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PubMed2004

Comparison of transperitoneal and extraperitoneal laparoscopic radical prostatectomy using match-pair analysis.

PURPOSE: Based on the experience of 1000 cases of laparoscopic radical prostatectomy, we compared the operative parameters of transperitoneal and extraperitoneal approaches in match-paired patient groups. PATIENTS AND METHODS: We reviewed the charts of 53 consecutive patients who underwent selectively extraperitoneal laparoscopic radical prostatectomy comparing it to 53 match-paired patients treated by transperitoneal laparoscopic radical prostatectomy. The patients were matched for age, PSA (ng/ml), prostate volume (g), pathologic stage, Gleason score, presence of pelvic lymph node dissection and type of nerve-sparing technique. Perioperative parameters (operating time, blood donation, complications) and postoperative results (duration and amount of analgesic treatment, catheterization time) as well as oncological (surgical margin status) and functional (continence rate) results were analyzed. RESULTS: Patients were 62.9 +/- 5.5 versus 62.9 +/- 5.4 years old, had 27.5 +/- 3.5 kg/m2 versus 26.7 +/- 2.8 kg/m2 body mass indices in the extraperitoneal and transperitoneal groups, respectively. Preoperative mean PSA and prostate volume were 7.4 +/- 4.6 ng/ml and 41.8 +/- 16.3 g in the extraperitoneal, 7.6 +/- 3.8 ng/ml and 42.0 +/- 14.8 g in the transperitoneal group. Pathologic stages were T2a in 12 vs. 13, T2b in 21 vs. 20, T2c in 7 vs. 8, T3a in 11 vs. 10 and T3b in 2 vs. 2 patients for both groups. Overall 211.8 vs. 197.1 minutes mean operative time (p = 0.328) and 21.9 +/- 15.4 mg vs. 26.3 +/- 15.8 mg narcotic analgesic requirements (p = 0.111) did not differ significantly in both groups. However, mean operating time was significantly longer in the extraperitoneal group when performing pelvic lymphadenectomy (244.5 vs. 209.6 minutes, p = 0.017). There was no statistical difference of complication rate (4% vs. 2%) and median catheter time (7 vs. 7 days), positive surgical margins (22.6% vs. 20.7%) and 12 months continence (86.7% vs. 84.9%). CONCLUSIONS: There was no significant difference between the extraperitoneal and transperitoneal approaches using the Heilbronn technique regarding all important parameters. In addition to the preference and experience of the individual surgeon, previous abdominal surgery, gross obesity and requirement of simultaneous inguinal hernia repair may be considered as selective indications for extraperitoneal laparoscopic radical prostatectomy.

Aged↗
PubMed2006

Laparoscopic radical prostatectomy: a critical analysis of surgical quality.

OBJECTIVE: To review the literature and answer the question of whether the laparoscopic approach meets the quality standards. METHODS: We conducted an extensive Medline literature search. The articles obtained and the experience at Memorial Sloan-Kettering Cancer Center were used for interpretation and critical analysis of results. Long-term quality indicators are oncologic efficacy, potency rate, and continence rate. Short-term quality indicators are blood loss and transfusion rate, hospital stay, postoperative recovery, and rate and severity of complications. RESULTS: Long-term quality indicators. Oncologic efficacy. Despite recent evidence that pelvic lymph node dissection (PLND) at radical prostatectomy may be necessary to detect occult positive lymph nodes, and that extended node dissection may also have a positive impact on disease-free survival, PLND is rarely performed during laparoscopic radical prostatectomy (LRP), which may have a negative impact on the long-term recurrence-free probability. Positive margins rates range from 11% to 26%, ranging from 6% to 8% for organ-confined disease and from 35% to 60% in those with extraprostatic extension. Most of these data include the first patients operated on when the technique of LRP was in early development. These rates seem high as compared to the contemporary data achieved in retropubic radical prostatectomy. Short-term biochemical recurrence rate have been published by only two centers and generalization to the whole laparoscopic patients and to long-term results are at present time hazardous. Functional outcome. Given the complexity of measuring, interpreting, and reporting continence and erectile dysfunction, the available results after LRP do not allow drawing any conclusion. Furthermore, the number of patients on whom results are reported is disproportionately low in relation to the large LRP experience accumulated so far. Short-term quality indicators. Assessment of LRP equanimity includes factors such as blood loss, transfusion rates, hospital stay, duration of catheterization, and complication profile. All the reports are concordant and demonstrate a benefit for the laparoscopic approach. However, no prospective and parallel studies compare the respective advantages of LRP and radical retropubic prostatectomy in reference centers. CONCLUSIONS: In a review of the published literature results of LRP, there is not enough evidence to answer the question of whether the laparoscopic approach meets the quality standards. The available biochemical recurrence information is promising but limited to the short-term and the experience of two centers only. The question of omitting the PLND or performing a limited one in high-risk patients needs to be answered. The functional results analyses suffer from a lack of uniformity in methodology, a limited follow-up, and a disproportionately small number of patients in relation to the accumulated experience. Future reports of the post-learning phase era are dramatically needed.

