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PubMed2003

Laparoscopic versus open radical prostatectomy: a comparative study at a single institution.

PURPOSE: There is an ongoing debate about the benefits of laparoscopic radical prostatectomy compared to the open retropubic approach. We compared the last 219 patients treated with open retropubic prostatectomy with 438 patients treated with laparoscopic radical prostatectomy at our institution, focusing on operative data, complications and mid-term outcome. MATERIALS AND METHODS: From December 1994 to November 1999 a total of 219 patients were treated with open prostatectomy and pelvic lymph node dissection (group 1). From March 1999 to September 2002, 219 patients underwent early (group 2) and 219 underwent late (group 3) laparoscopic radical prostatectomy and pelvic lymph node dissection. The same surgeons performed both operations. All 3 groups were similar with respect to mean patient age, mean prostate specific antigen value, median Gleason score, previous transurethral resection of the prostate and neoadjuvant treatment, although there was a slight stage shift in favor of the 2 laparoscopic groups. RESULTS: Mean operating time was significantly shorter after open surgery (196 minutes) compared to the early laparoscopic group (288) but it did not differ significantly from the late laparoscopic group (218). Mean blood loss (1,550 versus 1,100 versus 800 cc) and transfusion rates (55.7% versus 30.1% versus 9.6%) in groups 1 to 3 favored the laparoscopic groups. The complication rate in groups 1 to 3 was lower for laparoscopy (19.2% versus 13.7% versus 6.4%), but the spectrum differed. The early laparoscopic group had a higher incidence of rectal injuries (1.8% versus 3.2% versus 1.4% in groups 1 to 3, respectively) and urinary leakage (0.5% versus 2.3% versus 0.9%), whereas more lymphoceles (6.9% versus 0% versus 0%), wound infection (2.3% versus 0.5% versus 0%), embolism/pneumonia (2.3% versus 0.5% versus 0.5%) and anastomotic strictures (15.9% versus 6.4% versus 4.1%) occurred after open surgery. The amount of postoperative analgesia was significantly greater after open surgery (50.8 versus 33.8 versus 30.1 mg. in groups 1 to 3, respectively). Median catheter time was longer after open retropubic prostatectomy (12 versus 7 versus 7 days in groups 1 to 3, respectively) but the continence rates were similar in all 3 groups at 12 months (89.9% versus 90.3% versus 91.7%). The rate of positive margins did not differ significantly in groups 1 to 3 (28.2% versus 21.0% versus 23.2%), prostate specific antigen recurrence was equivalent related to the different observation periods. CONCLUSIONS: Laparoscopic radical prostatectomy is technically demanding, with an initially longer operative time, higher incidence of rectal injuries and urinary leakage. The overall outcome after 219 cases favors the laparoscopic approach. Consequently, at our institution laparoscopic radical prostatectomy has become the method of choice.

Adult↗
PubMed2003

Simple perineal prostatectomy: lessons learned from a modern series.

PURPOSE: Experience with simple perineal prostatectomy has not been well described in the recent literature. We describe our operative technique and compare objective demographic, preoperative, intraoperative and postoperative parameters in patients undergoing open prostatectomy for benign prostatic hyperplasia via 3 routes, namely perineal, retropubic, and suprapubic. MATERIALS AND METHODS: We retrospectively reviewed all cases of open prostatectomy at Veterans Affairs Medical Center, San Diego between August 2001 and September 2002. A total of 22 patients were identified. Objective parameters were recorded and compared, including patient age, history of urinary retention, ultrasound volume, prostate specific antigen, patient and specimen weight, operative time, estimated blood loss, transfusion requirement, days of hospitalization and postoperative analgesic requirement. RESULTS: In the 22 patients who underwent open prostatectomy the operative approach was perineal in 6, retropubic in 8 and suprapubic in 8. Operative time and hospital stay were significantly less in the perineal prostatectomy group. CONCLUSIONS: Simple perineal prostatectomy is a viable alternative for most patients considered candidates for open prostatectomy and it is our preferred approach for obese patients. With perineal prostatectomy patients may expect shorter hospitalization and less analgesic requirement but likely require a longer period of catheter drainage.

