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Biomedical subjects

C B Brendler

Publications and source records attributed to C B Brendler.

At least 19 recordsLinked to original sources
PubMed2001

Does the CaverMap device help preserve potency?

Erectile dysfunction remains a common complication following radical prostatectomy. The CaverMap Surgical Aid (UroMed, Boston, MA) was designed to aid the surgeon in identifying and preserving neurovascular bundles (NVBs). However, the size of the CaverMap nerve stimulator may make it difficult to trace the cavernous nerves before the prostate is removed, particularly in obese men or in patients who have a large prostate or a narrow pelvis. In a randomized, controlled study, the use of the CaverMap during radical prostatectomy resulted in improved nocturnal erections, but did not lead to improved overall sexual function. The CaverMap device, however, may be useful as a research tool in that it helps determine whether the NVBs have been successfully preserved after removing the prostate. However, preservation of the NVB does not guarantee recovery of potency, which may be prolonged despite successful stimulation of the cavernous nerves intraoperatively. This suggests that erectile dysfunction following radical prostatectomy is multifactorial.

Erectile Dysfunction↗
PubMed2001

High-grade prostatic intraepithelial neoplasia with adjacent atypia is associated with a higher incidence of cancer on subsequent needle biopsy than high-grade prostatic intraepithelial neoplasia alone.

OBJECTIVES: High-grade prostatic intraepithelial neoplasia (HGPIN) is often considered a premalignant lesion of the prostate. Its incidence ranges from 0.7% to 20% in all prostate biopsies, and patients with HGPIN on initial biopsy are reportedly found to have a higher risk of cancer on subsequent biopsy. The purpose of our study was to determine the incidence of HGPIN in our patients who underwent prostate biopsy and to determine whether a further pathologic subclassification of HGPIN between HGPIN alone and HGPIN with adjacent atypical glands has any prognostic value in predicting the rate of prostate cancer on subsequent prostate biopsy. METHODS: A total of 485 patients who underwent prostate biopsy between January 1998 and October 1999 were included in the study. Each set of slides was reviewed by a single urologic pathologist to determine the presence of HGPIN alone or HGPIN with adjacent atypical glands. If any HGPIN was identified, a repeat biopsy was performed, and the presence of cancer was recorded. RESULTS: The overall incidence of HGPIN alone and HGPIN with adjacent atypical glands on initial biopsy was 33 (6.8%) of 485. Of these 33 patients, 21 (64%) had HGPIN alone and 12 (36%) had HGPIN with adjacent atypical glands. Three (14%) of 21 patients with HGPIN alone were found to have cancer on subsequent biopsy compared to 9 (75%) of 12 patients with HGPIN with adjacent atypia on initial biopsy. This difference is statistically significant (P <0.005). CONCLUSIONS: The incidence of HGPIN alone in our experience is 4.3% (21 of 485). Patients with HGPIN with adjacent atypical glands suspicious for cancer have a significantly higher incidence of cancer on subsequent biopsy than patients with HGPIN alone.

Aged↗
PubMed2001

Indications and contraindications for nerve-sparing radical prostatectomy.

Nerve-sparing radical prostatectomy can be performed safely in most men undergoing radical prostatectomy. As is true in many aspects of prostate cancer diagnosis and therapy, the key element is patient selection. With many prostate tumors diagnosed at an earlier stage, the authors have seen a shift toward more favorable pathologic findings at the time of surgery. Concomitant with the success of early detection of prostate cancer is the realization that men are younger at the time of diagnosis and more interested in preserving sexual function. This article has described factors associated with an increased risk for extraprostatic tumor and, subsequently, an increased possibility of postprostatectomy cancer recurrence. Except for the previously mentioned absolute contraindications, none of these factors, by themselves, should be used to exclude a patient from nerve-sparing prostatectomy. Instead, meticulous attention must be given to the surgical dissection. If any doubt remains regarding residual tumor, the surgeon should err on the side of caution and remove the neurovascular bundle. The use of standardized intraoperative frozen-section analysis can help guide these decisions. The patient must be informed before surgery regarding the risks of nerve-sparing surgery, the potency rates of the surgeon, and the possibility that, to ensure adequate cancer control, the nerves may be sacrificed despite any preoperative optimism favoring the potential for their salvage.

