Texas Robotic Surgery

About Dr Kella

2009-12-22T16:58:00.003-06:00

Dr Kella completed a degree in Chemical Engineering from Stanford University and went on to receive his MD degree from University of Texas at Southwestern Medical School in Dallas, TX. After finishing residency at Tufts University in Boston, MA, he went on for further fellowship training at Baylor School of Medicine in Houston, TX to develop expertise in urological oncology and robotic surgery.

After his training, Dr Kella came to Urology San Antonio and performed the area's first robotic prostatectomy for prostate cancer and radical cystectomy for bladder cancer. He has performed over 1500 cases for prostate cancer, making him one of the most experienced surgeons in the nation. (Click here to learn about the importance of experience.) In 2009, Dr Kella performed more robotic prostate surgeries than anyone else in Texas, according to Intuitive Surgical. He is Director of Robotic Surgery and Assistant Director of Research at Urology San Antonio and served as Chief of Surgery at St Lukes Baptist Medical Center in San Antonio, TX. His routine is to perform 6 to 10 cases per week, with the same team at the same hospital.He is principal investigator on numerous clinical studies and has been involved in the study of many novel agents for prostate cancer including Protox, ZD4054, and GVAX. He has consulted for companies such as AMS and Intuitive Surgical.
He also has contributed to the literature in prostate cancer.

He is committed to making the patient experience as painless and as successful as possible.

In his spare time, he enjoys time with his family. playing sports, and working with new tech tools and gadgets.

Frequently Asked Questions

2009-12-22T16:57:00.000-06:00

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Hospital Stay Beyond Two Nights for Robotic Assisted Laparoscopic Prostatectomy

2009-12-21T22:48:00.001-06:00

The following abstract was accepted for presentation at the International Robotic Urology Society meeting in Las Vegas for 2010.

Hospital Stay Beyond Two Nights for Robotic Assisted Laparoscopic Prostatectomy
Kusuma Kurmayagari MD, Naveen Kella MD
San Antonio, TX

In experienced hands, robotic assisted laparoscopic prostatectomy generally results in quick discharge home. Reasons for hospital stay beyond 2 days are examined from electronic hospital data from a single-surgeon series of 707 consecutive cases from April 2007 to September 2009 at a community-based institution. The surgeon had performed over 700 cases previously within a different system. A transperitoneal technique using the Montsouris approach was used. Criteria for discharge include pain control on oral medication, ability to ambulate and tolerate a regular diet and to be medically stable. Drains were removed prior to discharge in the vast majority, except in cases of increased drainage after a lymph node dissection. No open conversions were performed. 72% of patients were discharged after one night in the hospital. 21% were discharged after two nights in the hospital. The most common diagnosis for stay beyond two nights was ileus in 10 of the 34 patients (1.4%). The second most common reason was nonmedical in 7 of 34 patients. Post operative anemia requiring blood transfusion occurred in 4 patients (0.5%). Heavy drainage due to a urinoma was noted in one patient who was discharged drain free after 4 nights. The longest hospitalization was for 28 days due to unrecognized bowel perforation during adhesolysis. This was the only patient requiring a return to the operating room. No thromboembolic events or deaths were noted. Robotic prostatectomy can be a procedure with acceptable complication rates during the post-operative period, making the procedure suitable for an community-based practice.

Post Prostatectomy Erectile Dysfunction Rehabilitation Program

2009-10-02T14:09:00.006-05:00

This will serve as a guide to your recovery following your robotic treatment for Prostate Cancer with Dr Kella. While current technologies and practices have made significant improvement on the long term complications following your Prostate Cancer treatment, it is still possible there could be resulting erectile function complications. We have developed this Erectile Function Rehabilitation program in an effort to minimize the potential for immediate and long-term erectile function complications following your treatment or procedure.

The following information is designed to answer any questions about your current penile rehabilitation program. This is a multi-faceted approach that includes both therapeutic and physical therapy components. It is important that you make every effort to adhere to the program as outlined herein. Each medication and physical therapy component plays a specific role and each must be taken as directed whenever possible.

We are pleased that you have entrusted us with your prostate cancer care and look forward to working with you on your recovery.

Click here to view the protocol.

Sincerely,

Naveen Kella MD
Director of Robotic Surgery
Urology San Antonio

2009-09-25T15:16:00.123-05:00

Dr Kella's Erectile Preservation Protocol

Two weeks prior to surgery:

MUSE Intraurethral Suppository: Begin with 125 mcg suppository three times weekly on the days that PDE5 Inhibitor is not used. The goal with use of this product (at this low dose) is to produce some erectile action, not necessarily sufficient for sexual intercourse. Starting the suppository now will help you comfortably continue treatment after surgery and possibly get your nerves and blood flow in "better shape." If possible, Dr Kella will provide you some samples (keep them in the refridgerator) to get started.
Continue what you do already if you have erectile dysfunction.

After surgery:
Wait until the foley catheter is removed and until Dr Kella gives you the go ahead to start rehabilitation.

