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PubMed1999

Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations.

OBJECTIVE: To evaluate the technical feasibility, oncological efficacy and intraoperative and postoperative morbidity of laparoscopic radical prostatectomy. METHOD: We describe an original technique of laparoscopic radical prostatectomy performed in 40 patients between 26th January and 12th October, 1998. RESULTS: Radical prostatectomy was performed entirely by laparoscopy in 35 patients (87.5%) and only one conversion was performed in the last 26 patients (4%). Pelvic lymphadenectomy was performed in the light of preoperative staging data in 14 patients (35%). The median total operating time was 270 min. The only major complication was a rectal injury (patient 8), sutured laparoscopically with an uneventful postoperative course. Postoperative vesical catheterization lasted an average of 7.65 days. Seven patients were transfused (17.5%) with an average of 2.8 units of packed cells (range: 2-3). The reduction of postoperative pain is an element allowing for a rapid discharge of the patients by the 3rd postoperative day. The oncological results were as follows: 36 patients had a pT2 tumor (90%); prostate tumor was staged as N0 in 14 cases and NX in 26 cases. Surgical margins were negative in 33 patients (82.5%). Two patients had a doubtful resection margin (1 at the apex and 1 at the bladder neck) and 5 patients had positive margins. The last PSA level was undetectable (<0.1 ng/ml) in 26 (89.7%) of the 29 patients in whom PSA level was available more than 1 month after the operation. Functional results are not yet available and will be published later. CONCLUSIONS: Radical prostatectomy is an operation which can be routinely performed by laparoscopy by a team experienced with this technique. Operative and postoperative morbidity was low. Short-term oncological data appear identical to the results of conventional retropubic surgery. The improvement of operative visibility was considerable allowing a much more precise dissection. The laparoscopic approach appears to represent a technical improvement of the radical prostatectomy if the functional results of this operation improve parallel to the quality of dissection. A long-term follow-up is needed to define definitively the place of this new approach to radical prostatectomy.

Adenocarcinoma↗
PubMed2000

Urinary continence following radical prostatectomy assessed by a self-administered questionnaire.

OBJECTIVES: A total aim of this study was to assess the incidence of urinary incontinence in patients following radical prostatectomy and determine the factors that may influence this incidence. METHODS: A total of 135 men underwent radical retropubic prostatectomy at our center between 1987 and 1997. 120 patients were sent a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if need be and additional postoperative procedures. Patient age, date of surgery, number of neurovascular bundles resected at prostatectomy and duration of follow-up were also noted. RESULTS: Of the 120 patients, 116 (96.7%), a mean of 65.2 (range 48-76) years old, responded to the questionnaire. Mean follow-up was 4.3 years (range 1-10.8). Continence was defined as no regular use of pads. Our overall urinary incontinence rate was 14.4%. Of the respondents, 88. 8% (103/116) had achieved final continence status by 6 months postoperatively, and 95% (110/116) would undergo surgery again if need be. Of the patients considered incontinent postoperatively, 66. 6% had associated urgency. Age, year of surgery, number of neurovascular bundles resected at prostatectomy, preoperative urinary leakage of postvoiding dribbling, postoperative pelvic floor exercises, and anastomotic stricture had no significant impact on postoperative continence status. CONCLUSIONS: Using an anonymous self-administered questionnaire, we found a 14.4% incontinence rate after radical prostatectomy. These results allow patients to have realistic expectations when counseled prior to this operation.

Aged↗
PubMed1976

[Urinary continence after radical prostatectomy: the urodynamic proof of an anatomical hypothesis (author's transl)].

