Body Mass Index, Weight Change, and Risk of Prostate Cancer in the Cancer Prevention Study II Nutrition Cohort
Written by Ricardo Sanchez-Ortiz, MD
Thursday, 15 February 2007
BERKELEY, CA (UroToday.com) – In the last five years, a large body of evidence has been accumulated supporting the association between obesity and high-risk prostate cancer.
Despite this advancement in our knowledge of prostate carcinogenesis, the exact interplay between BMI and patient risk remains poorly understood.
In the January issue of Cancer Epidemiology, Biomarkers, Rodríguez and colleagues from the American Cancer Society report data from the Cancer Prevention Study II Nutrition Cohort evaluating the relationship between obesity and prostate cancer risk. Beside its large size, this study is newsworthy because it substratified prostate cancer patients based on tumor grade and stage.
3,159 men studied
15 years long-term follow-up data
Primary data end point – Death, not PSA Recurrence
Weighted & Adjusted Outcomes in all Cohorts
Patients Treated with Radical Prostatectomy or Radiotherapy shown to live longer than patients in the Watchful Waiting Category
Overall Survival Rate is in favor of Radical Prostatectomy vs. Radiotherapy vs. Watchful Waiting (65%, 50%, 35% respectfully)
** The increased survival duration was 8.6 years for Radical Prostatectomy vs. 4.6 years for Radiotherapy (An 87% difference in favor of Radical Prostatectomy)
I recently had an encounter with United Healthcare that initially resulted in a denial of a request to treat one of their patients with UPJ stenosis (partial obstruction of the drainage leading from the kidney to the bladder) with a robotic repair of the condition. The denial was initially based on the perception that such surgery was “experimental” and not a generally accepted form of treatment. After nearly two months of back and forth, I have approval to do the procedure and I believe I have convinced United Health to accept the procedure generally for all its subscribers. I have posted below several references to articles that I forwarded to the medical director in the course of our discussions. Most pyeloplasties are done in children and you can see that the articles reflect that, although my patient was an adult. Perhaps they will be of help to someone else in a similar situation.
I agree that the reimbursement for a radical prostatectomy should be more than it is, but that is true for nearly everything we do these days at the hospital. You are paid a little more for the code for a laparoscopic prostatectomy (the code for a dVP) than for an open radical and with experience you can do a dVP in about the time it takes many urologists to do an open (2-3 hours). Granted some folks can do an open in 90 minutes, but, given the lower positive margin rates with the da Vinci and slightly better potency and continence rates, I don’t see how anyone can continue to justify doing opens.
From the World Congress of Endourology
Saturday, 19 August 2006
O Elhage1, AP Shortland , BJ Challacombe , D Murphy , A Sahai , P Dasgupta 2 1 1 1 11Department of Urology, Guy’s Hospital and GKT School of Medicine, London, UK, One SmallStep Gait Laboratory, Thomas Guy House, Guy’s Hospital, London, UK.2
Introduction: Considerable controversy surrounds the benefits or otherwise of robotics in urology. Sceptic laparoscopic urologists believe it to be just another expensive tool due to the lack of robust scientific evaluation. In addition to the effect of robotics on patients we have been carefully studying its effects on the surgeon.
Method: The Da Vinci robot underwent real time ergonomic analysis in our motion lab. Multiple high definition cameras tracked the motion of the surgeon seated at the console as opposed to standing during laparoscopic surgery. Motion sensors and EMG electrodes were attached to the torso, arms and a head band with continuous recordings during five standardised, repeated laparoscopic tasks in a dry lab to assess overall and specific muscular fatigue.
Result: Due to reduced head and body movement in the seated position with eyes fixed to the stereoscopic view finder, overall fatigue and specifically that of the trapezius seems to be reduced by robotic surgery allowing surgeons to perform complex laparoscopic procedures for longer periods.
Conclusion: It is time to start thinking about the well being of surgeons in addition to their patients. Robotics may just be the answer.
I recently saw a patient who had been biopsied by another urologist, found to have cancer and sent to a second urologist for evaluation for surgery. That second urologist does not do robotic prostatectomies and did not mention the option. He was also put off by the size of the prostate as estimated by ultrasound at the time of biopsy, 172 cc’s. (A normal prostate in a man in his 20s might measure 25 cc’s +/- and a volume of 50-100 cc’s is not uncommon in men in the age range of 50-70 that constitute the majority of cancer patients being considered for radical surgery.) The second urologist recommended open surgery, but only after at least 4 months treatment with hormone deprivation (blocking the production of testosterone) to shrink the prostate. He gave him a shot to accomplish reduction (leuprolide) and planned to see him back in 4 months. The patient is now experiencing the side effects of the shot, hot flashes and progressive erectile dysfunction, while he waits for his surgery. Is this necessary?
Surgical robot makes prostate removal safe for obese men
“The use of a robotic system could make surgery for prostate cancer an option for thousands of obese men who might otherwise be turned down, report researchers from the University of Chicago in the April 2006 issue of the journal Urology.”
I, and I think Dr. Savatta, would agree that one can operate with a robot on the obese and it is sometimes easier than an open.
Dr. Menon gave a presentation at the Pacific Rim Robotics Conference on nerve preservation and the anatomical concept that he has named the veil of Aphrodite. After first reviewing the history of impotence after radical prostatectomy he described the latest modification of his techniques, which he claims further improves the preservation of potency. Originally, of course, radicals were associated with nearly 100% impotence until Dr. Walsh introduced the concept of “nerve sparing”. While Walsh has at times claimed very high rates of preservation, many others felt that preservation in perhaps 50-60% of patients having a nerve sparing represented excellent results. In the introductory remarks to his talk Dr. Menon cited several papers that quoted rates of “normal” erections of only 4-33% after nerve sparing. There is clearly room for improvement.
At the Pacific Rim Robotics Conference last month there was a session on robotic pyeloplasty. It was held on Saturday afternoon, the last day of the conference, and featured a lecture by Dr. Elspeth McDougall and a live broadcast of the operation from UC Irvine performed by Dr. Ralph Clayman. Dr. McDougall described the operation as they perform it at UCI and then showed their results in about a half dozen cases, including a bilateral pyeloplasty in a horseshoe kidney. The outcomes were at least as good as with open, laparoscopic or endoscopic pyeloplasty techniques. The steps that she described in her lecture were those that we would see Dr. Clayman follow in the live demo that was presented imediately after her talk. I was interested because I have done about a half dozen or more myself and my partner has done several as well.
Debra Morrison, MD, anesthesiologist at UCI gave a talk on anesthesia and robotic prostatectomy. While many of the points she reviewed have been covered elsewhere, there were a couple of suggestions that she had that I had not heard of before. She mentioned that with the extreme Trendelenburg position not only is the diaphragm pushed up into the chest but the trachea can be displaced towards the head. This can result in the ET tube migrating into the right mainstem bronchus and an abrupt increase in difficulty ventilating the patient. She is a pediatric anesthesiologist so perhaps she has seen this in that age group but I have not seen or heard of it happening in an adult. Still, it is worth keeping in mind in case you ever experience a sudden deterioration in the patient’s status. The problem may be corrected by simply withdrawing the tube a cm or two until ventilation is returned to normal. At least try that before aborting the procedure and breaking everything down.