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PubMed1988

Prostatectomy in patients with bleeding disorders.

Urological surgery is becoming increasingly necessary in patients with acquired or congenital bleeding disorders. We reviewed the management of 10 such patients who required prostatectomy. The average age of the patients at operation was 65.7 years. Seven patients underwent transurethral prostatectomy and 3 underwent suprapubic prostatectomy. Postoperative bleeding occurred in 9 patients who required secondary procedures. Bleeding occurred an average of 13 days postoperatively. The mean hospital stay was 24 days. Partial thromboplastin time when determined was uniformly elevated in all patients preoperatively. The amount of factor and blood replacement is presented. Perioperative management of these patients is discussed in detail. A rational approach for the prevention of postoperative bleeding is presented.

Adult↗
PubMed1988

Physician-generated cost containment in transurethral prostatectomy.

Cost containment need not be imposed on physicians by government, insurance companies and hospital administrators. Decreases in hospital cost can be achieved voluntarily by physicians without sacrificing quality of care, especially for common procedures with relatively homogeneous patient populations, such as transurethral prostatectomy. Variations in existing practice were identified and shared, and optimal scientific practice was discussed at 5 meetings of the division of urology during a 16-month period. Strict guidelines were not developed; surgeons were encouraged to apply cost-related knowledge individually. Resource use was measured before, during and after the intervention. A total of 356 transurethral prostatectomies was studied. There were significant decreases in preoperative and postoperative length of stay, specific ordering practices and total hospital charges. University faculty differed from community urologists and individual surgeons varied considerably. Suggestions for scientific cost management in prostatectomy are presented.

California↗
PubMed1988

Intermediate-term survival results in clinically understaged prostate cancer patients following radical prostatectomy.

To determine the natural history of clinically understaged prostatic cancer patients who were followed without adjuvant therapy for at least 6 years after radical prostatectomy we reviewed the clinical courses of 21 patients (1 with clinical stage A and 20 with clinical stage B disease). All patients underwent radical retropubic prostatectomy and 9 had pathological stage C disease (6 with capsular penetration only and 3 with seminal vesicle invasion). A total of 12 patients had pathological stage D1 disease by virtue of positive nodes on permanent sections after frozen sections were read as negative. Among the patients with pathological stage C disease 67 per cent were free of recurrence 6 years after radical prostatectomy. Of the patients with seminal vesicle invasion 33 per cent had recurrence compared to 17 per cent of those with capsular penetration only. Among the 12 stage D1 cancer patients 75 per cent were free of recurrence at 6 years. In both groups patients who were followed beyond 7 years had a diminished survival free of tumor owing to late tumor recurrences. The results indicate that the intermediate survival rates free of tumor in patients with clinically understaged A or B prostatic cancer are remarkably good without adjuvant therapy. However, survival without recurrence appears to decrease after 7 years. All patients who failed treatment did so distantly; no patient failed with local recurrence alone. These results may be important in the evaluation of adjuvant therapy protocols currently under investigation for patients with clinically understaged prostate cancer.

Adenocarcinoma↗
PubMed1988

Potency-sparing radical perineal prostatectomy: anatomy, surgical technique and initial results.

By integrating a re-examination of perineal anatomy with the recently described anatomy of the pelvic nerve plexus and the cavernous nerves, a modification of radical perineal prostatectomy that can preserve potency has been developed. In 16 patients who underwent this procedure immediately after bilateral pelvic lymphadenectomy the traditional low morbidity of radical perineal prostatectomy was retained, and potency was preserved in 5 of 9 patients (56 per cent), including all whose tumor was confined within the specimen margins. Review of the anatomy of the pelvic fascia also demonstrates that additional fascia around the lateral and dorsal surfaces of the prostate can be removed during radical perineal prostatectomy when one is willing to sacrifice the cavernous nerves to achieve a more radical excision of the prostate.

Adenocarcinoma↗
PubMed1988

The volume and anatomical location of residual tumor in radical prostatectomy specimens removed for stage A1 prostate cancer.

