Smith Blog

A common question asked by couples considering a vasectomy reversal is “What is the success rate”. There is no precise way to determine success (which we will define as return of sperm to the ejaculate) prior to a procedure. There is certainly good data demonstrating a direct relationship between the time since the vasectomy and the success of the procedure.  However, many patients have a normal semen analysis after a vasectomy reversal, even when the reversal was done greater than 20 years after the vasectomy. Success is also a function of other factors besides the time from a vasectomy. For instance: site where sperm is found (vas deferens or epididymis) at the time of procedure, testicular size and function, length of viable vas deferens present…and of course the experience of the Surgeon.  In addition, if you define success as pregnancy then female factors must also be considered.  Oftentimes, many factors can be identified prior to the procedure by a comprehensive physical examination and review of the medical history. This will allow the Urologist to discuss the realistic expectations. Also, sperm banking of vasal/epididymal or testicular sperm done at the time of the procedure will assure that IVF (in vitro fertilization) can be done without the need for any additional procedures.

Bruce R. Gilbert, M.D., Ph.D., FACS
Director, Reproductive and Sexual Medicine
Smith Institute for Urology

Surgery was born centuries ago out of a raw necessity to cure in the context of a limited medical armamentarium. Early surgeons were pioneers in demonstrating the now obvious reality that the extirpation of tumors, drainage of infected kidneys, and removal of stones could alleviate pain and suffering. Initial focus addressed the disease and how to perform procedures with reasonable patient survival. With the 20th century came rapid advances in anesthetic techniques, perioperative care, antibiotics and organized surgical education, resulting in reliable surgical methods.Society has charged the modern era of surgery with an additional agenda.  Patients want and expect less: less pain, less incisions, less recuperation and less expense all with a classically successful surgical outcome.  The focus upon issues such as function and lifestyle has challenged our specialty to better understand the human body, diseases and surgical processes.  These requirements have engendered several novel minimally invasive techniques, radically different than traditional open surgery.  These approaches require a different set of surgical skills, collaborative efforts with disciplines outside of traditional surgical sciences and a creative spirit.

Over the past 30 years there has been acceleration in minimally invasive surgery that has indelibly changed the landscape of urologic practice.  Endoscopic and transcutaneous surgery for stone disease has supplanted open techniques.  Laparoscopic approaches to adrenal and renal pathology have evolved into not only acceptable alternatives but indeed the preferred surgical technique at qualified centers. Society will continue to push us to reevaluate the approach to every urologic pathologic condition, both benign and malignant.  Moreover what is minimally invasive today may not be minimally invasive by morning.

As “less” is expected by patients, our duty as surgeons continues to become more complex. Even the monumental accomplishment of removing a stone through a keyhole incision, halving the hospital stay associated with a partial nephrectomy, or slashing recovery time following RPLND is not enough. We must continue to analyze and refine all aspects of surgery.  This will require an ongoing investment in scientific inquiry, a tolerance for seemingly counterintuitive approaches and a continuous postgraduate learning process.

Lee Richstone MD

Louis Kavoussi MD

The Smith Institute for Urology
North Shore-LIJ Health System
Long Island, NY

The “Miracle on the Hudson” of US Airways flight 1549, with the survival of all 155 aboard, caused us to pause and think about the events that led to the happy outcome. We must all realize that careful planning and extensive training played a large part in this miraculous outcome.  First there are safety checklists.  Every aspect of mechanical soundness and procedural steps are reviewed.  Even the passengers are involved through the educational safety instructions prior to takeoff.  In the vast majority of air flights, safety measures help avoid situations that can lead to disaster.  Moreover, the pilots are experienced and train for hours on simulators that can reproduce any imaginable equipment failure.  Finally there was the “luck factor”: weather, empty river and nearby help.

Over the past several years, surgeons have been looking to adopt some of these practices from the airline industry to minimize complications.  Indeed a recent study by the Harvard School of Public Health in conjunction with the World Health Organization demonstrated that a simple 19 point checklist could considerably decrease complications and even death*.  Some of the items are as simple as identifying the correct side of the operation, having team members identify themselves, and checking equipment prior to surgery.  Patient education prior to surgery is also important to help assure a good outcome.  Instructing patients to avoid certain medications preoperatively, to bring films to the operating room and clean out the bowels all are important safety measures.

Unfortunately many important measures are not as easy to transfer from the airline industry to the operating room.  Although surgical simulators do exist, they are limited in their ability to truly re-create the surgeon’s experience, the precision of the procedure, and of course, the varying anatomy  that is seen with a real patient.  As such, normal routine procedures, let alone the given patient pathology, cannot be practiced for a given patient.  This differs markedly from the airline industry where planes of each manufacturer all are constructed and function in a predictable manner.  Medicine realizes that surgeon experience is important, however, there are no simulators or required mechanical exercises that surgeons must pass.  Indeed most hospitals do not set a limit on the minimal number of a case a surgeon must do to be considered competent.

