August 30, 2010, 5:00 pm A Rush to Operating Rooms That Alters Men’s Lives
By DANA JENNINGS
Jeanette Ortiz-Burnett/The New York TimesAs I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.
Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.
But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?
And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.
Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.
Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.
About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.
Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.
They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”
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.Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48.
And surgery, of course, is most often recommended by surgeons and urologists — who are also surgeons. Mr. Blum writes: “As one seasoned observer of the prostate cancer industry told me, ‘Your prostate is worth what Ted Turner would call serious cash money.’ ” As for patients, their rational thinking has been short-circuited by the word “cancer.” Scared, frantic and vulnerable — relying on a doctor’s insight — they are ripe to being sold on surgery as their best option. Just get it out.
Every urologist I met with after my diagnosis recommended surgery, even though it was believed then that I had a low-risk Stage 1 cancer. The best advice came from my personal urologist, who declined to do my operation because it was beyond him: “Avoid the community hospital guys who do a volume business in prostates.”
I did, but I’m still maimed. In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them.
Despite the impression the authors give, though, judging the velocity or voraciousness of a prostate cancer can still be imprecise. I know this firsthand.
After my biopsy, it appeared that I had a Stage 1 cancer, a doddering old nag that the authors would have designated for active surveillance. As it turned out, I had an especially pure Stage 3 cancer, a real top-fuel eliminator in terms of velocity (and hunger).
I’m a wild card, the 1 man in 48 saved by surgery. Without it, my doctors wouldn’t have learned the cancer was so advanced, and wouldn’t have given me the hormones and radiation that helped keep me alive.
So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008.
But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?
I don’t know. I’m a man, not a statistic.
THE FOLLOWING ARE DR. SUAREZ' COMMENTS ON THE ABOVE ARTICLE:
There are so many valid points in this article and in this book. However, there is no mention of the alternative to surgical removal of the prostate. I am specifically referring to a technology known as High Intensity Focused Ultrasound (HIFU). The manufacturer of the technology is USHIFU, it is called the Sonoblate-500 and is based in Charlotte, N. C. This is a non invasive treatment for prostate cancer that has been approved in Europe and throughout the world since 1998. It is in final phase of investigation clinical trials by the FDA, and should be approved in the U.S. in the next 18-24 months. It provides an efficacy and cure rate similar to surgery and/or radiation, but it has less risks of complications such as referred in the article: impotence and urinary incontinence. It utilizes ultrasound energy that has no toxicity, and provides a precise treatment without scatter or displacement of the treatment to surrounding tissue. Therefore, less risk of collateral damage.
The U.S. is typically the last country to adopt new technology and new medical treatments. Mostly due to the rigors of FDA clinical evaluation, and this is a good thing. No one wants to be rendered a treatment that has not undergone proper evaluation for patient safety, efficacy and clinical outcomes. Once HIFU is approved, it will be the only prostate cancer therapy that would have undergone FDA approval. As all other therapies have had "grand fathered approval" by virtue that they were procedures performed prior to revision of FDA guidelines in 1976.
HIFU is an excellent alternative that merits consideration by men diagnosed with localized prostate cancer. It is available, and being performed by hundreds of American board certified urologist in countries where it is approved. In certain cases it is covered by insurance. The technology is based on similar delivery of energy used to break up kidney stones. It is called piezoelectric energy in the form of extracorporeal shock wave lithotripsy (ESWL). Before ESWL, patients underwent major surgery to remove kidney stones. With ESWL, they are now treated in an out patient setting with non invasive technology.
The advances in computer technology and imaging capabilities continue to transform the practice of medicine at fast and rapid speed. Some of these technologies may be considered disruptive by older , and less adopting physicians. But this the natural and normal course of evolution of medical care. I am convinced that HIFU will be the state of the art treatment of choice in the future.
For additional information, please visit website: www.hifumedicalexpert.com or www.ushifu.com.
George M. Suarez, M.D.
Medical Director,
The Miami Urology Center of Excellence
9195 Sunset Drive
Miami, Florida, 33173
Tel:305-595-0199. 1-877-949-5325
www.hifumedical.expert.com
Tuesday, August 31, 2010
PROSTATE CANCER SCREENING FOR OBESE MEN
Prostate Cancer Screening Should Be Adjusted For Overweight, Obese Men. Fact: Overweight and obese men may have diminished prostate cancer detection.
