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PubMed1998

Long-term results of radiation therapy for prostate cancer recurrence following radical prostatectomy.

PURPOSE: Following radical prostatectomy, radiation therapy may be beneficial in select patients with isolated local recurrence. Pathological stage, Gleason score and the timing of prostate specific antigen (PSA) elevation are useful in distinguishing men with local recurrence from those with distant metastases. We test the ability of these criteria to predict long-term suppression of PSA recurrence following post-prostatectomy radiation therapy. MATERIALS AND METHODS: Of 1,699 men treated with radical prostatectomy from 1982 to 1995, 82 with an isolated PSA elevation or local recurrence following surgery underwent radiation therapy to the prostatic bed and were followed for at least 2 years. No patient had evidence of metastases at the time of radiation. RESULTS: Of the men 17 (21%) had an undetectable PSA (less than 0.2 ng./ml.) for 2 or greater years following radiation. The 5-year actuarial PSA recurrence-free rate after radiation was 10%. PSA remained at undetectable levels for 2 or greater years in no patients with Gleason score 8 or greater (12 cases), positive seminal vesicles (12) or positive lymph nodes (3), and in only 1 of 16 men (6%) who had a PSA recurrence within 1 year of prostatectomy. As the interval to PSA recurrence increased, the likelihood of responding to radiotherapy increased to 44% if initial disease detection occurred 5 or more years after prostatectomy. There was no demonstrated advantage to radiating men with an isolated PSA elevation before a documented local recurrence. CONCLUSIONS: Patients with Gleason score 8 or greater, positive seminal vesicles or lymph nodes, or a PSA recurrence within the first year following surgery rarely benefit from radiation therapy. As the interval to PSA recurrence increases, the likelihood of responding to radiation therapy increases substantially. These parameters are useful in the selection of patients with prostate cancer recurrences who are likely to benefit from radiation to the prostatic bed.

Follow-Up Studies↗
PubMed1995

Incontinence after radical prostatectomy: detrusor or sphincter causes.

PURPOSE: Prospective studies have shown a high prevalence of decreased compliance immediately after radical prostatectomy, which may be a temporary phenomenon in men in whom incontinence persists for more than 1 year. We examined the video urodynamic records of 74 consecutive men referred to our urodynamic laboratory with incontinence as the predominant symptom following radical prostatectomy to evaluate voiding parameters and bladder function. MATERIALS AND METHODS: The urodynamic assessment was made an average of 3.8 years postoperatively. All men presented with persistent post-prostatectomy incontinence, and 64 underwent radical retropubic and 10 radical perineal prostatectomy. RESULTS: A total of 42 men (57%) had sphincter weakness alone, 29 (39%) had detrusor instability and/or decreased compliance combined with sphincter weakness and only 3 (4%) had detrusor instability alone. Of 29 men with a combination of factors 8 had decreased compliance, with 3 also having detrusor instability. Anastomotic strictures occurred in 24% of the patients. A total of 31 patients voided by straining without demonstrable detrusor contraction (42% overall). CONCLUSIONS: Decreased compliance is an infrequent finding after radical prostatectomy. Detrusor abnormalities in general are rarely the sole cause of incontinence, with sphincter weakness being present in the majority of patients.

Aged↗
PubMed2006

Robotic extraperitoneal radical prostatectomy: an alternative approach.

PURPOSE: Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded. RESULTS: Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured. CONCLUSIONS: The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Adult↗
PubMed2006

Laparoscopic versus open simple prostatectomy: a comparative study.

