Saturday, November 24, 2007

Swiss study shows higher cure rates with surgery for prostate cancer

There have been several studies recently that show a higher cure rate for surgery over radiation for prostate cancer.
Prostatectomy Is Best PCa Option
Superiority of surgery is seen at 10 years
Ten-year prostate cancer-specific survival was 83%, 75%, and 72% for men treated with surgery, radiotherapy, and watchful waiting, respectively, the researchers reported in Archives of Internal Medicine (2007;167:1944-1950). At 10 years, patients treated with radiation or watchful waiting had a significant twofold higher risk of death from prostate cancer compared with men who underwent surgery.
The increased mortality associated with radiotherapy and watchful waiting was observed mainly in men younger than 70 years and in patients with poorly differentiated tumors, the authors noted.
 blog it

Saturday, May 26, 2007

UroToday - AUA 2007 - Cystectomy in the Elderly: does the Survival Benefit in Younger Patients Translate to the Octocenarians?

UroToday - AUA 2007 - Cystectomy in the Elderly: does the Survival Benefit in Younger Patients Translate to the Octocenarians?:
"The authors thus concluded that while all age groups derive an overall and cancer-specific survival benefit following a radical cystectomy, this benefit is smaller in octogenarians than for younger patients."

This is an interesting study that shows the benefit of surgery for bladder cancer decreases as paient's are older.

I actually performed this operation in 6 patients in their 90s. All the patients did well with surgery without major complications, but most died within 1 year. 3 from other causes and 1 from recurrent bladder cancer. 2 were still alive at 18 months the last time I looked into it.

Saturday, April 7, 2007

High quality or Low cost doctor?

There was an interesting article I came across on MSNBC:
Doctors angered by insurers' rating systems

It appears that many insurance companies are rating physicians. This "ratings" are then used to compensate physicians that they see as providing better care with bonuses or by having lower co-pays for patients to see these preferred doctors.

The insurance company says:
"We believe consumers should have information and access to all their doctors but we want to (give them incentives) to go to high quality providers," said Dr. Jeffrey Kang, senior vice president and chief medical officer at Cigna. Such products can lower health care costs by 3 percent to 5 percent, he said.

One physician response is:
"We're concerned that as insurers try to maximize profits they are saying that the doctor that charges the least amount of money is the highest quality," said Dr. Jim Rohack, a cardiologist who is an AMA board member.

The problem with the ratings are delineated in the article:
Some physicians were rated poorly for managing diseases that patients did not have.
If patients did not have tests that were ordered done, this would cause negative marks.

Other problems I see with this are the possibility that insurance companies can reward providers for spending less money (generic drugs) or avoiding ordering tests.

They can also lead patients to doctors that they pay less. Many people do not know this, but many insurance carriers pay different doctors different fees. This is different than the government (Medicare) that pays the same to all in a region.

If there were set criteria that were reliable, I would be fine with this system. As it is I doubt this is the case.

I wonder how much weight patients put on these preferred status.

Thursday, April 5, 2007

Removing the wrong testicle

All the steps to prevent this wrong-site surgery went awry.

Source: Kevin, MD

This is the second time I remember Kevin MD finding wrong site surgery in my field, urology.

The last time was on a kidney:

I read some of these comments and without taking sides, here are some facts:
The cancerous testicle should have been removed when he first has cancer. I am sure the physicians advised him of this many years ago.

As for all the risks he will be exposed to, they are inaccurate. The main problem with removing the incorrect testicle has to do with infertility. He will not be able to father his own children. He wanted a vasectomy, so this should not be as big of a deal as it otherwise would be.
The other side effects can be prevented with testosterone replacement.

Several of my testicular cancer patients are on testosterone for supplementation since their remaining testicle isn't producing enough anyways.

As for what amount is appropriate for compensating this poor gentleman, I guess that depends on how you look at it.

The last point I had a problem with is the patient saying he did not read the consent. I do not have my patients read the entire consent, but I do read the important points to them. They can read it if they want to.

Tuesday, April 3, 2007

Grand rounds is up at UroStream

UroStream: Grand Rounds Vol. 3, No. 28


I have the honor of hosting Grand Rounds for the second time! I can't believe it has already been a year since the last time I put all these great medical posts together. Time does indeed fly when you are blogging away.

