- FAQ's about the prostate, and treatment options
- FAQ s about incontinence and prolapse

What is the prostate gland?
The prostate gland is a walnut sized gland that is located between the bladder and urethra. When men urinate they actually urinate through the prostate. As men age the middle of the prostate enlarges under the influence of the male hormone, testosterone. This is called benign prostatic hyperplasia or BPH. As the prostate enlarges, the urinary flow may become restricted leading to a decrease or intermittent force of the urinary stream, a more frequent need to urinate, urgency of urination, or a sense of incomplete voiding. All of these symptoms are caused by BPH, not cancer.

What does the prostate gland do? What is its purpose?
The prostate gland is known as a secondary reproductive organ. The gland produces fluids which contain enzymes and other substances which assist the sperm in fertilization.  One third of the ejaculate fluid is produced by the prostate itself and the remaining two thirds is produced by the seminal vesicles or ejaculatory ducts.

What is the cause of prostate cancer?
There are no known causes of prostate cancer. Approximately 10 % of prostate cancers are inherited but the remaining cases occur at random. A “prostate cancer gene” has not yet been identified. There are links between diets rich in saturated fats and an increased incidence of prostate cancer but this evidence is based on epidemiologic data and not based on data obtained from clinical practices. Men with a first degree relative with prostate cancer (father or brother) diagnosed prior to the age of 64 are at a three times greater risk for developing the cancer as the greater population. As such, screening for high risk men should begin at age 40.

What can I do to lower my risk for prostate cancer?
While there is no known cause for prostate cancer it makes sense to limit the amount of calories from saturated fats consumed on a daily basis. In addition, there are studies which have suggested that prostate cancer risk may be reduced by consuming zinc, vitamin E, and lycopene. White Plains Hospital Center is participating in a randomized double blind prospective study known as the S.E.L.E.C.T. trial in which men are randomized to receive Vitamin E and or selenium and or placebo to determine whether the incidence of prostate cancer may be reduced.

The results of this study will not be available for years.; Peanuts are a good source of selenium and cooked tomatoes are an easily consumed source of lycopene. Vitamin E is readily available in pill form or as part of a multivitamin. It also makes just good medical sense to limit the amount of calories obtained from saturated fats.

What are the symptoms of prostate cancer?
Localized and curable prostate cancer has no symptoms. If you are experiencing a decrease in the force of the urinary stream or other voiding issues, this is most likely due to BPH and not prostate cancer. If it turns out that you do have localized prostate cancer and some problems with urination, BPH is occurring coincidentally with the prostate cancer.

Men with advanced prostate cancer may have similar symptoms as men with BPH including obstruction of the urinary flow, blood in the urine, painful urination, and urgent urination but localized and curable prostate cancer most often has no symptoms. Therefore, screening is vital for early detection.

Does BPH place you at an increased risk for prostate cancer?
No, they are separate disease processes. BPH occurs in the center of the prostate gland known as the transition zone. The overwhelming majority of prostate cancers occur in the outside part of the prostate which is adjacent to the rectum. This is known as the peripheral zone.

How is prostate cancer detected?
Prostate cancer screening should begin at age 50. In men at increased risk, including those with first degree relatives with prostate cancer and men of African American descent, screening should start at age 40.; African American men have the highest incidence of prostate cancer in the world as well as the highest risk of prostate cancer death. As such, early detection is the key element for cure.

Prostate cancer screening consists of two simple tests - Prostate Specific Antigen blood test known as a PSA and a digital rectal examination (DRE). It is imperative to have both tests as almost one third of men with localized prostate cancer will have the disease detected or diagnosed solely on the basis of an abnormal DRE in the face of a normal PSA blood test.

How is a diagnosis made?
If a man is found to have an elevated PSA or an abnormal DRE, a prostate biopsy is recommended. This is a painless 5-10 minute procedure most often performed in the office under local anesthesia. Most patients are able to return to full activity on the day of the biopsy. Fortunately, the majority of men with a new diagnosis of cancer obtained via screening efforts have early disease, localized to the prostate gland. Routine staging tests often include a CAT scan of the abdomen and pelvis and a bone scan.; An MRI of the prostate is occasionally helpful.

What is the Gleason score?
As with any other cancer, prostate cancer is characterized by grade and stage. Over 90 % of prostate cancers are known as adenocarcinomas or cancer of glands. The grade of a cancer is indicative of a cancer’s aggressiveness. The higher the grade the faster is the cell growth and the greater the risk for spread beyond the organ where the tumor starts. Prostate cancer is graded on the basis of the Gleason scoring system. This ranges from 2, the lowest grade and least aggressive form of the disease to 10, the most virulent form of the cancer. Most men have tumors in the 5 -7 range.

