HIFU EXPERTS BASED IN MIAMI, FLORIDA

Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds

2011-02-27T15:13:00.000-08:00

I thought you might find this interesting, and something you may want to pass on to your doctors. This confirms the extraordinary number of cases necessary to become proficient in robotic prostatectomy surgeries. The thought of the number of cases resulting in erectile dysfunction, urinary incontinence and positive surgical margins to get to a level of proficiency is way to high. As the New York times recently wrote: "Robotic prostatectomy: "more marketing than merit."But even smart and wealthy people make erroneous decisions. Just ask Bernie Madoff.

George M. Suarez. M.D.

Doctors Need 1,600 Robot-Aided Prostate Surgeries for Skills, Study Finds
By Michelle Fay Cortez - Feb 16, 2011

Doctors who perform robotic-assisted prostate cancer surgery aren’t proficient and able to remove all the malignant cells surrounding the tumor until they have done the procedure more than 1,600 times, researchers said.

Results from a study suggest the operations using Intuitive Surgical Inc.’s da Vinci robot are being performed too often at community hospitals by surgeons without enough experience, said Prasanna Sooriakumaran, lead author and urologist at the Weill Cornell Medical College in New York. Doctors have embraced the approach because studies show it can be learned quickly, uses smaller incisions, causes less blood loss and speeds recovery.

More than 90,000 men in the U.S. have their prostate gland removed each year because of cancer, according to the American Society of Clinical Oncology. The surgery is done mainly with robotic technology introduced in 2000 by Sunnyvale, California- based Intuitive Surgical, typically by doctors who perform 100 or fewer procedures annually, Sooriakumaran said.

“The operation is not easy to perform and it takes a lot of experience in order to get the best results for our patients,” he said in a conference call. “The enthusiasm in the United States needs to be tempered in terms of what sort of hospital needs to be purchasing this equipment and what sort of surgeons should be allowed to do these operations.”

The researchers tracked three surgeons learning the technique over a six-year period at high-volume centers at the University of Pennsylvania in Philadelphia, Karolinska Institute in Stockholm and Weill Cornell in New York City. Surgery times decreased with each operation, while the doctor’s ability to remove all the cancer increased, Sooriakumaran said.

Removing Cancer Cells

The surgeons needed to perform more than 1,600 operations before they were able to gauge with at least 90 percent accuracy how much tissue surrounding the tumor they needed to remove to get all the malignant cells. Leaving stray cancerous cells in the margins, at the edge of the tissue removed during surgery, can lead to recurrences of the disease.

Every hospital has its own system to train surgeons and it’s not up to the company to determine when the doctors reach proficiency, said Calvin Darling, a spokesman for Intuitive Surgical.
While he hasn’t yet seen the study, the 1,600 number “strikes me as absurd,” Darling said today in a telephone interview.

Training Time

“The average time it takes to get to proficiency as defined by our hospitals in their training protocols is typically mid- double digits,” he said. “This is an order of magnitude higher.”

Intuitive Surgical reported $660.3 million in 2010 sales of the da Vinci system, according to a company filing.
The company’s shares fell $1.20, or less than 1 percent, to $339.99, at 4 p.m. New York time in Nasdaq Stock Market composite trading.

More than 700 operations a year are done in medical centers that specialize in the surgery, compared with just a handful a month for smaller, community-based hospitals, Sooriakumaran said. The procedure needs to be centralized so that surgeons can get the amount of experience needed to gain the best results for their patients, he said.

The results will be presented tomorrow at the Genitourinary Cancer Symposium in Orlando, Florida. The investigators are now gathering information on additional surgeons to expand their findings. It is likely that other doctors, who are in lower- volume medical centers, will take even longer to get the experience they need, Sooriakumaran said. Intuitive Surgical has provided funding for Ashutosh Tewari, an author of the study and a urology professor at Weill Cornell.

Increased Use

Use of robotic technology is growing exponentially, said Nicholas Vogelzang, an oncologist at the Comprehensive Cancer Centers of Nevada in Las Vegas and chair of U.S. Oncology’s developmental therapeutics committee. Doctors need to ensure their abilities are keeping up, he said.
“This data today will make everyone pause,” said Vogelzang, who pointed out that traditional open surgery also requires years of practice. “Maybe it’s time to go a little bit farther before we rush into this surgery. Experience really does matter.”

To contact the reporter on this story: Michelle Fay Cortez in Minneapolis at mcortez@bloomberg.net
To contact the editor responsible for this story: Reg Gale at rgale5@bloomberg.net

®2011 BLOOMBERG L.P. ALL RIGHTS RESERVED.

IN RESPONSE POSTED BY DR. ANDRES BODEWIG, M.D.

2010-10-25T15:43:00.000-07:00

Dr. Scionti has was trained by the HIFU "Guru and Master" of the HIFU technology, Dr. George M. Suarez, who still is the most experienced recognized HIFU doctor in the world.

NEW POST BY ANDRES BODEWIG, M.D. ON DR. VORSTMAN

2010-09-22T08:36:00.000-07:00

right: Andres Bodewig, M.D.

This is a great article by Dr. Bert Vorstman clearly outlining the facts about prostate cancer diagnosis and the essential need for a biopsy. Needle tracking or spread has never been documented by any urologist or pathologist in the world. There may be the rare single physician that may be an advocate if this concept. But there is no science merit to this. This concept just is not true. The reason that a biopsy is essential is that it provides hugely valuable information as to the Gleason score and the aggressiveness of the cancer. We as urologist depend on this information for planing the appropriate treatment for that individual. As well as obtaining additional information on the prognosis of the cancer. Unfortunately, there are no imaging (x-ray studies) with capabilities to determine the presence or absence of prostate cancer without a biopsy. Similar to breast cancer, no women would have their breast removed by a diagnosis based on a mammogram without having confirmation by biopsy. Like wise, no man should undergo treatment of his prostate without a biopsy.

Dr. Vorstman makes a very valid point in that the one or two urologist in America that relay on MRI, as opposed to a biopsy, are the same doctor's recommending post treatment MRI's. As well as the same physicians' that have a personal interest and ownership in the MRI equipment. As pointed out by Dr. Vorstman, there is no scientific proof or merit for a post treatment MRI. The best parameter to measure the clinical outcome of prostate cancer treatment is by periodically following the PSA.

There are three elements that are important in selecting a physician: 1) Is he board certified in his specialty?, 2) How often has he performed the recommended procedure? 3) How will the information will the test he is recommending impact on the proposed treatment? And if he is recommending a prostate MRI over a biopsy, ask for medical peer review literature to confirm that this has scientific merit,

I welcome the comments of my colleagues that treat prostate cancer on a regular basis. Can anyone them really say that they can diagnose prostate cancer with an MRI ?Can anyone of them in their professional conduct recommend an MRI over a biopsy and treat prostate cancer as such...without biopsy?

Do Prostate Needle Biopsies Spread Cancer Cells? – NO THEY DO NOT!

Posted by admin in Uncategorized on September 20, 2010
no responses

Prostate needle biopsies and needle tracking marks DO NOT spread cancer cells. Furthermore,the inflammation that brings about healing of the needle track DOES NOT cause cancer.

There are purveyors of pseudo science even in the world of urology who repeatedly offer false science that is peppered with irrelevant references and non sequitur arguments to present their case.
The sole purpose for perpetuating these untruths is to confound a vulnerable target (men who have or are at risk of having prostate cancer) and steering them towards evaluations that are self serving. Invariably,this disordered rhetoric is generated and encouraged by those physicians and organizations that have most to gain. In this regard,in-house imaging equipment such as MRI’s are well known to be potential instruments for financial abuse. Therefore, at risk patients are easily encouraged to undergo needless and expensive in-house MRI studies. This convenient arrangement and investment by owner physicians, represents a huge potential conflict of interest in managing prostate cancer patients.