I thought of many different ways to 'spice up' Grand Rounds. After much deliberation, I finally decided to' stick to the basics' and just present 'the facts', as I did many times before as a resident during our weekly nerve-wracking, anxiety-inducing Urology Grand Rounds.

Saturday, March 31, 2007

Why HOT girls are pushing pharmaceutical drugs

Mia Heaston, the current Miss Illinois and one of the 2007 Miss USA
hopefuls, is also a pharmaceutical rep -- one of the many hot girls Big Pharm
hires to push pricey meds onto Doctors and eventually into you. Why?

We have pharmaceutical reps in our office almost daily. Most are attractive/handsome, and some are more knowledgable than others.The 16 cheerleaders that are drug reps was a little surprising.

read more digg story

Thursday, March 29, 2007

Clinical Cases and Images - Blog: Blog Advice

Clinical Cases and Images - Blog: Blog Advice: "Every blogger hits a 'writing block' every now and then. Most good bloggers overcome it and just go on, stronger and better than ever. Some other good bloggers get stuck in the 'writing block' and their web sites join the virtual cemetery of dead blogs respectfully maintained by GruntDoc."

Excellent blogging help by clinical cases.

Monday, March 26, 2007

Kevin, M.D. - Medical Weblog: Requiring surgeries to be videotaped

Kevin, M.D. - Medical Weblog: Requiring surgeries to be videotaped:

beige_quote.bmpRequiring surgeries to be videotaped
Believe it or not, there is a bill in Massachusetts suggesting just a thing. A plaintiff malpractice lawyer's dream? Surprisingly, they are against the idea as well.

I read the actual paper. Its amazing, audio and video. I thought we had it rough in New Jersey, but this is worse than anything I've seen here.

Internet changing the way people manage their health - The Cancer Blog

Internet changing the way people manage their health - The Cancer Blog:

beige_quote.bmp62% reported using online health tools.
56% reported improvement in their health management due to personal technology.
2% of patients with chronic diseases thought that online health tools had
improved their management.
One third of patients thought that online tools enabled them to be an 'equal partner with my care providers in making health
62% reported that they would go to their personal physician for information and advice; 44% said they sought information and advice on medical Web sites; 32% said that found healthcare information and advice through an online search.
The Internet ranked as number 3 among the top 5 sources for
medical information.

62% said that their physician did not utilize the Internet to manage their health.
Among ways respondents said that their physicians do utilize the Internet include: direct e-mail communication with patients; scheduling of appointments; offering a way to check on practice and credentials on a Web site.
27% thought their physician fully embraced the Internet.

Only 11% of physicians communicate by e-mail even though 45% of
Americans would like this method of contact.

34% of patients wanted to access lab results by a secure Web site while only 7% stated that they had this option.
33% would like to schedule appointments online but only 7% said that this was currently available to them.
40% of patients had privacy concerns with the use of the Internet. A quarter of patients were concerned that private medical information could be used inappropriately.

Interesting statistics about people's use of the internet and what they would like.
I was surprised that 45% would like to have a physician's email.

I do this only with my major surgical patients.

Sunday, March 25, 2007

Updating Norton Utilities for Windows Vista

I purchased a computer just before the windows vista release that is supposed to be vista compatible.

One of today's project was to do the upgrade. Although I know a decent amount about computers, these things are always time consuming.

The only meaningful software I own that was not vista compatible is norton security, which I also recently purchased.

i wasted a few hours today trying to figure out how to upgrade it. These is a dead link on symantec's site that is supposed to do this for you automatically.

I found a page that lets you choose which software you have and do the upgrade. My nortons is now vista compatible, and I will wait until next week for the remainder of the project.

If you have norton and need an upgrade, go there.

Saturday, March 17, 2007

bookofjoe: What's on your email signature?

bookofjoe: What's on your email signature?:

What's on your email signature?

Olivia Barker's February 28, 2007 USA
Today article focused on the new new thing: putting your entire life story along
with your resumè, a list of personal references and various and sundry
disclaimers after your name in outgoing emails.
Mine is short but sweet and
appears above as the illustration for this post.