Prostatic carcinoma can be cured by a radical operation. In radical prostatectomy the whole so-called internal sphincter is removed. It is generally accepted and often proved that the external sphincter which is mostly somatically innervated cannot resume the funciton of continence. The postoperative urinary incontinence after radical prostatectomy is frequent and therefore the radical prostatectomy is not performed in many places. The problem of postoperative continence as well as incontinence after enucleation of the adenoma will be briefly discussed. In 1966, HUTCH described the so-called 'baseplate'. It is a bundle of smooth muscle fibers, circulary arranged around the bladder neck, which are also responsible for passive continence. He proposed that a certain sphincter function can be achieved by a tubular anastomosis of this anatomical substratum with the distal urethral stump. We were able to prove this anatomical hypothesis urodynamically. A specially constructed double-lumen perfusion catheter enabled us to register the so-called functional urethra profile and simultaneously register a new sphincter pressure wave in the transformed 'baseplate' which was responsible for the continence. We could observe this new sphincter region in all continent patients after radical prostatectomy whereas in the incontinent patients it was absent. Since 1972 we have employed the procedure proposed by HUTCH and have performed 20 radical prostatectomies. All these patients have been postoperatively completely continent. We are of the opinion that undue restraint concerning radical prostatectomy is no more justified.

Humans↗
PubMed2003

3D-ultrasound guided radiation therapy in the post-prostatectomy setting.

Daily transabdominal ultrasound-directed localization has proven valuable in correcting for setup error and organ motion in the treatment of prostate cancer with three-dimensional conformal radiation therapy (3DCRT). The present study sought to determine whether this transabdominal ultrasound technology could also be reliably applied in the post-operative adjuvant or salvage setting to improve the reproducibility of coverage of the intended volumes and to enhance conformal avoidance of adjacent normal structures. Sixteen consecutive patients who received external beam radiotherapy underwent daily localization using an optically guided 3D-ultrasound target localization system (SonArray, Zmed, Inc., Ashland, MA). Six of the above patients were treated in a post-prostatectomy setting, either adjuvantly or for salvage, while the remaining 10 with intact prostates were treated definitively. Because the bladder neck generally approximates the postoperative prostatic fossa, it was used during ultrasound localization as the primary reference structure for the post-prostatectomy patients. For patients treated definitively, the prostate was the primary reference structure. Daily shifts were recorded and port films were taken weekly immediately after ultrasound-based repositioning. By comparing port films taken after ultrasound localization, which evaluates for both set-up error and internal shift, with the original digitally reconstructed radiographs (DRRs), which represents a zero clinical set-up error situation, the degree of variability in organ position was determined. The average absolute, ultrasound-based shifts from the clinical set-up position in the anterior/posterior, lateral, and cranial/caudal directions for the post-prostatectomy patients were 5 +/- 4 mm SD, 3 +/- 3 mm SD, and 3 +/- 4 mm SD over the entire course of treatment, respectively. The average vector length shift was 8 +/- 4 mm SD. For patients treated with an intact prostate, the analogous average absolute shifts in the anterior/posterior, lateral, and cranial/caudal directions were 4 +/- 3 mm SD, 4 +/- 3 mm SD, and 4 +/- 3 mm SD over the entire course of treatment. The average vector length shift was 7 +/- 4 mm SD. Vector length shifts representing interfraction internal motion were estimated by comparing post-ultrasound port films with DRRs. These were 5 +/- 3 mm SD and 4 +/- 4mm SD for post-prostatectomy and intact prostate patients, respectively. These ultrasound-based displacements were not statistically different in patients with an intact prostate versus patients post-prostatectomy (p > 0.1). In conclusion, daily transabdominal 3D-ultrasound localization proved to be a clinically feasible method of correcting for set-up and internal motion displacements. The bladder neck, which serves as an adequate localization reference structure for the prostatic fossa, could be readily ultrasound imaged and repositioned as necessary. Daily internal motion errors that would have occurred if only pre-treatment port films were used were similar in magnitude to those observed for the patients with intact prostates and were of sufficient magnitude to support the use of daily pre-treatment ultrasound localization in the post-prostatectomy setting.

Humans↗
PubMed2002

Comparing the costs of radiation therapy and radical prostatectomy for the initial treatment of early-stage prostate cancer.

