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PubMed1995

[Rectal injuries in radical prostatectomies for cancer. Survey of the ANFUC (Association National de Formation Urologique Continue) 1994].

This survey was conducted by 28 urologists members of the ANFUC who reported rectal wounds observed during radical prostatectomy procedures performed for cancer. There were 1,816 procedures reported, 1,785 suprapubic prostatectomies and 28 perineal operations. Kraske access was used in 3 cases. There were 33 wounds to the rectum reported by 17 operators including 31 in suprapubic prostatectomies (1.7% of the operations) and 2 after transperineal operations (7.14%). Preoperative radiotherapy was never used and mechanical preparation was performed in most of the cases with rectal complications (27/33). The wound was sutured in all cases and a colonic derivation was required in 4. Retrospectively this procedure was judged unnecessary in 2 or 3 cases. The post-operative period was uneventful in all cases and the derivations were closed 2 or 3 months later. The conclusions drawn from this survey were the following: the rate of rectal complications in radical prostatectomy is higher in the perineal route. When no preoperative radiotherapy has been performed, simple suture of the rectal wound is sufficient and colonic derivation is not always necessary. It does not appear necessary to interpose an epiploic flap in such cases which would have the disadvantage of requiring opening the peritoneal cavity. These considerations are only applicable to the nonirradiated rectum. Preoperative radiotherapy would undoubtedly have a major effect, but we have had no experience in this series.

Data Collection↗
PubMed1995

[Radical prostatectomy].

Radical prostatectomy can cure cancer of the prostate if the malignancy is localized within the gland and the patient has a life expectancy sufficiently long enough to appreciate efficacy. The expectations raised by this technical progress, particularly since the number of diagnosed cases is constantly on the rise, should however be tempered by questions concerning indications and therapeutic efficacy, pathology findings in surgical specimens, factors of prognosis and certain doubts about the quality of life, therapeutic alternatives and cost evaluation. 10-year survival after radical prostatectomy is 85% for localized (pT1 and pT2) forms and prostate specific antigen levels provide an easily accessible means of detecting recurrence. However, due to the insufficient sensitivity of imaging techniques, preoperative staging is generally underestimated compared with pathology reports. Postoperative incontinence is the major factor in quality of life after prostatectomy and has been estimated to concern from 0% to 26% of the patients. No comparative data is available to evaluate alternative treatment such as external radiotherapy. These observations emphasize the uncertain nature of current indications for radical prostatectomy and the importance of further research.

Humans↗
PubMed1996

Histological characteristics of radical prostatectomy specimens in men with a serum prostate specific antigen of 4 ng./ml or less.

PURPOSE: Of most reported radical prostatectomy series 20% consist of men with a serum prostate specific antigen (PSA) of 4.0 ng./ml. or less. Since our series is not only prospective but all prostates are reconstructed at 3 mm. intervals, we determined the clinical and histological findings in this important subset of men undergoing radical prostatectomy. MATERIALS AND METHODS: Of 911 consecutive men undergoing radical prostatectomy 187 (21%) had a preoperative serum PSA of 4.0 ng./ml. or less (values equivalent to those of the Hybritech Tandem-R assay). RESULTS: Mean tumor volume was 2.3 cc. Of the 187 cancers 156 (83%) were in the peripheral zone and 31 (17%) in the transition zone, while 137 (73%) were organ-confined and 50 (27%) showed capsular penetration. No patient had positive pelvic lymph nodes, only 5 had seminal vesicle invasion and positive surgical margins were present in 14%. Cancer volumes less than 0.5 cc were noted in 9% of the patients and were probably insignificant. At an average followup of 37 months, only 16 men (9%) had a detectable serum PSA. These 16 patients had a larger tumor volume (3.7 cc versus 2.2 cc, p < 0.05), and a greater percent of Gleason grade 4 and/or 5 disease than the 171 with undetectable PSA. CONCLUSIONS: Men with prostate cancer and a serum PSA of 4.0 ng./ml. or less are excellent candidates for radical prostatectomy if the 9% with clinically insignificant tumors can be avoided. Since 70% of all men had a suspicious prostate on digital rectal examination, this evaluation is important for men with a serum PSA of 4.0 ng./ml. or less.

