits U.S. blacks especially hard.
'The importance of it is that this is the first real evidence of the genetic basis of prostate cancer,' said Dr. Brian Henderson, dean of the Keck School of Medicine at the University of Southern California and one of the researchers of the study released on Sunday.
'It gives us the first real insight we've had into the cause of this disease and how we might do something about it,' Henderson added.
Source: Yahoo! News
This has important implications for researchers and will likely to lead to improved ways to predict who is at risk.
Chromosome 8 was implicated by Harvard researchers last August. I am still predicting the day when urologists will be performing prophylactic prostatectomies similar to the removal of breast for women at high risk of developing breast cancer.
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