Us Too! Prostate Cancer Education and Support - HotSheets

#Doc Moyad’s What Works and What is Worthless Column—Provenge�

# Cell Genesis Reports Phase II Results with GVAX Immunotherapy

# A Survivor Reviews the 2007 ASCO Prostate Cancer Symposium

The robotic-assisted laparoscopic prostatectomy is rapidly becoming the
“standard of care” for those who choose surgery.

IMRT (Intensity Modulated Radiation Therapy) is the “standard of care” for
external beam radiation, but there remains an important place for brachytherapy
(radioactive seed implants).

Docetaxel is the “standard of care” for those who need chemotherapy.

# UCSD Researchers Report Ability to Detect Cancer at Earliest, Curable Stage

# New Blood Test for Prostate Cancer—Can EPCA-2 be on the Horizon?

This is an excellent newsletter that included A review of the 2007 ASCO prostate cancer symposium, an update on EPCA-2, a test that will help in screening for prostate cancer and may replace PSA on day as the best screening test, and the significance of PSA doubling time after prostate removal.

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Lap technique may play a role in treating BPH - UrologyTimes

Berlin—A laparoscopic preperitoneal approach cannot only serve as a teaching platform for laparoscopic skills for surgeons, but it also demonstrates reproducible outcomes in the treatment of BPH, according to Belgian researchers who presented their results at the European Association of Urology annual congress here.

Researchers from the Institut Jules Bordet, Universite Libre de Bruxelles in Brussels, conducted a 102-patient prospective study comparing a classical open Millin's retropubic transcapsular adenectomy in 51 patients and a laparoscopic preperitoneal approach in 52 patients according to a step-by-step transposition of Millin's procedure described in European Urology (2004; 45:103-9).

Preoperative characteristics were comparable between the groups with respect to age, prostate volume measured by trans-rectal ultrasonography, preoperative micturition, post-void residual volume, and International Prostate Symptom Score (IPSS).

This study was done with laparoscopy and looked at open vs laparoscopic prostatectomy for BPH for smaller prostates.

I have performed over 10 robotic prostatectomies for BPH with over 150 grams of tissue removed on many men. I think the robotic approach is harder to learn than either of the 2 above methods, but when mastered, leads to an easier and quicker operation.

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Dietary changes may reduce prostate cancer risk, raise PSADT - Expert recommends 'active holistic surveillance,' including low-fat diet, supplements - UrologyTimes

For patients at low risk for developing the disease, Dr. Katz recommended using the term "active holistic surveillance" instead of "watchful waiting." This involves instructing patients to adhere to the following dietary modifications:

* Switch to a low-fat diet.
* Increase intake of fresh vegetables and lycopene.
* Supplement your diet with soy products, vitamin E, and selenium.
* Drink pomegranate juice and two to four cups of green tea daily.

This was a summary that Dr. Aaron Katz gave at the winter urologic forum. There is also a nice table in this article that explains why some of these things may help protect against prostate cancer. Consult your own urologist as to the benefit of any of these therapies for you and the proper dosing.

The article also points out how things that help prevent cancer will likey help prevent a recurrence as well.

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Symposium: Robotic surgery in urology: Hype, hope, and reality - Modern Medicine

Community urologists who want to learn this must have an adequate volume of cases, at least 20 prostatectomies a year, and it probably will take 20 or 30 procedures before they are comfortable. For someone doing less than 20 cases a year, it doesn't make much sense. You have to do this procedure with some regularity to keep up your skills.
Pruthi: I hesitate to suggest a number because of the different issues we have mentioned. In the Henry Ford experience, when they looked at complications, the learning curve was 200 cases.2 At Vanderbilt, the surgeon-reported learning curve was 250 cases.2

The panel from Duke, Tulane, and the University of North Carolina discuss robotic surgery, focusing in robotic prostatectomy. It is a good read for urologists considering starting to do robotic surgery or ones early on in the learning curve. The range to get comfortable with robotic surgery was from 10 to 30 cases.

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Luna Innovations Signs Multi-Year Development and Supply Agreement with Intuitive Surgical: Financial News - Yahoo! Finance

Luna Innovations Signs Multi-Year Development and Supply Agreement with Intuitive Surgical
Thursday June 14, 9:21 am ET
Luna's Sensing Technology to be Integrated into Intuitive's Surgical Products

ROANOKE, Va.--(BUSINESS WIRE)--Luna Innovations Incorporated (NASDAQ:LUNA - News) announced today that it has entered into an IP licensing, development, and supply agreement with Intuitive Surgical, Inc. (NASDAQ: ISRG - News), the global technology leader in robotic-assisted minimally invasive surgery (MIS). Under the terms of the multi-year agreement, Luna will develop and supply its fiber optic-based shape sensing and position tracking system for integration into Intuitive Surgical's products, which includes the da Vinci� Surgical System.

