Tag Archive | "prostatectomy"

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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Urine Test Can Help Detect and Sort Prostate Cancer

Researchers report that an investigational urine test can detect and stratify prostate cancer in men with elevated prostate specific antigen (PSA).  According to Arul Chinnaiyan, MD, PhD, of the University of Michigan Medical School in Ann Arbor and colleagues, the test is based on the detection of a gene fusion that is specific to prostate cancer combined with another marker.  Stratifying patients by the combined marker identified groups with markedly different risks of cancer, high-grade cancer, and clinically significant cancer on biopsy.

This noninvasive test may allow some men with elevated PSA to avoid a needle biopsy.  Although many more men have elevated PSA than actually have cancer, the test could be an intermediate step before getting a biopsy.

The fusion that doctors look for in the test involves the genes transmembrane protease, serine 2 (TMPRSS2), and v-ets erythroblastosis virus E26 oncogene homolog (avian) (ERG).  This fusion appears in roughly half of all prostate cancers, but when it does appear, it is almost 100% specific for malignancy.  Through a series of experiments, the research team showed that the fusion gene was associated with indicators of clinically significant cancer at biopsy and prostatectomy.  The indicators included tumor size, high Gleason score at prostatectomy, and upgrading of Gleason grade at prostatectomy.

Because this fusion gene is not always present, the team created a model that combined it and the prostate cancer antigen 3 (PCA3) gene.

The researchers use the model to stratify 1,065 men who underwent biopsy into three groups – lowest, intermediate, and highest levels of the combined genes.

These tests, however, remain investigational.  Additionally, the researchers note that most of the men studied thus far have been Caucasian.  More studies are needed to see if the results can be generalized.

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MRI Highly Effective in Identifying Prostate Cancer Recurrence Even at Low PSA Levels

According to a study conducted by researchers at MD Anderson Cancer Center in Houston, a pelvic MRI scan with IV contrast and rectal balloon is highly effective in identifying local recurrence even at low PSA values in prostate cancer patients with a rising or persistently elevated PSA after prostatectomy.

For prostate cancer patients with rising PSA, a scan is typically performed after a prostatectomy and before salvage radiation therapy treatment. This is to determine the potential recurrence and the location of the recurrence. Researchers were not surprised that high rates of cancer recurrence were picked up by the MRI than the traditional CT scan as an MRI is able to differentiate between soft tissues better. The surprise was the low PSA levels at which the MRI could determine recurrent disease.

Lead author of the study and assistant professor of radiation oncology at MD Anderson Cancer Center in Houston said “Being able to identify such patients is beneficial, as it would be predictive of response to salvage radiation therapy. It also may allow a radiation oncologist to treat the area of recurrent cancer to a higher radiation dose with or without hormone ablation therapy to increase the chance of cure.”

The study evaluated 389 post prostatectomy patients treated between January 2004 and October 2010, with 143 receiving a pelvic MRI to determine if cancer cells were still present in the area of the surgical bed. Of those patients, 35 had suspicious MRI findings suggesting a local recurrence where 26 patients were then biopsied, with 23 showing cancer.

The study showed that about one-third of patients with a biopsy proven recurrence after suspicious MRI finding had a PSA of less than 1, with several having a PSA as low as 0.3.

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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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New Prostate Cancer Recurrence Prediction Method

A new test to determine prostate cancer recurrence has been developed by Myriad Genetics, Inc. The 46-gene prognostic test is called Prolaris™, and works by quantitatively determining the risk of recurrence in patients who have undergone prostatectomy surgery. With this new launching, physicians now have a direct molecular measure of a prostate tumor’s capacity to divide and grow by examining the mechanics of growth at the molecular level.

“After undergoing a radical prostatectomy, men often worry about their continuing risk of cancer recurrence,” said Peter R. Carroll, M.D., M.P.H., Professor and Chair, Urology, University of California, San Francisco. “Prolaris may offer very important information to the patient and his physician about the risk of his cancer recurring.”

Prolaris is actually a molecular diagnostic assay that provides urologists with more accurate results that can be used to determine the risk of recurrence of prostate cancer. This new technology is based on cell growth and tumor biology and provides quantitative measures of the expression levels of multiple genes related to progression of the cell cycle.

The test provides results at a 95% accuracy level, which can give men the confidence they need for aggressive treatment. Men with high Prolaris scores can then be considered for more intensive screening and therapy to address the disease. Additional clinical tests and studies will be performed in order to expand the utility of Prolaris.

“Prolaris is a valuable additional tool that will enable urologists to provide an accurate, individualized recurrence risk score to men who have undergone a radical prostatectomy,” stated Mark C. Capone, President, Myriad Genetic Laboratories, Inc. “We view Prolaris as the first of a strong emerging stable of RNA signature tools based on fundamental tumor biology which Myriad will offer to the urology/oncology community.”

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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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May 2021
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