Speeding Recovery From Prostate Cancer Surgery

A Robotic Surgeon and Holistic Medicine Physician Collaborate to Help Patients

New York (Oct 27, 2009)

In the wake of surgery for prostate cancer men have three common concerns, says Aaron Katz, MD, Director of the Center for Holistic Urology at NewYork-Presbyterian Hospital/Columbia University Medical Center. They want to know: Is the cancer out – am I surgically cured? How can I ensure a quick return of urinary control? And how can I regain sexual function? "Some men are much more concerned about the return of sexual function than about their disease," he said, "while others don't care if they are leaking if the cancer is out. There is not one factor that is the most important for everyone." Dr. Katz and Ketan Badani, MD, Director of Robotic Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center, collaborate with each other to ensure that their patients' primary concerns are answered and that they have a rapid return to health after surgery.

Robotic Surgery

Robotic surgery itself helps ensure a speedy recovery, Dr. Badani notes. "The operation is minimally traumatic because it's laparoscopic." Because the incision is very small there is no incisional pain, they are not bedbound, and they are walking that night. Ninety-six percent of men go home after one night in the hospital.

Ketan Badani, MD

Blood loss from the surgery is minimal. "On average men lose 100 cc of blood during a robotic procedure compared with 1200 cc during a traditional prostatectomy. In the day or two following surgery most men are up and walking one to three miles a day, their energy is better, they feel better overall. Once the catheter is removed a week after the operation, most men can go back to work soon afterward."

In most men with prostate cancer, surgery is curative. But about 30 percent are found to have one or more unfavorable prognostic features – extracapsular extension of cancer or a Gleason score of seven or eight or a high tumor volume – and these men have a heightened risk of recurrence. Dr. Badani refers men in this group who are interested in and might benefit from a holistic approach to Dr. Katz and his colleagues at the Center for Holistic Urology (CHU).

With Help From Holistic Medicine

Dr. Katz and his staff work with patients in this group to lower their risk of recurrence through dietary modification and supplementation. "Studies have shown that men who have higher levels of fat in their diet have a greater chance of recurrence," Dr. Katz said. "Levels of LDL have also been shown to be an independent predictor for prostate cancer on biopsy in a recent study. So we alter their diets so they take in less fat, no red meat or fried food, and we add more soy products and cruciferous vegetables like broccoli and cauliflower, and encourage them to eat steamed and raw vegetables rather than cooked."

Aaron Katz, MD

For many patients Dr. Katz also recommends antioxidants including lycopene and pomegranate extract pills, vitamin D supplements as well as a multivitamin, and a novel herbal formula called Zyflamend. Dr. Katz and his team at NewYork-Presbyterian/Columbia recently published a pilot trial showing that daily Zyflamend could prevent the development of cancer in men with pre-cancerous cells in the prostate. "We also measure patients' c-reactive protein, a measurement of inflammation, and monitor them very closely," he said. Recent research has revealed that the inflammatory pathway is directly linked to the development of cancer.

The CHU is studying the effectiveness of soy compounds from Sapporo, Japan such as genistein, a potential angiogensis inhibitor, as well as a medicinal mushroom compound that has been demonstrated to enhance the active components of the immune system. The mushroom's enhancement of the activity of CD4+ cells and cytokines has been demonstrated in clinical trials. In Japan, where the incidence of prostate cancer is the lowest in the world, these compounds are used extensively to treat and prevent malignancy, and they are just starting to gain interest in the United States.

Return to Urinary Continence

Most men who have undergone prostate surgery hope for a quick return to urinary continence. Newer robotic techniques are making that possible, said Dr. Badani. "The muscles that control urination are in the deepest part of the pelvis, where they are hard to reach and to see during traditional surgery. With robotic surgery we have a camera and tools that allow us to get to that deep part of the pelvis, so our ability to identify and preserve those muscles is much better than with traditional surgery." After removing the prostate, Dr. Badani now reconstructs the urethra and the fascia that encases the prostate in a way that more closely emulates normal anatomy. "We not only reconnect the bladder and the urethra, but connect all the muscles back together and put the facial layer back together," he mentions. Using this approach, most men return to continence about three months sooner than men who underwent traditional reconstruction techniques. At the CHU, Dr. Katz helps patients recover urinary control more quickly through a program designed to build up the pelvic floor muscles including kegel exercises.

Return to Sexual Function

Restoring sexual function after prostate surgery is challenging, but urologists are gaining a better understanding of how to do this. "Sexual function is controlled by a network of millions of tiny microscopic nerves that envelope the prostate. During an enhanced nerve-sparing procedure we not only peel off and preserve the posterial-lateral nerves at the back of the prostate, but we can use the tiny hands of the surgical robot and preserve the nerves from the sides of the prostate as well." At one year following surgery, 65 percent of men with traditional nerve-sparing surgery have a regained potency compared with 78 percent of men who have had an enhanced procedure.

"The other half of the story is rehabilitation," Dr. Badani said. Patients are put on an aggressive rehabilitation protocol for the sexual nerves that includes the use of PDE-5 inhibitors immediately after surgery as well as the daily use of a vacuum erection device, a simple cylinder that is put over the penis and mechanically draws blood into it. This regimen prevents scarring and hardening of the spongy tissues in the penis during the time the nerves are healing. Dr. Katz takes the exercise and blood flow connection even further by having patients incorporate daily exercise that increases blood flow throughout the body, not just to the penis, to engage the entire body in the healing process.

Working Together, From Start to Finish

"Dr. Katz and I work very closely together, from the very first decision point: does this patient need surgery or not?," said Dr. Badani. "If they don't need an operation but would benefit from holistic therapy I send them to Dr. Katz. And post-operatively we decide together what therapies will help patients most quickly recover. We are continuously working together." Columbia Urology's team approach is key to patients' physical and emotional recovery. "Integrating a holistic treatment approach to cancer, or to those at high risk of developing it, is gaining attention in the medical field. We need to start thinking about the patient as a whole rather than just focusing on target areas such as the prostate," Dr. Katz concluded.

Faculty Contributing to this Article:

Aaron Katz, MD is Director of the Center for Holistic Urology at NewYork-Presbyterian Hospital/Columbia University Medical Center, and a Professor of Clinical Urology at Columbia University College of Physicians and Surgeons.

Ketan Badani, MD is Director of Robotic Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center, and an Assistant Professor of Urology at Columbia University College of Physicians and Surgeons