Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds

I thought you might find this interesting, and something you may want to pass on to your doctors. This confirms the extraordinary number of cases necessary to become proficient in robotic prostatectomy surgeries. The thought of the number of cases resulting in erectile dysfunction, urinary incontinence and positive surgical margins to get to a level of proficiency is way to high. As the New York times recently wrote: "Robotic prostatectomy: "more marketing than merit."But even smart and wealthy people make erroneous decisions. Just ask Bernie Madoff.

George M. Suarez. M.D.


Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds
By Michelle Fay Cortez - Feb 16, 2011

Doctors who perform robotic-assisted prostate cancer surgery aren’t proficient and able to remove all the malignant cells surrounding the tumor until they have done the procedure more than 1,600 times, researchers said.

Results from a study suggest the operations using Intuitive Surgical Inc.’s da Vinci robot are being performed too often at community hospitals by surgeons without enough experience, said Prasanna Sooriakumaran, lead author and urologist at the Weill Cornell Medical College in New York. Doctors have embraced the approach because studies show it can be learned quickly, uses smaller incisions, causes less blood loss and speeds recovery.

More than 90,000 men in the U.S. have their prostate gland removed each year because of cancer, according to the American Society of Clinical Oncology. The surgery is done mainly with robotic technology introduced in 2000 by Sunnyvale, California- based Intuitive Surgical, typically by doctors who perform 100 or fewer procedures annually, Sooriakumaran said.

“The operation is not easy to perform and it takes a lot of experience in order to get the best results for our patients,” he said in a conference call. “The enthusiasm in the United States needs to be tempered in terms of what sort of hospital needs to be purchasing this equipment and what sort of surgeons should be allowed to do these operations.”

The researchers tracked three surgeons learning the technique over a six-year period at high-volume centers at the University of Pennsylvania in Philadelphia, Karolinska Institute in Stockholm and Weill Cornell in New York City. Surgery times decreased with each operation, while the doctor’s ability to remove all the cancer increased, Sooriakumaran said.

Removing Cancer Cells

The surgeons needed to perform more than 1,600 operations before they were able to gauge with at least 90 percent accuracy how much tissue surrounding the tumor they needed to remove to get all the malignant cells. Leaving stray cancerous cells in the margins, at the edge of the tissue removed during surgery, can lead to recurrences of the disease.

Every hospital has its own system to train surgeons and it’s not up to the company to determine when the doctors reach proficiency, said Calvin Darling, a spokesman for Intuitive Surgical.
While he hasn’t yet seen the study, the 1,600 number “strikes me as absurd,” Darling said today in a telephone interview.

Training Time

“The average time it takes to get to proficiency as defined by our hospitals in their training protocols is typically mid- double digits,” he said. “This is an order of magnitude higher.”

Intuitive Surgical reported $660.3 million in 2010 sales of the da Vinci system, according to a company filing.
The company’s shares fell $1.20, or less than 1 percent, to $339.99, at 4 p.m. New York time in Nasdaq Stock Market composite trading.

More than 700 operations a year are done in medical centers that specialize in the surgery, compared with just a handful a month for smaller, community-based hospitals, Sooriakumaran said. The procedure needs to be centralized so that surgeons can get the amount of experience needed to gain the best results for their patients, he said.

The results will be presented tomorrow at the Genitourinary Cancer Symposium in Orlando, Florida. The investigators are now gathering information on additional surgeons to expand their findings. It is likely that other doctors, who are in lower- volume medical centers, will take even longer to get the experience they need, Sooriakumaran said. Intuitive Surgical has provided funding for Ashutosh Tewari, an author of the study and a urology professor at Weill Cornell.

Increased Use

Use of robotic technology is growing exponentially, said Nicholas Vogelzang, an oncologist at the Comprehensive Cancer Centers of Nevada in Las Vegas and chair of U.S. Oncology’s developmental therapeutics committee. Doctors need to ensure their abilities are keeping up, he said.
“This data today will make everyone pause,” said Vogelzang, who pointed out that traditional open surgery also requires years of practice. “Maybe it’s time to go a little bit farther before we rush into this surgery. Experience really does matter.”

To contact the reporter on this story: Michelle Fay Cortez in Minneapolis at mcortez@bloomberg.net
To contact the editor responsible for this story: Reg Gale at rgale5@bloomberg.net

®2011 BLOOMBERG L.P. ALL RIGHTS RESERVED.

IN RESPONSE POSTED BY DR. ANDRES BODEWIG, M.D.

