Robotic surgery in urology

by Dr. Chin Chong Min

The introduction of the robot into urology has made minimally-invasive surgery a safer and technically superior one. Robotic surgery is a variation on laparoscopic surgery, where the operation is performed through small incisions over the abdomen. As opposed to standard laparoscopic surgery where hand-held rigid instruments are used, in robotic surgery the surgeon controls robotic arms which move articulate surgical instruments. A common misconception is that the robot performs the surgery. The robot is not performing surgery; the surgeon performs the surgery using the robot as the interface. Why use a robot rather than traditional hand-held laparoscopic instruments? Robotic instruments have the advantage of greater dexterity in movements than standard laparoscopic instruments, with superior precision, intuition and 3-dimensional magnified vision. Currently, "Intuitive Surgical" is the only manufacturer of the da Vinci robot and robotic surgical instruments.

Use in radical prostatectomy

The da Vinci surgical robot was originally developed to perform minimally-invasive heart surgery, but its application has since spread to other specialities like gynecology, lung surgery, general surgery, and urology. Its use in urology began in 2000, when the robot was used to perform radical prostatectomy. Radical prostatectomy is the surgical removal of the whole prostate and used for cancerous prostates. Prostate cancer is the most common cancer in men in the USA, but its incidence is also rising in Asia. Prior to the use of robotic surgery, prostatectomy surgery was done via a long incision over the lower abdomen.

Besides greater wound pain and slower recovery after surgery, the open method carried a higher blood loss, with a blood transfusion rate as high as 67%. With the robotic method, the blood loss is usually less than 200 ml, resulting not only in negligible transfusion rate but also quicker recovery and return to normal activity. As of 2008, about 75% of all radical prostatectomies in the USA were performed robotically.

Other advantages of the robot

Robotic urologic surgery has become widespread because of both patient and physician preference. Is it true that robotic radical prostatectomy is better compared to open surgery? Many urologists who use the robotic method find that the robot helps them remove the prostate with less trauma to adjacent nerve and muscle. The biggest challenge of removing the prostate is avoiding injury to the penile nerves lying beneath it. When this occurs, impotence results. The urinary sphincter that sits below the prostate and controls the continence mechanism is also at risk. When it is damaged, incontinence results. Recent published literature has demonstrated robotic radical prostatectomy to be equivalent at avoiding impotence and incontinence compared to the traditional open approach. There is also some evidence that the robotic approach results in earlier return of continence and potency.

My own experience with robotic radical prostatectomy is that there is less nerve injury with the robotic approach because of less tension on the nerves during surgery. The better, more magnified view of the prostate and its surrounding structures also helps the preservation of these delicate nerves. In other words, surgeons are able to perform more "exacting surgery" with the aid of the robotic vision and instruments.

The challenge

The real challenge is which approach removes the cancer better with fewer complications. Short-term cancer control has proven equivalent for both approaches. Interest in robotic radical prostatectomy has resulted in more urologists using the robot, and for other types of surgeries too. Urologists are now using the robot to remove kidney tumours, entire bladders and reimplant injured ureters.

The widespread incorporation of robotic surgery is still limited because of the high financial outlay. The set-up cost, maintenance cost, and training requirements makes it prohibitive for many institutions to own the da Vinci robot. One is tempted to predict that overtime there should be an even greater use of robots not only in urology but also other surgical specialities. Whatever the outcome, robotic technology will improve, become more affordable, and perhaps in the future, become the standard of care for many surgeries.

(The writer is Consultant urologist, Mt. Elizabeth Medical centre, Singapore)

Cancer recurrence:

Women with dense breasts are at greater risk

by Drucilla DYESS

Women who have dense breasts, and undergo lumpectomies for the treatment of breast cancer, are at a greater risk of a recurrence of the disease. In fact, breast cancer patients with more dense breasts are four times as likely to have their cancer return than women with less dense breasts.

The new information comes from research performed by Steven A. Narod, M.D., of the Women's College Hospital in Toronto, and colleagues.