Aged↗
PubMed2004

Do concerns about more advanced pathological features increase the likelihood of neurovascular bundle resection in black men undergoing radical prostatectomy?

PURPOSE: Traditionally black men undergoing radical prostatectomy have presented with higher serum prostate specific antigen (PSA) levels, Gleason grade and pathological stage compared to white men. We evaluated men undergoing radical prostatectomy at our institutions to determine if race was an independent predictor of neurovascular bundle resection and if racial differences existed with regard to clinical and pathological outcomes in men undergoing a nerve sparing procedure. MATERIALS AND METHODS: Between July 1995 and March 2000, 316 men underwent radical retropubic prostatectomy for clinically localized prostate cancer. Patient data were gathered prospectively and reviewed with regard to age, race, preoperative serum PSA, operative procedure, pathological findings and patient followup. Racial differences were analyzed by the chi-square test or student's t statistic. Predictors of neurovascular bundle resection were evaluated using multiple logistic regression. RESULTS: Of the 316 men who underwent a radical retropubic prostatectomy, 126 were black and 190 were white. Overall, a nerve sparing procedure was performed in 77 (40.5%) white men and 44 (34.9%) black men. When evaluating only potent men preoperatively, a nerve sparing prostatectomy was performed in 69.3% of white men and 58.6% of black men. There was no statistically significant racial difference with regard to the proportions of men undergoing a nerve sparing procedure. Predictors of neurovascular bundle resection during radical prostatectomy were preoperative erectile function, serum PSA level before prostate biopsy, biopsy Gleason score and number of cores positive for cancer. In men undergoing a nerve sparing radical prostatectomy there were no significant racial differences with regard to age, preoperative serum PSA, Gleason score, pathological stage, postoperative potency, continence or disease-free survival (mean followup 44 months). CONCLUSIONS: At our institutions a similar proportion of black and white men undergo nerve sparing radical prostatectomy, which appears to produce similar clinical outcomes in black and white men.

Black or African American↗
PubMed2004

The impact of open radical retropubic prostatectomy on continence and lower urinary tract symptoms: a prospective assessment using validated self-administered outcome instruments.

PURPOSE: We determined the impact of radical retropubic prostatectomy on continence and lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Between October 2000 and August 2002, 500 men with clinically localized prostate cancer underwent radical retropubic prostatectomy by a single surgeon, and completed the UCLA Prostate Cancer Index and American Urological Association (AUA) symptom index at baseline, 3, 6, 12 and 24 months after radical prostatectomy. Univariate analysis was performed to identify factors predisposing the early return of continence. RESULTS: A total of 100%, 98.3%, 97.1%, 94.2% and 98.6% of patients filled out the UCLA Prostate Cancer Index and AUA symptom index at baseline, and 3, 6, 12 and 24 months, respectively. Based on protective pad requirement or frequency of incontinence 100%, 90.9%, 87.2%, 92.1% and 98.5% vs 98.8%, 80.6%, 91.2%, 95.2% and 98.5% of men were continent at baseline, 3, 6, 12 and 24 months after surgery, respectively. Age, severity of lower urinary tract symptoms, Gleason score, nerve sparing status, blood loss or presence of benign prostatic tissue in the apical soft tissue margin did not predict early return of continence. All of the individual urinary symptoms captured by the AUA symptom score showed significant improvement after radical retropubic prostatectomy. Radical prostatectomy was associated with a mean 5.4 unit decrease in AUA symptom score (40% decrease) in men with baseline moderate/severe LUTS (AUA symptom score 8 or greater). CONCLUSIONS: The majority of men regain continence after radical retropubic prostatectomy and maximal continence is achieved by 24 months. No factors were identified that predicted early return of continence in our cohort of men undergoing radical prostatectomy. Radical prostatectomy has a clinically significant impact on improving LUTS.

Humans↗
PubMed1996

Trends in radical prostatectomy in New York State.