A detailed histological analysis of 21 prostatectomy specimens for stage A1 disease was performed. Three cases (14 per cent) demonstrated no tumor, although all had foci of severe dysplasia. Of the prostates 18 (86 per cent) contained residual tumor: 13 (62 per cent) had minimal residual tumor and 5 (24 per cent) had substantial tumor. The residual carcinoma in the prostates with minimal tumor was predominantly in the apex of the gland or peripherally adjacent to the capsule such that complete removal by repeat transurethral resection would have been unlikely. Of the 5 specimens with substantial tumor, although some would have been upstaged by repeat transurethral resection, others would have remained stage A1 because of the peripheral location of the residual tumor. Within the definition of stage A1, using either the percentage of tumor involvement, weight of tumor or number of tumor foci in the transurethral resection specimen, one could not predict whether the prostatectomy specimen would have no, minimal or substantial residual tumor. Postoperatively, all patients are continent and 93 per cent are potent. Because some men with stage A1 carcinoma of the prostate will have substantial residual tumor not necessarily detected by repeat transurethral resection and the majority will have minimal residual tumor, which also appears to have an increased long-term risk of progression, radical prostatectomy should remain an option in the management of relatively young men with stage A1 disease.

Adenocarcinoma↗
PubMed1987

Postoperative radiotherapy for patients with carcinoma of the prostate undergoing radical prostatectomy with positive surgical margins, seminal vesicle involvement and/or penetration through the capsule.

Between 1970 and 1983, 442 patients were treated for carcinoma of the prostate at our university medical center. Of the patients 319 underwent radical prostatectomy and 159 (50 per cent) had positive surgical margins and/or seminal vesicle involvement. Of these 159 patients 46 received postoperative irradiation and the actuarial survival was 96, 90 and 90 per cent at 5, 10 and 15 years, respectively. Among the remaining 113 patients who were treated with an operation alone the corresponding figures were 82, 62 and 21 per cent, respectively (p equals 0.02). Considering deaths only of cancer, the surgery only patients had a 15-year actuarial survival of 25 per cent compared to 90 per cent for those who underwent postoperative radiotherapy (p equals 0.07). Actuarial survival free of disease for the surgery plus postoperative irradiation group at 15 years was 40 per cent compared to 28 per cent for the surgery only group (p equals 0.34). Actuarial local control in the irradiated patients was 96 per cent at 15 years versus 32 per cent for the surgery only group (p equals 0.009). Actuarial survival free of distant disease at 15 years was 42 per cent in the irradiated versus 72 per cent in the nonirradiated groups (p equals 0.104). Severe complications attributable to radiation included 3 cases of radiation cystitis, 1 patient with urinary incontinence and leg edema in 9 per cent of the patients undergoing postoperative irradiation compared to 2 per cent of those treated with radical prostatectomy only. Postoperative irradiation appears to be indicated in patients with carcinoma of the prostate who undergo radical prostatectomy and who have positive margins and/or seminal vesicle involvement. Local control is markedly improved (p equals 0.009) and actuarial survival also is benefitted. There was a trend toward decreased deaths of cancer with postoperative irradiation that approached statistical significance. Postoperative irradiation did not improve survival rates free of disease and free of distant disease over those achieved with surgery alone. This finding suggests that while postoperative irradiation may not improve the ultimate cure rate by controlling local disease, early deaths of cancer are reduced resulting in a meaningful increase in survival for these patients.

Actuarial Analysis↗
PubMed1986

Lower tract urolithiasis after prostatectomy.

Nine cases of lower tract urolithiasis after prostatectomy are reported. In addition to these 9 cases 223 from the world literature and 10 from our previous experience also are reviewed. Stones may form after prostatectomy in various locations of the lower urinary tract, including the bladder, bladder diverticulum, prostatic fossa, simultaneously in the bladder and prostatic fossa, and, occasionally, in an iatrogenic pouch. They occur after all forms of prostatectomy, that is surgical or endoscopic, and after benign as well as malignant prostatic lesions. Calculi that form in the bladder most frequently are the result of stasis owing to bladder neck contracture or recurrence of prostatic enlargement. Calculi that form in the prostatic bed (or fossa) are caused by a ligature, infection or a chip of prostate left behind in the prostatic bed. Diagnosis is sometimes difficult because these stones are not always radiopaque and they are not always seen on endoscopy. The interesting theoretical considerations concerning the etiology of these calculi and the measures that could be helpful in their prevention, such as meticulous postoperative care, are discussed.