Surgery must be made safer for our patients, and this is a major research initiative at the Smith Institute for Urology.  In fact, we have embarked on several initiatives that reach toward this goal. Credentialing requires documentation of experience.  Minimum volumes are required to grant privileges for high risk or robotic procedures.  Moreover, we are truly at the cutting edge of simulation and skill-assessment.  We are involved in the development of novel surgical simulators that one day may allow surgeons to practice an operation prior to coming to the operating room.  In a truly groundbreaking set of experiments, we have shown for the first time ever that surgeon’s eye and pupil function can predict surgeon skill in an objective and reproducible way.  Taking this concept even further, we have demonstrated that the brain function of novice vs. expert surgeons actually function differently based on MRIs!

Reducing the risks of human errors is critically important in high-stakes enterprises such as air-flight and surgery.  At the Smith Institute we pride ourselves at being at the cutting edge of this process, in order to make surgery safer for our patients.

*”A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” (N Engl J Med 2009;360:491-9)

Some good press on our telerounding work!

http://www.queenstribune.com/news/1174814933.html

 http://www.northshorelij.com/body.cfm?id=15&action=detail&ref=881

 http://www.brunoandtheprofessor.com/2007/03/i_am_your_robot_and_im.php

By Lee Richstone, MD

 The treatment of kidney cancer has changed DRASTICALLY in the last 10 years.  It was not long ago that essentially all patients with a kidney tumor (cancer), regardless of the tumor size, had the entire kidney removed surgically through a large and painful “open” incision.  This procedure is called a open radical nephrectomy.  Fortunately this is no longer necessary in most cases. 

The paradigm has changed in two critical ways.  FIRST, for smaller kidney tumors we now know that a partial nephrectomy, whereby only the part of the kidney containing the tumor is removed, is just as good as complete nephrectomy.  This has major advantages to patients.  This type of surgery is considered nephron-sparing surgery (NSS), and can be performed through a large open incision or with minimally invasive surgery (laparoscopically) through 3 small holes.  

Second, when a larger tumor is present and the whole kidney needs to be removed, a laparoscopic operation (laparoscopic radical nephrectomy LRN) offers major advantages to patients over open radical nephrectomy through a large incision.  These include less pain, shorter hospitalization (typically 2 nights instead of a week in the hospital), less narcotic pain medication, higher quality of life scores,  and better cosmesis. 

To summarize: state of the art urologic surgery means nephron sparing (partial) surgery for small tumors, and if you need to take out the whole kidney, do it laparoscopically.

Recently, it has been reported that both these techniques (nephron sparing surgery and laparoscopy) are greatly underutilized in the United States despite the evidence that they are advantagous to patients. The under-use of NSS and laparoscopy reported by Miller et al. is indeed is striking. In their report of 5483 patients who underwent surgery for renal cancer between 1997 and 2002 in the United States, only 11.1% of patients underwent nephron sparing surgery, and only 11% of radical nephrectomies were performed laparoscopically.  This is a major public health concern, and reflects that advanced surgical techniques do not always “diffuse” into widespread practice despite the evidence.

In contrast, at The Smith Institute for Urology, our use of both laparoscopy and nephron sparing surgery clearly demonstrates our place at the cutting edge.  In contrast to the national average of 11% utilization of NSS,  at The Smith Institute 49% of all patients who underwent surgery for RCC underwent an NSS approach!  Furthermore, when you consider patients with smaller tumors (<4cm), 85% of our patients get NSS compared to 23% around the country!.  What is even more telling is that we perform a full 87% of these partial nephrectomies laparoscopically.  Few hospitals in the country can post such numbers.

Moreover, when patients do need their entire kidney removed, at The Smith Institute 71% of these patients get the operation laparoscopically, compared to only 11% nationwide. 

SEE OUR EDITORIAL IN THE NATIONALLY RENOWNED JOURNAL CANCER THAT HIGHLIGHTS THESE ISSUES in the BLOG entry below.

Editorial: BARRIERS TO THE DIFFUSION OF ADVANCED SURGICAL TECHNIQUES

Lee Richstone, MD, Louis R. Kavoussi, MD *

Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York

email: Lee Richstone (lrichsto@nshs.edu)

The surgical management of renal cortical tumors has undergone a tectonic shift in recent decades. No longer does radical extirpative surgery rule the day. Early detection and stage migration have allowed for the introduction of organ-sparing, minimally invasive, yet oncologically sound surgery. Cancer control concerns are matched now by heightened demands to reduce the morbidity and disfigurement caused by our interventions. Justifiably, today, less is more is the force that drives us.