Intersting post. This was mine:

Domenico Savatta, MD
Chief of Minimally Invasive and
Robotic Adult Urologic Surgery
Newark Beth Israel Medical Center

Associates in Urology, LLC
741 Northfield Ave.
West Orange, NJ 07052

Robotic Surgery Blog

I got rid of my position at the hospital after reading this. I like my blog logo however and will keep it.

S.C. may cut jail time for organ donors - Yahoo! News

S.C. may cut jail time for organ donors - Yahoo! News:
COLUMBIA, S.C. - Inmates in South Carolina could soon find that a kidney is
worth 180 days.
Lawmakers are considering legislation that would let
prisoners donate organs or bone marrow in exchange for time off their sentences.
A state Senate panel on Thursday endorsed creating an organ-and-tissue
donation program for inmates. But legislators postponed debate on a measure to
reduce the sentences of participating prisoners, citing concern that federal law
may not allow it.

Interesting article on a program to trade a kidney for a reduced sentence of 6 months. There has always been a tendency to remove any incentives to donate an organ by UNOS. There is a state tax deduction in many states.

As for time off of a sentence, there are obvious ethical considerations. Would this be taking advantage of incarcerated prisoners? I personally am not opposed to this law. Prisoners would be giving a great service to society in donating an organ. 6 months does not seem like a great incentive, but will help give something back to someone who did a great thing.

250 daVinci prostatectomies- What does that mean and is that enough

One of the more common questions patients ask me is how many of the robotic prostatectomies have I done. I blogged on this topic at the robotic surgery blog at my 1 year mark (Nov 2005) previously.

Ive been doing robotic surgery for well over 2 years and will perform my 250th robotic prostatectomy for prostate cancer this week.

The one factor that I can say for sure is that I can do the surgery much faster than before. The only way to make these claims is to collect data (I have a blank spreadsheet that urologists can download that has most of the information that I track) and look back afterwards and analyze my results. For my surgical times I have done this recently. I am performing more complicated prostate cancer operations that I did earlier and the times are still significantly faster.

I am in the process of collecting my data since I haven't updated it in several months. Once I do I can see what the results have been. In the operating room, I feel that I am doing a better nerve sparing operation now, especially on the harder nerves to spare. I know I have been trying to spare more nerves even with more aggressive tumors. I will need to see if this correlates to better recoveries for my patients.

As for what I mean when I state that I will do my 250th daVinci prostatectomy, I mean that I have collected every patient I have operated on and I can give an accurate number. This figure does not include removing parts of the prostate robotically for BPH (9 times), removing a prostate and bladder at the same time robotically for bladder cancer (4 times), removing a prostate laparoscopically, removing a prostate open, watching people remove prostates as a proctor, or assisting another surgeon in removing a prostate.

The reason why I state it like this is that there are many ways to count, or estimate the number of procedures that a surgeon has done. Unless we as surgeons keep accurate track of our numbers and data, our memory is often inaccurate.

I have several examples that support this: A patient of mine told me that he had seen another surgeon for an opinion and was told he had done about 100 operations. I had an email from the head of surgery that they were nearing 100 prostatectomies in total for the 5 urologists that do robotics there a few months before. Maybe he meant his whole department had done 100.

My partner told me that someone he knew was going to have his surgery at a well known hospital from a surgeon who had done 80 robotic prostatectomies. I thought that was a very good number, but had was not familiar with the surgeon. I could not find him on the davinciprostatectomy site which usually only requires 20 console side operations to be listed. The console side surgeon is listed at the discretion of the operative team however, so if 2 surgeons are sharing time on the console, either of them can be listed.

My point is that surgeons need to collect data and sometimes clarify what they mean when they answer questions, as there are multiple correct answers. I am sure I do not do this perfectly, but by keeping this in mind I can give more accurate answers.

Thursday, March 15, 2007

Prostate cancer treatment options

This is a copy of the basic counselling sheet I use for prostate cancer patients. This page is meant to be helpful in stating the basic options available in the New Jersey area, but should only be used under the guidance of a urologist. Each case should be indiviidualized based on the patients medical conditions and desires.



Amount of cancer

Size of Prostate (urinary symptoms)


Bone Scan

CT Scan:

Overview: Reviewed options of watchful waiting, radiation (brachytherapy, external beam, combination brachytherapy and external beam), cryotherapy, hormonal therapy and surgery.