PURPOSE: Radical prostatectomy and external-beam radiation are the most common treatments for localized prostate cancer. Given the absence of clinical consensus in favor of one treatment or the other, relative costs may be a significant factor. This study compares the direct medical costs during the month before and 9 months after diagnosis for patients treated primarily with external-beam radiation or radical prostatectomy for early-stage prostate cancer. METHODS: Patients age 65 or older and coded by the Surveillance, Epidemiology, and End Results (SEER) registry as having been diagnosed with adenocarcinoma of the prostate treated primarily with external-beam radiation or radical prostatectomy during 1992 and 1993 were identified. The initial treatment costs, as measured by Medicare-approved payment amounts, for each strategy were analyzed using linked SEER-Medicare claims data after adjusting for differences in comorbidity and age. An intent-to-treat analysis was also performed to adjust for differences in staging between the two groups. RESULTS: For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P <.001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P <.001). CONCLUSION: For patients with early-stage prostate cancer, average costs during the initial treatment interval were at least 23% greater for radical prostatectomy than for external-beam radiation. Major limitations of the research include not studying costs after the initial treatment interval and questionable current applicability, given changes in management of early prostate cancer.

Adenocarcinoma↗
PubMed1989

[A study of urinary incontinence after prostatectomy].

With respect to prostatectomies carried out in clinic since the opening of the Kinki University Hospital in 1975, incontinence after prostatectomy was investigated with 470 patients as subjects for whom a follow-up study after the operation was possible. Also, the usefulness of the urodynamic tests for diagnosing underlying diseases was investigated. 1) Overall incidence of incontinence after transurethral resection of the prostate (TUR-P), retropubic prostatectomy (RPP) and cryoprostatectomy was 5.7 percent. 2) The incidence of incontinence was 7.1 percent of the patients with TUR-P and 3.5 percent of patients with RPP. The incidence of incontinence after cryoprostatectomy was none. 3) There was no clear differences among the incidence of incontinence after prostatectomy and the weight of resected tissues. 4) There was no clear differences among various types of incontinence after each procedures of prostatectomies. 5) The incontinence was satisfactorily treated and disappeared in 18 patients within one year after the operation. In patients who failed to get continence within a year, the incontinence was likely to persist furthermore. 6) The cure rate was low in patients with abnormal findings in a cystometrogram performed prior to the operation. Associated diseases which could cause disorders in nervous system were frequently encountered in such patients. 7) Drugs and functional electrical stimulation (FES) were introduced for the treatment of incontinence after prostatectomy. FES was effective in 36.4 percent in which drug therapy was not effective. Since multiple drug regimen was administered in most of the patients, it was difficult to make a precise evaluation of judgement for effect of each of drugs.

Cryosurgery↗
PubMed2000

The effect of hospital volume on mortality and resource use after radical prostatectomy.

PURPOSE: The value of radical prostatectomy for patients with prostate cancer depends on low morbidity and mortality. We assessed whether patient outcome is associated with how many of these procedures are performed at hospitals yearly. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample, which is a stratified probability sample of American hospitals, we identified 66,693 men who underwent radical prostatectomy between 1989 and 1995. Cases were categorized into volume groups according to hospital annual rate of radical prostatectomies performed, including low-fewer than 25, medium-25 to 54 and high-greater than 54. We performed multivariate logistic regression to control for patient characteristics when assessing the associations of hospital volume, in-hospital mortality and resource use. RESULTS: Overall adjusted in-hospital mortality after radical prostatectomy was relatively low (0.25%). However, patients at low volume centers were 78% more likely to have in-hospital mortality than those at high volume centers (adjusted odds ratio 1.78, 95% confidence interval 1.7 to 2.6). Overall length of stay decreased at all hospitals between 1989 and 1995. However, average length of stay was longer and total hospital charges were higher at low than at high volume centers (7.3 versus 6.1 days, p<0.0001, and $15,600 versus $13,500, p<0.0001, respectively). CONCLUSIONS: Hospital volumes inversely related to in-hospital mortality, length of stay and total hospital charges after radical prostatectomy. Further study is necessary to examine the association of hospital volume with other important outcomes, including incontinence, impotence and long-term patient survival after radical prostatectomy.

