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PubMed2005

The combined percentage of Gleason patterns 4 and 5 is the best predictor of cancer progression after radical prostatectomy.

PURPOSE: Clinical outcome is variable in prostate cancer patients treated with radical prostatectomy. The Gleason histologic grade of prostatic adenocarcinoma is one of the strongest predictors of biologic aggressiveness of prostate cancer. We evaluated the significance of the relative proportion of high-grade cancer (Gleason patterns 4 and/or 5) in predicting cancer progression in prostate cancer patients treated with radical prostatectomy. PATIENTS AND METHODS: Radical prostatectomy specimens from 364 consecutive prostate cancer patients were totally embedded and whole mounted. Various clinical and pathologic characteristics were analyzed. All pathologic data, including Gleason grading variables, were collected prospectively. RESULTS: A multiple-factor analysis was performed that included the combined percentage of Gleason patterns 4 and 5, Gleason score, tumor stage, surgical margin status, preoperative prostate-specific antigen (PSA), extraprostatic extension, and total tumor volume. Using Cox regression analysis with bootstrap resampling for predictor selection, we identified the combined percentage of Gleason patterns 4 and 5 (P < .0001) and total tumor volume (P = .009) as significant predictors of PSA recurrence. CONCLUSION: The combined percentage of Gleason patterns 4 and 5 is one of the most powerful predictors of patient outcome, and appears superior to conventional Gleason score in identifying patients at increased risk of disease progression. On the basis of our results, we recommend that the combined percentage of Gleason patterns 4 and 5 be evaluated in radical prostatectomy specimens. The amount of high-grade cancer in a prostatectomy specimen should be taken into account in therapeutic decision making and assessment of patient prognosis.

Adenocarcinoma↗
PubMed2005

Achieving optimal outcomes after radical prostatectomy.

PURPOSE: The most favorable outcome that can be achieved after radical prostatectomy is complete tumor resection without recurrence and full recovery of continence and potency. Risks of erectile dysfunction, incontinence, and disease recurrence are well described, but in isolation, do not adequately inform patients of the possibility of becoming cancer-free while at the same time returning to their preoperative functional state. We sought to determine the frequency of optimal outcomes after radical prostatectomy and the time to such outcomes. PATIENTS AND METHODS: Patients who underwent radical prostatectomy performed at a tertiary referral center between July 1998 and July 2003 for clinical stage T1 to T3 prostate cancer were identified. Patients were excluded if they were incontinent or impotent preoperatively, or if they had received radiotherapy or neoadjuvant androgen deprivation therapy previously. Six hundred forty-seven patients were analyzed for time to recovery of full continence and potency without cancer recurrence after surgery. Optimal outcome probability was calculated with a Markov state transition model to simulate clinical outcomes in the first 4 years following radical prostatectomy. RESULTS: Mean patient age was 58 years, and mean pretreatment prostate-specific antigen was 6.9 ng/mL. Cancer-free status with full continence and potency was achieved in 30% of men at 12 months, 42% at 24 months, 47% at 36 months, and 53% at 48 months postoperatively. CONCLUSION: Optimal outcomes after radical prostatectomy can be achieved in a small majority of cases. Time to full recovery is primarily dictated by recovery of erectile function. This information is helpful for patients interested in their chances of returning to their preoperative functional state.

Adult↗
PubMed2006

Laparoscopic and robotic radical prostatectomy.

Radical retropubic prostatectomy is the current gold standard for surgical removal of the prostate gland. Recently, laparoscopic radical prostatectomy has been developed in an attempt to decrease surgical morbidity, and the technical difficulty of laparoscopy has been countered with the development of the da Vinci robotic interface. Studies that have compared the minimally invasive approaches with the traditional open approach have reported comparable perioperative outcomes. While long-term oncological data are available for open prostatectomy, there are only short-term studies available for laparoscopic prostatectomy. Functional outcomes, including urinary continence and sexual function, appear to be similar between the surgical approaches in the short term. However, currently, costs appear to favor open surgery, with the da Vinci-assisted prostatectomy having the highest expenses. Longer-term data are required to confidently determine the optimal balance between morbidity, oncological efficacy, functional outcomes and cost among the differing surgical approaches.