Adult↗
PubMed1996

Cathepsin D and epidermal growth factor receptor immunohistochemistry does not predict recurrence of prostate cancer in patients undergoing radical prostatectomy.

PURPOSE: We determined if immunohistochemical expression of the epidermal growth factor receptor and cathepsin D in the primary tumor was of prognostic value in clinically localized prostate cancer after radical prostatectomy. MATERIALS AND METHODS: Immunohistochemical staining for epidermal growth factor receptor and cathepsin D was performed on 105 radical prostatectomy specimens from 2 academic centers. The epidermal growth factor receptor and cathepsin D expressions were graded using H scoring by an experienced pathologist blinded to other patient data, and compared with age, grade, stage, race and initial serologic (prostate specific antigen) recurrence. Univariate and multivariate statistical testing was performed. RESULTS: Immunohistochemically detectable epidermal growth factor receptor and cathepsin D expression was not correlated to age, race, stage or Gleason grade. In univariate and multivariate testing epidermal growth factor receptor and cathepsin D were not prognostic markers for disease progression following radical prostatectomy. CONCLUSIONS: Immunohistochemical analysis of the biomarkers cathepsin D and epidermal growth factor receptor in radical prostatectomy specimens does not predict disease recurrence. Further biological marker study is needed in clinically localized prostate cancer.

Aged↗
PubMed1996

Black race is an adverse prognostic factor for prostate cancer recurrence following radical prostatectomy in an equal access health care setting.

PURPOSE: We determined if black men with clinically localized adenocarcinoma of the prostate have the same recurrence-free outcome following radical prostatectomy, and whether they have similar preoperative, operative and pathological characteristics as white men in an equal access health care environment. MATERIALS AND METHODS: We studied consecutive single hospital case series of 366 white and 107 black patients who underwent radical prostatectomy between 1975 and February 29, 1995. Evaluation included comprehensive retrospective chart review, prospective data collection and proactive followup. Univariate and multivariate statistical analyses were done of preoperative, operative, pathological and recurrence data by race. RESULTS: Although the incidences of hypertension and diabetes, pretreatment prostate specific antigen (PSA) and serum creatinine measurements, elevated PSA as an indication for biopsy and clinical stage were greater in black men, the operative variables of blood loss, operative time and performance of a nerve sparing procedure were not different. The incidence of margin positivity was greater in black patients but pathological stage, Gleason score and seminal vesicle or nodal involvement were not different. Black race was an adverse prognostic factor for recurrence following radical prostatectomy after multivariate adjustment for pretreatment PSA and acid phosphatase, organ confinement status and tumor grade. CONCLUSIONS: The poorer recurrence-free outcome for black patients even after multivariate adjustment suggests a potentially more aggressive variant of prostate cancer in this population, the etiology of which is unknown. Race should be a stratification factor in clinical trials, especially those including radical prostatectomy and using recurrence-free outcome as an end point.

Adenocarcinoma↗
PubMed1996

The artificial urinary sphincter for post-radical prostatectomy incontinence: impact on urinary symptoms and quality of life.

PURPOSE: We addressed the impact of the artificial urinary sphincter on the health related quality of life and urinary symptoms in men with post-radical prostatectomy incontinence. MATERIALS AND METHODS: A total of 30 men with an AMS800 artificial urinary sphincter following radical prostatectomy responded to a questionnaire dealing with the impact of the symptoms on activities of daily living and quality of life. We compared these results to those of 31 patients who underwent radical prostatectomy but did not require an artificial urinary sphincter. RESULTS: Incontinence was minimal in both groups. Irritative symptoms were noted in the artificial urinary sphincter group, as well as some impairment in activities of daily living. No significant differences were noted with respect to quality of life. CONCLUSIONS: The artificial urinary sphincter is an effective form of therapy for post-radical prostatectomy incontinence but irritative voiding symptoms occur, which tend to limit activities of daily living.

Activities of Daily Living↗
PubMed1996

[Recent improvements and results of radical prostatectomy].