There simply is NO reliable evidence to support the notion that MRI with or without spectroscopy will ever dispense with needle biopsies of the prostate.
Imaging studies are unable to definitively diagnose a prostate cancer let alone make determinations on a Gleason grade and score.
No man should ever consider treatment of his alleged prostate cancer based solely on the dubious images generated by an MRI.
Even benign lesions may mimic a prostate cancer and the only reliable method for detecting a prostate cancer is based upon a needle biopsy.
Similarly,there is no evidence that “scientific” targeted biopsies of suspicious areas provides any benefits over the standard needle biopsy without the expensive MRI. In fact,using the targeted MRI approach to the prostate may detect very early low grade,low volume cancers that are usually clinically insignificant and can be managed by active surveillance.

In addition,the questionable practice of recommending routine post HIFU MRI studies on the pretext of early recognition of incompletely treated men simply represents a further shameless and unadulterated assault on the wallets of patients and insurance companies.
Only a well designed and executed trans rectal ultrasound and needle biopsy of the prostate by an experienced urologist can answer all of the questions as to the true nature of a man’s prostate cancer.
The unabashed, pseudo intellectual and illogical recycling of these myths about prostate needle biopsies spreading cancer cells
by physicians is unfounded,unconscionable and malicious.

Certainly,those urologists that are board certified are required to practice by an ethical and scientific standard. Others,however,appear to practice the peddling of half truths and this non Hippocratic behavior taints all physicians and may be considered malpractice.

UNINSURED PROSTATE CANCER PATIENTS TEND TO HAVE MORE SEVERE DISEASE AT DIAGNOSIS

2010-09-21T07:42:00.001-07:00

Uninsured Prostate Cancer Patients Tend To Have More Severe Disease At Diagnosis.

HealthDay (9/17, Preidt) reported that, according to a paper in Cancer Epidemiology Biomarkers and Prevention, "prostate cancer patients who are uninsured or on Medicaid at the time of their diagnosis tend to have more severe disease, likely because they have less access to medical care." In fact, "compared to patients with private insurance, those who were uninsured or Medicare-insured had higher PSA levels and Gleason scores, and were more likely to be diagnosed with advanced cancer." Before reaching those conclusions, investigators "analyzed National Cancer Database records of 312,339 prostate cancer patients diagnosed between 2004 and 2006."

Emory researchers eventually discovered that "uninsured and Medicaid-insured patients had approximately 4 ng/ml higher PSA levels than their privately insured counterparts," MedWire (9/17, Guy) reported. "Furthermore, being uninsured was clearly associated with having an advanced Gleason score, with odds ratios (ORs) of 1.97 and 1.67 for uninsured and Medicaid insured men, respectively, compared with privately insured patients. Being Black, Asian, or Hispanic also increased the risk for poor Gleason score compared with being White," while "being uninsured and Medicaid-insured...increased the risk for being diagnosed with advanced-stage disease, 1.85 and 1.49 times, respectively, compared with being privately insured."

PSA SCREENING IN MEN WITH SPECIFIC GENETIC MUTATIONS

2010-09-15T08:32:00.000-07:00

New Research Provides Support For Continued PSA Screening In Men With Specific Genetic Mutations.

BBC News (9/10) reports, "PSA screening has been contentious in the past because of concerns about over-diagnosis," and the medical community also remains at odds about "how effective it was at reducing mortality." Aiming to clarify the issue, UK scientists set about analyzing preliminary data culled from the "first large international prostate cancer screening study," which is "targeted at men with a known genetic predisposition to the disease." Investigators eventually concluded that "it appears that PSA screening is reasonably accurate at predicting potentially aggressive prostate cancer among men at higher risk of the disease due to a genetic predisposition." In other words, their work "provides support for continued screening in men with genetic mutations." Reuters (9/10, Kelland) also covers the study.

George M. Suarez, M.D.

INTERESTING ARTICLE OF THE SECONDARY EFFECTS OF RADIATION

2010-09-09T13:24:00.000-07:00

The following is a very interesting article that appeared recently in Cancer regarding the potential secondary effects of Radiation Therapy associated with treatment for prostate cancer. Patients are often mislead into choosing radiotherapy without full informed consent of the potential side effects. As well as their fear of even greater complications associated with surgery. As HIFU continues to prove it's efficacy with decreased side effects, it is rapidly becoming the fastest growing new treatment for localized prostate cancer. For additional information on HIFU, please visit: www.hifumedicalexpaert.com.

George M. Suarez, M.D.

___________________________________________________________________________________________________
5 Common Unwanted Effects Of Radiation Therapy With Regard To Prostate Cancer

Cancer 2010-09-07

There are three techniques used in prostate cancer treatment. One of these is via radiation therapy. This kind of treatment can be delivered in two ways, outwardly and internally. Outwardly treatment methods are done in several sessions wherein the high-frequency x-ray device is used in order to destroy most cancers tissue. The internal method or medically known as brachytherapy utilizes the implantation of radioactive seed products into the prostate gland. They are efficient methods in treating cancer. Nevertheless, they can trigger some unwanted effects towards the various areas of the body.

Among the prostate cancer radiation side effects is actually tissue damage. The tissues from the body are very vulnerable to radiation. However only a small percentage of the patients undergoing this sort of treatment encounter this sort of impact. The actual tissues associated with a few organs which are near the prostate such as the skin, vesica or rectum are broken because of the contact with radioactive supplies. When this happens it can produce loss of function and may need surgery in order to cure it.

Radiation therapy with regard to cancer of the prostate may also trigger unwanted effects for example bowel problems such as diarrhea, bowel emergency as well as hemorrhoids. Since the radiation can even achieve through the bowels due to its location adjacent to the prostate, the individual undergoing the radiation can encounter this kind of problem. The radiation does not only have an effect on cancer tissue but it also kills the standard cells causing problems about the function associated with a few internal organs like that from the bowel. Drugs receive to treat these unwanted effects.

A mans individual getting radiation therapy additionally encounters urinary incontinence. This happens to about 10 percent of those who have this sort of treatment. The actual sphincter of the urinary system bladder is actually damaged that caused seapage and incontinence. Occasionally, following radiation the patient should put on a mat just to maintain him through wetting his trousers. If this situation gets worse or does not take care of, the individual will have to go through surgical treatment and make required repair about the damage of the vesica to stop this kind of healthcare issue.

Another side-effect associated with radiation therapy with regard to prostate cancer is impotence as well as inability to conceive. Because, the actual prostate gland is actually the main man reproductive system; functions associated with male sexuality are reported. There is a issue with regards to male erection and the patient will even have a issue generating sperm. Mentionened above previously, radiation therapy does not just affect most cancers cells but also those which are typical such as the semen. The patient must find out about this because it is a great issue related to his lovemaking life.

Finally, the patient will really feel weak as well as fatigue could be experienced for about a few several weeks after the process. You have to follow the related diet that will help get through with this problem. These are the common unwanted effects that a individual experiences following a radiation therapy. But the definitive goal of the remedy outweighs these minor problems. Individual education is really essential so that the individual may know what to do during the process as well as what to expect after the therapy is carried out.

Radiation therapy with regard to prostate cancer is an effective mode associated with remedy however there are certain side effects how the patient should learn and the physicians must monitor.

George M. Suarez, M.D.

Medical Director,

The Miami Urology Center of Excellence

the SONOBLATE 500 and the Ablatherm pros and cons

2010-09-07T14:03:00.000-07:00

The article below that recently (Endourol. 2010 Aug 30.) reports on a fairly high incidence of bladder outlet obstruction following HIFU utilizing the Ablatherm (EDAP) HIFU technology. This is another example of the difference between this HIFU technology and the Sonoblate-500 (Focus Surgery). Because Ablatherm HIFU lesion is limited to .25 cm in height and is not adjustable, versus the Sonoblate has multiple size transducers capable of creating the desired HIFU lesion height. HIFU treatment at the bladder neck and at the apex are very challenging when one is limited to a single large height HIFU lesion. The scatter of energy inadvertent propagated into the

In my experience, using the Sonoblate -500, I have not encountered very many cases that have resulted in having bladder neck contraction or obstruction. Which I feel is attributable to the option of smaller size transducers resulting in the desired size lesions. Thereby, decreasing the risk of the HIFU energy scatter into the surrounding tissue and creating scar formation. We also typically maintain a fairly full bladder during the actual hifu treatment with an effort to allow any scatter of energy result in a "heat sink effect" when the transference of energy to heat is dissipated into the filled bladder.