PURPOSE: Laparoscopic simple prostatectomy has recently been developed to remove large prostatic adenomas causing bladder outflow obstruction. To our knowledge the advantages of the laparoscopic vs the standard open approach to this procedure remain undefined. We compared laparoscopic and open simple prostatectomy. MATERIALS AND METHODS: Perioperative data on the first 30 consecutive laparoscopic simple prostatectomies performed by 1 surgeon were collected prospectively and compared with retrospectively collected data on a series of 30 consecutive open simple prostatectomies. A Millin and a transvesical-prostatic technique were used in the laparoscopic group and a transvesical technique was used in the open group. RESULTS: There was no significant difference in prostatic size, patient age or body mass index between the 2 groups. In the laparoscopic group the mean International Prostate Symptom score +/- SD improved from 22.4 +/- 6.9 to 5.7 +/- 3.6 and the urinary flow rate improved from 8.1 +/- 2.5 to 24.6 +/- 12.1 ml per minute (each p <0.001). Mean total blood loss (367 +/- 363 vs 643 +/- 647 ml), irrigation time (0.33 +/- 0.7 vs 4 +/- 3.5 days), duration of catheterization (4 +/- 1.7 vs 6.8 +/- 4.7 days) and hospital stay (5.1 +/- 1.8 vs 8 +/- 4.8 days) were significantly less in the laparoscopic group than in the open group. Mean operative time was longer in the laparoscopic group (115 +/- 30 vs 54 +/- 19 minutes). Of the 30 patients in the laparoscopic group 24 did not require bladder irrigation. There was no apparent difference in the incidence or severity of complications. There was no difference in perioperative parameters or functional results between the 2 different laparoscopic techniques. CONCLUSIONS: Laparoscopic simple prostatectomy has inherent advantages over the open technique. Further studies are indicated to determine whether this technique should be considered the treatment of choice for prostatic adenomas too large for safe endoscopic resection.

Aged↗
PubMed2002

Is ethnicity an independent predictor of prostate cancer recurrence after radical prostatectomy?

PURPOSE: Prostate cancer incidence and mortality are higher in black than in white American men. We determined whether ethnicity is an independent predictor of disease recurrence in men undergoing radical prostatectomy. MATERIALS AND METHODS: We studied 1,468 patients who underwent radical prostatectomy at the University of California, San Francisco or as part of the Cancer of the Prostate Strategic Urological Research Endeavor database, a longitudinal disease registry of patients with prostate cancer. Preoperative characteristics, including age, race, prostate specific antigen (PSA) at diagnosis, clinical T stage, biopsy Gleason score and percent positive prostate biopsies at diagnosis were determined in each patient. Disease recurrence was defined as PSA 0.2 ng./ml. or greater on 2 consecutive occasions after radical prostatectomy or second cancer treatment at least 6 months after surgery. Cox proportional hazards analysis was performed to determine independent predictors of time to disease recurrence. To control for pretreatment disease characteristics simultaneously patients were assigned to previously described risk groups based on clinical tumor stage, PSA at diagnosis and biopsy Gleason score. The likelihood of disease recurrence per risk group stratified according to ethnicity was determined using the Kaplan-Meier method and compared using the log rank test. Additional multivariate analysis was performed in the subset of patients enrolled in Cancer of the Prostate Strategic Urological Research Endeavor on whom education and income information was available. RESULTS: Disease recurred in 304 of the 1,468 patients (21%). Black ethnicity, serum PSA at diagnosis, biopsy Gleason score and percent positive prostate biopsies were independent predictors of recurrence on multivariate analysis. Black ethnicity remained an independent predictor of disease recurrence in the multivariate model after stratifying patients into risk groups (p = 0.0007). Ethnicity was most important in patients at high risk, in whom estimated 5-year disease-free survival was 65% and 28% in white and black men, respectively. Education, income and ethnicity correlated highly. When education and income were entered into the multivariate model, ethnicity was no longer an independent predictor of outcome after prostatectomy. CONCLUSIONS: Ethnicity appears to be an independent predictor of disease recurrence after adjusting for pretreatment measures of disease extent in patients undergoing radical prostatectomy. It appears to be particularly important in those with high risk disease characteristics. However, black ethnicity, education and income are highly correlated variables, suggesting that sociodemographic factors may contribute to the poorer outcomes in black patients even after adjusting for differences in pretreatment disease characteristics.

Black or African American↗
PubMed2002

Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor.

