Beyond the nerve-sparing radical prostatectomy.
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Adenocarcinoma↗
Biomedical subjects
C B Brendler
Publications and source records attributed to C B Brendler.
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↗
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↗
Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup.
PURPOSE: The efficacy of nerve sparing radical cystoprostatectomy for the treatment of bladder cancer has been evaluated. We reviewed our 10-year experience with this technique to ascertain survival and local recurrence rates. MATERIALS AND METHODS: The charts of 101 patients treated with nerve sparing cystoprostatectomy between March 1982 and November 1989 were reviewed and updated. RESULTS: The disease-specific 10-year survival rate for all stages of bladder cancer treated was 69% and the 10-year survival rate free of local recurrence was 94%. Recovery of sexual function following nerve sparing cystectomy correlated with patient age: 62% in men 40 to 49 years old, 47% in men 50 to 59 years old, 43% in men 60 to 69 years old and 20% in men 70 to 79 years old. CONCLUSIONS: Nerve sparing radical cystoprostatectomy does not compromise cancer control and provides improved postoperative quality of life.
Actuarial Analysis↗
Evaluation of erectile function in men with sickle cell disease.
OBJECTIVES: To evaluate and characterize erectile manifestations associated with sickle cell disease using nocturnal penile tumescence testing with polysomnography (NPT/PSG) and magnetic resonance imaging (MRI) of the penis. METHODS: Six variably potent men with sickle cell disease, of whom 5 reported a history of priapism, underwent comprehensive evaluations of erectile function. Evaluations involved a medical history and physical examination with completion of priapism and sexual function questionnaires, followed by NPT/PSG and MRI of the penis. RESULTS: Many different erectile abnormalities were identified in this group using NPT/PSG, although nocturnal erection durations as well as detumescence times were uniformly prolonged. Various axial rigidity measurements were obtained, which correlated fairly well with individual reports of erectile function. MRI findings ranged from normal corporeal anatomy to corporeal destruction with intracorporeal fibrosis and hemosiderin deposition. CONCLUSIONS: In sickle cell disease, the erectile dysfunction that commonly occurs may be markedly different among men with this disease and may not always be predicted on the basis of clinical history of priapism. Generally, clinical assessments of erectile function may be derived from clinical histories and physical examinations. NPT/PSG and MRI of the penis are in accord with these assessments, obviating their routine use, although they may be valuable management adjuncts in certain situations.
Adolescent↗
Selection of men at high risk for disease recurrence for experimental adjuvant therapy following radical prostatectomy.
OBJECTIVES: Following surgery, men with recurrent prostate cancer have an isolated elevation in serum prostate-specific antigen (PSA) well in advance of measurable metastatic disease. Rational patient selection for new forms of adjuvant therapy, for example, gene therapy, is imperative. METHODS: In a retrospective study of two cohorts, we used proportional hazards regression analysis to develop and validate a multifactor model for identifying men who are at high risk of cancer recurrence. The model cohort consisted of 216 men with clinical Stage T2b and T2c treated by 1 urologist. The validation cohort consisted of 214 men with Stage T2b and T2c disease. RESULTS: A model for log relative risk, Rw, used serum PSA with a sigmoidal transformation (PSAST), radical prostatectomy Gleason score (GS), and pathologic stage (PS) as specimen confined or nonspecimen confined: Rw = (PSAST x 0.06) + (GS x 0.54) + (PS x 1.87). Recurrence risk categories were determined as low risk if Rw is less than 4.0, intermediate risk if it is 4.0 to less than 5.75, and high risk if Rw is more than 5.75. The observed Kaplan-Meier actuarial analysis of the three risk groups correlated well with the predictions determined for the model cohort. We then validated this model independently using a second cohort of 214 men with similar age, stage, and grade treated by 3 different urologists at two different institutions. CONCLUSIONS: The recurrence rates for men in the high-risk group are similar to those for men with positive lymph nodes and justifies exploration of experimental adjuvant therapy within this group using this model of patient selection.
Actuarial Analysis↗
Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia.