Erectile Dysfunction↗
PubMedDate not supplied

Management of rectal injury during laparoscopic radical prostatectomy.

PURPOSE: Because laparoscopic radical prostatectomy remains a challenging procedure, rectal injury is always a potential complication. We review the incidence of rectal injuries at our institution in the first 110 consecutive laparoscopic extraperitoneal radical prostatectomies. MATERIALS AND METHODS: Nine (8%) out of the first 110 laparoscopic extraperitoneal radical prostatectomies performed between December 2001 and February 2004, were complicated by rectal injury. Mean patient age was 64.9 years (range 52 to 74) and mean prostate specific antigen was 11.45 ng/mL (range 4.8 to 37.4). Median preoperative Gleason score was 6 (range 4 to 8) and clinical stage was T1c, T2a, T2b in 6, 2 and 1 patient, respectively. Mean operative time was 228 minutes (range 150 to 300). RESULTS: From 9 injuries, 6 were diagnosed and repaired intraoperatively and 3 were diagnosed postoperatively. From the 6 cases of intraoperative diagnosis and repair, 3 patients healed primarily without colostomy and a recto-urinary fistula was evidenced by pneumaturia in the remaining three. These 3 patients were managed conservatively with urethral catheterization during 30 days. One of the patients required secondary fistula repair by anterior transphincteric, transanal surgical approach (ASTRA). Urinary fistula was diagnosed postoperatively on 3 patients. A diverting colostomy was performed on one patient with secondary fistula repair by ASTRA. Another patient required laparotomy due to peritonitis and urinary fistula was later managed with ASTRA. On the third patient conservative management with urethral catheter was successful. All fistulas repaired with ASTRA evolved uneventfully. There was no perioperative mortality. CONCLUSIONS: Rectal injury during laparoscopic radical prostatectomy can be managed intraoperatively or by a minimally invasive procedure without the need of colostomy. Laparoscopic radical prostatectomy is a challenging procedure and is associated with a very flat learning curve; the incidence of rectal injuries is prone to diminish with experience.

Aged↗
PubMed2006

Erectile dysfunction following radical retropubic prostatectomy: epidemiology, pathophysiology and pharmacological management.

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

Administration, Oral↗
PubMed1998

High-power potassium titanyl phosphate laser vaporization prostatectomy.

In a search for potential therapeutic strategies for benign prostatic hyperplasia (BPH) that would be associated with less morbidity than transurethral resection of the prostate, various types of laser prostatectomy have been used. Although the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser allows performance of prostatectomy in an almost bloodless field and without absorption of irrigant, the remaining necrotic tissue causes bladder outlet obstruction and related symptoms for 5 to 7 days after treatment. In contrast, the potassium titanyl phosphate (KTP) laser has been found to vaporize tissue with minimal coagulation of the underlying structures. With use of the KTP laser, heat is concentrated into a small volume, the tissue is ablated by rapid vaporization of cellular water, and a 2-mm rim of coagulated tissue is left. After favorable results were obtained in studies of canine prostates and human cadavers, we implemented clinical use of 60-W KTP laser prostatectomy in selected patients. In 10 patients with symptomatic BPH who ranged in age from 52 to 80 years, outpatient KTP laser prostatectomy yielded significantly increased mean peak urinary flow rates (from 8.0 mL/s preoperatively to 19.4 mL/s within 24 hours after the procedure). No patient had hematuria, dysuria, or incontinence after removal of the catheter, and no patient required recatheterization. One patient, however, had urgency, and two other patients became febrile during the 24-hour observation period. Overall, KTP laser vaporization prostatectomy can provide immediate relief from obstructive symptoms of BPH and is not associated with dysuria.