Endourol. 2010 Aug 30. [Epub ahead of print]

Development of Bladder Outlet Obstruction After a Single Treatment of Prostate Cancer with High-Intensity Focused Ultrasound: Experience with 226 Patients.

Netsch C, Pfeiffer D, Gross AJ.

Department of Urology, Asklepios Hospital Barmbek , Hamburg, Germany .

Abstract

Abstract Purpose: To investigate the occurrence of bladder outlet obstruction (BOO) after high-intensity focused ultrasound (HIFU) therapy of prostate cancer, the need for secondary transurethral interventions for BOO, and the benefit of transurethral resection of the prostate (TURP) before HIFU. Patients and Methods: After a single HIFU treatment between 2002 and 2007, 226 consecutive patients were examined and followed at least 2 years. The Ablatherm Maxis and the Integrated Imaging devices were used. The sites of BOO were recorded. Results: Median follow-up after HIFU was 52 months (range 24-80 mos). BOO developed in 58 (25.66%) patients. Repeated BOO episodes were observed in 27 (11.94%), three to seven episodes in 13 (5.75%) patients. Patients with repeated BOO were older than patients with singular BOO (71.75 +/- 4.97 vs 68.18 +/- 5.03; P = 0.024). In primary BOO, multiple sites of obstruction were more often involved than in repeated BOO (25/58 vs 8/27). Conversely, isolated bladder neck stenosis was predominantly found in patients with >/=two episodes of BOO. The rate of primary BOO was significantly different between patients who had undergone TURP the same day as HIFU or within 2 days of HIFU (33/96; 34.38%) and patients with TURP more than 1 month (16/89; 17.98%) before HIFU (P = 0.032). BOO occurred in 21.95% (9/41) of the patients who were treated with HIFU only. Conclusions: BOO after HIFU is common, particularly affecting the bladder neck. The risk of repeated BOO is associated with age. A longer interval between TURP and HIFU (>1 month) might reduce the risk for the development of BOO.

PMID: 20804429 [PubMed - as supplied by publisher]

George M. Suarez, M.D.

Medical Director,

The Miami Urology Center of Excellence

Cell: 305-310-8238

ReplyReply AllMove...AMERICAN ALBILL McCOLLUMcd folderCONTINENTAL ALGLOBALINSURANCEHIFU FOLDERIMPORTANT SAVEDJOBSEARCHJOSHsavesavedsearchSUAREZ

GEORGE M. SUAREZ, M.D. AT DOCTOR'S HOSPITAL IN THE BAHAMAS

2010-09-07T12:43:00.000-07:00

Pictured left to right: Barry Rassin, President, Doctors Hospital; Dr. George M. Suarez, F.A.C.S., F.A A.P. Medical Director, USHIFU, International HIFU, Board Certified Urologist; James Roth, HIFU patient in the Bahamas

By Michele Rassin

Sep 1, 2010 - 4:49:13 AM
Nassau, Bahamas - Doctors Hospital has been a pioneer in minimally and non-invasive surgeries in the Bahamas with the first Laparoscopic colon surgery performed locally in 2009; today high intensity focused ultrasound (HIFU) has been added to its portfolio for treatment of prostate cancer. Doctors Hospital thus joins a select group of hospitals that is offering this innovative treatment for prostate cancer and becomes the first hospital in the Bahamas to offer this technology.

HIFU delivered with the Sonablate® 500 medical device (“Sonablate HIFU”) destroys prostatic tissue with extreme heat generated from focused ultrasound waves. Initially, the Sonablate captures real-time images of the prostate gland, allowing the physician to create a customized treatment plan for each patient. The physician then uses the Sonablate to deliver the ultrasound energy to extremely small target sites, or focal points, throughout the prostate gland. The ultrasound energy is delivered in rapid-fire succession to targeted tissue throughout the gland. The tissue at each target is destroyed while surrounding tissue remains unharmed.

HIFU treatment typically is a one-time, 2-4 hour procedure performed on an out-patient basis under spinal anesthesia. Patients generally are up and walking within hours after HIFU and can return to a normal lifestyle within a couple of days.

Men over age 50 years are still encouraged to have an annual rectal examination and a blood test called a PSA as prostate cancer is the most common non-skin cancer in men and the third leading cause of male cancer deaths worldwide.

NEW INFORMATION ON GEORGE M. SUAREZ, M.D.'S WEBSITE

2010-09-02T11:30:00.000-07:00

STUDY ON FINASTERIDE

2010-09-02T11:27:00.000-07:00

Study Suggests Finasteride May Not Be Widely Prescribed For The Prevention Of Prostate Cancer.

Bloomberg News (8/11, Fridson) reports, "Researchers urged doctors to discuss with patients the benefits of Merck & Co.'s Proscar for preventing prostate cancer, after a study found that prescribing of the product didn't increase when a 2003 trial showed the medicine wards off tumors." The "drug, also sold generically as finasteride, was shown to reduce some men's risk of developing prostate cancer by a quarter, to 18 percent from 24 percent," according to the 2003 paper in the New England Journal of Medicine.

Thus, the "American Society of Clinical Oncology and the American Urological Association issued a joint guideline in 2009 recommending that 5-alpha reductase inhibitors be considered for prostate cancer prevention in healthy asymptomatic men with a prostate-specific antigen (PSA) level of 3.0 ng/mL or less who receive regular screening for prostate cancer," Medscape (8/10, Nelson) reported. "But, according to the new survey, 64% of urologists and 80% of primary care physicians never prescribe finasteride for prostate cancer chemoprevention." In the study published in Cancer Epidemiology, Biomarkers & Prevention, "55% of urologists expressed concern about inducing high-grade tumors, and 52% of primary care doctors were unaware that finasteride could be used as a chemopreventive agent."

DR. GEORGE M. SUAREZ PERFORMING HIFU IN THE BAHAMAS

2010-09-01T12:47:00.001-07:00

PICTURED BELOW IS DR. GEORGE M. SUAREZ, M.D., FACS,FAAP. MEDICAL DIRECTOR OF USHIFU AND INTERNATIONAL HIFU, BOARD CERTIFIED UROLOGIST

Doctors Hospital has been a pioneer in minimally and non-invasive surgeries in the Bahamas with the first Laparoscopic colon surgery performed locally in 2009; today high intensity focused ultrasound (HIFU) has been added to its portfolio for treatment of prostate cancer. Doctors Hospital thus joins a select group of hospitals that is offering this innovative treatment for prostate cancer and becomes the first hospital in the Bahamas to offer this technology.

HIFU delivered with the Sonablate® 500 medical device (“Sonablate HIFU”) destroys prostatic tissue with extreme heat generated from focused ultrasound waves. Initially, the Sonablate captures real-time images of the prostate gland, allowing the physician to create a customized treatment plan for each patient. The physician then uses the Sonablate to deliver the ultrasound energy to extremely small target sites, or focal points, throughout the prostate gland. The ultrasound energy is delivered in rapid-fire succession to targeted tissue throughout the gland. The tissue at each target is destroyed while surrounding tissue remains unharmed.

HIFU treatment typically is a one-time, 2-4 hour procedure performed on an out-patient basis under spinal anesthesia. Patients generally are up and walking within hours after HIFU and can return to a normal lifestyle within a couple of days.

Considered a promising technology within the non-invasive or minimally invasive therapy segments of medical technology, HIFU uses non-ionizing, or clean, energy and may be repeated if necessary should there be a recurrence and may be used as a salvage therapy if some other treatments have failed.

Men over age 50 years are still encouraged to have an annual rectal examination and a blood test called a PSA as prostate cancer is the most common non-skin cancer in men and the third leading cause of male cancer deaths worldwide.

The newest facility to become a part of the US HIFU international treatment program, Doctors Hospital joins more than one hundred (100) centers in thirty-plus countries to offer the innovative treatment. The program provides patients from the United States access to the Sonablate technology in international facilities. Just a forty-five minute flight from Florida, this high- tech procedure can now be offered close to home for some US patients and in a beautiful island setting.