Contraindications↗
PubMed2000

Sildenafil in the treatment of erectile dysfunction after radical prostatectomy.

OBJECTIVES: To evaluate the efficacy of sildenafil for the treatment of erectile dysfunction after radical prostatectomy and to determine whether age, preservation of the neurovascular bundles (NVBs), or the interval between surgery and the initiation of sildenafil therapy influences the response to sildenafil. METHODS: We began this study in April 1998, immediately after the Food and Drug Administration approved sildenafil. We surveyed 170 men who had undergone radical retropubic prostatectomy, had not recovered natural erections sufficient for intercourse, and subsequently received sildenafil between 3 and 24 months postoperatively. The data were collected through a confidential mail survey conducted by a clinical nurse. The men used a dose of 50 mg sildenafil and increased this to 100 mg if they did not obtain an adequate response. RESULTS: In the 120 men who began taking sildenafil at least 12 months after surgery, the overall response rate was 29%. Results varied markedly by patient age and number of NVBs preserved. In men younger than 55 years in whom both NVBs had been preserved, the response rate was 80%. In contrast, no patient older than 55 years in whom only one NVB had been preserved reported an adequate response. Regardless of age, no patient in whom both NVBs had been excised reported success with sildenafil. Of the 50 patients who began taking sildenafil less than 9 months after surgery and who had not recovered natural sexual function, none reported erections adequate for intercourse using sildenafil. CONCLUSIONS: Sildenafil is an effective treatment for men with erectile dysfunction after radical retropubic prostatectomy, particularly in younger men in whom both NVBs have been preserved. It is ineffective in men in whom both NVBs have been excised, and it is also ineffective in older men in whom only one NVB has been preserved. Sildenafil appears ineffective in the first 9 months after prostatectomy.

Age Factors↗
PubMed2000

Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy.

OBJECTIVES: To determine whether preoperative biofeedback training improves urinary continence overall or the rate of return of continence in men undergoing radical prostatectomy. METHODS: One hundred men scheduled to undergo radical prostatectomy were randomized to receive graded pelvic muscle exercise training with biofeedback 2 to 4 weeks before surgery or to a control group performing pelvic muscle exercises without biofeedback. The biofeedback group was instructed to continue exercises four times per day until surgery and to resume exercises when the urethral catheter was removed following surgery. The control group received written and brief verbal instructions in pelvic muscle exercises before surgery and again after catheter removal. Urinary continence was assessed by personal or phone interviews. RESULTS: Six months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the biofeedback and control groups, respectively (P = 0.596). Also, the rate of return as determined at time points 1, 2, 3, and 4 months after surgery was not significantly different between the two groups. CONCLUSIONS: Preoperative biofeedback training did not improve the outcome of pelvic muscle exercises on overall continence or the rate of return of urinary control in men undergoing radical prostatectomy.

Biofeedback, Psychology↗
PubMed2000

A positive caver map response poorly predicts recovery of potency after radical prostatectomy.

OBJECTIVES: To determine whether preservation of the neurovascular bundles (NVBs), defined by a positive CaverMap response, correlates with the recovery of potency after radical prostatectomy. METHODS: We studied a group of 60 men who were potent preoperatively who underwent radical retropubic prostatectomy by one surgeon. The CaverMap was used after removal of the prostate to assess the integrity of the NVBs. Postoperative potency was assessed by a postal questionnaire and telephone interview, administered independently of the treating surgeon. Men were considered potent if they reported postoperative erections consistently sufficient for vaginal penetration with or without the use of sildenafil. RESULTS: The mean patient age was 59 years, and the median follow-up was 365 days. A positive CaverMap response was obtained in 73 (77%) of the 95 NVBs tested. The overall potency rate was 18%. No patients with a bilateral negative CaverMap response were potent, and 2 (22%) of 9 with a unilateral CaverMap response (negative versus unilateral response, P = 0.46) and 6 (27%) of 22 with bilateral CaverMap responses (negative versus bilateral response, P = 0.32) were potent. CONCLUSIONS: A positive CaverMap response, suggesting that a successful nerve-sparing prostatectomy had been performed, was obtained in 77% of the NVBs tested. Nevertheless, with a median follow-up of 12 months, most patients with a positive CaverMap response remained impotent. This suggests that other factors are critical to the recovery of sexual function after radical prostatectomy.

