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PubMed2005

Use of fourth arm in da Vinci robot-assisted extraperitoneal laparoscopic prostatectomy: novel technique.

INTRODUCTION: The da Vinci robot-assisted laparoscopic radical prostatectomy is a relatively new approach that is revolutionizing the surgical treatment of localized prostate cancer. Since its introduction, several improvements have been made in the robot design model, as well as in the surgical technique for prostatectomy. One of the more recent advances in this technology has been the introduction of a four-arm robot model. This modified system allows the operating surgeon to use the fourth arm for key steps and maneuvers during the operation, thereby decreasing the reliance on advanced assistant laparoscopic skills. In this report, we describe our modifications for the extraperitoneal approach for laparoscopic removal of the prostate using the four-arm da Vinci surgical system. TECHNICAL CONSIDERATIONS: During a 24-month period, 154 consecutive patients with clinically localized prostate cancer underwent extraperitoneal robot-assisted laparoscopic radical prostatectomy using the four-arm da Vinci robot system. All cases were videotaped and subsequently reviewed. Important factors regarding extraperitoneal access, patient positioning, port placement, and assistant role with or without the fourth arm were defined. CONCLUSIONS: Our experience has revealed that the extraperitoneal approach allows for a more natural patient position during the operation and avoids intraperitoneal organ injury. The addition of the fourth arm to the da Vinci robot provides the operating surgeon with a great deal of independence, which facilitates all aspects of robot-assisted laparoscopic prostatectomy. It allows the operating surgeon to retract tissue during critical steps in this challenging operation and reduces the reliance on highly trained laparoscopic assistants.

Equipment Design↗
PubMed2005

Reoperation versus observation in men with major bleeding after radical retropubic prostatectomy.

OBJECTIVES: To compare the postoperative and quality-of-life outcomes for men experiencing major bleeding after radical retropubic prostatectomy that was managed with reoperation or observation. METHODS: A total of 916 men underwent radical retropubic prostatectomy by a single surgeon between October 2000 and August 2004. Of the 916 men, 15 (1.6%) experienced major bleeding, defined as the transfusion of 3 U or more of allogeneic blood within the first 36 hours after radical prostatectomy. The outcomes were compared between the 5 men undergoing reoperation (group 1) and the 10 men whose bleeding was managed with observation (group 2). RESULTS: The mean total number of allogeneic blood units transfused was significantly greater in group 1 (7.4 U) than in group 2 (4.1 U; P = 0.002). Group 1 also experienced a significantly longer hospital stay (4.6 versus 2.6 days). Those men undergoing reoperation had a significantly lower probability of moderate to severe extravasation on initial cystogram compared with group 2 (0% versus 70%). In addition, the urinary catheter was indwelling for a shorter interval (9.6 versus 23.5 days). We also found a suggestion of better continence in group 1. CONCLUSIONS: Reoperation for major bleeding after radical retropubic prostatectomy facilitates both healing of the vesicourethral anastomosis and removal of the urinary catheter.

Humans↗
PubMed2006

Prospective study evaluating efficacy and safety of Adjustable Continence Therapy (ProACT) for post radical prostatectomy urinary incontinence.

OBJECTIVES: To examine a new prosthesis, the Adjustable Continence Therapy (ProACT), to determine its ability to treat effectively post radical prostatectomy urinary incontinence. Urinary incontinence is one of the most significant complications of radical prostatectomy. Although the artificial urinary sphincter (AUS) is considered the standard treatment for this condition, many men seek a simpler and less expensive treatment option. METHODS: From November 2000 to March 2004, 25 patients with severe post radical prostatectomy urinary incontinence were treated using the ProACT device. The preoperative evaluation included pad count, Valsalva leak point pressure determination, and Incontinence Quality-of-Life scores. In the follow-up, the same parameters, as well as complications, were analyzed and compared with the baseline measurements to assess the efficacy. RESULTS: The follow-up period was 6 to 48 months (mean 22.4). Of the 25 patients, 23 had follow-up data available for analysis. The improvements in pad count, Incontinence Quality-of-Life score, and Valsalva leak point pressures from baseline to the last follow-up examination were all significant (P <0.05). Overall, of the 23 patients followed up, 15 (65.2%) were continent using 0 to 1 pad daily and satisfied, 3 (13%) were improved but unsatisfied, and 5 (22%) did not have any improvement. Balloon adjustments were performed in all patents to achieve continence. Revision surgery was required in 4 (17%) of 23 patients. CONCLUSIONS: The use of ProACT represents a safe and effective treatment for post radical prostatectomy incontinence with a good degree of patient satisfaction and a low complication rate. Postoperative adjustments were necessary in most patients and were undertaken as a simple outpatient visit.