According to an article published in one of the local dailies, there is a sizeable medical tourism market for the Bahamas to tap into. In 2007, some seven hundred and fifty thousand (750,000) Americans traveled abroad for overseas medical services, spending approximately $2.1 billion. The former number is predicted to swell to within six million by the end of this year.

Poised to take advantage of the door the medical tourism opens, Doctors Hospital recently accredited by Joint Commission International (JCI), Doctors Hospital joins an elite group of few hospitals worldwide, which have passed JCI’s stringent clinical quality standards. Joint Commission International (JCI) is the global arm of the US-based Joint Commission on the Accreditation of Healthcare Organizations (JCAHO); The distinction certifies that the hospital’s programs meet international standards and follow the latest US clinical guidelines establishing it as a facility with exceptionally high standards, and as part of a high-quality network offering highly-skilled doctors, state-of-the-art equipment and innovative treatment.

Source: Doctors Hospital

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SOME MEN MAY EXPERIENCE URINARY PROBLEMS, TEMPORARY ED AFTER PROSTATE CANCER

2010-09-01T08:26:00.001-07:00

Some Men May Experience Urinary Problems, Temporary ED After Prostate Biopsy.

Reuters (8/31, Norton) reports that some men may experience urinary problems or temporary erectile dysfunction after undergoing a prostate biopsy, according to a German study published in the Journal of Urology. After randomizing 198 men to one of three types of biopsies, investigators discovered that those who were subjected to saturation biopsies were more likely to visit the bathroom during the night or find it difficult to pass urine. As for ED, that group, as well as those who underwent standard and 10-sample biopsies, had issues.

SEXUAL DYSFUNCTION AFTER CURIETHERAPY

2010-09-01T08:20:00.001-07:00

Sexual dysfunction after curietherapy and external radiotherapy of the prostate for localized prostate cancer]
[Article in French]
Huyghe E, Bachaud JM, Achard JL, Bossi A, Droupy S; les membres du comité d'andrologie de l'AFU.
Service d'urologie CHU de Toulouse, Hôpital de Rangueil, 1 avenue du Professeur Jean Poulhès, Toulouse cedex 9, France. huyghe.e@chu-toulouse.fr
Abstract
OBJECTIVES: Knowing the importance of sexuality items in the choice by the patient of the modality of treatment of localized prostate cancer, we aimed at reviewing and updating the effects of prostate radiotherapy and brachytherapy on sexual functions.
METHOD: A PubMed search was done using the keywords: prostate cancer, erectile dysfunction, radiotherapy, brachytherapy, ejaculation and orgasm.
RESULTS: After both radiotherapy and brachytherapy, sexual troubles occur progressively, the onset of occurrence of erectile dysfunction being 12-18 months after both treatments. Even though the pathophysiological pathways by which radiotherapy and brachytherapy result in erectile dysfunction have not yet been fully clarified, arterial damage and exposure of neurovascular bundle to high levels of radiation seem to be two main causes of erectile dysfunction after radiotherapy and brachytherapy. The radiation dose received by the corpora cavernosa at the crurae of the penis may also be important in the etiology of erectile dysfunction. Another important factor following radiotherapy is the treatment modality. Not many data about ejaculation and orgasm after radiation treatments have been published yet. Recent data show that most of the population treated by brachytherapy conserves ejaculation and orgasm after treatment, even if a majority describe reduction of volume and deterioration of orgasm. Patients need to be correctly informed on the possible sequela of radiotherapy and brachytherapy on their sexual well-being while planning their treatment. Patients should also be informed about the possible treatment modalities for erectile dysfunction.
George M. Suarez, M.D.
Medical Director,
The Miami Urology Center of Excellence
Cell: 305-310-8238

A RUSH TO OPERATING ROOMS THAT ALTERS MEN'S LIVES

2010-08-31T13:57:00.000-07:00

August 30, 2010, 5:00 pm A Rush to Operating Rooms That Alters Men’s Lives
By DANA JENNINGS

Jeanette Ortiz-Burnett/The New York TimesAs I scuffed through the stations of the prostate-cancer cross these past two years, I sometimes wondered whether I wasn’t a dupe caught up in a Robin Cook medical thriller.

Sure, the biopsy (so I was told) showed that my prostate was cancerous. And after it was removed, the pathology report revealed that the cancer was unexpectedly aggressive, thrusting me from the relative comforts of Stage 1 to the deep woods of Stage 3.

But at least on the surface, the cancer itself never did any damage. It was the treatments that razed me — the surgery, radiation and hormones producing a catalog of miseries that included impotence, incontinence and hot flashes. And a small voice kept whispering: What if this is all a lie? A dark conspiracy of the global medical-industrial complex?

And now comes “Invasion of the Prostate Snatchers,” by Ralph H. Blum and Dr. Mark Scholz, effectively confirming my whimsical paranoia.

Mr. Blum, a cultural anthropologist and writer, has lived with prostate cancer for 20 years without radical treatment, and Dr. Scholz is an oncologist who has treated the disease exclusively since 1995.

Their book, written tag-team style, is a provocative and frank look at the bewildering world of prostate cancer, from the current state of the multibillion-dollar industry to the range of available treatments.

About 200,000 cases of prostate cancer are diagnosed each year in the United States, and the authors say nearly all of them are overtreated. Most men, they persuasively argue, would be better served having their cancer managed as a chronic condition.

Why? Because most prostate cancers are lackadaisical — the fourth-class mail of their kind. The authors say “active surveillance” is an effective initial treatment for most men.

They add that only about 1 in 7 men with newly diagnosed prostate cancer are at risk for a serious form of the disease. “Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”

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.Yet radical prostatectomy is still the treatment recommended most often, even though a recent study in The New England Journal of Medicine suggested that it extended the lives of just 1 patient in 48.

And surgery, of course, is most often recommended by surgeons and urologists — who are also surgeons. Mr. Blum writes: “As one seasoned observer of the prostate cancer industry told me, ‘Your prostate is worth what Ted Turner would call serious cash money.’ ” As for patients, their rational thinking has been short-circuited by the word “cancer.” Scared, frantic and vulnerable — relying on a doctor’s insight — they are ripe to being sold on surgery as their best option. Just get it out.

Every urologist I met with after my diagnosis recommended surgery, even though it was believed then that I had a low-risk Stage 1 cancer. The best advice came from my personal urologist, who declined to do my operation because it was beyond him: “Avoid the community hospital guys who do a volume business in prostates.”

I did, but I’m still maimed. In my experience, doctors play down punishing side effects like incontinence, impotence and shrinking of the penis. Those are just words when you hear them, but beyond language when you go through them.

Despite the impression the authors give, though, judging the velocity or voraciousness of a prostate cancer can still be imprecise. I know this firsthand.

After my biopsy, it appeared that I had a Stage 1 cancer, a doddering old nag that the authors would have designated for active surveillance. As it turned out, I had an especially pure Stage 3 cancer, a real top-fuel eliminator in terms of velocity (and hunger).

I’m a wild card, the 1 man in 48 saved by surgery. Without it, my doctors wouldn’t have learned the cancer was so advanced, and wouldn’t have given me the hormones and radiation that helped keep me alive.

So yes, prostate cancer is a dark and mysterious country, and Mr. Blum and Dr. Scholz are good, levelheaded guides through these thickets. And in telling men to slow up and take a deep breath after they learn they have prostate cancer, they provide an invaluable service. I wish I had had this book back in 2008.

But all of this raises one last stark question: Was my life worth the 47 other prostatectomies that probably didn’t have to be performed?

I don’t know. I’m a man, not a statistic.

THE FOLLOWING ARE DR. SUAREZ' COMMENTS ON THE ABOVE ARTICLE:

There are so many valid points in this article and in this book. However, there is no mention of the alternative to surgical removal of the prostate. I am specifically referring to a technology known as High Intensity Focused Ultrasound (HIFU). The manufacturer of the technology is USHIFU, it is called the Sonoblate-500 and is based in Charlotte, N. C. This is a non invasive treatment for prostate cancer that has been approved in Europe and throughout the world since 1998. It is in final phase of investigation clinical trials by the FDA, and should be approved in the U.S. in the next 18-24 months. It provides an efficacy and cure rate similar to surgery and/or radiation, but it has less risks of complications such as referred in the article: impotence and urinary incontinence. It utilizes ultrasound energy that has no toxicity, and provides a precise treatment without scatter or displacement of the treatment to surrounding tissue. Therefore, less risk of collateral damage.