What is my stage?
Stage of cancer refers to the approximate size of a tumor. Prostate cancer staging is based primarily on DRE. Most men with prostate cancer have normal prostate examinations. This is referred to as stage T1c disease. A small abnormal area on DRE known as a prostate nodule is classified as T2a, a larger nodule as T2b. Patients with large nodules felt to represent tumor that has grown beyond the confines of the prostate or beyond the capsule have stage T3 disease. If the tumor is felt to invade the adjacent bladder or pelvis the cancer is stage as T4.

What are the treatment options for localized prostate cancer?
There are several therapeutic options including external beam radiotherapy, known as intensity modified radiotherapy (IMRT), brachytherapy (radioactive seed implantation), combination radiotherapy (IMRT with seed implant), and radical prostatectomy.

What are the surgical options?
There a several different types of radical prostatectomies or complete prostate removal. They include robotic prostatectomy, radical retropubic prostatectomy, radical perineal prostatectomy and laparoscopic prostatectomy.

What is a robotic radical prostatectomy?
A radical robotic prostatectomy incorporates the advantages offered with laparoscopy together with the delicate maneuvers and techniques previously only available with open surgery. Standard laparoscopic instruments can be cumbersome and do not avail themselves to delicate surgical procedures. Minimally invasive robotic radical prostatectomy allows the surgeon to perform sensationally an "open" radical prostatectomy without the need for the large incision.

The robotic approach, utilizing the da Vinci Surgical System, provides easy access to the patient’s internal anatomy through five half-Inch incisions. The robotic instruments, which are completely controlled by the surgeon, have wrist and hand-like maneuverability, which allows the surgeon to move them like his own hands during traditional open surgery. The surgeon, during the minimally invasive robotic prostatectomy, is performing the operation while looking through a viewer that provides him/her with an excellent 3-dimensional visualization and 10-fold magnification. As such, a robotic radical prostatectomy utilizing the da Vinci system enables the surgeon to perform a radical prostatectomy via a laparoscopic or minimally invasive approach. The surgeon is controlling all of the robot’s movements in a “master and slave” relationship or a direct extension of the surgeons hands rather than it being a true robot.

The surgeon is always in control of the instrumentation. A camera is inserted into the patient through one of the half-inch incisions. It provides a precise three dimensional magnified view of the operative field superior to that achieved with the naked eye during a standard open radical prostatectomy.; The robotic instruments are inserted through small pencil like channels known as trocars. The da Vinci robot reproduces the surgeon’s outside movements and actions inside the body. The surgeon’s movements are precisely translated allowing the graceful maneuvers that are required to surgically remove the cancerous prostate gland, while preserving the delicate adjacent nerves and blood vessels responsible for normal sexual function. Also the integrity of the urinary sphincter is maintained, assuring urinary control.

The same principles that I have used for years during standard open nerve sparing (for the preservation of sexual function) radical prostatectomy are applied to the robotic surgery. The da Vinci system is not a replacement for surgical skill and experience or extensive knowledge and understanding of pelvic anatomy. It is merely another tool such as an advanced scalpel and microscope that I can use to perform radical prostatectomy while maintaining the patient’s quality of life.

What are the advantages to robotic radical prostatectomy?
•Reduced or minimal post-operative pain
•Reduced blood loss thus reduced transfusion rates
•Shorter hospital stay (many patients are discharged home one day after the procedure)
•Faster recovery period thus a sooner return to work
•Quicker catheter removal
•Reduced scarring
•Greater surgical precision, which, in turn, potentially means more accurate removal of cancer and reduced risk of impotence and incontinence

What are the disadvantages to robotic radical prostatectomy?
While the da Vinci technology allows for the precise translation of the surgeon's movements while eliminating any tremor present in all surgeons’ hands it does not provide tactile feedback. As surgeons however, we rely on tactile sensation only when we do not have an accurate or clear view of the operative field. The camera system utilized with the da Vinci system is a clear 3 dimensional field with ten times the magnification of even the surgeon with 20-20 vision. The superior visualization offered by robotic surgery more than replaces the perceived loss of tactile sensation.

Are the cure rates observed with robotic surgery the same?
Although there are not yet long term data with respect to cure rates with robotic prostatectomy, the pathological results are comparable to those with open radical retropubic prostatectomy. As such, one can expect the same excellent long-term cure rates realized with the traditional surgery.

Why should I have my surgery at White Plains Hospital Center?
When initially faced with the diagnosis of prostate cancer the impulse may be to go to “the city” or to a “teaching hospital”. But community hospitals are often more efficient, cleaner, safer and more technically advanced compared to larger institutions. Specifically White Plains Hospital Center surgeons have performed more minimally invasive surgical procedures for prostate cancer and colon cancer than any other center in Westchester County. Over the last decade I have performed more radical prostatectomies than any other surgeon in Westchester County.

In addition I have performed more robotic radical prostatectomies in this region as well, and I was the first surgeon in New York State to utilize the da Vinci S type device (the most advanced robotic surgical device now available).