Fill the prescription (provided during the post-operative visit) for the Vacuum Erection Device (VED). Prescription devices are more durable and carry a lifetime warranty. Over the counter devices are available at a lower price point if cost considerations or insurance coverage become an issue. Dr Kella's office will submit the initial paperwork on your behalf. You should follow-up with a phone call a few days later to the company to inquire on the status of your insurance coverage. We will provide you a booklet and video along with teaching to use the device successfully.
Complete "Pump and Release" 5 repetitions every morning and evening with your VED. This is intended to mimic the penile nocturnal erection function that is usually disrupted early after surgery. Use the VED without the constriction bands. A "repetition" is to pump the device 3-4 times then pause for a count of 5, then pump 3-4 more times, stopping for another count of 5. Continue this process until the penis is reasonably full. At this point, count to 10 and press the release button on the pump mechanism itself. The erection will go down quickly. Repeat this process for a total of 5 repetitions every morning and evening. It is expected to feel some tightness and pressure, but don't pump as to cause pain.
Start Muse 250 mcg every other day or at least three times a week. Vivus has generously provided a toll-free line 888.367.6873 to provide patients with trained healthcare staff to answer questions about MUSE and guide you through the administration process. Of course, you can always make an appointment with Dr Kella's office. In addition, with the expensive cost of medications like Viagra to consider, Vivus has started the Apricot program, which will try to get pre-authorization for coverage from your insurance company.
PDE-5 drugs like viagra, cialis, and levitra can be used but may not be efficacious at this early stage of healing.
If your erections are sufficient for intercourse, Dr Kella suggests avoiding vigorous activity until your body has had more time to heal.

6 weeks post-surgery:

Evaluate progress and responses to previous regimen.
Increase MUSE to 500 mcg dose if erection obtained is not yet sufficient for meaningful sexual activity. Continue at three times weekly.
Continue VED daily. At this point, the constriction bands can be utilized for maintaining the erection for sexual activity.
Sexual activity at this time should be fine.

3 months after surgery:

Evaluate progress and responses to previous regimen.
If erection is not yet sufficient for meaningful sexual activity, consider increasing MUSE to 500 or 1000mcg does for "on demand" function. For scheduled preservation, continue at the 250mcg dose.
Penile Injection therapy with penile duplex ultrasound should be considered at this point.
PDE5 Inhibitors (Cialis, Levitra, Viagra) can be added to the regimen if not being used already. Full dose tablets can be used at most once a day. Dr Kella generally recommends at least twice a week. Discuss this at the 3 month follow up if necessary with Dr Kella.

6 months after surgery:

If erections are sufficient for sexual activity spontaneously (or with assistance), consider stopping scheduled MUSE dose and continue with PDE5 Inhibitor and VED.
If erections are not yet satisfactory, discuss further therapy at your follow-up appointment.
Continue regular MUSE, POE5 Inhibitor, VED, with possible addition of penile injections.
This can be tailored to each individual person at this point, as penile injections can be used in low dose on schedule for "rehab" purposes. This may require the elimination of some options and substitution of others in their place.

Final Note:
After nerve sparing surgery, erections and orgasmic function should only continue to improve with time. Most patients start reporting erections Most healing takes place by 1 - 2 years. Factors to consider include your function before surgery, your general health, and Dr Kella's ability to spare your nerves.

Dr Kella has performed over 1500 robotic procedures, with over 350 last year, ranking him as the busiest surgeon in Texas for 2009. Surgical experience, using the latest techniques, and usage of the newest Da Vinci Si, while not a guarantee, can help your odds of recovering as much of your original sexual function as possible.

Good luck through your rehabilitation!!

Useful reference:
Rev Urol.2008 Fall. Renewing intimacy: advances in treating erectile dysfunction postprostatectomy. Lepor H, Engel JD.

Nutrición y Salud de la Próstata

2009-01-16T16:46:00.003-06:00

Una dieta favorable para todos los hombres interesados en la salud de la próstata es la Mediterránea Modificada. El beneficio de este tipo de régimen incluye la salud de corazón, la salud de la próstata y qué actúa como un mecanismo para desacelerar el proceso de envejecimiento. La cardiopatía es prevaleciente en todas las edades pero más comúnmente en hombres entre 40 y 70 años de edad. Similarmente la enfermedad de la próstata es prevaleciente en todas edades comenzando tan pronto como nuestra adolescencia y prolongando a lo largo de nuestras vidas de adulto. La dieta es recomendada idealmente para todos los hombres que desean prevenir la enfermedad cardiaca y enfermedad de la próstata al paso de los años. Para hombres que ya tienen la enfermedad cardiaca o enfermedad de la próstata nunca es muy tarde para empezar una dieta apropiada. Aparte de este comentario alimenticio, animo el apoyo nutritivo de vitaminas para la próstata, también ejercicio regular diariamente, y reducción del estrés.

Frutas Frescas
Los ejemplos incluyen pero no se limitan a: naranjas, mandarinas, plátanos, cerezas, toronjas, sandía, melón, guayaba, Kiwi, fresas, arándanos, frambuesas, zarzamoras, arándanos rojos, papaya, uvas, manzanas, granadas, y ciruelas. Pienso que la fruta fresca entera es mejor que beber el jugo de fruta.