PURPOSE: Bladder neck invasion by prostate cancer in radical prostatectomy specimens is uncommon and, thus, its influence on disease recurrence has not been well defined. Consequently the classification of bladder neck invasion in the TNM staging system is controversial. We studied our cohort of patients with stage pT4 disease and bladder neck invasion to clarify the true clinical behavior and prognostic significance of bladder neck invasion in radical prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 4,090 consecutive patients treated with radical prostatectomy at one of our institutions between 1983 and 2001. Median followup was 53.1 months (range 1 to 189). After excluding from analysis patients treated with neoadjuvant androgen withdrawal or preoperative irradiation 72 of the remaining 2,571 (2.8%) with bladder neck invasion were classified with stage pT4 disease and their specimens were reviewed. Progression-free probability was determined by Kaplan-Meier analysis. Using the Cox proportional hazards model the independent prognostic significance of bladder neck invasion was assessed after controlling for pretreatment prostate specific antigen, final Gleason sum, extracapsular extension, surgical margins status, seminal vesicle invasion and lymph node involvement. RESULTS: Of the 72 patients categorized with stage pT4 disease 14 (19%) had poorly differentiated Gleason sum 8 to 10 cancer, 38 (53%) had established extracapsular extension, 24 (33%) had seminal vesicle invasion and 8 (11%) had lymph node involvement. However, 26 patients (36%) had cancer confined to the prostate and 28 (39%) had negative surgical margins except for the bladder neck site. The mean 5-year progression-free probability plus or minus SD in all stage pT4 cases was 68% +/- 7%, which was better than in cases of seminal vesicle invasion (52% +/- 5%, log rank test p = 0.0156) but worse than in those of extracapsular extension (84% +/- 4.1%). Univariate analysis of the stage pT4 cohort revealed that higher prostatectomy Gleason sum, more extensive extracapsular extension and seminal vesicle invasion were significantly associated with an adverse prognosis. However, in a multivariate model that included all radical prostatectomy cases the finding of bladder neck invasion or stage pT4 disease did not independently predict prostate specific antigen recurrence. CONCLUSIONS: Stage pT4 disease comprises a heterogeneous group of tumors with various pathological features and inconsistent outcomes. Assigning the pT4 stage to cases of microscopic bladder neck invasion provides no independent ability for predicting disease progression after adjusting for other adverse disease features. Due to this and previously reported data the definition of stage pT4 disease should be modified in the next version of the TNM staging system.

Adult↗
PubMed2002

Neoadjuvant therapy before radical prostatectomy for clinical T3/T4 carcinoma of the prostate: 5-year followup, Phase II Southwest Oncology Group Study 9109.

PURPOSE: Several investigators have examined the role of hormonal therapy before definitive local therapy for locally advanced prostate cancer to improve outcome. We evaluated the resectability rate and clinical response rate to 16 weeks of total androgen blockage therapy for clinically locally prostate cancer before radical prostatectomy, and progression-free survival in this multi-institutional study. MATERIALS AND METHODS: Southwest Oncology Group 9109 was a phase II feasibility study designed to treat patients with clinical stage C prostate cancer (T3, T4, N0 and M0). Cases were classified by stage T3 versus T4 and bulky (greater than 4 cm.) versus nonbulky (or less 4 cm.) disease. The neoadjuvant agents used were goserelin and flutamide before radical prostatectomy. RESULTS: A total of 62 patients were accrued to the study and 1 patient was ineligible. There were 2 protocol deviations and these patients refused to undergo prostatectomy after hormonal therapy. Four patients went off protocol treatment because they were not considered surgical candidates. The racial distribution was 72% white, 20% black, 7% Hispanic and 2% Asian. Clinical stage at diagnosis was T3 in 97% and T4 in 3% of cases. Of the patients 39% were diagnosed with bulky disease. Of the 61 eligible patients 55 (90%) underwent a prostatectomy. The 5-year progression-free survival estimate was 70% (24 of 61 cases failed) and the 5-year survival estimate was 90% (11 of 61 deaths). Most of the patients in this trial would have been considered inoperable and referred to radiation oncology. CONCLUSIONS: Neoadjuvant hormonal therapy followed by radical prostatectomy is reasonable and appropriate for clinical stage T3 prostate cancer. A progression-free and overall 5-year survival of 70% and 90%, respectively, compares favorably to Radiation Therapy Oncology Group neoadjuvant trial outcomes for this stage of prostate cancer.

Aged↗
PubMed2001

Outpatient radical prostatectomy: impact of standard perineal approach on patient outcome.