Hospital Costs↗
PubMed2000

Effect of radical prostatectomy on sensory threshold and pressure transmission.

PURPOSE: The mechanisms involved in post-radical prostatectomy incontinence remain unclear despite previous anatomical and functional studies. In addition, the factors responsible for the restoration of continence are not well studied. To improve our understanding of the alterations in continence mechanisms, we prospectively investigated the temporal changes in urodynamic parameters after radical prostatectomy. MATERIALS AND METHODS: Cystometry, urethral pressure profilometry and posterior urethral sensory threshold measurements were performed in patients undergoing radical prostatectomy. Preoperative pressure transmission was determined by the maximal urethral pressure divided by the maximal abdominal pressure during cough maneuvers at a bladder volume of 200 ml. Postoperative sensory threshold, pressure transmission (% of pressure transmission), maximal urethral closure pressure and functional sphincter length were measured 6 weeks and 6 months after prostatectomy. These parameters were compared between continent and incontinent patients. RESULTS: Preoperative and postoperative urodynamic studies were completed in 34 patients. The continence rate after 6 weeks was 18% (6 patients) and improved to 82% (28) after 6 months. Preoperatively sensory threshold was 16 +/- 11 mA. After 6 weeks and 6 months, respectively, sensory threshold was significantly higher in incontinent (84 +/- 11 mA., 70 +/- 8 mA.) compared to continent (65 +/- 8 mA., 41 +/- 12 mA.) patients. Preoperative proximal urethral sensory threshold was not correlated with degree of postoperative incontinence determined by pad tests. Pressure transmission was not different in continent and incontinent patients postoperatively. After 6 weeks and 6 months, respectively, pressure transmission was 77% and 91% in continent, and 37% and 58% in incontinent patients (p = 0.04, p = 0.03). Maximal urethral closure pressure was significantly higher in continent patients (35 +/- 6 cm. H2O) compared to incontinent patients (11 +/- 9 cm. H2O). Sphincter length decreased from 50 mm. preoperatively to 24 mm. after 6 weeks and 25 mm. after 6 months. There was no difference in sphincter length between continent and incontinent patients. CONCLUSIONS: Posterior urethral sensitivity and pressure transmission are impaired immediately after prostatectomy. An improvement in these parameters after 6 months is associated with the restoration of continence. These observations suggest that urinary continence after radical prostatectomy depends on the integrity of posterior urethral sensation and the efficiency of pressure transmission.

Humans↗
PubMed2000

Long-term hazard of progression after radical prostatectomy for clinically localized prostate cancer: continued risk of biochemical failure after 5 years.

PURPOSE: Cure from malignancy is commonly defined as a disease-free state lasting 5 years after treatment. We analyzed clinical and biochemical progression rates after radical prostatectomy for men with clinically localized prostate cancer with particular attention to recurrence beyond 5 years. Annual hazard rates of progression were calculated to determine the probability of recurrence at specific intervals following surgery. MATERIALS AND METHODS: The records of 2,782 men with clinically localized prostate cancer (cT1-T2) undergoing radical prostatectomy between 1987 and 1993 were reviewed. All patients were treated in the prostate specific antigen (PSA) era so that serial followup PSA values were available from the time of surgery. Analysis was limited to patients who did not receive adjuvant treatment within 90 days of radical prostatectomy. Disease progression was defined as documented local recurrence, systemic progression and/or PSA 0.4 ng./ml. or greater. Lymph node positive cases were eliminated from analysis since almost all received adjuvant hormonal therapy. Annual hazard rates for progression were calculated using the formula: [No. events / No. patients at risk] x 100. Progression-free survival probabilities were determined using the Kaplan-Meier method. RESULTS: Pathological stage was pT2a-b, N0 (68%), pT3a, N0 (21%) and pT3b, N0 (11%). Biochemical progression-free survival at 5 and 10 years was 76% and 59%, respectively, for the entire study population while those with pathologically organ confined (pT2, N0) cancers had progression-free survival rates of 82% and 68% at 5 and 10 years, respectively. A total of 819 patients (29%) eventually had disease progression, including 160 (6%) with progression after 5 years. Annual hazard rates were highest during the first 2 years after radical prostatectomy for the entire population. Patients with adverse prognostic features (pT3b, PSA 10 ng./ml. or greater, Gleason score 8-10 and nondiploid cancers) had high initial hazard rates that decreased with time to lower levels. Those with pathologically organ confined cancer had low but constant hazard rates throughout followup. CONCLUSIONS: Although progression after radical prostatectomy usually occurs early, reflecting the impact of clinical under staging, a significant number of men, including those with organ confined cancers, will continue to have disease progression after 5 years. Patients undergoing radical prostatectomy should be subjected to long-term followup to allow the option of early intervention should progression occur.