Animals↗
PubMed1999

Fluorescence in situ hybridization aneuploidy as a predictor of clinical disease recurrence and prostate-specific antigen level 3 years after radical prostatectomy.

OBJECTIVE: To determine if fluorescence in situ hybridization (FISH) analysis of fresh-tissue biopsy specimens obtained at the time of radical prostatectomy is able to predict prospectively clinical disease progression or prostate-specific antigen (PSA) level in patients 3 to 4 years after surgery. MATERIALS AND METHODS: FISH analysis was performed on fresh-tissue touch preparations obtained from 90 randomly selected radical prostatectomy specimens. Cut surface touch preparations from 40 specimens resected in 1992 were analyzed with DNA probes for chromosomes 4, 6-12, 17, 18, X, and Y. Needle-biopsy specimens were obtained from 50 tumors resected in 1993, and touch preparations from these specimens were studied with DNA probes for chromosomes 7, 8, 11, and 12. Serum PSA levels and clinicopathologic data were recorded, and each patient was followed up from the time of surgery to determine cancer progression. RESULTS: Of 90 patients undergoing radical prostatectomy in 1992 and 1993, 89 returned for follow-up. Three patients received preoperative hormonal therapy, and in 2 patients, antiandrogen therapy was continued postoperatively. Fifteen patients underwent intraoperative orchiectomy immediately after radical prostatectomy, while 9 patients had postoperative adjuvant hormonal therapy. Six patients underwent postoperative radiation therapy. Fourteen patients (15.7%) demonstrated systemic, local, or PSA progression. Only 2 (4.7%) of 43 patients with FISH diploid tumors demonstrated cancer progression. Conversely, 10 (30.3%) of 33 FISH aneuploid and 12 (26.1%) of 46 FISH nondiploid tumors demonstrated cancer progression (P=.004 and P=.006, respectively). Unlike FISH, flow cytometric aneuploidy was not associated with early cancer progression. Elevated preoperative PSA concentration, increased preoperative and postoperative Gleason score, and increased preoperative and postoperative T or N stage were not statistically significantly associated with cancer progression. While chromosome 7 and 8 aneusomies were not statistically associated with cancer progression, 2 of 5 (P=.04) chromosome 12 aneusomic tumors demonstrated cancer progression. CONCLUSION: Early (within 4 years) local, systemic, or PSA progression occurred more frequently (P<.05) in radical prostatectomy patients with FISH aneuploid, nondiploid, and chromosome 12 aneusomic tumors. Flow cytometric ploidy status, preoperative serum PSA concentration, and clinical or pathologic grade or stage, including seminal vesicle involvement, margin status, and capsular perforation status, were not associated with early prostate cancer progression in this group of 89 patients. FISH analysis appears to be a useful preoperative tool for predicting aggressive vs indolent prostate cancer.

Aged↗
PubMed2002

Suprapubic transvesical prostatectomy in a rural Kenyan hospital.

OBJECTIVE: To evaluate the effectiveness, safety and complications of suprapubic transvesical prostatectomy in a rural Kenyan hospital. DESIGN: A prospective audit of suprapubic transvesical prostatectomy. SETTING: Africa Inland Church, Kijabe Hospital, Kijabe, Kenya. SUBJECTS: One hundred and six men with lower urinary tract obstruction, clinically due to benign prostatic hyperplasia, undergoing suprapubic transvesical prostatectomy. INTERVENTIONS: Suprapubic prostatectomy. MAIN OUTCOME MEASURES: Age, presentation, comorbidity, type of anaesthesia, pathology, bladder irrigation time, Foley time, post-operative stay, complications-mortality, blood transfusion rate, return to theatre for bleeding, incontinence, urine leak, urinary retention. RESULTS: One hundred and six men entered the study with a mean age of 72.8 years. Seventy eight per cent were in retention and 25% had significant medical problems. Spinal anaesthesia was used in 94%. The mean prostate weight was 70.4 g and 11% had carcinoma. The Foley's catheter was removed at a mean of 4.2 days after surgery and the mean post-operative stay was 6.0 days. The 30 day mortality was 0.9%, the blood transfusion rate was 4.7%, the return to theatre for bleeding rate was 0.9% and 4.7% of patients developed a urine leak. CONCLUSION: Suprapubic transvesical prostatectomy, performed under spinal anaesthetic, by general surgeons in rural Kenya, is a safe and effective way of managing benign prostatic hyperplasia and its complications.

