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PubMed2006

Implementation of a map in radical prostatectomy specimen allows visual estimation of tumor volume.

INTRODUCTION: Tumor volume is one of the best documented prognostic factors for prostate cancer. There are several methods to gain this important parameter but unfortunately most of the clinicians in the world do not get this information in their routine practice from the pathologist. We developed a standardized method to handle radical prostatectomy specimens including a special form of mapping in order to document relevant morphological data. The aim of this study was to investigate if our model of mapping prostate cancer, which we use in routine practice, may serve for visual estimation of tumor volume. METHODS: We estimated the tumor volume of prostate cancer by visual estimation of 350 maps of radical prostatectomy specimens and correlated these data with established prognostic parameters and clinical outcome. RESULTS: Significant correlations between tumor volumes, as obtained from our mapping, and known prognostic parameters such as preoperative serum levels of prostatic specific antigen, loss of differentiation, histological grade, lymph node metastasis, and margins were found. In a multivariate analysis, only Gleason score and tumor stage were shown to be independent prognostic parameters. DISCUSSION: We demonstrate that mapping of prostate cancer is more than a simple method of documentation but may serve as a method for visual estimation of tumor volume of prostate cancer after radical prostatectomy. This method can further be used for a visual documentation of the tumor stage independent of changes in the TNM classification. The method is inexpensive and practicable and can therefore be applied in routine surgical pathology.

Adenocarcinoma↗
PubMed2004

Current and future strategies for preventing and managing erectile dysfunction following radical prostatectomy.

INTRODUCTION AND OBJECTIVES: As radical prostatectomy remains a commonly used procedure in the treatment of clinically localized prostate cancer, we critically analyzed current and future strategies for preventing and managing postoperative erectile dysfunction. METHODS: Systematic literature review using Medline and CancerLit from January 1997 to June 2003. Abstracts published in the journals European Urology, The Journal of Urology and the International Journal of Impotence Research as official proceedings of internationally known scientific societies held in the same time period were also assessed. RESULTS: Patient selection and surgical technique are the major determinants of postoperative erectile function. Apoptosis of corporeal smooth muscle cells plays a role in the development of cavernous veno-occlusive dysfunction following radical prostatectomy. Pharmacological prophylaxis and treatment of postoperative erectile dysfunction is effective and safe. The concepts of cavernous nerve reconstruction and neuroprotection have been associated to promising results. CONCLUSIONS: In the hands of experienced surgeons, properly selected patients undergoing a nerve sparing radical prostatectomy should achieve unassisted or medically assisted erections postoperatively.

Erectile Dysfunction↗
PubMed2003

Combined reporting of cancer control and functional results of radical prostatectomy.

INTRODUCTION: The results of radical prostatectomy (cancer control, continence and sexual potency) are currently presented separately, while the success of this surgery depends on a combination of good cancer control with maintenance of continence and erections. We propose a score to jointly evaluate and report cancer control and functional results. METHODS: The results of 205 radical prostatectomies were studied at one year. Cancer control was evaluated by PSA. Continence and sexual potency were evaluated by a self-administered questionnaire. Each patient was attributed 0 or 4 points according to the presence of absence of biochemical progression (PSA>0.2 ng/ml), 0 or 2 points according to the presence or absence of urinary incontinence (use of pads) and 0 or 1 point according to the presence or absence of impotence (no erections). The sum of these points provided a score classifying the patient into 8 distinct categories, from 0 to 7, each corresponding to a specific status (from 0 (0+0+0): no cancer control-incontinence-impotence to 7 (4+2+1): cancer control-continence-sexual potency). RESULTS: One year after the operation, 175 (85%) of patients had a PSA less than 0.2 ng/ml, 135 (65.8%) were continent and 64 (32.7%) reported erections. All patients with a score > or =4 had good cancer control, with no functional disorders for a score of 7 (4+2+1) (20%), no disorders of continence for a score of 6 (4+2+0) (31.5%), no disorders of erection for a score of 5 (4+0+1) (8.3%), or with incontinence and impotence for a score of 4 (4+0+0) (21.9%). All patients with a score <4 had a PSA>0.2 ng/ml, but with no functional disorders for a score of 3 (0+2+1) (2.4%), no incontinence for a score of 2 (0+2+0) (8.3%), and no impotence for a score of 1 (0+0+1) (1.9%). 1.9% of patients were incontinent, impotent and showed signs of biochemical progression (score 0=0+0+0). CONCLUSION: This score allows analysis of the global (cancer control and functional) results of radical prostatectomy and would facilitate comparisons between various surgical techniques (type of approach, nerve-sparing techniques) and various centres.