OBJECTIVES: There are conflicting reports on the influence of different anesthetic techniques, such as regional versus general anesthesia, on intraoperative blood loss. The purpose of this study was to elucidate the effects of anesthetic technique on intraoperative blood loss in men undergoing radical retropubic prostatectomy (RRP). METHODS: One hundred patients undergoing RRP for prostate cancer were randomly assigned to receive either epidural anesthesia (EA), combined epidural and general anesthesia (EG), or general anesthesia alone (GA). Intraoperative blood loss was calculated by using a formula that accounted for the volume and hematocrit of the fluid suctioned from the surgical field, blood absorbed on surgical pads, and the patient's hematocrit. RESULTS: Mean blood loss in the EA group (1490 +/- 90 mL; mean +/- SEM) was significantly less than mean blood loss in both the EG group (1810 +/- 100 mL) and the GA group (1940 +/- 130 mL) (P = 0.01). Blood loss was not different between the EG and the GA groups (P = 0.7). Significantly less blood was transfused during surgery in the EA group (730 +/- 50 mL) compared with the EG (960 +/- 60 mL) and GA (950 +/- 70 mL) groups (P = 0.02). CONCLUSIONS: Similar blood loss in patients receiving general anesthesia, either alone or when combined with epidural anesthesia, implies that epidural anesthesia did not reduce bleeding, but, rather, that general anesthesia increased blood loss.
Anesthesia, Epidural↗
Characteristics of prostate cancer found with early detection regimens.
This article reviews the clinical and pathologic characteristics of nonpalpable (Stage T1c) prostate cancer reported in five studies published to date. Stage T1c tumors more closely resemble palpable prostate cancers (Stage T2) than they do incidental prostate cancers detected in cystoprostatectomy specimens. The mean tumor volume of Stage T1c tumors is about 50 times greater (2.0 mL vs 0.04 mL) than incidental cystoprostate cancers. Only about 20-25% of T1c tumors have a tumor volume < 0.5 mL; tumors > 0.5 mL are considered to have significant biologic potential. Futhermore, 30-50% of T1c tumors have penetrated the prostatic capsule, 20-30% demonstrate positive surgical margins, and 5-10% demonstrate seminal vesicle invasion and/or positive pelvic lymph nodes. Possible reasons for nonpalpability of T1c tumors include tumor location in the central and/or anterior zones of the prostate and increased gland volume due to benign prostatic hyperplasia, making T1c tumors more difficult to palpate. A combination of serum prostate-specific antigen (PSA) density < 0.1 and favorable needle biopsy pathology (no Gleason 4 or 5 pattern in any core, < 3 cores positive for cancer, and < 50% involvement of any single core) will identify about 75% of men with tumors < 0.5 mL who might be followed without immediate treatment. Overall, however, these data indicate that most T1c tumors are significant cancers > 0.5 mL that warrant aggressive treatment in accordance with age and other health considerations.
Biopsy↗
Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer.
OBJECTIVES: We examined preoperative clinical and pathologic parameters in men with clinical stage T1c disease who underwent radical prostatectomy and correlated these findings with the pathologic extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed up without immediate treatment. DESIGN AND PATIENTS: A case series of 157 consecutive men who underwent radical prostatectomy for clinical stage T1c disease compared with 64 similarly treated clinical stage T1a cancers (incidental minimal cancers found on transurethral resection of prostate) and 439 clinical stage T2 (palpable) cancers. MAIN OUTCOME MEASURES: Pathologic stage, grade, and margins; tumor volume; and tumor location. RESULTS: Sixteen percent of tumors were insignificant (< 0.2 cm3 and confined to the prostate, with a Gleason score < 7); 10% were minimal (0.2 to 0.5 cm3 and confined to the prostate, with a Gleason score < 7); 37% were moderate (> 0.5 cm3 or capsular penetration, with a Gleason score < 7); and 37% were advanced (capsular penetration, with a Gleason score > or = 7 or positive margins, seminal vesicles, or lymph nodes). These findings are intermediate between those found in clinical stage T1a and stage T2 disease. The following parameters were not predictive of tumor extent: age, reason for evaluation, method of detection, and transrectal ultrasound. The best model predicting insignificant tumor was prostate-specific antigen (PSA) density less than 0.1 ng/mL per gram and no adverse pathologic findings on needle biopsy, or PSA density of 0.1 to 0.15 ng/mL per gram, with a low- to intermediate-grade cancer smaller than 3 mm found in only one needle biopsy core specimen. The positive predictive value of the model was 95%, with a negative predictive value of 66%. We accurately predicted 73% of cases with insignificant tumor. CONCLUSIONS: Eighty-four percent of nonpalpable prostate cancers diagnosed by screening techniques are significant tumors and warrant definitive therapy. However, 16% are insignificant. Serum PSA level, PSA density, and needle biopsy pathologic findings are accurate predictors of tumor extent. It may be reasonable to follow up some patients whose tumors are most likely insignificant with serial PSA measurements and repeated biopsies.