Adult↗
PubMed2000

Factors predicting recovery of erections after radical prostatectomy.

PURPOSE: Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function. MATERIALS AND METHODS: Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented. RESULTS: Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves. CONCLUSIONS: Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.

Adult↗
PubMed2001

Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases.

PURPOSE: We critically examined the intraoperative and postoperative complications associated with radical retropubic prostatectomy in the modern era. MATERIALS AND METHODS: Between April 18, 1994 and July 13, 2000, 1,000 men underwent radical retropubic prostatectomy performed by a single surgeon. The whole inpatient hospital medical record of 909 patients, the outpatient charts of 955 and a self-administered patient survey completed by 679 were reviewed by 2 data managers not involved in surgical management or followup care. In all 1,000 cases at least 1 of the 3 data sources was reviewed. RESULTS: Mean patient age was 60.3 years. In 73%, 99.8% and 95.7% of cases serum prostate specific antigen was 10 ng./ml. or less, disease was clinical stage T1 or T2 and Gleason score was 7 or less, respectively, while 19.9% of pathological specimens showed positive margins. There were 8 intraoperative complications (0.8%). All 5 rectal injuries and the single ureteral injury were detected during the initial surgical procedure and repaired without sequelae. Only 14 men (1.4%) had any other complications during hospitalization. Until postoperative day 30, 4 pulmonary emboli (0.4%) with or without deep vein thrombosis and 5 myocardial infarctions (0.5%) developed. There were no intraoperative or in-hospital postoperative deaths and only 1 postoperative death secondary to myocardial infarction during the initial 30 days. Reexploration was done for hemorrhage and a disrupted anastomosis in 3 and 2 cases, respectively. Mean hospitalization was 2.3 days, 9.7% of patients required allogenic blood transfusion and 15 (1.5%) were rehospitalized. CONCLUSIONS: Our series represents a rigorous assessment of the complications associated with radical retropubic prostatectomy. It shows that in the hands of an experienced urological surgeon, this procedure is associated with minimal intraoperative and postoperative morbidity. Of the patients 98% had no intraoperative or postoperative complications. Our series enables appropriate contemporary comparisons to be made with laparoscopic prostatectomy and radiation therapy. This outcomes analysis implies that radical retropubic prostatectomy cannot be assumed to have greater morbidity than radiation therapy and it sets a high standard for those advocating laparoscopic radical prostatectomy.

Blood Loss, Surgical↗
PubMed2001

Role of early adjuvant hormonal therapy after radical prostatectomy for prostate cancer.

