Robotic Surgery Blog: Best Blog Posts Archives

October 28, 2007

Sex After Robotic Prostatectomy: Penile Rehabilitation

I have previously written about sexual function and how it changes after prostate cancer surgery.
As men are being diagnosed with prostate cancer at a younger age and at an earlier stage, the preservation of erectile function and the ability to maintain satisfactory erections has become more important. My partners and I offer a variety of options to assist in the recovery of erections including having a vacuum device specialist come in to the office once a month, teaching patients how to give penile injections and intra-urethral suppositories, and prescribing viagra, levitra, and cialis on a maintenance, preventative basis.

One of the most frustrating things is insurance companies not paying for maintenance medicines even though most urologists feel these medicines help erections return sooner and possibly more fully. There was an excellent review of the literature by Dr. McCullough of NYU that I read this weekend. He is one of the world's authorities on erectile dysfunction.

This is a great source of information for urologists who can receive 1.5 CME credits.

I will start giving this link out to patients with a letter to see if it helps get them at least partial payment from insurance companies.

I hope patients report any positive experiences with insurance companies paying for their PDE5 inhibitors after surgery.

I have been personally prescribing 1/2 of a pill of the maximum strength to be taken on Mon, Wed, and Friday evenings.

March 26, 2007

Do you need to remove the whole prostate if I have prostate cancer surgery

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.

March 15, 2007

Prostate cancer options now on google documents.

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.

Age

Gleason

Amount of cancer

Size of Prostate (urinary symptoms)

PSA

Bone Scan

CT Scan:

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.

March 3, 2007

What is proper etiquette for the newly diagnosed cancer patient/doctor relationship?

I received a phone call yesterday from a young man that was newly diagnosed with prostate cancer from the southeast.

He was interested in robotic surgery and had several questions.

He told me he found a local urologist who performs robotic surgery and asked me what kind of questions he could ask. He was turned off by his primary urologist who he felt, was not interested in speaking about robotics.

Among the questions he asked me was "Can I ask the robotic surgeon how many of these operations he has done?"

That got me to thinking about what are proper questions to ask and what are proper things a physician should do?

The specifics of my thoughts will be for prostate cancer, but the generalities can be diagnosed for many cancer, surgical, and other medial problems.

I personally perform about 6-10 consultations per week for newly diagnosed urologic cancer (mostly prostate, but also bladder and kidney, and less often adrenal and testis.)

What I usually tell patients is that they should feel free to ask anything. They can also interrupt me if they need to without worry while I am speaking.

I think the number of a certain procedure that someone performs is fair. I think how old they are is also fair. Board certification, how long they have been in private practice, and any question is OK to ask.

I recommend patients come in with their families and to take notes. Several patients have had recorders, which I personally do not like very much, but do let patients record our consultation if they choose.

I am open to discussing any therapy for their ailment. For example, for my newly diagnosed prostate cancer patients, we discuss watchful waiting, hormonal therapy, surgery (concentrating on open and robotic (touch on laparoscopic non-robotic); radiation (XRT, seeds, combination, and now cyberknife as a local hospital is advertising it); cryosurgery and HIFU (which is currently not approved by the FDA in the US).

I have had one experience I did not appreciate. I was helping my partner with a patient of his who had a few questions for me. The patient stood up and stepped into my personal space (about 6 inches from my face) and asked me a direct question while staring at me. He explained later he wanted to look into my eyes to see if he believed my answer, regarding whether I could perform his complicated surgery. I did answer questions for about 5 minutes after that.

Other than that, I do not recall being bothered by any question, and if I feel it is irrelevant, may choose not to answer a question, but am not insulted by it.

I also do not have a problem referring patients to different institutions or for different therapies than I can not provide. Our group has not performed an open prostatectomy in over 2 years, so if someone wants an open operation, I refer them to a few excellent open surgeons in our area.

My goal is to make the patient and his family feel as comfortable as possible and choose the therapy or surgeon that they feel most comfortable with. That being said I do, as most physicians do, recommend the therapy that I do best: robotic surgery for prostate cancer. I provide a secure email and ask patients to call or email me if they have any followup questions.

I also suggest second opinions as I believe it helps a patient have more than one opinion on their problem. I often give out the name of a radiation oncologist who I trust, but sometimes a medical oncologist if that would be beneficial.

I also give out the names of 2 robotic surgeons that I would go to if someone in my family had prostate cancer if asked.

I give patients the option of speaking to 2 patients of mine that are similar to them in age and preoperative medical condition. This allows them to speak to someone who had what I expect to be a similar experience. Having a 73 year old man speak to a 53 year old man will not help very much, but he should speak to someone who is in his 70s.

I would welcome input from other physicians and patients about their feelings on this topic, as I am sure my views are not the only views.

June 18, 2006

Sexual life after prostate removal

This post is for all the men who have prostate cancer or are worried about prostate cancer. One of the most feared side effects of therapy for prostate cancer is the impact on sexual health.

Hopefully this will give men a better idea of what to expect and take some of the fear of the unknown away.

The prostate makes the liquid in the ejaculate. This is necessary for the sperm to work and therefore to have children. Other than having children, the prostate is of little use later in life and only causes problems with urination (BPH) and is a leading cause of cancer.

The "nerves" that go to the penis course very close to the prostate. They are only a few millimeters from the prostate and can be affected by surgery or radiation. These nerves are solely responsible for erections, or the ability of the penis to get hard.

Continue reading "Sexual life after prostate removal" »

May 27, 2006

AUA Live Telecast Summary

On Monday, May 22nd, I performed a live telecast from Newark Beth Israel to the American Urologic Association Conference in Atlanta of a dvP. This was my first live telecast of a surgical procedure.

Our case was a success. The patient did very well and was discharged within 24 hours with minimal pain.
The robotic time was 80 minutes for the procedure.

I would like to thank my team at NBI and the administration for the support, as well as intuitive surgical and their engineers for helping to make the telecast go without a glitch.

I am hopeful to get a copy of the video/audio feed to stream on my website.

Some points about the procedure that were discussed:

Continue reading "AUA Live Telecast Summary" »

May 21, 2006

Prostate cancer on The Open Line

I would like to thank James Mtume and Bob Pickett for having me on their show today.

We had an excellent discussion with several points that Id like to summarize. I will also be taking questions from their listeners that can be emailed to
dsavatta@njurology.com

The broadcast can be heard on a series of MP3 files archived on my website.

Continue reading "Prostate cancer on The Open Line" »

January 21, 2006

Telling someone they have prostate cancer

One of the most difficult things that a urologist has to do is to tell his patient that he has cancer. I recently had a somewhat heated debate with my partner in robotic surgery.

Prostate cancer is the leading solid organ cancer in men and is diagnosed by a biopsy in the office. The reasons for a biopsy are given by the urologist when scheduling the procedure and the urologist is present for the biopsy.

I have had discussions with my partners about the two main ways of doing this for prostate cancer and there is a difference in opinion. The two ways are over the phone or face to face.

Continue reading "Telling someone they have prostate cancer" »

January 8, 2006

Should we do PSA Screening?

This is a frequently asked question and the answer will vary on who you ask.

PSA screening is recommended by the American Urologic Association . An excellent review of the original guidelines can be found at the American Family Physician website.

I came across a post on medlogs.com from a blog (retired doc\'s thoughts) by Dr. Gaulte. He summarizes that studies in the literature not only do not answer this question, but also are contradictory.

Continue reading "Should we do PSA Screening?" »