Diagnostic Techniques, Neurological↗
PubMed2000

A new technique for securing a foley catheter.

We describe a new technique to secure a urethral catheter using a horizontal drain tube stabilizer. This device is reliable, inexpensive, and more comfortable for patients than either adhesive tape or leg straps.

Humans↗
PubMed1999

Duplicated seminal vesicle.

We report a case of complete, unilateral seminal vesicle duplication without concomitant reproductive duct or renal anomalies encountered during radical retropubic prostatectomy. We also discuss the possible embryologic origin of this anomaly and the clinical implications.

Humans↗
PubMed1998

An analysis of watchful waiting for clinically localized prostate cancer.

PURPOSE: We reviewed recent series of watchful waiting for prostate cancer to place this management strategy in appropriate perspective MATERIALS AND METHODS: We reviewed the literature and analyzed the 9 articles on watchful waiting published in leading medical journals in the last decade. RESULTS: Watchful waiting is probably the best treatment option for men with well and perhaps moderately differentiated, low volume prostate cancer who have a life expectancy of less than 10 years. However, the conclusions derived from watchful waiting studies of older men cannot and should not be applied to younger, healthier men or to those with more advanced or aggressive disease. If treated ineffectively, many of these men will die of prostate cancer. CONCLUSIONS: Most men with prostate cancer who have a life expectancy greater than 10 to 15 years should be treated with curative intent.

Age Factors↗
PubMed1998

Surgical modifications of radical retropubic prostatectomy to decrease incidence of positive surgical margins.

PURPOSE: We sought to determine whether recent surgical modifications in the technique of radical retropubic prostatectomy decrease the incidence of positive surgical margins. MATERIALS AND METHODS: We reviewed the records of 144 consecutive patients a mean of 60.8 years old who underwent radical retropubic prostatectomy using a modified surgical technique. Mean prostate specific antigen was 8.6 ng./ml. and mean Gleason grade was 5.8. Surgical modifications included division of the dorsal venous complex of the penis 10 to 15 mm. distal to the prostatic apex; transection of the urethra 3 mm. beyond the prostatic apex; division of the anterior aspect of the urethra, leaving the investing periurethral musculature intact, and division of the posterior aspect of the urethra en bloc with the striated urethral sphincter; sharp dissection of the rectourethralis muscle and remaining attachments of the prostate to the rectum; wide excision of the neurovascular bundle posterolateral to the prostate when adjacent induration or tumor is present, and division of the bladder neck, leaving a 5 mm. cuff of bladder tissue with the prostate. RESULTS: Of 144 consecutive patients 16 (11.1%) had positive surgical margins at a total of 20 sites, including 7 (35%) at the apex, 8 (40%) posterolateral, 3 (15%) anterior and 2 (10%) at the bladder neck. These results compare favorably with the positive surgical margin rates after radical prostatectomy previously reported in the literature. CONCLUSIONS: These surgical modifications appear to have decreased the incidence of positive surgical margins after radical retropubic prostatectomy.

Aged↗
PubMed1998

Pain and quality of life following radical retropubic prostatectomy.

PURPOSE: We assess pain and quality of life following radical retropubic prostatectomy and determine whether intraoperative anesthetic management has any long-term effects on outcomes. MATERIALS AND METHODS: A total of 110 patients undergoing radical retropubic prostatectomy were randomly assigned to receive epidural and/or general anesthesia. Patients responded to a questionnaire mailed 3 and 6 months following surgery that assessed prostate symptoms, pain related to surgery, quality of life and mood. RESULTS: No long-term effects of anesthesia were observed. Of the 103 respondents (94%) at 3 months 49% had some pain related to surgery. Although pain was not related to anesthesic technique, patients who had it at 3 months used significantly more pain medication on postoperative day 3. Pain at 3 months was mild, averaging 1.5 on a scale of 0 to 10, and associated with poor perceptions of overall health (p <0.02), and reduced physical (p <0.01) and social (p <0.01) functioning. Pain at 3 months was associated with higher levels of preoperative anxiety (p <0.05). At 6 months 36 of 90 patients (35%) had some pain related to surgery and the impact was similar. CONCLUSIONS: Long-term effects of intraoperative anesthesic technique were not apparent. Mild pain following radical retropubic prostatectomy was common and associated with reduced quality of life, particularly social functioning. Affective distress, particularly anxiety, before surgery and use of pain medications following surgery may be predictors of chronic pain following radical retropubic prostatectomy.