Dr. Scionti has was trained by the HIFU "Guru and Master" of the HIFU technology, Dr. George M. Suarez, who still is the most experienced recognized HIFU doctor in the world.

NEW POST BY ANDRES BODEWIG, M.D. ON DR. VORSTMAN

          right:   Andres Bodewig, M.D.

This is a great article by Dr. Bert Vorstman clearly outlining the facts about prostate cancer diagnosis and the essential need for a biopsy. Needle tracking or spread has never been documented by any urologist or pathologist in the world. There may be the rare single physician that may be an advocate if this concept. But there is no science merit to this. This concept just is not true. The reason that a biopsy is essential is that it provides hugely valuable information as to the Gleason score and the aggressiveness of the cancer. We as urologist depend on this information for planing the appropriate treatment for that individual. As well as obtaining additional information on the prognosis of the cancer. Unfortunately, there are no imaging (x-ray studies) with capabilities to determine the presence or absence of prostate cancer without a biopsy. Similar to breast cancer, no women would have their breast removed by a diagnosis based on a mammogram without having confirmation by biopsy. Like wise, no man should undergo treatment of his prostate without a biopsy.


Dr. Vorstman makes a very valid point in that the one or two urologist in America that relay on MRI, as opposed to a biopsy, are the same doctor's recommending post treatment MRI's. As well as the same physicians' that have a personal interest and ownership in the MRI equipment. As pointed out by Dr. Vorstman, there is no scientific proof or merit for a post treatment MRI. The best parameter to measure the clinical outcome of prostate cancer treatment is by periodically following the PSA.

There are three elements that are important in selecting a physician: 1) Is he board certified in his specialty?, 2) How often has he performed the recommended procedure? 3) How will the information will the test he is recommending impact on the proposed treatment? And if he is recommending a prostate MRI over a biopsy, ask for medical peer review literature to confirm that this has scientific merit,

I welcome the comments of my colleagues that treat prostate cancer on a regular basis. Can anyone them really say that they can diagnose prostate cancer with an MRI ?Can anyone of them in their professional conduct recommend an MRI over a biopsy and treat prostate cancer as such...without biopsy?



Do Prostate Needle Biopsies Spread Cancer Cells? – NO THEY DO NOT!

Posted by admin in Uncategorized on September 20, 2010
no responses

Prostate needle biopsies and needle tracking marks DO NOT spread cancer cells. Furthermore,the inflammation that brings about healing of the needle track DOES NOT cause cancer.

There are purveyors of pseudo science even in the world of urology who repeatedly offer false science that is peppered with irrelevant references and non sequitur arguments to present their case.
The sole purpose for perpetuating these untruths is to confound a vulnerable target (men who have or are at risk of having prostate cancer) and steering them towards evaluations that are self serving. Invariably,this disordered rhetoric is generated and encouraged by those physicians and organizations that have most to gain. In this regard,in-house imaging equipment such as MRI’s are well known to be potential instruments for financial abuse. Therefore, at risk patients are easily encouraged to undergo needless and expensive in-house MRI studies. This convenient arrangement and investment by owner physicians, represents a huge potential conflict of interest in managing prostate cancer patients.

There simply is NO reliable evidence to support the notion that MRI with or without spectroscopy will ever dispense with needle biopsies of the prostate.
Imaging studies are unable to definitively diagnose a prostate cancer let alone make determinations on a Gleason grade and score.
No man should ever consider treatment of his alleged prostate cancer based solely on the dubious images generated by an MRI.
Even benign lesions may mimic a prostate cancer and the only reliable method for detecting a prostate cancer is based upon a needle biopsy.
Similarly,there is no evidence that “scientific” targeted biopsies of suspicious areas provides any benefits over the standard needle biopsy without the expensive MRI. In fact,using the targeted MRI approach to the prostate may detect very early low grade,low volume cancers that are usually clinically insignificant and can be managed by active surveillance.

In addition,the questionable practice of recommending routine post HIFU MRI studies on the pretext of early recognition of incompletely treated men simply represents a further shameless and unadulterated assault on the wallets of patients and insurance companies.
Only a well designed and executed trans rectal ultrasound and needle biopsy of the prostate by an experienced urologist can answer all of the questions as to the true nature of a man’s prostate cancer.
The unabashed, pseudo intellectual and illogical recycling of these myths about prostate needle biopsies spreading cancer cells
by physicians is unfounded,unconscionable and malicious.

Certainly,those urologists that are board certified are required to practice by an ethical and scientific standard. Others,however,appear to practice the peddling of half truths and this non Hippocratic behavior taints all physicians and may be considered malpractice.

