The Truth About Da Vinci Surgery

Talking to my patients and visiting numerous prostate cancer forums, I get the impression that the one treatment option for prostate cancer that everyone wants to know about is robotic or Da Vinci surgery.  Economically, it is a force to be reckoned with.  Hospitals are buying up million dollar robots as if they were bedpans and surgeons are rushing out to learn the new technology to be able to offer it to their patients.  Patients also seem to love it because it involves new, cutting edge technology.  All of this has led to a tremendous surge in robotic prostate surgery around the country which has led to an enormous increase in costs.  In the face of this Da Vinci tidal wave, patients all want to know if the procedure really lives up to the hype.  In this post I will attempt to separate the myth from reality and give you a more clear perspective on the benefits of robotic surgery for prostate cancer.

To begin with, in order to get a fair assessment of robotic surgery we need to compare apples to apples.  In so doing, lets see how this new technology stacks up to the gold standard: open radical prostatectomy.  To do this, let me first point out the technical differences between robotic and open surgery.  The traditional surgery involves making an incision about 5-7cm in length that starts midway between the belly button and the pubic hair and extends down to the pubic hair.  The prostate is exposed in the pelvis and the surgery is performed in the open.  Robotic surgery, in contrast, is performed with tiny incisions through which a small camera and robotic arms are inserted into the pelvis.  The surgery is performed within the body with the assistance of a three dimensional camera rather than through an open incision.  The benefit of the robot is that the robotic arms that are inserted have a great deal of range of motion.  What that means is that they can turn in several different directions at varying degrees.  Through this range of motion the robotic arms within the patient can simulate the motions of a human hand working through traditional surgery.  This ability is a significant advantage over simple camera surgery called laparoscopy.  In laparoscopy, the instruments can only make simple movements ( up, down, and side to side) which makes subtle, delicate parts of the procedure harder to do as compared with robotic surgery. 

Of course, the robot is not actually performing the surgery.  The surgeon sits at a computer console, usually within the same room as the robot and patient.  The surgeon looks through a specialized view finder and sees the surgery in 3D.  The surgeon places his hands and fingers within a specialized apparatus on the console.  As the surgeon moves his hands and fingers, the robot mimics these movements with its robotic arms within the patient.  The result is that the surgeon is performing the operation like he or she would during open surgery except that the surgery is done entirely within the body of the patient without an open incision. 

Any technology buff would be impressed by this innovation.  I mean doesn’t it sound amazing?  A surgeon can do with robotic arms inside the body everything that he could do with his own hands through an open incision.  You would think that through this new technology and the ability to see everything close up with a 3D camera, robotic surgery would blow traditional surgery out of the water.  The truth, however, is not that dramatic.  While the robotic surgery is a tremendous innovation, the original open surgery did a pretty good job in its own right.  This surgery, in its refined state, has been around for over 30 years and has actually produced some pretty good results in terms of cancer control.   Studies comparing traditional with robotic surgery have come to the conclusion that the two types of surgery are basically equivalent in terms of positive margins.  As a result, robotic surgery and standard open surgery do an equivalent job in removing the cancer completely and, in turn, curing patients of prostate cancer. 

While serving as a great operation in terms of cancer cure rates, standard open surgery has been haunted by its very well known complications.   Impotence and incontinence are feared by all men undergoing surgery for prostate cancer.  Studies have demonstrated that impotence affects approximately 50% of all men undergoing traditional prostatectomy for prostate cancer.  Fortunately, the rate of incontinence or leakage of urine is substantially less at approximately 15%.  You would imagine that robotic prostatectomy, with all of its innovations, would demonstrate substantial improvements over open surgery in terms of incontinence and impotence.  Unfortunately, studies comparing the rates of these complications from open versus robotic surgery have found few (if any) differences.

