Real-time pathology during prostate surgery

What a great idea and it is good to know that there is a surgeon out there that it doing this. We are told often that there are no do-overs with surgery, that your pathology is what it is but this doctor allows for changes in this script.

It is interesting that he gets that pathologist of look over the entire surface of the prostate - most pathologists in their post surgical report don't take this approach instead slicing that then fixing the prostate and reporting on the surface area of each slice.

Good idea to try it. I can't imagine how they are able to inspect every square-mm of inked surface for cancer in any reasonable amount of time, but even checking, say square-centimeters of surface might be useful. I know he always did frozen sections, but that is only when the urologist is able to detect cancer without dyes and microscopes that look at the cellular level. Unfortunately, they can't always cut wider to get more of the cancer, but where they can it might be a good idea.

Has he been doing it long enough to see if it has reduced recurrence? Any statistics yet?

Tewari is the only one I can remember being mentioned here that does frozen sections during surgery. I'd like to know....doing this process would depend on having a seriously top notch pathologist on hand. As far as Zzarth's question, I haven't seen a lot of publicly available data that compares surgeons by side effect profiles etc. I agree, it would be great to see something like that.

What they need is a registry. But who is going to pay for it and run it? Patient-reported outcomes are seldom even asked for. Usually there's only toxicity data.

They have two registries for SBRT. And, I agree there are problems with them, but at least there is some uniform collection of data:

/pcnrv.blogspot.com/2016/08/sbrt-registries.html

There's also a registry for cryoablation called the Cold Registry.

Being not very cynical, I doubt there is much falsification of records - there's just not a lot to be gained, and anyone discovered breaking that law will lose his license and incur stiff penalties.

When I got my RP, the tumor had kissed my colon so they cut out a chunk of that and sent it to the lab. They kept me on the table while they waited for the results. Due to my robust lifestyle, I bled quite a lot during surgery so ended up spending a week in hospital. The operation took more than 3 and 1/2 hours due to that lab check of the colonic tissue. I kinda doubt the surgeon would want to keep me hanging upside down in surgery much longer than he already had.

Excellent idea, I don't know why more surgeons don't do this.

My wife had a resection of her intestine for crohns and the surgeon had a pathologist in the OR with him checking the samples of intestine that were removed for traces of crohns so as to make sure he got everything before he closed up. Five years later , my wife is still symptom free.

gedman said...
I had my 19 month check-up with Dr. Ash Tewari last week. He made one major "upgrade" since moving to Mt. Sinai: As soon as the prostate is removed, it is rushed to pathology while the patient is still on the operating table. Pathology folks inspect the entire surface of the prostate for cancer cells. If there are any positive margins, that info is relayed to Dr. Tewari within minutes so he can remove more tissue in that area and hopefully remove any remaining cancer.

Is anyone aware of other surgeons who get real-time pathology of the full prostate surface during surgery?

(When I had my surgery with Dr. Tewari at NY Presbyterian, only a few tissue samples were sent to Pathology during the surgery.)

-Gedman

This is an interesting historical evolution of the frozen section process. History lesson:

Twenty years ago or more, in the pre-robotic surgery days, there were still many men presenting with advanced disease, and the imaging tools were not as sophisticated or “good” as they are today. Back then, when a surgeon opened up a patient, he more frequently found “surprises” such regional metastasis to lymph nodes (LNs). The practice then became to look first at LNs and resect (remove) several before even touching the prostate; the procedure was “on-hold” until those results were called into the OR. The LNs were rushed to pathology, and if cancer was found, then the patient was closed-up without the removal of the cancerous prostate; the point being that since there was already regional spread, the surgery wasn’t going to solve the problem, and the better thing for the patient was to minimize the trauma/side effects and send the patient promptly to radiation therapy.

Next came robotic prostatectomies. Robots are super expensive tools which the hospital seeks to maximize utilization of, and the intraoperative frozen LN sectioning became basically vetoed by the hospital operations management team…took too much time. That turned out to be not bad because it coincided with the dramatic shift from men presenting with advanced cases to the majority presenting with smaller-and-smaller cases of less advanced or even benign PC, so far fewer cases with regional spread.

Today, mpMRI has emerged as a pre-operative tool to help guide the surgeons to maximize the opportunities for nerve-sparing procedures while minimizing the possibilities for positive surgical margins; surgeons use mpMRI results in the decision making process to select a nerve-sparing approach.

But time is still money in the operating room equipped with a multi-million dollar robot, but necessity is the mother of invention. Recent innovations have recently been marketed to assist in the rapid resection/extraction of the prostate into a nifty package ready to be taken to pathology in the next room…it’s been marketed as “easy and fast,” and today adds only about 10 minutes to the total OR time (which is still a controversial consumption of resources in many hospitals).

Oncological outcomes have been demonstrated to be improved for patients with higher Gleason scores. (Low Gleason score are not impacted, as they didn’t need surgery anyhow.) The improved oncological outcomes are achieved by secondary resection, or re-resection, or simply “going back for more.” This typically happens in the difficult-to-reach bladder neck area.

It’s not perfect…there were still patients who were declared to have negative margins of their frozen sections during surgery but did, indeed, have PSMs at final pathology. But that was outweighed by the higher number of patients who were found to have PSM of their frozen section but no issues afterward. The final pathology is still the gold standard for margin status analysis.

Hey gedman....are you sure he told you they check the "entire, full" prostate? It's my understanding that the guys who do this only check where positive margins are mostly found. (the apical portion, or...whatever it's called...)

Checking the entire prostate for surgical margins takes hours. (or so I'm told)