September is prostate cancer awareness month. The following was provided by the American Urologic Association, and is placed here for educational purposes.
MedWire (8/27, Guy) reported, "Overweight and obese men may have diminished prostate cancer detection owing to low prostate-specific antigen (PSA) levels," University of Texas researchers found after evaluating data on 3,697 individuals. More specifically, "potential explanations for the association between overweight/obesity and PSA is a possible hemodilution effect caused by greater blood volume, or the suppression of PSA production caused by lower testosterone levels and higher estrogen levels," according to the paper in Urology. Thus, the study authors "recommend adjusting prostate cancer screening to allow for the impact of body mass index (BMI)."
September is prostate cancer awareness month. The following was provided by the American Urologic Association, and is placed here for educational purposes.
MedWire (8/27, Guy) reported, "Overweight and obese men may have diminished prostate cancer detection owing to low prostate-specific antigen (PSA) levels," University of Texas researchers found after evaluating data on 3,697 individuals. More specifically, "potential explanations for the association between overweight/obesity and PSA is a possible hemodilution effect caused by greater blood volume, or the suppression of PSA production caused by lower testosterone levels and higher estrogen levels," according to the paper in Urology. Thus, the study authors "recommend adjusting prostate cancer screening to allow for the impact of body mass index (BMI)."
Monday, August 30, 2010
HIFU Shows Promise as a Prostate Cancer Therapy
HIFU Shows Promise As a Prostate Cancer Therapy
AMSTERDAM—High-intensity focused ultrasound (HIFU) shows promise as a treatment for early-stage prostate cancer, according to interim study results presented here at the 7th Meeting of the European Association of Urology's Section of Oncological Urology.
The study included 20 men with stage T1c-T2b, N0, and M0 unilateral prostate cancer. All subjects had a PSA of 15 ng/mL or lower, a Gleason score of 7 or less, and a prostate size of 40 cc or less. Six months after treatment with HIFU, 95% of men were able to achieve erections and had pad-free urinary continence. Also six months post-procedure, 55% of men had wet ejaculations and no patient had rectal toxicity. One man refused a biopsy at six months. Of the 19 men who underwent biopsy, two (10.5%) had cancer recurrence. One patient was switched to active surveillance and the other underwent another HIFU treatment. Six months later, magnetic resonance imaging and biopsy revealed no evidence of disease.
“By treating the disease using focal therapy we avoid the morbidity associated with radical therapy, while restoring men to a position in which they can have access to active surveillance,” said lead investigator Mark Emberton, MD, Consultant Urologist at University College London Hospital in London. “It's controversial, but it's definitely exciting—focal therapy is currently the only strategy on the table that might lead to significant and important reductions in treatment-related harms.”
AMSTERDAM—High-intensity focused ultrasound (HIFU) shows promise as a treatment for early-stage prostate cancer, according to interim study results presented here at the 7th Meeting of the European Association of Urology's Section of Oncological Urology.
The study included 20 men with stage T1c-T2b, N0, and M0 unilateral prostate cancer. All subjects had a PSA of 15 ng/mL or lower, a Gleason score of 7 or less, and a prostate size of 40 cc or less. Six months after treatment with HIFU, 95% of men were able to achieve erections and had pad-free urinary continence. Also six months post-procedure, 55% of men had wet ejaculations and no patient had rectal toxicity. One man refused a biopsy at six months. Of the 19 men who underwent biopsy, two (10.5%) had cancer recurrence. One patient was switched to active surveillance and the other underwent another HIFU treatment. Six months later, magnetic resonance imaging and biopsy revealed no evidence of disease.
“By treating the disease using focal therapy we avoid the morbidity associated with radical therapy, while restoring men to a position in which they can have access to active surveillance,” said lead investigator Mark Emberton, MD, Consultant Urologist at University College London Hospital in London. “It's controversial, but it's definitely exciting—focal therapy is currently the only strategy on the table that might lead to significant and important reductions in treatment-related harms.”
Thursday, August 26, 2010
SUBACUTE PENILE NUMBNESS AFTER BRACHYTHERAPY FOR PROSTATE CANCER
Friday, 20 August 2010
Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Penile numbness is a rare complication of permanent prostate brachytherapy, and optimal clinical management remains unclear. We present such a case and discuss pathophysiology and clinical management strategies.