Aged↗
PubMed2004

Prospective randomized trial comparing flutamide as adjuvant treatment versus observation after radical prostatectomy for locally advanced, lymph node-negative prostate cancer.

OBJECTIVE: To assess the efficacy and the tolerability of flutamide as adjuvant treatment after radical prostatectomy for locally advanced, lymph node-negative prostate cancer. METHODS: Men with locally advanced, lymph node-negative prostate cancer were randomized after radical prostatectomy to receive either flutamide 750mg daily or no adjuvant treatment. Recurrence-free and overall survival were the study end points. Recurrence was defined as a PSA value greater than 5ng/ml or two values greater than 2ng/ml more than three months apart with increasing tendency or three values greater than 1ng/ml more than three months apart with increasing tendency or any clinical recurrence. RESULTS: 309 patients (157 in the control arm and 152 in the flutamide arm) were eligible for efficacy analysis. The median follow-up was 6.1 years. Recurrence-free survival was better in the flutamide group ( P=0.0041), there was, however, no detectable difference in overall survival ( p=0.92 ). Moreover, there was a considerable toxicity reported in the flutamide group. CONCLUSION: Although having some effect on disease recurrence, adjuvant flutamide treatment does not improve median-term overall survival after radical prostatectomy for locally advanced, lymph node-negative prostate cancer.

Aged↗
PubMed2005

Pfannenstiel versus vertical laparotomy in patients undergoing radical retropubic prostatectomy with spinal anesthesia: results of a prospective, randomized trial.

OBJECTIVE: To evaluate the impact of a standard vertical laparotomy versus a Pfannenstiel transverse laparotomy on intra-, peri-operative, and 6-month follow-up outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia. METHODS: Between January 2003 and June 2003, 69 age-matched consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia and were randomized into Group 1 (vertical laparotomy: 35 patients) and Group 2 (Pfannenstiel laparotomy: 34 patients). An extensive analysis of the critical intra-, peri-operative, and 6-month follow-up clinical parameters was performed. RESULTS: Both the hemodynamics and the biochemical balance were not significantly different between the two groups. Overall blood loss (p = 0.78), autologous (p = 0.88) and homologous (p = 0.36) blood transfusions were similar regardless of the type of laparotomy. Surgical time was not significantly (p = 0.27) different between the two groups. Similarly, the two forms of laparotomy did not differ regarding the length of the surgical incision (p = 0.21), as measured at the end of the procedure. Post-operative oxygen saturation percentage by pulse oximetry, as well as post-op sedation score, were not significantly different (p = 0.06 and p = 0.97, respectively). Waiting time in the post-operative holding area (p = 0.15), and pain score in the post-operative holding area (p = 0.9) as well as on post-operative day 1 (p = 0.1) were not significantly different between the two groups. The rate of first flatus passage and of unassisted ambulation were similar regardless of the type of laparotomy during post-operative day day 1. The two types of incision made it possible to remove a similar (p = 0.34) number of pelvic lymph nodes and were associated to a similar rate of positive surgical margins among pT2 patients. At the 6-month follow-up the occurrence of a pelvic lymphocele and of deep venous thrombosis was similar in the two groups (p = 0.6 and p = 0.16, respectively). Complete urinary continence and spontaneous erectile function recovery was reported in a similar number of patients regardless of the type of surgical incision (p = 0.59 and p = 0.40, respectively). CONCLUSIONS: These results suggest that a Pfannenstiel transverse suprapubic laparotomy does not result in a significantly different outcome from a standard vertical laparotomy in patients undergoing a radical retropubic prostatectomy with pelvic lymphadenectomy with L2-L3 spinal anesthesia for clinically localized prostate cancer.

