Setting the standard in single port and robotic radical prostatectomy
PROSTATE CANCER
If you have been diagnosed with prostate cancer, the first thing you need to know is that you are not alone. Prostate cancer is incredibly common, and approximately 300,000 men are diagnosed every year. The second thing you need to realize is that the vast majority of men with prostate cancer can be cured, and will not die of prostate cancer. Fortunately, prostate cancer is not as uniformly dangerous as, let's say, pancreas cancer. In fact, many men with prostate cancer may not even need treatment. Despite being a surgeon, I do not recommend surgery for all my patients. In fact, approximately 25% of my patients with prostate cancer are on "active surveillance" and another 25% receive radiation. These are options we can discuss together in a face to fact meeting.
Men diagnosed with prostate cancer face many difficult questions. What kind of prostate cancer do I have? Is it dangerous? Do I need treatment at all? If I need treatment, how do I decide between all of the options? What kind of side effects will I experience? If I choose surgery, who should be my surgeon?
Typically, my initial consultations with patients with newly diagnosed prostate cancer are about 45 minutes to an hour in length. That is time with me personally. That is because of all the patients I see, I deeply believe that my initial visits with patients with prostate cancer require time to address all the questions above. The material below will "get you started", but cannot replace the in-person consultation where we dive deep into the "big three": cancer related issues, urinary issues, and sexual issues.
I want to stress one thing: there is no single approach that is best for all patients. Choosing the treatment that is right for you depends on your health status, the values you and your loved ones hold most important, your age, the risk stratification of your cancer, and other factors. Patients hear about what this baseball coach did, or that mayor or senator. That is a dangerous way to make your decision as this is not a one size fits all situation. It is important that we tailor the approach to fit you.
WHAT IS THE PROSTATE?
Before speaking about all the important prostate cancer issues we need to address together, I want to take a brief moment to talk about the prostate and anatomy. The prostate is a male organ that plays an important part in reproduction. The prostate makes a significant proportion of semen, and prostate fluid is important for sperm function and survival. Beyond it's role in fertility (making babies!), the prostate does very little for men except give them urinary problems as they get older! The prostate is situated in a very complicated spot. The prostate sits just below the bladder. Unfortunately the urethra (the "water tube" that runs through your penis) travels right through the middle of the prostate like the core through an apple. So, as your prostate grows with natural aging, the urethra can be compressed and obstructed making it difficult to urinate. This prostate growth that often comes with age is referred to as "benign prostatic hyperplasia" (BPH) and is very different from prostate cancer. There are several other anatomical issues that make prostate cancer treatment very challenging. First of all, the nerves that go to the penis and control erections sit right on the prostate "like the skin on an orange". They sit so close to the prostate, and are so delicate, that surgery or radiation treatment to the prostate can injure those nerves and affect erections. There is another important part of your anatomy that is very close to the prostate and can be impacted by treatment: your urethral sphincter. The sphincter is the muscle that opens and closes around the urethra and is important in urinary control. Damage to the urethral sphincter can lead to urinary leakage.
WHAT KIND OF PROSTATE CANCER DO I HAVE?
The first thing we review when we sit down together is get to know one another a bit, and a history and physical exam. Where are you are from, what kind of work you do, what your hobbie or interests are, are you married, have children? Not only is it important to connect with patients on these basic levels, but sometimes these personal issues can impact what treatment is right for you. Then we tackle "what kind of prostate cancer" you have. Urologists refer to this process of determining how dangerous your prostate cancer is as "risk stratifcation". Risk stratification allows us to group patients into "VERY LOW RISK”, “LOW RISK", "INTERMEDIATE RISK" and "HIGH RISK" patients, according to the potential of the cancer to harm you. Very low risk/low risk prostate cancer is much less likely than high risk prostate cancer to harm you. To determine your risk, we rely on your PSA values, MRI, the physical exam (the "digital rectal exam"), and various aspects of your biopsy result.
I will review your PSA scores in the office. PSA values less than 10 are needed to stay in a low risk group. PSA values between 10 and 20 indicate you are at least intermediate risk. PSA values greater than 20 mean you are at high risk of the cancer being dangerous to you. To understand prostate cancer risk further, you need to understand "grade" and "stage". Prostate cancer "grade" refers to how prostate cancer looks under the microscope. At that microscopic level, the grade tells us how aggressive ("bad") the cancer looks. The cancer is given a Gleason Score, which is a term you are likely familiar with now. As a side note, Donald Gleason, MD was a pathologist who looked under the microscope and came up with the grading system, after demonstrating that the microscopic appearance of the cancer correlated with how patients fared after treatment. We can talk about the details of Gleason scoring in the office, but you should know this much: Gleason 6 (Grade Group 1) prostate cancer is most often LOW RISK and on the "less dangerous" spectrum of prostate cancer. Gleason 7 (Grade Group 2 and 3 - on your biopsy this may say 3+4=7 or 4+3=7) is typically INTERMEDIATE RISK. Gleason 8, 9, or 10 prostate cancer (Grade Group 4 and 5) is the most dangerous and would mean the cancer is HIGH RISK. Technically, Gleason scores can range from 2 through 10, however, we do not see Gleason 2, 3, 4, or 5 cancers anymore. With very few exceptions, patients these days have Gleason 6 though 10 cancer.