Biopsy, Needle↗
Radical prostatectomy for impalpable prostate cancer: the Johns Hopkins experience with tumors found on transurethral resection (stages T1A and T1B) and on needle biopsy (stage T1C).
We review the pathological findings of impalpable prostate cancer detected by transurethral resection (stages T1a and T1b) and needle biopsy (stage T1c). The short-term (4 years) and long-term (8 to 10 years) natural histories of untreated stage T1a prostate cancer are examined, as are options to follow patients expectantly. The findings on radical prostatectomy for stages T1a and T1b disease are reviewed and compared. Of the 64 cases of stage T1a disease 13 (20%) showed substantial tumor, including 7 with more than 1 cc of tumor, 5 with capsular penetration and 1 with a Gleason grade 4 + 5 = 9 tumor. Based on preoperative pathological parameters, one could not predict which cases had minimal versus substantial tumor. In a study from our institution that undertook complete histological examination of 39 radical prostatectomy specimens of stage T1b carcinoma, we found that all prostates contained residual carcinoma, 26% had capsular penetration and 10% had invasion of the seminal vesicles. When comparing morphometrically determined volumes of carcinoma with similar data from 56 patients with stage T2 carcinoma, stage T1b tumors were much more heterogeneous in grade, location and volume than were stage T2 lesions. Unless all 3 variables (grade, volume and location) were known, the final pathological stage of T1b cancers could not be predicted with confidence. Finally, we examined preoperative clinical and pathological parameters in 157 men with clinical stage T1c disease undergoing radical prostatectomy, and correlated these findings with pathological extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed conservatively. Of the tumors 16% were insignificant (less than 0.2 cc, organ confined and Gleason grade less than 7), 10% were minimal (0.2 to 0.5 cc, organ confined and Gleason grade less than 7), 37% were moderate (more than 0.5 cc or capsular penetration with Gleason sum less than 7) and 37% were advanced (capsular penetration with Gleason sum 7 or more, or positive margins, positive seminal vesicles or positive lymph nodes). These findings are intermediate between those found in clinical stages T1a and T2 disease. The best model predicting insignificant tumor was a prostate specific antigen (PSA) density of less than 0.1 and no adverse pathological finding on needle biopsy or PSA density of 0.1 to 0.15 with less than 3 mm. low to intermediate grade cancer on only 1 needle biopsy core. The positive predictive value of the model was 95% with a negative predictive value of 66%.(ABSTRACT TRUNCATED AT 400 WORDS)
Aged↗
Femoral neuropathy following major pelvic surgery: etiology and prevention.
We report a case of femoral neuropathy occurring after radical cystoprostatectomy and continent urinary diversion. Urologists who perform major pelvic surgery need to be familiar with this complication to prevent its occurrence.
Cystectomy↗
Comparison of duplex ultrasonography and nocturnal penile tumescence in evaluation of impotence.