The purpose of this study was to examine trends in radical prostatectomy in New York State for the period 1991-1993. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries in New York State for the period 1991-1993. Basic trend data were also analyzed for 1990. Pattern analysis was conducted on the 4,154 procedures performed between 1990-1993. In depth hospital chart review was conducted of the 220 cases of radical prostatectomy performed in patients 75 years of age and over between 1991 and 1993 and of a random sample of 263 of 1,266 patients 70-74 years of age. A total of 452 hospital charts were examined for a broad range of information, including family history and therapeutic preferences, preoperative work-up, staging, intraoperative and postoperative transfusions, postoperative complications, and mortality. The rate of radical prostatectomy dramatically rose among New York State male Medicare beneficiaries between 1990 and 1992 and remained at a high plateau in 1993. Pattern analysis revealed a tripling of the procedure rate among those 70-74 years of age and a doubling of the rate in those 75 years of age and older. It was also found that a high proportion of radical prostatectomies in men 70 years of age and older were performed by relatively few hospitals. Although rates of radical prostatectomy rose in New York State during the period under study, these rates were lower than those reported several years earlier in other parts of the country. This may reflect an overall conservative approach to the management of prostate cancer, especially among older men, on the part of New York's urologic community. The overall postoperative complication rate was 18.5% and the mortality rate 1.3%. These rates are similar to those found in other series. Prostate cancer in older men usually has a protracted course. Radical prostatectomy in such men is associated with operative risks, and significant immediate and long-term complications. In addition, the procedure provides only marginal benefit of 10 years because of competing mortality in older men. The results of this study show a need for provider and patient focused educational efforts to reduce the numbers of radical prostatectomies in older men where the benefits are marginal compared to operative risks and significant immediate and long term complications.

Aged↗
PubMed2006

Robotic prostatectomy: a pooled analysis of published literature.

OBJECTIVE: Robotic prostatectomy has been recently added to the treatment armamentarium of localized prostate cancer. We reviewed published data on this modality with critical appraisal of outcomes and complications. METHODS: A Medline search was performed that encompassed all published articles on robotic prostatectomy. Select data on open radical retropubic (RRP) and laparoscopic (LP) prostatectomy from centers of excellence in the USA and Europe were included for objective comparison. Perioperative parameters, pathological results, including surgical margin rate, complications and postoperative continence and potency rates were reported. Advantages and shortcomings of robotic prostatectomy, and the learning curve and cost issues were also addressed. RESULTS: Robotic prostatectomy offers advantages of minimally invasive access surgery, including enhanced visualization, decreased bleeding and transfusion rate, shorter hospital stay and faster recovery. Pathological outcomes are comparable to RRP and LP with acceptable positive margin rate. At short-term follow-up, continence and potency results appear to be equivalent to RRP and LP. The learning curve of robotic prostatectomy is faster than that of LP. Cost remains a matter of debate at the present time. Long-term cancer control results of robotic prostatectomy are still maturing. CONCLUSIONS: Robotic prostatectomy is a promising minimally invasive surgical approach for men with localized prostate cancer. Short-term clinical and pathological results compare favorably to RRP and LP.

Humans↗
PubMed2006

No residual cancer on radical prostatectomy after positive 10-core biopsy: incidence, biopsy findings, and DNA specimen identity analysis.

CONTEXT: It is uncertain whether extensive prostate-specific antigen (PSA) testing and extended biopsies currently performed will increase the incidence of no residual cancer on subsequent prostatectomy. OBJECTIVE: To identify the incidence of cases with no residual cancer on prostatectomy after a positive 10-core biopsy and to review the clinical, biopsy, and prostatectomy findings and the results of specimen identity analysis. DESIGN: We identified 9 patients with no residual cancer in 1351 consecutive prostatectomies and we reviewed the clinical, biopsy, and prostatectomy data from our institutional database. In 6 cases encountered after 2003, we also performed a polymerase chain reaction-based microsatellite analysis on formalin-fixed tissue to confirm the identity of the biopsies and prostatectomies. RESULTS: All patients had positive biopsies in 1 or 2 cores: 1 in 7 and 2 in 2 patients (1 each, unilateral and bilateral). Mean total cancer length on biopsy measured 2.5 mm, which represented 1.7% of the total biopsy tissue. Gleason score 6 was found in 8 of 9 patients and 1 patient had Gleason score 9. Patients' age was 60.3 years, preoperative PSA was 6.0 ng/mL, and PSA density was 0.1 (all means). In 6 cases tested for microsatellite identity, the patient identity was confirmed. CONCLUSIONS: Incidence of no residual cancer on prostatectomy of 0.67% after 10-core positive biopsy is higher than previously reported. In most cases, finding no residual cancer on prostatectomy after exhaustive work-up may indicate minimal patient disease. Microsatellite analysis provides a useful and cost-effective test in establishing specimen identity.