Aged↗
PubMedDate not supplied

[Local recurrence after radical prostatectomy and salvage radiotherapy].

OBJECTIVE: To evaluate the efficacy of radiotherapy to the prostatic bed in patients with biochemical recurrence prostate cancer after radical prostatectomy. METHODS: We analyse the outcomes of 292 patients who underwent radical prostatectomy for localized prostate cancer T1-T2 between January 1992 and June 2003, with an average follow-up of 36 months (range 6 months to 12 years). We detected biochemical recurrence (PSA > 0.20 ng/ml) in 75 (26%) patients. 75 patients with biochemical recurrence, 9 (12%) were diagnosed of local recurrence by the following criteria: a) First PSA obtained 6 weeks after radical prostatectomy < 0.20 ng/ml. b) Time to biochemical recurrence > 6 months. c) Prostate specific antigen doubling time > 6 months. d) Prostate specific antigen velocity after radical prostatectomy < 0.75 ng/ml/year. e) Prostate specific antigen level after radical prostatectomy < 2.5 ng/ml. The 9 patients diagnosed of local recurrence received an average dose of 56.42 Gy to the prostate bed. RESULTS: Of all 9 patients with local recurrence, 8(88.8%) have complete response with a mean follow-up of 30 months (12-36 months). The time between the radiotherapy and the response, in patients with complete response, was lower than 3 months in 7 patients and 12 months in 1 patient. Significant adverse effects associated to radiotherapy were not observed. CONCLUSIONS: Salvage radiotherapy may be beneficial in selected patients with local recurrence. The characteristics of prostate specific antigen elevation are useful in distinguishing men with local recurrence from those with distant metastases.

Follow-Up Studies↗
PubMed1998

Health-related quality of life in Australian men remaining disease-free after radical prostatectomy.

OBJECTIVE: To determine the health-related quality of life (HRQOL) of Australian men after radical prostatectomy. DESIGN: Cross-sectional study. SETTING: Private and public practices of three urologists in south-east Queensland, July 1989 to June 1995. PARTICIPANTS: 140 men with no evidence of disease recurrence 1 to 6 years after radical prostatectomy. MAIN OUTCOME MEASURES: Voiding and erectile potency and HRQOL. Recall of preoperative status and status at survey were established by an independently administered multi-item questionnaire. RESULTS: 112 men (80%) completed the study questionnaire. Difficulty with bladder control before the operation was reported by 25 (22%; 95% confidence interval [CI], 15%-31.2%), and the incontinence rate after treatment was 22/112 (20%; 95% CI, 12.7%-28.2%). Men with incontinence after operation were more likely to recall preoperative urinary symptoms. Eighty-four (75%) men were happy or coping with their sexual function after radical prostatectomy despite an erectile potency rate of only 12% (95% CI, 7%-20%). Twenty-eight (25%) had tried penile injections and three have had penile prostheses since their operation. Impotence was reported more frequently (40%) as the treatment-related problem most affecting life, followed by "concern about cancer" (12%) and incontinence (8%). Impotence was also the most common cause given for diminished HRQOL. CONCLUSIONS: Loss of sexual function after radical prostatectomy is more commonly perceived as a major problem and is more likely than urinary incontinence to adversely affect HRQOL. Loss of sexual function and its effect on HRQOL needs to be given greater emphasis in counselling before radical prostatectomy.

Cross-Sectional Studies↗
PubMed2006

Key issues in handling and reporting radical prostatectomy specimens.