So what are the advantages of robotic surgery.  Well, there are a few.  First, robotic surgery leads to substantially less bleeding than open surgery.  In fact,  Da Vinci surgery results in only about 20% as much bleeding as its counterpart.  This difference can be critical for a patient with heart disease in whom more blood loss can increase the risk of heart attack and other complications during surgery.  Another advantage of the robotic surgery is hospitalization time.  While patients undergoing open surgery usually stay in the hospital for 2 days, those undergoing Da Vinci surgery only need to stay 1 day.  Similarly, the overall recovery time after robotic surgery is approximately one week shorter than that for open surgery.  These differences in hospital stay and recovery are mainly attributed to the fact that Da Vinci surgery usually results in less pain than the open surgery.  Finally, robotic surgeons usually remove the dreaded foley catheter from the bladder a few days earlier than open surgeons, avoiding a few extra days of discomfort.

What is the take home message from all of these comparisons?  Da Vinci surgery is a great innovation but it is not a cure all.  It is going to get you out of the hospital faster and allow you to go through surgery with minimal chance of needing a blood transfusion.  It will get you back to work faster and with less pain.  And it will lead to smaller scars on your belly when all is said and done.  That being said the presence of a robot at your surgery will not increase your chances of curing your cancer.  It will not increase the likelihood that you will maintain your erections after surgery.  It will also not decrease the probability, albeit small, that you may need to wear pads or diapers after surgery.  These critical outcomes (cure rate, potency, and continence) are dependent not on the type of surgery you get but who is doing the surgery.  Studies have repeatedly demonstrated that high volume prostate surgeons have much better results than those that perform the surgery a few times a year.  This is especially true for robotic surgery.  Surgeons who have mastered robotic surgery feel that at least 50 cases are necessary before they feel comfortable with the procedure.  The problem is that with this wave of demand for Da Vinci surgery, more and more surgeons are offering the procedure to their patients even though they have not mastered it. 

So what does this mean for you?  If you can find a GOOD robotic surgeon with a great deal of experience with the procedure, you should definitely consider it over open surgery given the advantages of the robotic approach.  However, if your choice is between an amateur robotic surgeon and an excellent open surgeon, you would be much better served undergoing the open surgery instead.  Remember, the robot is only as good as the surgeon operating it!

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

Pomegranate: Prostate Cancer Wonder Drug?

Many of my patients ask me about natural ways to fight prostate cancer.  Some of them have been diagnosed with prostate cancer and are looking for ways to control it.  Others are at risk for prostate cancer and are searching for ways to prevent it.  Either way, they are all hoping for a solution that is natural and has minimal side effects.  Believe it or not, one such solution is the pomegranate.  Yes, the funny looking red fruit with all of its little seeds may very well be a prostate cancer wonder drug.

The medicinal properties of pomegranates were described in ancient times.  Recently, the true benefits of the fruit have been discovered to come from flavonoids found in high concentrations within them.  Flavonoids have also been found in high quantities in both wine and green tea.  The main benefit of this compound is its antioxidant and anti-inflammatory properties.  Numerous studies have demonstrated that antioxidants can play an important role in cancer treatment and prevention.  With their high concentration of flavonoids, pomegranates have demonstrated significant effects on numerous malignancies including lung, breast, colon cancer.  Some of the most dramatic effects of pomegranates have been demonstrated against prostate cancer.

Studies have evaluated the efficacy of pomegranates in fighting prostate cancer in cell cultures, animal models and humans.  The most basic of these studies incubated prostate cancer cells with various concentrations of pomegranate extracts to see the effects on the growth of the cells.  These studies demonstrated that the pomegranate kept the prostate cancer cells in suspended animation, preventing them from multiplying.  This effect was demonstrated on both moderate and highly aggressive, hormone resistant prostate cancer cells.  These studies also demonstrated that the pomegranate extract also decreased the propensity of these aggressive cancer cells to invade and spread to adjoining tissues and areas. 

Inspired by the very encouraging results from these basic studies, another set of experiments demonstrated the effects of the pomegranate extracts on the growth of prostate cancer cells in mice.  In these studies, two groups of mice were inoculated with human prostate cancer cells which were then allowed to grow and form tumors.  One group of mice was fed regular water while the other was given water mixed with pomegranate extract at various concentrations.  The study demonstrated that the mice given the pomegranate/water mix grew much smaller tumors.  This reduction in the size of the prostate cancer tumors grown (as compared to mice drinking regular water) was proportional to the concentration of pomegranate extract within the water.  In addition, mice drinking the pomegranate/water mix demonstrated blood PSA levels 70-85% lower than those found in mice drinking plain water.  Again, the extent of the decrease was proportional to the concentration of pomegranate extract in the water.