Duplex ultrasound is used commonly to evaluate vascular function in impotent men. There is evidence, however, that some men with normal vascular function may have falsely abnormal duplex ultrasound results because of suppression of response to pharmacological stimulation due to anxiety. We performed a prospective blinded study of 40 impotent men comparing duplex ultrasound to a formal nocturnal penile tumescence evaluation. Duplex ultrasound was done with a standard 10 MHz. color Doppler unit after intracorporeal pharmacological stimulation. Nocturnal penile tumescence was performed at a sleep laboratory, and included measurements of penile circumference, axial rigidity, arterial pulsations, and direct patient and observer evaluation of erections. Of 40 men 20 had an abnormal duplex ultrasound result (maximum arterial velocity less than 30 cm. per second), including 9 who had normal nocturnal penile tumescence with at least 1 rigid erection (greater than 550 gm. axial rigidity) lasting at least 5 minutes. All 9 men had evidence of psychogenic dysfunction on history and personality inventory, and only 1 had evidence of vascular disease. Of the other 11 patients with abnormal duplex ultrasound and nocturnal penile tumescence findings, only 2 had evidence of psychogenic impotence and 9 had evidence of vascular disease. In these 11 men there were significant correlations between maximum arterial velocity on duplex ultrasound, and maximum rigidity and arterial pulsations on nocturnal penile tumescence. Of 40 patients 20 had a normal duplex ultrasound finding (maximum velocity greater than 30 cm. per second). Nine of these patients had a normal nocturnal penile tumescence test, of whom 5 had evidence of psychogenic impotence and only 1 had evidence of vascular disease. Eleven men with normal duplex ultrasound had an abnormal nocturnal penile tumescence test, including only 2 with any evidence of psychogenic impotence, while 9 had vascular disease and 1 had a history of neurological disease. Based on this study 9 of 14 men (64%) with a normal nocturnal penile tumescence test and other evidence of psychogenic impotence had abnormal duplex ultrasound. Therefore, an abnormal duplex ultrasound study should be interpreted cautiously if there is evidence of psychogenic impotence. In men with vasculogenic impotence there is an excellent correlation and cross-validation between maximum velocity on duplex ultrasound, and axial rigidity and arterial pulsations on nocturnal penile tumescence.
Adult↗
Postoperative morbidity is similar in patients anesthetized with epidural and general anesthesia for radical prostatectomy.
OBJECTIVES: To compare the effect of epidural and general anesthesia on the postoperative course and complication rate in patients undergoing radical prostatectomy. METHODS: Ninety-eight men scheduled for radical retropubic prostatectomy (RRP) were randomly assigned to receive epidural anesthesia only (EA, n = 34), combined epidural and general anesthesia (EG, n = 33) or general anesthesia only (GA, n = 31). In the EA group, epidural anesthesia was induced and maintained with bupivacaine. In the EG group, patients received epidural bupivacaine after the induction of general anesthesia. In the GA group, anesthesia was induced with morphine and maintained with isoflurane. In the postoperative period, epidural patient-controlled analgesia (PCA) was maintained in all patients for 3 to 5 days. Patients were evaluated throughout the hospitalization period and at 3, 6, and 12 weeks following surgery. RESULTS: The three groups did not differ with regard to postoperative pain, bleeding, urine output, fever, length of paralytic ileus, or length of hospitalization. No major cardiovascular, pulmonary, or neurologic complications occurred in any of the patients either perioperatively or in the first 3 months postoperatively. CONCLUSIONS: Intraoperative anesthetic technique was not associated with a different postoperative complication rate in patients undergoing RRP. The very low incidence of complications and the uniform postoperative analgesic regimen may have contributed to the similarity between groups.
Analgesia, Patient-Controlled↗
Influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer with established capsular penetration.