PURPOSE: Recent prospective randomized studies have shown that adjuvant hormonal therapy combined with local treatment can significantly improve overall survival in patients with locally advanced disease. This finding challenges the previous belief that adjuvant hormonal therapy may not be beneficial for minimal stages TxN + M0 or less prostate cancer, particularly when combined with local treatment. We reviewed the benefits of adjuvant hormonal therapy in patients at risk for disease progression, especially when administered after radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed the current literature and evaluated clinical information on stage pT3b cancer from a large single institution prostate cancer database to determine the current role of adjuvant hormonal therapy after radical prostatectomy for prostate cancer. RESULTS: Retrospective experimental and clinical studies have proved the impact of adjuvant hormonal therapy for decreasing prostate specific antigen (PSA) and clinical disease progression in patients with regionally limited prostatic cancer. This finding applies to stage pT3b as well as to lymph node positive cancer. Our literature review and current data from the Mayo Clinic database show that adjuvant hormonal therapy after prostatectomy has a significant impact on prostate specific antigen (PSA) progression but it also decreases systemic progression and cause specific death in patients with stage pT3b and lymph node positive disease. After adjusting for preoperative PSA, margins, grade, ploidy and patient age the risk ratio for stage pT3b disease in 707 cases was 0.3 (95% confidence interval 0.2 to 0.7). A recent prospective randomized trial showed a significant decrease in cancer death in N+ cases when adjuvant hormonal therapy was administered after radical prostatectomy, supporting previous Mayo Clinic data on N+ disease that favors combination therapy. In the PSA era, that is 1987 and after, our database data on stage pTxN+ cancer indicates that radical prostatectomy and hormonal therapy for single node positive disease resulted in 94% 10-year cause specific survival, which was not significantly different from the rate in patients with N0 disease after adjusting for local stage, Gleason grade, margins, ploidy, PSA and adjuvant hormonal therapy. CONCLUSIONS: Our literature review, including prospective randomized studies, and more recent results in the PSA era from our database indicate that early adjuvant hormonal therapy has a significant impact on time to progression and cause specific survival in patients with seminal vesicle invasion and limited lymph node disease who undergo radical prostatectomy, although in a retrospective nonrandomized study. Future prospective studies with longer followup are needed to evaluate the potential benefit of adjuvant treatment in regard to survival for stages pT2 and pT3a disease with unfavorable pathological variables.

Aged↗
PubMed2002

Neoadjuvant androgen ablation before radical prostatectomy in cT2bNxMo prostate cancer: 5-year results.

PURPOSE: In the initial report of the Lupron Depot Neoadjuvant Prostate Cancer Study Group patients who received 3 months of androgen deprivation had a significant decrease in the positive margin rate. We monitored these patients for 5 years and to our knowledge present the longest followup of any neoadjuvant trial. MATERIALS AND METHODS: A multi-institutional prospective randomized trial was performed between February 1992 and April 1994 involving patients with stage cT2b prostate cancer, including 138 who received 3 months of leuprolide plus flutamide before radical prostatectomy and 144 who underwent radical prostatectomy only. Patients were followed every 6 months with serum prostate specific antigen (PSA) testing for 5 years. Biochemical recurrence was defined as PSA greater than 0.4 ng./ml. RESULTS: At 5 years there was no difference in the biochemical recurrence rate. PSA was less than 0.4 ng./ml. in 64.8% of the patients in the neoadjuvant androgen ablation plus prostatectomy and 67.6% in the prostatectomy only group (p = 0.663). CONCLUSIONS: Although 3 months of androgen deprivation before radical prostatectomy resulted in an apparently significant decrease in positive surgical margins, a 5-year followup does not indicate any difference in the recurrence rate. Until studies document improvement in biochemical or clinical recurrence with longer periods of treatment, induction androgen deprivation before radical prostatectomy is not indicated.

Androgen Antagonists↗
PubMed2001

[Epidemiology and physiopathology of urinary incontinence after radical prostatectomy].