It has been demonstrated clearly that nephron-sparing surgery (NSS) for renal cortical tumors that measure 4 cm offers improved renal functional outcomes,[1][2] superior quality of life,[3][4] and, at the same time, long-term oncologic efficacy.[5] For patients with larger tumors who require radical nephrectomy, laparoscopy has replaced open surgery as the gold standard with a myriad of well established benefits that include shorter hospitalization, decreased pain, a more rapid convalescence, and equal long-term survival.[6][7] However, the adoption of these advanced surgical techniques into widespread practice has occurred at an unexpectedly slow rate. What are the barriers to the less is more revolution?

In this issue of Cancer, Miller et al.[8] shed light on this matter. Previously, this group exposed the gross under-use of both NSS[9][10] and laparoscopic radical nephrectomy (LRN)[11][12] among urologists in the United States. Not surprisingly, those reports associated the use of laparoscopy and NSS with urban, high-volume, or teaching hospitals.[10][11] This indirectly pointed the finger at surgeon- or hospital-specific practice patterns, rather than patient or tumor factors, as the underlying cause for this sluggish diffusion of modern, less morbid surgical techniques. However, the lack of data regarding tumor specifics and the indications for surgery limited past conclusions.

In contrast, in their current study, Miller et al.[8] employed linked data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database and from Medicare, enabling them to distinguish the impact of patient/tumor factors versus surgeon-attributable variance on the observed trends. After adjusting for demographics, comorbidities, tumor size, and surgeon volume, surgeon-attributable factors consistently outweighed the factors related to patient characteristics. The authors correctly concluded what we know from clinic experience: that the care surgeons provide depends more on [their] practice style than on the characteristics of the patient and his or her disease. This represents a significant quality-of-care issue, and the barriers to diffusion must be identified and overcome.

The under-use of NSS and laparoscopy reported by Miller et al.[8] indeed is striking. In their report of 5483 patients who underwent surgery for renal cancer between 1997 and 2002, only 11.1% of patients underwent NSS, and 11% of radical nephrectomies were performed laparoscopically. Even when the indications for NSS and LRN were strongest (tumors 4 cm and >4 cm, respectively), the use of NSS was only 23.5% and the use of LRN was only 16.2% in 2002. These are incriminating numbers. The finding that these practice patterns reflect surgeon/hospital-based variance is supported strongly by our own data. At our institution, 49% of all patients who underwent surgery for RCC underwent an NSS approach, including 85% of patients with tumors 4 cm. Moreover, 87% of these partial nephrectomies were performed laparoscopically. When a higher stage tumor mandated radical nephrectomy, 71% of those procedures were performed laparoscopically (unpublished data). It appears that, de facto, a 2-tiered system of urologic care is developing.

Why have other laparoscopic procedures, such as cholecystectomy and fundoplication, taken hold? These rapidly accounted for the majority of annual procedures within several years of their introduction.[12] What has made the management of renal tumors different? It clearly is not because urologists are unreceptive to new technology or are trailing in educational efforts. Indeed, urologists consistently have proven to be leaders in both arenas. Perhaps this is evidenced best by the meteoric rise of the robotic prostatectomy. A technically demanding procedure with a steep learning curve, robotic prostatectomy accounted for <1% of all prostatectomies in 2000 and 2001. However, rapid diffusion followed: Ten percent of prostatectomies were performed robotically in 2004, 20% in 2005, 35% in 2006, and it is predicted that the majority of prostatectomies in 2007 will be performed robotically.[13][14] These differences exist despite the fact that laparoscopy and NSS were introduced into practice and residency training programs 10 years before robotic surgery. Moreover, intensive American Urologic Association educational efforts promoting laparoscopic training have been in place for a decade and involve multiple courses annually. The obstacles to integrating advanced surgical techniques into widespread practice clearly are not uniform.

The diffusion rate of these techniques does not appear to be proportional to their respective objective benefits. For example, the functional and/or convalescence-related benefits of robotic versus open prostatectomy are far outweighed by those of laparoscopic over open radical nephrectomy. Although there are developing data to suggest a quicker return of urinary continence, the only objective, consistently proven benefit of robotic versus open prostatectomy to date is reduced intraoperative blood loss, which is of questionable clinical significance.[15] Identical hospital stay[16] and postoperative pain[17] have been reported for both procedures. Therefore, unlike the consistently demonstrated advantages of laparoscopic nephrectomy, the morbidity of robotic versus open prostatectomy appear to be equivalent. Nor does this appear to be related to lingering concerns over the oncologic efficacy of NSS or LRN compared with that of robotic prostatectomy. To the contrary, whereas the oncologic equivalency of partial versus radical nephrectomy and laparoscopic versus open nephrectomy has been firmly established, the oncologic results of robotic versus open prostatectomy continue to be evaluated, and no long-term data have matured. Thus, it is extremely unlikely that valid medical concerns present these barriers.

