Tag Archive | "prostate surgery"

Study Shows Good Outcome for Delayed Prostate Surgery


Men with early prostate cancer who put off surgery is almost the same as men who had prompt surgery. On average, their tumors were no likely to develop into a more aggressive form than men who had surgery immediately after diagnosis. Additionally, after eight years, .9 percent of men who delayed surgery had died compared to .7 percent of men who had prompt surgery.

“Our findings show that if a man is diagnosed with a localized low-risk prostate cancer, there is no rush to decide which treatment choice (is) best,” said lead researcher Dr. Benny Holmstrom, of Gavle Hospital in Sweden.

The results add to data that some patients can safely opt for “active surveillance” — where the prostate cancer is monitored with regular PSA blood tests, digital rectal exams and possibly prostate biopsies and costly, painful surgical procedures are avoided.

A study published last year in the Journal of the National Cancer Institute estimated that since 1986, around 1 million U.S. men received unnecessary treatment for prostate tumors that were not life threatening.

As experts and health providers are increasingly calling for expanded use of active surveillance in monitoring prostate cancer, this study is particularly significant. However, Holmstrom warned that further, long-term studies are still needed to insure that active surveillance is truly the best option for prostate cancer patients.

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Prostate Surgery Causing Problems for Sexual Function


A new long-term follow-up study indicates that many men continue to feel distressed about their reduced sexual function years after prostate surgery.  In fact, the study reveals that sexual function is so important to them that adapting to a lower level of functioning is much more difficult than adapting to temporary urinary problems, explains Dr. Walter R. Parker and colleagues from the University of Michigan Health System in the Ann Arbor report.

Of the 434 men in the study with localized prostate cancer, all underwent radical prostatectomy, which is the complete removal of the gland.  This type of surgery is creating controversy among urologists and surgeons because it is commonly used to treat early-stages of the disease.  Men with early-stage prostate cancer are at a low risk that the disease will be fatal, yet the impact of the surgery is quite negative on the men’s quality of life.

Long-term quality of life is extremely important in men when they have a high likelihood of survival from prostate cancer.  Parker’s team at the University of Michigan developed a survey called the Expanded Prostate Cancer Index Composite (EPIC), which is designed to assess various aspects of quality of life after prostate cancer treatment.  This study is the first to compare men’s scores before the surgery and five years after the surgery.

The study shows that 38 percent of the men who had undergone radical prostatectomy reached baseline levels of urinary function 12 months after the surgery (despite an instantaneous, but temporary, decrease in urinary function and incontinence right after the surgery).  But by four years the improvement declined.

The study revealed even less promising results in regards to sexual function of the men.  Although sexual function began to improve after the surgery, only 28 percent had actually returned to the level of sexual function they reported before the surgery.  After three years from the surgery, 37 percent reported the same level of sexual trouble they reported before undergoing the surgery.  Only 11 percent of the men returned to their pre-surgery sexual function after two years from when they underwent the surgery.  This means that about 63 percent of the men were experiencing low sexual function after undergoing prostatectomy surgery.

The recommended recovery program for sexual function after the surgery includes Kegel exercises and prescription drugs.  These are intended to restore erectile function.  Yet studies have shown that many prescription drugs for erectile dysfunction leave the patients feeling sick and with many side-effects.

Researchers are initiating a “structured early and long-term erectile rehabilitation program to augment sexual recovery as early as possible, yet also convince patients to maintain their erectile rehabilitation efforts long-term,” states Reuters.

But something different needs to be included in these rehabilitation programs.  Many men are searching for alternative treatments for their erectile dysfunction and sexual function problems.  Natural supplements offer safe, often effective, and clinically proven results.  If you have undergone prostatectomy surgery and are considering natural supplements, contact your urologist for further information.

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Pre-op Counseling For Prostate Surgery Not Effective


Researchers have found that over half of men undergoing radical prostatectomy have unrealistic expectations about some of the outcomes.

Daniela Wittmann, MSW, and colleagues at the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan found that despite a pre-operative education program, 61 percent of men expected the same or better sexual function a year after surgery as they had before.  Sixty percent of men expected difficulties with urinary incontinence to be the same or better.  These findings were published in the Journal of Urology.

Wittmann and colleagues found that a substantial proportion of patients, 17 percent and 12 percent, respectively for both effects, expected better performance a year after surgery than before even though they had been told that such an outcome was improbable.  The researchers argued that this finding suggests that pre-op education should be followed up with post-surgery support for prostate cancer survivors.