Verduras Frescas
Frescas, nunca enlatadas con la excepción del puré de tomate y tomates cocidos. Los ejemplos incluyen pero no se limitan a: Las verduras crucíferas perteneciendo a la clasificación Brassica incluyendo - el brócoli, broccolini, col de Bruselas, colirrábano, col rizada, berza, col china, espinacas de mostaza, Col, Coliflor; Verduras que tienen la clasificación Brassica, incluyen pero no se limitan a: Los tomates y los productos derivados del tomate incluyendo lo antedicho, puré de tomate, tomates cocidos y salsa de tomate; Los chiles incluyendo chile pimiento, chile ancho, chile Habanero, etcétera; cebollas, chicharos, zanahorias, espinacas, betabeles, ejotes, hongos (Shitake, Portabella, Cagarria, Maitake, Ostra, Porcini etcétera.); Las verduras cocidas al vapor, sofritas o salteadas (a la sartén) son más nutritivas; Limite el consumo de elote, el uso de sus productos y recetas relacionadas al elote. Evite aros de cebolla fritos.

Aceites para Cocinar
El aceite de oliva es mejor; El aceite de canola es una alternativa cuándo el aceite de oliva no puede ser utilizado; Evite el aceite de palma, aceite de coco, aceite de maíz y aceite vegetal.
Use como aderezo e / o intégre cualquier platillo con ajo, pepino, lechuga, apio, curcumina, cilantro, pimienta, orégano, jengibre, romero, tomillo, perejil, salvia, mostaza, pepinillos en vinagre, y aceitunas. Evite la mayonesa y alimentos untables cremosos.

Fuentes de Proteina
Pescado de aguas frías incluyendo pero no limitado a: atún fresco o enlatado (en agua o aceite de oliva), el salmón silvestre siempre que sea posible, fletán, sardinas, y verdel; El pavo y el pollo (sólo la carne blanca, sin pellejo),tocino de pavo, salchichas de pavo, frijoles (todos los tipos), claras de huevo y mantequilla de cacahuete; Las vieiras, camarón, cangrejo, langosta y calamar están bien dependiendo en como son preparados;

Evite: La carne roja, incluyendo Hamburgesas, perros calientes (hot dogs), chorizo, chile con carne, carne roja asada, Bistecs, costillas, carne de cerdo o carnero, carne de animal silvestre, alitas de pollo, Sloppy Joe (sandwich de carne molida con salsa de tomate y especies), tocino, salchichoneria de puerco, jamon de pierna (paletilla), pepperoni, salame, mortadela, queso de puerco, despojos (hecho de menudencias), Spam
jamón, carnes ahumadas; El pescado que debe evitar incluye: Tilapia, pescado Espada y Salmón criado.

Productos Lácteos
El yogur bajo en grasa, claras de huevo o las mezclas de huevo, leche desnatada, queso descremado, requesón descremado; Evite las grasas asociadas con productos lacteos incluyendo queso, leche entera, lechecrema, crema, helado, yemas de huevo, y salsas de crema incluyendo pero no se limitan a la salsa Holandesa, salsa bearnesa y la salsa de menudillos.
Pasta y / o Carbohidratos
La harina integral o el arroz son mejores aunque los panes de grano entero tambien se recomiendan; Modere su consumo de Pizza, aunque si la va a consumir, es mejor que sea de pan de trigo entero y que sea servido con salsa de la tomate o Marinara; El Arroz Integral; Los camotes se prefieren mas que las papas blancas aunque la piel de ambas son nutritivas; Procure no comer pastas simples como espagueti y fideos, y evite los aperitivos de pan (breadsticks), pan blanco, arroz blanco y azúcares simples como el azúcar blanca refinada y miel; Evite: Papas fritas a la francesa. Substitutos de azúcar incluyen: Splenda, la cual se puede usar para cocinar

Ensaladas
Verduras frescas de hoja con pepinos, tomates, aguacate, pasas, rábanos, cebollas, pimientas, aceitunas, zanahorias, frutas secas y verduras frescas a su gusto; El mejor aderezo es el aceite de oliva extra virgen con vinagre balsámico; Evite otros aderezos. Evite cubitos de pan frito.

Galletas
La harina integral es mejor; Evite galletas saladas hechas con aceites parcialmente hidrogenados incluyendo pero no se limita a: aceite de algodón y aceite de soja (las transgrasas).

Sopas
De tomate con verduras, tomate, pollo con arroz, fideo de pollo; Evite sopas cremosas.

Postres
Las moras de temporada o un pedazo de chocolate negro. Evite reposterías, pastel de queso, galletas, helado y pasteles.

Soja
Minimice o modere el insumo de soja que contiene los componentes Genistein y Diadzein; Soja adicional que puede ser consumida incluye leche de soja descremada, miso, y tofu. Evite salsa de la soja con contenido alto de sal.

Aperitivos (en moderación)
Un pretzel bajo en grasa, cacahuates, avellanas, pistachos, nueces de Brasil, almendras, nueces persas, nueces lisas, avellanos, uvas, chocolate negro, mezcla de frutas secas y nueces (hecho en casa), frutas secas, palomitas de maíz cocinadas al vapor, un pedazo de fruta fresca; Evite refrescos, papas fritas, fritos de maíz, dulces, leche con chocolate, chicharrones, palomitas de maíz hechas en horno de microondas, galletas.