We have assembled a skilled team of robotic surgical registered nurses with a combined clinical experience of over 60 years. The robotic nursing team was recently profiled for their excellence in the journal “Advance for Nurses".

As with any surgical procedure the skill of the anesthesiologists is as important as the skill of the surgeon and his or her staff. The anesthesiologists on the robotic team are specifically trained in the nuances of the anesthetic management in patients undergoing minimally invasive surgery. They are all board certified and have extensive experience in all facets of management of the surgical patient. As White Plains Hospital Center is not a teaching hospital the attending anesthesiologist is assigned to the patient’s case from start to finish.

White Plains Hospital Center has received the National Research Corporation’s “Consumers Choice” award five times in the last seven years and was the sole winner in Westchester County in 2007. White Plains Hospital Center (WPHC) has also been rated in the top five percent in the nation for overall outcomes in 26 medical procedures and diagnoses by HealthGrades, the nation’s leading provider of independent hospital ratings. This new rating has given WPHC the distinction of being named a “Distinguished Hospital for Clinical Excellence.”

A recent HealthGrades study indicates that patients checking into a hospital rated in the top five percent in the country have, on average, a 27 percent lower chance of mortality and a 14 percent lower risk of complications.  The annual HealthGrades study identifies hospitals in the top five percent in the nation in terms of mortality and complication rates across 26 procedures and diagnoses, including back and neck surgery, bypass surgery, heart attack, stroke, pancreatitis, radical prostatectomy, knee and hip-replacement surgery, and several other areas. HealthGrades (Nasdaq:HGRD) is the leading healthcare ratings organization, providing ratings and profiles of hospitals, nursing homes and physicians to consumers, corporations, health plans and hospitals.

Millions of consumers and hundreds of the nation’s largest employers, health plans and hospitals rely on HealthGrades’ independent ratings and decision-support resources to make healthcare decisions based on the quality of care. More information on the company can be found athttp://www.healthgrades.com.

FAQ s ABOUT INCONTINENCE AND PROLAPSE

Is urinary incontinence and normal part of the aging process?
Even though the prevalence of urinary incontinence tends to increase age, it is certainly not a normal phenomenon. Some people mistakenly believe that it is something they have to live with without realizing that there are numerous safe and effective treatments to help people gain a better quality of life.

When should I see doctor about urine leakage?
The short answer is that one should seek medical attention when leakage begins to interfere with ones normal daily activities. However, it is never a bad idea to be evaluated and to hear ones options when urine leakage becomes apparent.

Does incontinence ever get better by itself?
In general, the natural progression of urinary incontinence is for it to become worse over time. However there are cases when leakage resolves without treatment. Pregnant women often experience urine leakage which stops soon after delivery. Sometimes by making simple dietary changes such as decreasing caffeine and overall fluid intake and performing pelvic muscle therapy (kegels exercises), incontinence becomes much more manageable.

Are there different types of incontinence?
Yes. Urge incontinence results from an overactive bladder. The bladder is made of muscle and when that muscle contracts before the person is ready to urinate, incontinence results. Stress incontinence is leakage with coughing and activity and is not caused by a problem with the bladder at all. It results from weakness in the supporting tissues and muscles around the bladder and urethra. When a person has both kinds of leakage then the diagnosis is "mixed incontinence".

Can I take a medicine to treat incontinence?
Medications are often used to treat urge incontinence. These medicines, called anti-muscarinics, are bladder muscle relaxants and are useful in patients with overactive bladder and mixed urinary incontinence. They do not benefit patients with stress incontinence alone. These medicines are well tolerated and effective in greater than 65% of patients who try them. The common side effects are dry mouth and constipation.

When is incontinence treated by surgery?
People with stress urinary incontinence have the option for surgical correction of their urine leakage. The procedure called a TVT sling (Tension Free Vaginal Tape) is minimally invasive and very effective. The recovery time it is 2 to 7 days.

What is pelvic organ prolapse?
When the supporting tissues of the bladder, uterus and rectum become weakened by childbirth, aging and/or previous pelvic surgery, these organs can herniate producing a vaginal bulge. There are various degrees of prolapse from mild (Stage 1) to severe (Stage 4). Sometimes, but not always, prolpase is accompanied by urine leakage. Many people will experience pelvic pressure, difficulty urinating, frequent urinary infections and discomfort.

How is prolapse treated?
In patients who are not bothered by their prolapse, nothing needs to be done to correct it. Patient's who have discomfort may be candidates for pessary placement which is a silicon-rubber disc that is inserted into the vagina to hold up the pelvic organs. Other patients will elect to have surgical correction which, most of the time can be performed vaginally. When the uterus is involved, surgery often involves hysterectomy. Then the remaining organs can be lifted and suspended to strong deep ligaments in the pelvis.

How long is the recovery period after surgery?
In general most of the discomfort from surgery resolves after the first 2 weeks. People usually require 4 to 6 weeks to gain their full strength back.

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