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PubMed1996

Prediction of progression following radical prostatectomy. A multivariate analysis of 721 men with long-term follow-up.

We studied 721 men with clinically confined disease who underwent radical prostatectomy. No patient received preoperative or postoperative radiotherapy or hormone therapy until progression occurred. For those men without progression, the mean follow-up was 6.5 years with a median of 6 years (range 1 to 12 years). Because patients with lymph node metastases or seminal vesicle invasion had such a high risk of progression, enhanced prognostication was not needed in men with these findings. Thus we focused this analysis on the 617 men without lymph node metastases or seminal vesicle invasion. In the multivariate analysis, Gleason score (P < 0.0001), surgical margins (P = 0.004), and capsular penetration (P = 0.007) were all independent predictors of progression. Tumors with a Gleason score of 2 through 4 were almost invariably cured, with a 10-year progression-free risk of 96%. At the opposite end of the spectrum, the 10-year actuarial progression-free risk for men with a Gleason score of 8 through 9 was 35%. Men with Gleason score 2 through 4 or 8 through 9 tumors could not be stratified into different risks of progression based on the presence or extent of capsular penetration or margin status. For the men with Gleason score 5 through 7 tumors (88.2% of cases), predicting their risk of progression was enhanced by knowledge of their tumor's capsular penetration and margin status. Tumors with a Gleason score of 5 through 6 and 7 were each stratified into three groups with different risks of progression. Using the actuarial curves within this study, physicians will be able to more accurately determine a patient's risk of progression following radical prostatectomy based on a combination of the radical prostatectomy Gleason score, extent of capsular penetration, and status of surgical margins of resection.

Disease Progression↗
PubMed1997

Increasing incidence of minimal residual cancer in radical prostatectomy specimens.

Residual cancer in radical prostatectomy specimens from men with biopsy-proven adenocarcinoma occasionally may be difficult, or even impossible, to identify. Although this finding was recently described as "minimal residual cancer" or the "vanishing cancer phenomenon," there are no data on the incidence of this phenomenon in surgical pathology practice. We evaluated 3,038 consecutive radical prostatectomies performed at the Johns Hopkins Hospital between 1988 and 1995, excluding cases with a history of transurethral resection, prior therapy with a luteinizing hormone-releasing hormone agonist, focal Gleason grade 4 or 5, capsular penetration, or a positive surgical margin. Of this group, 84 cases with minimal or no residual cancer were identified. In 60 of these cases, residual cancer was "difficult to find" (mean total volume, 0.03 cc; range, 0.01-0.08 cc); in 20 cases, residual cancers were classified as "minute" (mean total volume, 0.07 cc; range, 0.03-0.13 cc). In four cases, no residual cancer could be identified, including two cases in which the diagnosis of cancer on needle biopsy was confirmed, one case in which review of the diagnostic needle biopsy revealed only high-grade prostatic intraepithelial neoplasia, and one case in which molecular analysis demonstrated mislabeling of the needle biopsy specimen. The annual incidence of minimal residual cancer increased from 0.5% in 1988 to 4% in 1993 and has begun to plateau at 3 to 4% since 1993 (p = 0.0016 for increasing trend). These data confirm the general impression that with more vigilant screening of men for prostate cancer, there has been an associated increase in cancer with little or no residual cancer at radical prostatectomy.

Adenocarcinoma↗
PubMed2004

The prognostic significance of tertiary Gleason pattern 5 in radical prostatectomy specimens.

In the Gleason grading system for prostatic cancer only the two most prevalent patterns are reported, although a third (tertiary) pattern grade may be present. We compared the pathologic stage of 227 radical prostatectomies with tertiary pattern 5 to the pathologic stage of 604 radical prostatectomies lacking a tertiary component. Gleason score 3 + 4 tumors with a tertiary pattern of 5 were more likely to present with higher stage disease than those Gleason score 3 + 4 tumors without a tertiary component (P = 0.012) and at a stage similar to Gleason score 3 + 5 tumors. Gleason score 4 + 3 tumors with a tertiary pattern of 5 were less likely to be organ-confined than Gleason score 4 + 3 tumors (P = 0.02) and less likely to have lymph node metastases than Gleason score 4 + 4 tumors (P = 0.027). However, Gleason score 4 + 4 with a tertiary pattern of 5 were indistinguishable from Gleason score 4 + 4 tumors. The relative effects of a tertiary pattern of 5 were greatest when the primary and secondary stages were low but become obscured by the already aggressive nature of advanced primary and secondary patterns. Therefore, except for very high-grade tumors, tertiary scoring of prostatic adenocarcinoma at radical prostatectomy should be reported as it has prognostic significance.