Bebidas
Un vaso de vino tinto está bien; Disminuya su consumo de cualquier bebida alcohólica incluyendo vodka, whisky, tequila, ginebra, whisky escocés (scotch), ron, cerveza.

Evite: Malteadas de leche, refrescos y licores de crema.

Nutrición
Considere los suplementos disponibles en tiendas de vitaminas. La investigación detrás de la gran colección de suplementos disponibles es escasa. Además, los métodos de producción pueden diferir ampliamente. Soy un partidario de Theralogix, el cual es poseído por un urólogo quien hace el esfuerzo de sólo incluir aquellos ingredientes mejor respaldados por literatura disponible. Además, el control de producción es acentuado.

Evite freir y en lugar asar a la parrilla o asar al horno
Si usted está tratando de perder peso, especialmente para la cirugía, empiece cada comida con un vaso de agua de 8 onzas.

Si usted cocina sus alimentos a la parrilla, asegurese de no recocer o quemar lo que desea comerse.
Evite el uso de mantequilla o margarina.

Porque es importante la experiencia

2009-01-16T15:15:00.002-06:00

Dr. Kella es un urólogo entrenado especializando en oncología. Él esta clasificado como uno de los 10 especialistas mas destacados en cirugias roboticas de cáncer de la próstata en los Estados Unidos y compartirá sus perspectivas en este sitio.
¿Es el robot simplemente una herramienta?

Durante el ultimo año, me he asombrado con qué rapidez la cirugía robótica se está volviendo el estándar para pacientes que necesitan cirugía para cáncer de la próstata. Aun cirujanos que no practican robótica han decidido referirme a sus pacientes como un servicio ellos. Inicialmente, pensé que la robótica tendría una larga curva de aprendizaje para que cirujanos,con lo ocupados que son, pudieran amaestrarla completamente. Por eso es que tomé un año para continuar mi formación y viajar para presenciar a cirujanos expertos ejecutar sus casos. Ahora que he hecho centenares de casos y viajo para ver como nuevos cirujanos en robótica ejecutan sus casos, mi opinión original ha cambiado un poco.

Si un cirujano es lo suficientemente dedicado, finalmente hay suficientes videos quirúrgicos buenos y procuradores adiestrados para ayudar a reducir la curva de aprendizaje considerablemente. ¿Cuántos casos? No estoy seguro, pero no quisiera ser uno de los primeros 25 pacientes. El robot es simplemente una herramienta de lujo. Si se sabe cómo usarlo, uno puede hacer cosas grandiosas. De otra manera podría arriesgar un gran daño a el paciente y a si mismo. Un sitio Web útil de Intuitive Surgical lista a cirujanos que han hecho por lo menos 20 casos. ¡Ésto es por lo menos es un principio - algunos informes sugieren que usted debería buscar a cirujanos que han hecho al menos cien casos!

Sobre el Dr. Kella

2009-01-16T15:05:00.003-06:00

Dr Kella completó un titulo en Ingeniería Química y procedió a recibir su doctorado en University of Texas at Southwestern Medical School en Dallas, Texas. Después de terminar su residencia en Tufts University en Boston, Massachusetts, continuo su formación en Baylor School of Medicine en Houston, Texas para desarrollar su maestría en oncología urológica y cirugía robótica.

Después de su entrenamiento, Dr Kella vino a Urology San Antonio y realizó por primera vez en el área una prostatectomia robótica para cáncer de la próstata y una cistectomía radical para cáncer de la vejiga. Él ha realizado mas de 1000 casos de cáncer de la próstata, convirtiendole en uno de los cirujanos con más experiencia de la nación. (Seleccione este enlace para enterarse de la importancia de la experiencia.) Su rutina es realizar de 6 a 10 casos por semana, con el mismo equipo en el mismo hospital. Él regularmente entrena a otros cirujanos y está participando en investigación clínica de cáncer de la próstata. Él también ha contribuido a literatura en cáncer de la próstata.

Él está comprometido en crear una experiencia para el paciente tan menos dolorosa como tan exitosa posible.

Robotic Surgery Patient Video

2009-01-15T15:10:00.000-06:00

This video is an introduction to minimally invasive surgery for prostate cancer using a surgical robot.

Brochure on Minimally Invasive Prostatectomy (English and Spanish)

2009-01-15T15:00:00.000-06:00

Open English Publication

Open Spanish Publication

Nutrition for Prostate Health

2009-01-02T18:08:00.003-06:00

A favorable diet for all men concerned about prostate health is a Modified Mediterranean. The benefit of this type of diet includes heart health, prostate health and as a mechanism to slow the aging process. Heart disease is prevalent in all ages but most commonly in men aged 40- 70. Similarly prostate disease is prevalent in all ages beginning as early as our teen years and extending throughout our adult lives. The diet is ideally intended for all men who want to prevent heart disease and prostate disease as they age. For men who already have heart or prostate disease it is never too late to start with a proper diet. Beyond the dietary commentary, I encourage prostate nutritional support with vitamins, regular daily exercise, and stress reduction.