While no large randomized, controlled trials have been conducted to evaluate the effects of pomegranate in a clinical setting, a small study from UCLA demonstrated some very impressive results.  This Phase II study evaluated 48 patients with prostate cancer who had a recurrence of cancer after initial therapy with either surgery or radiation.  The study determined that these men had a PSA doubling time of 15 months.  PSA doubling time is an indicator of how aggressive the cancer is and how quickly it spreads.  The lower the number of months to double the PSA, the more aggressive the cancer turns out to be.  All of these men were given 8 ounces of pomegranate juice over a 2 year period.  The study found that the PSA doubling time increased to 54 months with the pomegranate juice as opposed to 15 months demonstrated prior to the treatment.  Through this amazing finding, the study demonstrated that pomegranate can actually slow the spread of prostate cancer in humans!   Although the study was limited by its small patient numbers and lack of a control group (a group of patients who were followed but not given treatment), it demonstrated a significant benefit of pomegranate that cannot be ignored.

So what do we take from these very impressive studies?  Should a good daily helping of pomegranate juice replace surgery, radiation, or other accepted therapies for prostate cancer.  Of course not!  While these studies are very impressive, they do not show that pomegranates can CURE prostate cancer.  Instead, they demonstrate that pomegranates MAY decrease the growth of prostate cancer.  However, because pomegranates are natural fruits without any significant side effects, they should be strongly considered as a great ADJUNCT to any normally accepted treatment for prostate cancer.  The pomegranates may work synergistically with surgery or radiation to improve outcomes for patients with prostate cancer.  In addition, patients at risk for prostate cancer may want to consider pomegranates as a preventative measure. 

As I always tell my patients, medicine almost never offers a free lunch.  Any treatment you chose has its own side effects to tolerate.  Pomegranates offer as close to a free lunch as you can get.  Aside from causing some loose stools in some patients, pomegranates are a safe, natural way to battle prostate cancer.  I look forward to more studies evaluating this very promising fruit!

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

Prostate Cancer Prevention: Is Avodart Friend or Foe?

Whenever I discuss prostate cancer prevention with my patients, the topic of  Avodart always comes up.  Avodart  ( Dutasteride is the generic name) is a hormonal medicine that is used to treat urinary symptoms associated with BPH (benign prostatic hyperplasia) in men with very large prostates.  It has been shown to work synergistically with another class of drugs called alpha blockers ( Hytrin, Cardura, Flomax) to help improve urinary symptoms and prevent urinary retention.  The way Avodart works is that it blocks an enzyme located in the prostate which converts the male hormone Testosterone to a more potent hormone Dihydrotestosterone.  By blocking this hormone, Avodart actually causes the glands of the prostate to shrink, allowing urine to more easily flow through it.

If Avodart is a medicine used to treat BENIGN enlargement of the prostate, why does it come up in conversations about prostate CANCER prevention?  The answer to that question comes in the form of a landmark study called the Prostate Cancer Prevention Trial which was published in the New England Journal of Medicine in 2003.  This study evaluated a drug similar to Avodart called Proscar (Finasteride is the generic name) in over 10,000 men.  The theory of the study was that the medicine can not only shrink normal glands in the prostate but also prostate cancer glands as well.  In so doing, the authors thought, Proscar could actually prevent small areas of prostate cancer in the prostate from growing and developing into full blown cancer.  The study had some groundbreaking and yet confusing results.  The authors demonstrated that taking Proscar could decrease the risk of prostate cancer by 25%.  This was truly an astounding discovery!  Unfortunately, however, it came with a catch.  The men who did get prostate cancer while taking Proscar were 27% more likely to have a more aggressive, life threatening form. 