The research team asked men undergoing radical prostatectomy to fill out the short form of the Expanded Prostate Index Composite questionnaire, both before and a year after surgery to get an idea of their urinary, bowel, hormonal, and sexual function.

The men were also asked, after pre-op counseling but before surgery, to fill out the Expanded Prostate Index Composite-Expectations questionnaire, which detailed what level of function they expected a year later.  Both questionnaires assess five domains: incontinence, urinary irritative symptoms, bowel function, hormonal function, and sexual function.

Analysis of the 152 participants showed that 36 percent and 40 percent expected the same function at one year as at baseline in urinary incontinence and sexual function, respectively, while 12 percent and 17 percent expected better function.  Forty-seven percent and 44 percent of patients had lower than expected function for urinary incontinence and sexual function, respectively.  Expectations matched or were better than outcomes for 78 percent of patients for urinary irritative symptoms.  Expectations of bowel and hormonal function largely matched outcomes, with 92 percent and 86 percent, respectively, having outcomes that were the same as or better than expected.

Wittmann said that these differences may arise from the way that the pre-op counseling is given.  The research tem cautioned that the study had a low response rate.  Out of 526 patients who signed consent forms, only 152 completed all the questionnaires.  This makes it difficult to generalize the findings.  Also, while the counseling on sexual matters was standardized, the information provided by surgeons on other outcomes was not.

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New Technology May Encourage Doctors to Recommend Prostate Surgery


A new study finds that after hospitals in Wisconsin received robotic surgery technology, the number of prostate removals there doubled within three months.  In contrast, the number of prostate surgeries remained the same at hospitals that did not purchase this new two-million dollar technology.

This finding was published in the peer-reviewed journal Cancer. It comes just months after a Johns Hopkins report showing that hospital websites often hype robotic surgery without considering the risks and play up the benefits leading the study authors to worry that the new technology is encouraging doctors to recommend surgery to patients.

Each robot, in addition to the initial cost of nearly $2 million, requires more than $100,000 per year for maintenance.  Jim Hu, MD, director of urologic robotic surgery at Brigham and Women’s Hospital in Boston, who was not involved in the new study, suggested that hospitals that acquire this expensive technology might feel pressure to cover its costs by performing more surgeries.    The new technology is now used in almost three-quarters of all prostate removals nationwide.  Yair Lotan, MD, from the University of Texas Southwestern Medical Center at Dallas, who was not involved in the study, said that The bulk of evidence, however, does not show it to be more effective in saving lives than traditional surgery.

Joan Neuner, MD, MPh, of the Medical College of Wisconsin and colleagues found that between 2002 and 2008, Wisconsin hospitals performed more than 10,000 prostate removal surgeries. Almost one in four hospitals purchased surgical robots in that period.  Although fewer men had prostate cancer in 2007, there were 1,760 prostatectomies in 2007 compared to 1,400 in 2002.

Dr. Neuner and colleagues attribute these findings partly to patient demand, driven by aggressive marketing by manufacturers and hospitals.  Dr. Lotan reports that patients often request the robotic surgery without knowing the risks involved.  While shorter recovery times, less blood loss, and smaller scars are benefits of the robotic system, the technology extends the operation time. Dr. Hu emphasizes that the safety of surgeries depends more on the skills of the surgeon than on the technology involved.

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Post Prostate Surgery Pelvic Floor Exercises Ineffective in Improving Male Incontinence


According to a two randomized trials reported in The Lancet one-to-one pelvic floor exercise therapy for urinary incontinence after prostate surgery is no more effective than standard care.

Cathryn Glazener, PhD, from the University of Aberdeen, United Kingdom, and colleagues, reported that urinary incontinence is common immediately after prostate surgery.  As a result men are often advised to do pelvic floor exercises, but evidence to support this had been inconclusive.  The study sought to establish if formal one-to-one pelvic floor muscle training reduces incontinence.  It was supported by the National Institute of Health and Health Technology Assessment Programme.

The first trial enrolled men in the United Kingdom who had incontinence six weeks after radical prostatectomy, and the second trial enrolled men in the United Kingdom who had incontinence six weeks after transurethral resection of the prostate (TURP).  These trials compared the effect of four one-to-one therapy sessions during a three-month period to standard are and lifestyle advice only.

In trial 1, the rate of urinary incontinence at 12 months in the intervention group was not significantly different from that in the control group. Findings were similar in trial 2. These findings were unchanged by adjustment for minimization factors or by treatment-received analyses.  There were no adverse effects reported in either trial.

The authors conclude that one-to-one conservative physical therapy for men who are incontinent after prostate surgery is unlikely to be physically effective or cost effective.