In Japan, the proportion of patients with localized prostate cancer treated by radical prostatectomy is increasing rapidly. The recent improvements and treatment results of radical prostatectomy were reviewed. As for the qualifications of patient candidates for radical surgery, including patient age, various clinical and pathological findings to predict tumor extent and disease-free outcome (clinical stage, serum prostate specific antigen, PSA density, number of positive biopsies, histological grade, etc) must be kept somewhat tidy. Recently, there has been increased interest in the application of preoperative hormone treatment for localized tumor group in order to improve radicality and survival. Several studies reported the results of neoadjuvant endocrine therapy. As for stage C tumors, the proportion of patients with capsular invasion, positive surgical margin, invasion of seminal vesicle and positive node metastasis are 67-86%, 39-64%, 32-47% and 38-50%, respectively. Prospective randomized studies should provide conclusive information on the potential benefits of this treatment modality. The new anatomical approach to radical retropubic prostatectomy with its nerve-sparing option assures preservation of erection. This procedure achieves excellent cancer control for patients with a definite organ-confined tumor, but it is difficult to diagnose a specimen-confined tumor preoperatively. There is limited information on cancer control with the nerve-sparing option. More time is needed to obtain information on the long-term outcome after radical prostatectomy.

Aged↗
PubMed1996

A new technique for treatment of simple post-prostatectomy urinary incontinence: preliminary experience.

PURPOSE: Because of the complexity of reconstructive surgical techniques, the high failure rate and cost of the devices used, as well as the associated mechanical malfunctions there is need for an alternative operation to treat post-prostatectomy urinary incontinence. We present a new procedure along with promising results in cases of simple post-prostatectomy incontinence after transurethral resection of the prostate or open prostatectomy. MATERIALS AND METHODS: The principles of our technique include lysis of the pelvic urethra with preservation of the neurovascular bundle, as well as suspension of the prostatic capsule to the anterior abdominal wall. With this technique we corrected post-prostatectomy sphincteric incompetence in 21 patients. Preoperative evaluation included physical examination, excretory urography, ascending urethrocystography and urethrocystoscopy. Urodynamic investigations included uroflowmetry, cystometrography and urethral pressure profilometry. The patients were reevaluated radiologically and urodynamically 3 months postoperatively. Mean followup was 19 months. RESULTS: All patients tolerated the procedure well. Few intraoperative and postoperative complications were encountered. The success rate was 81% and these 17 patients became continent day and night. CONCLUSIONS: Our procedure combines the continence enhancing features of pelvic urethral elongation, urethral suspension, angulation of the prostatomembranous junction and prostatic fixation. The preliminary success rate of this technique is encouraging. However, larger numbers of patients and long-term followup are needed to confirm our findings.

Humans↗
PubMed1997

Use of the transurethral prostatectomy clinical path to monitor health outcomes.

PURPOSE: We evaluated the effect on cost and medical care quality of use of the transurethral prostatectomy clinical path. MATERIALS AND METHODS: Results in 100 patients treated when the transurethral prostatectomy clinical path was used were compared to those of 100 treated by the same physicians before implementation of this path. RESULTS: After implementation of the transurethral prostatectomy clinical path the length of hospital stay was significantly decreased from 5.9 to 5.0 days (p < 0.01) and Foley catheterization time was significantly decreased from 3.13 to 2.84 days (p < 0.01). Antibiotics were routinely used from the day before surgery to the day of hospital discharge as required by patient conditions. Therefore, a shorter hospital stay will significantly decrease the use of antibiotics. After implementation of the clinical path the average admission charges were decreased significantly by 17% (p < 0.01). Although some results from use of this path will not significantly affect costs, they will reflect some quality improvement. The effect of clinical path implementation on length of hospital stay between patients treated by junior and senior attending physicians was not significant. However, there was a statistically significant difference (p < 0.01) between results obtained by junior and senior attending physicians regarding average admission charges. CONCLUSIONS: Implementation of the transurethral prostatectomy clinical path can improve health care outcome by decreasing length of stay and admission charges, and improving quality of medical care, particularly for patients treated by junior attending physicians.

Aged↗
PubMed1997

The 'urogenital diaphragm', external urethral sphincter and radical prostatectomy.

