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Blockage and prostate cancer treatment a team effort

August 24, 2017 | UCI Health
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Tony Mastrangelo with his wife of 46 years, Georgiann.

Tony Mastrangelo keeps himself fit and has enjoyed good health overall except for some asthmatic allergies. But when real trouble came, it came quickly.

He was in the shower when a blast of pain in his back hit so hard that it dropped him to his knees. A trip to the emergency room at UC Irvine Medical Center resulted in quick medications to relieve the pain and then a series of tests that revealed a urinary obstruction where the funnel-shaped renal pelvis drains into the ureter.

“That was the precipice that started this whole domino effect,” Mastrangelo recalls now, a year later.

Within a few months, he would undergo two surgeries for two completely separate medical problems discovered by testing — the blockage and prostate cancer. And two weeks after each surgery, Mastrangelo said, he was back to work as head of the international department at American Business Bank.

Ureteropelvic junction obstruction treatment

The doctors started with the immediate problem, the ureteropelvic junction obstruction.

These days, UPJ obstruction is most often diagnosed in babies, largely because it can be seen clearly on ultrasounds routinely given to pregnant women. In Mastrangelo’s case, it isn’t known whether this was a condition he always had that remained symptom-free or whether it developed later in life. Either way, if untreated, UPJ obstruction can cause severe and permanent kidney damage.

That’s how he came to see Dr. Jaime Landman, chair of the UCI Health Center for Urological Care and a specialist in kidney disease. Landman employed a novel CT imaging technique to reach a diagnosis. “It gives precise, detailed anatomy with about 40 percent less radiation,” Landman said.

With the CT scans and a renal scan, Landman found the problem: an artery adhering to and pressing against the area. It would have to be peeled away and the openings to both the ureter and renal pelvis widened.

Pioneering technology to treat patients

UCI Health urologists pioneered the use of less-invasive laparoscopic surgery for these kinds of cases, Landman said. But such surgeries also require pumping gas into the abdominal area to create space for the surgeon to work, and that gas creates postoperative pain and discomfort. Landman has been at the forefront of solving that problem.

“We have technology to perform these procedures using half the normal gas pressure,” Landman said. “We were the first to document the extraordinary precision of this device which helps patients get out of the hospital a little bit faster and with less pain.”

In Mastrangelo’s case, that meant a very short hospital stay of a day and a half; the obstruction was completely resolved. But once he recovered fully, there was still the prostate cancer to deal with.

Malignant lesions discovered on prostate

He had been told for years by his regular doctor that his intermittently rising PSA levels, from a blood test that measures prostate-specific antigen, were nothing to worry about. As it turned out, after further testing by UCI Health physicians, he had two malignant lesions in the prostate.

Prostate cancer is especially difficult to biopsy. Magnetic resonance imaging (MRI) can find the cancer, but needles for the biopsy can’t be used in the machines. Ultrasound allows doctors to see where the needles are going in real time, but can’t locate the lesions, so doctors insert the needles at short, regular intervals that can still miss the cancer.

UCI Health has been a pioneer in the use of the Artemis device, which fuses MRI imaging onto the ultrasound, giving doctors an accurate, 3-D real-time guide for taking exactly the right tissue samples. The result is fewer needle jabs with far more accurate results.

Prostate cancer treatment options

The question for Mastrangelo, once the cancer was confirmed, was whether to proceed with surgery, radiation or “watchful waiting.”

When genetic testing revealed a propensity for aggressive forms of cancer, his mind was made up.

“Relatives on my mom’s side have died in their 60s of prostate cancer. So for me, it was time to think about trying to cure this.”

He was referred to Dr. Thomas E. Ahlering, a UCI Health specialist in urologic oncology and vice chair of the Department of Urology, who has built a reputation for fine-tuned prostate surgery that removes all cancerous cells while preserving urinary or sexual function. Damage to either or both is a well-known side effect of prostate surgery.

Advanced robotic surgery techniques

Ahlering found the way to preserve that function with DaVinci® robotic surgery technology, again using a laparoscopic procedure. He became an early adopter of the robotic technique for prostate surgery some 15 years ago, and has taught it to others.

Most surgeons are aware of the need to retract tissue to keep the nerves that control urinary and sexual function away from the tissue being removed, Ahlering said. “The problem is that if they push on those nerves to retract them, the nerves are still being damaged."

The key, he said, is to dissect the prostate away from the nerve, not the other way around.

Arming others with information

Mastrangelo couldn’t be happier with the results. He’s even amazed by the inconspicuous appearance of the 11 small incision marks on his abdomen. “It’s true, he’ll just pull up his shirt to anyone to show them,” his wife Georgiann Mastrangelo said, as the two of them burst into laughter.

“We live in a world of caution,” Tony Mastrangelo said. “You have to know when to trust people.” He found those people at UCI Health, with Landman, Ahlering and, he said, all the staff.

Tony Mastrangelo said he’s more the analytical than worrying type; his natural inclination is to figure out the best steps to take next. And that, he said, is why he is telling others now about his experience.

“If somebody can benefit by this,” he said, “if it makes a decision easier, make someone less anxious, then that’s a good reason to tell my story.” 

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