Changing the experience of prostate surgery

    Changing the Experience of Prostate Surgery

    Minimal invasive surgery

    Harnessing the high-tech power of robotics with Da Vinci prostatectomy

    This year in the United States, as many as 180,000 men will be told that they have prostate cancer. By age 50, about one-third of American men have microscopic signs of prostate cancer and by age 75, half to three-quarters have some cancerous changes in their prostate glands.

    Fortunately, most of these cancers remain latent, producing no signs of symptoms, or they are so slow-growing that they never become a serious threat to health. However, about 16 percent of American men will be diagnosed with prostate cancer during their lives: 8 percent will develop significant symptoms: and 3 percent will die of the disease.

    The incidence of prostate cancer is much higher in the US than the Asian population. Technically speaking, the difference between Western and Asian prostate cancer rates may be partly due to genetic polymorphism in the androgen receptor and androgen metabolism pathway enzymes as well as to dietary or environmental factors. In particular, phytochemicals, such as isoflavonoids and tea polyphenols, which are common in Asian diets, show promising anti-mitotic activity in animal and clinical studies. In fact, we don't know for sure. All we do know is that as the lifestyle of Asia becomes more Western, many Asian countries appear to be losing their cultural protective factors and acquiring high-risk ones.

    According to a study by the Department of Urology, Singapore General Hospital, some low-risk countries, such as Japan and Singapore, have been reporting a more rapid increase than high-risk countries. The hospital's study found that the incidence of prostate cancer had risen by 5-118% in its indexed Asian countries from 1978-1997. Incidences in Japan rose as much as 102% whilst the incidence in Singaporean Chinese increased 118% from 6.6 to 14.4 per 100,000 person-years.

    The mortality data for prostate cancer showed a similar rising trend. The increases in age-adjusted mortality rates per 100,000 person-years ranged from 50% in Thailand to 260% in Korea.

    Dr. Kulwat Prasertsuntarasai, a urology doctor at Bangkok Hospital Medical Centre, says that the hospital's screening programme is currently diagnosing about ten men a month with prostate cancer.

    What is the prostate?

    The prostate is a chestnut-shaped gland of the male reproductive system about the size of a walnut. It is located in front of the rectum and just below the bladder, and surrounds the beginning of the urethra (the tube that carries urine and semen out of the body).

    The main purpose of the prostate is to produce fluid for semen, which transports sperm during the male orgasm, and to protect the bladder against bacterial invasion. The nerves involved in penile erection are located posteriorly on each side of the prostate gland. Therefore, the prostate is also considered to be an accessory sex organ.

    The prostate normally increases in size around the age of puberty and then usually remains constant until the age of 45 to 50 years, at which time it may begin to undergo varying degrees of enlargement stimulated by rising levels of the male hormone testosterone. This non-cancer-related process is called benign prostatic hyperplasia (BPH) and can cause urinary problems in older men. Approximately 33% of men over the age of have BPH.

    The prostate can also develop cancer. Carcinoma of the prostate is the most commonly diagnosed male malignancy in the U.S. Because it grows so slowly, it often produces no symptoms and men often die of other causes before the cancer becomes an issue. Early detections is the key to successful treatment with a 5-year survival rate of greater than 80%

    In general, prostate cancers grow very slowly. It is known that the growth rate of prostate cancers increases in response to the presence of male hormones (androgens). Therefore, several treatments are targeted at reducing or elimination androgens in the body.

    In its advanced stages, prostate cancer can spread (metastasize) to other parts of the body including the lymph nodes, bone, spine, liver, lungs, adrenal glands and the brain.

    The first decision in the management of patients with prostate cancer is how aggressively the cancer is to be treated. Aggressive treatment usually includes surgery, radiation, and/or hormonal therapy. Less aggressive therapy may consist of radioactive implants or hormone therapy, either at the time of diagnosis or later, when symptoms appear.

    The decision to aggressively evaluate and treat a prostate cancer depends on several factors, including age, life expectancy, general health status, stage of the tumor, the desire to maintain erectile function, the individual wishes of the man regarding the desire for cure versus palliation.