Aged↗
PubMed2005

Does the tertiary Gleason pattern influence the PSA progression-free interval after retropubic radical prostatectomy for organ-confined prostate cancer?

INTRODUCTION: The Gleason sum is an important prognostic parameter for patients treated with radical prostatectomy for localized prostate cancer. However, frequently more than two predominant Gleason patterns are present in one specimen. In this study we investigated the prognostic significance of tertiary Gleason patterns in radical prostatectomy specimens. PATIENTS AND METHODS: Between 1994 and 2001, 277 patients underwent radical retropubic prostatectomy (RRP) for clinically localised prostate cancer in our institute. We collected information on Gleason score and cancer volume (CV) for all tumour localizations, clinical and pathological stage, seminal vesicle invasion (SVI) and extra capsular extension (ECE). In case one pattern was seen in more than 95% of the tumour, this pattern was used both for the primary and secondary Gleason pattern, and any other pattern (actually the secondary pattern) was called tertiary. Charts were examined retrospectively for clinical follow up. PSA progression was defined as two subsequent rising PSA measurements above 0.10 ng/ml. Kaplan-Meier time to PSA progression was compared between patients with and without a tertiary pattern. RESULTS: Overall, of the 223 patients, 106 (48%) were found to have a tertiary pattern, which on average, was 7% of the total tumour volume. Patients with a tertiary pattern had a 5-year risk of PSA progression of 37.3% versus 12.6% in case no tertiary Gleason pattern was present (log rank p=0.0002). There was no prognostic difference between patients with a higher-grade tertiary pattern as compared to those with a lower grade tertiary pattern. CONCLUSIONS: If present, a tertiary Gleason pattern, whether better or worse than the primary or secondary pattern, is an indication for a worse outcome, as indicated by a shorter time to PSA progression. This suggests that tumour multifocality, rather than the presence of a higher-grade tertiary Gleason pattern has prognostic value.

Biomarkers, Tumor↗
PubMed2005

Digital rectal examination is no longer necessary in the routine follow-up of men with undetectable prostate specific antigen after radical prostatectomy: the implications for follow-up.

OBJECTIVES: We determined the role of Digital Rectal Examination (DRE) in the follow-up of those patients treated with radical prostatectomy for clinically localised prostate cancer having an undetectable PSA. We discuss the implications of our findings. MATERIALS AND METHODS: An analysis was performed of a prospectively organised data base of 1118 patients treated at our institution by radical prostatectomy after the introduction of PSA in 1987. A strict definition of PSA progression was used, that is any elevation above undetectable PSA or lowest recorded post-operative PSA (nadir), in order not to miss a single patient who may have recurrent local disease or distant metastases without PSA progression. We counted local recurrent disease as those patients having histologically proven adenocarcinoma on TRUS directed biopsies, and distant disease as those patients having detectable metastatic disease on radionuclide bone scan. RESULTS: The median follow-up was 4.0 years (3 months to 15 years). 524 men (46.9%) had a follow-up of more than 5 years and 88 men (7.9%) of more than 10 years. A total of 397 men (35.5%) had biochemical progression according to our strict definition. 53 patients (4.7%) developed a histological local recurrence and 57 men (5.1%) developed bony metastases; none of these men had an undetectable PSA or a stable PSA at nadir level at the time of detection. They all demonstrated a rising PSA. CONCLUSIONS: DRE is no longer necessary in the routine follow-up of patients with an undetectable PSA after radical prostatectomy. Following a period of approximately 2 years of out-patient clinic follow-up post-operatively in which issues such as incontinence and erectile dysfunction are addressed and treated, it is possible to restrict follow-up to PSA determinations alone and as long as the PSA remains undetectable counselling can be carried out by a nurse practitioner.

Adult↗
PubMed2005

Positive surgical margins and accessory pudendal artery preservation during laparoscopic radical prostatectomy.