Adenocarcinoma↗
PubMed1996

Radical prostatectomy with preservation of urinary continence.

PURPOSE: In an effort to improve postoperative urinary continence after radical retropubic prostatectomy, a new operation to preserve the bladder neck and a significant portion of the prostatic urethra has been developed. MATERIALS AND METHODS: The prostatic urethra is dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. RESULTS: A total of 24 patients who underwent the new continence sparing radical retropubic prostatectomy was compared retrospectively to 80 who previously underwent a nerve sparing procedure. Total continence was noted immediately in 11 patients, within 9 days in 15 and within 7 weeks in 21 of 24 who underwent the new operation, compared to 1, 5 and 33, respectively, of 80 who underwent the standard operation. Microscopic positive margins were noted in 2 of 24 patients with the new continence sparing operation. Early results of cancer control were good. CONCLUSIONS: Early followup of this new technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.

Aged↗
PubMed1997

Is heparin contraindicated in pelvic lymphadenectomy and radical prostatectomy?

PURPOSE: We initiated a prospective study to verify or refute the complications of lymphocele formation and excessive blood loss associated with heparin prophylaxis in pelvic lymphadenectomy and radical prostatectomy. MATERIALS AND METHODS: A prospective study was completed on 579 men undergoing pelvic lymphadenectomy usually in association with radical prostatectomy. Patients were assigned to group 1 (given preoperative and postoperative subcutaneous heparin) and group 2 (no heparin). All patients were evaluated 2 to 3 weeks after surgery with ultrasound for pelvic lymphocele. RESULTS: There was no statistically significant difference in the number or size of pelvic lymphoceles or blood loss in group 1 versus group 2. CONCLUSIONS: The use of heparin prophylaxis to prevent thromboembolic complications in conjunction with pelvic lymphadenectomy and radical prostatectomy is not associated with increased blood loss or increased rate of lymphocele formation.

Blood Loss, Surgical↗
PubMed1998

The male bulbourethral sling procedure for post-radical prostatectomy incontinence.

PURPOSE: We evaluate the efficacy of the male bulbourethral sling procedure in the treatment of post-radical prostatectomy urinary incontinence. MATERIALS AND METHODS: We reviewed the records of 64 consecutive men with severe post-prostatectomy incontinence who underwent the male bulbourethral sling procedure at Northwestern Memorial Hospital and Stanford University Hospital. Preoperatively 50% of the patients were completely incontinent (diapers, clamps or condom catheter), and the remainder required a mean of 4.7 pads per day. Data were collected by chart review, patient interviews at followup appointments and telephone interviews. Median followup was 18.1 months (mean 22.4, range 6.5 to 53.8). RESULTS: Following a single sling procedure 36 patients (56%) became dry, and 5 (8%) were significantly improved. In 17 patients 23 retightening procedures were performed, which decreased the median followup to 16 months and increased the success rate to 75% (67% cured, 8% improved). The revision, erosion and infection rates were 27, 6 and 3%, respectively. CONCLUSIONS: The male bulbourethral sling procedure is effective treatment for post-radical prostatectomy urinary incontinence. Patients who had received adjuvant radiation therapy demonstrated a lower continence rate than those who had not. Further followup is needed to assess long-term efficacy.

Aged↗
PubMed1998

Progression in and survival of patients with locally advanced prostate cancer (T3) treated with radical prostatectomy as monotherapy.

