David K. Ornstein

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Dr. Ornstein is an internationally recognized expert robotic surgeon. He has successfully completed nearly 500 robotic surgeries; including more than 400 robotic prostatectomies for prostate cancer and more than 65 robotic cystectomies for bladder cancer.
Dr. Ornstein is a pioneer and innovator in the field of robotic surgery and has published extensively on this topic in a variety of peer-reviewed medical journals. Dr. Ornstein has lectured and trained multiple robotic surgeons in the United States and around the world. He has performed several live robotic surgeries including a live robotic female cystectomy during a symposium at the Seoul National University Boramae Medical Center in South Korea. Following the successful surgery he was interviewed on the Arirang TV's daily talk show - "Heart to Heart." Arirang TV is Korea's first, domestically produced, English-language TV channel that is viewed in more than 51 million households in 188 countries throughout the world.

Award Winning Urologist
Dr. Ornstein has been recognized through multiple national awards for his clinical expertise in the care of patients with prostate and other urologic cancers as well as his skill as a robotic surgeon.
He has been named as one of the "Best Doctors in America" for the past 2 consecutive years.
In 2008 he was also named as a Physician of Excellence by the Orange County Medical Association and a Top Urologist by the Consumer's Research Council of America.
At the 2007 annual meeting of the American Urologic Association, Dr. Ornstein became the 6th recipient of the prestigious Investigator Award from the Society of Urologic Oncology. This award recognizes excellence in both research and clinical practice in the area of urologic oncology.

The challenge of cancer and other urologic problems may seem insurmountable at first, but these are hurdles that can be overcome. In fact, most people diagnosed with urologic disease, even those with urologic cancers (kidney cancer, ureteral cancer, bladder cancer, prostate cancer, testicular cancer) can be cured without significant impact on long-term quality of life. The development of better blood tests (prostate specific antigen) and radiographic imaging modalities (CT scan and MRI) has dramatically improved the opportunity to detect urologic cancers (particularly prostate cancer and kidney cancer) at a stage while they are still curable. The advent of robotic surgery such as robotic prostatectomy, robotic partial nephrectomy and robotic cystectomy with urinary diverson has now made it possible to not only cure most urologic cancers (prostate cancer, kidney cancer, bladder cancer) but to do so in a manner that does not cause excessive pain and maintains normal bodily functions such as urinary control and erectile function. Patients with prostate cancer can usually be successfully treated with robotic prostatectomy without causing urinary incontinence or sexual impotence. In many cases robotic partial nephrectomy can be performed to remove a kidney tumor (kidney cancer) without damaging the remaining healthy portion of the kidney.

My goal is to deliver care that provides the best possible chance for cure, and minimizes risk for treatment-related discomfort and long-term side effects. I completed residency and fellowship training in Urologic Oncology and have acquired substantial robotic surgical skills. I have developed expertise in robotic prostatectomy {robotic radical prostatectomy}, robotic partial nephrectomy and robotic radical cystectomy. First and foremost, I am committed to providing the most appropriate and highest quality of care possible, and to do so in an honest and compassionate manner. The successful interaction between patient and surgeon is dependent on mutual trust and respect, and better outcomes are usually achieved when the patient and doctor work as a team. I have always believed that it is a privilege to treat patients, particularly those with a life-threatening condition such as cancer. I hope to have the opportunity to help you in your time of need and look forward to a mutually successful and beneficial relationship.

Recently, results from 2 large prostate cancer screening trails were reported in the New England Journal of Medicine and the topic of prostate cancer detection has received significant attention in the national media. Although, both studies are inconclusive close examination of them yield important information about prostate cancer screening. The PLCO (Prostate, Lung, Colon, Ovarian) Cancer Screening trial included 77,000 men in the United States randomly assigned to a screening or control group. It has been reported that this trial failed to demonstrate a benefit from prostate cancer screening with annual PSA testing and digital rectal examination. It may not however, be accurate to conclude from this study that prostate cancer screening is not beneficial since there are several limitations to this study that compromise the published conclusions. In other words there are several explanations to explain why this study failed to detect a survival benefit for men undergoing prostate cancer screening even if one existed. Plausible explanations include: 1) The follow up in this study may not have been long enough to detect a benefit for screening since death from prostate cancer typically occurs more that 10 years after the diagnosis of prostate cancer. 2) The PSA cut off (4.0 ng/ml) used to recommend prostate biopsy in the PLCO study is likely too high and may have resulted in delayed detection of cancers after they were no longer curable. 3) More than 40% of men in the study had already been evaluated with a PSA test, and 50% of the patients in the control arm of the study underwent prostate cancer screening by their personal physician during the study period. Therefore, a positive effect for screening may have been obscured by this study contamination.
In contrast to the PLCO study, the ESPRC (European Randomized Study of Screening for Prostate Cancer) which screening 182,000 men in 7 European countries every 4 years demonstrated a benefit for prostate cancer screening. In this study prostate cancer screening reduced the risk of prostate cancer death by 20 percent, but 48 additional men needed to be treated for prostate cancer to prevent each prostate cancer death. This study supports the use of PSA-based prostate cancer screening for appropriately selected men, but also highlights the potential risks of over diagnosis and treatment of prostate cancer.
Although there are many unanswered regarding prostate cancer the propensity of evidence supports prostate cancer screening in appropriately selected men. The American Urological Association (AUA)continues to recommend routine prostate cancer screening for those men wishing to be screened. The AUA has revised its recommendation to begin screening with a baseline PSA test and digital rectal examination at the age of 40. They also recommend against the use of a specific PSA cut off, but rather to base the recommendation for prostate biopsy on other factors such as age, family history, ethnicity and the digital rectal examination in addition to the PSA value. The rate of PSA rise (PSA velocity) is also an important factor to consider in determining the need for prostate biopsy.
AUA Prostate Screening Guidelines