    After a diagnosis of prostate cancer, a man and his family face several choices and personal. Before making these decisions, it is very important to learn about all the options available. With this knowledge, a newly diagnosed prostate cancer patient can participate more confidently with his doctor in planning his individual treatment.

    The Da Vinci way

    The Da Vinci prostatectomy procedure is a new minimally invasive approach to prostate cancer surgery that offers considerable benefits to the patient.

    The Da Vinci surgical system is a state-of-the-art medical service comprised of a surgeon console and a patient-side robotics system with a high-resolution camera and micro instruments used in surgery.

    The computer-enhanced system scales the hand-movements of the surgeon at the console, down to micro movements of the surgical instruments on the patient-side system.

    Unlike standard microscopic instruments, the specialized Da Vinci instruments can articulate and rotate 360 degrees with unparalleled precision and flightability. The camera of the system gives a remarkably clear three-dimensional and 10X magnification view inside the body.

    Once the prostate is cleanly detached, the prostate is then removed through a small incision. The bladder is re-attached to the urine channel over a catheter. This catheter is left in place for a short period of time to ensure proper healing. The surgery is completed with the removal of the instrument and the closure of the small incisions in the abdomen.

    Prior to the Da Vinci prostatectomy, the conventional approach to removing the prostate gland required a large open incision in the lower abdomen. With the advent of this next procedure, recovery time is quicker and the patient enjoys significant benefits that change the experience of surgery: smaller incisions, less pain, less blood loss, less risk of infection, shorter hospital stay, less scaring, quicker returning to normal activities.

    "There are three primary goals for this type of surgery-one is to put the patient in cancer-free status, the second is to preserve their continence, the third is to preserve their sexual function," explained Dr. Kulwat.

    The precision of the Da Vinci operative approach has been demonstrated to include improved cancer control, early return of urinary function and improved outcomes for potency, he added.

    Looking inside the pelvis, the anatomy around the prostate consists of muscles and delicate nerves that affect both urination and erections.

    During the removal of the cancerous prostate, the surgeon works to spare these very delicate structures utilizing the articulation Da Vinci instruments and a highly magnified 3-D view of the anatomy provided by the system. This added control and precision assists the surgeon in preserving the anatomy necessary for urinary continence as well as the nerve bundles responsible for erections. As a result, the patient will have a quicker return of erectile function after the surgery. The operation also preserves the sphincter which controls the continence after the surgery, urination, so the patient will return to the normal urination sooner than the traditional operation. In most cases, the patient stays in hospital 24 hours and at most two days. The whole procedure is over in around 2-3 hours.

    Bangkok Heart Hospital, one of the hospitals under Bangkok Hospital Medical Center acquired a Da Vinci Robot about two years ago and is now also using it for prostate surgery. Since introducing the procedure in March, the hospital has conducted several successful removals of the prostate which have left no cancer in the patient's bodies. Only one other hospital in Thailand, a government-run hospital, currently offers the treatment.

    "The treatment was invented in the US and in the past 3-4 years there have been about 1,000 operations world-wide. It is now well on its way to become the standard procedure for prostate removal in leading hospitals," said Dr. Kulwat.

    With men who have a genetic tendency to prostate cancer, i.e. if it tends to run in the family, are recommended to start regular annual scanning for the disease at about 45 years of age. Those not in the high risk group are recommended to begin screening at 50 years of age.

    Screening is the only way of finding out about the cancer in time as most patients don't physically notice anything is wrong in the early stages.

    "The most important thing is to join the screening programme to detect the cancer in the early stages. Fortunately, prostate cancer is very slow-growing. It may take a matter of years before it starts to get out of hand. However, once the cancer spreads from the prostate into the other organs, the task becomes much more difficult, radical and uncertain."

    Prostate cancer is unique to each individual patient. No one can predict with absolute certainty what the outcomes will be after surgery. Patients should consult with their doctors about the specifics of their disease state for a better understanding of what to expect prior, during and after surgery.

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