Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses 2008 prostate cancer statistics and the aging of the population of prostate cancer patients. Prostate cancer is the second leading cause of death in men. There is a one in six probability of getting diagnosed with the disease. Men are living longer due to better health care and fitness so the number of cases is growing as a result. He also discusses the causes of prostate cancer, including racial, environmental, dietary and genetic factors, and the breakdown of patients by race and ethnicity.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses prostate cancer screening guidelines, whereby it is recommended for men over the age of 50 to get screened. Men in high-risk groups such as African-American or those with a family history should get screen at age 45. He also discusses the Prostate Specific Antigen (PSA) definitions, which is a basic blood test. He also discusses the density, velocity and implications of PSA results. It is important to note the rate of rise of PSA over time. The PSA value is not as important as the velocity rate, which is why three measures are taken over an 18-month period. Dr. Samadi also discusses biopsies, being that there are no standardized systems, therefore the number of PSA cores can vary from specialist to specialist. He also discusses the Gleason Pathologic Scoring system and important of obtaining second opinions.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the prostate and the goals of prostate cancer treatment. The primary goals of prostate cancer treatment options are cure, quality of life and continuance of sexual function. Dr. Samadi also reviews the various prostate cancer treatment options such as surgery, radiotherapies, seeds, HIFU, cryotherapy, etc.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the three main ways to remove the prostate: traditional radical prostatectomy (open surgery), laparoscopic prostatectomy, and robotic prostatectomy. He also discusses the hybrid use of these surgeries: open surgeons use laparoscopic surgery, some open surgeons use robotic surgery, and some laparoscopic surgeons use robotic surgery. Dr. Samadi discusses the order of steps needed for success in training: open surgery, laparoscopy and robotic surgery. Robotic surgeons need a foundation in oncology, open surgery and laparoscopic training.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the advantages of prostate removal versus other options such as radiation. Advantages include being the only option that removes the entire prostate. The other options keep the prostate intact. With prostate removal, a doctor can see exactly how much cancer there is, because of accurate staging, volume, grade of the tumor and margins. There is easier follow-up because PSAs are very sensitive post-op. There is no risk of secondary malignancy. Radiation is still an option after surgery but surgery after radiation remains a morbid case. This is also subject to personality preference where a patient may prefer to remove the prostate altogether.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the questions a patient should ask their doctor and also addresses some surgery myths. He discusses tactile feedback where urologists say that they must use their hands to perform cancer surgery. He goes over the pain issues and the morbidity issues of open surgery. He challenges the notion that if you add up the holes that are made in robotic surgery, it would equal the incision made during open surgery. The sum of holes or incisions is not what determines the pain. Dr. Samadi says that an expert in this field is someone who has handled a large volume of cases. The larger the caseload, the better the outcome of each case. Dr. Samadi handles surgery from beginning to end. The program is critical due to support of the team.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses robotic surgeon training. He also addresses the need for expertise for robotic surgeons in emergency situations such as if and when a robot fails. A robotic surgeon and his team must be able to know exactly what to do next. Do they have the skills to transfer to laparoscopy or open surgery or must they call on someone else to finish the procedure? He advises the importance of talking to other patients, getting their experiences, asking questions and getting feedback. It is important to individualize care according to patient. Dr. Samadi discusses the use of the robot model he uses. He advocates the facility at Mount Sinai as a way to help patients deal with their cancer and get support. Partners and spouses need to get credit for what they have to deal with, and here they can all support each other.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses open surgery with the use of a midline incision. Dr. Samadi shows an example of laparoscopic surgery, whereby a doctor is at a patient’s bedside. He shows 2D view of the seminal vesicle, which is a major advance in field compared to open surgery. With laparoscopy, there is 7x magnification, less pain, shorter hospital stay, and faster catheter removal. He discusses the limitations of laparoscopic surgery in that because it’s a 2D view, you can only use one eye to work, which provides no depth perception. There’s a lot of tremor at the tip of the instrument, which is tricky when dealing with neurovascular bundle.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the particulars of robotic surgery. In robotic surgery, there are 2 cameras, which provide a 3D view. It’s easier for open surgeons who don’t have laparoscopic experience to learn. There is a better range of motion. Surgeons are working in a very narrow space and more can be accomplished where before they were functioning blindly. In open surgery, there is a lot of blood, and you can’t see, so surgeons depend on tactile feedback. So the robot becomes more helpful in that case. As compared to 8 or 9 years ago, all cases have converted to robotic surgery. Nowadays, Samadi must be convinced in extreme cases to use open surgery. Dr. Samadi also discusses what the actual robot looks like.