Innovative Surgical
and Medical Regimens:
Advanced Urologic Care
July / August 2006
In urologic care, the loss of organ function is a real
threat with the potential to detrimentally impact a patient's
quality of life. Determining when surgery is appropriate
and, if it is appropriate, what type of organ or nerve preservation
can be achieved is vital to the treatment discussion.
“Penn offers a real multidisciplinary approach for
a patient's evaluation and choice of treatment,” says
Alan
Wein, MD, chief, Division of Urology; co-director, Voiding
Function and Dysfunction Program; and co-director, Urologic
Oncology Program at the Hospital of the University of Pennsylvania. “Our
role is to guide referring physicians and their patients,
informing them about their treatment or non-treatment options.”
Prostate Cancer
Important advances for a certain
subset of patients with prostate cancer include refinements
in brachytherapy and interstitial radiation therapy as well
as laparoscopic and robotic-assisted laparoscopic surgeries. “We're
also seeing active work in chemopreventative agents, which
have the potential to lower the incidence of prostate cancer,” says
Bruce
Malkowicz, MD, co-Director, Urologic Oncology at the
Hospital of the University of Pennsylvania.
Similarly, clinical
trials are currently under way to determine the efficacy
of agents like toremifine in preventing the progression
of prostatic intraepithelial neoplasia (PIN), a premalignant
lesion, to prostate cancer. Many patients will be diagnosed
with PIN on prostate needle biopsy, yet no intervention
except observation and repeat biopsy for monitoring is currently
available.
For patients who do have prostate cancer surgery, robotic
prostatectomy is now an additional choice. “The robotic
prostatectomy provides total removal of the prostate combined
with the benefits of minimally invasive surgery,” explains
David
Lee, MD, chief of the Division
of Urology at Penn Presbyterian
Medical Center. “The robotic procedure allows patients
to go home the day following the surgery, have a catheter
in for only one week, and usually return to work within two
to three weeks.”
Testicular Cancer
Penn offers one of the area's most
integrated clinical units for the treatment of testis cancer. “There
are approximately 9,000 cases annually, so the disease is
not as common as other cancers,” says David
Vaughn, MD, medical director, Abramson Family Research
Cancer Institute and chair, Data and Safety Monitoring Committee, Abramson
Cancer Center at the University of Pennsylvania. “Yet,
here at Penn we treat a large volume of these cases every
year, many more than most community hospitals, giving us
more experience with treatment of this disease.”
Research protocols are currently under way to determine
genetic susceptibility to testis cancer in an attempt to
prevent the disease. Fortunately for those patients who do
present with the disease, most testis cancer can be cured. “It's
the one solid-organ tumor that's seen the greatest
increase in cure,” says Dr. Wein.
Penn also offers
a long-term survivorship program since most of these patients
will be cured, but may be confronted with disease- or treatment-related
side effects. The Living Well After Cancer program provides
these patients with access to comprehensive care for late
effects of treatment, general health behavior guidance,
nutrition counseling, psychosocial counseling and clinical
trials, including a trial to examine cardiovascular risk
in testis cancer survivors.
One of the side effects the Penn team has been able to
help patients avoid is the inability to ejaculate. “Our
team performs advanced surgical techniques to repair lymph
nodes, sharpen the limits of lymph node dissection, and spare
the sympathetic nerve. In the past, a great majority of men
would lose their ability to ejaculate, but nerve-sparing
techniques are a huge advance in the quality of life for
these patients,” continues Dr. Wein.
Bladder Cancer
Improvements in the detection and
surveillance of bladder cancer are under investigation, including
newer forms of cystoscopy, which have been evaluated to better
detect disease not seen by normal optics. The judicious use
of genomic-based tumor markers further help physicians better
define the individual risk for recurrence and progression
of superficial tumors.
“Radical cystectomy remains the gold standard for
treating muscle-invasive disease,” says Dr. Malkowicz. “The
earlier use of this technique in patients with high-grade
T1 tumors and carcinoma in situ who have not responded to
intravesical therapy can result in better long-term survival.”
Continent urinary reconstruction can also be offered to
those patients requiring a cystectomy. “We have the
largest and longest standing program in this form of complex
surgery, which allows patients to avoid the need for external
collection bags by constructing a neobladder out of the bowel,” says
Dr. Malkowicz. “Depending on the situation, the neobladder
can be attached to the urethra to allow for normal voiding
or to the abdominal wall, where a discrete, small stoma is
catherized.”
A full range of options are available for the treatment
of muscle invasive disease and, in select cases, bladder-sparing
techniques may be used. “In some cases, patients with
muscle-invasive bladder cancer can be treated with a combination
of chemotherapy plus external beam radiation therapy after
an extensive cystoscopic resection, with potential curative
intent,” says Dr. Vaughn.
Kidney Cancer
“We're performing many
more partial nephrectomies to help preserve kidney function,” says
Dr. Wein. Penn offers radiofrequency ablation percutaneously
and laparoscopic cryosurgery with excellent results.
The multidisciplinary team also has experience treating
larger, more complicated tumors, especially those with vascular
involvement. Moving forward, targeted molecular therapies
may be the next advance in kidney cancer, with agents such
as sorafenib, which may increase the incidence of progression
free survival.
Regardless of urologic cancer type, communication is critical. “There
is constant communication between our team and the referring
physician,” says Dr. Wein. “We have the resources
to suggest the best possible treatment options, but I always
tell my patients they should sit down with their primary
care providers to discuss these options. The primary care
provider knows the patient better medically than anyone else.
It is important patients review their options with their
primary care physicians.”
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Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
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