Adenocarcinoma↗
PubMed1995

[Comparisons of histological grading between biopsy and radical prostatectomy specimens in prostatic adenocarcinoma].

PURPOSE: To examine how accurately biopsy specimens reflect the corresponding excised specimens in terms of histologic grades of prostatic adenocarcinoma, histologic grades of biopsy specimens were compared to those of radical prostatectomy specimen in 29 patients who underwent radical prostatectomy without any prior treatment. METHODS: For the assessment of histological grading, Japanese General Rule for Prostatic Cancer (JGRPC), in which adenocarcinoma was graded as being either well, moderately or poorly differentiated, and Gleason's system were applied. RESULTS: According to JGRPC, histologic grades of biopsy specimens were identical to those of the prostatectomy specimens in 83% of cases, with biopsy specimens given higher grades than those of the prostatectomy specimen in 4 (14%), and lower grades in 1 (3%). According to Gleason score histological grade of biopsy specimens were identical to those of the prostatectomy specimens in only 52%. However, the grouping category of Gleason score (2 to 5, 6, 7 and 8 to 10) assigned to the biopsy was lower than that of prostatectomy specimen in only 3 cases (10%) and was greater than that of prostatectomy specimen in 5 cases (17%). CONCLUSION: These results suggest that histological grades based upon biopsy specimens will predict those of the corresponding prostatectomy specimens in the majority (72% to 83%) but not all of the cases.

Adenocarcinoma↗
PubMed2005

[Comparison of radical retropubic prostatectomy under combined lumbar spinal and epidural anesthesia with that under combined general and epidural anesthesia].

PURPOSE: To evaluate the efficacy of combined lumbar spinal and epidural (CLSE) anesthesia in retropubic radical prostatectomy. MATERIALS AND METHODS: Twenty consecutive patients who underwent radical retropubic prostatectomy by a single surgeon (H.K.) under CLSE anesthesia from July of 2003 to February of 2004 were selected as subjects. They were compared with 20 consecutive patients who underwent radical retropubic prostatectomy performed by the same surgeon under combined general and epidural (CGE) anesthesia from April to December of 2002. Both periods were carefully selected to exclude radical prostatectomies with intraoperative complications to evaluate genuine effects of anesthesia. For lumbar spinal anesthesia, 0.5% hyperbaric bupivacaine hydrochloride or 0.5% hyperbaric tetracaine hydrochloride (dissolved in a 10% glucose solution) was used. An epidural tube was inserted for both lumbar spinal anesthesia and general anesthesia mainly for the purpose of controlling a pain after operation. RESULTS: Intraoperative blood loss was significantly less in the CLSE anesthesia group compared with CGE anesthesia group (p = 0.024). Postoperative water drinking was started at 0.4 days (average) for CLSE anesthesia and at 1.1 days (average) for CGE anesthesia (p < 0.0001). Postoperative diet was begun at 0.7 days (average) for CLSE anesthesia and at 1.5 days (average) for CGE anesthesia (p < 0.0001). Compared with the CLSE anesthesia group, the mean of the highest intraoperative mean blood pressure was significantly higher in the CGE anesthesia group (p = 0.002). CONCLUSION: Intraoperative blood loss was less, intraoperative change in blood pressure was less and recovery of postoperative intestinal peristalsis was earlier in patients who underwent prostatectomy under CLSE anesthesia than in patients who underwent prostatectomy under CGE anesthesia. We believe that prostatectomy under CLSE anesthesia is more advantageous than prostatectomy under CGE anesthesia.

Aged↗
PubMed1999

Preperitoneal prosthetic mesh hernioplasty during radical retropubic prostatectomy.