PURPOSE: To determine whether preservation of accessory pudendal arteries (APAs) adversely influences the rate of positive surgical margins (PSMs) during laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Between January 2003 and January 2005, 377 men with clinically localized prostate cancer underwent a LRP; 325 met inclusion criteria for this study. The variety (apical or lateral), laterality (left or right), size, and preservation status of all identified APAs were prospectively recorded. A genitourinary pathologist mapped the specimens and established tumor locations and PSM sites. RESULTS: Ninety-six of 325 men (30%) were found to have 125 separate APAs. The apical variety predominated; 56% of APAs were apical and 44% were lateral. Successful preservation was possible for 104/125 (83%) individual arteries. The overall rate of PSM was 11.7%. The rates for those with and without identified APAs were 9% and 13%, respectively (p=0.4). The incidence of PSMs in the ipsilateral region of APA localization was not affected by preservation status; ipsilateral PSM rates were 3% and 6% for those preserved and not preserved, respectively (p=0.5). CONCLUSIONS: Identification and preservation of APAs during laparoscopic radical prostatectomy did not adversely affect the rates of PSMs. APA preservation can be undertaken without compromise to the oncological integrity of the laparoscopic radical prostatectomy.

Arteries↗
PubMed2006

Laparoscopic and robotic assisted radical prostatectomy--critical analysis of the results.

OBJECTIVE: To evaluate the role of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RLRP) based on personal experience and a review of the literature. MATERIAL AND METHODS: Own experience at one European and one American LRP-center includes more than 2000 cases. We performed a MEDLINE search reviewing the literature on LRP and RLRP between 1992 and 2005 with special emphasis on historical aspects, technical considerations, comparison to open retropubic (RRP) and perineal radical prostatectomy (PRP), laparoscopic training, and the cost-efficiency of the techniques. RESULTS: Based on sophisticated training programs a continuous dissemination of the technique took place. In the United States, this process was accelerated by the use of the daVinci-robot. There is a trend towards the extraperitoneal access. Mid-term outcomes of LRP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower rate of complications, shorter convalescence, and better cosmesis. In contrast to RLRP, LRP may reach cost-equivalence with open surgery (i.e. by reduction of OR-time, use of multi-usable instruments). CONCLUSIONS: LRP reproduces the excellent results of open surgery providing the advantages of minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow. In contrast the United States, the use of robots is likely to remain limited in Europe.

Cost-Benefit Analysis↗
PubMed2006

Impact of a multidisciplinary continuous quality improvement program on the positive surgical margin rate after laparoscopic radical prostatectomy.

OBJECTIVE: Outcome after radical prostatectomy is highly sensitive to fine nuances in the surgical techniques. We sought to determine the impact of a process of continuous control and monitoring on the positive surgical margin rate in a contemporary series of laparoscopic radical prostatectomy. METHODS: Between January 2003 and October 2004, 301 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer (cT1-cT3a). A weekly case review conference involving surgeons, radiologists, and uropathologists was held to discuss the preoperative, intraoperative, and pathologic findings of significant cases. We analyzed the trend of positive surgical margins and compared the clinical and detailed pathologic characteristics of the cancer during the study period. RESULTS: We created logistic regression models with positive margin as the dependent variable and surgical experience as the predictor, adjusting for possible secular changes in disease severity (prostate-specific antigen, pathologic stage, and Gleason grade). There was a decrease in the rate of surgical margins: odds ratio 0.68/100 patients treated (95% confidence interval [CI] 0.44, 1.05; p=0.08). The predicted probability for a positive surgical margin falls from 17.3% for the first patient to 7.5% for the 301st. These values are close to the observed rates for the first and last 50 patients. There was no important change in surgical risk over the course of the study, and the rate of nerve sparing remained stable throughout the study period. CONCLUSIONS: In this contemporary series, which is unaffected by downward stage migration, the decreasing rate of positive surgical margins can be explained by subtle surgical technique modifications and a continuous multidepartmental effort for quality improvement.

Biopsy↗
PubMed2006

Oncologic outcome and continence recovery after laparoscopic radical prostatectomy: 3 years' follow-up in a "second generation center".

