Website for urologists specializing in prostate cancer

On, you will find a wide range of sophisticated clinical tools, nomograms, databases and other useful information that enable the delivery of personalized, evidence-based medicine. These Web-enabled problem-focused decision making support tools allow users to forge the increasing amount and diversity of clinical data into real world solutions for patients, all provided in a timely, graphically oriented, colorful, and user-friendly environment, at no cost.

A friend of mine, and excellent robotic surgeon, Dr. Kevin Slawin from Texas has introduced me to a new site.

I liked the nomogram for prostate cancer recurrence after surgery and will find the PSA velocity doubling time very useful.

Robotic Surgery Schedule

I found a way to place my robotic surgery schedule online.
I do not add my operations in advance that far ahead, but it is usually accurate for the upcoming 2 weeks. Urologists interesting in case observations can contact me to watch surgery.

Robotic Tips for Surgeons and Teams #1

This is a new topic to help explain some of the workings of the robotic systems.
This tip on black balance, white balance, and scope alignment comes form Sue Belluardo, my local intuitive surgical rep.

Remember 3 things:
– Black Balance is Camera Head Specific
– White Balance is Scope Specific
– Scope Alignment is Scope Angle Specific

Black Balance is not scope specific:  Black Balance with either scope
will be fine. I suggest doing your Black Balance without a Scope Prior to
draping the Camera; cover the Optics of Camera Head with the palm of your
hand completely (or press and hold the Camera Optics toward your stomach)
and press both the “ABC Button” on both the Left and Right CCU. (The Red
LED’s will stop blinking after about 20 Blinks; Black Balance is complete.
You will not have to Black Balance again unless you loose power to the CCU’s or Vision Tower.)

White Balance should be done each time you choose a different scope
(each scope will transfer light differently through the scope at different
brightness levels).

Scope Alignment
– White Balance Scope
– Put the appropriate end of the Scope Alignment Tool on the appropriate
– Select the Scope Angle
– Focus on the Crosshairs
– Select Align Scope Button
– Bring the Crosshairs together by using the Arrow Buttons
– When the Crosshairs are aligned; Press and Hold until you hear the 3 happy chimes…..(On a Standard daVinci the button is labeled “Test Image” on the daVinci-S it’s the the “Align Scope” button).
– Scope Alignment is Complete for the Selected Scope. Repeat the process
for the other Scope or Scope Angles.

The shortcut to remember is that black balance only needs to be done once, white balance twice (the 30 up and down are the same scope), and alignment 3 times if you plan on using the 30 up.
My team does all of these things prior to the patient coming into the room.
One time this was useful to know is when we dropped a scope (0 degree). It only took a white balance and 1 alignment of the new 0 scope.

Survival advantage with surgery for elderly patients with prostate cancer?

JAMA — Survival Associated With Treatment vs Observation of Localized Prostate Cancer in Elderly Men, December 13, 2006, Wong et al. 296 (22): 2683

This study suggests a survival advantage is associated with active
treatment for low- and intermediate-risk prostate cancer in elderly men
aged 65 to 80 years. Because observational data cannot completely adjust
for potential selection bias and confounding, these results must be
validated in randomized controlled trials of alternative management
strategies in elderly men with localized prostate cancer.

An important paper was recently published in JAMA that concluded that men between 65 and 80 may do better with surgery or radiation than with watchful waiting.
The authors did a good job with this observational study. They looked at all men with prostate cancer and compared those who had treatment with radiation or surgery and compared them to men who did not receive therapy for at least 6 months after diagnosis.
They found that there was a 30% lower mortality in the men that had therapy. The authors made an effort to compare the men with regard to other medical conditions and pointed out that without a randomized trial, there may be a selection bias since most urologists counsel men with good 10 year life expectancies to undergo therapy and men with poor life expectancies to have watchful waiting.
This is one study that I can use to help guide patients, but not an absolute decision maker in my opinion.
I reviewed my patients to see how many men I did robotic prostatectomies on. Over my first 200 robotic prostatectomies I operated on 19 men that were 70 or older:
5 were 70
11 were 71-74
1 was 76,78, and 80
I typically counsel them based on their health, the aggressiveness of their cancer and tell these men they will likely be equally cured with surgery or radiation.
12 of the 19 went home in 1 day, 6 in 2 days, and 1 in 3 days. The only medical problem I had was one patient who was re-hospitalized with a pulmonary embolus (blood clot in lung) a few days after going home and did well on blood thinners.
I do feel that these men often have significant BPH symptoms that is greatly helped by surgery. They do seem to have more incontinence in the short run, but they have done well. 9 of the prostates were big (larger than 50 grams), 5 were very big (greater than 75 gms), and 1 was huge (123 grams).
As for continence, 8 of the 15 that I have data on had 1 pad or less incontinence at 1 month, and 8 of 11 had 1 pad or less incontinence at 3 months, and 7 of 7 were in 1 pad or less at 6 months.

A single dose of prophylactic antibiotics may be enough

ScienceDaily: Single Dose Of Antibiotics Before Surgery Sufficient To Help Prevent Infection: “Single Dose Of Antibiotics Before Surgery Sufficient To Help Prevent Infection
A single dose of antibiotics prior to surgery appears to prevent infections occurring at the surgical site as effectively as a 24-hour dosing regimen, and with reduced antibiotic costs, according to an article in the November issue of Archives of Surgery, one of the JAMA/Archives journals.”

I have been using 3 total doses on antibiotics for most of my robotic kidney and prostate operations. I will need to review this study and may switch to a single dose for prevention of infection. I have not had a single wound or deep infection in almost 250 robotic operations. I have seen urinary tract infections that I think is the result of the catheter and 2 men developed testicle infections 2-3 weeks after robotic prostatectomy.


From the World Congress of Endourology
Source UroToday
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.

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