BACKGROUND: The present study was performed to determine whether a 'urogenital diaphram' exists, to examine the true nature of the striated external urethral sphincter and to evaluate whether the standard technique for radical prostatectomy damages the external sphincter. METHODS: Fifty radical prostatectomies were performed using optical magnification and the dorsal bunching technique, and the external sphincter was carefully examined. Ten human cadavers and one 5-year-old baboon were dissected with longitudinal (sagittal) and transverse sections being taken through the prostate apex, membranous and bulbar urethrae. During the standard technique for dorsal vein control during radical prostatectomy, the tissue incorporated within the ligature was examined for striated muscle. RESULTS: No 'urogenital diaphragm' could be demonstrated in any human or baboon tissue. The striated external urethral sphincter is a cylinder of muscle surrounding the membranous urethra, extending from the perineal membrane to the prostate and continuing over the prostate as part of the anterior fibromuscular stroma. Striated muscle was present in the ligated material from the dorsal venous complex. CONCLUSIONS: The 'urogenital diaphragm' is a myth. The standard technique of radical prostatectomy significantly damages the external sphincter.

Aged↗
PubMed1996

[Prognostic factors in patients with prostatic cancer treated with neoadjuvant hormonal therapy and radical prostatectomy].

UNLABELLED: The high incidence of clinical understaging and positive margins in patients undergoing radical prostatectomy for prostate cancer has led to the use of neoadjuvant hormone therapy to reduce tumor volume. OBJECTIVES: To determine the prognostic factors in patients with prostate cancer treated with hormone therapy and radical prostatectomy. METHODS: 80 patients received hormone therapy with LH-RH agonists and flutamide before undergoing radical prostatectomy. The clinical stage and serum PSA were determined before and after hormone therapy. Prostate volume was determined by transrectal US. RESULTS: In 91% of the patients, PSA levels fell within the normal ranges (< 4 micrograms/l) after hormone therapy. Prostate volume diminished by 39% on average. There were no operative deaths. Histological analysis of the surgical specimen showed no tumor (pTO) in 10% of the cases. Sixteen cases (19.5%) had pelvic node invasion. Positive margins were found in 35% of stage 2 and 56% of stage 3 tumors. Seminal vesicle invasion was found in 35% of T2 and 84% of T3 tumors. Seventy-five percent of the cases with initial PSA levels < 10 micrograms/l had intracapsular (pT2) or pTO tumor. All cases with PSA > 25 micrograms/l had extraglandular tumor. A correlation was found between baseline PSA and incidence of positive-margins. The finding of undetectable PSA after hormone therapy is not a useful prognostic factor since 55% of the cases had extracapsular tumor. CONCLUSIONS: Our results indicate that hormone therapy with LH-RH agonist and flutamide prior to radical prostatectomy in patients with prostate cancer is well-tolerated and has no severe side effects. Despite the high percentage of cases with undetectable PSA after hormone therapy, no correlation was found between reduction of PSA levels and tumor stage.

Aged↗
PubMed1995

Laser prostatectomy with the holmium: YAG laser.

Laser prostatectomy has generated considerable interest amongst urologists as an alternative to traditional transurethral resection for the treatment of benign prostatic hypertrophy. The majority of reports available concerning laser prostatectomy have described use of the neodymium: YAG wavelength delivered via contact or non contact fibers. Recently, a new laser wavelength has become available for urologic use. The holmium: YAG laser is a multipurpose device with many potential applications in urology as well as other surgical disciplines. At a wavelength of 2,100 nm, this laser possesses both ablative and hemostatic properties. Energy and frequency settings can be varied by the operator. Using the holmium: YAG laser as well as the neodymium: YAG laser in a combined procedure, we performed laser prostatectomies in 16 patients. In our series we used the holmium laser to vaporize a channel prior to producing quadrant irradiations with the Nd:YAG laser. At 3-month follow-up there was a mean reduction of AUA symptom scores from 19 to 9 and a mean improvement in peak flows from 13.9 to 16.6 ml/s. Early results show clinical effect but the optimal technique of combined holmium: YAG, Nd:YAG laser prostatectomy is yet to be determined.

Aluminum Silicates↗
PubMed1997

Sensitive prostate specific antigen measurements identify men with long disease-free intervals and differentiate aggressive from indolent cancer recurrences within 2 years after radical prostatectomy.