Humans↗
PubMed2006

Intra- and peri-operative outcomes comparing radical retropubic and laparoscopic radical prostatectomy: results from a prospective, randomised, single-surgeon study.

OBJECTIVES: To prospectively compare intra- and peri-operative outcomes of open radical retropubic prostatectomy (RRP) and laparoscopic prostatectomy (LRP) by a single surgeon. PATIENTS AND METHODS: One-hundred-twenty, consecutive, age-matched patients diagnosed with clinically localized prostate cancer were eligible for surgery. Sixty patients underwent RRP and 60, LRP. Intra- and peri-operative parameters, pathologic findings and early complications were recorded. A validated visual analogue scale was used to assess pain in the recovery room, 3 h after the operation and on post-operative days 1, 2 and 3. A cystogram was performed on post-operative day 5. RESULTS: Operating time was significantly shorter in the RRP group versus the LRP group (mean+/-SD, 170+/-34. 2 vs 235+/-49.9 min, p<0.001). Blood loss was significantly less in the LRP group versus the RRP group (mean+/-SD, 853.3+/-485 vs 257.3+/-177 ml, p<0.001), but no patient in either group underwent early re-intervention for bleeding. The RRP group showed a trend for higher use of analgesia. A watertight anastomosis was shown at cystourethrography and the catheter removed in 86% and 66% of LRP and RRP patients, respectively. The overall percentage of post-operative complications and positive margins were comparable. CONCLUSION: Laparoscopic prostatectomy is an attractive alternative to open prostatectomy, offering the advantages of reduced blood loss and safe early catheter removal. Furthermore, the laparoscopic procedure proved to be safe oncologically. Long-term follow-up is required to compare functional results in terms of continence and potency.

Aged↗
PubMed2006

Is radical prostatectomy feasible in all cases of locally advanced non-bone metastatic prostate cancer? Results of a single-institution study.

OBJECTIVES: Previous prospective studies of the surgical treatment of locally advanced prostate cancer have enrolled patients selected on the basis of a limited T3 disease extension. The aim of the present study was to assess the feasibility and the oncologic outcome of radical prostatectomy administered to a consecutive unselected series of advanced, non-bone metastatic prostate cancers. METHODS: Between March 1998 and February 2003 radical prostatectomy was offered at our institution to any patient diagnosed with prostate cancer with no sign of extranodal metastatic disease. Data on morbidity and survival for 51 clinically advanced cases (any T>/=3, N0-N1, or any N1 or M1a disease according to the TNM 2002 classification system) operated on by a single expert surgeon were compared with a series of 152 radical prostatectomies performed during the same period by the same operator for clinically organ-confined disease. Adjuvant treatment was administered according to current guidelines. RESULTS: The two groups did not differ significantly in surgical morbidity except for blood transfusion, operative time, and lymphoceles, which showed a higher rate in patients with advanced disease. The Kaplan-Meier estimate of overall survival and prostate cancer-specific survival at 7 yr were 76.69% and 90.2% in the advanced disease group and 88.4% and 99.3% in the organ-confined disease group, respectively. CONCLUSIONS: Even in the scenario of extensive surgical indications up to M1a disease, radical prostatectomy proved to be technically feasible and to have an acceptable morbidity rate compared with organ-confined disease. Our initial survival data strengthen the role for surgery as an essential part in the multimodal approach to treating advanced prostate cancer.