OBJECTIVES: Laparoscopic radical prostatectomy in major centers guarantees oncologic and functional results equal to open procedures. In our institution this operation was introduced in 2001 after an adequate training in laparoscopic surgery. We report the oncologic and functional results after 3 years of experience. METHODS: We considered our first 150 patients that had undergone transperitoneal laparoscopic radical prostatectomy. The following parameters were prospectively collected and analyzed: pathological findings, surgical margins, surgical time, blood loss, hospital stay, catheterization, complications, oncologic follow-up and continence. RESULTS: Single positive surgical margins were observed in 26 patients (17.3%) and multiple positive margins in 15 patients (10%). The rates of positive margins in organ confined tumors (pT2a/b) were 11.3%. Preoperative PSA>10 ng/ml (Chi-square p<0.01), pathological stage>pT2 (Chi-square p<0.001) and Gleason score>6 (Chi-square p<0.01) were significantly correlated with positive margins. Major complications occurred in 16 patients (10.7%). The total recurrence rate is 11.7%. The continence rate at 12 months is 91.7%.with 44.3% of patients completely continent at the moment of catheter removal. CONCLUSIONS: Laparoscopic radical prostatectomy in now a well codified operation that, after an adequate training, could be learned and reproduced safely. Actually this is our first choice surgical approach in patients with localized prostate cancer.

Adult↗
PubMed2006

Preliminary results on the off-label use of duloxetine for the treatment of stress incontinence after radical prostatectomy or cystectomy.

OBJECTIVES: Stress urinary incontinence (SUI) is a common compliant of patients after pelvic surgery. To date, no pharmacotherapy for men is available, but duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, has been successfully introduced and tested for SUI in women. The aim of our study was to evaluate if duloxetine is safe and effective for men with stress incontinence after radical prostatectomy or cystectomy. METHODS: Twenty patients were included in our study, 15 after radical prostatectomy and 5 after radical cystectomy and orthotopic ileal neobladder reconstruction. Each patient reported at least 3 wk of SUI despite doing consequent pelvic floor exercises. After exclusion of a urinary tract infection, we administered 40 mg duloxetine twice daily for a mean of 9.4 wk (range: 1-35 wk). RESULTS: After duloxetine, the average daily use of incontinence pads was lowered significantly (p < 0.001) from 8.0 (+/-6.5) to 4.2 (+/-5.9). Seven patients were completely dry or used one pad daily at most. Most patients reported mild side effects such as fatigue or a dry mouth, but these symptoms vanished after a short time. Six patients, however, had severe side effects, mainly massive fatigue or insomnia, and discontinued using duloxetine. CONCLUSIONS: Our preliminary results suggest that duloxetine is effective in men with SUI after prostatectomy or cystectomy. Further prospective studies with more patients included and a longer follow-up are recommended.

Aged↗
PubMed2006

Is pelvic lymph node dissection necessary in patients with a serum PSA<10ng/ml undergoing radical prostatectomy for prostate cancer?

OBJECTIVE: Controversy persists concerning the role of pelvic lymph node dissection (PLND) in patients with preoperative PSA values <10ng/ml undergoing treatment for prostate cancer with a curative intent. The aim of this study was to determine the incidence of lymph node metastasis in this subgroup of patients. METHODS: Patients with clinically localized prostate cancer and a serum PSA<10ng/ml, without neoadjuvant hormonal or radiotherapy, with negative staging examinations who underwent radical retropubic prostatectomy with bilateral extended PLND and with >/=10 lymph nodes detected by the pathologist in the surgical specimen, were included in the study. RESULTS: A total of 231 patients with a median serum PSA of 6.7ng/ml (range 0.4-9.98) and a median age of 62 years (range 44-76) were evaluated. A median of 20 (range 10-72) nodes were removed per patient. Positive nodes were found in 26 of 231 patients (11%), the majority of which (81%) had a Gleason score >/=7 in the surgical specimen. Of the patients with a Gleason score >/=7 in the prostatectomy specimen 25% had positive nodes, whereas only 3% with a Gleason score </=6 were node positive. CONCLUSIONS: The incidence of positive nodes in patients with clinically localized prostate cancer, a serum PSA<10ng/ml and a Gleason score >/=7 in the prostatectomy specimen was 25% after extended PLND. It seems that in this patient group extended PLND, including removal of nodes along the internal iliac vessels, is warranted.