The U.S. is typically the last country to adopt new technology and new medical treatments. Mostly due to the rigors of FDA clinical evaluation, and this is a good thing. No one wants to be rendered a treatment that has not undergone proper evaluation for patient safety, efficacy and clinical outcomes. Once HIFU is approved, it will be the only prostate cancer therapy that would have undergone FDA approval. As all other therapies have had "grand fathered approval" by virtue that they were procedures performed prior to revision of FDA guidelines in 1976.

HIFU is an excellent alternative that merits consideration by men diagnosed with localized prostate cancer. It is available, and being performed by hundreds of American board certified urologist in countries where it is approved. In certain cases it is covered by insurance. The technology is based on similar delivery of energy used to break up kidney stones. It is called piezoelectric energy in the form of extracorporeal shock wave lithotripsy (ESWL). Before ESWL, patients underwent major surgery to remove kidney stones. With ESWL, they are now treated in an out patient setting with non invasive technology.

The advances in computer technology and imaging capabilities continue to transform the practice of medicine at fast and rapid speed. Some of these technologies may be considered disruptive by older , and less adopting physicians. But this the natural and normal course of evolution of medical care. I am convinced that HIFU will be the state of the art treatment of choice in the future.

For additional information, please visit website: www.hifumedicalexpert.com or www.ushifu.com.

George M. Suarez, M.D.
Medical Director,
The Miami Urology Center of Excellence
9195 Sunset Drive
Miami, Florida, 33173
Tel:305-595-0199. 1-877-949-5325
www.hifumedical.expert.com

PROSTATE CANCER SCREENING FOR OBESE MEN

2010-08-31T09:42:00.001-07:00

Prostate Cancer Screening Should Be Adjusted For Overweight, Obese Men. Fact: Overweight and obese men may have diminished prostate cancer detection.
September is prostate cancer awareness month. The following was provided by the American Urologic Association, and is placed here for educational purposes.

MedWire (8/27, Guy) reported, "Overweight and obese men may have diminished prostate cancer detection owing to low prostate-specific antigen (PSA) levels," University of Texas researchers found after evaluating data on 3,697 individuals. More specifically, "potential explanations for the association between overweight/obesity and PSA is a possible hemodilution effect caused by greater blood volume, or the suppression of PSA production caused by lower testosterone levels and higher estrogen levels," according to the paper in Urology. Thus, the study authors "recommend adjusting prostate cancer screening to allow for the impact of body mass index (BMI)."

HIFU Shows Promise as a Prostate Cancer Therapy

2010-08-30T10:47:00.001-07:00

HIFU Shows Promise As a Prostate Cancer Therapy

AMSTERDAM—High-intensity focused ultrasound (HIFU) shows promise as a treatment for early-stage prostate cancer, according to interim study results presented here at the 7th Meeting of the European Association of Urology's Section of Oncological Urology.
The study included 20 men with stage T1c-T2b, N0, and M0 unilateral prostate cancer. All subjects had a PSA of 15 ng/mL or lower, a Gleason score of 7 or less, and a prostate size of 40 cc or less. Six months after treatment with HIFU, 95% of men were able to achieve erections and had pad-free urinary continence. Also six months post-procedure, 55% of men had wet ejaculations and no patient had rectal toxicity. One man refused a biopsy at six months. Of the 19 men who underwent biopsy, two (10.5%) had cancer recurrence. One patient was switched to active surveillance and the other underwent another HIFU treatment. Six months later, magnetic resonance imaging and biopsy revealed no evidence of disease.
“By treating the disease using focal therapy we avoid the morbidity associated with radical therapy, while restoring men to a position in which they can have access to active surveillance,” said lead investigator Mark Emberton, MD, Consultant Urologist at University College London Hospital in London. “It's controversial, but it's definitely exciting—focal therapy is currently the only strategy on the table that might lead to significant and important reductions in treatment-related harms.”

SUBACUTE PENILE NUMBNESS AFTER BRACHYTHERAPY FOR PROSTATE CANCER

2010-08-26T13:02:00.001-07:00

Friday, 20 August 2010
Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Penile numbness is a rare complication of permanent prostate brachytherapy, and optimal clinical management remains unclear. We present such a case and discuss pathophysiology and clinical management strategies.
A 68-year-old male presented with a serum prostate-specific antigen level of 6.9 ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. After a permanent prostate brachytherapy implant with (125)I monotherapy to a dose of 145Gy, the patient developed complete penile numbness postoperatively on the third day.
The patient experienced complete restoration of penile sensation and function by postoperative day 9 with conservative management.
Subacute penile shaft numbness after brachytherapy is rare and is caused by dorsal penile nerve compression. Over the course of a week, the restoration of penile sensation is likely to occur with conservative management.
Written by:
Sharp HJ, Swanson DA, Patel H, Gorbatiy V, Frenzel JC, Frank SJ. Are you the author?
Reference: Brachytherapy. 2010 Aug 2. Epub ahead of print.
doi: 10.1016/j.brachy.2010.02.197
PubMed Abstract
PMID: 20685173
UroToday.com Prostate Cancer Section

#

HEALTHDAY NEWS

2010-08-24T11:46:00.001-07:00

MONDAY, Aug. 23 (HealthDay News) -- The initial treatment given to prostate cancer patients has a major impact on short- and long-term costs of care, a new study has found.
For example, while some may opt for an initial treatment that is less expensive in the short-term, the long-term costs of that treatment may actually be higher, the study authors explained.

Treatments options for early-stage prostate cancer include surgery, radiation therapy, hormonal treatment, watchful waiting, or combinations of those methods. Decisions about which treatment to use are based on a variety of factors, including cost, according to background information in the study, published online Aug. 23 in the journal Cancer.
In the study, U.S. researchers analyzed data from 13,769 prostate cancer patients, aged 66 and older, who were diagnosed in 2000 and followed-up for a period of five years. The data came from the Surveillance, Epidemiology and End Results (SEER)-Medicare database.
The men were divided into groups based on the treatment they received during the first nine months after being diagnosed with prostate cancer: watchful waiting, radiation, hormonal therapy, hormonal therapy plus radiation, and surgery. The men in the surgery group may also have received hormones and/or radiation therapy.
For most of these cases, treatment costs were highest in the first year and then declined sharply and remained steady over the next several years. According to the report, watchful waiting had the lowest initial ($4,270) and five-year total costs ($9,130), and hormonal therapy had the second lowest initial cost but the highest five-year total cost ($26,896).
The highest initial treatment costs were observed among those receiving hormonal therapy plus radiation ($17,474), and those undergoing surgery ($15,197), the investigators noted.
Over five years, total costs for hormonal therapy plus radiation were $25,097, and $19,214 for surgery.
When the researchers took into account that costs of treatment in the last 12 months of life are different than other treatment years and excluded the costs for that year, they found that total costs were highest for hormonal therapy plus radiation ($23,488) and hormonal therapy only ($23,199).
"This demonstrates that treatments that may be less expensive in the short term may have higher long-term costs," study leader Claire Snyder, of the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health in Baltimore, said in a journal news release.
More information
The U.S. National Cancer Institute has more about prostate cancer.

ARE YOU CONSIDERING CRYOSURGERY?

2010-08-23T11:10:00.000-07:00

Prostate Cancer Cryotherapy:
Common Side Effects
Prostate cancer cryotherapy (cryosurgery) freezes the entire prostate gland through a minimally invasive procedure involving ultrathin cryoneedles. Side effects usually occur due to damage of the surrounding tissue during the procedure. The severity and occurrence of side effects are largely affected by the relative health of a patient as well as whether cryosurgery is a primary or salvage treatment option. The advent of the minimally-invasive ultrathin cryoneedles and more precise imaging techniques has greatly decreased the occurrence of many side effects, with the exception of impotence.

