Robotic Surgery Blog: Prostatectomy Outcomes Archives

April 26, 2008

Long-Term Functional and Oncological Outcomes of Patients Undergoing Sural Nerve Interposition Grafting during dvP

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.

April 9, 2008

Upgrading after radical prostatectomy

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.

February 13, 2008

Effect on prostate size on prostatectomy recovery

clipped from www.medwire-news.md

"Prostate size has no effect on continence or biochemical recurrence at 1 year after laparoscopic radical prostatectomy, but affects intra-operative blood loss, potency and surgical margins," Aron et al write in the BJU International.

The study points out what most people are concluding in regards to positive margins. Smaller prostate tend to have higher rates of positive margins. The results show that at 1 year the continence is similar, but the short term recovery of urinary function is not addressed. I think men with larger prostates take longer to regain urinary control.

October 13, 2007

Swiss study shows survival advantage for surgery over radiation therapy for prostate cancer

Prostate Cancer: Surgery Best Option?

Men who choose surgery for early prostate cancer are more likely to be alive 10 years later than men who opt for other treatments, a Swiss study shows.
"If you look not only at this study but at the studies we brought out in the last three or four years, in terms of survival for 10 or even 15 years, there is a distinct advantage in patients who underwent surgery for localized prostate cancer," Tewari tells WebMD. "This has implications for patients comparing different treatment options."

October 7, 2007

Experience matters for prostate cancer surgery

Study tracks 'learning curve' in prostate surgery - CNN.com

In this study, experience was measured not by age or years as a surgeon but by the number of times doctors performed this operation.
"Advice for patients is to try to seek out experienced surgeons, and they're likely to be ones who specialize in the procedure," Andrew Vickers of Memorial Sloan-Kettering Cancer Center in New York City, one of the researchers, said in a telephone interview.
The researchers followed 7,765 prostate cancer patients who underwent an operation called radical prostatectomy performed by 72 surgeons at four U.S. academic medical centers in New York, Texas, Michigan and Ohio from 1987 to 2003.
As the number of times a doctor performed it increased, the number of patients who remained cancer-free five years after the surgery also rose, the researchers wrote in the Journal of the National Cancer Institute.
But at a certain point the improvement in surgical outcome topped out and stabilized regardless of how many more times a surgeon did the procedure.

"The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations," the researchers wrote.

Surgeons should not be judged on their age or years of experience (35 years old and 8 years of experience for me), but by the number of prostates they have removed. This is one of many studies that shows better cure rates from more experienced surgeons.

This study looked at open surgeries, but I think robotics will also be similar. My personal numbers are over 500 prostatectomies of all types and over 350 robotic prostatectomies.

June 10, 2007

Surgical volume related to cancer cure rates after prostate cancer surgery

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.

Continue reading "Surgical volume related to cancer cure rates after prostate cancer surgery" »

June 8, 2007

Prostate cancer surgery: Should we consider a more comprehensive gleason grading after surgery

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.

Continue reading "Prostate cancer surgery: Should we consider a more comprehensive gleason grading after surgery" »

April 12, 2007

Prostate cancer surgery: Small prostates

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.

April 11, 2007

Positive Margins in Laparoscopic prostatectomy

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.

April 9, 2007

Robotic Prostatectomy Results from Vattikuti Institute

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.

April 8, 2007

Robotic Prostatectomy Review

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.

December 11, 2006

Improvement in positive margins with robotic surgery

Robotic Prostatectomy can reduce positive margins
Source- Surgery News p. 13

This was an abstract presented at SLS meeting in Boston in September.
The 2 urologists showed a dramatic improvement in positive margins from their last 100 prostatectomies done open to the first 93 done robotically.

The organ confined changes for each surgeon were 37% and 27.5% for their last open ones to 5.7% and 8% for their first robotic ones.

This is a study that showed a drastic improvement in margins for private practice urologists.

My questions would be if these patients were comparable.
Their open margin rate seems well above national averages and they had better than expected results for their fist 50 patients. Most surgeons see an increase in positive margins when they first start robotics.

I did not track my open results, but I would guess the organ confined results were in the 15% for open. My first 70 patients had a 20% positive margin rate for organ confined disease and the last 100+ have been under 5%. I also have performed all prostatectomies robotically and have not turned down anyone for surgery based on amount of cancer.