One day we may look back at this as an important purchase.

What many physicians do not understand yet is that a surgical platform can provide you with many things that traditonal open or laparoscopic can not. I do not know the details of Luna's products, but this seems to be a way for the robotic system to track other organs that are inside the operative field. This is an important step in truly computer assisted surgery.

I will look forward into reading about this new technology.

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Telemedicine: Proven results and promise for the future - With recent advances in telecommunications and surgical robotics, telemedicine is poised to increase the efficiency of urologic practices and bring access to specialists and surgeons to even the most rural communities. - Modern Medicine

The future of telesurgery and telementoring. As telecommunications and robotic technology continue to advance, telesurgery is likely to take on a more prominent role in urologic practice. Citing an emerging body of literature supporting the idea of a correlation between a surgeon's level of experience and clinical outcomes, many advocate the centralization of surgical care to centers of excellence. Telesurgery has the potential to play a significant role in this process, allowing for such centralization while obviating the need for patients to travel great distances to obtain such levels of care.

CONCLUSION

Much like the introduction of the telephone and email to the practice of medicine, the introduction of more sophisticated technology has been met with skepticism and concerns over quality of care. However, just as the telephone has become pivotal in the rapid and effective transmission of medical information, advanced telemedicine is likely to become part of routine urologic practice.

This was an excellent review of the current state of technology in tele-rounding (seeing patients from afar with the help of a robot), tele-surgery, tele-proctoring, and more. This was led by Drs. Lee and Kavoussi from Long Island Jewish on Long Island.

It is an excellent piece to read for all urologists and anyone interested in how technology is changing medicine.

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The Surgical Revolution In Minimal Access Surgery- The Robotic Connection

Dr. Satava, Professor of Surgery, University of Washington discussed that robots are 12-15 times faster and function with greater precision than humans. Robots can work around the clock without taking coffee breaks, he said. Information is a basis for surgery in the new age. "Holomer" is a total body scan to guide intra-operative navigation during surgery. A surgeon could then use this to perform a virtual operation on a patient prior to the real operation. A robot is an information machine, rather than a machine, he said. Thinking as such will permit greater integration into our healthcare system. The surgeon is then an information manager, and can integrate all aspects of the care to include preoperative planning, surgical approaches, etc. The robot can give 1mm accuracy using a virtual robot to practice an operation ahead of time on a virtual patient.

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UroToday - AUA 2007 ABST[550] Curtain Dissection of the Lateral Prostatic Fascia and Potency Following Laparoscopic Radical Prostatectomy - A Veil of Mystery

Conclusions: CD produced a significantly higher potency rate at 1 month following LRP but similar rates thereafter, which are in step with previously reported values (Rozet, 2004). Notably, CD failed to reproduce the results of Menon et al. despite the advantage of avoiding cautery at all stages during NVB preservation in our patients. We believe that the merit of this technique is in allowing a clearer appreciation of the contour of the prostate base at the commencement of antegrade NVB dissection, rather than preserving important nerve fibres. This may explain the lower basal positive margin rate in the CD group of 0% vs 5.8% in control cases (p=0.007).

I often save the veil of aphrodite, but I am not sure that it helps much either in terms of nerve preservation.

I am not sure if the nerve fibers that are seen high on the prostate are going to the penis. I am also concerned about getting too close to the prostate in this area. I think the more important factor that helps restore erections is to leave the prostatic fascia over the neuro-vascular bundles. This leads to less stretch and trauma to the nerves. This intrafascial plane likely leads to the best nerve sparing.

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The robotic revolution: Advancing laparoscopy and urology further into the future - The introduction of robotic technology and its increasing acceptance in urology have helped surgeons overcome many technical barriers to complex laparoscopic procedures. While preliminary safety and efficacy results for a number of procedures are promising, long-term data are needed to establish its role relative to more traditional approaches. - Modern Medicine

Laparoscopy has the potential for decreasing surgical morbidity, with smaller incisions, decreased blood loss, less postoperative pain with decreased intake of narcotics, shorter hospital stays, and faster recovery compared with open surgical procedures. While these benefits have been realized for urologic procedures such as nephrectomy, adrenalectomy, and pyeloplasty, technical obstacles have hindered its adoption in more advanced procedures such as prostatectomy.