Aged↗
PubMed1985

Blood transfusion and anesthetic practices in radical retropubic prostatectomy.

We have attempted to lessen blood transfusion requirements during radical retropubic prostatectomy. The influence of temporary occlusion of the hypogastric arteries, anesthetic techniques and autologous blood transfusions were studied in 93 men undergoing radical retropubic prostatectomy with pelvic lymph node dissection. Operations performed with the patient under general or regional anesthesia with hypogastric artery clamping required significantly less blood replacement than those performed without hypogastric artery clamping (1.8 plus or minus 0.3 versus 3.5 plus or minus 0.3 units, respectively, mean plus or minus standard error). Preoperative autologous banking of blood eliminated the need for heterologous transfusions in 10 of 15 patients in whom any autologous blood was banked (2 to 4 units per person). We conclude that temporary hypogastric artery clamping can reduce significantly the need for blood product replacement in radical retropubic prostatectomies during the perioperative period. We also are encouraging the preoperative banking of autologous blood to lessen further exposure to heterologous blood products with their attendant risks.

Adenocarcinoma↗
PubMed1985

Nerve-sparing radical prostatectomy: extraprostatic tumor extension and preservation of erectile function.

A total of 52 patients underwent a nerve-sparing radical retropubic prostatectomy for clinical stage A or B prostatic cancer. The incidence of positive surgical margins (18 per cent of the patients with stages A and B1, and 57 per cent with stage B2 disease) was not significantly different (p less than 0.5) from that of 25 patients who underwent a standard radical retropubic prostatectomy by the same surgeon (18 per cent with stages A and B1, and 50 per cent with stage B2 cancer). Of 42 patients who were sexually potent preoperatively 41 (98 per cent) have had partial return of erectile function and 22 (52 per cent) have had return of erections sufficient for vaginal penetration. No correlation between clinical or pathological stage and postoperative potency was observed. Erections sufficient for penetration returned in 67 per cent of the patients less than 60 and 43 per cent of those more than 60 years old. The results suggest that with the nerve-sparing modification of radical retropubic prostatectomy sexual function can be preserved in the majority of patients with clinical stage A or B prostatic cancer without compromising the adequacy of tumor excision.

Humans↗
PubMed1985

Radical prostatectomy with adjuvant radioactive gold for prostatic cancer: a preliminary report.

A total of 71 patients with prostatic carcinoma underwent radical prostatectomy combined with instillation of radioactive gold seeds between January 1, 1977 and July 1, 1982. Gold seeds were implanted intraoperatively into the region of the prostatic vascular pedicles and surrounding fibrolymphatic tissue after removal of the prostate and seminal vesicles. Of the patients with disease confined to the prostate clinically 46.7 per cent had microscopic extraprostatic local tumor extension. We believe that patients with extraprostatic local tumor derive therapeutic benefit from the addition of adjuvant radioactive gold seeds at prostatectomy. Because of the inaccuracy of clinical staging by rectal examination, we have elected to use radioactive gold seeds in all of our patients at prostatectomy. To date, local recurrence has been noted in 5.6 per cent of our patients and systemic progression in 14.1 per cent.

Adenocarcinoma↗
PubMed1984

Transurethral polytetrafluoroethylene injection for post-prostatectomy urinary incontinence.

Transurethral polytetrafluoroethylene (Teflon) injections were performed on 69 men with incontinence following prostatectomy. The etiology of incontinence was transurethral resection of the prostate in 27 patients (group 1), open prostatectomy in 15 (group 2) and radical prostatectomy in 27 (group 3). All patients had been incontinent for more than 1 year and had failed to improve with conservative management. Cure or improvement occurred in 85.1 per cent of the patients in group 1, 79.9 per cent in group 2 and 48.1 per cent in group 3. Reasons for failure included severe bladder instability, severe periurethral fibrosis and leakage of paste. Clinically significant particle migration was not observed.

Aged↗
PubMed1984

External beam radiation salvage for residual or recurrent local tumor following radical prostatectomy.