Humans↗
PubMed2006

Impact of extent of lymphadenectomy on survival after radical prostatectomy for prostate cancer.

OBJECTIVES: Controversy exists regarding the benefit of extended lymphadenectomy at radical prostatectomy for prostate cancer. We sought to determine whether more extended lymphadenectomy, along with radical prostatectomy, resulted in a decreased risk of prostate cancer-specific death at 10 years. METHODS: Data on all patients undergoing radical prostatectomy (with or without lymphadenectomy) for prostate cancer obtained from the Surveillance, Epidemiology, and End Results Program (1988 to 1991) were examined. All surviving patients had a minimal follow-up of 10 years. Multivariate Cox proportional hazards analysis was used to determine the independent effect of lymphadenectomy on the risk of prostate cancer-specific death. RESULTS: Patients undergoing excision of at least 4 lymph nodes (node-positive and node-negative patients) or more than 10 nodes (only node-negative patients) had a lower risk of prostate cancer-specific death at 10 years than did those who did not undergo lymphadenectomy. The removal of a greater number of nodes was associated with a greater likelihood of the presence of positive nodes. The presence of more than one positive node was associated with a greater risk of prostate cancer-related death. CONCLUSIONS: Performing more extensive pelvic lymphadenectomy in patients undergoing radical prostatectomy could improve the accuracy of staging and reduce the risk of prostate cancer-specific death in the long term.

Adult↗
PubMed2006

Radical prostatectomy for high-grade prostate cancer.

OBJECTIVES: Patients with high-grade clinically localized disease often have disease beyond the prostate and, if so, are unlikely to benefit from radical prostatectomy in the long-term. The objective of this study was to assess whether use of other known prognostic factors could be helpful in defining which men with Gleason 8 to 10 prostate cancer are most likely to benefit from surgical management. METHODS: A retrospective analysis was performed on men with biopsy Gleason 8 to 10 prostate cancer who underwent radical prostatectomy at two major university centers. No patients received hormonal therapy as part of initial treatment or adjuvant radiation therapy. Surgery was performed using a retropubic approach, and lymph node dissection was performed in all patients. Risk groups were defined based on prostate-specific antigen (PSA) value and percent positive biopsy cores (%PBC). A Cox proportional hazards analysis was performed to assess for differences in pretreatment prognostic factors. Kaplan-Meier curves were generated for each group, and then comparisons between groups were performed using log-rank analysis to assess for differences in 5-year actuarial freedom from biochemical failure. RESULTS: Radical prostatectomy was performed on 196 patients between 1987 and 2002, of whom 168 had sufficient data for analysis. Median follow-up was 18 months (range, 1 to 130 months), with 31 patients at risk for more than 5 years. Patients with a PSA value of less than 10 ng/mL and %PBC of less than 50% had a 5-year actuarial biochemical control rate of 67% versus 23% for all other patients (P = 0.0001). CONCLUSIONS: PSA value and %PBC are useful in selecting patients with high-grade prostate cancer most likely to benefit by radical prostatectomy.

Follow-Up Studies↗
PubMed2006

Laparoscopic radical prostatectomy in a renal allograft recipient.