This was an article out of contemporary urology. The October 2006 issue had several articles on the advances in urology made possible by technology. The article was written by Dr. Vip Patel's at Ohio State.

It is an excellent read for urologists, primary care physicians, and patients and people interested in robotic surgery.

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UroToday - AUA 2007 - The Effect of Surgical Volume on the Rate of Seconday Treatment After Radical Prostatectomy

They conclude that surgical volume is a determinant of treatment-failure when evidenced by the use of secondary therapies. Surgeons performing 24 RPs per year had the lowest rate of secondary treatment use.

This study out of Germany, Canada, and Italy looked at patients chances of needing further therapy after open prostatectomy. Surgeons varied from performing only 1 surgery per year to 57 in the last year.

The results for the higher volume surgeons were better than the lower volume surgeons. This data is for open surgery and even the busiest surgeons were only performing about 1 per week. I think the data for robotics will be similar. I wonder if surgeons like myself who do about 4 per week and surgeons that are even busier like Dr. Patel (over 400 a year) will compare.

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UroToday - Remote Telepresence Surgery: The Canadian Experience

This important report from Canada presents 22 telerobotic general surgery laparoscopy cases performed by two surgeons over a distance of 400 kilometers; from a teaching hospital in Hamilton, Ontario to a community hospital in rural Northern Ontario.

I think it is very important that robotic surgery can be done at a distant. Reading over the limitations of robotic surgery makes it clear that it is not ready for regular use, but with technology increasing rapidly I think the bandwith issue will be resolved.

There are also more and more robots in use every month. I think the first clinical application will be in robotic teleproctoring. I can see proctoring someone who is far away with the ability to remotely operate if it is necessary. This would be ideal to teach someone who has a solid robotic background a new procedure.

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Robotic surgery on prostate cancer arrives in R.I. | Rhode Island news | Rhode Island news | projo.com | The Providence Journal

This is robot-assisted surgery — and some say it’s the future of surgery. Miriam Hospital is the first hospital in the state to acquire the robot, called the da Vinci Surgical System, which makes it easier to operate in the tighter corners of the human body.

I helped to train the first group of urologists from Rhode Island a few months ago and I am happy to see that their program is off to a success. Over 70 cases is an excellent start for the state's first robotic program.

I belive the remaining states without a robot are New Mexico, Vermont, Montana, and Wyoming.

I think that Montana will be the next state to add a robot.

My friend, Dr. Russell thinks that Wyoming will be last. My guess is for Vermont to be last.

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UroToday - Should the Gleason Grading System for Prostate Cancer be Modified to Account for High-Grade Tertiary Components? A Systematic Review and Meta-Analysis

BERKELEY, CA (UroToday.com) - A systematic review and meta-analysis by Dr. Harnden and associates suggests that a tertiary Gleason grade is associated with worse oncologic prostate cancer (CaP) outcomes and warrants greater prospective analysis and consideration for inclusion in the Gleason grading system. This report appears in the May 2007 issue of the Lancet Oncology.
The standard prostate pathology report includes a primary and secondary Gleason grade. On some occasions, a tertiary grade is reported. In 2005 an International Consensus Conference of uro-pathologists suggested that the Gleason system for prostatic biopsy reports should be modified to account for the presence of a poorly differentiated or undifferentiated tertiary component. The modified approach would sum the most prevalent primary grade and the highest grade. Thus, in the situation with a primary grade 3 and a secondary grade 4, cancers with a tertiary grade of 5 would be classified as high grade (3 5). This proposal has not been implemented, as the existing system is well rooted in clinical practice.

I have thought about this on several occasions. The most common situation is a patient who has a gleason score of 3+4 = 7 with a tertiary pattern of 5 after robotic prostatectomy.

My feeling is that the small amount of 5 is probably significant. Most studies have shown that the first two numbers (the most common type and second most common type) are the important ones, but it would make sense that the any gleason score of 5 (the most aggressive) would be important. I also think tumor volume is very important. One day we may list the total volume of gleason score 5 and then 4 as important factors to determine risk of recurrence of prostate cancer after surgery.

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FDA approves third new targeted therapy for advanced RCC - UrologyTimes

The FDA has approved the enzyme inhibitor temsirolimus (Torisel) for the treatment of advanced renal cell carcinoma.
The approval of temsirolimus follows the December 2005 approval of sorafenib (Nexavar) and the January 2006 approval of sunitinib (Sutent), which represent a new class of targeted therapies for advanced RCC.