PURPOSE: We determine the progression and survival rates in patients with locally advanced prostate cancer treated with radical prostatectomy without adjuvant treatment, and investigate subgroups of patients who may not benefit from this treatment. MATERIALS AND METHODS: Radical prostatectomy was performed in 83 patients with T3 prostate cancer. The patients were divided in subgroups with T3G1 to 2 and T3G3 tumors, which were evaluated for clinical progression, local recurrence, distant metastases, biochemical progression, and overall and cancer specific survival at 5 and 10 years by Kaplan-Meier curves. The results were compared to those of 190 patients with locally confined tumors. RESULTS: At 5 and 10 years overall survival was 75 and 60%, and cancer specific survival was 85 and 72%, respectively. At 5 and 10 years clinical progression was 41 and 69%, local recurrence 18 and 44%, and distant metastases 31 and 50%, respectively. Biochemical progression at 5 years was 71%. Patients with poorly differentiated tumors showed significantly lower survival and higher progression rates compared to those with well or moderately differentiated tumors. Progression and survival in patients with T3G1-2 tumor were not significantly different from those for patients with locally confined tumors. CONCLUSIONS: Radical prostatectomy as monotherapy in patients with locally advanced nonmetastatic prostate cancer (T3) produces acceptable results in those with well or moderately differentiated tumors. The results of progression and survival are not significantly different from those in patients with locally confined prostate cancer. However, patients with poorly differentiated tumors (T3G3) have early progression and need adjuvant treatment following surgery.

Actuarial Analysis↗
PubMed1998

Cancer recurrence and survival rates after anatomic radical retropubic prostatectomy for prostate cancer: intermediate-term results.

PURPOSE: We evaluate cancer recurrence and survival rates following anatomic radical retropubic prostatectomy. MATERIALS AND METHODS: From 1983 through August 1997, 1 surgeon performed anatomic radical retropubic prostatectomy in 1,778 men (mean age plus or minus standard deviation 63+/-7), using a unilateral or bilateral nerve sparing modification when feasible (93%). Postoperative adjuvant radiation therapy (mean dose 60 Gy.) was given to 4% of patients because of adverse pathological findings. Patients were followed with semiannual prostate specific antigen (PSA) tests and annual digital rectal examinations. Followup PSA 0.3 ng./ml. or greater was considered evidence of cancer recurrence. We used Kaplan-Meier product limit estimates to calculate 7-year cancer recurrence-free probabilities, prostate cancer specific survival and all cause survival (overall, and stratified by age, preoperative PSA, tumor grade and tumor stage). We used multivariate Cox proportional hazards models to determine clinical and pathological parameters that provided unique predictive information about cancer recurrence. RESULTS: The 7-year recurrence-free survival was significantly associated with lower preoperative PSA (estimated probability of nonprogression 76 to 93% for PSA less than 10), nonpalpable, localized clinical stage (79%), lower tumor grade (84 and 68% for well and moderately differentiated, respectively) and localized pathological stage (81% for pT1 or pT2) (all log rank test p <0.0001) but not age at surgery. All predictors except clinical stage and age remained significant within the multivariate model. Controlling for all other predictors, adjuvant radiation therapy in patients with unfavorable pathology was significantly associated with better recurrence-free survival (p=0.02). The estimated 7-year prostate cancer specific survival rate was 97% and the all cause survival rate was 90%. Cancer specific and all cause survival were significantly associated with lower grade and localized pathological stage (p <0.0001). CONCLUSIONS: Anatomic radical retropubic prostatectomy with the nerve sparing modification can be performed with good cancer control.

Adult↗
PubMed1999

Can perineural invasion on prostate needle biopsy predict prostate specific antigen recurrence after radical prostatectomy?

PURPOSE: We evaluated the role of perineural invasion identified on prostate needle biopsy as a predictor of prostate specific antigen (PSA) recurrence after radical prostatectomy. MATERIALS AND METHODS: Between 1993 and 1998 radical prostatectomy was performed in 319 consecutive patients. Prostate needle biopsies were reviewed in all cases. We compared perineural invasion with other preoperative parameters, including digital rectal examination, PSA and biopsy Gleason score, for the ability to predict PSA recurrence with recurrence defined as any serum PSA level greater than 0.2 ng./ml. RESULTS: Perineural invasion was identified on 77 of 319 preoperative prostate biopsies (24%). There was PSA recurrence in 46 patients (14.4%) at a mean followup of 25.4 months (range 0.2 to 62.1). Perineural invasion statistically correlated with PSA recurrence. Kaplan-Meier analysis revealed disease-free survival rates of 24 versus 64% when perineural invasion was and was not present in the prostate biopsy (p = 0.0003, log rank 12.92). Multivariate analysis demonstrated that perineural invasion (p = 0.012) and PSA (p = 0.005) were independent preoperative predictive factors of PSA recurrence. When perineural invasion was compared with postoperative parameters, including disease stage, surgical margins and seminal vesicle invasion, it was not an independent predictor because it closely correlated with tumor stage. CONCLUSIONS: Perineural invasion on preoperative prostate needle biopsy is a strong independent predictor of PSA recurrence in patients in whom prostate cancer was treated with radical prostatectomy.