According to Dr Narod, "The composition of the breast tissue surrounding the breast cancer is important in predicting whether or not a breast cancer will return after surgery." The study report can be found in the journal Cancer.

The researchers analyzed data on 335 breast cancer patients having an average age of 63.5 years, who had undergone lumpectomies for the removal of cancerous tumors from their breasts.

Findings revealed that for women having more dense breasts, the risk of the cancer recurring over 10 years was more than four times higher at 21 percent than the 5 percent average. In addition, women who did not receive radiation as part of their initial treatment faced an even higher risk (40 percent) of a tumor recurrence that puts them at an 8 times greater likelihood of developing the disease again.

With the use of mammography, about one in three of the women in the study were found to have large amounts of dense tissue in their breasts.

Breast density was discovered to be higher among the younger women in the study, and these women were less likely to be postmenopausal than the others. Of the total number of women in the study, 99 had low-density breasts with dense tissue in less than 25 percent of the breast, 107 had intermediate density in 25 percent to 50 percent of the breast, while 129 women had high-density breasts with more than 50 percent density.

Although it is not known why the density of a woman's breast has an impact on the risk of developing cancer, it is known that high breast density can reduce the sensitivity of a mammogram by causing a masking effect. In addition, it is the belief of the researchers that the hormonal profile of denser breast tissue makes it more susceptible to cancer. Although Dr Narod noted that breast density has been found to be modifiable to some extent by physical activity and hormone therapy, the researchers cautioned that it is not clear whether these measures would impact the risk of breast cancer recurrence.

Due to this significant increase in risk for cancer recurrence, the researchers maintain that women having more dense breasts should undergo additional treatment after surgery to decrease the chances of the cancer returning. On the other hand, since radiation therapy appeared to eliminate the increased risk for cancer recurrence, they also acknowledged that the findings are an indication that women with low-density breasts may be able to safely avoid radiation. However, they also cautioned that because the study was small, further research will be necessary determine if this is the case.According to The American Cancer Society an estimated 192,370 new cases of invasive breast cancer will be diagnosed in 2009, and of these 40,170 lives will be lost. Breast cancer is the most common cancer among women in the United States, other than skin cancer.

It is also the second leading cause of cancer death among women, after lung cancer. About 1 in 8 women will develop breast cancer at some time during life, and about 1 in 35 will lose the battle against the disease.

-healthnews

A stressful lifestyle can cause adrenal fatigue

by Melanie GRIMES

In this hectic society, many people experience adrenal fatigue and arenot aware of it. The adrenals are two small organs located on top ofthe kidneys. They secrete hormones that trigger stress reactions suchas the "fight or flight" instinct, and are involved in a complexhormone interaction between the hypothalamus and the pituitary glands.A diagnosis of hypoadrenalism means the adrenals have a reducedhormonal response. This inhibits an individual's ability to handlestress, as well as many other disorders. Addison's disease is thechronic condition of adrenal insufficiency. Weak adrenals areinherited, and the condition runs in families.Symptoms of adrenal fatigue include chronic fatigue, dizziness, andfainting. Memory loss and forgetfulness can also be caused by lowadrenal function. It can also be caused by extremes in weather (hot orcold), physical trauma or injury, or a period of stress, such as along-term illness. Diet plays a role as it can rob the body of Bvitamins. Metal toxicity can trigger adrenal fatigue as well, withexposure to lead, mercury, cadmium or aluminum.

The adrenals alsomanufacture aldosterone, which controls salt and potassium balance.Without enough of this hormone, the body can become dehydrated.Low blood pressure can be another indicator, and one that isfrequently overlooked, as low blood pressure is not considered anabnormal medical condition. Standing blood pressure versus sittingblood pressure can be used as a diagnostic. A healthy person will havea higher blood pressure after standing, but those with hypoadrenalismwill have a drop in BP.Adrenal fatigue can also lead to insomnia. While some natural remediesfor insomnia may relieve the problem temporarily, if the underlyingcause is in the hypoadrenalism, the adrenals will need to be healedfor lasting relief to occur.Allergies can be related to adrenal failure as well, because peoplewith low adrenal function can stop producing the hydrochloric acidneeded for digestion.