The article in the New England Journal of Medicine showed an improvement in survival of 3 months with temsirolimus. This will be an important addition in helping patients with advanced kidney cancer.

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UroToday - Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer after Radical Prostatectomy

This retrospective study with a large cohort of patients treated with salvage radiotherapy after prostatectomy suggests that up to 50% of patients may remain free of disease 6 years after treatment if it is instituted before their serum PSA rises above 0.5 ng/ml. The nomogram proposed predicts with reasonable accuracy which patients are more likely to exhibit a favorable response to salvage radiotherapy and may aid in clinical decision-making.

The timing of radiation after prostate cancer surgery is not clearly established yet.

Some people advocate immediate radiation therapy for high risk patients (adjuvant radiation therapy) and other recommend only giving radiation to patients that have recurrent PSA values. Since PSA is made by healthy prostate tissue and prostate cancer cells, a rising PSA after surgery likely means that the cancer is recurrent.

This study suggests that starting treatment before a level of 0.5 for a recurrent PSA is more effective than waiting until a higher level.

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This past week, Intuitive Surgical participated in the 2007 AUA (American Urological Association) Meeting held in Anaheim, California. As noted, this years AUA Meeting was clearly the most prominent in the history of Intuitive Surgical.

We had a very strong showing with increased booth & program activities, higher visibility amongst leading academic & community urologists, 5 "Live" broadcasted da Vinci Procedures (including a formal AUA Satellite Live 3-D Broadcast) and a record attendance on the exhibit floor.

It was very clear that da Vinci Urology Procedures, such as dVP, are becoming routinely adopted across a larger audience of both urologists and hospitals. The ISI theme this year was focused on da Vinci Prostatectomy - "The Fastest Growing Treatment for Prostate Cancer", the launch of da Vinci Nephrectomy & the promotion of da Vinci S with HD (High Definition) This theme was promoted through the showing of "Live" Telesurgery, Continuous HD narrated & unedited 3-D video, New Clinical Data, New Robotic Techniques, & New Upcoming Instrumentation.

Key Highlights:

3 - AUA Sanctioned Robotic Courses focused on da Vinci Urological Procedures. Over 200 urologists paid and attended these courses

2 - AUA Sanctioned "Lunch with the Experts" Programs covering: Techniques, Maximizing Outcomes, & Getting Started with da Vinci in Your Practice

78 - Moderated Abstracts: (This was an increase of 279% over 2006. Abstracts in 2006 were 28). 2007 AUA Abstracts covered: dVP, da Vinci Pyeloplasty, da Vinci Cystectomy, da Vinci Nephrectomy, & others

AUA Plenary Presentation: Dr. Pat Casale (Children's Hospital of Philadelphia) gave an outstanding State-of-the ART Lecture presentation to an audience of more than 1,000 attendees titled, "The Application of Robotics in Pediatric Urology". Dr. Casale showed the da Vinci System as a valuable tool for the Pediatric Urologist. Procedure talking points and video clips covered da Vinci Pyeloplasty, Ureteral Reimplantation, Appendicovesicostomy, & several other reconstructive urological procedures.

This year the AUA & ISI held a Hands-On Course, where da Vinci Pediatric Urology procedures were featured utilizing 3 surgical stations (2 with da Vinci Systems & and 1 with computerized simulation from Mimic) . 40 urologists paid and attended this course. This course was taught by Dr. Craig Peters (University of Virginia), Dr. Pat Casale (Children's Hospital of Philadelphia), & Dr. Thomas Lendvay (Seattle Children's Hospital)

ISI Booth Presentations: Booth Presentations covered da Vinci Prostatectomy, da Vinci Nephrectomy & Partial Nephrectomy w/ 3-D HD Video, da Vinci Pyeloplasty, & da Vinci Cystectomy.

5 exceptional "Live" Telesurgery Broadcasts (4 -dVP and 1-dVN) drew packed crowds of hundreds to the ISI Booth & accompanied Satellite Program.

Dr. Ash Tewari (Cornell University) performed a beautiful bilateral Nerve-sparing dVP in a swift 60 minutes (console time) to an audience of 150+ urologists. His anastomosis time was under 5 minutes using da Vinci. This surgery was moderated by Dr. Peter Carroll (University of California San Francisco), Dr. Dave Albala (Duke University), Dr. Robert Meyers (Mayo Clinic Rochester) & Dr. Dan Barocas (Cornell University).