PURPOSE: As managed care becomes more prevalent, urologists must critically evaluate the economic aspect of and patient satisfaction with urological practice patterns. We have previously reported the advantages of radical perineal prostatectomy, which decreases hospitalization and morbidity, and provides a more rapid return to normal activity, translating into cost savings. We have since evaluated the satisfaction of patients who underwent outpatient radical prostatectomy with and without laparoscopic pelvic lymph node dissection. MATERIALS AND METHODS: We evaluated the charts of 250 consecutive patients who underwent outpatient radical perineal prostatectomy with less than 24 hours of hospitalization from 1992 to 1997. Complications, pain management, blood transfusion, and bowel and urinary dysfunction were assessed. Validated quality of life questionnaires were mailed to 200 patients several months postoperatively and a 62% response rate was achieved. RESULTS: Mean followup in the series was 30 months. In the perioperative period there were rectal perforation in less than 2% of patients, anastomotic stricture in 3%, perineal fistula in 0.4% and blood transfusion in 11%. Some problems with bowel movements immediately after the procedure, such as diarrhea, constipation or soiled underwear, developed in 17% of patients, of whom up to 20% had had some bowel dysfunction before surgery. In the majority bowel problems resolved in an average of 7.3 weeks. Persistent new onset bowel trouble developed in 9 of the 124 patients (7%). The questionnaire demonstrated persistent significant urinary incontinence in 8 cases (7%). Nerve sparing was attempted in 54 patients, including 22 (41%) who achieve erection sufficient for vaginal penetration and are satisfied with sexual function. Of the patients 17% reported problems after hospital discharge that were mostly related to Foley catheter management. Overall 94.8% of patients were satisfied with treatment. Physical and social/family well-being appeared to be excellent according to the questionnaire. Only 12% of patients would have preferred longer hospitalization. The preferred method of pain control was nonsteroidal anti-inflammatory drugs. CONCLUSIONS: Radical perineal prostatectomy is a low morbidity alternative for localized prostate cancer. Outpatient radical perineal prostatectomy may be performed with good patient satisfaction and safety. There appear to be few bowel problems after long-term followup.

Aged↗
PubMed2000

Laparoscopic radical prostatectomy: the Montsouris technique.

PURPOSE: Laparoscopic radical prostatectomy has become standard at our institution based on experience with 260 consecutive cases operated on between January 1998 and December 1999. In view of the favorable short-term outcomes we describe our standardized laparoscopic radical prostatectomy technique. MATERIALS AND METHODS: Two urologists trained in open retropubic radical prostatectomy and laparoscopy combined their experience to develop a specific technique of nonincisional radical prostatectomy for localized prostate cancer. Patients presented with clinical stages T1b to T2 prostate cancer and tumor size was approximately 18 to 130 gm. Operations were performed by 1 senior surgeon and 1 assistant, with the help of a voice controlled robot and with the patient under general anesthesia. The 2, 10 mm. ports and 3, 5 mm. ports were placed in the umbilicus and iliac fossa. The laparoscopic procedure was performed transperitoneally, combining anterograde and retrograde approaches in 7 standardized steps. Urethrovesical anastomosis was performed with 3-zero interrupted sutures tied intracorporeally. Technical details were compiled, summarized and illustrated with schematic views. RESULTS: Operating time was approximately 3 hours for the last 120 cases. Estimated average blood loss was 250 ml. with a transfusion rate of less than 1%. The conversion rate was 0%. Postoperative pain was minimal and analgesics were generally not required by postoperative day 2. The accuracy of dissection and sutures allowed patients to be discharged home without urethral catheterization starting on postoperative day 3. CONCLUSIONS: Laparoscopic radical prostatectomy is now not only feasible, but more importantly reproducible. Each step has been checked and validated, and the procedure is standardized and has definitively replaced the retropubic approach in our practice.

Humans↗
PubMed2000

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy.

PURPOSE: Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence. MATERIALS AND METHODS: Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4. RESULTS: There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours. CONCLUSIONS: Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.

Humans↗
PubMed2000

Artificial urinary sphincter for post-prostatectomy incontinence: impact of prior collagen injection on cost and clinical outcome.

PURPOSE: We retrospectively reviewed our experience with the artificial urinary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. MATERIALS AND METHODS: The records and preoperative urodynamic studies of 30 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had undergone prior collagen injection (collagen group) and 7 had not (noncollagen group). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of less than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen injection and chosen artificial urinary sphincter primarily. RESULTS: Of the 30 patients 24 (80%) were incontinent following radical retropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients alternated the use of pads with the use of clamps or a condom catheter to aid in controlling leakage. Mean number of collagen treatment sessions for the injection group was 2.9 (range 1 to 7). There was a significant difference in mean time from prostatectomy to artificial urinary sphincter between the noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the groups, including mean age (66.2 years, range 45 to 83), mean followup (26.2 months), mean preoperative pads daily (5.8+/-3.4), median preoperative quality of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsalva leak point pressure (42.7+/-21.4 cm. water). For all patients in the study the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically significant differences between the collagen and noncollagen groups in any of these parameters. Among the collagen group 17 patients (73.9%) had a Valsalva leak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary sphincter) to be 12.9 months and the additional treatment costs (including pads daily and mean number of collagen syringes per patient), the direct costs of treatment for the collagen group were 85.6% higher than those for patients who chose artificial urinary sphincter primarily. CONCLUSIONS: Prior collagen therapy did not adversely influence the surgical complication rate or compromise effectiveness of the artificial urinary sphincter. However, patients with Valsalva leak point pressure less than 60 cm. water have lower rates of success with collagen injection therapy and could benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary therapy.