Watchful waiting. Usually inadvisable in an otherwise healthy man with a greater than 10 year life expectancy. Prostate cancer that is found early and has a low Gleason (2-6) may grow slowly and may be monitored rather than treated.

Advantages- No side effects from therapy.

Disadvantages- Cancer eventually may spread and be incurable.

Hormonal therapy. Prostate cells need testosterone to maintain themselves. Removing a man’s testosterone may slow down the growth of prostate cancer cells. Usually inappropriate for long term therapy of localized disease. There is evidence that the cancer can spread even during long term hormonal therapy. Hormonal therapy is not curative. Hormonal therapy may be given prior to radiation.

Disadvantages- Hot flashes, osteoporosis, etc.

Radiation: High energy x-rays are used to kill cancer cells.


Procedure: Performed as outpatient, under anesthesia. Places radioactive seeds into the prostate to burnout the cancer from within.

Concerns: Seeds may migrate during placement leading to over or under treatment of certain areas of the prostate (and cancer). Therefore, as a sole modality, may be less effective than external beam or combination radiation therapy.

Side effects: Radiation cystitis and proctitis (probably will be worse than other forms of radiation); erectile dysfunction (may be less so than external beam or combination radiation therapy).

Advantages: Short duration of therapy. Few side effects up front if the prostate is small.

Disadvantages: Least effective treatment,. Side effects can occur even years after therapy and may be underappreciated by some radiation oncologists. Bladder outlet obstruction can occur and be difficult to treat, especially if the prostate is enlarges.


External Beam:

Procedure: Cast is made of the body. Radiation is applied to the prostate through many ports, 5d/week for 7-8 weeks. Each session lasts about 20 minutes.

Side effects: Radiation cystitis, proctitis, and erectile dysfunction.

Advantages- Cure rates similar to surgery at 10-15 years with hormones added

Disadvantages- Daily therapy for 2 months causes a systemic effect. Side effects can happen later. Radiation effect in long term is unknown- new study shows a 70% higher rate of rectal cancer after XRT.

Combination External Beam and Brachytherapy

Combination of above, but external beam will only last about 5 weeks. Same Side effect profile and cure rate as external beam alone.


Procedure involves removal of the entire prostate and seminal vesicles. The goal of this procedure is to completely remove the cancer while it is contained within the prostate. Surgery is typically about 3 hours long, and is considered major surgery. Average blood loss is 2 units, but may be higher. Patients are usually asked to bank blood for themselves prior to surgery (“autologous blood”). Average hospital stay is about 3 days. A catheter remains in the bladder for about 1-2 weeks. Back to work is usually no sooner than 1 month after surgery.

Small risks of injury to rectum or ureters, blood vessels, nerves.

Side effects: Incontinence, usually lasting a few months. Erectile dysfunction.

Advantages: We can more accurately predict your prognosis. Best long term cure rates. Least amount of bladder outlet obstruction.

Disadvantages: Major surgery with blood loss and recovery.

Robotic Prostatectomy:

The Robotic Radical Prostatectomy represents a quantum leap forward in prostate cancer surgery. The da Vinci Surgical System enables urologic surgeons to perform a radical prostatectomy with similar, or improved technique when compared to the standard open procedure, while maintaining all the advantages of minimally invasive surgery.

The robot controls tiny jointed instruments, which can move at the tip like the human hand. Unlike conventional laparoscopy and its two dimensional image, the da Vinci camera has two lenses that combine to provide the surgeon a true 3-D image with 10x magnification. Also, any position or movement of the surgeon’s hands is enhanced with scaling and tremor reduction and is mirrored in real time.

Advantages of the minimally invasive procedure may include reduced pain, scarring, risk of infection, and less operative blood loss. Additionally, these benefits have translated into shorter hospital stays, faster recovery times, and a quicker return to employment and recreational activities.

The robotic radical prostatectomy can be performed with minimal blood loss and patients are no longer advised to donate blood for their operation. Patients typically go home after one night and can return to work within one to two weeks. The urinary catheter remains in place for approximately six days and continence is achieved more quickly and completely than with the other surgical techniques. Erectile function is regained more quickly and with greater frequency.