UNINSURED PROSTATE CANCER PATIENTS TEND TO HAVE MORE SEVERE DISEASE AT DIAGNOSIS

Uninsured Prostate Cancer Patients Tend To Have More Severe Disease At Diagnosis.

HealthDay (9/17, Preidt) reported that, according to a paper in Cancer Epidemiology Biomarkers and Prevention, "prostate cancer patients who are uninsured or on Medicaid at the time of their diagnosis tend to have more severe disease, likely because they have less access to medical care." In fact, "compared to patients with private insurance, those who were uninsured or Medicare-insured had higher PSA levels and Gleason scores, and were more likely to be diagnosed with advanced cancer." Before reaching those conclusions, investigators "analyzed National Cancer Database records of 312,339 prostate cancer patients diagnosed between 2004 and 2006."

        Emory researchers eventually discovered that "uninsured and Medicaid-insured patients had approximately 4 ng/ml higher PSA levels than their privately insured counterparts," MedWire (9/17, Guy) reported. "Furthermore, being uninsured was clearly associated with having an advanced Gleason score, with odds ratios (ORs) of 1.97 and 1.67 for uninsured and Medicaid insured men, respectively, compared with privately insured patients. Being Black, Asian, or Hispanic also increased the risk for poor Gleason score compared with being White," while "being uninsured and Medicaid-insured...increased the risk for being diagnosed with advanced-stage disease, 1.85 and 1.49 times, respectively, compared with being privately insured."

PSA SCREENING IN MEN WITH SPECIFIC GENETIC MUTATIONS

New Research Provides Support For Continued PSA Screening In Men With Specific Genetic Mutations.


BBC News (9/10) reports, "PSA screening has been contentious in the past because of concerns about over-diagnosis," and the medical community also remains at odds about "how effective it was at reducing mortality." Aiming to clarify the issue, UK scientists set about analyzing preliminary data culled from the "first large international prostate cancer screening study," which is "targeted at men with a known genetic predisposition to the disease." Investigators eventually concluded that "it appears that PSA screening is reasonably accurate at predicting potentially aggressive prostate cancer among men at higher risk of the disease due to a genetic predisposition." In other words, their work "provides support for continued screening in men with genetic mutations." Reuters (9/10, Kelland) also covers the study.





George M. Suarez, M.D.

INTERESTING ARTICLE OF THE SECONDARY EFFECTS OF RADIATION

The following is a very interesting article that appeared recently in Cancer regarding the potential secondary effects of Radiation Therapy associated with treatment for prostate cancer. Patients are often mislead into choosing radiotherapy without full informed consent of the potential side effects. As well as their fear of even greater complications associated with surgery. As HIFU continues to prove it's efficacy with decreased side effects, it is rapidly becoming the fastest growing new treatment for localized prostate cancer. For additional information on HIFU, please visit: www.hifumedicalexpaert.com.


George M. Suarez, M.D.



___________________________________________________________________________________________________
5 Common Unwanted Effects Of Radiation Therapy With Regard To Prostate Cancer

Cancer 2010-09-07

There are three techniques used in prostate cancer treatment. One of these is via radiation therapy. This kind of treatment can be delivered in two ways, outwardly and internally. Outwardly treatment methods are done in several sessions wherein the high-frequency x-ray device is used in order to destroy most cancers tissue. The internal method or medically known as brachytherapy utilizes the implantation of radioactive seed products into the prostate gland. They are efficient methods in treating cancer. Nevertheless, they can trigger some unwanted effects towards the various areas of the body.



Among the prostate cancer radiation side effects is actually tissue damage. The tissues from the body are very vulnerable to radiation. However only a small percentage of the patients undergoing this sort of treatment encounter this sort of impact. The actual tissues associated with a few organs which are near the prostate such as the skin, vesica or rectum are broken because of the contact with radioactive supplies. When this happens it can produce loss of function and may need surgery in order to cure it.



Radiation therapy with regard to cancer of the prostate may also trigger unwanted effects for example bowel problems such as diarrhea, bowel emergency as well as hemorrhoids. Since the radiation can even achieve through the bowels due to its location adjacent to the prostate, the individual undergoing the radiation can encounter this kind of problem. The radiation does not only have an effect on cancer tissue but it also kills the standard cells causing problems about the function associated with a few internal organs like that from the bowel. Drugs receive to treat these unwanted effects.