Adult↗
PubMed2006

Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review.

OBJECTIVE: To review the literature available on robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: A literature search was performed using EMBASE, MEDLINE, and Web Science databases through a "free text" protocol, including the following terms: robotic radical prostatectomy, da Vinci, and radical prostatectomy. Three of the authors separately reviewed the records to select the papers relevant for the topic of the review, with any discrepancies solved by open discussion. The selected articles were recorded in an electronic database and analysed by version 13.0 SPSS software. RESULTS: We identified 71 manuscripts. Eleven papers focused on surgical technique, and 35 manuscripts reported clinical, pathologic, and/or follow-up data. Seven studies included clinical data concerning surgical series with fewer than 10 patients, whereas the remaining 26 series reported larger surgical series of RALP. RALP turned out to be a feasible procedure, with limited blood loss, favourable complication rates, and short hospital stays. Positive surgical margin rates decreased with the surgeon's experience and technique improving, reaching percentages similar to those of retropubic and laparoscopic series. The available oncologic data are only preliminary. Especially interesting are the data on postoperative continence rates, whereas results on potency, although promising, are based only on a limited number of patients and have to be considered as incomplete and premature. CONCLUSION: Literature showed that RALP had a short learning curve and interesting postoperative results, especially with regard to continence recovery. The available data on recovery of erectile function and oncologic follow-up are still incomplete.

Humans↗
PubMed2006

Complications, urinary continence, and oncologic outcome of 1000 laparoscopic transperitoneal radical prostatectomies-experience at the Charité Hospital Berlin, Campus Mitte.

OBJECTIVES: Laparoscopic transperitoneal radical prostatectomy (LRP) is an alternative to open radical prostatectomy, but data based on large populations are not frequently available. This study was initiated to evaluate LRP with regard to complications, urinary continence, and oncologic outcome. METHODS: We retrospectively reviewed 1000 consecutive patients with a mean age of 62 yr (SD+/-6 yr) and clinically localized prostate cancer. Between May 1999 and October 2004, all 1000 patients underwent LRP performed by eight urologists at one institution (Charité Hospital Berlin, Campus Mitte). The review procedure was based on complete patient documents (hospital stay, n=1000) and an interview by one physician. Histopathologic results, intraoperative and early and late complications, continence rate, and time to first PSA increase (n=952) were recorded. Erectile function was not part of this review. Twenty-two patients received neoadjuvant treatment for >2 mo. RESULTS: The median follow-up was 28.8 mo (range: 7.2 to 69.7). Intraoperative and early complications occurred in 11.8% of patients. In 77.6% the urethrovesical anastomosis tested by cystography at day 5 or 6 after LRP was intact; 76% used none or not more than one pad per 24h. The overall PSA-free survival was more than 90% for pT2, 80.3% for pT3a, and 72.4% for pT3b until July 2005. The mortality rate was 0.3%. CONCLUSIONS: In the present series of 1000 patients, a specific disadvantage of LRP compared with the open approach, as reported in the literature, could not be shown. On the basis of short-term follow-up data, our retrospective evaluation confirms that LRP provides satisfactory results. We believe that laparoscopic radical prostatectomy can be the technique of choice in the future.

Adult↗
PubMed2006

Zonal origin of localized prostate cancer does not affect the rate of biochemical recurrence after radical prostatectomy.

OBJECTIVE: To investigate whether transition zone (TZ) prostate cancers demonstrate different rates of biochemical recurrence after radical prostatectomy compared to peripheral zone (PZ) cancers. METHODS: In 1262 consecutive patients treated with radical prostatectomy, computerized planimetry defined tumour origin as either TZ tumours (>70% TZ location) or PZ. Kaplan-Meier and multivariate Cox regression models tested the association between zonal origin and the rate of biochemical recurrence (prostate-specific antigen >0.1ng/ml and rising). We used the Harrell's concordance index to quantify the accuracy of various Cox regression models. RESULTS: TZ prostate cancers were diagnosed in 115 patients (9.1%). Biochemical recurrence was recorded in 16 TZ and in 201 PZ prostate cancers patients. In multivariate Cox models, the rate of biochemical recurrence was not significantly different between TZ and PZ prostate cancers (p=0.4). Combined multivariate predictive accuracy of biochemical recurrence predictions was 81.2% accurate when zonal origin was included versus 81.0% when zonal origin was omitted. CONCLUSIONS: The zonal origin of prostate cancers does not affect the rate of biochemical recurrence after radical prostatectomy.