Fresh Fruits
Examples include but are not limited to: Oranges, Tangerines, Bananas, Cherries, Grapefruit, Watermelon, Cantaloupe, Guava, Kiwi, Strawberries, Blueberries, Raspberries, Blackberries, Cranberries, Papaya, Grapes, Apples, pomegranate, and plums. I think fresh whole fruit is better than drinking juice.

Fresh Vegetables
Fresh, never canned with the exception of tomato paste and stewed tomatoes. Examples include but are not limited to: Cruciferous vegetables belonging to the Brassica classification including - Broccoli, Broccolini, Brussels Sprouts, Kohlrabi, Kale, Collard Greens, Bok Choy, Mustard Greens, Cabbage, Cauliflower; Non-Brassica vegetables include but are not limited to: Tomatoes and Tomato related products including the aforementioned Tomato Paste, Stewed Tomatoes and Tomato Sauce; Peppers including Chili Pepper, Bell Pepper, Habanera Pepper etc; Onions, Peas, Carrots, Spinach, Beets,
String Beans, Mushrooms (Shitake, Portabella, Morel, Maitake, Oyster, Porcini etc.); Steamed, sautéed or Wok prepared vegetables are most nutritious; Limit Corn and Corn related products and recipes. Avoid fried onion rings.

Cooking Oils
Olive Oil is best; Canola Oil is an alternative where Olive Oil can’t be used; Avoid Palm oil, Coconut oil, Corn oil, Vegetable oil.
Garnish and/or integrate any dish with Garlic, Cucumbers, Lettuce, Celery, Curcumin, Cilantro, Pepper, Oregano, Ginger, Rosemary, Thyme, Parsley, Sage, mustard, relish pickles, olives. Avoid Mayonnaise and Creamy bread spreads

Protein Sources
Cold water fish including but not limited to: Tuna fresh or canned (in water or olive oil), Wild Salmon whenever possible, Halibut, Sardines, and Mackerel; Turkey and Chicken (white meat only, without skin), Turkey bacon, Turkey sausage, Beans (all types), Egg whites and Peanut Butter; Scallops, Shrimp, Crab, Lobster and Calamari are OK depending on the preparation;

Avoid: Red Meat including Hamburgers, Hot Dogs, Sausage, Chili with ground beef, Barbecued beef, Steaks, Prime Rib, Pork or Lamb, Wild Game, Chicken Wings, Sloppy Joes, Bacon, Pork Roll, Prosciutto, Pepperoni, Salami, Bologna, Head Cheese, Organ Meats, Spam,
Ham, Smoked Meats; Fish to avoid includes: Tile Fish (Tilapia), Sword Fish and Farm Raised Salmon

Dairy
Non-fat Yogurt, Egg Whites or Egg Beaters, Skim Milk, Non-Fat Cheese, Non-fat Cottage Cheese; Avoid Fat associated with dairy including cheese, whole milk, half & half, cream, Ice cream, egg yolks, and cream sauces including but not limited to Hollandaise, Béarnaise, and Giblet gravy

Pasta and/or Carbohydrates

Whole wheat or rice is best while whole grain breads are encouraged; Moderate consumption of Pizza, while Whole Wheat crust is best when served with Pizza Sauce or Marinara; Brown Rice; Sweet Potatoes are preferred over white baking potatoes although the skins of both are nutritious; Skip simple pasta like spaghetti and noodles and avoid bread sticks, white bread, white rice and simple sugars such as refined white sugar and honey; Avoid: French Fries. Sugar Substitutes include: Splenda could be used for cooking

Salads
Fresh garden greens with cucumbers, tomatoes, avocado, raisins, radishes, onions, peppers, olives, carrots, nuts and fresh vegetables to suit; the best dressing is extra virgin Olive oil and balsamic vinegar; Avoid other dressings. Avoid croutons.

Crackers
Whole Wheat is best; Avoid crackers made with partially hydrogenated oils including but not limited to cottonseed oil and soy bean oil (trans-fats)

Soups
Tomato with vegetables, Tomato, chicken with rice, chicken noodle; Avoid creamy soups.

Desserts
Seasonal berries or a piece of dark chocolate. Avoid pastries, cheese cake, cookies, ice cream and pies

Soy
Minimize or moderate intake of soy including Genistein and Diadzein components; Additional soy that may be consumed include low fat soy milk, miso, and tofu. Avoid soy sauce based on high salt content

Snack Foods (in moderation)
Non-fat Pretzels, Peanuts, Hazelnuts, Pistachios, Brazil Nuts, Almonds, Walnuts, Pecans, Filberts, Grapes, Dark Chocolate, Trail Mix (homemade), Dried Fruits, air-popped Popcorn, , a piece of fresh fruit; Avoid soft drinks, potato chips, corn chips, candy, milk chocolate, pork rinds, microwave popcorn, cookies.

Beverages
A glass of red wine is fine; Minimize the intake of any alcoholic beverage including vodka, whiskey, tequila, gin, scotch, rum, beer.

Avoid: Milk shakes, soft drinks, cream liquors.

Nutrition
Consider supplements available in the vitamin store. The research behind the array of supplements available are sparse. In addition, production methods can vary widely. I am a supporter of Theralogix, which is owned by a urologist and takes the effort to only include agents best supported by the available literature. In addition, control of production is stressed.