Part of the answer may lie in the finding that the incidence of prostate cancer far outweighs that of renal cell carcinoma. The numbers of newly diagnosed patients with prostate cancer and renal cancer are estimated at 220,000 patients and 51,000 patients for 2007, respectively.[18] Case volume indeed is important for the acquisition of new skills. Unlike general surgeons, urologists do not have a high-volume, low-complexity laparoscopic or robotic operation to hone their skills, such as cholecystectomy. Understandably, urologists may be less inclined to learn new and challenging techniques if they do not see a significant volume of patients that require the procedure to justify the significant expenditure of resources. Although it is plausible that the greater prevalence of prostate cancer allows more opportunity for urologists to acquire new skills, it seems unlikely, because 90% of urologists who perform radical prostatectomy in the United States perform <10 such procedures anually.[14] It appears that either low-volume surgeons are disproportionately making the effort to learn robotic prostatectomy in contrast to NSS or laparoscopy or that they disproportionately are referring patients with prostate cancer versus renal cell carcinoma to centers with advanced technical skills available instead of moving forward with open surgery. Why?

The observed practice patterns are driven by complex patient, physician, economic, and marketing forces working below the surface. For example, robotic surgery has an allure that has captured the public imagination. Innumerable television, magazine, and newspaper articles featuring the robotic surgical platform have provided unparalleled advertising. Nearly all of these reports claim reduced pain, swifter convalescence, and improved functional outcomes for robotic prostatectomy that have not been proven. Of course, robotic surgery also is driven by a significant industry and marketing effort that is invested in promoting the technology. No parallel exists for NSS or laparoscopy. In addition, high-technology robotic surgery is a natural partner with the worldwide web, and urologists are constructing websites at a blistering rate to promote the technique and capture market share. Hospitals, too, feel the pressure. Despite the substantially increased operative and total hospital costs, as well as the considerable capital expense associated with acquiring a robotic system,[19] hospitals in the United States are doing so rapidly to keep up with the Joneses, in contrast to other countries.[14] Patients appear to be seeking out robotic surgery disproportionately because of these factors. Based on demographic differences, it is also likely that prostate cancer patients are more likely to seek out high-technology treatment on the internet than patients with renal cell carcinoma. Thus, market-driven consumer demands may dictate that urologists have little choice in the matter. Seen in this light, it is entirely possible that urologists are disproportionately incorporating robotic surgery into their practice compared with open partial nephrectomy or LRN. Although robotic surgery offers no direct financial incentive or greater reimbursement, the pressures to offer cutting-edge care in this environment are great, lest an entire practice seem out of date.

Conversely, urologists are likely to refer patients for robotic prostatectomy more often than for NSS or laparoscopy. This is multifactorial. For the urologist without robotic training, deciding to perform an open radical prostatectomy rather than to refer a patient for a robotic procedure is a significant, and not necessarily profitable, commitment. Consultations regarding prostate cancer decision-making are lengthy and complex. The operation itself is time consuming and is accompanied by significant complication rates and postoperative concerns, such as incontinence and erectile dysfunction. Because the reimbursement rates per hour for surgical procedures have dropped 28.5% in less than a decade, whereas office-based evaluation and management billing has increased inversely,[20] a disincentive to perform complex, time-consuming operations has developed that may have led to a disproportionate rate of referral for prostatectomy.[20] In contrast, for the surgeon without the skills to perform NSS or a laparoscopic nephrectomy, the less complicated, open radical nephrectomy still can be offered. The procedure is a straightforward, less time-consuming operation with which all urologists are familiar. There are fewer postoperative concerns and morbidity to contend with. In addition, despite the cited benefits with respect to long-term renal functional outcomes, many urologists still question the necessity of nephron-sparing surgery in the presence of a normal contralateral kidney. In addition, neither the patients nor the industry drive the treatment to the extent that they do for prostate cancer surgery.

Surgeon practice styles dictate patient care delivery, often at the expense of meaningful patient benefits. This, indeed, is a significant public health issue that receives little attention. A controversial solution would be to limit the performance of complex procedures to tertiary, high-volume centers. The current data may provide another meaningful argument for this approach in addition to the numerous recent publications relating surgeon volume to successful outcomes.[21][22] Further study will be necessary to understand the complex web of market, provider, and consumer forces responsible for the barriers that continue to block the diffusion of advanced surgical care. We must remember that our duty as physicians is not only primum non nocere but to do less harm when intervention is required.

