Reproduced from Medwire News. Author: Sarah Guy

Prostate cancer patients with small prostates have worse histopathological outcomes than their counterparts with large prostates, report US researchers who hope that a small prostate will act as a “red flag” for treatment with surgery rather than observation.

Specifically, small prostates (<40 cm3) – which are common in young men – can indicate a higher Gleason score at biopsy, a higher pathological stage at surgery, and a greater incidence of positive surgical margins (PSMs) at surgery, than large prostates (>70 cm3).

Study author Ashutosh Tewari (Weill Cornell Medical College, New York) explained to MedWire News that in a smaller prostate there is less barrier tissue to prevent the cancer spreading beyond the prostate into other tissues, which could impact the treatment patients are offered.

“If the prostate is very big, there normally is much more barrier tissue around the cancer and you have enough time to wait it out and try to do things which can be relatively non-invasive,” he said.

Also speaking to MedWire News, fellow researcher Prasanna Sooriakumaran added that young men or men with small prostates may be better served by treatment with surgery rather than active surveillance or watchful waiting policies.

Tewari, Sooriakumaran, and team investigated the relationship between oncologically important histopathological variables and prostate volume in a cohort of 2207 men who underwent robotic-assisted radical prostatectomy.

Patients with small prostates were younger and had lower prostate-specific antigen levels than those with large prostates.

However, a small prostate also indicated a worse Gleason score after surgery, a greater tumor volume, more evidence of extraprostatic extension, and a greater incidence of PSMs, at 11.5% versus 5.6% for prostates less than 40 cm3 and greater than 70 cm3, respectively.

“You have a very time-sensitive duration/window of opportunity in which you can take the entire organ out and not let cancer cells escape the prostate,” said Tewari.

“So that needs to be factored into the decision-making process, because if cancer has indeed gone out of the smaller prostate by the time you intervene, you’ve lost an opportunity to cure,” he added.

“We want small prostate volume to act as a red flag in terms of it suggesting these patients need something more actively done about it,” Sooriakumaran concluded.

Link here.

As mentioned before, Dr. Tewari has just been featured on Dr. Aron Katz’ radio show on 770 WABC discussing his thoughts on prostate surgery; below we are sending you the link to the podcast. In that 30 minute segment he thoroughly covers what he does and leads us to an understanding of how he does it so well. We hope you find it interesting.

Download prostate cancer podcast here.

Our group at the LeFrak Center for Robotic Surgery and the New York Presbyterian Hospital/Weill Cornell Medical Center Institute of Prostate Cancer have published two new papers reviewing Laparoendoscopic Single Site (LESS) surgery. These publications will appear in upcoming issues of European Urology and the British Journal of Urology International. The references can be found on our publications page. Single site surgery could have large implications in prostate cancer treatment as well as other organ systems.

Laparoscopic or ‘keyhole’ surgery has developed in an effort to reduce the complications associated with large incisions during ‘open-access’ surgery. Over the last 15 years the results of this approach have been unanimous across a variety of procedures, demonstrating intra- and postoperative benefits which, for example, have led to a quicker recovery with less blood loss, hospital stay, scar pain and hernia formation.

Recently, an extension of this principle of ‘minimal invasion’ has been proposed in the form of LaparoEndoscopic Single-Site (LESS) surgery. Here, instead of operating through several small (e.g. 1-2cm) incisions, a slightly larger single incision (e.g. 3-5cm) is used to provide access for all the operating instruments. This incision is still smaller than the open incision, and can be concealed within the umbilicus with good cosmetic effect.

However, it remains to be seen whether the same surgical results can be achieved when using several instruments via a single access device. Such an approach complicates triangulation of laparoscopic instruments, because the instruments have to enter the body at the same point, thus making the technique challenging even in expert hands. Nevertheless, proof of principle has been demonstrated by several groups describing the safe implementation of various single-site procedures, particularly for operations involving the kidney.

In order to overcome the spatial limitations single-site surgeons have benefited from the creative use of flexible and pre-bent instruments. One further advance is being trialled through the incorporation of robotics. Since the advent of robotic technology, surgeons have been able to overcome the restrictions of traditional ‘keyhole’ surgery while providing the same intra- and postoperative benefits when compared to traditional open surgery. Furthermore, the robotic approach benefits from superior  ergonomics and Endowristed instruments which can somewhat alleviate the spatial constraints of operating through a single site using laparoscopic equipment. Unfortunately current robotic technology has not been designed for this use, and external arm clashing still restricts single site procedures.

In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of organs from inside the body. The use of magnetic anchors might also go some way to freeing up space at the point of access, using for example external magnets to hold internal cameras.

However, the final promise in minimally invasive surgery is Natural Orifice Transluminal Endoscopic Surgery (NOTES), with its scarless technique, which occurs via operating through a natural orifice (such as the mouth or vagina). It naturally follows that this ‘indirect’ pathway to abdominal organs is even more difficult to navigate compared to LESS surgery, and such procedures are very much at the experimental stage.

It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical superiority over standard laparoscopic methods.

British Journal of Urology International abstract can be found here.

European Urology abstract can be found here.

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Podcast of today’s show on 770 WABC is already available.

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This morning Dr. Ash Tewari will be on 770 WABC at 7:00 taking your questions about prostate cancer treatment.

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