The results of the Prostate Cancer Prevention Trial really put patients and urologists in a tough situation.  On one hand, Proscar significantly decreased the overall risk of prostate cancer.  On the other hand, however, those that did get prostate cancer got a more aggressive form.  Numerous theories were offered to explain these conflicting findings.  Some doctors argued that by shrinking the prostate, Proscar only helped to FIND the more aggressive prostate cancer on biopsies because the cancers were more noticeable with less benign prostate tissue around.  Others maintained that by shrinking the normal glands, Proscar allowed aggressive prostate cancer to grow without restriction in the prostate.  Taking all of this into account, experts finally recommended that men who have enlarged prostates that would benefit from Proscar from a urinary standpoint should still be offered the medicine.  In terms of prostate cancer prevention, however, the substantial benefits and risks meant that the medicine had to be considered on a patient by patient basis.

A few years after the Prostate Cancer Prevention Trial, a new medicine called Avodart was brought to market.  As I mentioned, this medicine, like Proscar, blocked the enzyme transforming Testosterone into a more potent compound called Dihydrotestosterone.  Avodart had the added advantage in that it blocked two forms of this enzyme as opposed to Proscar which only blocked one.  The theory is that Avodart may be more effective because of this additional enzyme which it blocks. Given this new drug, another large study was carried out to determine if it could prevent prostate cancer as well.  Called the REDUCE trial, the study compared the risk of cancer in over 3,000 men who took Avodart as compared to another 3000 similarly matched men who did not.  The study found that Avodart decreased the risk of Prostate Cancer by 23%.  In addition, over the 4 year course of the study, no difference in high grade, aggressive cancers was noted between the two groups.  Interestingly, however, in the last 2 years of the study, 12 of the patients taking Avodart developed prostate cancer as opposed to only 1 of the patients not taking it.  Once again, like Proscar, while Avodart appeared to reduce the overall risk of prostate cancer significantly, it appeared to also increase the chance that people who did get prostate cancer would have more aggressive variants. 

Recently, a request was made to the FDA for approval to market Avodart and Proscar for the indication of prostate cancer prevention.  The committee rejected the proposal unanimously.  They felt that the benefits of prostate cancer prevention did not outweigh the risks of at least potentially causing more aggressive prostate cancer in some patients.  So what is the take home message of all of this information?  Is it to tell you not to ever take Proscar or Avodart?  No. People who would benefit from it from a urinary standpoint should consider it.   The point of the post is simply to inform you that trying to prevent prostate cancer with these medicines is not a straightforward endeavor.  If your doctor recommends that you take these drugs solely to prevent prostate cancer, make sure you discuss these risks with him or her and are comfortable that they are worth taking.

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

The Prostate Biopsy: What to Expect

Whenever I tell one of my patients that he needs a prostate biopsy, the same look of fear usually comes over his face.  Fortunately, a prostate biopsy no longer has to be the painful, embarrassing procedure that it has been known for in the past.  In this post I want to provide the answers to common questions I hear from my patients about prostate biopsies:

1)      Why do I need a prostate biopsy?

A prostate biopsy needs to be performed when there is a suspicion that you may have prostate cancer.  That suspicion may be from an elevated PSA blood test (see previous post) or an abnormality of the prostate felt during a rectal exam.  It is the most definitive way to determine whether there is cancer in your prostate.

2)      Do I need any preparation for the biopsy?

Yes.  You will need to take oral antibiotics and some enemas around the time of your biopsy.  Every Urologist has a different preparation but most will involve 1-2 days of oral antibiotics around the time of the biopsy.  Most will also have you do an enema the night before and the morning of the biopsy.  An important aspect of preparation is to avoid any blood thinners like Aspirin, Motrin, Aleve, Ibuprofen, Plavix, or Coumadin for 7-10 days prior to the biopsy.  If you take any of these medicines, make sure that you let your Urologist know well in advance of the biopsy.  Something not well known is that some vitamins and supplements such as Vitamin E, Fish Oil, and Glucosamine also have blood thinning properties and should also be stopped prior to a biopsy.

3)      What are the risks of a biopsy?