PURPOSE: Commonly available prostate specific antigen (PSA) assays have detection limits of greater than 0.05 ng/ml., limiting their ability to identify residual or recurrent prostate cancer after radical prostatectomy or to provide prognostic information within the first several years after surgery. We investigated the ability of a sensitive PSA assay to identify residual prostate cancer and men at risk for early recurrence after radical prostatectomy. MATERIALS AND METHODS: We measured PSA in 1,037 serum samples obtained serially from 127 men after radical prostatectomy using the IMMULITE third generation PSA assay. RESULTS: The IMMULITE PSA assay has an analytical sensitivity of less than 0.002 ng./ml. and a clinically useful decision threshold of 0.01 ng./ml. With this assay our patients were classified into 3 groups: 1) 50 with a postoperative baseline PSA of less than 0.01 ng./ml. that did not change during an average of 36 months postoperatively, 2) 66 with increasing PSA that exceeded 0.01 ng./ml. in all cases by 30 months postoperatively (20 with clinical cancer recurrences) and 3) 11 with slowly increasing PSA of greater than 0.01 but less than 0.02 ng./ml. at an average of 36 months postoperatively. CONCLUSIONS: The IMMULITE PSA assay provides clinically useful information not previously available from PSA assays with conventional sensitivity, which is highly predictive of cancer activity in patients within 2 years after radical prostatectomy.

Aged↗
PubMed1997

Transvesical prostatectomy in elderly patients.

PURPOSE: We assessed the results of transvesical prostatectomy in patients older than 80 years. MATERIALS AND METHODS: We studied 98 patients 80 to 90 years old who underwent transvesical prostatectomy between 1986 and 1993, including those with a large prostate (preoperative estimated weight more than 80 gm.), numerous or large cystolithiasis and large bladder diverticulum, which are indications for open prostatectomy. Clinical data were obtained by chart review. RESULTS: The indications for surgery were urinary retention in 53 patients (54%), severe obstructive urinary symptoms in 18 (18.4%), cystolithiasis in 17 (17.3%), prostatic bleeding in 10 (10.2%) and bladder diverticulum in 2 (2%). Accompanying diseases were present in 69 patients (70.6%), including ischemic heart disease in 41 (42%), diabetes mellitus in 17 (17.3%) and arterial hypertension in 14 (14.3%). A total of 59 patients (60.2%) underwent surgery while under general anesthesia and 39 (39.8%) received regional anesthesia. Average operative time was 62 minutes. Of the patients 40 (40.8%) received 1, 14 (14.3%) received 2 and 2 (2%) received 4 units of blood. No postoperative deaths or life threatening complications were noted. The immediate postoperative complications included urinary tract infection in 20 patients (20.5%), wound infection in 3 (3.0%) and orchiepididymitis in 3 (3.0%). Postoperative mild to moderate incontinence was noted in 2 patients (2.0%). Bladder neck constriction and urethral strictures occurred in 4 (4.1%) and 3 (3.0%) patients, respectively. CONCLUSIONS: Transvesical prostatectomy can be performed safely in elderly patients with a low morbidity rate.

Age Factors↗
PubMed1997

One core positive prostate biopsy is a poor predictor of cancer volume in the radical prostatectomy specimen.

PURPOSE: In view of the recent increase in patients presenting with only 1 core positive for prostate carcinoma, we examined the correlation in tumor volume between the biopsy and the subsequent radical prostatectomy specimen. MATERIALS AND METHODS: We studied a total of 169 consecutive prostate biopsies with matched radical prostatectomy specimens and selected 48 patients with only 1 positive core. RESULTS: Cancers found in the biopsy regardless of their size were associated with a wide range of cancer volume in the radical prostatectomy specimens, and the amount of cancer in the biopsy was a poor predictor of the volume of cancer in the prostatectomy specimen. Even with a cancer of 3 mm. or less in the biopsy, 57% of patients had cancer of clinically significant volume (greater than 0.5 ml.). Other modalities for the evaluation of prostate cancer such as Gleason score and clinical stage were not helpful in segregating patients with clinically significant from those with insignificant volume of cancer. However, when combined with a preoperative serum prostate-specific antigen higher than 10 ng./ml., 1 core positive biopsy could reliably predict the presence of cancer of significant volume. CONCLUSIONS: One core only positive prostate biopsy, when accompanied by an elevated serum prostate specific antigen value (greater than 10 ng./ml.), strongly suggests the presence of clinically significant cancer.

Adenocarcinoma↗
PubMed1997

Hematolymphoid malignancies diagnosed at the time of radical prostatectomy.