Aged↗
PubMed2006

The anatomic radical perineal prostatectomy: an outcomes-based evolution.

OBJECTIVE: Radical prostatectomy is the most effective treatment for localized prostate cancer. With increasing use of minimally invasive treatment methods, clinical outcomes are becoming important assessment tools to compare one option to another. Perineal prostatectomy is modified to incorporate contemporary surgical ideas, including preservation of cavernosal nerve bundles, sphincteric urethra at the prostatic apex, and the bladder neck. METHODS: Objective parameters and physician-reported clinical outcomes are collected prospectively on 704 consecutive patients undergoing radical perineal prostatectomy (RPP) by one surgeon. The technique described herein is the current state of evolution of RPP. The enclosed digital video is edited from two recent nerve-sparing RPPs. RESULTS: Freedom from prostate-specific antigen (PSA) detectability by stage is 94.5%, 80.0%, and 81.5% for organ-confined, specimen-confined, and margin-positive disease with actual 5-yr follow-up. Margins are positive in 18% of cases. By 1, 3, 6 mo and 1 yr, 52%, 71%, 85%, and 94% of the men are free from using pads. Although >97% of nerve-spared patients have spontaneous erections, >80% can penetrate to complete intercourse. CONCLUSIONS: This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function in the majority of men presenting with clinically localized prostate cancer. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic RPP is a cost-efficient, outcome-effective minimally invasive method of treating men with localized prostate cancer.

Erectile Dysfunction↗
PubMed2004

Radiotherapy after radical prostatectomy: does transient androgen suppression improve outcomes?

PURPOSE: The long-term biochemical relapse-free survival and overall survival were compared for patients receiving either radiotherapy (RT) alone or radiotherapy combined with a short-course of total androgen suppression for failure after radical prostatectomy. METHODS AND MATERIALS: Between 1985 and 2001, a total of 122 patients received RT after radical prostatectomy at our institution. Fifty-three of these patients received a short-course of total androgen suppression (TAS) 2 months before and 2 months concurrent with RT with a nonsteroidal antiandrogen and an luteinizing hormone-releasing hormone (LHRH) agonist (combined therapy group); the remaining 69 patients received RT alone. Treatment failure was defined after postoperative RT as a detectable PSA >0.05 ng/mL. Clinical and treatment variables examined included: presurgical PSA, clinical T stage, pathologic Gleason sum (pGS), seminal vesicle (SV) involvement, lymph node involvement, surgical margins, pre-RT PSA, prostate dose, pelvic irradiation, indication for postoperative RT (salvage or adjuvant), and time interval between surgery and RT. Minimum follow-up after postoperative RT was 1 year and median follow-up was 5.9 years (maximum, 14 years) for patients receiving RT alone, and 3.9 years (maximum, 11 years) for patients receiving RT with TAS (combined therapy group). Kaplan-Meier analysis was performed for PSA failure-free survival (bNED) and for overall survival (OS). Cox proportional hazards multivariable analysis examined the influence all clinical and treatment variables predicting for bNED and OS. RESULTS: The median time to PSA failure after postoperative RT was 1.34 years for the combined therapy group and 0.97 years for the RT alone group (p = 0.19), with no failures beyond 5 years. At 5 years, the actuarial bNED rates were 57% for the combined therapy group compared with 31% for the RT alone group (p = 0.0012). Overall survival rates at 5 years were 100% for the combined therapy group compared with 87% for the RT alone group (p = 0.0008). For pGS or=8 the 5-year bNED rates were 65% for combined therapy and 17% for RT alone (p = 0.075). The 5-year OS rates for pGS or=8 was 100% for combined therapy and 54% for RT alone (p = 0.04). On multivariable analysis, only SV involvement (p = 0.0145) and the addition of short-course TAS to postoperative RT (p = 0.0019) were significant covariates predicting for bNED and, similarly, approached significance for overall survival (p = 0.0594 and p = 0.0856, respectively). CONCLUSIONS: Radiotherapy combined with a short-course TAS after radical prostatectomy appears to confer a PSA relapse-free survival advantage and possibly an overall survival advantage when compared with RT alone. The hypothesis that a transient course of androgen suppression with salvage or adjuvant RT after prostatectomy improves outcomes will need to be tested in a randomized trial.