In the current immunosuppression era, most renal transplant recipients with a functioning allograft are living healthier and longer lives. In men, because of prostate-specific antigen screening, more patients are diagnosed with early prostate cancer and offered curative treatment with radical prostatectomy. Laparoscopic radical prostatectomy is an accepted minimally invasive treatment for a middle-aged man with organ-confined prostate cancer. To our knowledge, laparoscopic prostatectomy has not yet been reported in renal transplant recipients. This is a case report of laparoscopic prostatectomy for biopsy-proven localized prostate cancer in a renal transplant recipient.

Humans↗
PubMed2006

Laparoscopic radical prostatectomy in a community hospital without robotic assistance.

OBJECTIVES: To develop a laparoscopic radical prostatectomy program in a community-based hospital without robotic assistance. METHODS: A total of 60 consecutive patients underwent laparoscopic radical prostatectomy by a single urologist in a community-based hospital without the use of the da Vinci robotic system. A general surgeon with advanced laparoscopic experience was initially used as the proctor. The data of all patients were kept on a database and included the preoperative and intraoperative data and postoperative results. RESULTS: The median operative time was 259 minutes, and the last 10 cases had a median operative time of 192 minutes. The median blood loss was 168 mL. The postoperative median hospital stay was 2.3 days, the median morphine use was 4.2 mg, and the median catheter dwell time was 5.5 days. At 6 months postoperatively, 90% of patients were continent, using 0 to 1 pad per day. No major complications occurred. One case was converted to open radical prostatectomy. CONCLUSIONS: Laparoscopic radical prostatectomy can be performed in a community-based hospital without robotic assistance. The use of a laparoscopically trained general surgeon and time spent in a dry laboratory are essential to the success of this program.

Aged↗
PubMed2006

Pathologic outcome of laparoscopic and open radical prostatectomy.

OBJECTIVES: To compare the clinicopathologic data of 286 laparoscopic radical prostatectomies (LRPs) and 714 open radical prostatectomies (RRPs) performed at the Massachusetts General Hospital from 2001 to 2005. METHODS: A total of 1000 radical prostatectomy procedures were analyzed for prostate weight, pathologic stage, Gleason score, surgical margin status, and positive margin location. RESULTS: The mean patient age was 58.6 and 59.1 years for the LRP and RRP groups, respectively. The mean preoperative prostate-specific antigen level was 5.96 and 6.00 ng/mL, respectively. Clinical Stage T1c cancer was seen in 86.4% of the LRP and 90.5% of the RRP patients. Gleason score 7 or less disease was seen on biopsy in 97.5% of the LRP and 96.9% of the RRP patients. The average prostate weight was 46.8 g for LRP and 46.0 g for RRP. In the radical prostatectomy specimens, 94.4% of LRP and 93.3% of RRP patients had Gleason score 7 or less disease and 86.0% of LRP and 81.7% of RRP patients had pathologic Stage pT2 cancer. The rate of positive surgical margins was 15.0% and 17.4% for the LRP and RRP groups, respectively. The positive margins occurred mainly at the peripheral and apical regions in both groups. No significant difference was found in the preoperative variables or final pathologic findings between the two surgical groups. CONCLUSIONS: With similar case selection, LRP and RRP achieve similar pathologic outcomes.

Adult↗
PubMed2006

Robotic-assisted laparoscopic prostatectomy: first 100 patients with one year of follow-up.

OBJECTIVES: To report our initial experience of 100 patients with robotic-assisted laparoscopic radical prostatectomy. Continued technological advances have expanded our armamentarium of minimally invasive devices and techniques to offer our patients. Robotic-assisted laparoscopic radical prostatectomy has been adopted at many centers. METHODS: This was a nonrandomized prospective study evaluating our initial 100 patients who underwent robotic-assisted laparoscopic radical prostatectomy. The follow-up data were obtained prospectively using the validated Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index preoperatively and at 1, 3, 6, and 12 months postoperatively. Patients who required open conversion were excluded from the outcome analysis. Patients who received a sural nerve graft were excluded from the operative analysis. RESULTS: The average age and body mass index of all patients were 58.4 years (range 42 to 70) and 28.5 kg/m2 (range 18.1 to 50.6), respectively, with a median follow-up of 12 months. The average prostate-specific antigen level was 6.07 ng/mL. Seven patients required conversion to an open technique, and four underwent sural nerve grafting. The positive surgical margin rate was 16% (15 of 92). Using the Rand 36-item health survey, version 2, and the University of California, Los Angeles, Prostate Cancer Index health surveys, the average percentage of return to baseline urinary function was 52%, 70%, 79%, and 84% at 1, 3, 6, and 12 months, respectively. The overall average percentage of return to baseline sexual function was 51%, 58%, 66%, and 80% at 1, 3, 6, and 12 months, respectively. CONCLUSIONS: Robotic-assisted laparoscopic radical prostatectomy is a safe and efficient method for achieving prostate cancer control even during the initial learning curve for this procedure.