PURPOSE: The number of radical retropubic prostatectomies performed in the United States has increased during the last decade. There are 5 to 10% of candidates for radical retropubic prostatectomy who have a detectable inguinal hernia on physical examination. Furthermore, recent data suggest that there is an increased incidence of inguinal hernia after radical retropubic prostatectomy. We evaluated the role of simultaneous inguinal hernioplasty during radical prostatectomy. MATERIALS AND METHODS: During 575 radical prostatectomy procedures from June 1991 to June 1997, 70 hernioplasties were performed in 48 patients. Retrospective chart review was performed for all men who underwent simultaneous hernia repair. Mean patient age was 60.9 years (range 43 to 73). Polypropylene or polyester fiber prostheses were used for mesh hernioplasty. All repairs were performed using a preperitoneal approach during radical retropubic prostatectomy. RESULTS: There were 35 hernioplasties performed without and 35 with mesh. Mean postoperative followup was 24 months (range 6 to 66). Of the hernias 71% were indirect and 29% were direct. No recurrence was detected after mesh hernioplasty, whereas 5 hernias (14%) recurred in the nonmesh group. In this group 2 men (4%) also had de novo hernias on the contralateral side during followup. All recurrent hernias were diagnosed within 1 year of the initial operation. No patient had wound infection, persistent neuralgia or ischemic orchitis. CONCLUSIONS: Simultaneous repair of inguinal hernias during radical retropubic prostatectomy is effective and technically feasible. There is convenient access to the preperitoneal space during radical retropubic prostatectomy and hernia repair adds only 5 to 10 minutes of operative time. Mesh repair appears to offer optimized results compared to the nonmesh technique. Despite the use of prosthetic material, no complications were attributable to its application during these genitourinary procedures.

Adult↗
PubMed1999

Radical retropubic prostatectomy plus orchiectomy versus orchiectomy alone for pTxN+ prostate cancer: a matched comparison.

PURPOSE: Untreated stage pTxN+ prostate cancer is associated with a poor outcome. Monotherapy (surgery, radiation, hormonal therapy) alone is associated with a high progression rate. We evaluate whether radical prostatectomy and pelvic lymphadenectomy plus early adjuvant orchiectomy impart a survival advantage compared to pelvic lymphadenectomy and orchiectomy alone in a matched cohort of patients. MATERIALS AND METHODS: Between 1966 and 1995, 382 and 79 patients with stage pTxN+ prostate cancer underwent pelvic lymphadenectomy and radical prostatectomy plus early adjuvant orchiectomy (within 3 months of prostatectomy), and pelvic lymphadenectomy and orchiectomy only, respectively. We selected 79 matched controls from the prostatectomy plus orchiectomy group for the orchiectomy group. Patients were matched according to the number of positive nodes, clinical grade, clinical stage, age, year of surgery and preoperative prostate specific antigen (after 1987). The Kaplan-Meier method and stratified Cox proportional hazards model were used to estimate overall and cause specific survival for the 2 groups. RESULTS: There was an overall survival advantage at 10 years for the prostatectomy plus orchiectomy (66+/-6%) compared to the orchiectomy (28+/-6%) group (p <0.001, risk ratio 0.36, 95% confidence interval 0.20 to 0.66). There was also an advantage in cause specific survival at 10 years in the prostatectomy plus orchiectomy (79+/-5%) versus the orchiectomy (39+/-7%) group (p <0.001, relative risk 0.28, 95% confidence interval 0.13 to 0.59). After 1987, when matched on preoperative prostate specific antigen, the apparent survival advantage at 5 years with radical prostatectomy was smaller (79+/-8 versus 63+/-9% orchiectomy) and not significant (p = 0.19). CONCLUSIONS: This retrospective study of patients with stage pTxN+ PC suggests that radical prostatectomy with early adjuvant orchiectomy may provide a significant advantage in overall and cause specific survival compared to orchiectomy alone.

Aged↗
PubMed1999

Preoperative p53, bcl-2, CD44 and E-cadherin immunohistochemistry as predictors of biochemical relapse after radical prostatectomy.