CONTEXT: Patients with prostatic adenocarcinoma commonly undergo radical prostatectomy, and it is often difficult and time consuming to handle the resulting specimens and to report the findings. Pathologic information derived from the radical prostatectomy specimen is used for selecting adjuvant therapy, such as radiotherapy and hormone therapy, and for determining a patient's prognosis. The prostate specimen must be handled in a systematic fashion to derive the appropriate prognostic parameters. OBJECTIVE: To review the prognostic factors of relevance in classifying radical prostatectomy specimens, using the College of American Pathologists categorization system, including a detailed survey of the morphologic-based factors but excluding other factors such as DNA ploidy and novel phenotypic and genotypic markers. CONCLUSIONS: Gleason score, pathologic stage, and margin status are considered category 1 prognostic factors, which are of proven prognostic significance and are useful in patient management. Factors such as tumor volume (intraglandular extent) and tumor subtype are considered category 2 prognostic factors, which show significant promise but require validation in multivariate analysis. Lymphovascular space invasion is a promising category 3 prognostic factor that needs additional study. Perineural invasion is an almost ubiquitous finding in radical prostatectomy specimens and is considered a category 3 prognostic factor. After prognostic factors have been analyzed at the histologic level, it is critical to report the findings in a clear and unambiguous fashion. The synoptic style of reporting is ideal for describing complex cancer resection specimens. A synoptic report based on an evidence-based checklist, such as the one developed by the College of American Pathologists, effectively communicates complex cancer-related data, such as radical prostatectomy specimen findings. This information is used not only for individual case management with respect to treatment and prognostication but also for purposes such as education, research, quality monitoring, and system planning.

Adenocarcinoma↗
PubMed1999

Charge and length of hospital stay analysis of radical retropubic prostatectomy and transperineal prostate brachytherapy.

PURPOSE: For the treatment of clinically localized prostate cancer radical retropubic prostatectomy with its attendant hospital stay should be associated with higher charges than transperineal prostate brachytherapy. We report a comparative case series to determine patient charges and length of hospitalization of 2 modalities of monotherapy for localized prostate cancer. MATERIALS AND METHODS: A total of 35 consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy (16) or transperineal prostate brachytherapy (19) at the Arthur James Cancer Hospital and Research Institute. Complete charge and length of hospital stay data were collected for each patient. Total charges were calculated and the 2 modalities were compared. RESULTS: Charge data were available in 33 cases. Average total charges in the prostatectomy and brachytherapy groups were $15,097 and $21,025, respectively ($5,928 difference, p <0.0001). The difference increased further when outliers were excluded from study. Average length of hospital stay and average charge in the prostatectomy group were 3.8 days and $1,897. The higher charges for transperineal prostatic brachytherapy were due to dosimetry calculations, radioactive seeds and seed implantation. CONCLUSIONS: At our institution the average total charges for transperineal prostate brachytherapy are significantly higher than those for radical retropubic prostatectomy.

Brachytherapy↗
PubMed1999

Molecular determination of surgical margins using fossa biopsies at radical prostatectomy.

PURPOSE: Status of the surgical margins after radical prostatectomy is a key factor for predicting postoperative outcome. Current methods used to determine margin status are tedious, costly and vary among institutions. Sensitive and inexpensive detection of prostate cells in the circulation of patients with prostate cancer has been achieved using reverse transcriptase (RT) polymerase chain reaction (PCR) for prostate specific antigen and prostate specific membrane antigen. Therefore, we designed and tested a novel and objective molecular assay for assessing surgical margins at radical prostatectomy based on the detection of prostate specific markers using RT-PCR. We also compared this assay to standard pathological examination. MATERIALS AND METHODS: A total of 30 consecutive patients with local prostate cancer underwent radical prostatectomy. At the completion of gland excision 5 biopsies of the prostatic fossa were obtained for histopathological and molecular analysis. We performed RT-PCR analysis for prostate specific antigen and prostate specific membrane antigen messenger ribonucleic acid in these biopsy specimens, and compared the results with pathological stage. Men free of prostate cancer who underwent radical cystoprostatectomy for bladder cancer or abdominoperineal resection for rectal cancer served as controls. RESULTS: There were positive molecular margins in all patients with positive margins and/or extracapsular extension. No controls had a positive molecular assay. In 4 of 16 patients (25%) histopathological evaluation revealed organ confined disease but biopsies were positive by the molecular assay, including those in 2 (50%) who had been treated with neoadjuvant hormonal therapy before surgery because of a higher estimated risk of extracapsular disease. Results in 4 cases were uninformative. CONCLUSIONS: Our results with an objective molecular assay aimed at assessing surgical margins after radical prostatectomy reveal an excellent correlation with conventional pathological analysis. In addition, molecular assessment of the prostatic fossa identifies patients in whom extracapsular disease may have been unidentified by conventional pathological examination. In addition, this assay yields clues to why neoadjuvant hormonal treatment before radical prostatectomy does not seem to decrease the biochemical failure rate in these patients. Larger studies with longer followup are required to determine the prognostic significance of these positive molecular margins.