Adult↗
PubMed1999

Is there a role for digital rectal examination in the followup of patients after radical prostatectomy?

PURPOSE: We determine the role of digital rectal examination in the followup of patients after radical prostatectomy. MATERIALS AND METHODS: We retrospectively analyzed data on 501 consecutive patients who underwent radical retropubic prostatectomy between 1992 and 1998, and were followed at the University of Miami. Patients were evaluated at 3 to 6-month intervals after surgery with serum prostate specific antigen (PSA) and digital rectal examination. Biochemical recurrence was defined as PSA greater than 0.2 ng./ml. and increasing on at least 2 consecutive measurements. Local recurrence, detected by an abnormal digital rectal examination, was defined as an induration or nodularity in the prostatic fossa. RESULTS: Mean followup plus or minus standard deviation was 25.4+/-20.8 months. Disease recurred in 72 patients (14.4%) and was biochemical in all. An abnormal digital rectal examination was noted in 4 patients, none of whom had an undetectable PSA at the time of a palpable abnormality. CONCLUSIONS: Our results suggest that an abnormal digital rectal examination after radical prostatectomy is always associated with a detectable PSA, which implies that performing a digital rectal examination in the absence of a detectable PSA may not be necessary.

Adenocarcinoma↗
PubMed2001

Bone anchored sling for the treatment of post-prostatectomy incontinence.

PURPOSE: This ongoing study evaluates the safety and efficacy of a new minimally invasive sling procedure for treating post-prostatectomy incontinence. MATERIALS AND METHODS: A total of 16 men 56 to 74 years old (mean age 67) underwent the procedure using the Straight-In bone anchoring system. Time after prostatectomy was 1.5 to 5 years (mean 2.5). Of the 16 patients 14 had urodynamically confirmed stress urinary incontinence, while 2 had mixed incontinence with stress incontinence and detrusor instability. The procedure is performed with the patient in the lithotomy position using a perineal approach. Four miniature bone screws with pre-attached pairs of No. 1 polypropylene sutures are placed directly into the medial aspect of the inferior rami of the pubic bone. A pair of bone anchors is placed just below the symphysis on each side, and the second pair is inserted 3 to 4 cm. lower. To support the bulbar urethra a gelatin coated polyethylene terephthalate trapezoid shaped sling or cadaveric fascia lata is tied to the pubic bone using the 4 pairs of sutures attached to the bone anchors. Urethral resistance is increased to 30 to 50 cm. water above baseline pressure. RESULTS: Followup was 4 to 20 months (mean 12.2). Of the 14 men with the preoperative urodynamic diagnosis of genuine stress incontinence 12 were cured of incontinence, defined as subjectively dry with no or only 1 pad used daily for security without any episode of leakage, while 2 were improved subjectively with a decrease of 50% or more in pads daily. Two other patients with the preoperative diagnosis of mixed urinary incontinence were improved. Postoperatively urodynamic study in these patients revealed resolved stress incontinence but persistent urge urinary incontinence. They responded to anticholinergics and are completely dry. Intraoperative and postoperative complications were minimal with no erosion, infection or osseous complications. CONCLUSIONS: This new minimally invasive male sling procedure is safe and efficacious. Adjusting sling tension by measuring urethral resistance results in a low rate of over correction and failure. Further experience is needed to establish this procedure as treatment for post-prostatectomy incontinence.

Aged↗
PubMed2001

Bilateral nerve graft during radical retropubic prostatectomy: 1-year followup.