PURPOSE: Since radical prostatectomy is performed to cure prostate cancer, identification of markers enabling preoperative prediction of relapse after radical prostatectomy is essential to counsel and select patients for adjuvant therapy. Aberrant p53, bcl-2, CD44 and E-cadherin immunohistochemistry has been associated with aggressiveness in prostate cancer. We assessed these biomarkers in biopsy and radical prostatectomy specimens as predictors of biochemical relapse. MATERIALS AND METHODS: A total of 76 patients with untreated clinically localized prostatic adenocarcinoma underwent radical prostatectomy. Preoperative (prostate specific antigen, biopsy Gleason score) and postoperative (pathological stage and margin status) variables, biopsy and radical prostatectomy biomarker immunohistochemistry were correlated with relapse. Univariate and multivariate statistical analyses identified significant predictors. RESULTS: Of the 76 patients 23 (30%) had relapse (mean followup 38 months). Aberrant p53, bcl-2, CD44 and E-cadherin expression was observed in 64, 12, 85 and 12% of biopsies and 57, 20, 64 and 49% of radical prostatectomy specimens, respectively. Biopsy Gleason 7 to 10 and biopsy p53, respectively, gave the highest positive and negative predictive values for relapse. Relapse occurred in 13% of patients with normal biopsy p53 and in half with aberrant p53. Multivariate analysis revealed Gleason score and p53 to be independent preoperative predictors (p = 0.01 and 0.02, respectively). Estimated risk of relapse was 3.5 times higher in patients with Gleason scores 7 to 10 and 24% higher in those with aberrant p53. Significant postoperative predictors were bcl-2, p53, Gleason score and margin status (p = 0.01, 0.01, 0.04 and 0.01, respectively). CONCLUSIONS: Aberrant biopsy p53 is associated with a significantly worse outcome after radical prostatectomy than normal p53, highlighting a potential clinical role for p53. Postoperative p53 and bcl-2 were significant predictors of outcome after radical prostatectomy.

Aged↗
PubMed2000

Preoperative prostate needle biopsy p27 correlates with subsequent radical prostatectomy p27, Gleason grade and pathological stage.

PURPOSE: Loss of p27 protein expression in radical prostatectomy specimens has been shown to be an adverse prognostic factor in patients with clinically localized prostate cancer. To our knowledge no studies have examined p27 expression in prostate needle biopsies. To test the potential predictive power of p27 in prostate biopsies we compared p27 expression in preoperative biopsies and matched prostatectomy specimens of patients with clinically localized prostate cancer. MATERIALS AND METHODS: Matched biopsies and radical prostatectomy specimens from 44 patients were examined. Mean followup was 22.7 months (range 1 to 46). Tumors expressing less than 30% positive nuclei were classified as low expressors and tumors expressing greater than 30% positive nuclei were classified as high expressors of p27 protein. RESULTS: Expression of p27 in prostate biopsies correlated significantly with subsequent p27 expression in radical prostatectomy specimens (p = 0.002). Sensitivity and specificity of biopsy p27 for predicting subsequent prostatectomy p27 were 87.5% and 88.9%, respectively (p <0.001). Univariate analysis showed that low expression of p27 in the biopsy correlated significantly with biopsy and prostatectomy Gleason score (p = 0.000 and 0.001, respectively), and final pathological stage (p = 0.028). Despite the small sample size and short followup, 36.4% of patients with low p27 expression had a biochemical recurrence compared to only 12.1% with high expression (hazards ratio 3.56). In addition, Kaplan-Meier analysis suggested that low p27 expression in prostate biopsies may be associated with a shorter time to recurrence, although this did not reach statistical significance (p = 0.081). CONCLUSIONS: Expression of p27 in prostate biopsies can be used to predict the degree of expression in radical prostatectomy specimens. As loss of p27 protein expression in prostatectomy specimens has been shown to correlate with biochemical recurrence and shortened prostate specific survival, these results suggest that biopsy p27 may help identify high risk patients preoperatively.

Adult↗
PubMed2002

[Gleason scores of prostate needle biopsy specimens and of radical prostatectomy specimens, a comparative study].