Advantages: Best therapy available with least amount of side effects overall in experienced hands.

Disadvantages: Blood loss is still possible, as are other side effects of surgery. Surgery can be longer than open for inexperienced surgeons.

Requires a general anesthesic.

Learning curve is longer than open surgery.

Cryosurgery: Involves the use of liquid nitrogen to freeze and destroy cancer cells. Its main use currently is for the control of local disease if primary therapy is unsuccessful. Long term results using current technology are still not known.


Similar to cryosurgery except we are heating up the prostate with a focused ultrasound probe instead of icing the prostate.

Advantages: Probably least amount of side effects overall.

Disadvantages: It is currently experimental in the US and available in Canada and Europe.

The worst cure rates at the current time.

This is a google document I made that shows the basic options I discuss at a prostate cancer counselling session.

Prostate Treatment. Enlarged Prostate Help.: BPH Treatment

Prostate Treatment. Enlarged Prostate Help.: BPH Treatment:
The final form of surgery used today is the open prostatectomy. Carried out
under general anesthetic, an incision is made in the lower abdomen to allow the
surgeon to gain access to the prostate and the inner core of the prostate is
then removed. Patients will normally remain in hospital for several days and
will also be required to use a catheter for a time at home after surgery.
Recovery from open surgery typically takes about three to six weeks during which
time patients may experience a moderate degree of pain or discomfort. The main
side effect of open surgery is incontinence which will be seen in about 6% of

In my practice I have converted my prostates that are too big and would require the open prostatectomy to robotic prostatectomy.

The robotic simple prostatectomy is much more difficult to perform than the dvP (robotic prostatectomy) for cancer, but has less side effects than the cancer one and is a great option for men with prostates greater than 80 grams. The only common side effect is retrograde ejaculation. I believe I have one of the worlds largest series of these operations (9 operations).

Monday, March 12, 2007

TimCT, an MRI with CT-like Scanning - Medgadget -

TimCT, an MRI with CT-like Scanning - Medgadget -

For the first time, T-class with syngo TimCT continuously scans patients
from head to toe as it does in Computed Tomography. During the examination, the
table moves continuously through the magnet. First and foremost, syngo TimCT
improves the workflow. Prior to this technology, pelvic/leg angiography, for
example, was performed step-by-step. This required more time than continuous
table movement. Depending on the patient's symptoms, examinations need to be
performed of various locations in the body. The greater the number of individual
work steps, the more intricate and error-prone the examination. But syngo TimCT
reduces the number of work steps for a pelvic/leg angiography by 50 percent.
This saves time and also reduces costs while increasing diagnostic safety. At
the same time syngo TimCT improves the image quality as the body region just
being scanned is in the center of the magnet. Here the measurement results
produce the highest level of quality.

This will be a nice addition to our imaging. MRIs give excellent imaging of certain organs, but are much longer than CTs. They are also more difficult to read (for me at least) due to the multiple series of images that are made.

Sunday, March 11, 2007

Gay bashing in the medical blogosphere or just humor? You decide

Kevin, M.D. - Medical Weblog: Gay bashing in the medical blogosphere?:
Gay bashing in the medical blogosphere?
Some controversy this weekend.
Scalpel and Graham have at it.

I found this on Kevin's site and it caught my attention.

Blogging can be dangerous, and I try to be sensitive to the topics I write about. Part of the reason I started my new blog is to have some more freedom, but I always worry about offending readers.

To summarize the situation, scalpel made some remarks about an apparently homosexual patient.

Graham did not approve and has boycotted scalpel.

Scalpel has a response as well explaining his remarks.

I have to admit that I side with scalpel. Although I do not agree with parts of his post, he has the right to blog about it. I also think graham has the right to boycott him, but I will not be doing that.

I await the votes and will like to see who is in the minority.

Friday, March 9, 2007

UroStream: Weird question of the week

UroStream: Weird question of the week

"Can I have sex with my catheter in?"

Interesting reading the comments.

I have a hard time with some of my patients after robotic prostatectomy in regards to sexual function.
The 2 important questions are when to start viagra/levitra/cialis after surgery. Some urologists do not use it at all, some use it even before surgery, and some after the catheter comes out.