Affect↗
PubMed1996

Extended followup of the influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer and extensive capsular perforation.

PURPOSE: The effect of wide excision of the neurovascular bundles on disease-free survival was determined in men with clinically localized prostate cancer and pathological evidence of extensive capsular perforation in the region of the neurovascular bundle. MATERIALS AND METHODS: We previously analyzed 107 men with clinically localized prostate cancer and pathological evidence of extensive capsular perforation in the region of the neurovascular bundles. Wide excision of the neurovascular bundle on the sides of palpable induration resulted in negative surgical margins in 58% of patients compared to only 45% in whom the neurovascular bundles were left intact (p = 0.03). At a mean followup of 20 months, median interval to disease recurrence as defined by a measurable PSA level was 33 months in patients whose neurovascular bundle(s) were widely excised versus 22 months in those whose neurovascular bundle(s) were left intact (p = 0.03). However, by 43 months 75% of the patients in both groups had a detectable prostate specific antigen and the Kaplan-Meier curves had converged, suggesting that wide excision of the neurovascular bundle(s) did not confer a sustained survival advantage. RESULTS: With an additional followup of 28 months, the probability of having an undetectable prostate specific antigen level at 5 years was 47% in patients with negative versus 6% with positive surgical margins (p < 0.001). CONCLUSIONS: Our extended followup suggests that some patients with extensive capsular perforation can be rendered free of disease with wide excision of the neurovascular bundle(s).

Actuarial Analysis↗
PubMed1996

Color Doppler imaging and transrectal sonography of the prostatic fossa after radical prostatectomy: early experience.

OBJECTIVE: Our objective was to determine if the addition of color Doppler imaging (CDI) during transrectal sonography can improve the detection of residual or recurrent prostatic cancer after radical prostatectomy. MATERIALS AND METHODS: Thirty patients who had undergone radical prostatectomy for prostatic cancer were evaluated with transrectal sonography and transrectal sonography with CDI. Twenty-three of these 30 patients were evaluated for suspicion of local tumor recurrence. The remaining seven patients were not suspected of harboring recurrent tumor and served as controls. Transrectal sonography and CDI-directed needle biopsies of the vesicourethral anastomosis (four-quadrant) and perianastomotic soft tissues were obtained in the 23 patients suspected of recurrent tumor. The ability of transrectal sonography to detect local tumor recurrence was compared with transrectal sonography with CDI. RESULTS: Fourteen of 23 patients (61%) had positive transrectal sonography or transrectal sonography and CDI-directed biopsies. Transrectal sonography alone detected grayscale abnormalities in 11 of 23 patients (48%), of whom 10 (43%) had positive transrectal sonography-directed biopsies. CDI during transrectal sonography showed hypervascularity in 12 of 23 patients (52%). Biopsies of these hypervascular regions were positive in all 12 patients (100%). Hypervascularity was detected in 10 of 11 (91%) gray-scale abnormalities initially detected with transrectal sonography alone. CDI during transrectal sonography detected two patients with hypervascular areas without associated gray-scale findings. Both patients had positive biopsies of their hypervascular sites. Transrectal sonography had a sensitivity and specificity of 71% and 89%, respectively, with positive and negative predictive values of 91% and 67%, respectively. CDI during transrectal sonography had a sensitivity and specificity of 86% and 100%, respectively, with positive and negative predictive values of 100% and 82%, respectively. CONCLUSION: CDI used during transrectal sonography improves the detection of early recurrent or residual prostatic cancer compared with transrectal sonography alone. Although most gray-scale abnormalities that are recurrent tumor show hypervascularity, CDI can detect additional tumor recurrences not identifiable with transrectal sonography alone.

Biopsy↗