UroToday – Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair – Abstract

Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair

We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

UroToday – Trial Evaluation of Erectile Function after Attempted Unilateral Cavernous Nerve-Sparing Retropubic Radical Prostatectomy With Versus Without Unilateral Sural Nerve Grafting for Clinically Localized Prostate Cancer – Abstract

Source Urotoday

The trial planned to enroll 200 patients, but an interim analysis at 107 patients met criteria for futility and the trial was closed. For patients completing the protocol to 2 yr, potency was recovered in 32 of 45 (71%) of SNG and 14 of 21 (67%) of controls (p=0.777). By intent-to-treat analysis, potency recovered in 32 of 66 (48.5%) of SNG and 14 of 41 (34%) of controls (p=0.271). No differences were seen in time to potency or quality of life scores for ED and urinary function. Limitations included slower-than-expected accrual and poor compliance with ED therapy: < 65% for VED and < 40% for injections.
The addition of SNG to a UNS RP did not improve potency at 2 yr following surgery.

This study was comparing men who were going nerve sparing prostatectomy on one side and adding a nerve graft on the other side. Nerve grafting takes more time and has some side effects depending on which nerve you use. This study, like many before it, did not find a benefit in performing a nerve graft.

I’ve always felt that this wwould be the case since the neurovascualr bundle is a series of small microscopic nerves, not a large nerve that you can see.

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

From UroToday:

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.

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.

Catheter withdrawal and suturing times of connection during robotic prostatectomy

UroToday – WCE 2007 – Single Knot Anastomosis (SKA) For Laparoscopic Radical Prostatectomy: An International Multicenter Outcome Survey of 5235 Cases

They have shown that the time to complete the anastomosis for the expert, second generation, and trainee surgeons were 16, 23, and 30 minutes respectively. Additional stitches were necessary only in 1.1%. The anastomosis was water tight in 94.2%.
Early leakage requiring prolonged catheter drainage occurred 6.8% of laparoscopic cases and 0% in the robotic assisted cases. Mean catheter time was 7.1 days. The bladder neck contracture rate was 0.8% at 12 months and the rate of acute urinary retention was 0.5%.

Dr. van Velthoven deserves credit dor being the first to devise a simpler, likely better way to make the bladder to urethra connection. Most surgeons, including myself, use this technique.

This large series shows the average time for a connection is 16 minutes and the average catheter is kept in for 1 week.

Some surgeons catheter times are much faster. I have watched Dr Patel and Dr Tewari perform the connection in well under 10 minutes, probably about 5.

My main work currently is trying to reduce the catheter time to as a few days as possible. I think with robotics we can cut down the catheter time to 3 days at least.

Us Too Newsletter for June

Us Too! Prostate Cancer Education and Support – HotSheets

#Doc Moyad’s What Works and What is Worthless Column—Provenge�
# Cell Genesis Reports Phase II Results with GVAX Immunotherapy
# A Survivor Reviews the 2007 ASCO Prostate Cancer Symposium
The robotic-assisted laparoscopic prostatectomy is rapidly becoming the
“standard of care” for those who choose surgery.
IMRT (Intensity Modulated Radiation Therapy) is the “standard of care” for
external beam radiation, but there remains an important place for brachytherapy
(radioactive seed implants).
Docetaxel is the “standard of care” for those who need chemotherapy.
# UCSD Researchers Report Ability to Detect Cancer at Earliest, Curable Stage
# New Blood Test for Prostate Cancer—Can EPCA-2 be on the Horizon?

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Robotic Surgery Review in Contemporary Urology

The robotic revolution: Advancing laparoscopy and urology further into the future – The introduction of robotic technology and its increasing acceptance in urology have helped surgeons overcome many technical barriers to complex laparoscopic procedures. While preliminary safety and efficacy results for a number of procedures are promising, long-term data are needed to establish its role relative to more traditional approaches. – Modern Medicine

Laparoscopy has the potential for decreasing surgical morbidity, with smaller incisions, decreased blood loss, less postoperative pain with decreased intake of narcotics, shorter hospital stays, and faster recovery compared with open surgical procedures. While these benefits have been realized for urologic procedures such as nephrectomy, adrenalectomy, and pyeloplasty, technical obstacles have hindered its adoption in more advanced procedures such as prostatectomy.

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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.

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Rhode Island joins robotic community

Robotic surgery on prostate cancer arrives in R.I. | Rhode Island news | Rhode Island news | projo.com | The Providence Journal

This is robot-assisted surgery — and some say it’s the future of surgery. Miriam Hospital is the first hospital in the state to acquire the robot, called the da Vinci Surgical System, which makes it easier to operate in the tighter corners of the human body.

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Robotic Prostatectomy Review

Robotic Assisted Laparoscopic Radical Prostatectomy

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.

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