It is unclear how long patients need to wait to have intercourse after their catheters are removed. Some say 6 weeks, some 4, and some less. I used to say 2 weeks until 1 man had a painful time after 2 weeks. Since then I have patients wait at least 3 weeks.

Ive had several patients have intercourse in less time than that, with the record being 9 days. Ive had some patients have erections with the catheter in and without medicines, but have never thought they may give it a shot with the catheter in. I may need to change my postoperative instructions.


Thursday, March 8, 2007

Dr.Kattlove's Cancer Blog: Should you have your cancer surgery done by a robot?

Dr.Kattlove's Cancer Blog: Should you have your cancer surgery done by a robot?: "Herman Kattlove
I am a retired medical oncologist. For the last seven years I was a medical editor for the American Cancer Society where I helped develop much of the information about specific cancers that is posted on the website at I attended the University of Chicago as an undergraduate and also received my MD there. I trained in hematology and oncology at Montefiore Hospital and Medical Center in New York and then spent 5 years as an assistant professor at UCLA. Following that, I went into practice in Long Beach, California. In 1992 I received a masters degree in public health from UCLA and then worked in managing cancer care in HMOs for some time till joining the ACS. I retired from the ACS in November, 2006. "

Welcome to a new cancer blogger.

Sunday, March 4, 2007

Nerve Grafts May Restore Erectile Function After Prostatectomy

Nerve Grafts May Restore Erectile Function After Prostatectomy: "'Although the sural nerve is considered the gold standard for grafting, genitofemoral nerves were also used in our study, based not only on the initial successful work by Quinn et al, but also on the ease of harvest and avoidance of potential complications related to sural nerve harvesting,' the clinicians note.
They found there was no 'statistically significant difference in erectile function recovery or the achievement of clinically meaningful erections using sural nerve grafts compared to genitofemoral nerves, even in the 28 patients with complete neurovascular bundle resection and no salvage radical prostatectomy after radiotherapy.'
Based on their experience, Dr. Secin and colleagues think bilateral cavernous nerve grafts might be beneficial in select patients, although a definitive answer awaits a multicenter, randomized, controlled trial."

I have never used nerve grafts as I was skeptical of them working. It doesn't make sense to me that nerve bundles, which are not discrete nerves, can coalesce and find a grafted nerve.

At least the morbidity of taking genito-femoral nerves is less than that of the sural nerve.

Robotic Surgery Blog: Robotic reliability

Robotic Surgery Blog: Robotic reliability: "This is a special thank you to Dr. Savatta . Last summer my in law was living in Greece and was informed that he had prostate cancer. He decided to come to the US and get other opinions , we saw a few doctors and they all recommended no surgery due to his age , however he wanted the cancer out of him . That's when i did a little research and we went to see Doctor Savatta . I must say we were very happy with the Doctor's knowledge and personality .
A good person that understands the patient's feelings and the families concerns .The Surgery was performed last july and today 7 months later no problems at all , all bloodwork comes back OK and most of all absolutely no leakage .
A special thanks to Doctor Savatta and and staff
Keep up the Good Work!!"

This was a comment left from the relative of a patient of mine on the Robotic Surgery Blog.

I remember the original consultation and went over the treatment options. Age alone should not be an exclusion for surgery. With robotic surgery, I have been able to operate for prostate cancer up to age 80 and for BPH up to age 88. I have not had a higher complication rate for these conditions in my older patients.

Usually the cure rate for surgery over radition is lessened or eliminated in older patients, but the quality of life from a urinary standpoint is often improved in the long run compared to radiation. It helps to have the prostate out from a BPH and bladder outlet standpoint.

There is difference in opinion in whether or not robotic surgery (or any surgery) should be offered in elderly patients, but I think it can be done safely and can be done if the patient chooses it after a proper counselling session and radiation oncology opinion.

I blogged on this awhile back on the robotic surgery blog and cited a study out of the Mayo clinic.

Travelling for robotic surgery

I found a neat thing online that I was hoping would come at some point.

I have had many patients travel to see me for robotic surgery and was looking for an easy way to show that.

I found a site,, that allows custom maps.

I simply placed the location that my out of state patients have travelled. Due to HIPAA reasons, it is only accurate to a state or country, not a town.