Although still less common than prostate cancer, the incidence of kidney cancer is rising. Fortunately, most people diagnosed with kidney cancer can be treated with partial nephrectomy (nephron-sparing surgery aka remove only the kidney tumor and leave the normal healthy kidney behind). Surgeons have experimented with pure laparoscopic approaches to partial nephrectomy, but even in the most experienced hands the risk for complications and renal failure are higher than for open surgery. Robotic surgery is ideal for less invasive kidney surgery since magnified and enhanced 3D vision facilitates accurate removal of the kidney tumor and successful repair of the renal defect. In fact, several recent studies have shown that robotic partial nephrectomy is easier to learn and is associated with shorter warm ischemic times and fewer complications than for standard laparoscopic nephron sparing surgery. Dr. Ornstein applies his robotic surgical skills to the treatment of kidney cancer and routinely performs robotic partial neprectomy. As a recognized expert on robotic kidney surgery, Dr. Ornstein has served on the faculty of several instructional courses. Most recently, he was on faculty for an advanced robotic workshop on robotic renal surgery in which more than 100 practicing urologists from around the United States participated in.

Robotic-Assisted Minimally Invasive Surgery
By dramatically enhancing visualization, precision, control and dexterity, the da Vinci System overcomes the limitations of traditional laparoscopic technology, helping physicians to perform complex surgery in a manner never before experienced. With enhanced surgical capabilities, physicians are now able to extend the benefits of minimally invasive surgery to the broadest possible range of patients.

Experience counts! There is more and more scientific evidence that patient outcomes for prostate cancer surgery are directly related to the experience of the surgeon. A recent survey of 72 prostate cancer surgeons demonstrated that the risk for cancer recurrence was reduced by 40% if the surgeon had performed more than 250 open radical prostatectomies. It has also been shown that complications are less in the hands of experienced surgeons. Robotic surgery is equally challenging to master and it has been demonstrated that the learning curve for robotic prostatectomy is a minimum of 250 cases. It has also been shown that experience is not the only determinant of surgical outcome since not all high volume surgeons achieve equally good results. Thus, when choosing a robotic surgeon it is not only important to ask about experience, but one should also ask about results.

Dr. Ornstein tracts his results carefully in order to help him continually improve his techniques so that he can provide his patients the best opportunity for successful outcomes.
In last 100 robotic prostate cancer surgeries performed by Dr. Ornstein the average total surgical time was 179 minutes (137 minutes of robotic consul time), the average blood loss was 74 cc and no patient required a blood transfusion. A surgical drain was not used in any of these cases and 99% stayed in the hospital less than 24 hours (1 patient stayed 2 days). There was only 1 complication; a small rectal tear that was repaired robotically without consequence. No patient required readmission for any reason, and the foley catheter was removed within 10 days of surgery for all patients.

The primary goal of robotic prostatectomy is cancer control which is accomplished best by removing the entire prostate and all of the cancer. The true measure of success is long-term cancer free survival, but one of the most important short-term indicators of a successful robotic prostatectomy, as it pertains to prostate cancer control, is the surgical margin status. The surgical margin is determined by the pathologist examination of the prostate once it has been removed from the patient's body. A positive surgical margin means that the pathologist sees cancer cells at the border of the cut edge of surgical specimen (the prostate and surrounding tissue that has been removed from the patient). If it is not an artifact,a positive surgical may be an indicator that prostate cancer has been left behind in the patient and that the patient may need additional prostate cancer treatments such as radition therapy.Fortunately,when Dr. Ornstein performs robotic prostatectomythe canceris successfully removed with negative surgical margins 91% ofthe time(i.e. Dr. Ornstein's overall positive surgical margin rate is 9%). For patients with prostate cancer that had not invaded beyond the prostatic capsule (stage pT2) the positive surgical margin rate is 3.7%. Dr. Ornstein continuously reviews his results and modifies his technique when he feels that his outcomes can be improved. For example in his first 216 cases the overall positive surgical margin rate was 14.8%, and 5.4% for pT2 cancers. After reviewing multiple videos of prior cases and modifying his technique he was able to lower his positive margin rate to 9% overall and 3.7% for pT2 cancers.

Another example of where a modification in surgical technique has directly resulted in improved outcomes relates to urinary control. For many robotic surgeons, including Dr. Ornstein, their early experience with robotic prostatectomy was associated with good outcomes in regards to continence, but for many patients it took as long as 1 year for urinary control to recover. Dr. Ornstein recognized that this delay in regaining urinary control negatively impacted his patients quality of life so he sought out to modify his surgical technique to hasten recovery of urinary control. To this effect he developed a technical modification that aims to reconstruct the normal anatomy of the sphincter that is responsible for urinary continence. Hehe has termed this novel anti-incontinence procedure the PRASS the technique. This technique is simple to perform, requires only 1 additional suture and takes less than 5 minutes to perform. By incorporating the PRASS technique during robotic prostate surgery (robotic prostatectomy), Dr. Ornstein has improved his 3 month continence rate (1 or fewer pads) from 43 to 91%.

Prostate cancer is the most common non-skin cancer in United States men and the second leading cause of cancer related deaths (figure 1). It is estimated that in 2009192,280 men will bediagnosed with, and 27,360 men die from prostate cancer. The lifetime risk for a man in the United States to be diagnosed with prostate cancer is 1 in 6. All men can get prostate cancer but those with a family history and African American men are at a substantially greater risk. Although the exact cause of prostate cancer is not known it has been suggested the high fat diets are associated with increased prostate cancer risk while diet rich in fish and fruits and vegetables can reduce the risk. Prostate cancer tends to more aggressive in African Americans and obese men.