Avoid frying in favor of broiled or baked
If you are trying to lose weight, especially for surgery, start every meal with an 8 ounce glass of water.

If you grill your dinner, do not over cook or burn what is to be consumed
Avoid the use of butter or margarine.

PSA doubling calculator

2008-12-31T10:39:00.003-06:00

PSA doubling calculator. If your PSA is rising, it can be risk-stratified by calculating a logarithmic doubling time. The longer the doubling time, the slower growing the cancer.

If the doubling time is over 9 months, this is considered very favorable.
If the doubling time is less than 3 months, this is very concerning.

The link is an easy calculator to use from a prostate cancer support group in Cincinnati.

Book Chapter on Robotic Prostatectomy

2008-12-20T12:02:00.002-06:00

Open publication

Find Us! / Encuéntrenos

2008-12-06T16:57:00.004-06:00

Dr Kella office and operating rooms are in San Antonio, TX.

El consultorio del Dr. Kella y lo quirófanos se encuentran en San Antonio, Tx.

View Larger Map

Beyond the Prostate

2008-10-11T17:10:00.000-05:00

Robotic surgery continues to find useful applications outside of radical prostatectomy. Besides bladder removals, kidney surgery, and hysterectomy, I have found the system to be perfect for repairing vesicovaginal fistulas. These are conditions where an abnormal connection materializes between the bladder and the vagina. Urine flows from the bladder and out of the vagina, creating considerable mental anguish for the patient. Usually, this occurs after a pelvic surgery such as a hysterectomy. So far, I have seen 4 cases, which I was able to fix successfully using the robot.

EPCA-2: Promising new biomarker for prostate cancer

2007-05-27T11:16:00.000-05:00

Perhaps as an adjunct or even as a replacement, EPCA-2 represents one of many potential new biomarkers, which may help patients better determine their risk for having prostate cancer and even avoid unnecessary biopsies.

"Practicing urologists are all too familiar with two common problems inherent in the management of prostate cancer: the lack of specificity of the PSA test and the lack of a method to distinguish between progressive and indolent disease. A new biomarker, which is under investigation at Johns Hopkins, shows great potential to address both of these controversial issues..." For more, click here

Into the Future—Today

2007-01-20T18:57:00.000-06:00

This article was submitted to Bexar County Medical Society

Urology, like the rest of medicine, has seen innovations arise at a dizzying pace. Most urologists would agree that their practice of medicine today is dramatically different than what they were trained for at the finish of their residency. Fortunately, urologists have adopted technologies such as robotics if they advance patient care.
Originally conceived for military surgery on the battlefield, robotics has evolved into powerful, state-of-the-art technology adopted for civilian use as the daVinci robotic system (Intuitive Surgical). Radical prostatectomy, which is the removal of the prostate for prostate cancer, quickly became the most common procedure performed with the daVinci robot after FDA approval in 2001. Today, the company estimates 30 to 40% of all prostatectomies performed will be with the robot. San Antonio, through the Baptist Medical System, was an early adopter of this promising technology. As of 2007, over 500 robotic procedures have been performed, with over 400 of these procedures being for prostate cancer.
The System allows the surgeon's hand movements to be scaled, filtered and translated into precise movements of micro-instruments within the operative site. The magnified, three-dimensional view the surgeon experiences enables him to perform precise surgery in complex procedures through laparoscopy. The surgeon sits comfortably at a console, located a few feet away from the patient. The robot “docks” to the laparoscopic ports and a patient-side assistant helps with retraction, suction, and instrument changes.
For qualified candidates, robotically assisted prostate surgery offers numerous potential benefits over the traditional open prostatectomy, including shorter hospital stay, less pain, less risk of infection, less blood loss and transfusions, less scarring, faster recovery, and quicker return to normal activities.
These potential benefits depend on the individual case as well as the experience of the surgeon. Most urologists would agree that learning curve for robotics is steep. For the author, who has personally performed over 400 robotic prostatectomies, an initial comfort level arose at 20 cases and then another level at 150 to 200 cases. This perhaps is the most important point. While the robot is truly a tool capable of improving patient outcomes, its abilities ultimately rest on the surgeon’s experience and skills.

Immunotherapy for Advanced Prostate Cancer

2006-10-15T21:17:00.000-05:00

What is this vaccine therapy? After hormones fail, patients with advanced prostate cancer face dismal options for fighting their disease. Chemotherapy can prolong median survival for a few months. Cell Genesys
has manufactured "off the shelf" medication to use for advanced prostate cancer. Currently in Phase III trials, the drug will be compared to chemotherapy using Taxotere and steroids. Patients must have detectable evidence of prostate cancer spread. A rising PSA alone on hormones is not enough.

This drug is unique because it is made from two genetically modified cell cancer lines. One is from metastatic prostate cancer and the other is from a localized prostate cancer cell line. The patient does not have to innoculate his own blood to develop a vaccine therapy, although other companies are pursuing this type of treatment.