Beginning in the 1980s, a series of anatomical discoveries were introduced to modify the classic retropubic radical prostatectomy proposed by Millin in 1942 in an effort to reduce intra and postoperative complications such as intraoperative bleeding and postoperative erectile dysfunction and incontinence. Urinary incontinence post retropubic "anatomical" radical prostatectomy remains a distressing problem for the patient and the physician rating from 6 to 20% even in the hands of experienced surgeons from high volume Academic Centers. The reason for the discrepancy in results is unclear and should be searched in surgical experience of the surgeon, volume of surgical activity of the Center, and selection of the patients undergoing the radical retropubic procedure. In the Literature we identified methodological factors which can bias the data on post radical retropubic prostatectomy such as 1) Consensus is lacking on definition of continence and/or incontinence following radical retropubic prostatectomy 2) Different surgical techniques are compared: sphincter damaging, versus repairing, versus preserving; bladder neck sparing versus non sparing; nerve sparing versus non sparing 3) Patients with preoperative urinary incontinence are included in the series and the preoperative continence status is not known. 4) Different timing in registration of incontinence. 5) Different methods in data collection. This latter seems to be the most important reason for discrepancy in the collection of the data. Self administered questionnaires oriented to evaluate incontinence analyzed by a third party seem to be the most powerful and objective tool for post prostatectomy incontinence rating. Post prostatectomy incontinence may be attributed to sphincter dysfunction as a result of surgical injury during prostatic surgery and/or to bladder dysfunction including detrusor instability and decreased compliance resulting in stress or urge or mixed stress/urge postoperative incontinence. In the Literature bladder dysfunction is considered to be responsible or jointly responsible for post RRP incontinence in a rate as high as 93%. More recently, a major role is considered to be played in post RRP incontinence pathophysiology by intrinsic sphincter insufficiency. Rarely bladder dysfunction is an isolated cause of incontinence. Moreover the symptom of stress incontinence accurately predicts the finding of intrinsic sphincter deficiency. The apical dissection and the preservation of the intrinsic sphincter remain the most complex parts of RRP and the keys to the maintenance of postoperative urinary continence.

Humans↗
PubMed2002

p53 and bcl-2 immunohistochemistry in preoperative biopsies as predictors of biochemical recurrence after radical prostatectomy.

OBJECTIVE: To evaluate p53 and bcl-2 immunohistochemistry in preoperative biopsies and radical prostatectomy specimens, as predictors of biochemical recurrence. PATIENTS AND METHODS: Preoperative biopsies from 73 men, and the radical prostatectomies from these men and from a further 47 men, were evaluated. The serum prostate specific antigen (PSA) level, Gleason score, pathological stage and margin involvement were recorded. The immunohistochemical expression of p53 and bcl-2 was studied on a representative area of tumour with the highest Gleason grade. The median follow-up was 53 months. RESULTS: During the follow-up 47 of the 120 patients had a biochemical recurrence. Capsular penetration was present in 63 (53%) and the surgical margins were positive in 47 (39%). The Gleason score was < 7 in 81 (68%) patients; p53 was positive in 40 (66%) of 61 biopsies and 84 (71%) of 118 prostatectomy specimens. Bcl-2 was positive in eight (13%) of 63 biopsies and 20 (17%) of 118 prostatectomies. On multivariate analysis the biopsy p53, Gleason score and serum PSA were significant predictors of recurrence. On multivariate analysis, capsular penetration, PSA and margin status at prostatectomy were significant predictors of recurrence. There was also a significant interaction between PSA and margin status. Although univariately significant, neither p53 nor bcl-2 featured in the final multivariate model. CONCLUSION: Biopsy p53 status significantly predicts recurrence after radical prostatectomy, but its low specificity and technical issues suggest that it will not be useful in the clinical setting. However, a patient with negative p53 on biopsy is likely to have a good prognosis on prolonged follow-up.

Aged↗
PubMed2002

[Localization of positive surgical margins after retropubic, perineal and laparoscopic radical prostatectomy].

OBJECTIVE: To study the sites of positive surgical margins after radical prostatectomy according to the technique used: retropubic, perineal or laparoscopic. MATERIAL AND METHODS: 538 radical prostatectomies were performed between 1988 and 2001: 184 via a retropubic approach, 119 via a perineal approach and 235 by laparoscopy. Clinical examination, PSA assay (Hybritech, Normal < 4 ng/ml) and transrectal biopsies were performed in all patients. The radical prostatectomy specimen was examined by the same pathologist according to the Stanford protocol. The frequency and site of positive surgical margins were studied as a function of pathological stage. RESULTS: The positive surgical margins rate was 32%, 18.5% and 26.4% for the retropubic, perineal and laparoscopic techniques, respectively. The most frequent site of positive surgical margins was the apex for retropubic (41.1%) and perineal (41.6%) prostatectomy and the posterolateral part of the prostate for laparoscopic prostatectomy (41.9%). The most frequent site of positive surgical margins in pT2 tumours was the apex for the retropubic approach (50%), the base of the prostate (bladder neck) for the perineal approach (41.6%) and the apex and posterolateral part of the prostate for the laparoscopic approach (44.4% and 41.6%). CONCLUSION: Each radical prostatectomy technique corresponds to a preferential site of positive surgical margins: the apex for the retropubic approach, the bladder neck for the perineal approach and the posterolateral part of the prostate for the laparoscopic approach.

Biomarkers, Tumor↗
PubMed2003

Recent data upon impotence, incontinence and quality of life issues concerning radical prostatectomy.

OBJECTIVE: To present recent data dealing with the two major post-radical prostatectomy complications incontinence and sexual dysfunction, and investigate if they affect the quality of life of the patients. METHODS: We evaluated recent data available on Medline, from different series examining the incidence, pathophysiology, evaluation and treatment of incontinence and impotence after radical prostatectomy. We also evaluated the effect upon quality of life of these complications. RESULTS: Many experienced surgeons observe low incidence rates of incontinence and sexual dysfunction after radical prostatectomy and it seems that meticulous surgical technique might prevent these devastating complications. However, there are many papers in the literature, which show a great variety of results with incontinence ranging from to 0.3 to 65.6% and potency rates from 11.6 to 86% among treated patients. Depending on the individual's opinion incontinence is a minor problem and does not have a great impact upon their quality of life. Impotence affects more frequently these men and seems to be the most disturbing complication after radical prostatectomy affecting the quality of life. CONCLUSIONS: Today avoidance of major complications after radical prostatectomy depends mostly upon high quality surgical technique. Post-radical prostatectomy incontinence does not seem to be a frequent event and when it occurs it does not dramatically affect patients' quality of life. Impotence although most annoying for the majority of the treated patients can be effectively managed by various methods when the neurovascular bundles are preserved.

Clinical Trials as Topic↗
PubMed2003

[Treatment results of radical prostatectomy in clinical stage B and C prostate cancer: comparison of the neoadjuvant therapy group versus the surgery group; retrospective analysis of 80 cases].

Between 1994 and 2001, 80 patients underwent radical prostatectomy without adjuvant therapy for clinical stage B and C prostate cancer. The patients were not treated with adjuvant therapy before biochemical prostate specific antigen (PSA) failure. Of all 80 patients, 35 patients (43.8%) received neoadjuvant hormonal therapy prior to radical prostatectomy (the neoadjuvant therapy group), 45 patients (56.2%) underwent prostatectomy alone (the surgery alone group). Retrospective analysis to evaluate the effects of neoadjuvant therapy was performed from clinicopathological findings and the biochemical PSA failure-free rate. Of all patients, 58 (72.5%) were in clinical stage B and 22 (27.5%) were in clinical stage C. Of 58 patients in clinical stage B, 19 (32.8%) underwent prostatectomy combined with neoadjuvant therapy. Of the 22 patients in clinical stage C, 17 (77.3%) underwent prostatectomy combined with neoadjuvant therapy. Pathologically, 37 (46.3%) were in stage B, 38 (47.5%) in stage C and 2 (2.5%) in stage D1. Three patients in the neoadjuvant therapy group had no malignant findings in specimens of prostatectomy. In comparison with the clinical stage, pathologically 8 (22.9%) showed overstaging, 4 (5.0%) understaging and 23 (28.8%) accurate staging in the neoadjuvant therapy group, respectively, 0 (0.0%), 20 (44.4%), and 25 (55.6%) in the surgery alone group. In clinical stage B and C, there was no significant difference in the biochemical PSA failure-free rate between the neoadjuvant therapy group and the surgery alone group. On the other hand, in pathological stages B, the 5-year PSA failure-free rate was 63.2% in the neoadjuvant therapy group, but 100% in the surgery alone group. Although neoadjuvant therapy may have some effect on downstaging, our retrospective analysis suggests that it has no significant effect on PSA failure-free rate.

Antineoplastic Agents, Hormonal↗