PURPOSE: With the interposition of a sural nerve graft to replace resected cavernous nerves at radical retropubic prostatectomy, we have previously reported the return of effective erectile function. We determine the efficacy of this procedure in a series of men with at least 1-year followup. MATERIALS AND METHODS: A total of 12 potent men (mean age plus or minus standard deviation 57 +/- 6 years) with clinically localized prostate cancer underwent radical retropubic prostatectomy, with deliberate wide bilateral neurovascular bundle resection and placement of bilateral nerve grafts. A series of patient and partner erectile dysfunction questionnaires, and patient interviews were performed at 3, 6, 12 and 18 months postoperatively. Only results for those men with a followup of 12 months or greater (mean 16 +/- 4) are presented. A control group of 12 men who had undergone bilateral nerve resection but declined nerve graft placement, was also followed. RESULTS: Of the 12 men 4 (33%) had spontaneous medically unassisted erections sufficient for sexual intercourse with vaginal penetration. An additional 5 (42%) men describe "40 to 60%" spontaneous erections, with fullness, no rigidity and not able to penetrate. Overall, 9 (75%) men had return of erectile activity. No demonstrable erections occurred before 5 months postoperatively. The greatest return of function was observed at 14 to 18 months after surgery. CONCLUSIONS: This surgical technique has minimal morbidity and represents a significant advance in prostate cancer surgery in men requiring bilateral nerve resection. Our study clearly demonstrates recovery of erectile function in men who underwent bilateral nerve graft placement during radical retropubic prostatectomy when both cavernous nerves were deliberately resected.

Aged↗
PubMed2001

Laparoscopic radical prostatectomy with a remote controlled robot.

PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci* robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Humans↗
PubMed1978

Defense of the radical perineal prostatectomy.

There is sharp disagreement as to what constitutes the proper surgical approach to localized carcinoma of the prostate. We have performed 31 radical perineal prostatectomies in a six-year period with no mortality and minimal morbidity. Thirteen of these patients were understaged preoperatively and had extraprostatic cancer; however, only one has died from his tumor. One patient is incontinent but none has troublesome local symptoms. These patients required an average of 15 postoperative days, none required more than two units of blood, and careful preoperative consultation has minimized the psychologic stress of impotence. These data contrast sharply with the published morbidity and mortality statistics associated with a preliminary staging lymphadenectomy and a definitive radical retropubic prostatectomy. Also, we are convinced that our patients with stage C cancer have been done a real service by removing the prostate gland even though cancer remains in the stumps of the seminal vesicles. Unless the advocates of the staged procedure can demonstrate an improvement in the patients' survival data, we believe the radical perineal prostatectomy remains the procedure of choice for the cure of localized prostatic cancer and we would advocate this operation as an acceptable palliative approach to selected patients with stage C lesions.

Aged↗
PubMed2000

Salvage radical prostatectomy for radio-recurrent prostate cancer: is this a viable option?

The role of salvage prostatectomy for radio-recurrent prostate cancer remains unclear. Recurrent prostate cancer after radiation therapy is in many cases biologically aggressive. It is unclear whether the biologic aggressiveness of radio-recurrent prostate cancer is due to time-dependent cancer clonal evolution (potentially induced by radiation damage), or is due to an innately aggressive tumor secondary to overexpression or mutation of apoptotic inhibitors that render these tumors resistant to radiation. Recent studies examined the role of DNA ploidy, p53 and bcl-2 expression, proliferative indices and glutathione S-transferase-pi in predicting response to radiation therapy or salvage prostatectomy. Because of the potential for significant morbidity after salvage prostatectomy, preoperative parameters that aid in the identification of the patients who are most likely to benefit from surgery are needed.

Biomarkers, Tumor↗
PubMed2000

Intraoperative cavernous nerve stimulation during nerve sparing radical prostatectomy: how and when?