Adenocarcinoma↗
PubMed2000

Disease recurrence in black and white men undergoing radical prostatectomy for clinical stage T1-T2 prostate cancer.

PURPOSE: The reported incidence and mortality of prostate cancer are higher among black than white men. Reasons for the disproportionate racial incidence of this disease are not known but most surveys suggest that increased mortality among black men is due to more advanced tumor stage at diagnosis. To determine if racial differences exist in men with similar stage disease we compared disease recurrence in black and white men who underwent radical prostatectomy for clinical stage T1-T2 prostate cancer. MATERIALS AND METHODS: We reviewed the records of all 257 white and 218 black men undergoing radical prostatectomy for clinical stage T1-T2 prostate cancer at the Louisiana State University Medical Center-Shreveport and the Overton-Brooks Veterans Affairs Medical Center between January 1990 and November 1998. Age, race, serum prostate specific antigen (PSA), ultrasound measured prostate volume, PSA density (PSA divided by prostate volume), histological features of the prostate biopsy, clinical stage, pathological stage, histological features of the radical prostatectomy specimen and disease recurrence were reviewed. RESULTS: Black men had significantly higher mean serum PSA and PSA density than white men (2-sided p = 0.005 and 0.03, respectively). There were no statistically significant differences by race in terms of patient age, prostate volume, clinical stage, biopsy Gleason score, pathological stage, positive pelvic lymph nodes, positive surgical margins or PSA recurrence rates. CONCLUSIONS: Black men with clinical stage T1-T2 prostate cancer who underwent radical prostatectomy had significantly higher serum PSA and PSA density than similarly treated white men. However, race appears to have no independent impact on pathological findings or disease recurrence in men with clinically localized prostate cancer treated with radical prostatectomy when the effects of differences in serum PSA are controlled.

Black or African American↗
PubMedDate not supplied

Trends in the use of radical prostatectomy for treatment of prostate cancer.

CONTEXT: The incidence of prostate cancer and rates of radical prostatectomy increased sharply in the Medicare population (men older than 65 years of age) after the introduction of prostate-specific antigen screening in the late 1980s. PRACTICE PATTERN EXAMINED: Trends in age-specific rates of use of radical prostatectomy in U.S. men between 1989 and 1995. DATA SOURCE: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: Overall, rates of radical prostatectomy more than doubled between 1989 and 1992 (from 78 per 100,000 men to 206 per 100,000 men) but decreased by a third between 1992 and 1995 (to 146 per 100,000 men). The pattern in overall radical prostatectomy rates between 1992 and 1995, however, obscures changes that occurred for men in different age groups. Decreases in radical prostatectomy rates were most dramatic in elderly persons, dropping 51% in men 70 to 74 years of age and 71% in men 75 years of age or older. In contrast, rates in younger men continued to increase between 1992 and 1995, rising 42% in men 45 to 49 years of age and 18% in men 50 to 54 years of age. In each age group, trends in surgery rates mirrored trends in cancer detection rates. CONCLUSIONS: Surgical treatment of prostate cancer in older men is decreasing; however, surgery rates are increasing in younger men. These divergent trends reflect the pattern of prostate cancer detection in clinical practice.