A 68-year-old male presented with a serum prostate-specific antigen level of 6.9 ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. After a permanent prostate brachytherapy implant with (125)I monotherapy to a dose of 145Gy, the patient developed complete penile numbness postoperatively on the third day.
The patient experienced complete restoration of penile sensation and function by postoperative day 9 with conservative management.
Subacute penile shaft numbness after brachytherapy is rare and is caused by dorsal penile nerve compression. Over the course of a week, the restoration of penile sensation is likely to occur with conservative management.
Written by:
Sharp HJ, Swanson DA, Patel H, Gorbatiy V, Frenzel JC, Frank SJ. Are you the author?
Reference: Brachytherapy. 2010 Aug 2. Epub ahead of print.
doi: 10.1016/j.brachy.2010.02.197
PubMed Abstract
PMID: 20685173
UroToday.com Prostate Cancer Section
#
Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Penile numbness is a rare complication of permanent prostate brachytherapy, and optimal clinical management remains unclear. We present such a case and discuss pathophysiology and clinical management strategies.
A 68-year-old male presented with a serum prostate-specific antigen level of 6.9 ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. After a permanent prostate brachytherapy implant with (125)I monotherapy to a dose of 145Gy, the patient developed complete penile numbness postoperatively on the third day.
The patient experienced complete restoration of penile sensation and function by postoperative day 9 with conservative management.
Subacute penile shaft numbness after brachytherapy is rare and is caused by dorsal penile nerve compression. Over the course of a week, the restoration of penile sensation is likely to occur with conservative management.
Written by:
Sharp HJ, Swanson DA, Patel H, Gorbatiy V, Frenzel JC, Frank SJ. Are you the author?
Reference: Brachytherapy. 2010 Aug 2. Epub ahead of print.
doi: 10.1016/j.brachy.2010.02.197
PubMed Abstract
PMID: 20685173
UroToday.com Prostate Cancer Section
#
Tuesday, August 24, 2010
HEALTHDAY NEWS
MONDAY, Aug. 23 (HealthDay News) -- The initial treatment given to prostate cancer patients has a major impact on short- and long-term costs of care, a new study has found.
For example, while some may opt for an initial treatment that is less expensive in the short-term, the long-term costs of that treatment may actually be higher, the study authors explained.
Treatments options for early-stage prostate cancer include surgery, radiation therapy, hormonal treatment, watchful waiting, or combinations of those methods. Decisions about which treatment to use are based on a variety of factors, including cost, according to background information in the study, published online Aug. 23 in the journal Cancer.
In the study, U.S. researchers analyzed data from 13,769 prostate cancer patients, aged 66 and older, who were diagnosed in 2000 and followed-up for a period of five years. The data came from the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
The men were divided into groups based on the treatment they received during the first nine months after being diagnosed with prostate cancer: watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery. The men in the surgery group may also have received hormones and/or radiation therapy.
For most of these cases, treatment costs were highest in the first year and then declined sharply and remained steady over the next several years. According to the report, watchful waiting had the lowest initial ($4,270) and five-year total costs ($9,130), and hormonal therapy had the second lowest initial cost but the highest five-year total cost ($26,896).
The highest initial treatment costs were observed among those receiving hormonal therapy plus radiation ($17,474), and those undergoing surgery ($15,197), the investigators noted.
Over five years, total costs for hormonal therapy plus radiation were $25,097, and $19,214 for surgery.
When the researchers took into account that costs of treatment in the last 12 months of life are different than other treatment years and excluded the costs for that year, they found that total costs were highest for hormonal therapy plus radiation ($23,488) and hormonal therapy only ($23,199).
"This demonstrates that treatments that may be less expensive in the short term may have higher long-term costs," study leader Claire Snyder, of the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a journal news release.
More information
The U.S. National Cancer Institute has more about prostate cancer.
For example, while some may opt for an initial treatment that is less expensive in the short-term, the long-term costs of that treatment may actually be higher, the study authors explained.
Treatments options for early-stage prostate cancer include surgery, radiation therapy, hormonal treatment, watchful waiting, or combinations of those methods. Decisions about which treatment to use are based on a variety of factors, including cost, according to background information in the study, published online Aug. 23 in the journal Cancer.