Limitations of this study include incomplete blinding and lack of objective measures of incontinence.

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Use Caution When Deciding on HIFU


Normally, high-intensity focused ultrasound (HIFU) is used as a salvage treatment for prostate cancer. Recently, a movement has taken place to push HIFU as a front-line use, but both the US Food and Drug Administration and the European Association of Urology classify the procedure as experimental.

The first case series to report outcomes in men after failed whole-gland HIFU and salvage radical prostatectomy suggests that there is reason for caution.

Researchers report they were alarmed at the pathology results. Morbidity appeared to be higher after salvage prostatectomy than after primary surgery.

Declan G. Murphy, MD, from the Department of Urological Oncology at the Peter MacCallum Cancer Centre in Melbourne, Australia, notes, “Whether it is that standard prostate biopsy cannot be relied on to predict final pathological outcome, or that HIFU ‘makes cancer angry,’ patients should be fully counseled about what we know and, importantly, what we do not know about HIFU treatment for localized prostate cancer today.”
“Our own initial experience with HIFU treatment for primary and recurrent prostate cancer unfortunately led us to conclude that the technology is not yet suitable for mainstream clinical practice, and led us to suspend our program,“ Dr. Murphy added.

Dr. Lawrentschuk believes that using radical prostatectomy as salvage treatment after the failure of primary HIFU is feasible; however, he is concerned about the rate of extraprostatic extension.

“HIFU is experimental and should only be done in studies where patients are told of the risks of failure and the poor results of salvage. They need very careful monitoring, follow-up biopsies, etc. I do not advise patients to have HIFU. There may be a problem with HIFU selecting out more aggressive cells, but this warrants further study,” explains Dr. Lawrentschuk.

“Experimental treatments are fraught with danger. I was surprised at the aggressive nature of the disease and the recurrences in this supposedly low-risk group,” he continues. “I think HIFU is inadequate in its current form, perhaps because of poor patient selection for HIFU and a lack of standardized ways of detecting post-HIFU recurrences in a timely fashion.”

Howard Sandler, MD, chair of radiation oncology at Cedars-Sinai Medical Center’s Samuel Oschin Comprehensive Cancer Institute in Los Angeles, California, also reviewed the study.

“I wouldn’t conclude that the high number with extracapsular extension is a result of HIFU. It is more likely that patients who fail HIFU had worse cancers in any case from the start. Additionally, there may have been a bit of a delay after some suspicion of recurrence before salvage surgery was done, given the presurgery PSA [prostate-specific antigen] of 3.8, with the nadir PSA of 1.0. Thus, patients waited on average for their PSA to rise from 1.0 to 3.8 before something was done. During this interval, extracapsular extension may have occurred,” Dr. Sandler explained.

Overall, Dr. Sandler believes that HIFU is a poor choice for whole-gland ablation and focal therapy.

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Men Suffer Smaller Penises after Prostate Cancer Surgery


One of the most recognized side effects of prostatectomy is erectile dysfunction. However, post-surgery penile length shortening (PLS) is known to occur in up to three-fourths of men. Penile length returns to preoperative length by nine months postoperatively, a study found.

The study, by Jason D. Engel, MD, of George Washington University Hospital, Washington, DC, and collaborators enrolled 127 patients who underwent robot-assisted laparoscopic radical prostatectomy (RALRP) for prostate cancer. Of these, 94 completed an 11-month follow-up period. Subjects had a mean age of 56.5 years. The baseline mean stretched penile length (SPL) prior to surgery was 11.77 cm.
At one month postoperatively, the length had decreased to 11.13 cm. However, mean SPL was not significantly different from baseline at nine, 10, and 11 months, according to a report in the Journal of Endourology.

Why does the radical prostatectomy damage the penis so much? “The operation removes the prostate and seminal vesicles and removing these structures leaves a gap that is sometimes filled by pulling the penis up into the body, effectively shortening it,” says Dr. Hennenfent. “In addition, nerve branches, arteries, and veins in the pelvis are always severed by the radical prostatectomy. These missing structures can no longer nourish the penis and it atrophies. One study suggests that the erectile tissue in the penis actually dies off after the radical prostatectomy.”