The main risks of a biopsy are bleeding and infection.  After a biopsy, you may notice blood in your urine or your stool for several days.  This blood usually goes away on its own if you drink lots of water.  If you have severe bleeding, make sure to let your doctor know or go the Emergency Room right away.  Blood in the semen is also a very common side effect of a biopsy that is rarely discussed.  Because semen is produced in the prostate, a prostate biopsy almost always leads to blood in the semen for several weeks.  It usually starts off red and then becomes a rust color.  It is absolutely nothing to worry about but you may want to wear a condom for a week or two during sex as it may be a little disturbing to you and your partner.

A fever is always concerning after a biopsy as it could mean that there is an infection of the prostate.  This infection can spread into the bloodstream and make you feel very sick.  If you have a fever after a biopsy, it is very important that you go to the Emergency Room right away as you may need intravenous antibiotics.  Fortunately, this complication is seen very rarely after a prostate biopsy.

4)      What should I expect during my biopsy?

The whole process should take about 20-30 minutes.  You will first be checked in by a nurse who will take your blood pressure and have you sign a consent form for the biopsy.  The nurse will also probably make sure that you have taken the preparation discussed above.

After you are checked in you will be asked to change into a gown and empty your bladder.  You will then be asked to lie down on a table.  The position you are in during the procedure depends on your doctor. Some Urologists(including myself) will have you lie on your side with your knees bent towards your chest while others will have you lie on your back and place your legs in stirrups(less common).  The doctor will then perform a rectal exam like you received in the clinic during your initial visit.  He will apply some topical anesthetic cream to your anus and prostate.  Once the cream has been applied, the doctor will then place an ultrasound probe inside the rectum.  This is a little bigger than a finger and may feel like a little more pressure in the rectum.  The doctor will then measure your prostate with the ultrasound.  While he is able to see the prostate during the procedure, the doctor will not be able to really see any cancer within the prostate unless it is very obvious.  After the measurements are taken, your doctor will give you some local anesthetic to numb the prostate.  This will feel like pinching and burning in your prostate not unlike when you get anesthetic at the dentist’s office.  After a minute or two, your doctor will start the biopsy.  You will hear some loud clicks as the biopsy gun deploys.  You may feel a slight pinch with each biopsy.  A total of 12 biopsies are done.  The whole process usually lasts between two and five minutes.  After the procedure is completed the ultrasound will be removed from the rectum and you will be asked to get dressed.

5)      What should I expect after the biopsy?

After the biopsy, most people say that they feel a little sore in their rectum.  Usually some Tylenol will help relieve the discomfort.  Make sure not to take Aspirin, Ibuprofen, or other blood thinners as this will cause bleeding.  As mentioned above, some blood in the urine or stool is normal after the procedure.  It may look frightening at first, but it should go away fairly soon.  You should try to take it easy for the next day or so to let everything settle down.  I would recommend that you avoid any sexual activity for at least a week after the biopsy.

As I mentioned before, fever after a biopsy is NOT NORMAL.  If you have a fever, make sure that you get medical attention right away.

6)      When do I find out the results?

Your doctor will generally call you within a week with the results of your biopsy.

I hope that this post was helpful for those of you about to undergo a prostate biopsy.  Although any kind of biopsy can be stressful, a prostate biopsy does not need to be a horrible experience.  Most of my patients tolerate the biopsy very well.  In fact, most tell me the same thing after the procedure is finished: the anticipation was the worst part.

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

PSA: Not Perfect But Vital

Three letters that many men fear are PSA.  These letters stand for Prostate Specific Antigen, a chemical produced by the prostate which is checked via a blood test to look for prostate cancer.  PSA has been an extremely important tool for doctors in identifying early prostate cancer.  Before PSA, prostate cancer could only be identified by means of a yearly rectal exam.  As prostate cancer is often advanced by the time it can be felt on an exam as a mass, many men at that time were diagnosed with prostate cancer after it had already spread outside of the prostate and could no longer be cured.  As a result, Urology wards in hospitals were often filled with men suffering from painful bone metastases that had no hope of cure.  After the advent of PSA, prostate cancer became a much more manageable disease.  Today, men are often diagnosed when just a few cells of prostate cancer are found in the prostate, making the cancer very curable and avoiding the unnecessary pain and suffering of metastatic disease.