So Gleason scores define your cancer grade and, along with your PSA values, are critical to defining the risk that your prostate cancer poses to you. Your cancer stage describes how far your prostate cancer has, or has not spread. Was it picked up only because the PSA was high and led to a biopsy, with no other findings of spread? This would be stage T1c (which is low stage). If your prostate cancer has grown big enough so it can be felt on the digital rectal exam or heaven forbid, has spread to the lymph nodes or bones, then it is higher stage and more dangerous. This too, we will discuss for your personal situation.
Determining your risk stratification is absolutely critical, as some treatments are better for prostate cancer of a given risk. For example, active surveillance (where we basically "watch" your cancer with PSA's, MRI's, and occasional biopsy) is something to consider for low risk cancer, not for high risk cancer.
DECIDING BETWEEN THE OPTIONS. WHAT DO I DO NOW?
Now is where things get difficult. There are so many options it can be overwhelming: just watch and wait, get "seeds", go for external radiation, CyberKnife (TM), or robotic surgery? And that is not even an exhaustive list of the options! We also offer focal therapy, cyrotherapy, and HIFU among other options. Although it certainly can seem overwhelming, I find that after putting all the pieces together during a consultation either one or two options become the most realistic for a given patient. When I spend time with patients trying to find the treatment that is best for them, I usually break down the discussion into three central categories: CANCER ISSUES, URINARY ISSUES, and SEXUAL ISSUES. Then we discuss the additional issues of risk of complications, amount of time it takes to receive treatment, and recovery, such as how long it will take to return to normal activities such as work and exercise.
CANCER ISSUES: Prostate cancer is not all the same. Some prostate cancers are so slow growing that they will never metastasize ("spread") and never cause any pain or suffering. On the other hand, some prostate cancers are extremely dangerous, accounting for roughly 30,000 deaths each year. Our first job together is to assess your cancer and what would be the risk of "just watching it", which we refer to as active surveillance. I believe in a very balanced approach: not all patients need surgery, and not all patients should get radiation. In fact about 25% of my patients with prostate cancer go on active surveillance because their prostate cancers are unlikely to be very harmful. Active surveillance involves check your PSA every 6 months, and using MRI scans and biopsies selectively to ensure the cancer is remaining low risk and contained. The other 75% of my patients decide to get some form of treatment -such as radiation or robotic nerve sparing radical prostatectomy (surgery). It is beyond the scope of this website to address all the issues that go into this decision. However, we will address several critical questions: what is my chance of cure with surgery vs. radiation? What is the likelihood of needing to take "hormone medications" that lower my testosterone if I undergo surgery vs. radiation? What will my follow up and PSA values be after surgery vs. radiation? If I should need a second treatment, are my options better if I start with surgery vs. starting with radiation? Does radiation increase my risk of getting other cancers such as bladder or rectal cancer? What is the value of being able to look at the entire prostate and the lymph nodes (the final pathology) after surgery as compared to radiation and other treatments? No patient with prostate cancer should make their treatment decision without speaking to a urologist and radiation oncologist who are willing to take the time to address all of these questions!
URINARY ISSUES: Almost all treatment options for prostate cancer can lead to urinary side effects. Studies have demonstrated that urinary quality of life after surgery and after radiation is probably very similar ("Quality of Life and Satisfaction with Outcome Among Prostate-Cancer Survivors", New England Journal of Medicine, 2008). However, the nature of urinary symptoms is very different with different treatments. After surgery, men usually have a period of urinary incontinence, or "leakage". This period varies in duration, and can last from weeks to months. Although the time to "drying up" is variable, 97% of my patients are free of wearing any pads by one year. Approximately 3% of patients fail to recovery to this extent, and still require pads of some kind. So their is some risk, but it is not excessive. On average, most patients dry up by about 2 to 3 months after surgery. Once patients are dry, the result is typically quite "stable" with late side effects being very unusual. After radiation, patients can also experience incontinence, but it is less common. However, they are more likely to have other symptoms such as frequency, urgency, bleeding, urinary retention, and rectal symptoms. Also, radiation effects can become a problem "down the road", with late side effects like hemorrhagic cystitis or obstruction requiring surgery. Again, there is no "one size fits all" treatment where urinary side effects are clearly better of worse with any given treatment making it the choice for all patients. When we sit down and have a lengthy discussion, we assess your current urinary issues, your overall health and priorities, and other factors that can help us determine which treatment makes the most sense for you with respect to urinary issues.SEXUAL ISSUES: Just like with urinary issues, almost all treatment options for prostate cancer can lead to sexual side effects. Just like with urinary issues, studies have demonstrated that sexual quality of life after surgery and after radiation is probably very similar but can take different time periods to manifest. Men undergoing surgery typically have a drop-off in erections immediately and then recover, whereas patients undergoing radiation have a drop-off in erections over time so that after several years they are likely to be in a similar situation ("Quality of Life and Satisfaction with Outcome Among Prostate-Cancer Survivors", New England Journal of Medicine, 2008). Also, especially for men with intermediate and high risk cancer, men undergoing radiation are more likely to need chemical castration that completely reduces their testosterone levels which can have significant impact on sex drive and erections.