We are involved with the clinical trials with this drug. It is too early to verify its superiority to chemo and steroids, but I can say that I am amazed at how little side-effects the patients have. For more, look here or click Urology San Antonio
Link

Hormonal Therapy

2006-10-08T22:44:00.000-05:00

Recently a patient decided on hormonal therapy after developing a recurrence of his prostate cancer after radiation. This is really acceptable therapy, but hearing about this reminded me that using hormones is a systemic treatment that can have side-effects beyond osteoporosis.

Link

HIFU High Intensity Focused Ultrasound

2006-10-01T11:38:00.000-05:00

HIFU, or High Intensity Focused Ultrasound, is a form of treatment for prostate cancer undergoing clinical trials right now in the United States. This treatment is not new- it has existed for years in Europe and Japan. Results have been mediocre to date, but this technology-driven treatment looks like it is finally ready for the big time.

What is HIFU?

HIFU technology developed in the 1950s originally and was used to treat central nervous system tumors. In the 1990s, experimental work was performed in dog prostate models followed by work with humans. HIFU is a noninvasive (well if you consider a rectal probe noninvasive... there are no incisions and that's why we call it noninvasive) treatment for prostate cancer still contained in the prostate. Ultrasound energy is focused on tissue, bringing its temperature to nearly 100 degrees Celsius in just 2 or 3 seconds. The tissue is literally denatured and dies off.

How does the technology work? The best analogy is to imagine a magnifying glass focusing light on a dry leaf. You could burn a hole in the leaf and literally leave the rest of the leaf untouched. HIFU works the same way. As long as you can image the tissue, you can treat it.

Is this better than radiation? Radiation treatments have made huge strides, especially with IMRT and proton beam treatments. However, these treatments are still radiation. If some surrounding tissue gets treated, who knows what kind of cellular changes could occur over the years to that radiated tissue. Documented cases of secondary cancers, which are worse than the original cancer have been seen years after the orignial treatment. (see: Irradiation sarcoma after external beam radiation therapy for localized adenocarcinoma of the prostate: report of three cases. If HIFU shows good results in its clinical trials, I think it will be a form of treatment that is less toxic than radiation. Ultrasound energy is not ionizing energy like radiation. After all, we use diagnostic ultrasound all the time for imaging body parts and even a pregnant woman's fetus!

What are the results so far?

Again, the technology is undergoing FDA trials right now. Our group, UrologySanAntonio.com is one of the first sites accepted to trial the Sonablate 500, a device manufactured by Focus Surgery in Indiana. The trial will be funded mainly by USHIFU, which is the exclusive distributor of the machine in the Americas. As a disclaimer: I don't have a financial interest in the company. During the trial, patients will be selected based on their prostate cancer's stage. (more later)

There is another HIFU device known as Ablatherm also hopefully starting trials soon. We are comfortable with the Focus Surgery device. Apparently, it is less limited by prostate size and the rectal probe is not as big. Undoubtedly, both companies will continue to innovate and I will try to keep you posted as changes occur.

A paper in Clinical Genitourinary Cancer published in December 2005 summarized available clinical trials to date. Unfortunately, the trials so far are difficult to compare with each other. Some are done with patients with localized cancer, others have patients with more advanced cancer or patients on hormonal therapy, which can confound PSA results. The data so far shows 5-year progression-free survival rates ranging from 68% to 88%. Most of the studies are from Europe and Japan. One American study is reported. This is a pilot study with the Sonoblate 500 device. The data looked at 20 patients with early, localized cancer. These patients actually had to undergo a repeat biopsy at 1 year to check for cancer. Negative biopsies were shown in nearly 2/3 of patients. Some patients needed more than one HIFU treatment.

What are the benefits?

HIFU is nearly painless. Patients typically have an epidural or spinal anesthetic and are home later the same day. The procedure is bloodless, so patients do not feel too weak afterwards. HIFU offers the potential to preserve men's sexual potency. From my observation, the imaging allows you to see the capsule of the prostate. The view becomes a little difficult at the apex and the base of the prostate, but as long as you can make out the capsule, you can precisely treat the prostate and avoid the tissue outside the capsule, which comprises the neurovascular bundle. The bundle is what helps with erections.

Risks?

HIFU is experimental therapy undergoing FDA trials. We need longer term data before we can say this is a substitute for radiation or surgery. There is a risk for urethral strictures, impotence, and incontinence after the procedure. There is also a learning curve. After participating in some treatments, I can say that an understanding of prostate anatomy and ultrasound is very important. An inexperienced surgeon may have real difficulty performing the procedure well. Fortunately, doing hundreds of laparoscopic, robotic-assisted prostatectomy surgeries as well as ultrasound procedures really helps to perform HIFU with a good understanding of the anatomy.

Interested in treatment?

The FDA trial is open to men with prostate size less than 40 cc, a Gleason score of 6 or less, PSA less than 10 who have not had any type of medication or surgery for their prostate cancer. Others who seek treatment and are not candidates for surgery or radiation may have to travel outside the United States for treatment. I have been to Mexico and the Dominican Republic to see these treatments and was astounded at how good the patients look after treatment. Close follow-up with the completion of the FDA trials will help confirm HIFU's role in the urologist's armamentarium against prostate cancer. Feel free to visit my website at www.urologysanantonio.com and email me for more information.