Smith Institute of Urology First in Area to Offer New Surgical Treatment for Patients with Bladder Cancer
05/08/2008

 see press release at:     http://www.northshorelij.com/body.cfm?id=15&action=detail&ref=1038

Bladder cancer surgery is entering a new era. As recent as 15 years ago, the “gold standard” for surgical treatment of bladder cancer was an open radical cystectomy (a long and complicated procedure in which a patient’s bladder was removed). Few options were available for the patient, at all but less than a handful of comprehensive cancer centers around the country. Since the 90s, the advent of technology have allowed for the refinement of laparoscopic techniques for the surgical removal of the bladder. This was due in part to the success of robotic assistance in radical prostatectomy, which has since led to robotic approaches for radical cystectomy.

A radical cystectomy is the surgical removal of all or part of the bladder. It is used to treat bladder cancer that has spread into the bladder wall (stages II and III) or to treat cancer that has recurred following initial treatment. Unlike prostate cancer, which is very slow growing, bladder cancer can be one of the most aggressive and rapidly growing forms of cancer.

According to the National Cancer Institute, bladder cancer is the fourth most commonly diagnosed cancer in men and the eighth most common in women. Depending on the stage and location, bladder cancer is often treated by surgically removing the bladder in a procedure called a cystectomy. This procedure can also involve removal of the nearby lymph nodes and part of the urethra, as well as the prostate (in men) and the uterus, fallopian tubes, ovaries and part of the vagina (in women).

Traditional cystectomies are performed through an open procedure involving a large incision across the lower abdomen. These surgeries can damage surrounding tissues and nerves and commonly result in loss or reductions in sexual function, including impotence. Robot-assisted cystectomy can avoid or minimize many of the problems associated with the traditional procedure. This minimally invasive technique helps preserve the surrounding tissue and spare the nerves to promote a return to normal sexual function.

Under the direction of Lee Richstone, MD, Director of Laparoscopy and Robotic Surgery at the Smith Institute for Urology, the minimally invasive robotic technique offers patients access to nerve-sparing urologic and prostate surgical procedures that help maintain normal function. “Compared to traditional surgery, these minimally invasive procedures result in quicker recovery, less pain and less scarring,” said Dr. Richstone. “In addition, patients generally return to a normal diet sooner and spend less post-surgical time in the hospital than they would if their procedure was performed in the traditional open procedure.”

There are probably fewer than a dozen facilities in this country where skilled urological surgeons perform robotic cystectomies.

The five-year survival rate for bladder cancer is about 60 percent, depending on how deep the cancer has penetrated the bladder wall. Risk factors for bladder cancer according to the National Cancer Institute include: tobacco use, age, some parasitic infections and personal history of bladder cancer. White males are also at greater risk. Common symptoms include blood in the urine, pain during urination and frequent urination. The symptoms, however, are not sure signs of bladder cancer and could be symptoms of infections, benign tumors, bladder stones or other problems.

The Arthur Smith Institute of Urology is the only facility on Long Island, and one of two in the New York area to routinely perform this procedure using this technique.

Media Contact: Adina Conn (516) 465-2620

Abstract

Radical prostatectomy in men aged ≥70 years: effect of age on upgrading, upstaging, and the accuracy of a preoperative nomogram

British Journal of Urology International

Volume 101 Issue 5 Page 541-546, March 2008

 

• Lee Richstone, *The Smith Institute for Urology, The North Shore-LIJ Health System, The Albert Einstein College of Medicine
• Fernando J. Bianco**Department of Urology, George Washington University Hospital, ,
• Hiral H. Shah,
• Michael W. Kattan††Department of Quantitative Health Sciences, Cleveland Clinic, ,
• James A. Eastham‡‡Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, and ,
• Peter T. Scardino‡‡Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, and and
• Douglas S. Scherr§§Department of Urology, New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA

• The Smith Institute for Urology, The North Shore-LIJ Health System, *Department of Urology, George Washington University Hospital, †Department of Quantitative Health Sciences, Cleveland Clinic, ‡Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, and §Department of Urology, New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA

Lee Richstone, Suite M41, The Smith Institute for Urology, The North Shore – LIJ Health System, 450 Lakeville Road, NY, USA.
e-mail: lrichsto@yahoo.com

: RRP , radical retropubic prostatectomy ; OCD , organ-confined disease ; MSKCC , Memorial Sloan-Kettering Cancer Center ; CSS , cancer-specific survival ; OS , overall survival ; EPE , extraprostatic extension ; SVI , seminal vesicle invasion ; PFP , progression-free probability.