Adult↗
PubMed2006

Two-year outcome of unilateral sural nerve interposition graft after radical prostatectomy.

OBJECTIVES: To study 41 men treated for prostate cancer with unilateral nerve-sparing radical prostatectomy and contralateral sural nerve grafting from January 2000 to September 2003. METHODS: Patients were considered for sural nerve grafting if they were considered at high risk of extracapsular extension before or during surgery, were younger than 70 years of age with good preoperative erectile function, were sexually active, and had no significant risk factors for erectile dysfunction. Potency was assessed by patient-reported questionnaires, including the International Index of Erectile Function erectile domain and Rigiscan testing. RESULTS: The mean follow-up was 27.4 +/- 14.5 months. At 24 months, 24 (63.2%) of 38 men had erections sufficient for intercourse, with or without phosphodiesterase type 5 inhibitor use. Four men had partial erections that were occasionally satisfactory (10.5%), and 10 men reported no sexual activity, no spontaneous erections, or partial erections unsatisfactory for intercourse (26.3%). In contrast, in a group of 49 men who underwent unilateral nerve-sparing prostatectomy without nerve grafting during the same period at our institution, 13 (26.5%) had rigid erections adequate for intercourse with or without phosphodiesterase type 5 inhibitor use at 24 months of follow-up. CONCLUSIONS: At 24 months of follow-up, men who had undergone unilateral nerve-sparing prostatectomy with contralateral sural nerve interposition graft repair of a cut cavernosal nerve had a greater rate of return of erectile function than men undergoing unilateral nerve-sparing prostatectomy alone.

Follow-Up Studies↗
PubMed1998

Biological aggressiveness of hereditary prostate cancer: long-term evaluation following radical prostatectomy.

PURPOSE: We answer the question of whether, following radical prostatectomy, prostate cancer in patients with a family history of prostate cancer relapses biochemically at the same rate as prostate cancer in appropriately matched patients with no family history. MATERIALS AND METHODS: The study was performed in 2 parts. In both parts prostate specific antigen (PSA) progression was defined as a postoperative elevation in serum PSA greater than 0.2 ng./ml. Part 1 included 656 patients who underwent radical prostatectomy by the same surgeon. Men with a family history of prostate cancer in a father or brother (94) were compared to those with no history of prostate cancer in a father or brother (562). Part 2 comprised 52 men with a family history of prostate cancer consistent with hereditary prostate cancer (HPC). HPC is defined as a family with 3 generations affected, 3 first-degree relatives affected or 2 relatives affected before age 55 years. Each member of this HPC group was matched by postoperative Gleason score and postoperative pathological stage with a patient who also underwent radical prostatectomy in the same time frame by the same surgeon but who reported no family history of prostate cancer by telephone interview and questionnaire. RESULTS: In part 1, 94 probands (14%) reported a history of prostate cancer in the father or in at least 1 brother. The remaining 562 probands (85%) reported no known history of prostate cancer in the father or brother(s). There was no statistically significant difference in the probability of maintaining an undetectable PSA between these 2 groups. In part 2, 45 of 52 pairs (87%) were matched identically for all matching criteria. Mean follow time for the sporadic and hereditary groups was 5.4 and 5.1 years, respectively. There was no statistically significant difference in the probability of maintaining an undetectable PSA between the 2 groups. CONCLUSIONS: Men with an affected father or brother, or those with a family history consistent with HPC have the same outcome following radical prostatectomy as men with no family history of the disease. Combined with our previous studies, these findings suggest that there is no biologically important difference between hereditary and sporadic prostate cancers.