External beam radiation therapy was used as a means of salvage in 32 patients with either incomplete excision or palpable local recurrence following radical prostatectomy. Patients were divided into 2 groups consisting of 13 patients who were referred within 4 months of incomplete excision (group 1) and 19 who were referred only after palpable local recurrence had developed (group 2). The 5 and 10-year actuarial survival free of disease in group 1 was 57 per cent, compared to 40 and 20 per cent for group 2 (p equals 0.05). Fourteen patients with an elevated pre-radiation therapy serum acid phosphatase level and/or bladder invasion had an especially poor prognosis, with a median survival free of disease of only 2.4 years. Ten complications were recorded in 5 patients (16 per cent), which were slightly higher than experienced in irradiated patients without a previous radical operation. The data support the contention that external beam radiation therapy may offer a means of post-radical prostatectomy salvage for selected patients with incomplete excision or palpable local recurrence. The best results were obtained in patients who were referred within 4 months of prostatectomy because of incomplete excision rather than waiting for palpable local recurrence to develop.

Adenocarcinoma↗
PubMed1984

Bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma confined to the prostate.

A total of 519 patients with clinical stage B disease underwent radical prostatectomy from 1966 to 1981: 65 (12.5 per cent) had pathologic stage D1, 72 (14.0 per cent) pathologic stage C and 382 (73.5 per cent) pathologic stage B disease. Of the 519 patients 320 with pathologic stage B1 (239) or B2 (81) adenocarcinoma of the prostate and no prior hormonal or radiation therapy underwent complete pelvic lymphadenectomy and radical retropubic prostatectomy. Stage, grade and size of tumor were associated significantly with interval to disease progression but not with survival. The probable explanation for this observation is that only 2 per cent of 186 patients who were followed for 5 years and 2 per cent of 46 who were followed for 10 years died of prostatic carcinoma within these intervals. The over-all survival of patients who had intracapsular prostatic carcinoma was not different from that of an age-matched surgical control group (men undergoing total hip arthroplasty during the same interval). These observations suggest that although morbidity from alternative therapies may vary no other treatment modality offers survival superior to that observed for pelvic lymphadenectomy and radical retropubic prostatectomy in patients with pathologic intracapsular prostatic cancer.

Adenocarcinoma↗
PubMed1983

Risk of urinary incontinence following radical prostatectomy.

Of 143 prostatic cancer patients treated with radical prostatectomy 38 had undergone transurethral resection of the prostate before the prostatectomy. After radical prostatectomy 5 per cent of the patients who did not have a resection and 8.1 per cent of those who did were severely incontinent. This difference is not statistically significant.

Adult↗
PubMed1982

Radical perineal prostatectomy for clinical stage B2 carcinoma of the prostate.

To refine the criteria for radical surgery in clinical stage B2 prostatic cancer a retrospective study was made of 53 patients who underwent radical perineal prostatectomy between 1951 and 1963. The 15-year survival free of tumor was 25 per cent, significantly less than the 51 per cent survival rate in a series of patients with clinical B1 disease undergoing radical perineal prostatectomy during the same period. Sixty-six per cent of the patients had extraprostatic extension of tumor on histological examination. The 15-year survival free of tumor in these patients was only 13 per cent, whereas those patients with tumor histologically confined to the prostate had a 15-year survival rate of 50 per cent, equal to an age-matched control population. Thus, although prolonged survival was demonstrated in patients without extraprostatic extension only a third of all clinical B2 cases were in this favorable category. Consequently, until improved reliable techniques for detection of extraprostatic extension become available it seems unwise to recommend radical prostatectomy as the treatment of choice for all men with clinical stage B2 disease.

Adult↗
PubMed1977

The morbidity of radical prostatectomy for multifocal stage I prostatic adenocarcinoma.

During a 25-year period 33 patients with stage I multifocal prostatic adenocarcinoma underwent radical prostatectomy. Carcinoma was present in 81 per cent of the specimens. The operative mortality was 3 per cent. Pelvic recurrence, rectal injury and urethrovesical stricture each occurred in 9 per cent of the cases. Fifteen per cent of the patients were totally incontinent and 42 per cent had stress incontinence. One patient required combined retropubic and perineal approaches to remove the specimen. The safest interval between the first and the radical procedure was 6 weeks or more. The 5 and 10-year relative survival rates were 100 per cent. The best candidate for a radical prostatectomy after transurethral prostatic resection or suprapubic enucleation prostatectomy is one with a thick surgical capsule in whom the first procedure procedes the radical procedure by at least 6 weeks.