Study Type – Therapy (outcomes research)
Level of Evidence  2b

OBJECTIVES

To determine the effect of age on clinicopathological features, the accuracy of the preoperative nomogram, and survival after radical retropubic prostatectomy (RRP), as there are limited data on elderly men undergoing RRP.

PATIENTS AND METHODS

A database of 258 men aged ≥70 years and 3777 aged <70 years who had RRP was reviewed to compare the clinicopathological features and survival between the age groups. The effect of age on the frequency of upgrading from biopsy Gleason sum 2–6 to pathology Gleason sum ≥7, and upstaging from clinical T1–T2 to pathological stage T3–T4 was also evaluated.

RESULTS

Men aged ≥70 years had cancers of higher clinical stage (P = 0.001), pathology Gleason sums (P = 0.01) and a lower frequency of organ-confined disease than men aged <70 years (58.1% and 69.9%, respectively, P = 0.001). There was upgrading in 76/169 (45.0%) men aged ≥70 years and in 936/2656 (35.2%) of men aged <70 years (P = 0.01). However, age was not associated with upgrading on a multivariate analysis. Upstaging was more frequent in older than in younger men (40.2% and 29.3%, respectively, P = 0.001). Age ≥70 years was associated with upstaging on multivariate logistic regression but did not affect the accuracy of the Partin tables (P = 0.14) or Kattan nomograms (P = 0.53). There was no difference in cancer-specific survival (96% at 10 years, P = 0.33) or biochemical progression-free probability between the age groups (74% and 75% at 10 years, respectively, P = 0.13).

CONCLUSIONS

Patients aged ≥70 years are more likely to be upstaged after RRP, but this does not affect cancer control. In addition, nomograms maintain their accuracy and remain valid tools in this rapidly growing patient population.

Below is a story that Reuters News Service ran earlier this week on Dr. Richstone’s publication regarding radical prostatectomy for treating older men with prostate cancer.

Reuters News Service

http://www.clpmag.com/reuters_article.asp?id=20080430clin019%2Ehtml Radical prostatectomy a good option for some older men with prostate cancer

by Martha Kerr

Last Updated: 2008-04-30 14:52:53 -0400 (Reuters Health)

NEW YORK (Reuters Health) - For men aged 70 years and older with prostate cancer but without major co-morbidities and who have a life expectancy of at least 10 years, radical retropubic prostatectomy (RRP) is “a real option,” a New York investigator told Reuters Health.

In an interview, Dr. Lee Richstone of The North Shore-LIJ Health System in New York, discussed results of a study he led involving 258 men aged 70 years and older who underwent RRP.

Dr. Richstone’s team compared clinical outcomes, pathology results and consequent upgrading of the Gleason biopsy score and upstaging of the tumor, and survival of the study group with that of 3,777 similar controls less than 70 years of age.

The older group had cancers of higher clinical stage and a lower frequency of organ-confined disease at the time of surgery than the younger men, at 58.1% and 69.9%, respectively.

There was an upgrading of Gleason score in 45.0% of older men compared with 35.2% of younger men. “However, age was not associated with upgrading on a multivariate analysis,” Dr. Richstone and colleagues report in the March issue of BJU International. Upstaging was more frequent in older men than in younger men, at 40.2% and 29.3%, respectively.

There was no difference in cancer-specific survival, which was 96% at 10 years, or in biochemical disease progression-free probability at 10 years, at 74% in older and 75% in younger men.

“It is well known that many physicians fail to consider radical prostatectomy as a treatment option for prostate cancer in men over the age of 70 due to an age bias,” Dr. Richstone commented to Reuters Health. “The truth is that men are living longer, and many septuagenarians are extremely fit, with few co-morbidities, and significant life expectancies in excess of 10 years.”

“Until now, there were limited data on the accuracy of predictive tables to guide treatment decisions, and we have demonstrated their validity in this setting,” Dr. Richstone said of his study.

“As with all treatment decisions regarding prostate cancer, the key issue is patient selection,” he cautioned. “We do not advocate RRP in all men older than 70 with prostate cancer, but for healthy older men with significant life expectancy, we demonstrate that RRP is a real option.”

BJU Int 2008;101:541-546.

Copyright Reuters 2008.

 The North Shore-LIJ Health System, The Arthur Smith Institute for Urology>Lee Richstone, M.D.,  Director of Laparoscopy and Robotic Surgery

Most men are likely to have health issues related to the prostate in the course of their lifetimes. With September being National Prostate Cancer Awareness Month, we have the opportunity to discuss this critical issue related to Men’s Health. Just like our gynecology counterparts who serve as advocates for Women’s Health, urologists aim to champion Men’s Health by raising awareness and helping to educate men about their bodies. With that in mind, here are some essential facts regarding prostate cancer that all men, and their loved ones, need to know.