A mans individual getting radiation therapy additionally encounters urinary incontinence. This happens to about 10 percent of those who have this sort of treatment. The actual sphincter of the urinary system bladder is actually damaged that caused seapage and incontinence. Occasionally, following radiation the patient should put on a mat just to maintain him through wetting his trousers. If this situation gets worse or does not take care of, the individual will have to go through surgical treatment and make required repair about the damage of the vesica to stop this kind of healthcare issue.



Another side-effect associated with radiation therapy with regard to prostate cancer is impotence as well as inability to conceive. Because, the actual prostate gland is actually the main man reproductive system; functions associated with male sexuality are reported. There is a issue with regards to male erection and the patient will even have a issue generating sperm. Mentionened above previously, radiation therapy does not just affect most cancers cells but also those which are typical such as the semen. The patient must find out about this because it is a great issue related to his lovemaking life.



Finally, the patient will really feel weak as well as fatigue could be experienced for about a few several weeks after the process. You have to follow the related diet that will help get through with this problem. These are the common unwanted effects that a individual experiences following a radiation therapy. But the definitive goal of the remedy outweighs these minor problems. Individual education is really essential so that the individual may know what to do during the process as well as what to expect after the therapy is carried out.



Radiation therapy with regard to prostate cancer is an effective mode associated with remedy however there are certain side effects how the patient should learn and the physicians must monitor.





George M. Suarez, M.D.

Medical Director,

The Miami Urology Center of Excellence

the SONOBLATE 500 and the Ablatherm pros and cons

The article below that recently (Endourol. 2010 Aug 30.) reports on a fairly high incidence of bladder outlet obstruction following HIFU utilizing the Ablatherm (EDAP) HIFU technology. This is another example of the difference between this HIFU technology and the Sonoblate-500 (Focus Surgery). Because Ablatherm HIFU lesion is limited to .25 cm in height and is not adjustable, versus the Sonoblate has multiple size transducers capable of creating the desired HIFU lesion height. HIFU treatment at the bladder neck and at the apex are very challenging when one is limited to a single large height HIFU lesion. The scatter of energy inadvertent propagated into the



In my experience, using the Sonoblate -500, I have not encountered very many cases that have resulted in having bladder neck contraction or obstruction. Which I feel is attributable to the option of smaller size transducers resulting in the desired size lesions. Thereby, decreasing the risk of the HIFU energy scatter into the surrounding tissue and creating scar formation. We also typically maintain a fairly full bladder during the actual hifu treatment with an effort to allow any scatter of energy result in a "heat sink effect" when the transference of energy to heat is dissipated into the filled bladder.



Endourol. 2010 Aug 30. [Epub ahead of print]

Development of Bladder Outlet Obstruction After a Single Treatment of Prostate Cancer with High-Intensity Focused Ultrasound: Experience with 226 Patients.

Netsch C, Pfeiffer D, Gross AJ.



Department of Urology, Asklepios Hospital Barmbek , Hamburg, Germany .



Abstract

Abstract Purpose: To investigate the occurrence of bladder outlet obstruction (BOO) after high-intensity focused ultrasound (HIFU) therapy of prostate cancer, the need for secondary transurethral interventions for BOO, and the benefit of transurethral resection of the prostate (TURP) before HIFU. Patients and Methods: After a single HIFU treatment between 2002 and 2007, 226 consecutive patients were examined and followed at least 2 years. The Ablatherm Maxis and the Integrated Imaging devices were used. The sites of BOO were recorded. Results: Median follow-up after HIFU was 52 months (range 24-80 mos). BOO developed in 58 (25.66%) patients. Repeated BOO episodes were observed in 27 (11.94%), three to seven episodes in 13 (5.75%) patients. Patients with repeated BOO were older than patients with singular BOO (71.75 +/- 4.97 vs 68.18 +/- 5.03; P = 0.024). In primary BOO, multiple sites of obstruction were more often involved than in repeated BOO (25/58 vs 8/27). Conversely, isolated bladder neck stenosis was predominantly found in patients with >/=two episodes of BOO. The rate of primary BOO was significantly different between patients who had undergone TURP the same day as HIFU or within 2 days of HIFU (33/96; 34.38%) and patients with TURP more than 1 month (16/89; 17.98%) before HIFU (P = 0.032). BOO occurred in 21.95% (9/41) of the patients who were treated with HIFU only. Conclusions: BOO after HIFU is common, particularly affecting the bladder neck. The risk of repeated BOO is associated with age. A longer interval between TURP and HIFU (>1 month) might reduce the risk for the development of BOO.



PMID: 20804429 [PubMed - as supplied by publisher]





George M. Suarez, M.D.

Medical Director,

The Miami Urology Center of Excellence

Cell: 305-310-8238



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