Androgen Antagonists↗
PubMed2006

Long-term outcome following radical prostatectomy in men with clinical stage T3 prostate cancer.

PURPOSE: We evaluated patients at our institution who underwent radical prostatectomy for clinical stage T3 prostate cancer to determine their long-term clinical outcomes. MATERIALS AND METHODS: We reviewed our prospective surgical database and identified 176 men who underwent radical retropubic prostatectomy for clinical stage T3 prostate cancer from 1983 to 2003. Clinical and pathological data were reviewed and evaluated in a Cox proportional hazards model to determine preoperative predictors of biochemical recurrence. Clinical progression following biochemical recurrence was evaluated and clinical failure was defined as the development of clinical metastases or progression to hormone refractory prostate cancer. RESULTS: Of the 176 patients with cT3 prostate cancer 64 (36%) received neoadjuvant hormonal therapy. At a mean followup of 6.4 years 84 (48%) patients had disease recurrence with a median time to biochemical recurrence of 4.6 years. The actuarial 10-year probability of freedom from recurrence was 44%. On multivariate analysis biopsy Gleason score, pretreatment serum prostate specific antigen and year of surgery were independent predictors of biochemical recurrence. Neoadjuvant hormonal therapy was not a significant predictor of biochemical recurrence. Following biochemical recurrence clinical failure developed in 30 of 84 (36%) men with a median time of 11 years. Overall the 5, 10 and 15-year probabilities of death from prostate cancer were 6%, 15% and 24%, respectively. CONCLUSIONS: More than half (52%) of our patients remained free of disease recurrence following radical prostatectomy. In our series neoadjuvant hormonal therapy offered no advantage with respect to disease recurrence. Radical prostatectomy remains an integral component in the treatment of select patients with clinical stage T3 prostate cancer.

Follow-Up Studies↗
PubMed2006

25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series.

PURPOSE: We report on 25-year cancer control and survival outcomes after radical prostatectomy in a single center series of patients treated during a 40-year period. MATERIALS AND METHODS: Between 1954 and 1994, 787 consecutive patients underwent radical prostatectomy at Virginia Mason Medical Center in Seattle, Washington. Kaplan-Meier 25-year probabilities of prostate cancer specific, overall, prostate specific antigen progression-free, local and distant progression-free survival were determined. Multivariate Cox regression models addressed prostate cancer specific mortality. RESULTS: Prostate cancer specific survival, overall survival, prostate specific antigen progression-free survival, local and distant progression-free survival ranged from 99.0% to 81.5%, 93.5% to 19.3%, 84.8% to 54.5%, 95.3% to 87.8% and 95.9% to 78.2%, respectively. In univariate analyses pathological stage, surgical margin status, pathological Gleason sum, delivery of hormonal therapy and radiotherapy represented statistically significant predictors of prostate cancer specific mortality (all p < or =0.001). In multivariate analyses only Gleason sum (p = 0.03) and delivery of hormonal therapy (p < 0.001) remained significant. CONCLUSIONS: This is one of the most mature radical prostatectomy series. It demonstrates that long-term biochemical cancer control outcomes after radical prostatectomy might be suboptimal. However, local and distant control outcomes are excellent, and cancer specific mortality is minimal even 25 years after surgery.

Adult↗
PubMed2006

Time to prostate specific antigen recurrence after radical prostatectomy and risk of prostate cancer specific mortality.