When this happens, the body is unable to digestprotein. This can lead to food allergies, nutrient deficiency orhypoglycemia.Strenuous exercise can be interpreted by the body as stress, andtrigger the "fight or flight" mechanism in the adrenals. Intenseexercise can cause adrenal fatigue and will deter from healing theadrenals. For those with hypothyroidism, exercising at a low intensityis advised, and slowly building back to the previous aerobic level.Cortisol levels can be tested via blood or saliva, to monitor adrenalfunction. The saliva test checks cortisol at different times of theday. Used to diagnose Cushing's syndrome and Addison's disease(serious adrenal disorders), physicians are now using these blood andsaliva tests more frequently to evaluate hypoadrenalism.

Normalcortisol levels are low in the evening and highest in the morning.Pregnancy, stress and illness can all increase cortisol levels.There are numerous natural methods to treat hypoadrenalism. Adaptogensare plants known to help reduce adrenal reaction. Rhodiola is one ofthe adaptogens used to treat stress and research has proven itseffectiveness. Vitamin C and the B complex help rebuild the adrenalgland. Supplements that contain raw animal adrenals have been usefulfor some.A natural diet helps heal the adrenal gland. Processed foods should beeliminated along with sugars, including honey, molasses or fruitjuices, to help stabilize the blood sugar. Whole foods and vegetablesadd fiber, nutrients and vitality that cannot be supplied insupplements.

Water helps maintain hydration.The most important factor in healing the adrenals is rest, bothphysically and emotionally. Meditation and relaxation are advised.Alternate being busy and active, with time to relax and restore. Doingand not-doing are the yin/yang of a healthy lifestyle.

-healthnews

Health News

Our ayurveda for European cities

by P. Krishnaswamy

Dr. Croospulle and Dr. Rajan Fernandopulle when they attended a conference on ayurvedic medicine at Bade City, Germany.

Dr. Croospulle with Indian a Ayurvedic specialist Dr. Swamy and a Sri Lanka ayurvedic physician during a conference in Ankona, Sinigalia, Italy.

Two Sri Lankan ayurvedic physicians, Dr. Ivan Royston Croospulle and Dr. Ranjan Fernandopulle have established flourishing Ayurvedic Medical Centres in Italy and Sweden and during their recent visit home told the Sunday Observer that their remarkable treatment of various diseases has been recognised and appreciated by a large number of Italians and Swedes. Thanks to their degree of success, they have been encouraged to open more new centres in Europe, they said. With their successful treatment in the two European cities, the ancient, time-tested medical system has become very popular in the two countries, they said.

Dr. Croospulle gives medical advice and treatment to patients in Ayurvedic Panchakarma and oil massage while Dr. Rajan Fernandopulle is practising other forms of ayurveda, acupuncture etc as treatment for chronic ailments. They also have many specialist Ayurvedic physicians from Sri Lanka assisting them to treat the large number of patients who are visiting their Medical Centres everyday. They hold ayurvedic medical workshops in many venues and attend events and conferences. Their centres are also being visited by experts in ayurveda medicine from India and many other parts of the world, they said.

During the past one year of their practice, over eighty percent of patients treated were fully cured and this is a remarkable achievement, they said. One of their objectives is also to establish an entirely authentic traditional health care complex in Sri Lanka to earn foreign exchage to the country, they said.

Dr. Croospulle who hails from Thoppuwa in Kochchikade said that his grandfather and his ancestors were reputed ayurvedic physicians for many generations. He studied under Dr. Jayasiri Mendis, 'Jeewaka Asapuwa, Rajagiriya, who is practising Ayurvedic medicine for over 35 years and works as a consultant to the Ministry of Indigenous Medicine. He later went to Kerala for further studies, he said.