I specialize in nerve sparing robotic surgery, including single port surgery solely through the navel, that spares the nerves that cause erections. By eliminating heat and traction during surgery the nerves are spared in a meticulous fashion to try and optimize your chances of sexual recovery. Take a look on the "videos" section of this website, where I demonstrate all steps in robotic radical prostatectomy. You will see nerves that are spared beautifully, without use of electricity/cautery. Personally, I don't think nerves can be spared any better than demonstrated here! In my opinion, the nerve sparing aspect of the surgery is the most important part of radical prostatectomy. Here, we act like neurosurgeons and protect those nerves with great care. Of course the critical question is "what are my chances of regaining my erections?". The likelihood of recovery is not the same for all patients. For example the results are not the same for a 50 year old man vs. a 70 year old man. The results are not the same for men already taking medications for erections compared to men with perfect erections going into surgery. The results are not the same for men in whom we can spare the nerves on both sides compared to men in whom we can only spare the nerves on one side because the biopsy and MRI results suggest the cancer is not contained on one side. Overall, most men can return to having sex either with or without medical therapy.
HOW IS A RADICAL PROSTATECTOMY PERFORMED? WHAT TO EXPECT?
Prior to surgery you will have an additional virtual appointment with nurse practitioner extraordinaire, Jackie Wentz, NP RN. We like to start patients on medication before surgery to optimize their chances of sexual recovery. This "penile rehabilitation" program is meant to maximize your outcome.
Our surgical team at the Lenox Hill Hospital has performed thousands of robotic prostatectomies, and it is really a team. From the moment you arrive the morning of surgery you will be greeted by nurses and anesthesiologists who have an incredible breadth of experience. We are not newcomers to robotic surgery, as we have led the way for 20 years.
I perform robotic nerve sparing radical prostatectomy either through a single one-inch incision in the navel (single-port) or 6 small incisions roughly the size of a fingertip (traditional multi-port robotics). In fact, I was the third surgeon in the world to perform a single-site radical prostatectomy and the longest experience in New York City with such surgery. The abdomen is filled with carbon dioxide gas and a camera is inserted through one of the small incisions. The prostate and seminal vesicles are removed from the pelvis and the bladder is reattached to the urethra. The neurovascular bundles (the critical nerves that allow for erections) are preserved in the process, without the use of cautery (electric heat) or traction that can lead to injury. The connection between the bladder and urethra (the "anastomosis") is completed in a careful manner to preserve the urethral length and sphincter, to maximize continence. Lymph nodes are removed from the pelvis to ensure that cancer is not present in the lymph nodes. At the end of the surgery, a catheter is placed in the bladder and comes out the penis to drain the bladder for one week. See the video section for full details of all the surgical steps and I'll walk you through a robotic prostatectomy.
I perform the surgery at the robotic console, and my assistant stands at the bedside to assist with the instruments. On average it takes approximately 2 hours to perform the surgery, with some time necessary for the anesthesia time to put you to sleep and wake you up. We don't rush - we concentrate on performing a perfect operation and maximally sparing nerves. As soon as we are completed, I will come and speak to your family and loved ones to let them know you are doing well. Shortly thereafter they will reunite with you in the recovery room. Pain after surgery is typically mild, with limited incisional pain and bloating. Patients usually go home within 24 hours - the next day after surgery - and our nurses make sure you are well prepared to take care of your catheter for a week.
FOLLOW UP
When you leave the hospital you will have your catheter and can attach it to a leg bag during the daytime so it is easy to walk around. Overnight, you will attach it to a larger overnight drainage bag. Don't worry...you will absolutely be able to handle it. I like to give patients my email address and cell phone number so if they have any issues at all getting through to the office line, they will be able to reach me. It is really unusual for patients to have issues during the this time, as things usually run smoothly.
The first follow up appointment is 1 week after discharge. We review your pathology which will give us a tremendous amount of information about your cancer and prognosis. For example, was the final Gleason score the same as the biopsy Gleason score? Was the cancer contained in the prostate or did it "break through" the capsule? Did it grow into the seminal vesicles? Did it spread to the lymph nodes? All of these important questions can only be answered through surgery and the final pathology report. During this appointment one week after surgery, we remove your catheter, which sounds horrible but is not as bad as it may sound. It takes less just seconds to remove. We discuss exercises to speed your urinary recovery (Kegel exercises) and discuss sexual rehabilitation through medication.
Your next appointment is six weeks after surgery. It is at this time that we check your first PSA blood test results after surgery. The PSA should be "zero" or "undetectable" at this point (<0.01 ng/ml). During this visit we assess your urinary and sexual recovery. Your follow up appointments after this occur every three to six months for the first two years.