Disease Progression↗
PubMed1998

Anatomy of radical prostatectomy as defined by magnetic resonance imaging.

PURPOSE: We examined and defined anatomical structures relevant to radical prostatectomy using magnetic resonance imaging. MATERIALS AND METHODS: Before radical prostatectomy, 15 men underwent high-resolution magnetic resonance imaging studies of their pelvic floors (fast spin echo, T2 weighting of 3- to 4-mm. contiguous or overlapping slices) in axial, coronal, and sagittal planes. RESULTS: Pubovesical ligaments, rather than the commonly reported puboprostatic ligaments, were observed attaching the bladder-prostate unit to the pubis. We suggest that the part of the urethra that extends from the apex of the prostate to the bulb of the penis, which is surrounded by the striated sphincter, should be termed the sphincteric urethra rather than the membranous urethra. Further, we found no evidence that supports the traditional concept of a urogenital diaphragm. The lower part of the striated urethral sphincter was flanked on its sides by the anterior recesses of the ischioanal fossae. The portion of the levator ani, which we have termed the puboanalis sling, flanked the apex of the prostate. The most anteromedial portion of this sling inserts into the perineal body and should be termed the puboperinealis. The terminal part of the gastrointestinal tract (the part continued beyond the levator ani) should be termed the anal canal, not the rectum, as used frequently in the urologic literature. Therefore, the initial plane of dissection in radical perineal prostatectomy passes along the anterior portion of the anal canal, not the rectum. CONCLUSION: We used magnetic resonance imaging to study male pelvic floor and perineal anatomy without the artifact of dissection. This study allowed us to devise a more precise nomenclature with respect to radical prostatectomy and, in so doing, to provide a better understanding of both the retropubic and the perineal operations.

Aged↗
PubMed1997

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE: Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy. MATERIALS AND METHODS: International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively. RESULTS: At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery. CONCLUSIONS: Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.

Acute Disease↗
PubMed1996

Malignant cytological washings from radical prostatectomy specimens: a possible mechanism for local recurrence of prostate cancer following surgical treatment of organ confined disease.

PURPOSE: Local recurrence of prostate cancer following complete and successful resection of organ confined disease has been variably reported in men. We hypothesized that observed secretions from the cut distal urethra during radical prostatectomy may contain malignant prostatic epithelial cells and contribute to this problem. MATERIALS AND METHODS: A prospective study was done of prostate cytology specimens from 50 consecutive men with clinically organ confined adenocarcinoma of the prostate undergoing radical retropubic or radical perineal prostatectomy. Direct cytological evaluation by 1 examiner was used to identify malignant or benign cells in these washings. RESULTS: Of 33 radical perineal and 17 radical retropubic prostatectomy specimens organ confinement was confirmed in 58%. Malignant prostatic epithelial cells were observed in 24% of all cytology specimens. Of cytological washings from prostates with pathologically confirmed organ confined cancers 17% showed malignant cells. While perineural invasion was noted in a majority of tumors with positive washings, only Gleason grade was a statistically significant predictor of recurrence (p = 0.009). Surgical approach did not alter the rate of positive cytology. CONCLUSIONS: Malignant prostatic epithelial cells can be identified in the prostatic washings from men with pathologically organ confined prostate cancer. Surgical approach did not change the cytological findings. Gleason grade is a statistically significant predictor of cytological malignancy. These cells may represent a mechanism of failure following successful radical prostatectomy.

Adenocarcinoma↗
PubMed1996

Radical prostatectomy: is complete resection of the seminal vesicles really necessary?