While very beneficial, however, PSA is far from perfect.  First, PSA is not specific for prostate cancer.  As I previously mentioned PSA is a functional enzyme NORMALLY produced by the prostate.  In other words, PSA is not JUST produced by prostate cancer.  As a result, many factors can cause an elevation in the PSA test.  The most common cause of an elevated PSA that is NOT caused by prostate cancer is sexual intercourse.  Men who have any type of sex that results in ejaculation within 2-3 days of giving a blood sample usually demonstrate an elevated PSA.  This elevation of  PSA is caused by natural production and secretion of PSA by the prostate for sex rather than by prostate cancer.  Other causes of an elevated PSA  include a urinary tract infection (that may be asymptomatic), retention of urine, and even riding a motorcycle.  As a Urologist I have countless patients referred to me by their primary doctors for an elevated PSA test. Unless I feel an abnormality of the prostate during a rectal exam, I almost always repeat the PSA test, making sure that the patient does not have sex for 2-3 days prior to the test.  I also have the patient give a urine test at the same time to make sure that there is no infection.  In at least 50% of my patients, a repeat PSA test comes back as normal.  Multiple academic studies have demonstrated the same likelihood of what is called a false positive PSA test.  This means that over half of men with a single elevated PSA could avoid unnecessary procedures and worry by simply repeating the test in the right way!

Another problem with PSA is that sometimes it is too sensitive, meaning that it does too good a job in finding prostate cancer.  Studies have shown that 80% of men over the age of eighty have prostate cancer.  Because prostate cancer is usually slow growing, most of these men will never be symptomatically affected by the disease and so will die with it rather than from it.  They will die from more aggressive diseases such as heart disease or stroke.  To some extent, the same situation can be applied to younger men as well.  For example, a 70 year old man found to have a tiny amount of moderately aggressive prostate cancer may live into his 80s or 90s before that prostate cancer grows to any significant extent.  Many studies both conducted in the United States and in Europe have recently demonstrated that many men are diagnosed and treated for prostate cancer as a result of an elevated PSA test that would otherwise never have been significantly affected by prostate cancer within their lifetimes.

So what do all of these problems with the PSA test mean?  Should we get rid of it altogether?  I definitely think not.  While PSA is not a perfect test, it is vitally important if used the right way.  As I mentioned before, prior to PSA, many more men were needlessly dying of metastatic prostate cancer.  In addition, while identifying prostate cancer in 80 year old men MAY not be useful, finding any prostate cancer in healthy, 50 or 60  year old men while the cancer is still contained is VITAL.  PSA can help doctors identify CLINICALLY SIGNIFICANT prostate cancer that WILL affect and possibly shorten the lives of men who suffer from it. 

The real question then is how do we use PSA appropriately and for the most benefit.  First, as I mentioned previously, care must be taken to make sure that the PSA reading is actually real.  Elevated PSA tests should be repeated while minimizing the effects of other factors causing elevation of the test such as sexual intercourse.  In addition, current recommendations are for men over the age of 75 to stop getting PSA tests altogether.  The thinking behind this recommendation is that, because prostate cancer grows slowly, men in their mid to late seventies are unlikely to live long enough for a small amount of prostate cancer to grow enough to significantly affect them.  I don’t completely agree with this thinking because I treat many men in their 70s who are very healthy and will most likely live for at least 20 years.  As a result, I think the decision of whether to do  PSA testing should be tailored to the individual health and wishes of each patient and should entail a detailed discussion between men and their doctors.  I think that this approach should be applied to all patients who undergo PSA tests.  You and your doctor should take many factors into account when deciding whether to get a PSA test and how to interpret the results of that PSA test including your age, health, and desires.  If used in this patient specific manner rather than a “knee-jerk” fashion the PSA test can help save many lives while avoiding unnecessary procedures, pain, and worry. 

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy