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PubMed2006

Perineal salvage prostatectomy for radiation resistant prostate cancer.

OBJECTIVES: No data are available on the use of perineal prostatectomy for salvage treatment of local recurrent prostate cancer after radiotherapy. Here we report on the clinical aspects and follow-up of salvage perineal prostatectomy. MATERIALS AND METHODS: Twenty-seven patients underwent a perineal salvage prostatectomy from 1997-2005 for biopsy-proven local recurrent prostate cancer after external beam (n=22) or brachyradiotherapy (n=5). Staging included physical examination, prostate-specific antigen (PSA), transrectal ultrasound, computed tomography scan, and bone scan. RESULTS: Mean PSA before surgery was 8.6 ng/ml (+/-2.8 ng/ml). Comparing clinical staging with final pathologic staging after salvage perineal prostatectomy showed a 67% clinical understaging. Mean blood loss was 677 cc, and perioperative morbidity consisted of prolonged anastomotic leakage (n=8), urosepsis (n=3), prolonged hematuria (n=3), urinary retention (n=2), and rectal perforation (n=1). One patient died during the postoperative course because of urosepsis and endocarditis. At an interval of at least 12 mo after surgery, 37% (10 of 27) and 7% (2 of 27) of patients reported normal continence and erectile function, respectively. Five patients died during a mean follow-up of 43 mo; two patients died of prostate cancer. Five-year biochemical recurrence-free survival was 31% (95%CI, 25-42%). In a multivariate Cox regression analysis the serum PSA and PSA doubling time (PSADT) at the time of surgery were the best predictors of biochemical recurrence-free survival. No patient with a PSA>2 ng/ml and a PSADT<12 mo was without biochemical recurrence 2 yr after surgery. CONCLUSIONS: Salvage perineal prostatectomy showed functional results that favorably compare with the retropubic approach, but considerable morbidity is still frequent. Proper patient selection therefore is mandatory. A serum PSA level of >2 ng/ml and PSADT<12 mo independently predict shorter biochemical recurrence-free survival.

Aged↗
PubMed2006

Vattikuti Institute prostatectomy: contemporary technique and analysis of results.

OBJECTIVES: Contemporary techniques of radical prostatectomy achieve excellent oncologic outcomes; erectile dysfunction is the most common adverse effect. We have modified our technique of robotic radical prostatectomy (Vattikuti Institute prostatectomy [VIP]) in an attempt to minimize decrease of erectile function while maintaining the excellent oncologic outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia ("veil of Aphrodite"). METHODS: A total of 2652 patients with localized carcinoma prostate underwent VIP. The salient features of our current technique are early transection of the bladder neck, preservation of the prostatic fascia, and control of the dorsal vein complex after dissection of the prostatic apex. Oncologic and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care. RESULTS: Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12-66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function. CONCLUSIONS: VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.

Adult↗
PubMed2006

Initial therapy with radical prostatectomy for high risk localized prostate cancer.

PURPOSE: This study provides a perspective on initial treatment in select patients with high risk, localized prostate cancer. MATERIALS AND METHODS: A select literature review was done with commentary on the philosophy of initial surgery followed by adjuvant or salvage therapies. RESULTS: Early detection and associated stage migration identify a cadre of men with unfavorable but apparently localized prostate cancer who historically would not have been viewed as appropriate candidates for radical prostatectomy. Decreased morbidity from radical prostatectomy and data demonstrating improved outcomes in some patients treated with multimodal therapy protocols provide a rationale for including radical prostatectomy as part of an aggressive treatment plan to achieve optimal local elimination of cancer. Data suggest that radical prostatectomy and adjuvant or possibly even salvage radiation therapy may provide the best elimination of large local cancers. Whether such an approach provides results that are better than or even as good as those of the common standard of radiation therapy plus androgen deprivation therapy remains to be seen and, if so, at what cost to the patient in terms of adverse effects. However, it is likely that optimal elimination of local disease is needed to achieve the maximum benefit from adjuvant systemic endocrine, chemotherapy or targeted treatments. In other words optimal local therapy may be necessary but not sufficient. CONCLUSIONS: Initial radical prostatectomy may have a role for treating high risk localized prostate cancer.

Humans↗
PubMed2006

Post-radical retropubic prostatectomy inguinal hernia: an analysis of risk factors with special reference to preoperative inguinal hernia morbidity and pelvic lymph node dissection.

PURPOSE: Inguinal hernia after radical retropubic prostatectomy has been reported to occur in 7% to 21% of patients. We analyzed the impact of simultaneous pelvic lymph node dissection, preoperative inguinal hernia morbidity, postoperative anastomotic stricture, duration of surgery and patient age. We also compared the detection rate of inguinal hernia events in a retrospective patient file survey to that in a prospective patient administered questionnaire. MATERIALS AND METHODS: A total of 498 patients underwent radical retropubic prostatectomy plus pelvic lymph node dissection and 166 underwent radical retropubic prostatectomy only. Mean followup was 40 months (median 37, range 3 to 85). All 664 patients were analyzed in the patient file survey. The patient administered questionnaire was mailed preoperatively, and after 3, 6, 12, 18, 24 and 36 months to 271 patients who underwent operation between 2001 and 2002. A total of 207 patients (76.4%) completed the preoperative questionnaire. RESULTS: The cumulative incidence of inguinal hernia after 24 months was 11.6% in the patient file survey and 15.7% in the patient administered questionnaire. In the patient file survey patient age was the only studied factor that significantly influenced risk. The patient file survey failed to detect half of the men with preoperative inguinal hernia morbidity and a third of post-radical retropubic prostatectomy inguinal hernias compared to the patient administered questionnaire. On patient administered questionnaire analysis preoperative inguinal hernia morbidity was a significant risk factor for postoperative inguinal hernia (log rank Mantel-Cox test p = 0.010). CONCLUSIONS: Previous inguinal hernia morbidity and age increase the risk of post-radical retropubic prostatectomy inguinal hernia. Simultaneous pelvic lymph node dissection, postoperative anastomotic stricture and duration of surgery were not significant risk factors in this study. The patient file survey is inferior to the patient administered questionnaire for detecting inguinal hernia events.

Hernia, Inguinal↗
PubMed2006

Radical prostatectomy after previous prostate surgery: clinical and functional outcomes.

PURPOSE: Radical prostatectomy has progressively become an elective treatment for primary localized prostate cancer as well as for incidental or subsequent prostatic cancer after previous surgery for obstructive benign disease. This increased acceptance opens concerns about oncological and functional outcomes. MATERIALS AND METHODS: Between July 1999 and August 2003, 109 patients underwent radical retropubic prostatectomy for prostate cancer as a second line approach after surgery for primary bladder outlet obstruction. Of these patients 88 had undergone previous transurethral resection of the prostate and 21 had undergone open prostatectomy. Incidental and delayed prostate cancer was detected in 71 and 38 cases, respectively. Perioperative and postoperative morbidity was evaluated in all patients, while postoperative functional outcomes were assessed by a subjective questionnaire in 43. RESULTS: As a second surgery, radical retropubic prostatectomy was generally more complex technically and it resulted in longer operative time compared to radical surgery in naïve patients. In contrast, early and delayed postoperative morbidity increased moderately. Complete urinary continence was documented in 32 (74%) and 37 patients (86%) at the 6 and 12-month follow-ups, respectively. In this patient cohort adequate erectile function was reported by 12%. CONCLUSIONS: Radical retropubic prostatectomy can be performed safely after previous prostate surgery for bladder outlet obstruction. However, a consistent surgical background in prostate surgery is needed to manage frequently unexpected difficulties. Candidates for second line prostate surgery should be informed that functional results are less predictable and satisfactory than those achieved after the same surgical approach in naïve patients.

Aged↗
PubMed2006

Management of lower urinary tract symptoms secondary to benign prostatic hyperplasia with open prostatectomy: results of a contemporary series.

PURPOSE: Surgical therapy remains the definitive treatment in patients with benign prostatic hyperplasia sequelae. Many patients with a markedly enlarged prostate are often not amenable to minimally invasive therapies. In these patients open prostatectomy is a preferred treatment. Most studies of this procedure are quite dated. Therefore, we describe the clinical results and complications of open prostatectomy performed in a modern setting using serum prostate specific antigen, the American Urological Association symptom index and quality of life scores to determine outcomes. MATERIALS AND METHODS: We performed a prospective study in 56 patients who underwent open prostatectomy at our institution. Patients were evaluated by history and physical examination, American Urological Association symptom index, quality of life forms, prostate specific antigen, transrectal ultrasound and post-void urine volume. RESULTS: Patients were followed up to 11 years postoperatively (mean 39.2 months). Of the patients 80.3% presented in acute urinary retention while on medical therapy. Baseline American Urological Association symptom index decreased from a mean +/- SD of 18.5 +/- 1.9 to 4 +/- 1.7 within 1 month. Similarly the quality of life score was 3.1 +/- 0.5 preoperatively, which decreased to 0.6 +/- 0.5 postoperatively. These improvements were maintained throughout followup. The most common complication was blood loss requiring transfusion in approximately 36% of cases. Three patients had urethral strictures and 3 had bladder neck contractures that required dilation. Baseline average prostate specific antigen was 13.34 +/- 1.70 ng/dl, which stabilized at less than 1 ng/dl postoperatively. CONCLUSIONS: Open prostatectomy may be curative in a select population of men with a large prostatic burden. To our knowledge this is the first study to demonstrate durable improvements in American Urological Association symptom index, quality of life score and prostate specific antigen along with a rare need for any further treatment after open prostatectomy.

Aged↗
PubMed2006

Age stratified functional outcomes after laparoscopic radical prostatectomy.

PURPOSE: We assessed health related quality of life in men treated for prostate cancer with laparoscopic radical prostatectomy. MATERIALS AND METHODS: Urinary continence and potency were prospectively assessed in 369 men stratified into age groups, including group 1-younger than 50, group 2-50 to 59 and group 3-60 years or older, by analyzing answers to the Expanded Prostate Cancer Index Composite questionnaire collected preoperatively, and 3, 6 and 12 months after laparoscopic radical prostatectomy. RESULTS: Younger men were more likely to achieve urinary continence (1 pad or less daily) 1 year after laparoscopic radical prostatectomy (groups 1 to 3 100%, 91% and 81%, respectively, p <0.01). Younger men were also more likely to be potent and engaging in intercourse 1 year after bilateral nerve sparing laparoscopic radical prostatectomy (groups 1 to 3 70%, 67% and 46%, respectively, p <0.01). The mean percent return to baseline Expanded Prostate Cancer Index Composite urinary continence subscale at 1 year in groups 1 to 3 was 80%, 79% and 74%, respectively (p = 0.49). The mean percent return to baseline Expanded Prostate Cancer Index Composite sexual function subscale at 1 year in groups 1 to 3 was 68%, 65% and 58%, respectively (p = 0.56). Binary logistic regression modeling using the variables age group, prostate weight, International Prostate Symptom Score and nerve sparing status demonstrated that only younger age group was associated with return to continence at all postoperative time points (p <0.05). Younger age group was associated with return to early potency at 3 and 6 months (p = 0.02 and <0.01, respectively). However, only nerve sparing status was associated with recovery of potency at all time points (p <0.05). CONCLUSIONS: Younger men treated with nerve sparing laparoscopic radical prostatectomy regain urinary control and potency earlier than older men. However, validated questionnaire subscale analyses demonstrated that the return to preoperative baseline urinary continence and sexual function is similar in all age groups by the end of postoperative year 1.

Age Factors↗
PubMed2006

Climacturia following radical prostatectomy: prevalence and risk factors.

PURPOSE: Following radical prostatectomy urine leakage during orgasm is a poorly defined entity. We defined the prevalence, quantity, bother and coping mechanisms associated with this complication, called climacturia. MATERIALS AND METHODS: A self-administered questionnaire was given to a cohort of sexually active men after radical prostatectomy. We inquired about the frequency, quantity, bother and coping mechanisms associated with climacturia. We also recorded uroflowmetry and an American Urological Association symptom score (International Prostate Symptom Score) in each patient. RESULTS: Of the 42 patients enrolled with a mean age of 58.9 years and average time since radical prostatectomy of 23.6 months climacturia was reported in 19 (45%). Of the men 68% reported that it happened rarely or only occasionally, while 21% reported that it occurred most of the time or always. In terms of urine quantity 58% of respondents reported only a few drops but 16% reported a loss of more than 1 ounce. Of the patients 52% percent reported no or minimal bother but 48% reported that climacturia caused significant bother. Only 21% of respondents thought that it was of significant bother to their partners. Of the respondents 84% emptied the bladder before intercourse and 11% used condoms. Age, Gleason score and time since surgery were not predictors of climacturia. No association between peak urine flow on uroflowmetry or International Prostate Symptom Score and climacturia was found. CONCLUSIONS: Climacturia is a common clinical entity, occurring in almost half of all patients after radical prostatectomy. It can be a significant problem with respect to urine volume loss, associated bother and condom use. Patients must be informed about this complication before undergoing radical prostatectomy.

Adaptation, Psychological↗
PubMed2007

Limited pelvic lymph node dissection at the time of radical prostatectomy does not affect 5-year failure rates for low, intermediate and high risk prostate cancer: results from CaPSURE.

PURPOSE: Limited bilateral pelvic lymph node dissection performed at radical prostatectomy provides staging information that is used to guide further disease management. Given the effects of widespread prostate specific antigen testing and stage migration, most procedures in the United States are performed for low risk disease, which has a low probability (less than 1%) of lymph node metastasis. We compared 5-year treatment failure rates in patients with low, intermediate and high risk disease who underwent radical prostatectomy with or without pelvic lymph node dissection. MATERIALS AND METHODS: We compared treatment failure rates for radical prostatectomy in 4,693 patients enrolled in the CaPSURE database who underwent radical prostatectomy with or without limited pelvic lymph node dissection. Secondary analysis was performed as a function of pelvic lymph node dissection and risk group based on pretreatment stage, grade and prostate specific antigen. Treatment failure rates were estimated by Kaplan-Meier analysis. RESULTS: The 5-year failure-free survival rate was 70% in the no pelvic lymph node dissection group and 74% in the limited pelvic lymph node dissection group (p = 0.11), while the rates in the low, intermediate and high risk groups were 81% and 82% (p = 0.83), 71% and 63% (p = 0.21), and 42% and 48% (p = 0.45) in the no vs limited pelvic lymph node dissection groups, respectively. Multivariate analysis demonstrated that pelvic lymph node dissection status was not a predictor of treatment failure (p = 0.93). CONCLUSIONS: This study demonstrates in a large cohort of patients that limited pelvic lymph node dissection at radical prostatectomy has no effect on treatment failure rates at 5 years in those at low, intermediate and high risk.

Aged↗
PubMed2007

Expression of major heat shock proteins in prostate cancer: correlation with clinicopathological outcomes in patients undergoing radical prostatectomy.

PURPOSE: We evaluated expression levels of major heat shock proteins in radical prostatectomy specimens to clarify the significance of heat shock protein expression in prostate cancer. MATERIALS AND METHODS: Expression levels of heat shock proteins 27, 70 and 90 in radical prostatectomy specimens from 172 patients with clinically organ confined prostate cancer who had not received neoadjuvant hormonal therapy were measured by immunohistochemical staining. Cell proliferative activities and apoptotic features in these specimens were investigated using Ki-67 immunostaining and TUNEL assay, respectively. These findings were analyzed with respect to several clinicopathological factors. RESULTS: Various levels of heat shock protein 27 expression were noted in all prostate cancer specimens. Expression levels of heat shock protein 27 in prostate cancer tissues was significantly associated with pathological stage, Gleason score, surgical margin status, lymph node metastasis and tumor volume but not with other parameters, including patient age, serum prostate specific antigen and perineural invasion. Similarly most prostate cancer tissues showed heat shock protein 70 and 90 expression. However, there was no significant correlation between expression levels of these 2 heat shock proteins and several clinicopathological factors examined. Cell proliferative activity in prostate cancer specimens was significantly associated with heat shock protein 27 expression but not with that of heat shock proteins 70 and 90, while there was no significant correlation between the apoptotic index and the expression of these 3 heat shock proteins. Furthermore, despite the lack of prognostic significance in heat shock proteins 70 and 90 expression, biochemical recurrence-free survival in patients with strong heat shock protein 27 expression in radical prostatectomy specimens was significantly lower than that in those with weak heat shock protein 27 expression. However, multivariate analysis showed that strong heat shock protein 27 expression could not be an independent predictor of biochemical recurrence after radical prostatectomy. CONCLUSIONS: These findings suggest that, despite the limited significance of heat shock proteins 70 and 90 expression, heat shock protein 27 may be involved in the progression of prostate cancer. The expression level of heat shock protein 27 in prostate cancer tissue could be used as a useful predictor of biochemical recurrence in patients undergoing radical prostatectomy.

Aged↗
PubMed2005

Combined radical prostatectomy and bladder augmentation for concomitant prostate cancer and detrusor instability.

OBJECTIVES: To determine the outcomes of a select cohort of patients with severe voiding dysfunction, refractory to medical management, and a concomitant diagnosis of prostate cancer, who were treated with radical prostatectomy and augmentation enterocystoplasty. METHODS: Four men with biopsy-proven prostatic adenocarcinoma, as well as a diagnosis of severe overactive bladder, underwent combined radical retropubic prostatectomy and augmentation enterocystoplasty. All patients underwent fluorourodynamic testing confirming nonobstructive detrusor instability or hyperreflexia. Three patients underwent nerve-sparing radical retropubic prostatectomy with a clamshell ileocystoplasty, and one with neurogenic hyperreflexia underwent sigmoid cystoplasty with a continent catheterizable stoma at radical retropubic prostatectomy. RESULTS: The mean follow-up was 21.5 months (range 8 to 48). All patients had an undetectable prostate-specific antigen level postoperatively. The average hospitalization was 8 days. Perioperative complications occurred in 2 patients, including a prolonged urine leak managed with catheter drainage and postoperative hematuria requiring cystoscopic clot evacuation. Erectile function was preserved in 2 patients with good preoperative erections. At last follow-up, the 3 patients who voided per urethra had minimal postvoid residual urine volumes and maintained good continence, with only 1 patient describing occasional mild stress incontinence. At last follow-up, the patient with the sigmoid cystoplasty catheterized every 4 hours with volumes of about 300 mL and complete stomal continence. No patient required anticholinergic medications postoperatively. CONCLUSIONS: The concomitant diagnosis of prostate cancer and severe detrusor instability may be difficult to treat. The results of our study have shown that for those desiring surgical management for their prostate cancer, a combined bladder augmentation and radical prostatectomy may be performed with minimal added morbidity and significantly improved voiding function in the properly selected individual.

Adenocarcinoma↗
PubMed2005

Laparoscopic extraperitoneal radical prostatectomy--learning curve of a laparoscopy-naive urologist in a community hospital.

OBJECTIVES: To describe the training approach that a laparoscopy-naive general urologist working in a nonteaching hospital used to successfully learn to perform laparoscopic extraperitoneal radical prostatectomy and describe the results obtained in the first 114 cases performed. METHODS: The urologist assisted an experienced laparoscopic surgeon for 20 extraperitoneal radical prostatectomies. During this time, he modified his technique of performing open radical retropubic prostatectomy to facilitate the acquisition of the laparoscopic techniques. Intracorporeal suturing was learned with the aid of a pelvic trainer. The clinical records of the first consecutive 114 cases were examined to evaluate the outcomes in terms of morbidity and oncological and functional concerns. A similar analysis was performed on a subgroup of 15 patients who had undergone laparoscopic extraperitoneal radical prostatectomy after previous transurethral resection of the prostate. RESULTS: The operating time progressively decreased during the learning curve. The mean duration of surgery was 160 minutes. Two conversions to open surgery were required owing to failure to progress. Of the 114 patients, 14% experienced complications, most of which were minor. The positive surgical margin rate was 17%. The average follow-up was 16 months. Undetectable serum prostate-specific antigen levels were observed in 82%, 87%, and 79% at 6, 12, and 18 months, respectively; 96% of patients used 0 to 1 pad per day for incontinence at 6 months of follow-up. The results in the transurethral resection subgroup were similar. CONCLUSIONS: Laparoscopic extraperitoneal radical prostatectomy can be successfully learned by a general urologist with no prior laparoscopic experience.

Adult↗
PubMed2005

Use of acute normovolemic hemodilution in patients undergoing radical prostatectomy.

OBJECTIVES: To evaluate the efficacy and safety of acute normovolemic hemodilution (ANH) in patients undergoing radical prostatectomy. Preoperative autologous blood donation (PAD) is widely accepted as a means of reducing the need for allogeneic blood transfusion in radical prostatectomy. ANH is an alternative method for obtaining autologous blood. METHODS: On the basis of our previous report that showed the equivalence of PAD and ANH, we prospectively replaced PAD with ANH as a standard practice for radical prostatectomy after September 1999. Of 174 radical prostatectomy patients between September 1999 and June 2004, 153 underwent ANH alone, 15 chose to receive both PAD and ANH, and ANH was contraindicated in 15 because of comorbidities. RESULTS: For the 153 patients undergoing ANH alone, 1032 +/- 201 mL of autologous blood was collected. With an intraoperative blood loss of 1602 +/- 926 mL, 14 patients (9.2%) received allogeneic blood transfusion. The preoperative, intraoperative nadir, and postoperative hematocrit value was 43.6% +/- 3.4%, 25.8% +/- 3.8%, and 31.9% +/- 4.3%, respectively. No patient experienced a perioperative adverse event related to hemodilution or blood transfusion. CONCLUSIONS: Our continued experience has shown that ANH is a safe and effective means of autologous blood procurement. Given its advantages, including lower cost, lower risk, and simplicity, we conclude that ANH can replace conventional PAD for use in radical prostatectomy, although the true value of ANH should be determined by future randomized studies including a no-treatment control group.

Aged↗
PubMed2005

Outcomes for men younger than 50 years undergoing radical prostatectomy.

OBJECTIVES: To compare the surgical outcomes after radical prostatectomy between men younger than 50 years and men 50 years old or older. METHODS: Between October 1, 2000 and December 31, 2003, 790 men underwent open radical retropubic prostatectomy by a single surgeon. The intraoperative, perioperative, and postoperative parameters were recorded in real time and entered into a database. The outcomes were compared for 66 men younger than 50 years of age (group 1) versus 724 men who were 50 years old or older (group 2). RESULTS: The pathologic stage, percentage of cancer in the surgical specimen, positive surgical margin rate, and Gleason score were not significantly different among the two age groups. No significant difference was found in the risk factors for prostate cancer between groups 1 and 2 (33.3% versus 28.9%, respectively; P = 0.63). The operative complications were exceedingly low in both groups. Of the men in groups 1 and 2, 93.3% and 97.1% achieved continence, respectively (P = 0.26). Of the potent men at baseline who underwent bilateral nerve-sparing prostatectomy, 100% of men in group 1 versus 81.4% in group 2 (P = 0.02) were having erections adequate for intercourse with or without phosphodiesterase-5 inhibitors or intracavernous injection therapy, as determined by direct patient interview. Of the men who underwent bilateral nerve-sparing radical retropubic prostatectomy, 78.3% of group 1 versus 62.6% of group 2 (P = 0.14) were potent with or without phosphodiesterase-5 inhibitors. CONCLUSIONS: The preoperative and pathologic predictors of organ-confined disease and biochemical recurrence were similar in both age groups. The results of this study have demonstrated that radical retropubic prostatectomy can be performed with good results and low complication rates in men with localized prostate cancer who are younger than 50 years of age.

Adult↗
PubMed2005

Robotic radical prostatectomy with preservation of the prostatic fascia: a feasibility study.

OBJECTIVES: To describe a feasibility study of our ability to preserve the prostatic fascia in men undergoing robotic radical prostatectomy. The prostate is covered anterolaterally by prostatic fascia, also called lateral pelvic fascia or the parietal layer of endopelvic fascia. The prostatic fascia is rich in vessels, nerves, and smooth muscle. We hypothesized that preservation of this fascial layer may result in improved postoperative potency. METHODS: The technique was first attempted in 15 men undergoing radical cystoprostatectomy, in which accidental entry to the prostatic tissue is not critical. Thereafter, it was performed in 6 impotent men undergoing robotic radical prostatectomy. The fascia was excised and stained for prostate-specific antigen and neural and muscle tissue. The technique was then performed in 35 potent men (Sexual Health Inventory for Men score greater than 21) undergoing robotic radical prostatectomy. Postoperative potency was evaluated with a self-administered questionnaire (Sexual Health Inventory for Men). RESULTS: Under the magnification of the da Vinci robotic system, and also shown histologically, the prostatic fascia is a multifascial layer of fibrovascular tissue, covering the anterolateral aspect of the prostate. It stains positive for smooth muscle and nerves, but negative for prostate-specific antigen. The amount of neural tissue in the fascia is variable, but never exceeds that in the neurovascular bundle. At 12 months of follow-up, 34 (97%) of 35 men undergoing fascia-preserving robotic radical prostatectomy had erections strong enough for vaginal penetration, and 30 (86%) had normal erections (Sexual Health Inventory for Men greater than 21). CONCLUSIONS: Preservation of the prostatic fascia is safe and feasible, without compromising the surgical margins, and allows enhanced preservation of neural tissue during robotic prostatectomy with an apparent improvement in potency.

Fascia↗
PubMed2006

Changes in quality of life in first year after radical prostatectomy by retropubic, laparoscopic, and perineal approach: Multi-institutional longitudinal study in Japan.

OBJECTIVES: To investigate the health-related quality of life of patients who underwent radical prostatectomy performed using retropubic, laparoscopic, and perineal approaches. METHODS: A total of 218 men who underwent retropubic prostatectomy, 65 who underwent laparoscopic prostatectomy, and 66 who underwent perineal prostatectomy were enrolled in our survey. A baseline interview was conducted before treatment. Follow-up interviews were conducted in person at scheduled study visits 1, 3, 6, and 12 months after surgery. We measured two validated questionnaires that assessed the general and disease-specific health-related quality of life. RESULTS: The retropubic group reported substantial deterioration in physical limitations, emotional limitations, social function, and bodily pain at 1 month. The perineal group reported less bodily pain just after surgery than the retropubic and laparoscopic groups. After 6 months, however, no significant differences were found among the three groups. Postoperative urinary function remained substantially lower than the baseline level in every treatment group. Each approach with a nerve-sparing procedure showed a similar recovery profile of urinary function postoperatively. The perineal group reported no significant difference in bowel function compared with the other two groups. All of the groups continued to have decrements in sexual function. CONCLUSIONS: The results of this study have demonstrated that retropubic, laparoscopic, and perineal prostatectomy have differences in the recovery of general and disease-specific quality of life in the early postoperative period. When performed by an experienced surgeon, the retropubic, laparoscopic, and perineal approaches appear to be equivalent in terms of health-related quality of life.

Aged↗
PubMed2006

Relapse after radical prostatectomy correlates with preoperative PSA velocity and tumor volume: results from a screening population.

OBJECTIVES: To evaluate, in a screening population, the impact of tumor volume and prostate volume on prostate-specific antigen (PSA) velocity (PSAV) and to find predictors of biochemical failure after radical prostatectomy. Longitudinal PSA changes in men with prostate cancer have been reported to be significantly different from those without prostate cancer. METHODS: PSAV was assessed in 102 men undergoing radical retropubic prostatectomy. The pathologic findings of specimens obtained at radical retropubic prostatectomy and pelvic lymph node dissection were analyzed separately for all patients. RESULTS: The median preoperative PSA in the 102 patients was 6.4 ng/mL, the median prostate volume was 32.8 cm3, and the median tumor volume was 1.27 cm3. The PSAV correlated significantly with tumor volume (P <0.05) but not with prostate volume (P = 0.142). The median tumor volume in men with biochemical progression after radical retropubic prostatectomy was 2.55 cm3 versus 0.94 cm3 in men who were free of disease 5 years after surgery. The median PSAV in the year before diagnosis in men with relapse after radical prostatectomy was 1.98 ng/mL/yr versus 1.05 ng/mL/yr in men who had no evidence of disease. CONCLUSIONS: The results of our study have shown that the main factor contributing to the PSAV in patients with prostate cancer is cancer load and that prostate volume is not significantly associated with the PSAV. Men with a PSAV of more than 2 ng/mL/yr in the year before cancer diagnosis are at a high risk of relapse. The PSAV may be helpful in identifying patients with small tumors and thus increase the detection rate of potentially curable prostate cancers.

Adult↗
PubMed1994

Perioperative nursing implications of radical perineal prostatectomy.

Improvements of surgical techniques for radical prostatectomy, including nerve-sparing methods, have made surgery the preferred treatment for prostate-confined tumors. Perineal prostatectomy is tolerated well by patients, especially the elderly and those who are at high risk. Blood loss during perineal prostatectomy versus retropubic prostatectomy is minimal. Additionally, the perineal approach provides the surgeon with better exposure for anastomosing the bladder neck to the urethra. The bowel does not have to be manipulated in the perineal approach, which minimizes paralytic ileus. Perioperative nurses must become familiar with the technique, positioning, and equipment necessary to care for patients undergoing radical perineal prostatectomy.

Humans↗