PURPOSE: We determined the frequency of prostate cancer extension into the distal 1 cm. of seminal vesicles, and reconsidered whether complete excision of the seminal vesicles during radical prostatectomy is always necessary. MATERIAL AND METHODS: After en bloc removal with the specimen in 71 consecutive radical prostatectomies, the distal 1 cm. of each seminal vesicle was transected and separately analyzed for tumor involvement. RESULTS: Mean patient age was 61.8 years (range 40 to 72). Preoperative prostate specific antigen (PSA) ranged from 0.8 to 37 ng./dl. (median 7.3), and 18 patients had a PSA of 10 or more. Clinical stages were T1b in 1 case T1c in 37, T2a in 12, T2b in 10, T2c in 6 and T3a in 1. Preoperative Gleason sums ranged from 4 to 8 (median 6) with 21 patients (30%) having a sum of 7 or more. Of 71 patients 12 (17%) and seminal vesicle invasion (5 bilaterally). In no case did tumor extend into the distal 1 cm. of the seminal vesicle. PSA at diagnosis ranged from 4.2 to 30 ng./dl., with 4 of 12 patients having a PSA of 10 or more. Preoperative clinical stages were T1c in 5 cases, T2a in 3, T2b in 2 and T2c in 2. Five of the 12 patients (42%) had positive surgical margins and 11 (92%) had a postoperative Gleason sum of 7 or more. CONCLUSIONS: In 71 consecutive patients undergoing radical prostatectomy no tumor was found in the distal 1 cm. of the seminal vesicles, including 12 with seminal vesicle invasion. We continue to advocate complete excision of the seminal vesicles during radical prostatectomy. However, if dissection is difficult and a small fragment is left behind, the prognosis is unlikely to be altered.

Adult↗
PubMed1995

Quality of life: radical prostatectomy versus radiation therapy for prostate cancer.

PURPOSE: The impact of radical prostatectomy and external beam radiotherapy on the quality of life of patients was compared. MATERIALS AND METHODS: A total of 136 patients underwent radical prostatectomy and 60 underwent external beam radiotherapy for clinically localized prostate cancer. Patients were asked to complete a questionnaire containing The Functional Living Index: Cancer, the Profile of Moods States, and a series of questions evaluating bladder, bowel and sexual function. RESULTS: The radical prostatectomy group had worse sexual function and urinary incontinence, while the external beam radiotherapy group had worse bowel function. Of the patients 90% from both groups stated that they would undergo the treatment again. CONCLUSIONS: Radical prostatectomy and external beam radiotherapy have comparable impact upon quality of life.

Adult↗
PubMed1997

Collagen injection therapy for post-radical retropubic prostatectomy incontinence: role of Valsalva leak point pressure.

PURPOSE: We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. MATERIALS AND METHODS: Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. RESULTS: Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compared to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). CONCLUSIONS: Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

Adult↗
PubMed1997

Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study.

PURPOSE: The impact was determined on post-prostatectomy urinary incontinence of a technique preserving the anterior attachments of the proximal urethra to the posterior pubis by comparison to the results of other surgical methods. MATERIALS AND METHODS: Urinary continence in 51 patients undergoing preservation of the anterior urethral attachments was compared to that of 70 patients undergoing an anatomical prostatectomy with resection of the bladder neck, 55 patients with preservation of the bladder neck and 14 patients undergoing a dorsal vein gathering procedure. Comparisons were made for rate of total continence, time to return of continence, incidence of extra organ disease and operative blood loss. RESULTS: Total continence at 1 year was 84.3%, 89.1%, 85.7% and 100% respectively. Immediate total continence after catheter removal was seen in 25.5% after preservation of the anterior urethral attachments, 80.4% at 3 months compared to 41.4%, 50.9% and 50% at 3 months for anatomical prostatectomy with bladder neck resection, preservation and dorsal vein gathering. Clinical staging with the incidence of specimen confined disease was similar in all groups. Mean operative blood loss was 1,031 ml. for those patients undergoing anatomical prostatectomy compared to 681 ml. for those with preservation of the anterior urethral attachments. CONCLUSIONS: Preservation of the anterior urethral attachments results in improved urinary continence and lower operative blood loss without an increase in positive surgical margins.

Aged↗