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Surgical treatment of prostate cancer
Prostate cancer is the most common solid organ malignancy diagnosed in men. It is estimated that in 2010, 217,000 men will be diagnosed with prostate cancer, and 32,000 men will die from it. Thanks to prostate-specific antigen (PSA) screening and early detection programs, the vast majority of new diagnoses represent clinically localized disease. Fortunately, many effective treatment options exist for men confronted with this disease. Combining all forms of therapy, the 5-, 10- and 15-year survival rates are 92 percent, 87 percent and 79 percent respectively.

Robotic Assisted Laparoscopic Prostatectomy (da Vinci Prostatectomy or RALP) has become the surgical treatment of choice nationally. The da Vinci Robot was FDA approved in 1995, and has been routinely performed in the United States in growing numbers since 2002. It is FDA approved for applications in urology, gynecolgy, general surgery and cardiothoracic surgery. As of June, 2010, there are 1,571 systems installed world wide, with 1,160 in the United States. The greater St. Louis region has six. In 2009, there were an estimated 90,000 radical prostatectomies performed in the United States, with 85 percent of these performed robotically. St. Luke's hospital, with the generous efforts of many, invested in this exciting technology in fourth quarter of 2007.

Benefits to this new, minimally invasive approach include decreased blood loss, less post-operative pain, decreased urinary catheter time and improved visualization which we feel leads to better recovery of urinary continence, erectile function and improved cancer control. Additionally, greater than 90 percent of our patients were discharged the next day. We have had very few complications.

This technology has caused an evolution in surgical therapy of prostate cancer at St. Luke's Hospital. In 2007, there were 84 prostatectomies performed: 53 open radical retropubic, 30 laparoscopic and one robotic. In 2008, there were 21 open retropubic, two laparoscopic and 116 robotic assisted prostatectomies. In 2009, there were 113 robotic prostectomies. Additionally, we are extending the indications for this operation, removing the prostate in men with advanced disease, who were previously considered too high risk for surgical extirpation.

Our data for 2009 compares favorably to the national data regarding margin status:

  Total Pos Margin Neg Margin Overall %
2009        
T2a 13 0 13  
T2b 4 2 2  
T2c 75 21 54 All T2 25%
T3a 16 13 3  
T3b 5 3 2 All T3 76%
Total 113 39 74 34%

T3 disease indicates spread outside of the prostate capsule into the periprostatic tissues and, in T3b cases, into the attached seminal vesicles. These men are typically referred for adjuvant radiotherapy to reduce chances for recurrence.

Review of the current literature shows RALP to be an effective oncologic procedure. Mani Menon, MD, an authority on minimally-invasive prostate surgery, recently reviewed 1384 cases completed between 2001 and 2005 with a median follow-up of 5 years, and found the biochemical recurrence to be 13.6 percent (189). In this series, there was a 25 percent incidence of positive surgical margins . Positive margin rate (PMR) is a surrogate endpoint to estimate oncological outcome. It is an independent risk factor for PSA/disease recurrence. Nationally, PMR rates are 9.4 to 25 percent, which is similar to Open RRP 12-25 percent. We continue to improve and modify our technique, in order to reduce our positive margin rates, improve urinary continence and recovery of erectile function. Through the first quarter of 2010, our margin rate is 11 percent. Continence rates for RALP range from 90.2 to 97 percent nationally, and we feel our data is reflective of this. Going forward, we hope to enhance our data collection to include information on potency, continence and PSA recurrence.

As our experience broadens, we continue to reduce our complication rates. In 2009, we had no conversions from robotic to open procedures. We had a transfusion rate of 2 percent and one re-operation for small bowel obstruction.

We feel fortunate to have a dedicated team of OR staff and anesthesiologists that have made our program an ongoing success. The efficiencies we have gained through experience, hard work and dedication translate into better outcomes for our patients.

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