OBJECTIVE: To compare the Gleason scores of the prostate needle biopsy specimens with those of the radical prostatectomy specimens. METHODS: Gleason scoring was made on the needle biopsy specimens from 40 patients with prostate carcinoma and then on the radical prostatectomy specimens from the same patients. The Gleason scores of the two sets of matched specimens were compared. RESULTS: The Gleason scores were 2 approximately 9 (5.6 +/- 1.7) of the prostate needle biopsy specimens, significantly different from those of the radical prostatectomy specimens [4 approximately 10 (6.4 +/- 1.3), P < 0.05]. The Gleason scores coincided in 23 cases (57.5%) between the two groups. The Gleason scores of 15 needle biopsy specimens were significantly lower than those of the matched radical prostatectomy specimens with an underestimation rate of 37.5% and were higher in 2 needle biopsy specimens than in the matched radical prostatectomy specimens with an overestimation rate of 5.0%. The number of cases with the Gleason score < or = 6 in the needle biopsy group were 25, significantly less than that in the radical prostatectomy group (P < 0.01). The number of cases with the Gleason score > or = 7 in the needle biopsy group was 15, not significantly different from that in the prostatectomy group (P = 0.07). CONCLUSION: Prostate needle biopsy under-grades the Gleason scores in comparison with radical prostatectomy. Measures should be adopted to avoid underestimation of the tumor grade.

Aged↗
PubMed2004

Laparoscopic radical prostatectomy - results of 200 consecutive cases in a Canadian medical institution.

PURPOSE: Since Guillonneau and Vallancien reintroduced transperitoneal laparoscopic radical prostatectomy in 1998, several other medical institutions in Europe have published their series and confirmed that laparoscopic radical prostatectomy (LRP) is a feasible and reproducible approach to the management of clinically localized prostate cancer; however, there have been few reports from North American medical institutions. We now report the results of our first 200 consecutive cases of LRP in a Canadian Medical Institution. MATERIALS AND METHOD: From February/2000 until April/2003, laparoscopic radical prostatectomy was performed on 200 out of 205 surgical candidates for radical prostatectomy. There were 120 transperitoneal laparoscopic radical prostatectomies (TP-LRP) and 80 extraperitoneal laparoscopic radical prostatectomies (EP-LRP). TP-LRP was based on posterior access to the seminal vesicles whereas EP-LRP was based on trans-bladder neck approach to the seminal vesicles. Patients' mean age was 63.5 (range 42-75). Patients were separated into two groups of 100 patients in order to assess the impact of the learning curve. RESULTS: There were 147 with pT2 disease and 53 with pT3 disease with a positive surgical margin of pT2a (0%), pT2b (20%), PT3a (52%) and pT3b (53%) respectively. The overall positive surgical margin rate is 27%. The median follow-up is 13 months. There were 111 patients available for a one-year follow-up with PSA recurrence-free rate of 95%. The positive surgical margin rates for low, intermediate and high-risk categories are 19%, 40%, and 63% respectively. The 6-month continence rate available in 160 patients was 88.2%. Spontaneous erection was reported in 21 out of the 46 patients (46%) with at least 6 months follow-up. The intra-operative and post-operative complication rate was 20% for Group 1 and 4% for Group 2 with an overall rate of 8%. The overall surgical time was 4.4 hours for Group 1 and 3.3 hours for Group 2. The hospital stay was 5.26 days for Group 1 and 2.44 days for Group 2. Transfusion rate was 8% for Group 1 and 2% for Group 2. The mean analgesic requirement in the last 50 cases was 5.5 mg of morphine with 58% of patients being analgesic-free post-operatively. CONCLUSION: Laparoscopic radical prostatectomy is a technically demanding procedure with a long and gradual learning curve. The present study confirms the impression of other large published series in that it appears to offer equivalent oncologic results and functional results when compared with open radical prostatectomy. The preservation of potency will require longer follow-up. Longer follow-up and large randomized control studies will be required to determine its exact role in the surgical management of clinically localized prostate cancer.

Adult↗
PubMed1996

Radical prostatectomy: lower rates among African-American men.