Although nerve-sparing prostatectomy is widely practiced, the results with respect to potency preservation often do not meet expectations. The concept of intraoperative cavernous nerve stimulation is rational. Recent data that link the response to sildenafil after prostatectomy to bilateral nerve sparing has increased the importance of optimizing nerve sparing. The cavernous nerves are often difficult to visualize and may have a variable course. A tumescent response to nerve stimulation can be consistently demonstrated. The response may be subtle, and characterized by a minimal increase in penile circumference and blood flow. Immediately after prostectomy, proximal nerve stimulation identifies whether neural continuity has been maintained, and is predictive of recovery of erectile function. A new device, the Cavermap, has been developed to permit intraoperative nerve stimulation with tumescence monitoring. An initial phase 2 and subsequent phase 3 single blinded, randomized, multicenter study that compared Cavermap-assisted prostatectomy with conventional nerve sparing demonstrated a significant benefit in terms of the duration of nocturnal tumescence by Rigiscan (Timm Medical Technologies, Eden Prairie, Minnesota) at 1 year. Other approaches are being explored, including sural nerve grafting, use of nerve stimulation during cystectomy or abdominal-perineal resection, and direct corpus cavernosum pressure monitoring during nerve stimulation. These approaches warrant further evaluation.

Clinical Trials as Topic↗
PubMed2003

Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure?

PURPOSE: In prostate cancer involvement of regional lymph nodes is regarded as a poor prognostic factor. Is this also true for micrometastasis if a meticulous lymph node dissection is performed? We determined progression rate and survival of patients with positive nodes following radical prostatectomy according to the number of metastases. MATERIALS AND METHODS: Between 1989 and 1999, 367 patients with clinically organ confined prostate cancer underwent meticulous pelvic lymph node dissection and radical prostatectomy. None of the patients received immediate adjuvant therapy. RESULTS: Of the patients 92 (25%) had histologically proven lymph node metastases. Followup of more than 1 year was available in 88 patients (96%), and median followup was 45 months (range 13 to 141). Of 19 patients (22%) who died of prostate cancer 16 had more than 1 positive node. Of the 39 patients with only 1 positive node 15 (39%) remained without signs of clinical or chemical progression. Whereas of the 20 and 29 patients with 2 or more positive lymph nodes only 2 (10%) and 4 (14%), respectively, remained disease-free. Time to prostate specific antigen relapse, symptomatic progression and tumor related death were significantly affected by the number of positive nodes. CONCLUSIONS: Meticulous lymph node dissection reveals a high rate of metastases (25%). In patients with positive nodes time to progression is significantly correlated with the number of diseased nodes. Some patients with minimal metastatic disease remain free of prostate specific antigen relapse for more than 10 years after prostatectomy without any adjuvant treatment. Meticulous pelvic lymph node dissection, particularly in patients with micrometastases, seems not only to be a staging procedure, but may also have a positive impact on disease progression and long-term disease-free survival.

Adult↗
PubMed2003

Temporal trends in radical prostatectomy complications from 1991 to 1998.

PURPOSE: We performed a retrospective, longitudinal, population based study to ascertain whether radical prostatectomy outcomes improved after the diffusion of surgical innovations during the last decade. MATERIALS AND METHODS: Using a 5% national random sample of Medicare beneficiaries we identified 12,079 men who underwent radical prostatectomy from 1991 to 1998. We analyzed relevant Medicare data to establish length of stay and the rate of in hospital complications (cardiac, respiratory, vascular, wound and genitourinary conditions) as well as the rate of anastomotic stricture, incontinence and impotence through 36 months after surgery. We performed multivariate logistic regression to control for age, race and geographic region when assessing the association of surgery year with outcomes of interest. RESULTS: Between 1991 and 1998 the in hospital complication rate decreased from 38% to 30% and mean length of stay decreased from 8.1 to 5.1 days. Each value had significant regional variation throughout the United States. The 3-year incontinence rate decreased from 20% in 1991 to 4% in 1995. However, no meaningful trends were observed in the rate of impotence, anastomotic stricture, or placement of artificial urinary sphincters or penile prostheses. On multivariate analysis, older age (75 years or older, OR 1.68, p <0.01) and nonwhite race (OR 1.35, p <0.01) were associated with more in hospital complications. Nonwhite patients were also more likely to be diagnosed with impotence (OR 1.25, p <0.01) and undergo penile prosthesis placement (OR 1.5, p <0.01). CONCLUSIONS: As urologists reach consensus on the ideal clinical characteristics for radical prostatectomy candidates, surgery in fewer elderly patients and the dissemination of surgical advances have been associated with shorter length of stay, fewer in hospital complications and a lower long-term incontinence rate. However, there is capacity for improvement, as evidenced by the unchanging rate of anastomotic stricture and impotence.

Aged↗