Adenocarcinoma↗
PubMed1994

Radiotherapy for isolated increases in serum prostate-specific antigen levels after radical prostatectomy.

OBJECTIVE: To assess the outcome of radiotherapy in patients with increased serum prostate-specific antigen (PSA) levels 6 months or more after radical prostatectomy. DESIGN: In 27 Mayo Clinic patients, we examined the results of radiotherapy relative to various potentially prognostic factors during a median follow-up of 25 months. MATERIAL AND METHODS: All 27 patients had no nodal involvement at the time of prostatectomy and no clinical evidence of disease, as determined by history, physical examination, a radionuclide bone scan, computed tomography of the abdomen and pelvis, chest roentgenography, complete blood cell counts, and serum chemistry profiles. With use of 10-MV photons and a four-field approach, these patients received irradiation to the prostatic bed (60 to 67 Gy in 1.8- to 2.0-Gy fractions). RESULTS: Levels of PSA initially decreased in 24 of the 27 patients (89%). In 16 of the 27 patients (59%), the PSA level decreased to 0.3 ng/mL or less without hormonal intervention. "Freedom from failure" (defined as the actuarial chance of maintaining a PSA level of 0.3 ng/mL or less) was 58% at 2 years and 48% at 3 years. The response to salvage radiotherapy was more favorable in patients with no tumor spread into the seminal vesicles and those with serum PSA levels of less than 1.1 ng/mL at the beginning of radiotherapy than in those with seminal vesicle involvement or higher PSA levels. In addition, patients who received radiation doses of 64 Gy or more had more favorable responses than did those who received lesser doses. Radiotherapy resulted in no severe toxicity. No patient had clinical evidence of disease at the time of this report. CONCLUSION: Isolated increases in serum PSA after prostatectomy indicate the presence of residual or recurrent disease, and radiotherapy effectively decreases the PSA in approximately half the cases. This result is achieved by eradicating residual or recurrent cancer in the postoperative tumor bed.

Aged↗
PubMed2000

Bladder neck involvement at radical prostatectomy: positive margins or advanced T4 disease?

OBJECTIVES: To assess the prognosis of patients with bladder neck (BN) involvement in radical prostatectomy specimens and compare it with patients with seminal vesicle invasion (SVI) presumed to have an inferior stage according to the TNM classification. METHODS: Two hundred eighty-six case files of consecutive radical prostatectomies were reviewed. The records of patients with pathologic BN involvement (pT4a) or SVI (pT3c) were thoroughly analyzed and compared. The mean and median follow-up periods were 30.8 and 35.5 months (range 9 to 40), respectively, for the patients with Stage pT4a and 40.8 and 44.1 months (range 8 to 86), respectively, for the patients with Stage pT3c. Particular attention was paid to the preoperative clinical and pathologic evaluation, the pathologic analysis of the prostatectomy specimen, and the postoperative follow-up data. Progression was defined as a prostate-specific antigen level of 0.2 ng/mL and rising. Adjuvant therapy was not initiated unless prostate-specific antigen failure had occurred. RESULTS: BN involvement was identified in 25 patients (8.7%) and SVI was found in 26 patients (9.1%). In 7 patients (2.4%), the BN was the only site of positive margins. Thirty-six percent of patients with BN involvement and 62% of patients with SVI demonstrated biochemical progression. Disease-free survival and metastasis-free survival rates were significantly better for the patients with Stage pT4a than for the patients with Stage pT3c at 24 and 36 months after surgery. Univariate analysis identified the prostate-specific antigen nadir to be the most significant predictor of prognosis. CONCLUSIONS: In this study, BN involvement in the surgical specimen carried a lower risk of progression than SVI. On the basis of our preliminary results and those in other studies, a conceivable downstaging of BN involvement in the TNM staging system should be considered. Possibly, additional modification of the TNM staging system should be contemplated on the basis of the results of pathologic analysis and prognosis. The significance of BN involvement and the role of adjuvant therapy in this group of patients need further evaluation.

Aged↗