Humans↗
PubMed2006

Anatomy and preservation of accessory pudendal arteries in laparoscopic radical prostatectomy.

OBJECTIVE: The incidence of laparoscopically diagnosed accessory pudendal arteries (APAs) varies depending on how proactive the surgeon is to find them. Their preservation depends on their calibre and location. Our objective was to provide a detailed description of how to identify, dissect, and preserve APAs during laparoscopic radical prostatectomy (LRP). METHODS: Between January 2003 and January 2005, we treated 377 men with LRP; 325 met inclusion criteria for this study. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudally towards the anterior perineum, other than cavernous arteries, corona mortis, and satellite arteries to the superficial and deep vascular complex. Two distinct varieties of APAs were identified: (1) lateral APAs course along the lateral aspect of the prostate and branch off any of the terminal branches of the hypogastric artery; and (2) apical APAs emerge through the levator ani fibres near the apical region of the prostate and most likely branch off the pudendal artery or corresponds to an aberrant course of the pudendal artery itself. We present a video depicting the laparoscopic anatomy of APAs and the technique to preserve them. RESULTS: Ninety-six of 325 men (30%) were found to have 125 separate APAs. Using the depicted surgical technique, we were able to preserve 83% of all APAs. Forty-nine of 55 lateral APAs (89%) and 55 of 70 apical APAs (79%) were preserved. Thirty-five of 38 large-calibre APAs (92%) and 70 of 87 small-calibre APAs (80%) were spared. The side-specific incidence of PSMs were 3% and 6% when APAs were preserved and not preserved, respectively (p=0.5). CONCLUSIONS: APAs are frequently identified during laparoscopic prostatectomy. Their preservation is feasible in LRP without increasing the risk of causing a PSM. It is reasonable to integrate APA preservation as part of the modern radical prostatectomy, although their role in functional outcomes still needs to be prospectively established.

Arteries↗
PubMed2006

Risk-adjusted analysis of positive surgical margins following laparoscopic and retropubic radical prostatectomy.

OBJECTIVES: To prospectively compare in a contemporary and contemporaneous series the positive surgical margin (PSM) rate between laparoscopic (LRP) and retropubic (RRP) radical prostatectomy at the same institution. METHODS: Between 1 January 2003 and 30 June 2005, 1177 consecutive men with clinically localized adenocarcinoma of the prostate underwent radical prostatectomy at the same institution: 485 laparoscopically and 692 through a retropubic approach. Partin table probability of organ-confined (OC) disease was used as an index of disease aggressiveness: The PSM rate between the two approaches was compared, with adjustment for the OC probability. RESULTS: Overall both surgical approaches had a comparable PSM rate of 11.3% after LRP and 11% after RRP. In a logistic regression analysis adjusting for OC probability, there was no statistically significant difference between LRP and RRP (odds ratio [OR]: 1.156; 95% confidence interval [%95 CI], 0.792, 1.686; p=0.5). There was a statistically significant decrease over time in the rate of PSM for LRP (OR: 0.71 per 100 patients treated; %95 CI, 0.57, 0.89; p=0.003), while that of RRP was unchanged (OR: 1.06 per 100 patients treated; %95 CI, 0.94, 1.21; p=0.3; p=0.002 for interaction between change over time and procedure). CONCLUSIONS: In our institution, laparoscopic and retropubic radical prostatectomy provide comparable PSM rates for patients with clinically localized prostate cancer. The PSM rate over the study period remained unchanged in the RRP experience, indicating a mature and well-established operative technique, while that of LRP underwent a significant decrease, demonstrating that the procedure and therefore the results continued to evolve during the study.

Adenocarcinoma↗