PURPOSE: In patients treated with radical prostatectomy who have biochemical recurrence we have previously reported that time from surgery to biochemical recurrence and postoperative prostate specific antigen doubling time are significantly related to the risk of prostate cancer death. We performed a more thorough examination of the association of time from surgery to biochemical recurrence and the risk of prostate cancer death. MATERIALS AND METHODS: We retrospectively studied the records of 379 patients treated with radical prostatectomy between 1982 and 2000 who had had biochemical recurrence. We examined the association of time from surgery to prostate specific antigen recurrence and prostate specific antigen doubling time, and the risk of prostate cancer death using the Spearman correlation and Cox proportional hazards regression, respectively. RESULTS: Longer time from surgery to prostate specific antigen recurrence was associated with a slower prostate specific antigen doubling time (Spearman r = 0.36, p < 0.001) and a decreased risk of prostate cancer death (RR 0.76, 95% CI 0.66 to 0.88, p < 0.001). The 15-year actuarial prostate cancer specific survival rate after biochemical recurrence in patients with recurrence at 3 years or less was 41% (95% CI 29 to 53) compared to 87% (95% CI 75 to 93) in patients with recurrence more than 3 years after radical prostatectomy. On multivariate analysis a shorter time from surgery to prostate specific antigen recurrence was associated with an increased risk of prostate cancer death (3 or less vs more than 3 years, RR 2.70, 95% CI 1.37 to 5.31, p = 0.004). CONCLUSIONS: Earlier prostate specific antigen recurrence is associated with an increased risk of prostate cancer death. These data suggest that perhaps time to prostate specific antigen recurrence may be a reasonable intermediate end point in patients treated with radical prostatectomy, although this must be validated in other studies.

Aged↗
PubMed2006

Age difference between patient and partner is a predictive factor of potency rate following radical prostatectomy.

PURPOSE: We evaluated the influence of partner age on postoperative erectile function in patients who underwent bilateral nerve sparing radical prostatectomy for localized prostate cancer. MATERIALS AND METHODS: The study group was a cohort of 240 consecutive patients treated with radical prostatectomy with a minimum 1-year followup. None had received adjuvant therapy. Evaluation was done by questionnaires mailed to a third party. Potency was defined by erection sufficient for sexual intercourse with vaginal penetration. A total of 200 patients were evaluable. RESULTS: The postoperative potency rate in 189 preoperatively sexually active patients was 59%. On univariate analysis patient age and the age difference between patient and partner were significantly associated with the potency rate following surgery, that is 60.8 and 6.8 years in the preserved potency group and 63.3 and 4.2 years in the impotent group (p <0.001 and p = 0.02, respectively). On multivariate analysis age difference was a predictive factor of postoperative potency independent of patient age (p = 0.008). Age difference was also an independent predictor of potency with and without aid (p = 0.037 and 0.002, respectively). CONCLUSIONS: To our knowledge this is the first study to identify the influence of age difference between patient and partner on potency preservation following radical prostatectomy. Age difference was a significant predictive factor of maintaining postoperative potency independent of patient age. We suggest that partner age difference should be reported in radical prostatectomy outcomes series because it influences postoperative potency rates. It is a new prognostic factor that might help counseling patients preoperatively.

Adult↗
PubMed2004

Cost comparison of radical retropubic and radical perineal prostatectomy: single institution experience.

OBJECTIVES: To perform a detailed comparison of the in-house hospital costs of patients undergoing radical perineal prostatectomy (RPP) and radical retropubic prostatectomy (RRP) performed with or without bilateral staging lymph node dissection (BPLND) for localized prostate cancer. METHODS: A retrospective cost review was done of a cohort of 402 consecutive radical prostatectomies performed at our institution during a 21-month period. The procedure was performed as RPP in 279 (69.4%) and RRP in 123 (30.6%) patients, of whom 10.4% and 61.8%, respectively, underwent BPLND under the same anesthesia. The hospital costs were evaluated for each patient using the categories of surgical, nursing, laboratory/transfusion, and pharmacy. Surgical costs were further subdivided into operating room, anesthesia, and recovery room costs. Univariate and multivariate statistical analyses were applied to identify predictors of procedure-related costs. RESULTS: The median hospital costs of patients undergoing RPP (7195 dollars, range 5052 dollars to 36,237 dollars) were substantially lower than those of patients undergoing RRP (9757 dollars, range 6935 dollars to 27,771 dollars; P = 0.001). The median costs for patients undergoing radical prostatectomy without BPLND were significantly lower in the RPP (7100 dollars, range 5052 dollars to 28,604 dollars) versus RRP (9169 dollars, range 6935 dollars to 16,705 dollars) patients (P = 0.001). The costs for RPP with BPLND (10,048 dollars, range 7529 dollars to 36,237 dollars) versus RRP with BPLND (9973 dollars, range 7658 dollars to 27,771 dollars) were not significantly different (P = 0.900). Patient age and nerve-preservation status did not significantly influence the procedure-related hospital costs. CONCLUSIONS: RPP may result in lower in-house costs per patient than RRP in those patients who do not require BPLND. Total hospital costs depend largely on the factors of operating room time, length of stay, and laboratory and transfusion requirements, which may vary among institutions.

Adult↗
PubMed2004

Long-term results of open transvesical prostatectomy from a contemporary series of patients.

OBJECTIVES: To provide information about the long-term efficacy of transvesical prostatectomy from a contemporary series of patients. When comparing minimally invasive procedures with open prostatectomy, the data for the latter are usually provided from old studies or from recent ones performed in developing countries. However, this procedure is still used frequently for large-size prostates. METHODS: During a 5-year period, 232 patients with large (greater than 75 g) prostates underwent open transvesical prostatectomy for symptomatic benign prostatic hyperplasia. Patient charts were retrospectively reviewed for preoperative and postoperative International Prostate Symptom Scores, postvoid residual urine volumes, maximal flow rates, early and late postoperative complications, and the need for reoperation. The preoperative International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate were compared with the corresponding postoperative data at 8 to 12 months and at the last follow-up visit. RESULTS: Complete data evaluation was possible for 151 patients, with a mean follow-up of 41.8 +/- 15.6 months. Improvement in International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate was statistically significant (P <0.001) at 8 to 12 months and remained statistically significant at the last follow-up visit. Long-term complications included bladder neck contraction in 5 (3.3%) occurring at a mean of 10 months (range 5 to 17), urethral strictures in 1 (0.6%), and meatal stenosis in 2 (1.3%) of 151 patients. Re-operation was required in 6 patients (3.9%). CONCLUSIONS: Transvesical prostatectomy in a contemporary series of patients proved to be successful, with a low rate of complications. Its success has a durable effect and only rarely was a corrective procedure necessary. This approach should be included in the list of possible treatments to discuss with the patient with a large prostate.

Aged↗
PubMed2004

Positive proximal (bladder neck) margin at radical prostatectomy confers greater risk of biochemical progression.

OBJECTIVES: To identify the prognostic significance of positive bladder neck margin as the sole positive margin after radical retropubic prostatectomy for treatment of prostate cancer. METHODS: We retrospectively analyzed the data from patients who underwent radical retropubic prostatectomy at Johns Hopkins Hospital between 1984 and 2001. Of 164 patients with positive margins, 38 had a positive margin only at the bladder neck margin and 126 had a positive margin at one or more locations separate from the bladder neck margin. RESULTS: Kaplan-Meier analyses showed that patients with a positive bladder neck margin had a greater biochemical progression risk than patients with positive margins at one or more locations other than the bladder neck margin. The 5-year actuarial risk of progression in men with positive and negative bladder neck margins was 69.8% and 33.0%, respectively. A positive bladder neck margin was statistically an independently significant predictor of progression (P = 0.001), along with the prostatectomy Gleason score (P = 0.0001) in the multivariate analysis. The hazard ratio for predicting progression for postoperative Gleason score and bladder neck positivity was 2.1 and 2.5, respectively. Serum prostate-specific antigen values, clinical stage, age, and the percentage of tumor at the bladder neck margin were not predictors of progression in either univariate or multivariate analysis. CONCLUSIONS: Patients with a positive bladder neck margin as the sole positive margin at radical retropubic prostatectomy have a greater risk of biochemical progression than patients with one or more positive margins at other locations, although not as adverse as the risk reported for those with Stage T4 disease.

Adenocarcinoma↗
PubMed2005

Does prior benign prostate biopsy predict outcome for patients treated with radical perineal prostatectomy?

OBJECTIVES: To determine the effect of prior benign prostate biopsies on the surgical and clinical outcomes of patients treated with radical perineal prostatectomy for prostate cancer. METHODS: A total of 1369 patients with clinically localized prostate cancer underwent radical prostatectomy by a single surgeon between 1991 and 2001. A subset of 203 patients (14.9%), who had undergone at least one prior benign prostate biopsy for a rising prostate-specific antigen and/or abnormal digital rectal examination, constituted our study population. A total of 1115 patients with no prior biopsy represented our control group. After prostatectomy, patients were evaluated at 6-month intervals for biochemical evidence of recurrence, defined as a prostate-specific antigen level of 0.5 ng/mL or greater. RESULTS: Patients with a prior benign biopsy had more favorable pathologic features with more organ-confined (74% versus 64%; P <0.001) and less margin-positive (9.8% versus 18%) disease. Only 24 patients (12%) in the study group (versus 20% in control group; P = 0.01) had eventual evidence of biochemical failure. Kaplan-Meier analyses suggested that patients with prior benign biopsies have improved biochemical disease-free survival, especially for those with more aggressive disease (Gleason sum 7 or greater; P <0.01). Overall, patients in the study group had lower probability (odds ratio 0.57, P <0.001) of biochemical failure compared with those in the control group. CONCLUSIONS: A prior benign prostate biopsy may be independently associated with more favorable surgical and biochemical outcomes after prostatectomy. Additional studies are needed to confirm these findings.

Adenocarcinoma↗
PubMed2005

Fecal incontinence after radical perineal prostatectomy: a prospective study.

OBJECTIVES: To assess, in a prospective study, the incidence of fecal incontinence after radical perineal prostatectomy. METHODS: Bowel symptoms were evaluated with questionnaires mailed to 132 patients preoperatively and 6 months postoperatively, and annually thereafter. All patients had undergone extrafascial perineal prostatectomy for Stage cT1-cT3N0M0 prostate cancer. The data of 116 patients (88%), who answered at least the preoperative and 12-month questionnaires, were analyzed. Reduced sensibility, reduced discrimination, urgency, or stool smearing were symptoms indicative of fecal incontinence. Patients with one symptom of fecal incontinence were evaluated further with a structured telephone interview. RESULTS: Daily stool smearing was reported preoperatively by 4% of the patients. Two symptoms related to fecal incontinence were present preoperatively in 6% of the patients. At 12 months postoperatively, 15 patients (13%) reported at least two symptoms of fecal incontinence. The structured telephone interview revealed that 6 of these 15 patients had symptoms of fecal incontinence that were related to the perineal prostatectomy; 9 patients had newly developed symptoms not related to surgery or symptoms due to tumor recurrence or radiotherapy. Patients with the presence of at least one symptom of fecal incontinence before surgery had an almost fourfold increased risk of developing at least two symptoms of fecal incontinence postoperatively compared with patients without any symptom of fecal incontinence. CONCLUSIONS: Significant fecal incontinence after radical extrafascial perineal prostatectomy is a rare event. The results of questionnaires should be supplemented by additional interviews to obviate wrong interpretations.

Adenocarcinoma↗
PubMed2005

Lateral pedicle control during laparoscopic radical prostatectomy: refined technique.

OBJECTIVES: To report a technique of lateral pedicle control during laparoscopic radical prostatectomy that completely eliminates any form of electrocautery, ultrasonic thermal energy, clips, or bioadhesives. METHODS: The technique was used in 25 men undergoing nerve-sparing laparoscopic radical prostatectomy. Our antegrade technique involves transient control of the lateral prostate pedicles with an atraumatic vascular bulldog clamp. The pedicles were divided by precise cold cutting, and the neurovascular bundles (NVBs) were teased away with gentle blunt and sharp dissection. Hemostasis was secured with meticulous, superficial suturing of transected blood vessels with 4-0 Vicryl. Real-time transrectal ultrasound monitoring was performed preoperatively, during bulldog clamp application, and postoperatively. RESULTS: The mean bulldog clamp time for the right and left prostate pedicles was 11.1 and 11.2 minutes, respectively. Transrectal ultrasonography confirmed continued arterial blood flow within NVB during active bulldog clamping. Before clamping, during clamping, and after prostatectomy, the mean number of visible blood vessels within each NVB was 3.4, 2.2, and 2.1 (P <0.001 before versus during or after), and the mean resistive index of arterial blood flow was 0.86, 0.85, and 0.85, respectively. Positive surgical margins occurred in 1 patient (4%). Potency and continence data are awaited. CONCLUSIONS: We describe a technique of lateral pedicle ligation during laparoscopic radical prostatectomy using monitored cold cutting and delicate 4-0 hemostatic suturing that completely eliminates all electrocautery, ultrasound thermal energy, clips, and bioadhesives. Bulldog clamp placement on the lateral prostate pedicles did not interrupt blood flow within the NVB.