Aged↗
PubMed1999

[Development of a clinical pathway for radical prostatectomy].

OBJECTIVE: To describe the clinical care path for retropubic radical prostatectomy of the La Paz teaching hospital and the results achieved after the first 6 months. METHODS: We have developed a clinical care path for radical prostatectomy with a hospital stay of 6 days. Thirty-one patients submitted to retropubic radical prostatectomy from June to November 1998 were included in the program. The mean length of total, preoperative and postoperative stay were analyzed and compared with those of 31 patients who had undergone radical prostatectomy before the program was developed. Readmissions, adverse effects and patient satisfaction were also analyzed. RESULTS: Of the 31 patients included in the clinical care path, 22 (71%) had a stay equal to or less than the program's length of stay. The mean total, pre and postoperative stay for the group of patients included in the clinical care path were 6.0 days (SD = 1.1), 1 day (SD = 0.0) and 4.9 days (SD = 1.1), respectively. The length of stay was significantly longer before the program was developed [mean total 10.2 days (SD = 4.9), mean preoperative 2.6 days (SD = 2.6) and mean postoperative 7.6 days (SD = 3.6)] (p < 0.001). Twenty-four patients (77.4%) completed the questionnaire on patient satisfaction, which was highly positive, the overall patient satisfaction rate being higher than the 90% standard. There were no readmissions or significant events ascribable to the program. CONCLUSIONS: In our experience, the clinical care path for radical prostatectomy is a useful tool to reduce the unwanted variability. Its design is based on the best possible evidence, therefore the scientific and technical quality, patient satisfaction and efficiency are enhanced. In our view, our results are attainable and feasible in any health care setting.

Critical Pathways↗
PubMed2000

Minilaparotomy radical retropubic prostatectomy: updated technique and results.

The purpose of this article is to reduce the incisional morbidity associated with standard radical retropubic prostatectomy using the minilaparotomy incision developed for pelvic lymph-node dissection, which was applied to radical retropubic prostatectomy. More than 522 patients underwent minilaparotomy radical retropubic prostatectomy from 1991 to 1997. Preoperative evaluation included history, physical examination, prostate-specific antigen (PSA), and Gleason's grade. Postoperative follow-up included serial PSA measurements and a determination of continence. The surgical technique is described in detail. Two hundred sixty-five patients responded to the mailed questionnaire out of a total 522 patients. Satisfactory continence, defined as 0 to 1 pad per day, was achieved in 85% of patients, and 83% of patients had a PSA < 0.2 at an average follow-up of 2.6 years. There was no operative mortality, and overall complication rate was similar to other surgeons. The typical patient was discharged home 3 days postoperatively. Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.

Humans↗
PubMed2000

Puboprostatic ligament sparing radical retropubic prostatectomy.

Prostate cancer is the most common solid malignancy and the second most common cause of cancer death in man. Radical prostatectomy is the therapeutic modality that currently provides the best long-term biochemical relapse-free survival rate. Yet many patients select alternative forms of therapy or no therapy at all because of fears that treatment will significantly alter quality of life. Urinary incontinence following radical prostatectomy has a significant deleterious effect on quality of life and, unfortunately, is much more prevalent following surgery compared with other treatment modalities, such as radiation therapy. Many efforts have been undertaken to avoid this complication with only modest success achieved. These include creation of a neobladder neck, bladder neck preservation, periurethral injection of bulking agents, and anterior urethropexy. A technique for radical retropubic prostatectomy that spares the puboprostatic ligaments, which preserves the normal anterior support of the urethra, is described herein. The outcome following this procedure demonstrates more rapid return of full urinary continence following radical prostatectomy in a controlled study. However, the "Holy Grail" of complete eradication of urinary incontinence following radical prostatectomy has not been achieved.

Humans↗