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the Mount Sinai operating room experience. Dr. Samadi sits at console, near the patient, while his assistant is next to patient. The entire surgery is performed at the console. Samadi can see inside of patient abdomen. The robot is an extension of the surgeon’s arm, navigating the camera and arms where it’s needed. The surgeon is shown navigating the robotic arms, and the robotic arms are shown performing the surgery. Robotic holes are made in abdomen; CO2 is introduced, which creates room in the abdomen to perform the surgery. He then shows diagram of patient in surgery. The robot is attached to the patient and the rest is done via remote control. Dr. Samadi then shows an illustration of the Samadi techique. In the Samadi technique, the curtain that wraps around the nerve is completely untouched without cautering or burning. The prostate is removed, the bladder is connected to the urethra and the procedure is completed, in 1.5 hours, maximum 2 hours with minimal blood loss.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses MRI screenings. As opposed to other institutions that are proponents of getting all types of tests, Dr. Samadi recommends customizing surgery for individual patients. He shows picture of a large volume of cancer at the left base, and the neurovascular bundle has been invaded by cancer. In this instance, he can’t spare the nerve because the cancer will be left behind. He discusses what happens when the nerve has to be cut, which happens in 10% of his patients. Plastic and orthopedic surgeons take a piece of nerve from an opening in the lower extremity, such as a foot (in picture shown) and replace it where it’s needed right during surgery. Dr. Samadi discusses how a prostate is removed with the use of a plastic bag connected to a string. He shows a photo of completed procedure. The less damage done to side of prostate where the nerves are will result in a better outcome.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the procedures of the Robotic Oncology group at Mount Sinai. Mt. Sinai, surgeries take about 1 to 1.5 hours, hospital stay is 1 day, and the catheter stays for 5-7 days. Recovery is faster, typically within 1 month. Unlike any other previously discussed modality, within 1 to 1.5 months, the patient knows if they are cancer-free moving forward. PSA levels should be zero.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses the success the program has had with high-risk patients. Patients that had a lot of previous procedures, such as penile implants, have gotten great results. He discusses patients, as young as 39, with paternal history of prostate cancer, which is not unheard of. Prostate cancer is not an old man disease anymore. It’s rare to operate on a 78 year old. The textbook says after the age of 70, surgeons don’t operate which he doesn’t agree with. You have to individualize care. He discusses preoperative and postoperative Gleason scores, with regards to why prostate is removed. Before surgery, the pathologist is looking at a few glands. It’s very subjective. After the prostate is removed, because you are looking at the whole specimen, you can get a more accurate Gleason score.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses continence and male erection after robotic prostatectomy. He says that with the majority of patients, they are dry within 3 months. Patients who wear pads do so for safety reasons. About 10% of patients struggle, but after time with the help of the team and exercises it goes down. Kegel exercises are often done wrong. It’s hard to educate. Everyone does it differently. But majority of patients in one year get their continence back and reduce need for pads. Factors for continence include obesity, improper or inadequate kegel exercises, lower urinary tract symptoms pre-op. He advocates conservative management with patients, counsels them to do their exercises, see their doctor every 3-6 months for improvement and heal at their own speed. Dr. Samadi says that preliminary studies show there is no strong data to support the use of Viagra after surgery. Insurance companies only give 6 pills at a time. Patients get drugs from India, etc. If erection comes naturally, doctor leaves it alone and it will get better. Sometimes Samadi prescribes low dose Viagra every night. 3 yr data is close to 90% of erectile function. If nerves are intact, then Viagra Cialis & Levitra will work.
Dr. David B. Samadi, Chief of Division of Robotics and Minimal Invasive Surgery for Mount Sinai School of Medicine, discusses erectile dysfunction treatment alternatives and the Mount Sinai Robotic Oncology office procedures. Patients fill out questionnaire to see how they are before surgery. Surgery will not make sexual function better. All surgeries are taped. And post-op there is another questionnaire. Patients are given low-dose Viagra and are asked to return in 3-6 months. In some cases, Dr. Samadi might recommend a suppository or a pump. But he advocates a more cautious approach. Hypertension, diabetes and smoking affect erections as well as operation success and skill. In conclusion, robotic surgery in centers of excellence is safe. It is far superior for someone who has had other types of procedures, but provides better quality of life and fewer traumas. There is less morbidity than in the past. The value of prostate support group is valuable. Dr. Samadi discussed his mailing list as a way for patients to learn from each other and share advice and tips.