After undergoing prostate cancer cryotherapy, some patients may experience the following side effects:

Swelling in the Genital Area after Cryosurgery
The entry of the needles through perineum (the skin and muscles between the scrotum and anus) causes irritation and inflammation. Many physicians will recommend using ice packs on the affected area or beginning a regimen of over-the-counter anti-inflammatory drug.

Scrotal Edema
A more severe complication, scrotal edema occurs when fluid collects in the scrotum. Proper evaluation most be performed by a doctor so that proper course of treatment may be chosen.

Irritation during Urination
Many men will experience itching or burning while urinating after undergoing prostate cryosurgery. Symptoms usually will dissipate in a few days. Some men will also experience urgency. Speak with your physician if symptoms worsen after a few days.

Hematuria: Blood in the Urine
Many men will experience blood in the urine (hematuria) after undergoing prostate cryotherapy. There are two types of hematuria, gross and microscopic. Gross hematuria is visible to the naked eye. If bleeding persists past a few days, please speak with your physician.

Urethral sloughing and Urinary Obstruction
The passage of dead tissue through the urethra, urethral sloughing occurs when the urethra is damaged during the cryotherapy. Fortunately, the use of a warming catheter has greatly decreased the occurrence of urethral sloughing. Severe cases of sloughing cause urinary obstruction and require medical treatment. Men who have undergone transurethral resection of the prostate (TURP) or another prostate cancer treatment, such as external radiation therapy, are at higher risk for urethral sloughing.

Urethro-Rectal Fistula
One of the more serious and rarer side effects is urethro-rectal fistula. Urethro-recto fistula occurs when an unnatural channel forms between the urethra, which carries urine or ejaculate out of the body, and the rectum, which holds fecal matter prior to defecation. This channel allows materials from one part of the body to pass into another. The results can include diarrhea or urinary tract infections. New techniques in prostate cryosurgery have lead to decrease in fistula. The warming catheter and the ultrathin, precise cryoneedles have contributed to the decrease of the occurrence of fistula.

Other Side Effects
Other side effects include impotence and incontinence. Prostate cryotherapy entails relatively low rates of incontinence after the catheter is removed. To read more about incontinence, please click here. Cryotherapy is associated with higher rates of impotence, which is the ability of maintain an erection satisfactory for sexual intercourse. To read more about impotence, please click here.

Prostate Cryotherapy Side Effects

Impotence

Incontinence

Prostate Cancer Treatment Overview

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IS ROBOTIC SURGERY REALLY BETTER THAN THE OLD?

2010-08-23T10:52:00.001-07:00

Is newer prostate surgery really better than the old

COMMENT: I had robotic prostate surgery at the end of 2009. I am unsatisfied with the results overall. The incontinence, ED, and worst of all my PSA has been rising gradually. If I had to do it over again this would definitely not the path I would have taken. My friend had the HIFU procedure out of the country and he is extremely satisfied. His sexual life is the same as before and PSA is back to normal.
Henry Woodridge

By Rachael Myers Lowe
NEW YORK | Mon Feb 22, 2010 4:30pm EST
NEW YORK (Reuters Health) - Robot-assisted laparoscopic, or "keyhole," surgery appears to be no better at reducing side effects than traditional "open" surgery to remove a cancerous prostate gland, according to new study from Memorial Sloan-Kettering Cancer Center in New York. Critics, however, claim the study relied on old data that doesn't reflect current practice.
Typically, in traditional open radical prostatectomy, a 6-inch long incision is made in the abdomen and the walnut-sized prostate gland and nearby lymph nodes are removed.
With the newer laparoscopic radical prostatectomy (LRP), several small incisions are made in the lower abdomen through which long-armed surgical instruments, including a camera, are inserted. While watching on a monitor, the surgeon manipulates the tools to cut away and extract the cancerous prostate and other tissue. Most laparoscopic surgeries performed today are robot-assisted.
While robot-assisted LRP usually leads to less blood loss and time spent in the hospital, the high cost of the equipment, its annual maintenance, and a long learning curve for surgeons has raised questions about its value, especially if patient outcomes are no better than the gold standard open surgery.
To investigate, Dr. William T. Lowrance and colleagues analyzed the outcomes for 5,923 men who had surgery to remove the prostate between 2003 and 2005. Overall, 4,858 men (82 percent) had the open procedure and 1,065 (18 percent) had the less-invasive LRP procedure. The claims data did not distinguish between LRP and robot-assisted LRP.
According to a report in The Journal of Urology, there were no differences between the older open procedure and the newer laparoscopic procedure in terms of deaths or medical or surgical complications 90 days after surgery, nor in use of additional cancer therapies in the year after surgery.
Yet, the researchers report that hospital advertising of LRP services was widespread and often overstated and implied benefits "not currently supported by existing evidence."
"It's perfectly reasonable for a man today to want a robot-assisted laparoscopic prostatectomy but patients need to have realistic expectations," which may be lacking, Lowrance told Reuters Health in an interview.
In a commentary published with the study, Dr. Yair Lotan, a cancer surgeon at the University of Texas Southwestern Medical Center in Dallas, wrote that the level of experience of the surgeon performing the procedure is more important for patient outcome than the type of procedure itself.
Lotan thinks patients "should be educated on likely outcomes of a procedure based on individual surgeon experience."
Dr. Jason Engel, Director of Urologic Robotic Surgery at George Washington University Hospital in Washington, D.C., agrees that surgeon experience is key to patient outcomes. He performs about 200 robot-assisted LRPs every year.
The Lowrance study, Engel told Reuters Health, is based on old data that does not reflect the level of surgeon expertise in robot-assisted LRP that is common today. In addition, the Medicare claims used in the study did not distinguish between patients who got the older LRP procedure and the new robot-assisted method.
"Nobody does the old LRP procedure any more," he said. "It's like comparing apples and oranges."
He acknowledged that some institutions over-sell the benefits of the robot-assisted LRP but he defended honest marketing campaigns.
"If I'm doing a great job, how am I going to get my name out there to let people realize there is this great product, when everyone knows to just go to an established institution, like Johns Hopkins, which specializes in the open RP (radical prostatectomy)," Engel said.
Engel also predicted that looking at data from surgeries performed more recently will likely show a difference in outcomes favoring robot-assisted LRP. The Lowrance study hinted at it, he noted, by finding no difference in outcomes at a time when surgeons were just starting to build experience.
"There's never been a head-to-head comparison between an experienced open surgeon and experienced robotic surgeon," Engel told Reuters Health.
Lotan believes the exponential growth of robot-assisted LRP services has been driven by a particularly American phenomenon - the perception that the newest high-tech procedures are the best even if supporting evidence is lacking.
Hospitals, noted Lotan, rarely recoup the millions of dollars spent on the robot equipment and its upkeep, but must have it to attract doctors and patients to their institutions.
Prostate cancer is the most commonly diagnosed cancer in American men. According to the American Cancer Society, more than 192,000 Americans are diagnosed with the disease annually; more than half are over the age 65.
SOURCE: The Journal of Urology, published online February 22, 2010.
Health

ROBOTIC SURGERY?

2010-08-23T10:37:00.000-07:00

Is Robotic Prostate Surgery Really Better?
By TARA PARKER-POPE
In today’s New York Times, health reporter Gina Kolata explores the marketing and the science behind robot-assisted prostate cancer surgery.

Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations. Ms. Kolata writes:

It is not known whether robot-assisted prostate surgery gives better, worse or equivalent long-term cancer control than the traditional methods … Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows.

MEN WITH A FAMILY HISTORY OF PROSTATE CANCER...

2010-08-23T10:27:00.000-07:00

The Los Angeles Times (8/19, Maugh) "Booster Shots" blog reported, "Men with a family history of prostate cancer are thought to be more likely to develop the disease themselves, so it is recommended they get screened for the disease more often." Accordingly, the "frequent screenings make it more likely a prostate tumor will be found -- including tumors that are not dangerous." But, does this mean "those men with a father or brother with the disease more likely to have a tumor diagnosis because of genetics -- or because they are more likely to be screened?" A new paper in the Journal of the National Cancer Institute "suggested that the answer was: a little bit of both."
Before reaching that conclusion, investigators "analyzed data from 22,511 brothers of 13,975 prostate cancer patients and found that the incidence of the disease was higher among brothers of prostate cancer patients than men of the same age in the general population,"HealthDay (8/10, Preidt) reported. "Disease incidence was highest among men who had two brothers with prostate cancer." Investigators also concluded that the "increased diagnostic activity among men with a family history of prostate cancer, which we observed, will inflate family history as a risk factor for prostate cancer in populations of men who commonly receive PSA

George M. Suarez, M.D.

PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER

2010-08-23T08:04:00.001-07:00

PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER

The following article was in the recent AUA newsletter. Although rectal injury is extremely rare in the HIFU patient. This article certainly merits for us to consider adopting a post HIFU protocol when treating previous failed radiation therapy patients. This protocol should also be adopted for all patient that have had a prior failed treatment such as prior HIFU, Brachytherapy, IMRT, RRP and Cryotherapy.

Correlation Exists Between Acute, Late Urinary, And Rectal Injuries In Prostate Cancer Patients Treated With RT.
MedWire (8/19, Guy) reported, "A significant correlation exists between acute and late urinary and rectal injuries in prostate cancer patients treated with radiotherapy (RT)." In fact, the "occurrence of an acute urinary or rectal event was associated with an approximately three-times higher risk for a late event in patients treated with RT alone or with RT after prostatectomy," according to an Italian study detailed in the International Journal of Radiation Oncology Biology Physics.

I would offer the following post HIFU protocol for prevention of fistula:
•Withhold voiding trial until minimum 2 weeks post HIFU.
•Maintain patient on prophylactic antibiotics while S.P. Catheter is in place.
•Place patients on anticholinergics for the first 10 - 12 days. ie: Vesicare 10 mg. Q day.
•Place patient on high residue diet for 2 - 4 weeks, or until voiding. This will need to be detailed and provided to patients. Their idea of high residue diet may not be the correct one.
•Add Metamucil daily/prn as a bulk forming laxative to combat potential constipation from anticholinergics. As well as a synergy to high residue diet.
•Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
•Hold off removing S.P. Catheter if the culture is positive and/or resistant to antibiotic patient is taking.
•Confirm ability to void by filling the bladder via S.P. tube, measure volume infused, and then measure volume voided. Do not remove the S.P. tube if greater than 20% residual urine.
•Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed. Confirm no residual of significant volume.
•Weekly nurse call to patient for the first 3-4 weeks on bi-monthly for the first 3 months, followed by monthly for the next 3 months.
•Absolutely "nothing per rectum" for 6 months.
•Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic ie: Gentamicin or Rocephin I.M.
•Emergency medic alert card with contact numbers to be mandatory carried at all times. Consider a wrist bracelet with contact information and telephone contacts. Provide back up emergency contact telephone in the event P.I. can not be reached.
•Patients should be urged to curtail any heavy excessive exercise or work.
•They should also be urged to not travel beyond the U.S. for the first six months.

George M. Suarez, M.D.

INCREASED SCREENING AMONG MEN WITH FAMILY HISTORY OF PROSTATE CANCER PATIENTS DISCUSSED

2010-08-23T07:52:00.001-07:00

VESICO-RECTAL FISTULA ASSOCIATED WITH HIFU

2010-08-23T07:47:00.001-07:00

Vesico-rectal fistula associated with HIFU

Clinical Presentation
Vesico-rectal fistula are extremely rare with HIFU with a less than .5% repoeterted incidence.The presenting symptoms and signs of enterovesical fistulae occur primarily in the urinary tract. Symptoms include suprapubic pain, irritative voiding symptoms, and symptoms associated with chronic urinary tract infection (UTI). The hallmark of enterovesical fistulae may be described as “Gouverneur syndrome”, namely, suprapubic pain, frequency, dysuria, and tenesmus. Other signs include abnormal urinalysis findings, malodorous urine, pneumaturia, debris in the urine, hematuria, and UTIs.

The severity of the presentation also varies. Chronic UTI symptoms are common, and patients with enterovesical fistula frequently report numerous courses of antibiotics prior to referral to a urologist for evaluation. Urosepsis may be present and can be exacerbated in the setting of obstruction. It has been demonstrated in dog models that surgically created colovesical fistulae are tolerated well in the absence of obstruction.
Pneumaturia and fecaluria may be intermittent and must be carefully sought in the history. Pneumaturia occurs in approximately 50%-60% of patients with enterovesical fistula but alone is nondiagnostic, as it can be caused by gas-producing organisms (eg, Clostridium species, yeast) in the bladder, particularly in patients with diabetes mellitus (ie, fermentation of diabetic urine) or in those undergoing urinary tract instrumentation. Pneumaturia is more likely to occur in patients with diverticulitis or Crohn disease than in those with cancer. Fecaluria is pathognomonic of a fistula and occurs in approximately 40% of cases. Patients may describe passing vegetable matter in the urine. The flow through the fistula predominantly occurs from the bowel to the bladder. Patients very rarely pass urine from the rectum.
Symptoms of the underlying disease causing the fistula may be present. Abdominal pain is more common in patients with Crohn disease, but an abdominal mass is discovered in fewer than 30% of patients. In patients with Crohn disease who have a fistula, abdominal mass and abscess are more common.

General evaluation of vesico rectal fistula

Iatrogenic pathophysiology
Iatrogenic fistulae are usually induced by surgical procedures, primary or adjunctive radiotherapy, cryosurgery, HIFU and/or post procedural infection. Surgical procedures, including prostatectomies, particularly the post radiated salvage radical prostatectomy patient, as well in resections of benign or malignant rectal lesions, and laparoscopic inguinal hernia repair have been associated with fistula formation. Unrecognized rectal injury at the time of radical prostatectomy is an uncommon but well-documented etiology of recto urethral fistula.

Scatter or emission of treatment from external beam radiation, brachytherapy, HIFU or cryotherapy to bowel in the treatment field can eventually lead to fistula development. Radiation-associated fistulae usually develop years after radiation therapy for a gynecologic or urologic malignancy. The post HIFU fistula is more likely to develop in association with blind instrumentation or spontaneously at two to three months after the procedure. In the first three months after HIFU, there is recognized sloughing of the entire prostatic urethra. This is as a result of coagulative necrosis secondary to HIFU. During this period of time the prostatic tissue is ulcerated and friable. Making it extremely sensitive to blind instrumentation and at greater risk of injury to penetrating the surrounding tissue, and more so the rectum.

Fistulae develop spontaneously after perforation of the irradiated intestine, with the development of an abscess in the pelvis that subsequently drains into the adjacent bladder. Radiation-associated fistulae are usually complex and often involve more than one organ (eg, colon to bladder). Although rare, fistulae due to cytotoxic therapy have been reported in a patient undergoing a CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) regimen for non-Hodgkin lymphoma. Therefore, past medical history of such medications should be considered.

The incidence of radiation-induced fistula associated with urologic and gynecological (recto vaginal or vesicovaginal) cancers is approximately 0.5% to 1%. The overall risk of a fistula formation is the same as the risk of rectal injury following a radical prostatectomy or various forms of EBRT, and interstitial prostate brachytherapy. The patients at highest risk of a fistula associated with HIFU are those undergoing a salvage procedure.

Traumatic pathophysiology
Urethral disruption caused by blunt trauma or a penetrating injury can result in fistulae, but these fistulae are typically rectourethral in nature. That is why any need for instrumentation in the post HIFU patient should be done under direct vision. In the post surgical, or HIFU patient, the history of prior surgery alone should be sufficient to properly diagnose the etiology of the fistula. However, one should always keep in mind the possibility of associated pathology such as bowel malignancy, inflammatory bowel disease and bladder cancer as a contributing factor. Particularly if the fistula fails to heal spontaneously after attempts at conservative management have been exhausted.

DIAGNOSTIC TESTING

· Charcoal test: Oral activated charcoal can confirm the diagnosis of enterovesical fistula.

Several hours after ingestion, flecks of charcoal can be noted in the urine.

· Cystoscopy and possible biopsy.

· Endoscopic visualization has the highest yield for the identification of enterovesical fistula.