In the study, U.S. researchers analyzed data from 13,769 prostate cancer patients, aged 66 and older, who were diagnosed in 2000 and followed-up for a period of five years. The data came from the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
The men were divided into groups based on the treatment they received during the first nine months after being diagnosed with prostate cancer: watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery. The men in the surgery group may also have received hormones and/or radiation therapy.
For most of these cases, treatment costs were highest in the first year and then declined sharply and remained steady over the next several years. According to the report, watchful waiting had the lowest initial ($4,270) and five-year total costs ($9,130), and hormonal therapy had the second lowest initial cost but the highest five-year total cost ($26,896).
The highest initial treatment costs were observed among those receiving hormonal therapy plus radiation ($17,474), and those undergoing surgery ($15,197), the investigators noted.
Over five years, total costs for hormonal therapy plus radiation were $25,097, and $19,214 for surgery.
When the researchers took into account that costs of treatment in the last 12 months of life are different than other treatment years and excluded the costs for that year, they found that total costs were highest for hormonal therapy plus radiation ($23,488) and hormonal therapy only ($23,199).
"This demonstrates that treatments that may be less expensive in the short term may have higher long-term costs," study leader Claire Snyder, of the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a journal news release.
More information
The U.S. National Cancer Institute has more about prostate cancer.
Monday, August 23, 2010
ARE YOU CONSIDERING CRYOSURGERY?
Prostate Cancer Cryotherapy:
Common Side Effects
Prostate cancer cryotherapy (cryosurgery) freezes the entire prostate gland through a minimally invasive procedure involving ultrathin cryoneedles. Side effects usually occur due to damage of the surrounding tissue during the procedure. The severity and occurrence of side effects are largely affected by the relative health of a patient as well as whether cryosurgery is a primary or salvage treatment option. The advent of the minimally-invasive ultrathin cryoneedles and more precise imaging techniques has greatly decreased the occurrence of many side effects, with the exception of impotence.
After undergoing prostate cancer cryotherapy, some patients may experience the following side effects:
Swelling in the Genital Area after Cryosurgery
The entry of the needles through perineum (the skin and muscles between the scrotum and anus) causes irritation and inflammation. Many physicians will recommend using ice packs on the affected area or beginning a regimen of over-the-counter anti-inflammatory drug.
Scrotal Edema
A more severe complication, scrotal edema occurs when fluid collects in the scrotum. Proper evaluation most be performed by a doctor so that proper course of treatment may be chosen.
Irritation during Urination
Many men will experience itching or burning while urinating after undergoing prostate cryosurgery. Symptoms usually will dissipate in a few days. Some men will also experience urgency. Speak with your physician if symptoms worsen after a few days.
Hematuria: Blood in the Urine
Many men will experience blood in the urine (hematuria) after undergoing prostate cryotherapy. There are two types of hematuria, gross and microscopic. Gross hematuria is visible to the naked eye. If bleeding persists past a few days, please speak with your physician.
Urethral sloughing and Urinary Obstruction
The passage of dead tissue through the urethra, urethral sloughing occurs when the urethra is damaged during the cryotherapy. Fortunately, the use of a warming catheter has greatly decreased the occurrence of urethral sloughing. Severe cases of sloughing cause urinary obstruction and require medical treatment. Men who have undergone transurethral resection of the prostate (TURP) or another prostate cancer treatment, such as external radiation therapy, are at higher risk for urethral sloughing.
Urethro-Rectal Fistula
One of the more serious and rarer side effects is urethro-rectal fistula. Urethro-recto fistula occurs when an unnatural channel forms between the urethra, which carries urine or ejaculate out of the body, and the rectum, which holds fecal matter prior to defecation. This channel allows materials from one part of the body to pass into another. The results can include diarrhea or urinary tract infections. New techniques in prostate cryosurgery have lead to decrease in fistula. The warming catheter and the ultrathin, precise cryoneedles have contributed to the decrease of the occurrence of fistula.
Other Side Effects
Other side effects include impotence and incontinence. Prostate cryotherapy entails relatively low rates of incontinence after the catheter is removed. To read more about incontinence, please click here. Cryotherapy is associated with higher rates of impotence, which is the ability of maintain an erection satisfactory for sexual intercourse. To read more about impotence, please click here.
Prostate Cryotherapy Side Effects
Impotence
Incontinence
Prostate Cancer Treatment Overview
Coping with Prostate Cancer
Are You at Risk for Prostate Cancer?