We analyzed 107 men with clinically localized prostate cancer who had pathologically established capsular penetration in the region of the neurovascular bundles to determine the effect of wide excision of the neurovascular bundle(s) on disease-free survival. In 38 patients established capsular penetration was not suspected clinically and the neurovascular bundle(s) were preserved. In 69 patients established capsular penetration was suspected, and 1 or both neurovascular bundles were excised widely with the prostate. Disease-free survival was defined by an undetectable serum prostate specific antigen (PSA) level postoperatively. Wide excision of the neurovascular bundle(s) resulted in negative surgical margins in 40 of 69 patients (58%) compared to only 17 of 38 (45%) in whom the neurovascular bundle(s) was left intact (p = 0.03). Median interval to disease recurrence, as defined by a measurable serum PSA level, was 22 months in the group in whom the neurovascular bundles were preserved versus 33 months in the group undergoing wide excision (p = 0.03). At 39 months, however, 70% of the patients in both groups had detectable PSA levels. Similarly, patients with positive surgical margins had a mean interval to recurrence of 17 months compared to 38 months for the group with negative surgical margins (p = 0.0004). By 43 months, however, 75% of the patients in both groups had a detectable PSA level and the Kaplan-Meier curves had converged. Although wide excision of the neurovascular bundle(s) resulted in negative surgical margins more often with resultant delayed disease progression, most patients with established capsular penetration ultimately failed radical prostatectomy despite wide excision of periprostatic soft tissue. It seems likely, therefore, that many of these patients have occult metastatic disease at operation. Thus, recent enthusiasm for radical prostatectomy in men with locally advanced prostate cancer may not be justified.
Adenocarcinoma↗
Tubularized neourethra following radical retropubic prostatectomy.
A 1.5 cm. tubularized neourethra was formed using an anterior bladder flap as part of bladder neck reconstruction after radical retropubic prostatectomy in 69 consecutive patients with clinically localized prostate cancer (study group). Postoperative continence (defined as requiring no protection for any activity) was assessed by history at 3 months (all men) and 6 months (45 of 69 men). Continence in the study group was compared to that of 45 men with 6 months of followup who underwent radical retropubic prostatectomy without tubularization of the anterior bladder (control group). At 3 months 38 of 69 men (55%) were continent in the study group and 14 of 45 (31%) were continent in the control group (p < 0.03). At 6 months 39 of 45 men (87%) were continent in the study group compared to 21 of 45 (47%) in the control group (p < 0.01). Upright cystograms performed on men with and without the tubularized neourethra after radical retropubic prostatectomy suggest that a neourethra proximal to the external sphincter may increase resistance in this area and result in early return of urinary control in men undergoing radical retropubic prostatectomy.
Aged↗
The use of nuclear morphometry in predicting recurrence of transitional cell carcinoma.
Despite apparently adequate surgical resection, metastases develop in about 50% of the patients who undergo radical cystectomy for invasive bladder cancer and they die of disease within 2 years of surgery. Recent reports have shown that combination chemotherapy with regimens including cisplatin results in significant improvement in time to progression and overall survival for patients with transitional cell carcinoma. We have used quantitative nuclear morphometry in an effort to predict which individual patients with muscle invasive transitional cell carcinoma are at increased risk for recurrence and in need of adjuvant therapy. A total of 14 patients with deeply invasive tumors without known metastases (tumors, nodes and metastasis stage P3A-B, N-, M0) who had not received perioperative radiation or systemic chemotherapy was studied. Of the patients 7 (group 1) had no evidence of disease with a mean followup of 41 months and 7 (group 2) had recurrent transitional cell carcinoma at a mean followup of 17 months. Both groups were similar with respect to age and could not be distinguished by standard pathological analysis of stage (p = 0.66) or grade (p = 0.99). A total of 150 tumor nuclei from each patient was digitized and analyzed by a high resolution quantitative morphometric imaging system, developed in this laboratory, to determine if nuclear shape descriptors could separate these 2 clinically distinct groups. A multivariate analysis combining 3 independent nuclear shape descriptors (average nuclear area, minimum feret-diameter ratio and kurtosis of feret-diameter ratio) was highly significant (p = 0.003) and separated patients in group 1 from group 2 without overlap. These encouraging results suggest that nuclear morphometry may be valuable in determining which patients are at increased risk of disease recurrence following radical cystectomy and, therefore, who should receive adjuvant chemotherapy.
Aged↗