First Annual Worldwide Robotic Renal Symposium
I had the honor of being selected on the faculty for the 1st robotic conference dedicated to kidney surgery. This should be an excellent conference for urologists who are performing robotic surgery for prostate cancer and would like to learn about current techniques for kidney surgery including partial nephrectomy. Transplant surgeons who currently perform laparoscopic donor nephrectomies and would like to learn about robotic surgery are also good candidates.

Location:
Eric P. Newman Education Center
Washington University Medical Center - St. Louis, Missouri
Course Chair:
Sam B. Bhayani, M.D.
Presented By:
The Division of Urologic Surgery
Sponsored By:
Washington University School of Medicine
Continuing Medical Education

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Medscape article summarizing PSA recommendations:
The most aggressive screening protocol is from the NCCN.

NCCN guidelines start from the premise that the patient has made a decision to seek early prostate cancer detection. They recommend beginning screening at age 40. The baseline PSA level, race, and family history are then used to determine the subsequent screening intervals. They recommend considering a biopsy for men with a total PSA level > 2.5 ng/mL, after further consideration of the PSA velocity, PSA density, and percent free PSA. They explain how these parameters can be used to lessen the possibility of confounding from benign prostatic hyperplasia. Furthermore, they describe how repeating PSA determinations with or without a trial of antibiotic therapy, as well as consideration of variability between different PSA assays, can reduce the likelihood of confounding from prostatitis or differences in PSA assay standardization. Moreover, they provide advice about whether or not repeat biopsies are needed and how to deal with the findings of high-grade prostatic intraepithelial neoplasia or atypical glands suspicious for carcinoma on an initial biopsy.

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New Study Compares Tort Systems -- Reform Improves Health Care for Patients

A new study by the Pacific Research Institute, US Tort Liability Index: 2008 Report, measures the best and worst tort systems in America. In the report, the authors examine evidence provided by top economists and legal scholars on the benefits of tort reform in peoples' lives and conclude that, among other things, reform improves health care and health care access. The report also discusses the cost of defensive medicine - most of which is prompted by medical liability concerns - which has now reached the astounding total of $163 billion a year. This is the sum of the direct costs of defensive medicine, estimated to be $124 billion a year by PriceWaterhouse Coopers, and PRI's own estimate of the $39 billion indirect costs from lost productivity due to reduced access to health care attributable to defensive medicine. According to PRI, increased health-care costs brought on by defensive medicine have also added some 3.4 million Americans to the rolls of the uninsured.

I used to work in Indiana, which has one of the more doctor friendly malpractice systems. Potential lawsuits are brought before a panel for an opinion prior to a lawsuit being filed. Indiana also has a cap, or limit, on how much money a plaintiff can win for pain and suffering. All this led to low malpractice insurance costs. In New Jersey it is quite different.

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From UroToday:

Despite optimism regarding SNG, long-term functional outcomes have been disappointing, particularly for BL nerve interposition. UL-SNG functional outcomes do not appear to improve outcomes when compared with men with UL nerve preservation. With the greater risk of PSM and BCR in patients who are considered candidates for SNG, newer treatment modalities are needed to cure their disease while preserving SF.

My friend Dr. Shalhav and his team at Chicago haver reported on their results for nerve grafting in men whose nerves are removed for better cancer control.

This study has been consistent with most studies that have not shown a benefit.

The main problem with the neurovascualr bundle is that it is not a nerve, but a fine complex of micro-nerves. It never made sense to me how one nerve would replace these and re-connect the nerves that are cut.

Possibly in the future we can have tissue that can build new nerves on it. I have not been performing these nerve grafts.

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UroToday - Prostate Cancer Volume at Biopsy Predicts Clinically Significant Upgrading - Abstract

Preoperative prostate specific antigen greater than 5.0 ng/ml (p = 0.036), prostate weight 60 gm or less (p = 0.004) and more cancer volume at biopsy, defined by cancer involving greater than 5% of the biopsy tissue (p = 0.002), greater than 1 biopsy core (p < 0.001) or greater than 10% of any core (p = 0.014), were associated with pathological upgrading. Upgraded patients were more likely to have extraprostatic extension and positive surgical margins at radical prostatectomy (p < 0.001 and 0.001, respectively).

This study gives some preoperative parameters that may be suggestive of a hogher gleason score after surgery. When prostates are removed, they are analyzed in more detail and a more accurate gleason score is obtained. In my series about 1/3 of gleason 6 prostate cancers are upgraded. I have noticed that tumor volume is related to upgrading similar to these authors.

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