The central theme to emerge from men who responded to the study was “resignation”, a conveyed awareness of their inability to return to a pre-cancerous lifestyle. Men adapted to the changes of having prostate cancer. All participants focused on the bigger picture and this allowed them to coexist with a diagnosis of prostate cancer. To focus on the bigger picture, they took into consideration past experiences, current state of affairs and hypothesized how potential outcomes would impact upon them. Family relations were prioritized, especially spousal communication. In addition, three sub-themes were identified; unaltered masculinity, the unimportance of penile length shortening and erectile dysfunction as a speed bump. None of the men perceived changes in their own evaluation of masculinity after noticing PLS after radical prostatectomy. While men saw themselves as being unable to perform a “masculine” role in procuring coitus, this did not mean that they saw themselves as unmanly. The men also felt that PLS was unimportant, in part due to the fact that they all experienced erectile dysfunction. It is unclear how PLS might impact potent men in this regard. Finally, all men identified return of erectile function as the event that would improve satisfaction with penile function.

The researchers concluded that “Patients should be counseled that penile length might decrease after radical prostatectomy.”

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Sexual Function May Improve After Prostate Surgery


Hope is still alive for men’s sexual function after prostatectomy. Mainly, those men who are still experiencing erectile function two years after surgery may still see an improvement in function. This improvement may leave men able to sufficiently function during sexual intercourse.

“The message to patients who have erectile dysfunction—even those who have failed to have erections after surgery—is that improvement does occur in a substantial number of men,” says researcher Jeffrey Schiff, MD, a resident in urology at the State University of New York Downstate Center in Brooklyn, New York.
According to Dr. Schiff, nearly one-third of men with marginal erectile function and one-fourth of men with serious erectile dysfunction after surgery continue to have improvement in erectile function on follow-up visits, even 24 months after the surgery was performed.

Schiff and fellow researchers examined the medical records of 128 men who had a radical prostatectomy and were evaluated for erectile function at follow-up visits to the doctor. The men were asked to rate their level of erectile function on a 5-level scale, with 1 corresponding to normal function and 5 representing no erections.

Before the surgery, two-thirds of the men evaluated themselves at level 1, meaning they had normal erectile function. The remaining one-third said they had diminished erections, but were still able to have intercourse.
After surgery, however, 51 men had rated themselves at level 3, meaning “partial erections occasionally satisfactory for intercourse.” At subsequent follow-up visits, 10% of these men had normal functioning and 22% recovered enough to have intercourse, although they did have diminished erections.

Eighty-seven men rated themselves at level 4 or 5, corresponding to partial erections not sufficient for intercourse, or no erections two years after surgery. Of these men, 1.1% recovered to normal erections and 10% recovered diminished erections, routinely sufficient for intercourse. Thirteen percent recovered partial erections occasionally satisfactory for intercourse.

Although those men who experienced the most severe erectile dysfunction still did not see any improvement after three years, men who had partial erections that were occasionally sufficient for intercourse continued to make progress for up to four years after surgery, explains Schiff.

“It’s common for men to have erectile dysfunction after prostatectomy and this shows they shouldn’t get discouraged if sexual functioning doesn’t come back right away,” says AUA spokesman Ira Sharlip, MD, of the University of California, San Francisco. “Even after two years, many will still improve.”

One confounding factor of the study is that about half the men in the study who suffered from sexual dysfunction took ED drugs like Viagra.

“This was not a controlled experiment, so we don’t’ know if these drugs were helpful in overcoming erectile dysfunction,” says the study’s head, Farhang Rabbani, MD, associate professor of urology at Montefiore Medical Center.

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Prostate Patients May Live Healthier Lives by Controlling Stress


Researchers have known for years that people who lead stressful lives often have many more health problems, such as frequent colds, stomach problems, and depression. And most research suggests that relaxation techniques may reduce symptoms such as depression and anxiety. But only recently has a new study emerged that shows these techniques may also extend to the health of prostate patients. A physician at the University of Texas MD Anderson Cancer Center reported that stress relief may boost immunity in men undergoing prostate surgery.

Lorenzo Cohen, MD, an oncologist and behavioral scientist, found that those patients who undergo stress counseling prior to prostatectomy, or full removal of the gland, had an association with higher post-operative levels of immune cells in the blood.

Dr. Cohen advised men with early-stage prostate cancer to attend therapy sessions twice weekly before and after surgery. In addition to the therapy, Cohen recommended deep breathing exercises, positive visualization techniques, and stress level discussions.

The results of this study were positive. The men who were de-stressed prior to the operation were more likely to have a healthy immune system afterward. Further, they also displayed fewer emotional outbreaks and mood disruptions before the surgery.

As a result of the study, researchers believe that stress management may be key to a healthy recovery process for men with prostate cancer. Decreasing stress levels is a valuable part of the preparation for prostate cancer surgery and important for the immune system. Cohen added that such techniques may naturally improve health while saving valuable public health funds.

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