Prostate Cancer News
Glossary
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Common Side Effects
Prostate cancer cryotherapy (cryosurgery) freezes the entire prostate gland through a minimally invasive procedure involving ultrathin cryoneedles. Side effects usually occur due to damage of the surrounding tissue during the procedure. The severity and occurrence of side effects are largely affected by the relative health of a patient as well as whether cryosurgery is a primary or salvage treatment option. The advent of the minimally-invasive ultrathin cryoneedles and more precise imaging techniques has greatly decreased the occurrence of many side effects, with the exception of impotence.
After undergoing prostate cancer cryotherapy, some patients may experience the following side effects:
Swelling in the Genital Area after Cryosurgery
The entry of the needles through perineum (the skin and muscles between the scrotum and anus) causes irritation and inflammation. Many physicians will recommend using ice packs on the affected area or beginning a regimen of over-the-counter anti-inflammatory drug.
Scrotal Edema
A more severe complication, scrotal edema occurs when fluid collects in the scrotum. Proper evaluation most be performed by a doctor so that proper course of treatment may be chosen.
Irritation during Urination
Many men will experience itching or burning while urinating after undergoing prostate cryosurgery. Symptoms usually will dissipate in a few days. Some men will also experience urgency. Speak with your physician if symptoms worsen after a few days.
Hematuria: Blood in the Urine
Many men will experience blood in the urine (hematuria) after undergoing prostate cryotherapy. There are two types of hematuria, gross and microscopic. Gross hematuria is visible to the naked eye. If bleeding persists past a few days, please speak with your physician.
Urethral sloughing and Urinary Obstruction
The passage of dead tissue through the urethra, urethral sloughing occurs when the urethra is damaged during the cryotherapy. Fortunately, the use of a warming catheter has greatly decreased the occurrence of urethral sloughing. Severe cases of sloughing cause urinary obstruction and require medical treatment. Men who have undergone transurethral resection of the prostate (TURP) or another prostate cancer treatment, such as external radiation therapy, are at higher risk for urethral sloughing.
Urethro-Rectal Fistula
One of the more serious and rarer side effects is urethro-rectal fistula. Urethro-recto fistula occurs when an unnatural channel forms between the urethra, which carries urine or ejaculate out of the body, and the rectum, which holds fecal matter prior to defecation. This channel allows materials from one part of the body to pass into another. The results can include diarrhea or urinary tract infections. New techniques in prostate cryosurgery have lead to decrease in fistula. The warming catheter and the ultrathin, precise cryoneedles have contributed to the decrease of the occurrence of fistula.
Other Side Effects
Other side effects include impotence and incontinence. Prostate cryotherapy entails relatively low rates of incontinence after the catheter is removed. To read more about incontinence, please click here. Cryotherapy is associated with higher rates of impotence, which is the ability of maintain an erection satisfactory for sexual intercourse. To read more about impotence, please click here.
Prostate Cryotherapy Side Effects
Impotence
Incontinence
Prostate Cancer Treatment Overview
Coping with Prostate Cancer
Are You at Risk for Prostate Cancer?
Prostate Cancer News
Glossary
Home
Coping with Prostate Cancer Are You at Risk for Prostate Cancer? Prostate Cancer News Glossary
Home Contact Us Disclaimer Privacy Policy Resources Add URL Site Map
©2008
IS ROBOTIC SURGERY REALLY BETTER THAN THE OLD?
Is newer prostate surgery really better than the old
COMMENT: I had robotic prostate surgery at the end of 2009. I am unsatisfied with the results overall. The incontinence, ED, and worst of all my PSA has been rising gradually. If I had to do it over again this would definitely not the path I would have taken. My friend had the HIFU procedure out of the country and he is extremely satisfied. His sexual life is the same as before and PSA is back to normal.
Henry Woodridge
By Rachael Myers Lowe
NEW YORK | Mon Feb 22, 2010 4:30pm EST
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
Health
COMMENT: I had robotic prostate surgery at the end of 2009. I am unsatisfied with the results overall. The incontinence, ED, and worst of all my PSA has been rising gradually. If I had to do it over again this would definitely not the path I would have taken. My friend had the HIFU procedure out of the country and he is extremely satisfied. His sexual life is the same as before and PSA is back to normal.
Henry Woodridge
By Rachael Myers Lowe
NEW YORK | Mon Feb 22, 2010 4:30pm EST
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
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