Urology Care

A recent article in the Wall Street Journal investigated the use of robotic surgery and reports of patient injuries from inexperienced practitioners.

Prostate Cancer

Patients have asked me, “What is ProstRcision®?”  A new ad has hit the Louisville radio airwaves and billboards touting “the highest documented cure rate* of any prostate cancer treatment”.  It appears that the Radiotherapy Clinics of Georgia (RCOG) have trademarked a clever word “ProstRcision®” to designate a well know treatment option, that is combination radioactive seed implantation followed by external beam radiation therapy. Read more…

Prostate Cancer, Radiation Therapy

Yesterdays New York Times had a front page article on robotic surgery for prostate cancer.  It rightly points out the lack of evidence that robotic surgery claims can be substantiated.  Worse still, some of the evidence suggests inferior results compared to standard open surgery.  Despite this, they point out that the majority of patients are being sold on a procedure which takes twice as long and costs twice as much due to heavy marketing by doctors, hospitals and the company that makes the robot. Read more…

Prostate Cancer

The National Cancer Institutes (NCI) bulletin reports on a recent article in JAMA reviewing results of robotic prostatectomy compared to open surgery.  The only advantages for robotics in this study was shorter hospital stay (2 days vs 3 days) and fewer blood transfusion.  Robotic surgery was found to have more than twice the risk of genitourinary complications including a 30% increased risk of incontinence and a 40% increased risk of erectile dysfunction.   The NCI concluded that open surgery should remain the “gold standard” for men who opt for surgery to treat localized prostate surgery.  The rapid increase in the robotic approach is because of aggressive marketing from hospitals, doctors and the company who makes the device.

Prostate Cancer

Status of Radical Prostatectomy in 2009:  Is There Medical Evidence to Justify the Robotic Approach?

Herbert Lepor, MD
New York University School of Medicine, New York, NY

This article presents the evolution of open radical retropubic prostatectomy (ORRP) into a minimally invasive procedure and reviews the literature to provide a legitimate comparison between ORRP and robotic-assisted laparoscopic radical retropubic prostatectomy (RALRP). The article is limited to manuscripts cited in the peer-reviewed literature, and an effort was made to identify those articles that fulfilled the highest level of medical evidence. In centers of excellence, ORRP is performed with no mortality, extraordinarily low technical and medical complications (1%), the rare need for blood transfusions, 1 to 2 day hospital stays, urinary catheters that are routinely removed in a week, the majority of men returning to work in 2 weeks, and up to 97% of men regaining urinary continence.  Return of potency remains a challenge, especially for older men with marginal erections. RALRP is now the most common approach for the surgical removal of the malignant prostate. A critical review of the literature fails to support the marketing claims that RALRP is associated with shorter hospitalization, less pain, better cosmetics, shorter catheter time, lower transfusion rates, or improved continence and potency rates.  The highest level of medical evidence suggests that RALRP may significantly compromise oncologic outcomes and that men undergoing this approach have higher regret rates than men undergoing ORRP.
[Rev Ural. 2009;11 (2}:61-70]

Prostate Cancer

Dr. William J. Catalona

Chicago, Illinois

Patients contemplating radical prostatectomy for prostate cancer want the answers to many important questions.  Will I be cured of my cancer? Will I be continent? Will I be able to have spontaneous erections?  What is my risk for other complications? How long will it take to return to my regular activities?  Open nerve sparing radical retropubic prostatectomy is the gold standard for the surgical treatment of prostate cancer, and the answers to these questions are well documented for open prostatectomy. The results have shown that high volume surgeons usually achieve excellent outcomes. Recently largely due to hype and aggressive marketing, there has been increasingly widespread use of robot assisted laparoscopic radical prostatectomy in the United States.¹   Reports directly comparing open and laparoscopic procedures are just beginning to be published because of the relatively recent use of laparoscopic operations to treat prostate cancer. However, during the last year several highly credible studies on comparative data have indicated important disadvantages of these minimally invasive approaches in terms of achieving cancer control, urinary continence and patient’s satisfaction.^2-4  Furthermore, recent studies have called into question whether robotic surgery offers any material advantage in terms of side effects or recovery time.^5,6   These comparative studies are more informative than reports merely claiming that laparoscopic or robotic surgery has significant advantages compared to open surgery.

Read more…

Prostate Cancer

The American Urological Association (AUA) Best Practice Statement has recently updated its prior recommendation from 2000 now suggesting that urologists start offering patients PSA testing beginning at age 40 years.  This is in contrast with a number of other medical organizations who disagree.

Screening

“Prostate-specific antigen (PSA) levels are significantly lower in aspirin users with latent prostate cancer than in similar patients who are not aspirin users,” say Vanderbilt University “scientists who caution that aspirin may affect prostate cancer detection.”

PSA, Prostate Cancer, Screening

 Medscape (4/2, Nelson) reported, “After a radical prostatectomy, the risk for recurrence is strongly affected by the experience of the operating surgeon,” an actuality that holds “true for both open and laparoscopic procedures.”  But, investigators at the Memorial Sloan-Kettering Cancer Center, also pointed out that the “learning curve for surgery — improvement in surgical outcomes with increasing surgeon experience — appears to accrue more slowly for laparoscopic radical prostatectomy than for open surgery.”  Lead researcher Andrew Vickers, PhD, explained, “If they are only doing a handful of radical prostatectomies a year, then [surgeons] are going to have a hard time getting up on the learning curve.  A great deal of surgical experience is required to treat prostate cancer optimally.”  Read more…

Prostate Cancer

Published data from the Prostate Cancer Prevention Trial demonstrated that there is no PSA level below which the risk of having prostate cancer is zero. For an individual patient, the significance of a PSA level should be interpreted in a broad clinical context, including age, race, family history, digital rectal exam, prostate size, results of prior prostate biopsy, and use of 5α-reductase inhibitors. Considering the high incidence of asymptomatic cancer in the general population that may not pose an ultimate risk to the patient, the decision to recommend urological evaluation or prostate biopsy should be individualized after considering all these factors.

The risk that a patient will have prostate cancer detected if a biopsy is performed at various levels of PSA is listed in the table below:

PSA Relative risk for prostate cancer

PSA, Prostate Cancer