What is the prostate?
The prostate is a gland involved in male reproduction. Specifically, it produces some of the ejaculate fluid that is released when a man reaches orgasm. Normal prostate fluid contains Prostate Specific Antigen (“PSA”), an enzyme that is necessary for the semen to result in a pregnancy. PSA is also important, as will be discussed in more detail later, because abnormal levels of PSA in the blood can be a clue that something is wrong with the prostate, including cancer.

Where is the prostate?
The prostate is roughly the size of a walnut; however, there is great variation in size, especially as men get older. The prostate lies just below the bladder and right in front of the rectum. The

Prostate cancer is the most commonly diagnosed cancer, and third leading cause of cancer related death, among American men.

urethra (the tube that drains urine from the bladder and out the penis) runs right through the middle of the prostate much like the core through an apple. As such, enlargement of the prostate can squeeze the urethra and make urination difficult. This can lead to symptoms such as poor urine flow and urinary frequency, both during the day and night. Such symptoms are most commonly caused by non-cancerous conditions, such as benign prostatic hypertrophy (BPH), inflammation, or infection. Although most prostate cancers are asymptomatic, prostate cancer can occasionally cause urinary symptoms or, if it spreads to the bone, pain.Examining the Prostate
Because the prostate sits right in front of the rectum, a physician can feel the surface of the prostate by placing a finger in the rectum (a “digital rectal exam”, or DRE). This can allow for the detection of any “lumps” or “bumps” which might represent prostate cancer. Another important anatomical point is that the nerves that allow a man to achieve an erection (the “neurovascular bundles” or “cavernous nerves”) lie on either side of the prostate, and are vulnerable to injury during radiation or surgery.

What is prostate cancer?
Every part of the body is made up of fundamental building blocks: cells. For example, the liver is made up of millions of liver cells and the prostate is made of innumerable prostate cells. Each individual cell is alive and has a variety of functions. All of this activity is tightly regulated, following the “instructions” encoded in our DNA.

Cancer is what happens when cells begin to grow, multiply, and act on their own in an unregulated fashion. The result is that a “mass” or “tumor” of such cells develops. These cells are abnormal in other ways, too. Instead of staying in their normal location, they can acquire the ability to travel throughout the body and start growing in other locations, causing problems. Prostate cancer develops when prostate cells start acting in these abnormal ways.

Who gets prostate cancer?
Prostate cancer is the most commonly diagnosed cancer, and third leading cause of cancer related death, among American men. In 2006, approximately 234,000 men will be diagnosed with prostate cancer, and about 27,000 will die from prostate cancer. Put another way, the average man has a 17% chance of getting prostate cancer in the course of his lifetime, and a 3% chance of dying from this disease. Men with a family history, black men, and overweight individuals, or those on a high fat diet are at increased risk of developing prostate cancer.

Who should be screened for prostate cancer, and when?
The American Urologic Association (AUA) recommends that all men beginning at 50 years old should be screened for prostate cancer. Screening involves both a blood test that detects higher than normal Prostate Specific Antigen (PSA) level and a digital rectal exam (DRE) that allows your physician to feel the prostate gland. Because either method of screening (PSA or DRE) can miss some cancers, both tests should be performed. In addition, men at higher risk, such as African American men and men with first-degree relatives who had prostate cancer, should be screened from age 40.

If my PSA or DRE is abnormal, does that mean I have prostate cancer?
Most studies demonstrate that approximately 3 out of 4 patients (75%) with abnormal screening tests will not have prostate cancer detected on prostate biopsy. Part of the reason for this is that other conditions (e.g. infection, urinary retention, or other causes) can cause elevations in blood PSA levels.Although PSA screening and digital rectal examinations are very sensitive tests for diagnosing people with prostate cancer (i.e. most people with cancer will be detected), they are not perfectly specific. This means that many people without cancer can also have an elevated PSA or abnormal DRE.

In order to make a conclusive diagnosis, a man with an elevated PSA or abnormal DRE needs to undergo a prostate biopsy, which involves microscopic examination of small pieces of prostate tissue to look for the presence of prostate cancer.

Cancer Grade and Stage
If a diagnosis of prostate cancer is made, several factors help doctors determine how “aggressive” the cancer is. Put another way, we try to determine the risk that the cancer is going to affect the patient’s health and survival. Making such an assessment allows the patient and physician to make informed decisions about the best treatment for each individual, based on cancer grade and stage.