Aged↗
PubMed1999

Significance and metabolism of complexed and noncomplexed prostate specific antigen forms, and human glandular kallikrein 2 in clinically localized prostate cancer before and after radical prostatectomy.

PURPOSE: We studied plasma concentrations and elimination rates of prostate specific antigen (PSA) complexed to alpha1-antichymotrypsin and alpha2-macroglobulin, free PSA, total PSA (free PSA plus PSA alpha1-antichymotrypsin) and human glandular kallikrein 2 before, during and after radical retropubic prostatectomy for clinically localized prostate cancer. MATERIALS AND METHODS: Plasma was collected and frozen within 10 minutes after sampling from 18 patients undergoing radical retropubic prostatectomy for prostate cancer. One sample was drawn preoperatively. Subsequent sampling intervals were 5 to 20 minutes perioperatively, 2 to 4 hours during the first 12 postoperative hours and 24 to 48 hours until postoperative day 14. Free PSA, PSA alpha1-antichymotrypsin, total PSA, PSA alpha2-macroglobulin and human glandular kallikrein 2 were measured with time resolved immunofluorometric assays. RESULTS: Preoperatively PSA alpha2-macroglobulin was undetectable (less than 2 ng./ml.) in 17 of 18 patients. Human glandular kallikrein 2, free PSA and total PSA but not PSA alpha1-antichymotrypsin were significantly higher in patients with extraprostatic cancer (pT3a-pT4a, pN1) compared to those with organ confined cancer (pT2a/b). Surgical manipulation of the prostate caused no detectable elevation of human glandular kallikrein 2, PSA alpha1-antichymotrypsin or PSA alpha2-macroglobulin. In contrast, a mean 9.6-fold increase (range 3.4 to 22) in free PSA was noted 5 minutes after prostatectomy. Free PSA was eliminated from plasma in a biphasic exponential pattern with an early plasma half-life of 55 minutes and a late plasma half-life of 18 hours. PSA alpha1-antichymotrypsin decreased slowly, whereas human glandular kallikrein 2 was detectable only 12 hours after prostatectomy. PSA alpha2-macroglobulin remained at insignificant, nondetectable concentrations during the entire perioperative and postoperative period. CONCLUSIONS: Release of free PSA contributes to the elevation of plasma total PSA after prostatectomy. Free PSA is enzymatically inactive as the release does not result in subsequent elevation of PSA alpha1-antichymotrypsin or PSA alpha2-macroglobulin. Biphasic exponential elimination of free PSA may be explained by rapid extracellular redistribution (early half-life) and glomerular filtration in the kidneys (late half-life). Our data suggest rapid metabolism of human glandular kallikrein 2 but do not support suggestions of the significance in vivo of complex formations with alpha2-macroglobulin as a major means to eliminate PSA from plasma in patients with clinically localized prostate cancer.

Aged↗
PubMed2006

Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy.

PURPOSE: The exact process and time required for rehabilitation of erectile function after nerve sparing prostatectomy remain unclear to date. Different theories of the pathophysiology of postoperative erectile dysfunction are currently being discussed. In a prospective study we performed recordings of nocturnal penile tumescence and rigidity during the acute phase after nerve sparing radical prostatectomy, ie in the first night after removal of the catheter, to assess the organic penile integrity. MATERIALS AND METHODS: In 27 patients with local prostate carcinoma who had been sexually active before the intervention, we performed unilateral or bilateral nerve sparing radical prostatectomy. Preoperative sexual function of all patients was evaluated by the International Index of Erectile Function-5 questionnaire. On the day of catheter removal (postoperative day 7 to 14) an NPTR recording was performed on the following night with an erectometer (RigiScan). RESULTS: All patients had a preoperative IIEF score greater than 18. After removal of the catheter 25 of 27 patients (93%) showed 1 to 5 nocturnal rigidity increases by greater than 70% for at least 10 minutes. In a control group of 4 patients who underwent radical prostatectomy without nerve sparing, no nocturnal erections were recorded. CONCLUSIONS: NPTR recording during the acute phase after nerve sparing radical prostatectomy showed residual erectile function as early as the first night after catheter removal. These results are significant for selecting adequate pharmacological treatment for optimal therapy and rehabilitation of satisfactory erections and sexual function. In cases of early nocturnal tumescence, application of a PDE5 inhibitor can support successive organ rehabilitation. However, if tumescence does not occur, penile injection therapy is recommended.