This study compares radical prostatectomy rates by race among male Medicare patients in New York. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries for the period 1991 through 1993. Basic trend data also were analyzed for 1990. Pattern analysis was conducted on the 4154 procedures performed between 1990 and 1993. The rate of radical prostatectomy rose dramatically during the 3-year period from 1990 to 1992 among New York's 1.1 million male Medicare beneficiaries. The rates rose for both African Americans and whites. However, the annual rates of radical prostatectomy for African Americans were significantly below those for whites. Lower rates of radical prostatectomies were observed for African Americans in all age groups except the < 65-year-old group. However, the total number of radical prostatectomies in this age group were small in number. An important finding was the lower annual rates of radical prostatectomy for African Americans in the 65- to 69-year-old age group. During the period under study, prostate cancer among Medicare patients in New York rose by 33.8% for African Americans and 26.5% for whites. Significantly, local disease was found at the time of diagnosis in 70% of whites but in only 55% of African Americans. These data reflect later stage at diagnosis among African-American males. These results indicate that despite higher national rates for prostate cancer, male African-American Medicare patients in New York have reduced access to radical prostatectomy as a treatment modality. This is especially of importance in the < 70-year-old group in whom most authorities consider the procedure appropriate. The reasons for this reduced access are discussed as are the measures needed to remedy the underlying inequities in health care.

Black or African American↗
PubMed1997

Use of radical prostatectomy among Medicare beneficiaries before and after the introduction of prostate specific antigen testing.

PURPOSE: We monitored the use of radical prostatectomy in medicare beneficiaries before and after the introduction of prostate specific antigen (PSA) testing. MATERIALS AND METHODS: Radical prostatectomies performed on medicare beneficiaries between 1984 and 1995 were identified through the medicare claims data base. Medicare enrollment files were used to define the population at risk and age-adjusted rates were standardized to the 1990 United States medicare population. RESULTS: Rates of radical prostatectomy have steadily increased since 1984. A sharp increase in radical prostatectomy rates followed the institution of PSA testing after which a prominent decrease, particularly among older age groups, was evident. During the peak year of 1992 the age-adjusted rates of radical prostatectomy for white and black men 65 to 79 years old in the United States were 461.2 and 294.5/100,000 men. Between 1992 and 1995 the rates of radical prostatectomy among white men decreased by 22, 47 and 69% for patients 65 to 69, 70 to 74 and 75 to 79 years old, respectively. The corresponding changes among black men were +6, -18 and -47%, respectively. Differences in the age-adjusted rates between white and black men have narrowed in recent years, ranging from 166.7 (1992) to 29.7 (1995)/100,000 men. CONCLUSIONS: Recent years have been marked by a rapid increase in the use of radical prostatectomy, which peaked in 1992. Subsequent to 1992 a sharp decrease occurred, which was particularly evident in older and white men. Racial differences in the use of radical prostatectomy have narrowed in recent years.

Aged↗
PubMed1998

Influence of radical prostatectomy on serum hormone levels.

PURPOSE: The influence of radical prostatectomy on the hypothalamic pituitary axis has not been well studied. It is also unclear how alterations in serum androgen levels that result from surgical removal of the prostate might influence the recovery of libido and sexual function following radical prostatectomy. We determined the influence of radical prostatectomy on the hypothalamic pituitary testicular axis of 63 men with clinically localized prostate cancer treated only with radical prostatectomy. MATERIALS AND METHODS: A total of 63 healthy men 43 to 67 years old were enrolled in this prospective study. Phlebotomy was performed immediately before and 1 year following radical retropubic prostatectomy. Sera were stored frozen and analyzed as a group at the end of the study. We measured serum testosterone, percent free testosterone, dihydrotestosterone (DHT), estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), sex hormone binding globulin and prolactin. RESULTS: Following radical prostatectomy there was a statistically significant increase in serum testosterone, free testosterone, estradiol, LH and FSH (p <0.0001), and statistically significant decrease in serum DHT (p <0.0001). No difference was noted in serum sex hormone binding globulin or prolactin levels. There was no statistically significant correlation between any serum hormone and sample storage time, patient age or prostate volume that could limit potential bias in study design. Serum hormone changes did not correlate with pathological stage or histological grade for this group of patients. CONCLUSIONS: Radical prostatectomy influences the hypothalamic pituitary axis by increasing serum testosterone, percent free testosterone, estradiol, LH and FSH while decreasing serum DHT levels. These findings suggest that the sexual dysfunction associated with radical prostatectomy cannot be explained by androgen deficiency alone. These data further suggest that the normal prostate and/or prostate neoplasm could secrete a substance or substances that give negative feedback control to pituitary gonadotropin secretion. Further investigation is warranted to identify this substance or substances.

Adult↗