•Eighty to 100 percent of cases demonstrate bullous edema, erythema, or exudation of feculent material from the fistula site
•Generally, colonic fistulas occur on the left side and dome of the bladder, whereas small bowel fistulas occur on the dome and right side of the bladder.
•Biopsy of the fistula is indicated in cases where malignancy is suspected. · Colonscopy and barium enema.

· Although less common than diverticular disease, it is important to exclude primary intestinal malignancy as the cause for the fistula.

· CT or MRI of the pelvis.

· Air in the bladder in the absence of prior lower urinary instrumentation is highly suggestive of an enterovesical fistula.

VCUG

· May demonstrate the fistulous connection.

· In some cases, however, the fistula can act as a "flap valve" and contrast will not be seen entering the bowel.

HIFU FISTULA: INTRA AND PERI-OPERATIVE PREVENTION

· Standard DRE, followed by slow and careful insertion of a second finger. I do not use forceful dilation, but simple leave the two fingers in place until the rectum and sphincter accommodate to both fingers...and it does relax and accommodate with time. This cannot be forced or hurried.

· Abort the procedure if unable to accommodate the index and middle finger in the rectal vault or if excessive bleeding.

· Keep the index finger pushing down at the 6 o'clock position during gentle and slow introduction of the probe.

· I prefer using the latex allergy condom. They are more durable and less likely to break. Therefore, less risk of having to reinsert the probe again. Multiple reinsertions only add to potential trauma to the rectum.

· I prefer two (double) “O rings” at the proximal end of the condom. This will reduce the potential of breaking the condom seal and the risk of getting air in the condom---another risk of having to remove and reinsert the probe again.

· I prefer bring the temperature of the Sonochill down to as low as possible in order to decrease heating.

· I prefer to use the minimum needed amount of water in the condom. This decreases the amount of pressure on the gland during treatment. My theory on this is that the less volume of interface between the transducer and the gland, the greater the coefficient of absorption of energy capability in the tissue. This, versus a greater volume of interface, may result in greater compression of the gland and less absorption of energy in the compressed gland. This can potentiate scatter of energy in the wrong direction, such as the rectal wall., NVB, sphincter.

· The rectal wall must have a minimum of 4-5 mm. in thickness without compression and a similar thickness should be maintained at all times. Undue compression of the rectal wall increases the risk of rectal wall injury. This is tissue that previously been treated and is more likely to be fibrotic and less vascular. Thereby compromising the ability of healing.

· The recurrent treatment glands are typically small and can be treated in two zones. All treatment zones (4 and 3 cm. probes) should be performed with the "extra" icon on (3 on, 6 off cycle)

· If the gland is very small with a short AP distance, try to get most of the overlap in the anterior zone. Even if it means extending the treatment outside the capsule. The distance from the anatomic capsule to the "surgical capsule" when doing a RRP is the thickness of the vascular pedicle and peri-prostatic fatty tissue. It is several mm. in thickness, and unlikely hurt anything by slightly treating lateral in this region.

· I am a firm believer in maintaining RWD at the same level in the reference and real time images as much as possible. I prefer to add water when the distance in the real time images changes beyond one-tenth of a mm. For example, if the real time image drops from 1.5 cm to > 1.4, I will pause and add small amounts of water to return to the reference image distance of 1.5 cm. I believe these changes occur due to build up of steam and swelling within the gland. This however, is more common in the primary therapy tan recurrent cases. The pause time will also allow more cooling time.

· I also believe in pausing and stacking at 1/3 interval into each zone. This will assure that there has not been movement of the gland toward the base. This allows the operator to remove HIFU lesions that are now anterior and above the apex- the site of the most common strictures. It also allows adding or subtracting any necessary lesions at the level of the base. Which is where the gland retracts. Stopping and stacking at 1/3 interval will also add cooling tome to the procedure.

THE MOST COMMON CAUSES AND SITE FOR A FISTULA

FORMATION ASSOCIATED WITH HIFU

· The most common cause of a fistula in the HIFU patient occurs when treatment results in misdirected energy into the rectal wall and/or below Denonvillier's fascia.

· Misdirected energy can occur from pre-focal heating, or from energy bouncing off calcifications or radioactive seeds. Continuous observation during treatment and adjustments of rectal wall distance and energy are the best method of preventing this from happening.

· The recommended energy adjustment to rectal wall distance should be continuously monitored. Particularly at the first lesions at Apex wish marks the beginning of each treatment row. This is where there can be the most variation in rectal wall distance as the sequence of lesions alternates from side to side (M versus P). This is easily accomplished by moving the "mouse" over the energy icon to the right of the watt adjustment slide bar. The adjustment can be performed moving the energy marker, or by clicking on the F12 icon and using the up or down arrow.

· Treatment into the rectal wall or below Denonvilliar’s fascia most commonly occurs during treatment of the posterior zone. But can occur in any zone, and at anytime. It is most likely to occur at the most lateral borders of the prostate where the crescent shape of the gland is most evident as the gland "tents downward." Likewise toward the apex, where it begins to take an upward orientation or slopes up as it gets closer to the external sphincter.

· Prevention of treatment below Denonvilier's fascia at the lateral borders and toward the upward slope of the prostate can be achieved by adjusting the stepper and/or water in the condom accordingly.

· Be extremely careful to not exceed the 2 cm limit rectal wall distance when treating toward the most lateral sides of the prostate.

· Always allow a 1 - 1.5 mm safety margin between the lower limits of the treatment limits to Denonvillier's fascia. The HIFU lesion is "cigar shaped" at the tip. This will allow some degree of treatment to be extended downward.

· I personally do not feel it is necessary to compromise the energy level or "power down" when treating the posterior zone, and in fact this is the site most likely to have cancer whether primary or recurrent.

POST HIFU PROTOCOL FOR PREVENTION OF RECTAL FISTULA IN RECURRENT TREATMENT CASES

· Withhold voiding trial until 2 weeks post HIFU in recurrent treatment cases.

· Place patients on anticholinergics for the first 10 - 12 days. i.e.: Vesicare 10 mg. Q day.

· Place patient on high residue diet for 2 weeks, or until voiding. This will need to be detailed and provided to patients.

· Add Metamucil as a bulk forming laxative to combat potential constipation. As well as a synergy to high residue diet.

· Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.

· Hold off removing S.P. if the culture is positive and/or resistant to antibiotic patient is taking.

· Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed.

· Weekly nurse call to patient for the first 3-4 weeks, bi-monthly for the first 3 months, followed by monthly for the next 3 months.

· Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic i.e.: Gentamicin or Rocephin I.M.

· Emergency medic alert card with contact numbers to be mandatory carried at all times.

· Patients should be urged to curtail any heavy excessive exercise or work.

· They should also be urged to not travel beyond the U.S. for the first six months.

MANAGEMENT OF POST HIFU FISTULA

· Always be on the lookout for early symptoms of the potential of a fistula in the post HIFU patient. Educate the patient to be alert of any of these symptoms.

· Early symptoms; New and acute onset of peri-rectal pain and/or sense of fullness. A sense constipation or desire to have a bowel movement but can't. Acute onset of watery diarrhea particularly associated with voiding. The presence of gas or fecal material per urethra. Fever, chills and general malaise.

· Immediate management: Place a Foley catheter or Suprapubic catheter. Either one should be done under direct vision. I prefer a Suprapubic catheter using a flexible cystoscope for guidance and confirmation. Obtain a urine culture, baseline CBC and blood culture if febrile. Place the patient on appropriate broad-spectrum antibiotics, anticholinergics and high residue diet. Obtain urine culture and sensitivity weekly. Restrict activities as much as possible to only necessary. If the Suprapubic remains in place for a prolonged period of time, change every three weeks.

· Consult a colo-rectal specialist. It is best to get him on board from the beginning in the event additional intervention such as a temporary diverting colostomy may be required. The post HIFU fistula is typically very small and will heal on it's own with the above measures. Be patient and consciously reassuring to patient and family.

· The post HIFU fistula will typically heal on it's own within 6 to 8 weeks. If clinical resolution of the fistula remain doubtful, a voiding cystourethrogram via the Suprapubic catheter and/or a CT Scan combination may be helpful in confirming closure.

George M. Suarez, M.D.

Co- Founder, Medical Director Emiritus

USHIFU. International HIFU

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