Hemostasis, Surgical↗
PubMed2005

Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation.

INTRODUCTION: We present our technique for clipless antegrade neurovascular bundle preservation during robotic laparoscopic radical prostatectomy, along with short-term follow-up of our patients' sexual function. TECHNICAL CONSIDERATIONS: Using the da Vinci three-arm robotic system, we performed robotic laparoscopic radical prostatectomy using a transperitoneal approach in an antegrade fashion. After division of the bladder neck, the posterior plane of the prostate was developed distally toward the apex of the prostate in the midline. This plane was then developed completely, releasing the vascular pedicles and neurovascular bundles in a medial to lateral direction, with occasional use of bipolar cautery and without the use of clips or monopolar cautery. Patients with a minimal follow-up of 3 months who did not require open conversion were included in this study. A total of 56 patients met these inclusion criteria between February 2003 and May 2004, with a mean follow-up of 6 months. Patients were given the validated Rand Medical Outcomes Study 36-Item Health Survey, version 2, with the University of California, Los Angeles, Prostate Cancer Index preoperatively and at 1, 3, 6, and 12 months postoperatively. The overall score for both unilateral and bilateral nerve-sparing groups was 35.0, 39.7, 49.4, and 49.6 at 1, 3, 6, and 12 months postoperatively, respectively. These coincided with a return to baseline potency rate of 47%, 54%, 66%, and 69% at 1, 3, 6, and 12 months, respectively. CONCLUSIONS: Antegrade dissection of the neurovascular bundle, avoiding the use of clips or monopolar cautery during robotic laparoscopic radical prostatectomy, may result in early return of sexual function and overall outcome similar to that after radical retropubic prostatectomy.

Adult↗
PubMed2005

Comprehensive urodynamics evaluation of 146 men with incontinence after radical prostatectomy.

OBJECTIVES: To assess the filling, storage, and voiding urodynamic parameters in a large group of men with urinary incontinence after radical prostatectomy. METHODS: We reviewed the videourodynamics testing results for 146 consecutive men referred for urinary incontinence after radical prostatectomy. RESULTS: The mean patient age was 69.0 years (range 48 to 85), and the mean interval since radical prostatectomy was 4 years (range 4 months to 19 years). All but four tests were performed more than 12 months postoperatively. Stress urinary incontinence (SUI) was demonstrated in 139 men (95%), with a mean abdominal leak point pressure of 59 cm H2O. A statistically significant correlation was found between the leak point pressure and static urethral pressure profilometry measurements (r = 0.46, P < 0.0001). The mean urethral pressure profilometry measurements in those with SUI were significantly lower than in those without (46.6 versus 69 cm H2O, P = 0.001). A total of 34 patients had diminished compliance or detrusor instability, but this was the sole finding in only 3. A hypocontractile detrusor response was seen in 49 patients, and 35 of these augmented voiding by abdominal straining. Patients with previous radiotherapy (n = 24) were more likely to have bladder outlet obstruction; the other parameters were similar to those in patients without radiotherapy. CONCLUSIONS: Incontinence after radical prostatectomy is caused by intrinsic sphincter deficiency in the vast majority of patients. Urethral pressure profilometry measurements correlated with the severity of SUI, as measured by abdominal leak point pressure. Bladder outlet obstruction may coexist with SUI in a significant portion of patients. During voiding, a hypocontractile detrusor response may be seen, but the clinical significance of this finding is unclear.

Aged↗