Can Men AVOID Prostate Biopsies?

2006-09-10T15:23:00.000-05:00

Recently, I have been hearing more and more about the possibility of detecting prostate cancer without having to do a biopsy. Biopsies are done after the urologist detects an abnormality on the rectal exam or blood PSA test. The rectal exam and PSA test are only screening tools. They don't tell us if the patient has cancer or not. Biopsies are performed by taking 10 to 12 "cores" with a needle gun through the rectum with an ultrasound probe. Yes, not too fun. So what is this new way of detecting cancer?

MRI and MRI spectroscopy
Magnetic Resonance Imaging, or MRI, can depict prostate anatomy with excellent contrast resolution and can uncover cancer in areas not routinely sampled on biopsy and not palpable on rectal examination. In addition, MRI allows assessment of local extent (read: extracapsular extension and seminal vesicle invasion), which can help with staging the cancer. The addition of spectroscopy to MRI can improve prostate cancer detection- combining the detail of MRI and the ability to "sniff" the biological aggressiveness of cancer with MR spectroscopy.

Would I operate based on the data from this new technology, without biopsies? The test is very sensitive and specific, but I still would not because you would try to avoid an unecessary operation at all costs. What if there was no cancer? However, there are situations where this test would be useful.

For example, if the patient has had prior biopsies done for an elevated PSA and they were negative. Unfortunately, the PSA keeps going up. The MRI might help the urologist FOCUS his area of biopsies.

Another case: a low but rising PSA. Many biopsies are uneccesary. The MRI could spare the patient the trauma of biopsies if the risk of cancer is low.

Also, the growing popularity of "watchful waiting" where the disease is monitored in low-risk patients- the MRI could give us a better idea than just depending on PSA. A picture of the disease could be compared yearly, giving us a precise view of the progress of disease.

Smart Bombs for Prostate Cancer

2006-09-03T15:51:00.000-05:00

One of the benefits with working with a large group of urologists is the ability to support clinical trials. These trials are funded by the pharmaceutical and medical device companies as well as academic centers. For example, we can offer patients cutting-edge treatments in prostate cancer that can save them from making long trips to unfamiliar places at a time when they may be most vulnerable.

One trial right now is with
Protox Therapeutics. They are currently conducting a Phase I clinical trial for patients with local recurrent prostate cancer using PRX302.

What is that and who is it for?

PRX302 is like a smart bomb for prostate cancer. The drug enters the body in a nonactivated form. Prostate cancer cells release PSA, which can cleave a protein off the drug and activate it into its cancer-killer state. The drug binds to the nearby prostate cancer cell and drills a hole into it, causing the cell to die.

This is very exciting because it can potentially minimize toxicities that are associated with the "shotgun" approach associated with chemotherapy, hormones and radiation. Only prostate cells are targeted. Also, the cancer is treated whether it is a slower growing cancer or a rapidly growing one, which is a potential drawback when treating with radiation or chemo. These treatments work better on faster growing tumors, and prostate cancer is often a relatively slower growing one.

This trial is for localized recurrent prostate cancer. For example, a patient who underwent radioactive seed placement and now has a rising PSA would have to undergo biopsies to verify cancer is present. Also, we would need to make sure the cancer has not spread elsewhere in the body.

The patient will then be injected with PRX302 into the prostate gland under ultrasound guidance. Changes in PSA levels will be measured and prostate biopsies performed after 30 days.

Early reports and animal studies have been very promising.

Is the robot just a powertool?

2006-09-03T12:48:00.000-05:00

Over the past year, I have been amazed at how fast robotic surgery is becoming the standard for patients who need surgery for their prostate cancer. Even surgeons who don't perform robotics have decided to refer patients to me as a service to their patients. Initially, I thought that the learning curve for robotics would be too steep for busy surgeons to fully master. That's why I took a year to do a fellowship and travel to see expert surgeons perform cases. Now that I have done hundreds of cases and travel to "proctor" new robotic surgeons as they do cases, my original opinion has changed a bit.

If a surgeon is dedicated enough, there are finally enough good surgical videos and trained proctors available to considerably shorten the learning curve. How many cases? I'm not sure, but I still would not want to be one of the initial 25 patients or so. The robot is just a fancy powertool. If you know how to use it, you can do great things. Otherwise you could risk a lot of damage to the patient and to yourself. A useful website by Intuitive Surgical lists surgeons who have done at least 20 cases. This at least is a start- some reports suggest that you should look for surgeons who have done at least a hundred cases!

First blog post!

2006-08-27T16:04:00.000-05:00

Well, hopefully, this won't be the last blog post, too. I was inspired to start this blog after seeing countless sites that were very static and very informative if we were in 2002.

I think a blog will allow people to reference the information by date and thus really see how "innovative" and new our discussions really are.

Finally, things you should know: I am a practicing urologist with a large group in Texas. I treat nearly 300 patients a year with prostate cancer with robotic surgery. However, surgery (even robotic) is not necessarily the best option for all patients. I am lucky enough to be in a large, progressive group that allows expert treatment with cutting edge radiation, cryotherapy, and clinical trials, which allow early access to drugs and treatments that are not yet available in the United States.

For more information, go to: urologysanantonio.com