Aged↗
PubMed1994

Post-radical prostatectomy penile blood flow: assessment with color flow Doppler ultrasound.

Cadaveric dissections have revealed that accessory blood vessels to the penis often arise near or through the apex of the prostate. These accessory vessels may be easily injured during radical prostatectomy. Increasing attention since the 1980s has focused on preserving potency after radical prostatectomy with a nerve sparing technique. However, many patients are impotent even after a nerve sparing procedure. An arterial, venous or psychological mechanism may be involved. A prospective study was designed to assess cavernous artery diameter, peak systolic flow velocity, penile blood flow, end diastolic flow velocity and resistance index preoperatively and postoperatively in patients undergoing radical prostatectomy. Ten patients with a mean age of 60 years were evaluated, of whom 8 underwent a unilateral nerve sparing procedure, 1 bilateral nerve sparing procedure and 1 bilateral nonnerve sparing procedure. Mean penile blood flow as calculated by the formula penile blood flow = peak systolic flow velocity x pi (diameter/2)2 increased 0.33 ml. per second (+26%) on the nerve spared side, while diminishing 0.68 ml. per second (-41%) on the nonspared side. Overall penile blood flow was diminished. End diastolic flow velocity increased on spared and nonspared sides after surgery. The resistance index for all radical prostatectomy patients diminished 7% from 0.83 preoperatively to 0.77 postoperatively (p = 0.16). While these findings were not statistically significant, they suggest that arterial insufficiency and corporeal venous occlusive dysfunction may be involved in sexual dysfunction after nerve sparing radical prostatectomy.

Adenocarcinoma↗
PubMed1994

The incidence and significance of detectable levels of serum prostate specific antigen after radical prostatectomy.

A total of 601 patients who underwent radical retropubic prostatectomy for localized prostate cancer at our institution was followed with serial prostatic specific antigen (PSA) determinations. Three separate groups were delineated by pathological stage: 293 patients with organ confined disease, 215 with involvement of the capsule or positive margins and 93 with extension to the seminal vesicles. Followup ranged from 12 to 237 months (median 34). Five and 10-year disease-free survival rates for the 601 patients were 86 +/- 2% and 78 +/- 3%, respectively. The rate of detectable PSA (greater than 0.4 ng./ml.), used as an indicator of cancer progression, revealed 5 and 10-year disease-free rates of 69 +/- 2% and 47 +/- 3%, respectively. When comparing the patients from an earlier series to those who underwent surgery after 1986, an improvement in the 5-year clinical disease-free rate was noted (78 +/- 2% versus 93 +/- 2%, respectively). Similarly, an improvement in the 5-year disease-free survival rate with nondetectable PSA level was demonstrated in our contemporary series (80 +/- 3%) compared to our historical series. Of the 601 patients 123 had a detectable post-prostatectomy PSA level with or without clinical evidence of metastasis. A PSA doubling time before onset of adjuvant therapy was determined in 94 patients. Post-prostatectomy PSA doubling times were significantly different when comparing the patients who ultimately had progression to distant metastases (median 4.3 months) to those with either clinical local recurrence or a PSA elevation as the sole indicator of recurrence (median 11.7 months). Radical retropubic prostatectomy, whether assessed by clinical or biochemical means, has demonstrated excellent disease-free survival rates, especially since the advent of PSA and anatomical radical prostatectomy.

Adult↗
PubMed1994

Can radical prostatectomy alter the progression of poorly differentiated prostate cancer?