Dr. Ingolf Tuerk (Lahey Clinic) performed an impressive extra-peritoneal dVP (First ever broadcasted dVP technique to AUA). The moderator was Dr. John Libertino (Chair of Urology, Lahey Clinic).

Dr. Domenico Savatta (Newark Beth Israel Medical Center) performed a very efficient da Vinci Nephrectomy to a large audience utilizing the da Vinci S System. (First ever broadcasted dVN to AUA). This surgery was moderated by Dr. Jay Yew (Sharp Memorial Healthcare - San Diego)

Dr. Randy Fagin (Westlake Hospital) performed a 4-arm Bilateral Nerve-sparing dVP in a quick 60 minutes (console time) to an audience of 150+ urologists. This surgery was moderated by Dr. Naveen Kella (Georgia Urology)

Dr. Timothy Wilson (City of Hope National Medical Center) performed a 4-arm Bilateral Nerve-Sparing & Endopelvic Fascia Sparing dVP to a large group of curious urologists. City of Hope has now performed over 2,300 dVP procedures. This surgery was moderated by Dr. David Josephson (City of Hope).

Source: email end of May

It is obvious to most robotic surgeons now that most prostatectomies will be done robotically in the near future. In the next 12 months dvP will likely replace open rrp as the most common prostate cancer operation.

It will be interesting to see how many other procedures will be done robotically in the future.

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I was honored to be chosen by Intuitive Surgical to perform the first live robotic kidney removal surgery at this years American Urologic Association conference (press release). This was the second year in a row that I have been chosen to perform l a live surgery.

Intuitive has been broadcasting live surgeries for 3 years now. I was one of 3 surgeons to perform a dvP (robotic prostatectomy) at the 2006 AUA convention. This year there were 4 live dvPs and my nephrectomy.

Robotic Kidney and adrenal specimen: click to enlarge

The surgery was performed on Sunday afternoon, May 20th, on an 80 year old gentleman who had a 2 inch right kidney tumor and a small tumor in his adrenal gland. I removed the right kidney and adrenal gland in about 80 minutes with less than 1 ounce of blood loss.

The gentleman was able to go home on Tuesday morning and only took 1 pain pill while at home. I saw him in the office after 12 days and he was fully recovered.

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UroToday - AUA 2007 - Experience with Robotic-Assisted Laparoscopic Living Donor Nephrectomy

This series demonstrates that robotic-assisted laparoscopic donor nephrectomy can be performed safely with low complication rates and outcomes similar to standard laparoscopic living donor nephrectomy.

I have thought about doing robotic kidney transplants for about 2 years now. In Indiana I was trained in open and laparoscopic donor nephrectomy. In NJ I am not involved with kidney transplants currently. The hospitals that I work at in the Saint Barnabas Health Care System have one of the top kidney transplants programs in the country.

My personal practice has changed to have most of kidney surgery done robotically. I think it is a little safer and quicker. I have offered training and assistance in starting a robotic surgery program at SBMC or NBI and expect that one day many of the donor nephrectomies will be done robotically.

For now we have one of the most talented transplant surgeons in the country and I think the results for donor nephrectomies at our institution are excellent.

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UroToday - Prostate Cancer Screening Decreases the Absolute Risk of Being Diagnosed with Advanced Prostate Cancer—Results from a Prospective, Population-Based Randomized Controlled Trial

Between the years1995 and 2004, 1,252 cases of CaP were diagnosed; 810 in the screening arm and 442 in the control arm. Men randomized to active screening had a 1.83-fold increased risk of being diagnosed with CaP compared to men in the control group. Most screened men had localized disease. The number of participants with metastatic CaP at the time of diagnosis (or with a PSA >100ng/ml) was 24 in the screening group compared to 47 in the control group (p=0.0084). This represents a 49% reduction in the risk of being diagnosed with metastatic CaP by screening over a 10-year period.
The study minimized selection bias as men were randomized without any prior information. A study limitation is that men had only sextant biopsy, although the biopsies were directly laterally.

There are studies being done in Europe currently to see the effect on prostate cancer screening. This one shows that advanced prostate cancer was much less likely to be found in screened patients.

The biopsies that were done (6) were less than are currently being done (at least 10) and patients were only screened every other year. Both of these things should lead to a further reduction in advanced cancer. I believe we are overtreating some patients, but I think we are definitely helping many people with vigilant screening.

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