Cancer grade is determined by the way the cancer cells look under the microscope. Specifically, the cancer can be given a score between 2-10, called the Gleason score. Cancers with low Gleason scores (i.e. closer to 2) are less “dangerous” than those with high scores (i.e. closer to 10). This is one important way that physicians can predict the behavior of a cancer, and help recommend appropriate treatment.

Cancer stage, in contrast, is a way to describe the extent of the cancer at the time of diagnosis. For example, if a cancer cannot be felt on rectal exam and was only detected via an abnormal PSA blood test, it would be deemed stage T1c. A cancer that could be felt on rectal exam but did not appear to spread outside of the prostate would be stage T2. Cancers that have already spread outside of the prostate are called stage T3 or T4, depending on the extent of spread. Like cancer grade, cancer staging helps to predict the behavior of the cancer and helps to guide treatment. In certain cases, a CT scan and/or a bone scan may be necessary to determine if it has spread outside of the prostate.

Options for Treatment
Perhaps the most important issue regarding prostate cancer is choosing the right treatment for each individual patient. Prostate cancer treatment can generally be divided into several options: active surveillance, radiation, surgery, ablative therapy (freezing or cooking), and hormone deprivation. Active surveillance, also referred to as “watchful waiting”, involves “watching” the cancer by checking PSA levels in the blood, feeling the prostate (by performing a DRE), and repeating the prostate biopsy. Most urologists treating patients in this manner check the PSA and perform the DRE every 6 months, and repeat the biopsy every 12 months. If any of these repeat tests (PSA, DRE, biopsy) suggest that the cancer is more “risky” than originally thought, “definitive” treatment with surgery or radiation is typically recommended.

Although most prostate cancers are clinically significant (i.e. they will affect the patient’s health and lifespan), sometimes doctors detect cancers that are small, low grade, and are unlikely to do any harm. With careful grading and staging of the cancer, certain patients can be “watched” successfully. More aggressive treatment can be initiated if the features of the cancer appear to “change”. In general, only patients with low risk (low grade and low stage) and low volume (small) cancers should be considered for active surveillance. It is critically important to have good, open communication with your urologist to explore all options to determine the right one for you.

Alternatively, many men choose radiation or surgical treatment for prostate cancer. Radiation can be administered via external beam radiation therapy (XRT), or brachytherapy (BT). The latter involves placing radioactive “seeds” within the prostate. New technology is available to minimize risk of radiating surrounding healthy tissue including the rectum, bladder and nerves responsible for errections. However, in order to treat the edges of the prostate, some surrounding tissue is affected. Brachytherapy may be as effective as XRT or surgery for men with low risk cancer, but caution should be taken when considering “seeds” for intermediate- and high-risk prostate cancers. Like all treatment options for prostate cancer, radiation can have significant side effects including, but not limited to, impotence, difficulty with urination, and rectal complaints.

Perhaps the most important issue regarding prostate cancer is choosing the right treatment for each individual patient.

Surgical treatment of prostate cancer involves completely removing the prostate, as well as the seminal vesicles. (The seminal vesicles produce some of the ejaculate fluid, and can be a site of prostate cancer spread). The traditional approach to removing the prostate is by “open” surgery (the radical retropubic prostatectomy, or “RRP”). This involves an incision in the skin, which starts from just under the umbilicus (“belly button”) and goes down to the pubic bone. The prostate, seminal vesicles, and lymph nodes are removed.

Over the past decade, urologists have developed laparoscopic radical prostatectomy (“LRP”) and robotic prostatectomy. Both the LRP and robotic prostatectomy employ small (1/4 inch) incisions. The robotic assisted prostatectomy is very similar to the LRP. Many believe that robotic technology offers better optics and instrumentation that translate to better outcomes, however, this has not been definitively proven. Although it is well documented that robotic and laparoscopic approaches cause less bleeding than open surgery, the additional benefits of the robotic/laparoscopic approach are still being elucidated. Like radiation treatment, surgery can cause side effects in some patients, including leakage of urine and problems with achieving erections.

Ablative therapies are being evaluated and involve freezing (cryoablation) or cooking (High Intensity Focused Ultrasound-HIFU). These are relatively new methods and used in very specific circumstances. Cryoablation, for example, may be very useful in patients who failed prior radiation. There is also work being done with these technologies to treat the tumor and spare some of the prostate. Early results are promising, but further long term results will be needed.

Choosing the right treatment for prostate cancer is a complex and highly personal decision, requiring in-depth discussion with your urologist. For more information about prostate cancer screening, prevention, and treatment options, the team of urologists at North Shore-LIJ is here to help.