A favorable outcome after radical prostatectomy for early stage prostate cancer has sometimes been attributed to the relatively benign natural history of the disease rather than the beneficial effects of treatment. Poorly differentiated tumors, however, are recognized as inherently aggressive and progress rapidly when managed conservatively. We determined the actuarial rate of treatment failure after radical prostatectomy for clinically localized (stages T1 to T3) poorly differentiated cancer, using as an end point an increase in the serum level of prostate specific antigen (PSA) to assess whether treatment altered the rapid progression expected of these cancers. Of 500 patients treated with radical prostatectomy, regardless of grade, the actuarial nonprogression rate was 76 +/- 5% at 5 years and 73 +/- 6% at 10 years. Poorly differentiated cancer, defined as Gleason score 7 or greater in the radical prostatectomy specimen, was present in 268 patients (54%) who had a nonprogression rate at 5 years of 55 +/- 12% compared to 92 +/- 4% for the 232 patients with a well or moderately differentiated (Gleason score less than 7) cancer (p < 0.00005). The extent of the cancer (confined or not confined) was strongly associated with progression (p < 0.00005). Only 76 of the 268 poorly differentiated tumors (28%) were confined to the prostate and the prognosis was excellent. At 5 years 85 +/- 18% of the patients had no evidence of progression, compared to 46 +/- 12% with poorly differentiated cancer extending outside the gland (p < 0.0001). In a multivariate analysis neither the grade nor volume of the tumor influenced the rate of progression when the cancer was confined to the prostate. Impalpable tumors detected by an elevated PSA level were as likely to be poorly differentiated as palpable disease (56% versus 63%) but were significantly more likely to be confined to the prostate (44% versus 24%, p < 0.01). Poorly differentiated cancers usually extend outside of the prostate by the time they are detected, and they progress rapidly. PSA increases the detection of impalpable high grade cancer confined to the gland. When these tumors are detected while still confined, most can be controlled by radical prostatectomy.

Actuarial Analysis↗
PubMed1994

Early complications of contemporary anatomical radical retropubic prostatectomy.

Anatomical radical retropubic prostatectomy is commonly performed to treat select patients with clinically localized prostate cancer. Because this recently introduced surgical technique is technically demanding, and since early detection programs have altered the age and stage distribution of men undergoing radical prostatectomy, earlier reports describing complication and death rates from radical prostatectomy may not accurately reflect contemporary experience. A retrospective review of 1,342 radical retropubic prostatectomies performed during a 5-year period showed an early complication rate of 7.4%. The most common complications were thromboembolic (pulmonary embolism) and cardiac (myocardial infarction). Patient age, mode of diagnosis (transurethral resection of the prostate versus needle biopsy) and pathological stage of the tumor did not correlate with the rate of complications. Three patients died in this series (0.2%). This retrospective review shows that contemporary anatomical retropubic radical prostatectomy may be performed with acceptably low early morbidity and mortality rates, and that appropriate selection of chronologically older patients is not associated with significantly greater rates of early complications. These data may be useful in decision analytic models evaluating the role of therapy for patients with early stage prostate cancer.

Adult↗
PubMed1994

Prognostic factors in men with stage D1 prostate cancer: identification of patients less likely to have prolonged survival after radical prostatectomy.

The role of radical prostatectomy in the management of stage D1 disease is controversial. Although cure is unlikely, some men survive for long intervals apparently free of metastatic disease. For this reason, effective palliation of the local lesion is desirable in men who will live long enough to benefit. In an effort to identify factors that correlated with interval to progression to distant metastases, we studied 113 men with stage D1 disease who underwent radical prostatectomy between 1974 and 1991. Progression of disease to distant metastases did not independently correlate with the size of the nodal metastases, number of positive lymph nodes or bilaterality of lymph node metastases. Only high Gleason score (8 to 10) on the preoperative biopsy correlated with rapid progression to distant metastases (p < or = 0.00001) in a multivariate analysis. If the Gleason score was less than 8, the likelihood of distant metastases was only 18% and 41% at 5 and 10 years, respectively, whereas 85% of men with a Gleason score of 8 to 10 had distant metastases by 5 years. For urologists who believe that radical prostatectomy is useful in providing local control in men with positive lymph nodes, frozen section analysis of lymph nodes is probably not necessary in men who are candidates for radical prostatectomy and have preoperative Gleason scores of less than 8. Conversely, in patients with a Gleason score of 8 to 10 on needle biopsy, careful analysis of lymph nodes is necessary to avoid radical prostatectomy in those who will derive little benefit.

Adenocarcinoma↗