PURPOSE: The clinical impact of hematolymphoid malignancies discovered during radical prostatectomy has not been previously defined to our knowledge. MATERIALS AND METHODS: From October 1988 to September 1995, 1,092 patients underwent radical retropubic prostatectomy. RESULTS: Of 1,092 radical prostatectomy specimens, 13 (1.2%) were found to have hematologic malignancies involving the prostate and/or lymph nodes sampled during concomitant pelvic lymph node dissection. The malignancies detected included Hodgkin's disease (3) and hairy cell leukemia (1), which required further therapy. However, 9 of the 13 patients (62%) demonstrated either chronic lymphocytic leukemia (3) or low grade, small lymphocytic lymphoma (6), which requires symptomatic treatment only. The transrectal ultrasound guided prostate biopsies revealed suspicious lymphocytic infiltrate in addition to prostatic adenocarcinoma in 2 of the 13 patients (15%). CONCLUSIONS: The majority of hematologic malignancies discovered at radical prostatectomy do not require further treatment and should not delay treatment of prostatic adenocarcinoma.

Adenocarcinoma↗
PubMed1997

Results of hospital cancer registry surveys by the American College of Surgeons: outcomes of prostate cancer treatment by radical prostatectomy.

BACKGROUND: The number of prostate cancer patients treated by radical prostatectomy has increased. Different data sources have yielded various estimates of the outcomes of this treatment and the need for additional therapy. To provide additional perspective on these issues, the American College of Surgeons conducted surveys of cancer registries and reviewed related data. METHODS: In 1993, in the first phase of the study, hospital cancer registries and programs were sent survey forms and instructions requesting data on up to 5 patients treated by radical prostatectomy at their institutions in 1990. In 1996, in the second phase of the study, additional data were requested on treatment administered to the 1990 patients up to 5 years after surgery, and hospitals were also invited to submit new data on patients diagnosed in 1993. Responses were received from 482 hospitals concerning 2122 patients for 1990, and 265 hospitals provided data on 1304 patients diagnosed in 1993. Follow-up data on 1076 of the 1990 patients were provided by 258 hospitals. Kaplan-Meier survival curves were calculated to determine the probability of additional treatment after radical prostatectomy. RESULTS: Similar surgical pathology outcomes were reported for the 1990 and 1993 patients. For 1990 and 1993, respectively, it was reported that 27.5% and 29.7% of patients maintained erectile function adequate for intercourse after surgery. For 1990 and 1993, respectively, complete control or only occasional urinary incontinence requiring no pads was reported for 81.3% and 79.8% of patients. The surgical mortality rates were less than 1% for both the 1990 and the 1993 patients. The 5-year cumulative probability of any additional treatment after radical prostatectomy was 10.5%. Seminal vesicle involvement, positive surgical margins, lymph node involvement, capsular penetration, high Gleason score, and high prostate specific antigen were significantly associated with greater probability of additional treatment. CONCLUSIONS: Hospital cancer registries are valuable sources of data on patterns of care and outcome for prostate cancer patients. Continuing evaluation of the outcomes of prostate cancer treatments is needed to reconcile the differences in outcomes reported from different data sources.

Erectile Dysfunction↗
PubMed1997

[New review of radical prostatectomy].

The author raises some doubts regarding arguments that have been used to justify the increase in the number of radical prostatectomies in localized prostate cancer. In well or moderately differentiated localized prostate cancer who undergo radical prostatectomy do not show marked differences in mortality in relation to patients subjected only to watchful waiting. Results between the two groups are similar even though their being slanted by significant differences between the two groups in the definition of tumour staging. Characterization is much more accurate in cases undergoing radical prostatectomy, where tumours not confined to the prostate are excluded from the operation by histological examination of regional lymph-nodes. This fact is clearly unfavourable in cases where conservative therapy is used and in which, frequently carcinomas apparently confined to the prostate are included, even though they are not really localized. The author concentrates on patients with undifferentiated, highly aggressive, tumours that seem to call for equally aggressive therapy. Radical prostatectomy has exhibited a cure rate in these patients which, though not very high, bears substantial significance since, without treatment, this type of aggressive carcinomas kills nearly one hundred percent of the patients.

Humans↗